28 Feb 2019 Yong Keng Hong · Prevention of Future Deaths report South London
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Concerns raised 7 Failure to seek further advice from an appropriate clinician View source Failure to implement the advised observation regime View source Failure to provide therapeutic engagement View source Failure to carry out a risk assessment before returning the call bell View source Failure to obtain interpreter support for assessment of needs View source Lack of training for care home staff in carrying out risk assessments View source Failure to provide a safety net View source See 4 more concerns
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Yong Keng Hong · 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
Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarendon Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to seek further advice from an appropriate clinician
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarendon Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the advised observation regime
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarendon Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide therapeutic engagement
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarendon Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out a risk assessment before returning the call bell
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell .
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarendon Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain interpreter support for assessment of needs
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarendon Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Lack of training for care home staff in carrying out risk assessments
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Clarendon Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a safety net
Wider context from the report “(1) His GP made an immediate referral to mental health services and advised constant observations, however:
(a) the observation regime advised by the GP was not implemented
(b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding
(c) no risk assessment was carried out prior to making the decision to return his call bell.
(2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement
(3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations