PFD report

MARTIN LEE TILLEY · Prevention of Future Deaths report

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Issued 12 Mar 2018•Gloucestershire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised2

  1. Failure to follow up patients after missed mental health appointments
    Part of recurring concern: Failure to maintain follow-up of patients who disengage from carePart of recurring concern: Failure to provide timely continuing mental health reviews and follow-upPart of recurring concern: Unreliable arrangement and communication of patient appointments and follow-up
  2. Lack of clear arrangements for emergency psychiatric referral following presentations involving self-harm, suicidal thoughts or hallucinations
    Part of recurring concern: Unreliable mental health referral pathways
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Failure to follow up patients after missed mental health appointments

Wider context from the report

“Prior to Mr Tilley's last appointment with the psychiatric nurse (CPN) attached to the Homeless Healthcare Team in July 2017 he was talking of self-harm, had suicidal thoughts and was apparently experiencing visual and auditory hallucinations. It appears that after not attending an appointment with the CPN in July Mr Tilley was no longer seen by the team. Prior to the inquest the Homeless Healthcare Team were asked to explain the circumstances in which such a presentation would result in a referral for an emergency assessment by a psychiatrist or the tertiary mental health services. No answer to this question was forthcoming. Furthermore there was no evidence that Mr Tilley was followed up by the Homeless Healthcare Team after July 2017. ”

Is this part of a recurring concern?

Yes — Failure to maintain follow-up of patients who disengage from care; Failure to provide timely continuing mental health reviews and follow-up; Unreliable arrangement and communication of patient appointments and follow-up.

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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 clear arrangements for emergency psychiatric referral following presentations involving self-harm, suicidal thoughts or hallucinations

Wider context from the report

“Prior to Mr Tilley's last appointment with the psychiatric nurse (CPN) attached to the Homeless Healthcare Team in July 2017 he was talking of self-harm, had suicidal thoughts and was apparently experiencing visual and auditory hallucinations. It appears that after not attending an appointment with the CPN in July Mr Tilley was no longer seen by the team. Prior to the inquest the Homeless Healthcare Team were asked to explain the circumstances in which such a presentation would result in a referral for an emergency assessment by a psychiatrist or the tertiary mental health services. No answer to this question was forthcoming. Furthermore there was no evidence that Mr Tilley was followed up by the Homeless Healthcare Team after July 2017. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

Open source report
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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