PFD report

Joanna Bowring · Prevention of Future Deaths report

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Issued 27 Jan 2016•Mid Kent and Medway

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.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised4

  1. Failure to advise carers about behaviours indicating increased risk of suicide
    Part of recurring concern: Incomplete and unreliable information about carers and care arrangements
  2. Failure to routinely include carers and actively seek their views and knowledge in risk assessment
    Part of recurring concern: Failure to obtain relevant collateral information from family and social supportsPart of recurring concern: Unreliable patient risk-assessment processes
  3. Failure to provide a clear understanding of the service available
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.7

  1. Action

    Complete and report an audit of care plans and risk assessments for evidence of carer involvement.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 27 January 2016.
  2. Action

    Provide family-inclusion training across the service line to frontline staff on engaging with families and carers.

    Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2016.
  3. Action

    Embed learning on engaging separately with patients and carers through clinician meetings, patient-safety meetings, face-to-face meetings and written guidance or policy updates.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 27 January 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    There is no universal suicide-risk red-flag marker; relevant warning behaviours are patient-specific, although identifying useful guidance is recognised.

    Stated by The TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 advise carers about behaviours indicating increased risk of suicide

Wider context from the report

“(3) Carers were not advised about any behaviours that might indicate an increased risk of suicide ”

Is this part of a recurring concern?

Yes — Incomplete and unreliable information about carers and care arrangements.

Open source report

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 routinely include carers and actively seek their views and knowledge in risk assessment

Wider context from the report

“(2) Carers were not routinely included in the risk assessment process and their views about the patient and knowledge of the patient were not actively sought ”

Is this part of a recurring concern?

Yes — Failure to obtain relevant collateral information from family and social supports; Unreliable patient risk-assessment processes.

Open source report

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 provide a clear understanding of the service available

Wider context from the report

“(1) The patient and carer left an initial assessment conducted on 4th April 2015 without a clear understanding of the service available and without a care plan ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 provide a care plan at initial assessment

Wider context from the report

“(1) The patient and carer left an initial assessment conducted on 4th April 2015 without a clear understanding of the service available and without a care plan ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Complete and report an audit of care plans and risk assessments for evidence of carer involvement.

Verbatim wording from the response

“• In February an Audit was carried out of care plans and risk assessments for evidence of Carer involvement. This has been carried out and a report of it provided to the Leadership Forum. I enclose recent slides”

Source location

Joanna-Bowring-Response
Page 2 · response
Published 27 January 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 family-inclusion training across the service line to frontline staff on engaging with families and carers.

Verbatim wording from the response

“• That this issue has also been separately discussed by the Trust at its Patient Safety Meetings, with the outcome that the Trust is commissioning a senior psychotherapist with expertise in family therapy to provide bespoke training to the Crisis and Community Mental Health Teams. I am pleased to confirm that Nigel Jacobs, Family Inclusion Project Lead, has started to provide training across the Service Line to all front-line staff on working with Families with the intention that it assists staff in engaging with carers”

Source location

Joanna-Bowring-Response
Page 2 · response
Published 27 January 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

Embed learning on engaging separately with patients and carers through clinician meetings, patient-safety meetings, face-to-face meetings and written guidance or policy updates.

Verbatim wording from the response

“• That the Trust has met with all clinicians as part of its learning process to emphasize the importance of engaging with the patient and carers separately,”

Source location

Joanna-Bowring-Response
Page 2 · response
Published 27 January 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

Audit implementation of the carers protocol to ensure it is being followed appropriately.

Verbatim wording from the response

“• The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for. A copy of the Protocol is attached. A review and audit will be undertaken in June to ensure that it is being implemented appropriately.”

Source location

Joanna-Bowring-Response
Page 2 · response
Published 27 January 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

Implement and trial an Initial Action Plan providing written assessment outcomes and next steps, while disseminating the proforma to staff and GP surgeries.

Verbatim wording from the response

“This is something the Liaison Psychiatry they have been working on since last year. As of the beginning of February 2016 after every assessment an Initial Action Plan is required to be completed at the end of an assessment each service user will have a written outcome so it is clear to both themselves and their carers what the next steps will be. I attach the Initial Action Plan Proforma (IAPP) that is completed for your information. The IAPP has been shared with staff through a newsletter, team meetings and supervision as well as shared with all GP surgeries. The IAPP is currently in the middle of its 12-week trial period with the intention of all feedback being reviewed at the end of the trial.”

Source location

Joanna-Bowring-Response
Page 2 · response
Published 27 January 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

Relaunch the carers protocol across the service, including guidance on potential warning signs and behaviours.

Verbatim wording from the response

“• The Trust has re-launched its carers protocol in February 2016 across the service which includes an outline of possible "red flags", and what behaviours carers may look out for. A copy of the Protocol is attached. A review and audit will be undertaken in June to ensure that it is being implemented appropriately.”

Source location

Joanna-Bowring-Response
Page 2 · response
Published 27 January 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

Develop Open Dialogue training so selected staff attend residential training and disseminate their learning to others.

Verbatim wording from the response

“• The Trust has also embarked on taking forward Open Dialogue Training where the focus will be on working with the individual and their family as equal partners in care. Medway is one of the two areas where this is being piloted. This is being taken forward currently, with the intention that selected individual will need to attend a 4 week residential course, and that it is envisaged that they will train others in what they have learned. It was accepted that this was the start of a longer term process.”

Source location

Joanna-Bowring-Response
Page 2 · response
Published 27 January 2016

Open published response

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

There is no universal suicide-risk red-flag marker; relevant warning behaviours are patient-specific, although identifying useful guidance is recognised.

Verbatim wording from the response

“It is hoped that the steps outlined in number 2 above will help address point 3. As explained in evidence this is however a very difficult and case specific point. I have liaised with the Medical Director and with other clinical staff who have indicated the difficulty as there is no one "red flag" marker which indicates an increased risk of suicide generally, it is dependent on the patient; but there has been a recognition that this could be useful (in line with the changes indicated above).”

Source location

Joanna-Bowring-Response
Page 3 · response
Published 27 January 2016

Open published response

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.1

  1. 1

    Commission STORM to deliver nationally recommended risk-assessment trainer training to key individuals.

    Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 27 January 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

Commission STORM to deliver nationally recommended risk-assessment trainer training to key individuals.

Verbatim wording from the response

“• The Service Line is to commission an external Risk Assessment Training company (STORM) to deliver Nationally Recommended Risk Assessment Training Trainers to key individuals”

Source location

Joanna-Bowring-Response
Page 3 · response
Published 27 January 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