Recurring concern

Failure to reliably obtain and verify SOAD approval for psychiatric treatment

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First reported 8 Mar 2016•Latest report 18 Nov 2024

Definition

What this concern includes

Includes failures in the SOAD process for psychiatric treatment, including arranging timely SOAD appointments, verifying whether a SOAD has been obtained for the relevant patient and medication or treatment, and ensuring treatment approval does not proceed without the required SOAD status being established.

Not included

  • Excludes general Mental Health Act assessment, detention or treatment failures where SOAD authorisation is not the deficient control.
  • Excludes delays in psychiatric treatment unrelated to obtaining or verifying SOAD approval.
  • Excludes generic pharmacy, staffing, communication or documentation deficiencies unless they directly impair the SOAD authorisation process.
  • Excludes failures occurring after SOAD approval has been reliably obtained and verified, including subsequent medication administration or clinical monitoring failures.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2016–2024

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
North London Mental Health Partnership1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Yemisi Cielto-Opaleye · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Yemisi Cielto-Opaleye, a psychiatric inpatient at St Pancras Hospital, died on 13 December 2023 after receiving an Olanzapine depot injection and developing Olanzapine toxicity. The report identified concerns about inadequate pre- and post-injection vital-sign monitoring, unclear staff responsibilities, insufficient escalation and contingency planning, and failures to obtain required approval and provide adequate information about risks.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of Lead Pharmacist approval to establish whether a SOAD has been obtained

    Wider context from the report

    “(c) There is a risk that approval from a Lead Pharmacist to initiate a non-formulary medicine such as an Olanzapine depot can occur without the Pharmacist knowing whether a SOAD has been obtained in relation to that medication and that patient; ”

    Source location

    Yemisi Cielto-Opaleye · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  2. Sunderland

    AI-generated summary

    Elsie Tindle · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elsie Tindle, who had severe depressive disorder with suspected cognitive impairment and a learning disability, received three ECT sessions in February and March 2015. She developed focal seizures and status epilepticus, later appeared to develop aspiration pneumonia, and died on 4 April 2015; the post-mortem recorded anoxic-ischaemic brain damage due to status epilepticus due to ECT. The principal concerns were delays in appointing SOADs and the risk that the urgent s62 MHA powers could become a default position when SOAD appointments were delayed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide timely SOAD appointments

    Wider context from the report

    “(2) For ECT, SOADs attend within 5 days in 82% of cases but I am concerned that in 1:5 cases this does not happen. (3) Practitioners anticipate delays with the appointment of SOADs and it is common to use the urgent powers under s62 MHA (it is immediately necessary to save the patient’s life or prevent a serious deterioration in their condition). (4) I am concerned that there is a danger of the use of s62 MHA becoming a default position and that the numbers of SOADs may be insufficient to deal with matters in a more timely way. ”

    Source location

    Elsie Tindle · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026