Category:Inquest cases - PFD reports
See Reports to Prevent Future Deaths.
The old category structure used on this page is comprehensive as it contains every relevant case. The new database structure was introduced in 2019, and is more potentially useful than the old categorisation system: it includes all cases since January 2016 (browse at Special:Drilldown/Cases) but only a minority of older cases. Asterisks below mark those cases which have been added to the new database structure.
The pages below are initially ordered according to the dates on which they were added to the site (most recent first). The order can be changed by clicking on the symbol beside a column heading: click on the symbol beside "Page and summary" for alphabetical order; click beside "Categories" for the order in which the cases were reported. Click on the arrow symbol again to reverse the order. Click on a page name to view the relevant page.
| Case and summary | Date added | Categories |
|---|---|---|
| * Gaps in service Re Sean Kay (PFD report sent to NHS Norfolk and Waveney CCG) [2021] MHLO 4 — The coroner's concern was that a gap in service provision meant Sean fell between services and did not receive appropriate care. He had been referred by his GP to mental health services. The Early Intervention in Psychosis Team (EIPT) assessed him as not meeting their criteria for first episode of psychosis but as being in the 'at risk mental state' (ARMS) cohort of patients, which meant that his level of risk was now too high for continued work with the Wellbeing Services. He also did not meet the criteria for the Community Mental Health Team, the Crisis Team, or the charity Mind. An Interface Team Meeting did not take place because of an administrative error so at the time of his suicide six days later he was waiting to hear whether and from whom he would receive support. In neighbouring Suffolk (and many other areas) ARMS patients would have met the EIPT criteria. | 2021‑04‑30 10:26:46 | 2021 cases, Cases, Inquest cases - PFD reports, Judgment available on MHLO, Neutral citation unknown or not applicable, Pages using DynamicPageList3 parser function, Transcript, 2021 cases
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| * Discharge to care home Re Alan Massam (PFD report sent to SSHSC, Greater Manchester Health and Social Care Partnership and CQC) [2021] MHLO 3 — The coroner's concerns included: (1) there was no clear agreement or arrangement between agencies as to how effectively to share information in complex cases such as this; (2) there was no national guidance/protocol about what an acute trust should do if attempts to contact a home are unsuccessful or about the obligation to ensure the home can accept the patient back (the care home had not answered the phone but, owing to his needs, would not have accepted him if asked; no observations were made before discharge and no discharge notice was sent with him); (3) there was no defined escalation process in the care home to ensure that the risk presented by his refusal of medication and fluids was recognised and acted upon; (4) there was a national shortage of suitable beds within the adult care sector for complex cases so, after the care home served notice on the family, he remained in a home where staff felt they could no longer safely meet his care needs during the search for a replacement. | 2021‑04‑30 09:01:11 | 2021 cases, Cases, Inquest cases - PFD reports, Judgment available on MHLO, Neutral citation unknown or not applicable, Pages using DynamicPageList3 parser function, Transcript, 2021 cases
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| * PFD report Re Susan Adams (PFD report sent to St George's Hospital, Stafford) [2021] MHLO 2 — The matter of concern was: Susan needed regular psychiatric assistance from secondary mental health services but there were significant difficulties because, living in Staffordshire but 50 feet from the border with Warwickshire, her home address and GP practice were in different counties; she could access the crisis team in Staffordshire but long-term treatment was supposedly to be provided in Warwickshire. The coroner wondered what could be done to facilitate arrangements in these circumstances. | 2021‑04‑24 20:45:47 | 2021 cases, Cases, Inquest cases - PFD reports, Judgment available on MHLO, Neutral citation unknown or not applicable, Pages using DynamicPageList3 parser function, Transcript, 2021 cases
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| * PFD report Re Mary Gwanyama (PFD report sent to Surrey and Borders Partnership) [2021] MHLO 1 — The matters of concern in this Preventing Future Deaths report included: (1) there was no policy to prevent a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit (Mary had been discharged without a discharge planning meeting and with no housing plan beyond 7 days in a Travel Lodge); (2) there was no policy mandating when or if a patient should be subject to face-to-face review by a consultant psychiatrist after discharge (Mary was not subject to a medical review between discharge on 28/3/18 and suicide on 26/5/18); (3) no formal risk assessment was undertaken, and no risk assessment was recorded; (4) informal risk assessments arrived at an incorrect assessment of risk having ignored the impact of discharge with an inchoate housing plan; (5) in part because the imperative to discharge took precedence over discharge planning and assessment, Mary was discharged prematurely with severe depression before sufficient time had been taken to observe the effectiveness of her prescribed medication, in breach of the CPA; (6) Mary was discharged on ineffective medication, without any coherent care plan, without her care coordinator being involved, in breach of the CPA; (7) there was no policy governing how often a patient should be seen in the community to review the risk assessment and monitor medication compliance (Mary was placed out of area which made community treatment and support difficult, and was not seen by her care co-ordinator in the 35 days before she died). | 2021‑04‑24 20:18:34 | 2021 cases, Cases, Inquest cases - PFD reports, Judgment available on MHLO, Neutral citation unknown or not applicable, Pages using DynamicPageList3 parser function, Transcript, 2021 cases
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Article titles
The following 4 pages are in this category.
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- Re Alan Massam (PFD report sent to SSHSC, Greater Manchester Health and Social Care Partnership and CQC) (2021) MHLO 3
- Re Mary Gwanyama (PFD report sent to Surrey and Borders Partnership) (2021) MHLO 1
- Re Sean Kay (PFD report sent to NHS Norfolk and Waveney CCG) (2021) MHLO 4
- Re Susan Adams (PFD report sent to St George's Hospital, Stafford) (2021) MHLO 2
The following category (in the blue box) can be clicked to view a list of other pages in the same category: