Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 33
Durham Constabulary Establish monthly multi-agency reviews of concern-for-safety incidents to identify lessons learned.
View source
Durham Constabulary Use the inquest findings in training supporting the new escalation policy, including refreshed training on senior-management messaging and negative influences on operational decisions.
View source
Durham Constabulary Implement an interim escalation policy defining police attendance, escalation routes, decision rationale, welfare-check powers, risk assessment and resource-deployment recording.
View source
Durham Constabulary Apply the Joint Decision Model, national risk principles and THRIVE assessments to command decision-making for relevant incidents.
View source
Durham Constabulary Communicate lessons from safety-incident reviews to command staff through structured training sessions.
View source
Durham Constabulary Develop the local Right Care, Right Person approach through a dedicated project team, partner consultation and multi-agency governance covering relevant mental-health and welfare procedures.
View source
Durham Constabulary Train frontline officers and commanders using the national Right Care, Right Person package and local guidance when the force adopts that protocol.
View source
Department for Work and Pensions Deliver mental-health training to customer-facing colleagues, including guidance on supporting customers with vulnerabilities.
View source
Department for Work and Pensions Apply additional wellbeing and support checks before suspending or stopping benefits for identified vulnerable customers.
View source
Department for Work and Pensions Use Vulnerable Customer Champions to support informed decisions concerning vulnerable customers.
View source
Department for Work and Pensions Coordinate policy development, guidance, organisational learning and change monitoring through the Customer Experience Directorate.
View source
Department for Work and Pensions Provide Visiting Officers to meet the service needs of customers with complex requirements, including vulnerable customers.
View source
Department for Work and Pensions Operate the Serious Case Panel to consider cross-service themes and agree service changes and improvements.
View source
Department for Work and Pensions Provide specialist support for vulnerable or complex-needs customers through the Working Age Customer Experience Advanced Support Team.
View source
Department for Work and Pensions Further strengthen guidance and training for supporting vulnerable customers through continuous improvement work.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Conduct monthly audits of risk assessments, formulations, safety plans and family or carer involvement, with governance scrutiny and follow-up.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Hold reflective practice, huddle and practitioner-reflection sessions on safety planning, family involvement, confidentiality and risk escalation.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Develop updated confidentiality guidance for carers and staff.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Discuss consent and confidentiality in team meetings and supervision.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Work with Durham Constabulary and partner agencies to implement the Right Care, Right Person model and its detailed welfare-check framework.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Develop and implement an Interim Concern for Safety Escalation Policy with Durham Constabulary for disputed welfare-check responsibilities.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Prepare and circulate a patient-safety briefing on communication and escalation when partner agencies disagree about risk.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Hold Patient Safety Team meetings to discuss learning from the patient’s journey.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Develop and disseminate literature on learning from the patient’s journey.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Develop and disseminate a Trust-wide communication plan for the updated confidentiality guidance.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Review confidentiality guidance to clarify decision-making about information sharing with families and carers.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Deliver carer-awareness training.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Reshare safety-summary, safety-plan and safety-planning video resources with staff.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust Conduct monthly supervision sessions to evidence that learning has been embedded.
View source
Independent Office for Police Conduct Make organisational learning recommendations arising from investigations and serious incidents.
View source
Independent Office for Police Conduct Expressly consider learning opportunities in investigations involving deaths or serious injuries.
View source
Police and Crime Commissioner for Durham Continue monitoring the Force’s progress in adopting Right Care Right Person across County Durham and Darlington.
View source
Police and Crime Commissioner for Durham Support the force and relevant partners in adopting the Right Care Right Person protocol.
View source Respondent positions A position is what a recipient says about a concern when it does not describe a specific action. 9
Durham Constabulary Overall responsibility for safety planning lies with the health provider, while police contribute through partnership working.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Department for Work and Pensions No further action was required after the call because no suicidal thoughts or intention to self-harm were reported.
No action considered necessaryThe respondent said that no further action was needed. View source
Department for Work and Pensions Existing guidance, support, training and service-assurance processes were considered sufficient to support vulnerable customers with complex needs.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Tees, Esk and Wear Valleys NHS Foundation Trust Without consent, clinicians could contact family or friends only where legal justification outweighed confidentiality and privacy duties.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
Tees, Esk and Wear Valleys NHS Foundation Trust Only the Police have authority to force entry to save life or limb or prevent serious property damage during welfare checks.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Tees, Esk and Wear Valleys NHS Foundation Trust Ongoing professional support was arranged through crisis-team contact and care-coordinator follow-up, so support was not absent.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
Independent Office for Police Conduct The complaints system provides a formal procedure for identifying learning from serious incidents, including investigations and consideration of learning opportunities.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Independent Office for Police Conduct Learning recommendations are non-mandatory, and the IOPC cannot require recipients to accept them.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action. View source
Independent Office for Police Conduct Individual reflection should be addressed by the Appropriate Authority and the Police and Crime Commissioner.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
× 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 complete serious incident investigations in a timely and responsive way
Wider context from the report “(1) The serious incident investigation by the Trust has been substantially delayed. Sarah died on the 10th of July 2022 and the Trust confirmed to the Coroner’s service that there was to be a serious incident investigation on the 26th July 2022. The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months and on the 13th of March 2023 as this remained the position I listed this case for inquest on the 24th April 2023. On the 17th April 2023 I was alerted by deceased’s family to possible progress in respect of the serious incident investigation in this case, subsequent to their formal complaint to the Trust. After making enquiries of the Trust I was informed that the report would be available at the end of May 2023 and I therefore acceded to a family request to adjourn the final hearing given the short delay this would cause. On the 25th of April 2023 the Coronial service was informed that in fact that it was unlikely that the report would be finalised by May and would be ‘likely end of July/August time’. On the 26th of June I was informed that the report would now not be available until the ‘end of September/beginning of October’ and that the initial dates given were “too ambitious”. The case was listed to commence on the 16th of November 2023 on that basis. On the 28th of July the deceased’s family notified me of a likely further delay in the report being available due to the author’s sick leave from work. The Trust offered reassurance that the report remained due ‘end of September/beginning of October’. On the 28th of September a Pre Inquest Review Hearing was held in relation to a separate discrete issue and I was informed that the report was to be further delayed and would not be available until the end of October.
(2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again.
(3) If the final version report is received by the end of October it will be some 15 months since Sarah’s death and some 13 months outside the NHS framework. This is neither timely nor responsive.
(4) I have previously issued a PFD report in relation to this issue as has the Senior Coroner for Durham and Darlington, Mr Chipperfield, who stated that Tees Esk and Wear Valleys NHS Foundation Trust routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations, TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths.
(5) I am concerned that these dangers persist, despite the Trust’s response to previous PFD reports and their assurances that remedial action was being taken to eradicate the delays , and as a result it is my statutory duty to make this further report.
” Open source report
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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 Establish monthly multi-agency reviews of concern-for-safety incidents to identify lessons learned.
Verbatim wording from the response “To supplement the escalation policy there will be a review procedure which will occur monthly to review any lessons learned. This will be co-ordinated by the Force Mental Health Lead, and builds on existing review approaches relating to other incident types that have been seen as good practice by His Majesty's Inspectorate. There is already a review procedure in place in relation to Section 136 detentions and persons reported as missing from Health Care Facilities, whereby Police and TEWV convene to discuss issues/concerns and this will be expanded to include concern for safety type incidents involving concerns for” Source location Response from Police
Open published response
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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 Use the inquest findings in training supporting the new escalation policy, including refreshed training on senior-management messaging and negative influences on operational decisions.
Verbatim wording from the response “The Force is using the findings of this inquest as part of the training material to support the new escalation policy.” Source location Response from Police
Open published response
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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 Implement an interim escalation policy defining police attendance, escalation routes, decision rationale, welfare-check powers, risk assessment and resource-deployment recording.
Verbatim wording from the response “Durham Constabulary recognises the additional value of a documented escalation approach to provide clarity for operational staff and has progressed priority activity in this regard.” Source location Response from Police
Open published response
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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 Apply the Joint Decision Model, national risk principles and THRIVE assessments to command decision-making for relevant incidents.
Verbatim wording from the response “The Joint Decision Model (JDM) and Risk Principles as defined by national Approved Professional Practice (APP) will be utilised by all commanders to support decision making. This will be underpinned by THRIVE assessment which is used for all incidents reported to Durham Constabulary. (For information, the JDM is recognised decision model for all emergency services responders.) THRIVE is a structured framework to evaluate and manage a policing response. The acronym stands for Threat – the threat posed to oneself or others; Harm - the potential consequences or damage that may occur from the threat; Risk – this relates to the risk assessment quantifying the likelihood and severity of the potential harm occurring; Investigation – this component focuses on identifying and gathering the relevant information as appropriate to the incident; Vulnerability – an assessment of the individual’s” Source location Response from Police
Open published response
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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 Communicate lessons from safety-incident reviews to command staff through structured training sessions.
Verbatim wording from the response “To supplement the escalation policy there will be a review procedure which will occur monthly to review any lessons learned. This will be co-ordinated by the Force Mental Health Lead, and builds on existing review approaches relating to other incident types that have been seen as good practice by His Majesty's Inspectorate. There is already a review procedure in place in relation to Section 136 detentions and persons reported as missing from Health Care Facilities, whereby Police and TEWV convene to discuss issues/concerns and this will be expanded to include concern for safety type incidents involving concerns for” Source location Response from Police
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 Develop the local Right Care, Right Person approach through a dedicated project team, partner consultation and multi-agency governance covering relevant mental-health and welfare procedures.
Verbatim wording from the response “HM Coroner will be aware that there is national work being undertaken to standardise the approach to incidents where an individual’s mental health is a factor. The national project is known under the title ‘Right Care, Right Person’ (RCRP) and is aimed at ensuring a person in crisis or nearing that point receives the best care from the right agency. Durham Constabulary has not yet implemented this policy approach, but the interim escalation approach acts to support those principles. A Force Project Team has been established to progress the national approach locally.” Source location Response from Police
Open published response
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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 Train frontline officers and commanders using the national Right Care, Right Person package and local guidance when the force adopts that protocol.
Verbatim wording from the response “RCRP will ensure that all frontline officers and commanders will be trained with a national training package and local guidance. RCRP is a national policing approach and the Force will adopt that protocol in due course. It’s important to highlight that we aren’t simply waiting for the implementation of Right Care Right Person, and the implementation of the escalation policy now will provide structure, guidance and governance to future decisions.” Source location Response from Police
Open published response
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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 Deliver mental-health training to customer-facing colleagues, including guidance on supporting customers with vulnerabilities.
Verbatim wording from the response “The department also has a detailed mental health training package which all customer facing colleagues undertake. This provides colleagues with learning that they can then apply to the different scenarios with which they may be faced. The training includes modules on appropriate actions to take to support customers with vulnerabilities including mental health issues.” Source location Response from Department for Work and Pensions
Open published response
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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 Apply additional wellbeing and support checks before suspending or stopping benefits for identified vulnerable customers.
Verbatim wording from the response “The department has reviewed the processes in place where existing benefits are suspended or stopped and has put in place additional steps to check on the wellbeing and support needs of customers it identifies as vulnerable. For example, Stopping Payments guidance introduced in 2020 ensures that payments are not stopped or suspended while the department considers a customer’s vulnerability.” Source location Response from Department for Work and Pensions
Open published response
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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 Use Vulnerable Customer Champions to support informed decisions concerning vulnerable customers.
Verbatim wording from the response “The role of the Vulnerable Customer Champion (VCC) was implemented to provide additional support to customers. VCCs help support Decision Makers to make more informed decisions when dealing with vulnerable customers, particularly those that fail to attend Work Capability Assessments or do not engage with DWP as required under the terms of their benefit entitlement.” Source location Response from Department for Work and Pensions
Open published response
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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 Coordinate policy development, guidance, organisational learning and change monitoring through the Customer Experience Directorate.
Verbatim wording from the response “Customer Experience Directorate” Source location Response from Department for Work and Pensions
Open published response
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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 Provide Visiting Officers to meet the service needs of customers with complex requirements, including vulnerable customers.
Verbatim wording from the response “The department’s national network of Visiting Officers allows DWP to meet the needs of customers with complex requirements who may be unable to access its services. This includes vulnerable customers and those needing additional support.” Source location Response from Department for Work and Pensions
Open published response
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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 Operate the Serious Case Panel to consider cross-service themes and agree service changes and improvements.
Verbatim wording from the response “The package is constantly evolving, and work is ongoing to further strengthen guidance and training as part of continuous improvement activities. These activities benefit all our customers, especially the many vulnerable people who rely upon us. One of these improvements is the introduction of the Serious Case Panel, which was set up in late 2019.” Source location Response from Department for Work and Pensions
Open published response
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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 Provide specialist support for vulnerable or complex-needs customers through the Working Age Customer Experience Advanced Support Team.
Verbatim wording from the response “The Customer Experience Advanced Support Team” Source location Response from Department for Work and Pensions
Open published response
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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 Further strengthen guidance and training for supporting vulnerable customers through continuous improvement work.
Verbatim wording from the response “The department also has a detailed mental health training package which all customer facing colleagues undertake. This provides colleagues with learning that they can then apply to the different scenarios with which they may be faced. The training includes modules on appropriate actions to take to support customers with vulnerabilities including mental health issues.” Source location Response from Department for Work and Pensions
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 Conduct monthly audits of risk assessments, formulations, safety plans and family or carer involvement, with governance scrutiny and follow-up.
Verbatim wording from the response “Separately to the learning identified as a result of the Trust investigation, HM Assistant Coroner is aware that the Trust has ongoing assurance around assessment and management of risk via the Quality Assurance Schedule (QAS). Senior Clinical Staff complete monthly audits to monitor the quality of narrative risk assessment and risk formulations and safety plans being produced by staff, the audits also consider evidence of co production with the service user and involvement of families / carers. The findings from these audits are then discussed and scrutinised at the Specialty Governance Group to identify whether any further action is required. Anything that remains a concern following the monthly audit is added to team meeting agendas for discussion to ensure that improvements can be implemented on a rolling basis.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Hold reflective practice, huddle and practitioner-reflection sessions on safety planning, family involvement, confidentiality and risk escalation.
Verbatim wording from the response “• Reflective practice sessions have now taken place to discuss the learning from this incident. There has also been discussion in huddles regarding safety planning and also on using the 'need to know' section to ensure core information is included in the safety plan. There has also been individual practitioner reflection around discussing risks with families, maintaining the trust in a therapeutic relationship and the circumstances where confidence has had to be broken, to mitigate risk.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 updated confidentiality guidance for carers and staff.
Verbatim wording from the response “The Trust has in place Common Sense Confidentiality guidance which considers how we work with carers where a service user states we cannot share information with their family / people close to them. This useful guidance is currently under review to provide further clarity to staff. In addition, discussions have already taken place at the Trust Fundamental Standards Group on 22 November 2023, to consider how this guidance can be further improved. Although plans are early in development, the intention is to create an updated guidance document to inform carers and support staff with decision making around confidentiality and information sharing. In addition, the Trust intends to develop a Trust-wide communication plan to disseminate the updated guidance. More information can be provided on this if required, as the information is collated and shared.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Discuss consent and confidentiality in team meetings and supervision.
Verbatim wording from the response “• Consent and confidentiality has been discussed in Team meetings and supervision.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Work with Durham Constabulary and partner agencies to implement the Right Care, Right Person model and its detailed welfare-check framework.
Verbatim wording from the response “I can reiterate the position that was explained at the inquest, that TEWV is currently working very closely with Durham Constabulary (along with other relevant stakeholders) with regard to the introduction of 'Right Care, Right Person' (RCRP). This will supersede the Interim Policy that has been developed and provide a more detailed Policy and framework for TEWV, Durham Constabulary and other partner organisations to work within in carrying out welfare checks. The Trust has attended an event in October and December 2023 with Durham Constabulary to establish work streams to implement the model, and is actively working with all partner agencies to progress this.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 and implement an Interim Concern for Safety Escalation Policy with Durham Constabulary for disputed welfare-check responsibilities.
Verbatim wording from the response “At the time of Sarah's involvement with services, there was no specific policy in place between TEWV and Durham Constabulary as to the appropriate agency to undertake welfare checks, however, the agencies have worked together to develop an Interim Policy pending implementation of 'Right Care, Right Person' (RCRP). This Interim Policy will be entitled 'Interim Concern for Safety Escalation Policy' and has been collaboratively created between Durham Constabulary and the Trust. The Interim Policy 'provides a process to support decision making in relation to Police attendance at concern for safety incidents'. The aim of the Interim Policy is to provide 'a framework for escalating incidents of concern for safety and welfare checks, in which a decision is made for Police not to attend and partner agencies disagreed'.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Prepare and circulate a patient-safety briefing on communication and escalation when partner agencies disagree about risk.
Verbatim wording from the response “In addition, prior to the implementation of the Interim Policy, the Trust committed to preparing a patient safety briefing regarding actions to be taken when a dispute arises with partner agencies. This has been completed and circulated to all clinical teams. I understand a copy was also provided to HM Assistant Coroner. The briefing provides a clear message to staff in respect of communication and escalation in circumstances where it is apparent that 'opinions of the level and immediacy of risk posted to an individual differs between organisations and that this may result in a delay in response'. Pending the introduction of RCRP, this provides staff with practical and appropriate guidance to so far as possible, manage patients in a safe and consistent manner.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Hold Patient Safety Team meetings to discuss learning from the patient’s journey.
Verbatim wording from the response “• Literature is being developed and disseminated across the Trust in relation to key learning from the patient's journey. In addition, the Patient Safety Team will be undertaking Teams meetings to discuss the same.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 and disseminate literature on learning from the patient’s journey.
Verbatim wording from the response “• Literature is being developed and disseminated across the Trust in relation to key learning from the patient's journey. In addition, the Patient Safety Team will be undertaking Teams meetings to discuss the same.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 and disseminate a Trust-wide communication plan for the updated confidentiality guidance.
Verbatim wording from the response “The Trust has in place Common Sense Confidentiality guidance which considers how we work with carers where a service user states we cannot share information with their family / people close to them. This useful guidance is currently under review to provide further clarity to staff. In addition, discussions have already taken place at the Trust Fundamental Standards Group on 22 November 2023, to consider how this guidance can be further improved. Although plans are early in development, the intention is to create an updated guidance document to inform carers and support staff with decision making around confidentiality and information sharing. In addition, the Trust intends to develop a Trust-wide communication plan to disseminate the updated guidance. More information can be provided on this if required, as the information is collated and shared.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Review confidentiality guidance to clarify decision-making about information sharing with families and carers.
Verbatim wording from the response “The Trust has in place Common Sense Confidentiality guidance which considers how we work with carers where a service user states we cannot share information with their family / people close to them. This useful guidance is currently under review to provide further clarity to staff. In addition, discussions have already taken place at the Trust Fundamental Standards Group on 22 November 2023, to consider how this guidance can be further improved. Although plans are early in development, the intention is to create an updated guidance document to inform carers and support staff with decision making around confidentiality and information sharing. In addition, the Trust intends to develop a Trust-wide communication plan to disseminate the updated guidance. More information can be provided on this if required, as the information is collated and shared.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Deliver carer-awareness training.
Verbatim wording from the response “• Carer awareness training has been carried out.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Reshare safety-summary, safety-plan and safety-planning video resources with staff.
Verbatim wording from the response “It is noted that HM Assistant Coroner has acknowledged that evidence was heard at the inquest about the implementation of training and improvements around safety planning and confidentiality. To reiterate, in accordance with the action plan developed as a result of the Trust investigation, the Trust has already;” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Conduct monthly supervision sessions to evidence that learning has been embedded.
Verbatim wording from the response “• Supervision sessions are carried out monthly to evidence that learning has been embedded.” Source location Response from Tees, Esk and Wear Valleys
Open published response
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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 Make organisational learning recommendations arising from investigations and serious incidents.
Verbatim wording from the response “9. Please consider the following data to be provisional, in the sense that it may yet change, but currently, our data suggests that in the last full reporting year, 1 April 2022 to 31 March 2023, we made 176 organisational learning recommendations, of which 134 were made under Paragraph 28A of the Police Reform Act, where recipients have a legal obligation to respond. 117 were accepted, 9 not accepted and responses are awaited for 8 recommendations.” Source location Response from Independent Office for Police Conduct
Open published response
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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 Expressly consider learning opportunities in investigations involving deaths or serious injuries.
Verbatim wording from the response “14. I think it could be said that there is therefore, a formal procedure by which learning can be identified from such serious events. If a matter is defined as a Death or Serious Injury incident, it will often have to be investigated. The terms of reference for such an investigation will usually include, among other things, whether there is an opportunity for learning. In cases involving the IOPC, as here, we will expressly consider the opportunities for learning.” Source location Response from Independent Office for Police Conduct
Open published response
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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 Continue monitoring the Force’s progress in adopting Right Care Right Person across County Durham and Darlington.
Verbatim wording from the response “I trust this response addresses the issues you have brought to my attention and I will continue to monitor the progress of Right Care Right Person being adopted across County Durham and Darlington, particularly the role of the Force.” Source location Response from Durham Police and Crime Commissioner
Open published response
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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 Support the force and relevant partners in adopting the Right Care Right Person protocol.
Verbatim wording from the response “Following this report, I have been reassured that the force swiftly implemented an interim escalation policy with TEWV, and this is pending progress on the roll-out of the national ‘Right Care Right Person’ approach which includes a clear escalation plan through strategic, tactical, and operational levels. This interim approach supports the principles of ‘Right Care Right Person’ and my office is supporting the force and relevant partners in adopting this protocol in due course.” Source location Response from Durham Police and Crime Commissioner
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Overall responsibility for safety planning lies with the health provider, while police contribute through partnership working.
Verbatim wording from the response “The overall responsibility in respect of safety planning for Ms Holmes lies with the health provider, in this case for Tees, Esk and Wear Valley Mental Health Trust (TEWV). Durham Constabulary have subsequently worked closely with TEWV to develop a strong partnership plan to respond to calls in the future, acknowledging that such a response should be a partnership conversation.” Source location Response from Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further action was required after the call because no suicidal thoughts or intention to self-harm were reported.
Verbatim wording from the response “A telephone call was made to Ms Holmes later that day at 14:04, in accordance with DWP guidance. The call notes confirm that “earning over the limit was discussed” and that Ms Holmes “advise[d] she will be reducing her hours to earn under PW limit and will send in PW1 form”. There is no mention of suicidal thoughts or an intention to harm, therefore no further action would have been required following this call.” Source location Response from Department for Work and Pensions
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing guidance, support, training and service-assurance processes were considered sufficient to support vulnerable customers with complex needs.
Verbatim wording from the response “The full circumstances of this case have been reviewed, and the department is satisfied that there is appropriate guidance and support in place to allow vulnerable customers with complex needs access to benefits. In addition, the department is continually looking at ways to support vulnerable” Source location Response from Department for Work and Pensions
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Without consent, clinicians could contact family or friends only where legal justification outweighed confidentiality and privacy duties.
Verbatim wording from the response “It is acknowledged that the mental health workers asked Sarah if they could contact her family or friends, and she asked that they didn't, as she did not want to worry her family when the crisis was felt to have passed. The inquest heard that the mental health workers felt they could not break confidentiality as there was not considered to be any immediate risk to Sarah, or others, and it was felt that Sarah had the capacity to make that decision. The mental health workers considered breaching confidentiality and weighed up the risk of Sarah going home without the support of a friend, against the risk of losing the strong therapeutic trusting relationship that Sarah had built up with services that would come with breaching her confidentiality. They felt that as Sarah had always worked with services, she would engage with the plan that she had collaboratively created on this occasion.” Source location Response from Tees, Esk and Wear Valleys
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Only the Police have authority to force entry to save life or limb or prevent serious property damage during welfare checks.
Verbatim wording from the response “The position remains that only the Police have the power to force entry into a property under section 17 Police and Criminal Evidence Act 1984 (PACE) in circumstances to save life or limb, or prevent serious damage to property. TEWV staff are encouraged to always use their best endeavours to make enquiries by telephone and in person to establish the wellbeing of a patient where concerns have been raised.” Source location Response from Tees, Esk and Wear Valleys
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ongoing professional support was arranged through crisis-team contact and care-coordinator follow-up, so support was not absent.
Verbatim wording from the response “home was very much made in collaboration with her. The mental health worker had considered the safety plan that Sarah had written with her community team and all options for treatment, including hospital admission were explored with Sarah. It was confirmed that, as would be expected by the Trust, the clinicians tried to go with the least restrictive options that would be the most beneficial for the patient. It is not accepted by the Trust that there was an absence of any ongoing professional support; a plan was in place for the crisis team to contact Sarah on the evening of 10 July 2022, and for her Care Co-ordinator to continue to engage and support after the weekend, on 11 July 2022.” Source location Response from Tees, Esk and Wear Valleys
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The complaints system provides a formal procedure for identifying learning from serious incidents, including investigations and consideration of learning opportunities.
Verbatim wording from the response “14. I think it could be said that there is therefore, a formal procedure by which learning can be identified from such serious events. If a matter is defined as a Death or Serious Injury incident, it will often have to be investigated. The terms of reference for such an investigation will usually include, among other things, whether there is an opportunity for learning. In cases involving the IOPC, as here, we will expressly consider the opportunities for learning.” Source location Response from Independent Office for Police Conduct
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Learning recommendations are non-mandatory, and the IOPC cannot require recipients to accept them.
Verbatim wording from the response “11. It is worth reiterating that our recommendations are not mandatory. They may be refused by the person or organisation to whom they are made. We cannot require any person to accept a learning recommendation. An IOPC learning recommendation should be practicable and meaningful, but the recipient is entitled to hold a differing view as to whether the learning recommendation is both justified, and thereafter practicable and meaningful.” Source location Response from Independent Office for Police Conduct
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual reflection should be addressed by the Appropriate Authority and the Police and Crime Commissioner.
Verbatim wording from the response “17. Regarding any lack of reflection in respect of individuals, forgive me but I do not believe it would be appropriate for me to comment further, beyond the findings that we reached on the case. I believe that such matters should better be addressed by the Appropriate Authority and the Police and Crime Commissioner.” Source location Response from Independent Office for Police Conduct
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