"GDPR Says Yes"

Christopher was admitted to a private mental health facility commissioned by the NHS. The handover notes at admission were incomplete; the MH facility didn't seek further information from the NHS or from Christopher's famjily, and indeed didn't access his care notes until after his death. Coroner noted that electronic access to NHS records for NHS-commissioned private providers is not provided as standard.

DWP failed to record information about Naz's mental health needs and vulnerability, despite provision in their IT system for this. Specifically they failed to record Naz's request that contact should be made through her daughter. This contributed to Naz's suicide.

Linda had learning difficulties and a mental health condition. She was under the care of the MH team, but they failed to notice her LD and made no reasonable adjustments. Linda overdosed on her medication, and died as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease

"Matthew’s death was probably the result of systemic failures across multiple agencies including the Prison services.... There was inadequate communication between agencies and a lack of information sharing. This probably led to a failure to identify his deteriorating mental health and increasing suicide risk.

"There was a lack of information sharing and investigation in relation to the discharge planning for Mr Clayton. Contrary to the Trust’s policy he was not identified as a vulnerable patient. His family was not involved in the discharge planning. On a number of occasions, they raised their concerns as to his ability to live independently and were ignored. Staff were unaware of the discharge planning policy. The underlying cause for his presentation was not diagnosed. Discharge decisions were taken in a vacuum without understanding the recent history of frequent admissions, his diagnosis and without sufficient investigation of his home circumstances."

Trevor was admitted to psychiatric hospital “in an agitated, even psychotic state” and unable to give staff his medical history His sister told staff that he was suffering heart problems, but they did not record this. Trevor died from his heart condition within 48 hours of being admitted to the psychiatric unit.

Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances." A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs. Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.

Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances." A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs. Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.

Jessie... where to start? The PFD report itself is addressed to the DHSC, and covers "the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admissions to inpatient mental health facilities and also A&E attendances." A lot of further detail emerged during the inquest, including failures to communicate both within and across the prrofessional teams caring for Jessie; failure to talk to (and listen to) Jessie and her parents; and a lack of professional/clinical curiosity which meant staff were not identifying and probing her underlying needs. Whilst I've been fortunate to find this further detail, it suggests that there may be more PFD reports providing evidence of these and perhaps other problems, and that the 228 reports I've identified here may only offer a partial view.

Anna was sectioned as she had suicidal thoughts. She was not observed as she should have been, partly due to staffing pressures, but staff backfilled the observation records to show that obs were being carried out correctly. The Coroner also noted an issue about messages from Anna's mother not being recorded or passed to staff, and about poor handover from day to night shift staff.

Ryan was a 20yo man with learning disabilities who was also diagnosed with depression. He was arrested and collapsed in the police van, complaining of chest pains. The police took him to hospital where signs of recent self-harm were found. However, the hospital did not investigate his mental state, despite NICE Guidelines which give clear instruction on doing so, and Ryan was released into police custody. (The NICE Guidelines referenced in the PFD report appear to have been superseded in 2022.) The Liaison and Diversion Service attended the custody suite, but failed to record his mental state, nor was he given a mental health assessment. Ryan expressed a desire to self-harm, but custody officers dismissed this as "attention-seeking". They released him to his father, but gave the father no information about what they had seen of Ryan's mental state.

Fern committed suicide after being told that her baby was going to be placed for adoption. This followed a catalogue of failings by Children's Social Care, rooted in their failure to recognise Fern's clinically diagnosed autism, to make any reasonable adjustments for it, or to provide her with an independent advocate while they carried out the s.17 investigation on her baby. The PFD report itself is addressed to the ambulance service and refers to the delay in getting her to hospital after taking an overdose. However, as with Jessie Eastland-Seares, there's a great deal of further detail in the report from georgejulian.co.uk, which paints a clear picture of the communication failures which led her to overdose.

Owen was a 19yo with severe learning disabilities. He also suffered from Pica (an eating disorder characterised by a tendency to eat non-edible substances). Owen's carer repeatedly raised concerns about him eating twigs, leaves and blue paper towels with his social worker and school. Despite this, Owen was left unsupervised and died after choking on blue paper towel.

Karmchand was admitted to hospital with acute intestinal obstruction. He was placed on the wrong referral pathway, resulting in severe delay to the surgery he needed. Observations were not carried out properly while he was awaiting surgery. Karmchand was unable to communicate the pain he was feeling to hospital staff. His family raised concerns, as did hospital staff who knew him, "but adequate notice does not appear to have been taken."

Michaela was in a relationship with a prolific offender who murdered her in her home by stabbing her in the eye. The Coroner found multiple failings across a number of services, including police, probation and adult and children's social care. These included: - An inadequate assessment of the risk posed to Michaela and her children by her partner - Multiple failures to communicate between agencies - A lack of professional curiosity leading to a failure to investigate the perpetrator's mental impairment, despite clear warning signs - Failure to act on or share information received from family members. The PFD report quotes from the Coroner's full judgement, which is not available at judiciary.uk, but which is likely to add clarity about these failings and the steps needed to correct them.

Kim died after being attacked by his son, who was under inadequate care from the MH team. They had not carried out MH assessments for the son in accordance with s.13 MHA, in that (among other things) they had disregarded the information repeatedly provided by Kim and his wife. A proper MH assessment would have led to Kim's son being sectioned and prevented from attacking Kim.

Morgan-Rose took her life while sectioned under the MHA. She was 18 with a diagnosis of Autism Spectrum Disorder; her transition from Children's to Adult1 Social Care had been badly managed, with a lack of information transfer between the two serevices and with no consideration of her own anxieties. MHU staff consistently failed to engage with Morgan-Rose, to the point where she felt they didn't have time for her. They failed to monitor her as they were required to, falsifying observation records and relying on the Oxevision automated observation system instead of face-to-face observations. When Oxevision triggered an alarm to say she had been unattended in the bathroom for three minutes, which should have resulted in an immediate welfare check, the system was reset by an unknown person and Morgan-Rose was left in the bathroom for 50 minutes. Staff had also failed to pick up on warning signals in her behaviour which should have led to heightened alertness. Basic record-keeping was extremely poor, as was the oversight and monitoring of records by senior staff.

Miles was arrested while driving under the influence of drink and drugs. He had longstanding mental health needs and was experiencing a psychotic episode. The Police appear not to have realised this and didn't carry out any meaningful assessment of his mental health. They didn't pay adequate attention to information provided by his parents, Adult Social Care and the Mental Health Line. Miles was released from custody, and subsequently crashed his car into an HGV while still suffering a psychotic episode.

Shahzadi, from Manchester, had been sectioned under the MHA and had been in a private MHU in Norfolk. Her family were unable to visit, leading to Shahzadi feeling isolated and clinicians not being able to have the family's input to her treatment. There were significant communication failures at the time of Shahzadi's discharge, leading to a failure to provide s.117 after-care and placement on the wrong clinical pathway. In the absence of the right care and support, Shahzadi took a fatal overdose.

Emmanuel had been diagnosed with paranoid schizophrenia and depression, and was under the treatment of the community MH team. They repeatedly failed to engage with his sister, with whom he lived and who wanted to be involved in his care. The Coroner highlighted four previous PFD reports she had sent to the Trust citing the same concern, dating back to 2015.

Rachel was known to the Intensive Home-Based Treatment Team (IHBTT) to be at high risk of suicide, but they failed to take all the necessary steps to protect her. Her family contacted IHBTT multiple times to raise concerns about her wellbeing, but these were not acted on, and nor were family members given any support and advice about how to care for Rachel.

1. There was a limited risk assessment and risk management plan documented for Gerard on ward B2 now Beech ward 2. There was an inadequate door board system for monitoring the return of patients after unescorted leave on ward B2. The same arrangements remain currently, despite the ward move to Beech ward on new premises 3. There was extremely limited family and carer involvement in Gerard’s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward 4. There was limited awareness of the ligature risk reduction pathway by staff on B2 now Beech ward

Sally died after being stabbed by her son, who had a history of schizophrenia. The Coroner found extensive evidence of professional failures by both the health service and adult social care to get effective treatment for her son, despite Sally having raised repeated concerns.

Sally died after being stabbed by her son, who had a history of schizophrenia. The Coroner found extensive evidence of professional failures by both the health service and adult social care to get effective treatment for her son, despite Sally having raised repeated concerns.

Multiple concerns about the Trust's approach to risk assessment (including a failure to prescribe appropriate medication); the way they carried out observations; and failure to pay regard to information provided by Larry's partner, which was put on the record but ignored.

Nursery failed to listen to Oliver's parents about how far he had progressed with weaning, and failed to tell his parents what they were feeding him. Oliver choked.

Tom sought help for depression, stating that he had suicidal thoughts. He was assessed by the MH team, but the assessment wasn't properly recorded; no discharge letter was sent to the GP, meaning that Tom didn't get the medication he needed. "It was acknowledged that obtaining collateral information from the family is vital, but in this case was delegated to a very Junior member of the team who was in the early stages of her training. It should be considered if this task is appropriate to delegate, and if so what information should be sought from families/carers and how that should be effectively used to support patient care."

Kirsty was diagnosed with both a learning disability and mental health conditions (EUPD and ADHD). The Coroner highlighted a lack of provision for LD/MH co-morbidities and a lack of communication between the two disciplines. In addition: "I remain concerned (as it is a matter I have raised on many occasions at inquest and again as a result of the experiences of the family in this case), that communication with the families of patients with mental health difficulties is still not being effectively achieved. Nor are such families being suffiently, effectively and meaningfuly listened to or understood when they voice concerns, based on their experience of the patient outside of a treatement or assessment environment. Consequently, I am concerned that such matters are not being reflected sufficiently or frequently enough in the onward treatment of those patients or in the clinical curiosity afforded to their conditions. "There remains an over-focus on patient centric assessments and patient only responses. It is recognised that patients can present quite differently to and in the presence of their families, who know them intimately, to how they may (or may be able to) present to assessing clinicians – with or without the intent to mask their condition. "Whilst consent to share is an understandable barrier in some cases, there should not be a bar to listening to or to actively encouraging feedback and input from families, especially where a family’s concerns are heightened by any sudden or marked changes in the behaviours, mood or presentation of their relative outside of the clinical/assessment environment – particularly in the case of neurodiversity. "Unless all concerns are heard and considered and all availble information is taken on board, holistically, there is a continuing risk that the masking of mental health conditions and the deterioration of them may occur or that significant red flags are missed. In this case, the family’s increasingly desperate concerns voiced about their daughter’s evident mental health deterioration in her final days went un-responded."

a.[REDACTED] evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and [REDACTED] of which treating clinicians were aware. On at least one of those occasions [REDACTED] spoke with Spenser Ward staff. I noted that Ms. Woodman had not [REDACTED] given consent for staff to contact [REDACTED] concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from [REDACTED]; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with [REDACTED] on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with . The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community. Although not causative of the death and I noted [REDACTED} ’ very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.