PFD report

Vanessa Christine DADSWELL · Prevention of Future Deaths report

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Issued 17 Feb 2016•Surrey

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of an intermediate urgent mental health referral timeframe
    Part of recurring concern: Unreliable community mental-health response to urgent GP concernsPart of recurring concern: Unreliable referral urgency categorisation and prioritisationPart of recurring concern: Unreliable urgent mental health referral and assessment pathways
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Action

    Enable Triage Team Leaders to book priority appointments directly.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
  2. Action

    Require daily review of out-of-hours referrals and arrange appointments within 24 hours when clinically indicated.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
  3. Action

    Develop a Coastal West Sussex protocol documenting the improved referral system, with the inquest checklist and flowchart appended.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 February 2016.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of an intermediate urgent mental health referral timeframe

Wider context from the report

“During the course of the inquest the evidence revealed that any urgent referral by a GP would be categorised by West Sussex Community Mental Health as either as a ‘4 hour’ referral or as a ‘within 5 day’ referral. A ‘4 hour’ referral would involve the service user having to attend A&E urgently for an assessment within 4 hours. A ‘within 5 day referral’ was exactly as described, an appointment within 5 days. The issue arose where a referring GP did not consider it necessary nor appropriate for a 4 hour referral and yet believed a 24 hour visit was necessary as 5 days would be too long. The deceased was not seen within 24 hours and committed suicide 3 days after the referral with no direct contact having been made. Evidence given by the Service manager for the Trust agreed that an intermediate option for referral would not be unreasonable. Consideration should be given to an alternative, intermediate referral time between the current ‘4 hour’ and ‘within 5 day’ periods for referrals together with effective management thereof. ”

Is this part of a recurring concern?

Yes — Unreliable community mental-health response to urgent GP concerns; Unreliable referral urgency categorisation and prioritisation; Unreliable urgent mental health referral and assessment pathways.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Enable Triage Team Leaders to book priority appointments directly.

Verbatim wording from the response

“• Triage Team Leaders now have direct bookable Priority Appointment slots and do not need to pass priority referrals to the Assessment & Treatment Duty Worker for booking.”

Source location

Vanessa-DADSWELL-Response
Page 1 · response
Published 17 February 2016

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require daily review of out-of-hours referrals and arrange appointments within 24 hours when clinically indicated.

Verbatim wording from the response

“• Every morning the Triage Team Leader assesses all incoming referrals received out of hours and, if the referrer has requested the service user to be seen within 24 hours but did not consider a 4 hour response was clinically required, appointments within 24 hours are arranged.”

Source location

Vanessa-DADSWELL-Response
Page 1 · response
Published 17 February 2016

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a Coastal West Sussex protocol documenting the improved referral system, with the inquest checklist and flowchart appended.

Verbatim wording from the response

“Penny Fenton, General Manager Coastal West Sussex Care Delivery Service (CDS), Nadia Anderson, Service Manager Western, Working Age Mental Health Services, Coastal West Sussex Care Delivery Service (CDS) and Liam Rudden, Service Manager for Adur, Arun & Worthing Assessment and Treatment Service are currently drafting a protocol encompassing the improved system throughout Coastal West Sussex CDS. The checklist and flowchart developed and exhibited at the inquest will be appended so there is a clear user friendly guide for staff. Dr Brian Solts, Divisional Clinical Director – Coastal West Sussex Care Delivery Service (CDS) has confirmed he will present the protocol, together with the learning from Mrs Dadswell’s inquest, to the Adult Management Board to maximize learning and embed the improvements introduced.”

Source location

Vanessa-DADSWELL-Response
Page 2 · response
Published 17 February 2016

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Fast-track referrals to the first available appointment based on risk assessment.

Verbatim wording from the response

“• Referrals can be fast track allocated by the Triage Team Leader so they do not wait up to 5 days for a slot; they are given the first available appointment, dependent on assessment of risk, often within 2–3 days.”

Source location

Vanessa-DADSWELL-Response
Page 1 · response
Published 17 February 2016

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Meet West Sussex mental health commissioners to jointly review the urgent care pathway in light of the improvements and current practice.

Verbatim wording from the response

“The Service Specification for the Urgent Care Pathway detailing the 4 hour and 5 day referral options was developed in partnership with our West Sussex Commissioners and is due for renewal. Dr Solts has requested a meeting to be arranged with the West Sussex Mental Health commissioners to review the pathway jointly with us, in light of the improvements we have made, and the greater flexibility we have introduced, so it reflects current practice.”

Source location

Vanessa-DADSWELL-Response
Page 2 · response
Published 17 February 2016

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. 1

    Document all referrals and referral decisions, including rationale, in the Trust-wide CareNotes electronic records system.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
  2. 2

    Disseminate anonymised inquest learning through the Trust’s monthly Report and Learn Bulletin and Quarterly Quality and Safety Report.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
  3. 3

    Host a Report and Learn Forum and share anonymised learning from the inquest for staff reflection and action.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 February 2016.
  4. 4

    Provide senior oversight, with Team Leaders owning referrals, contacting referrers and service users, prioritising work daily, and supporting triage staff.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
  5. 5

    Present the protocol and learning from the inquest to the Adult Management Board to support organisation-wide learning and embed the improvements.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 February 2016.
  6. 6

    Offer more home visits where clinically indicated.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
  7. 7

    Escalate concerns about out-of-hours referrals or appointment needs immediately to the on-call manager.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
  8. 8

    Recruit a full-time Band 7 staff member to cover Team Leader absences.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 February 2016.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Document all referrals and referral decisions, including rationale, in the Trust-wide CareNotes electronic records system.

Verbatim wording from the response

“• All referrals and referral decisions, including the rationale behind the decision, are documented on our new electronic records system, CareNotes, which all clinical staff Trust wide have access to.”

Source location

Vanessa-DADSWELL-Response
Page 2 · response
Published 17 February 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate anonymised inquest learning through the Trust’s monthly Report and Learn Bulletin and Quarterly Quality and Safety Report.

Verbatim wording from the response

“As a Trust we are committed to learning and improving safety. Lessons from Mrs Dadswell’s inquest were shared (anonymously) through the Trust’s monthly Report and Learn Bulletin and via the Trust’s Quarterly Quality and Safety Report, both are distributed throughout the Trust and externally with our Clinical Commissioning Groups.”

Source location

Vanessa-DADSWELL-Response
Page 2 · response
Published 17 February 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Host a Report and Learn Forum and share anonymised learning from the inquest for staff reflection and action.

Verbatim wording from the response

“Furthermore, Dr Solts is hosting a ½ day Report and Learn Forum for Coastal West Sussex CDS which will identify learning from incidents and inquests and he will share the learning (anonymously) from Mrs Dadswell’s inquest so CDS staff can reflect and take forward the lessons learned.”

Source location

Vanessa-DADSWELL-Response
Page 2 · response
Published 17 February 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide senior oversight, with Team Leaders owning referrals, contacting referrers and service users, prioritising work daily, and supporting triage staff.

Verbatim wording from the response

“• There is senior staff oversight of the new system whereby the Triage Team Leader takes ownership and makes contact with the General Practitioner and service user throughout the process. The Team Leader prioritises the incoming work on a daily basis and supports the triage workers.”

Source location

Vanessa-DADSWELL-Response
Page 1 · response
Published 17 February 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Present the protocol and learning from the inquest to the Adult Management Board to support organisation-wide learning and embed the improvements.

Verbatim wording from the response

“Penny Fenton, General Manager Coastal West Sussex Care Delivery Service (CDS), Nadia Anderson, Service Manager Western, Working Age Mental Health Services, Coastal West Sussex Care Delivery Service (CDS) and Liam Rudden, Service Manager for Adur, Arun & Worthing Assessment and Treatment Service are currently drafting a protocol encompassing the improved system throughout Coastal West Sussex CDS. The checklist and flowchart developed and exhibited at the inquest will be appended so there is a clear user friendly guide for staff. Dr Brian Solts, Divisional Clinical Director – Coastal West Sussex Care Delivery Service (CDS) has confirmed he will present the protocol, together with the learning from Mrs Dadswell’s inquest, to the Adult Management Board to maximize learning and embed the improvements introduced.”

Source location

Vanessa-DADSWELL-Response
Page 2 · response
Published 17 February 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Offer more home visits where clinically indicated.

Verbatim wording from the response

“• More home visits are now offered where clinically indicated (as in Mrs Dadswell’s case).”

Source location

Vanessa-DADSWELL-Response
Page 2 · response
Published 17 February 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Escalate concerns about out-of-hours referrals or appointment needs immediately to the on-call manager.

Verbatim wording from the response

“• If the member of staff taking the referral out of hours has any concerns about the referral or appointment needs, they now immediately escalate the referral to the on call manager.”

Source location

Vanessa-DADSWELL-Response
Page 1 · response
Published 17 February 2016

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Recruit a full-time Band 7 staff member to cover Team Leader absences.

Verbatim wording from the response

“In addition, we are recruiting a full time band 7 member of staff to provide cover to the Team Leaders in times of absence to ensure the system is robust and not reliant on any one individual.”

Source location

Vanessa-DADSWELL-Response
Page 2 · response
Published 17 February 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026