2 May 2026 Somtera Bibi · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Lack of a relapse prevention or risk management plan developed with the patient and family members View source Lack of home-environment risk assessment and practical safety advice for the family View source Failure to involve safeguarding or social care services to protect vulnerable family members View source Failure to complete or attempt a DASH risk assessment View source Failure to seek forensic psychiatric advice on identified violence risks View source Failure to respond adequately to attempts to formulate a family safety plan View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Somtera Bibi · 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
Somtera Bibi, aged 80, died from fatal stab wounds to the chest at her home on 2 April 2022. The report identified concerns about the absence of robust community mental-health risk management, including relapse prevention, family safety planning, DASH risk assessments, safeguarding referrals and multi-agency involvement, despite known risks posed by the family member who inflicted the injuries.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a relapse prevention or risk management plan developed with the patient and family members
Wider context from the report “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour.
Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically:
(i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family
(ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020
(iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened
(iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members
(v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members
(vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of home-environment risk assessment and practical safety advice for the family
Wider context from the report “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour.
Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically:
(i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family
(ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020
(iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened
(iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members
(v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members
(vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve safeguarding or social care services to protect vulnerable family members
Wider context from the report “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour.
Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically:
(i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family
(ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020
(iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened
(iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members
(v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members
(vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or attempt a DASH risk assessment
Wider context from the report “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour.
Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically:
(i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family
(ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020
(iii) No DASH risk assessment was completed or attempted , following incidents where family were harmed or threatened
(iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members
(v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members
(vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek forensic psychiatric advice on identified violence risks
Wider context from the report “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour.
Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically:
(i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family
(ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020
(iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened
(iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members
(v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members
(vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond adequately to attempts to formulate a family safety plan
Wider context from the report “The patient/perpetrator was identified as being a risk to others when unwell. His risk assessment identified domestic abuse; sexual abuse; possession/preoccupation with weapons; threats to kill family members. The risk assessment noted a prior conviction for possession of a knife and threatening behaviour.
Despite identifying the above risks over a period of many years, there was no relapse prevention plan; family safety plan or significant attempts to safeguard the family. Specifically:
(i) There was no adequate evidence of a response to multiple attempts by the police to formulate a safety plan for the family
(ii) No advice was sought from the forensic psychiatric team in light of the previous conviction; nature of risk and assault on his mother in October 2020
(iii) No DASH risk assessment was completed or attempted, following incidents where family were harmed or threatened
(iv) No attempts to involve the safeguarding or social care team to protect vulnerable family members
(v) No relapse prevention plan/risk management plan, drawn up with the input of the patient and family members
(vi) There was no risk assessment within the home environment with practical advice to the family on how to keep safe in the event of another violent relapse
” 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 Review and strengthen risk assessment and management processes, including clinical-recording-system changes and staff training.
Verbatim wording from the response “16. The Trust has a large piece of work underway reviewing and strengthening risk assessment and management processes. This will involve changes to our clinical recording system as well as staff training. This is intended to create processes that are more focused on risk formulation, based on current factors and historical risk. For clarity, these processes would always be expected to involve the service user and also family/carers where this is relevant.” Source location Response from East London Foundation NHS Trust
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 staff guidance and regular advice to service users and carers on safeguarding, community safety and police routes for mitigating identified risks.
Verbatim wording from the response “19. In relation to the specific risks relating to this case, the relevant actions are those around risk formulation in terms of identifying risks (as per concern 5). In terms of mitigating identified risks, these should flow from the risk assessment and include the home environment where relevant. In relation to family or carer safety, the appropriate actions will predominantly relate to either safeguarding processes (DASH assessment/ MARAC referral etc) or community safety/police liaison processes. Learning for these is covered in relation to concerns 1, 3 and 4 as per the learning statements.” Source location Response from East London Foundation NHS Trust
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 Train 60 Trust-wide Domestic Abuse Ambassadors in DASH assessment and provide quarterly supervision through Named Professionals.
Verbatim wording from the response “12. Throughout May and June 2026, the Corporate Safeguarding Team has been delivering training for 60 Trust-wide Domestic Abuse Ambassadors. The training sessions aim to upskill operational staff members to act as a local point of expertise on Domestic Abuse best practice, with Named Professionals as the next point of contact for staffing focus. The training focuses on DASH risk assessment as the tool for assessment. All Domestic Abuse Ambassadors will be provided with quarterly supervision delivered by Named Professionals.” Source location Response from East London Foundation NHS Trust
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 Reaffirm and circulate the process for obtaining forensic consultation, including direct referral routes.
Verbatim wording from the response “8. The process for seeking forensic consultation has been re-affirmed and circulated. Very simply, referrals can be made directly to a forensic colleague via their secretary. Where the threshold for review or consultation is met, the forensic consultant will take this forward.” Source location Response from East London Foundation NHS Trust
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 safeguarding case advice and regular safeguarding supervision, including enhanced inpatient safeguarding huddles and supervision.
Verbatim wording from the response “15. Named Professionals for Safeguarding provide case advice to clinicians when requested. Quarterly Safeguarding Supervision is delivered across the Trust. Inpatient mental health services have a fortnightly huddle and 4 weekly supervision with the Corporate Safeguarding Team.” Source location Response from East London Foundation NHS Trust
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 Integrate safeguarding work with Local Authority colleagues through joint case-review and planning forums.
Verbatim wording from the response “14. Since this tragic incident, the Trust’s Newham Mental Health Service has made great efforts to integrate our safeguarding work with Local Authority colleagues through the introduction and bolstering of joint forums where cases are reviewed and plans are agreed.” Source location Response from East London Foundation NHS Trust
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 Circulate Trust-wide expectations for contacting and communicating with police.
Verbatim wording from the response “7. On 21 April 2026 communication was circulated Trust-wide including expectations around contacting the police.” Source location Response from East London Foundation NHS Trust
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 Family and community safety risks should be addressed through safeguarding, community safety pathways or police liaison rather than direct health responses.
Verbatim wording from the response “19. In relation to the specific risks relating to this case, the relevant actions are those around risk formulation in terms of identifying risks (as per concern 5). In terms of mitigating identified risks, these should flow from the risk assessment and include the home environment where relevant. In relation to family or carer safety, the appropriate actions will predominantly relate to either safeguarding processes (DASH assessment/ MARAC referral etc) or community safety/police liaison processes. Learning for these is covered in relation to concerns 1, 3 and 4 as per the learning statements.” Source location Response from East London Foundation NHS Trust
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 Hazard-management advice is not practical or robust for long-term risk management or acutely dangerous situations.
Verbatim wording from the response “20. Other direct health based responses would be focused on treating the underlying mental health condition where this is relevant, as did happen in this case. The Trust might support hazard management advice (eg: locking away sharps) as a temporary measure, perhaps in the context of awaiting court approval for a MHA assessment. However, this would not be practical or robust for either a long-term approach or to manage an acutely dangerous situation. Safeguarding/Community Safety approaches or involving the police would be the approved and expected routes respectively. These are clearly outlined to staff and feature prominently in regular advice to both service users and carers respectively.” Source location Response from East London Foundation NHS Trust
Open published response
5 Mar 2026 Caroline Adeyelu · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Absence of safeguarding referrals for parents at risk of adult child to parent domestic abuse View source Lack of carer support View source Failure to provide prompt direct operational liaison between mental health services and police View source Failure to appreciate risks posed by mentally unwell adult children to parents View source Absence of multi-agency risk assessment and risk management View source Insufficient safeguarding training on adult child to parent domestic abuse View source Lack of home-based risk assessment View source Lack of information gathering from wider family members View source Lack of home visits by the clinical team View source See 6 more concerns
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Meet senior Metropolitan Police Service and NHS leaders to discuss changes and strengthen joint working, including direct liaison, escalation, safeguarding, frontline collaboration, and training.
Stated plannedThe respondent said that this action was planned when they made their response on 9 March 2026. View source
Action
Disseminate updated instructions to clinicians on contacting police and following agreed processes.
Stated completedThe respondent said that this action was complete when they made their response on 9 March 2026. View source
Action
Deliver an intergenerational domestic abuse training session through the annual safeguarding conference.
Stated completedThe respondent said that this action was complete when they made their response on 9 March 2026. View source
Action
Create a monthly liaison meeting between local police and the Tower Hamlets directorate to discuss inpatient and community service concerns.
Stated completedThe respondent said that this action was complete when they made their response on 9 March 2026. View source
Action
Update Tower Hamlets’ admissions checklist to include intergenerational safeguarding concerns.
Stated completedThe respondent said that this action was complete when they made their response on 9 March 2026. View source
Action
Strengthen mandatory Level 3 safeguarding training to address intergenerational domestic abuse, parental vulnerability, and risks to family members.
Stated completedThe respondent said that this action was complete when they made their response on 9 March 2026. View source
Action
Train Tower Hamlets staff on expectations for contacting police after Right Care, Right Person commenced.
Stated completedThe respondent said that this action was complete when they made their response on 9 March 2026. View source See 4 more actions
×
AI-generated summary
Caroline Adeyelu · 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
Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the police.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of safeguarding referrals for parents at risk of adult child to parent domestic abuse
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of carer support
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support ; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prompt direct operational liaison between mental health services and police
Wider context from the report “2. The inquest heard concerns from multiple witnesses about the lack of effective communication systems in place between the mental health services and the Metropolitan Police Service , in circumstances where there are dual forensic and mental health concerns. Whilst there are clearly higher-level meetings that take place between the trusts and the MPS, these do not address the needs of psychiatrists and police officers working on the frontline who are having to address pressing risk issues – both in assessing and in managing risk. Such liaison needs to be prompt – in some cases immediate. Liaison may be from the MPS to the Trust (for example in risk assessing missing persons) or from the trust to the police (for both risk assessment and how to best manage risk). The inquest heard that communication both ways was challenging . The challenges have increased since the introduction of the Right Care, Right Person policy has been introduced. In some cases, communication was not attempted at all , because of the assumption that the appropriate professional was unlikely to be reached. Both trusts and the MPS are asked to consider a process for direct and immediate operational liaison between the police and NHS mental health staff for individuals presenting with a risk of violence compounded by mental ill health.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate risks posed by mentally unwell adult children to parents
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son . This poor appreciation of risk was observed at all levels of clinical staff . Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of multi-agency risk assessment and risk management
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management . It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient safeguarding training on adult child to parent domestic abuse
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case . In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of home-based risk assessment
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment ; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of information gathering from wider family members
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members ; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of home visits by the clinical team
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team ; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Meet senior Metropolitan Police Service and NHS leaders to discuss changes and strengthen joint working, including direct liaison, escalation, safeguarding, frontline collaboration, and training.
Verbatim wording from the response “8. Upon receiving your Regulation 28 report the Trust has reflected on your concerns and agrees that it must continue to improve its communication with the police. This is especially the case as the police force’s dedicated mental health liaison workers have just been disbanded. This, alongside pre-existing limitations in information sharing between the Trust and the police and operational challenges associated with Right Care, Right Person will make joint working more difficult. To this end, on 1 May 2026, the Trust’s Chief Executive Officer, Deputy Chief Executive Officer and Chief Medical Officer will be meeting with the MPS Lead Responsible Officer for Mental Health, other senior MPS officers and North East London NHS Foundation Trust to discuss how to best manage these changes and strengthen integrating working in future. The following items will be considered:” Source location Response from East London Foundation Trust
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 Disseminate updated instructions to clinicians on contacting police and following agreed processes.
Verbatim wording from the response “• Updated communication sent to all clinicians highlighting how to contact police and the agreed processes.” Source location Response from East London Foundation Trust
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 Deliver an intergenerational domestic abuse training session through the annual safeguarding conference.
Verbatim wording from the response “• An intergenerational domestic abuse training session was held virtually at the Trust’s annual safeguarding conference (delivered by the charity Hourglass).” Source location Response from East London Foundation Trust
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 Create a monthly liaison meeting between local police and the Tower Hamlets directorate to discuss inpatient and community service concerns.
Verbatim wording from the response “• Creation of a monthly liaison meeting between the local police and Tower Hamlets directorate to discuss concerns arising across in-patient and community services.” Source location Response from East London Foundation Trust
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 Update Tower Hamlets’ admissions checklist to include intergenerational safeguarding concerns.
Verbatim wording from the response “• Tower Hamlets’ admissions checklist was updated on 23 December 2025 to include intergenerational safeguarding concerns.” Source location Response from East London Foundation Trust
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 Strengthen mandatory Level 3 safeguarding training to address intergenerational domestic abuse, parental vulnerability, and risks to family members.
Verbatim wording from the response “• The Trust’s level three safeguarding training now highlights domestic abuse from children (with or without mental health needs) to parents.” Source location Response from East London Foundation Trust
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 Train Tower Hamlets staff on expectations for contacting police after Right Care, Right Person commenced.
Verbatim wording from the response “• Training of all staff in Tower Hamlets in relation to expectations about contacting the police after Right Care, Right Person commenced.” Source location Response from East London Foundation Trust
Open published response
6 Feb 2026 Mansoor Zaman · Prevention of Future Deaths report East London
View report summary
Concerns raised 11 Failure to reappraise risk to the patient and others in light of erratic behaviour View source Repeated escape from the ward in identical circumstances View source Failure to use the required emergency 999 number for the report View source Failure to adequately document observations and care decisions View source Failure to reassess the frequency and quality of required observations View source Failure of the duty doctor to impose an S.5(2) MHA 1983 authorisation when indicated View source Delays in reporting an absconded patient as missing to the police View source Patient safety investigations failing to seek treating staff recollections View source Inaccurate categorisation of risk as medium after a patient absconds View source Failure to instigate an S.5(4) MHA 1983 authorisation when a patient returns after absconding View source Failure to communicate patient safety investigation findings to treating staff View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mansoor Zaman · 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
Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reappraise risk to the patient and others in light of erratic behaviour
Wider context from the report “3. The failure of Trust staff to reappraise the level of risk presented by Mr Zaman to himself and others in light of his erratic behaviour on 8th December 2024 , specifically,
a. His escape from the ward by violently kicking the fire exit door.
b. His aggression toward the duty doctor during assessment.
c. His assault upon a member of ward staff.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Repeated escape from the ward in identical circumstances
Wider context from the report “4. His second escape from the ward in identical circumstances to the first. The failure of Trust staff to re-assess the frequency and quality of observations that Mr Zaman should be subject to during the afternoon of 8th December 2024.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the required emergency 999 number for the report
Wider context from the report “8. The use of the police 101 number as opposed to the required emergency 999 number to make the report.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately document observations and care decisions
Wider context from the report “2. The failure of nursing staff on the ward to adequately document observations and care decisions.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess the frequency and quality of required observations
Wider context from the report “4. His second escape from the ward in identical circumstances to the first. The failure of Trust staff to re-assess the frequency and quality of observations that Mr Zaman should be subject to during the afternoon of 8th December 2024.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the duty doctor to impose an S.5(2) MHA 1983 authorisation when indicated
Wider context from the report “5. The failure of the duty doctor to act decisively and impose an authorisation under S.5 (2) MHA 1983 having been presented with an agitated patient who had minutes before escaped from the ward.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting an absconded patient as missing to the police
Wider context from the report “6. The dilatory response of staff on the ward to report Mr Zaman as a missing person to the police , an action that did not happen for almost three hours after it was known that he had absconded .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Patient safety investigations failing to seek treating staff recollections
Wider context from the report “9. The inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff , nor communicated the findings of the report to the same staff.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate categorisation of risk as medium after a patient absconds
Wider context from the report “7. The categorisation of the risk presented by Mr Zaman as of a medium level by the nurse in charge when considering action to be taken after he absconded.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to instigate an S.5(4) MHA 1983 authorisation when a patient returns after absconding
Wider context from the report “1. The failure of nurses on the ward to instigate an authorisation under S.5(4) MHA 1983 when Mr Zaman returned to the ward after absconding on the afternoon of 8th December 2024.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patient safety investigation findings to treating staff
Wider context from the report “9. The inadequacy of the Trust patient safety framework investigation which neither sought the recollections of treating staff, nor communicated the findings of the report to the same staff.
” Open source report
Concerns raised 4 Failure to check with the GP whether medication compliance was being maintained View source Withdrawal of medication administration support despite known lack of insight and need for medication compliance View source Absence of an MDT plan to address anti-psychotic depot medication non-concordance View source Failure to adequately address identified risks associated with violent behaviour, lack of insight and medication non-concordance View source See 1 more concern
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Embed depot-medication compliance auditing and weekly monitoring, with findings reported through local and Directorate governance and escalated where required.
Stated completedThe respondent said that this action was complete when they made their response on 8 January 2026. View source
Action
Reinforce medication non-concordance policies and procedures requiring weekly MDT discussion and comprehensive electronic-record documentation of missed depot injections or adherence concerns.
Stated completedThe respondent said that this action was complete when they made their response on 8 January 2026. View source
Action
Train relevant clinical staff to use the NHS Summary Care Record and routinely verify prescription issues and collection when adherence is significant to risk management.
Stated completedThe respondent said that this action was complete when they made their response on 8 January 2026. View source
Action
Formalise MDT risk oversight for medication non-adherence through risk-register inclusion, weekly RAG review, senior multidisciplinary attendance and recording of decisions and responsible clinicians.
Stated completedThe respondent said that this action was complete when they made their response on 8 January 2026. View source
Action
Deliver mandatory risk-assessment and safety-planning training across Community Mental Health Teams, covering disengagement, relapse prevention, escalation, legal frameworks and multi-agency working.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 January 2026. View source
Action
Implement enhanced monitoring and documented risk-management plans when service users with capacity decline medication, including documented consideration of family involvement.
Stated completedThe respondent said that this action was complete when they made their response on 8 January 2026. View source See 3 more actions
×
AI-generated summary
Mohammed Ashraful Islam CHOUDHURY · 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
Mohammed Ashraful Islam CHOUDHURY, aged 26, died at hospital on 11 January 2023 after being attacked and stabbed by another resident at his supported accommodation. The concerns included inadequate management of the other resident’s known risks, lack of a multidisciplinary plan after he stopped taking medication, and withdrawal of medication support without checking with his GP that prescriptions were being obtained.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check with the GP whether medication compliance was being maintained
Wider context from the report “(i) The risks identified in respect of ████████ on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022.
(ii) There was no MDT plan to address the significant development of ████████ non-concordance with his anti-psychotic depot medication from mid-September 2022.
(iii) Despite knowing that ████████ lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any checks made with his GP as to whether he was remaining complaint with this medication (which he was not) .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Withdrawal of medication administration support despite known lack of insight and need for medication compliance
Wider context from the report “(i) The risks identified in respect of ████████ on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022.
(ii) There was no MDT plan to address the significant development of ████████ non-concordance with his anti-psychotic depot medication from mid-September 2022.
(iii) Despite knowing that ████████ lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any checks made with his GP as to whether he was remaining complaint with this medication (which he was not).
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an MDT plan to address anti-psychotic depot medication non-concordance
Wider context from the report “(i) The risks identified in respect of ████████ on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022.
(ii) There was no MDT plan to address the significant development of ████████ non-concordance with his anti-psychotic depot medication from mid-September 2022.
(iii) Despite knowing that ████████ lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any checks made with his GP as to whether he was remaining complaint with this medication (which he was not).
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately address identified risks associated with violent behaviour, lack of insight and medication non-concordance
Wider context from the report “(i) The risks identified in respect of ████████ on his discharge from his second hospital admission in August 2020, which included the fact that his paranoid schizophrenia (unusually) was associated with violent behaviour and that he lacked insight into his mental illness, were not adequately addressed by his mental health provider. This was of particular concern when he became non-concordant with his anti-psychotic depot medication from mid-September 2022.
(ii) There was no MDT plan to address the significant development of ████████ non-concordance with his anti-psychotic depot medication from mid-September 2022.
(iii) Despite knowing that ████████ lacked insight into his mental illness and of the need to ensure that he remained compliant with all medication, the support provided to him with medication administration, in addition to his depot, was withdrawn without there being any checks made with his GP as to whether he was remaining complaint with this medication (which he was not).
” 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 Embed depot-medication compliance auditing and weekly monitoring, with findings reported through local and Directorate governance and escalated where required.
Verbatim wording from the response “An audit cycle has been embedded into routine practice to ensure compliance with these standards. A retrospective review conducted during 2024-2025 examined 275 service users on depot within Luton” Source location Response from East London Foundation Trust
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 Reinforce medication non-concordance policies and procedures requiring weekly MDT discussion and comprehensive electronic-record documentation of missed depot injections or adherence concerns.
Verbatim wording from the response “Response:
The Trust has reviewed and reinforced its operational policy and standard operating procedures regarding medication non-concordance. These now require that missed depot injections or concerns about adherence be formally discussed in the weekly multidisciplinary team (MDT) meeting and documented comprehensively in the electronic patient record.” Source location Response from East London Foundation Trust
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 Train relevant clinical staff to use the NHS Summary Care Record and routinely verify prescription issues and collection when adherence is significant to risk management.
Verbatim wording from the response “Response:
To address this gap, all relevant clinical staff have now been trained to access and use the NHS Summary Care Record (SCR). This enables clinicians to verify prescription issues and collection, thereby reducing reliance solely on self-report. The SCR is now routinely checked, where medication adherence forms a significant component of risk management.” Source location Response from East London Foundation Trust
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 Formalise MDT risk oversight for medication non-adherence through risk-register inclusion, weekly RAG review, senior multidisciplinary attendance and recording of decisions and responsible clinicians.
Verbatim wording from the response “Response:
The MDT has reflected on this learning and strengthened processes accordingly. Where a service user misses a depot injection or demonstrates medication non-adherence, the matter is now formally raised within the weekly MDT and added to the MDT risk register where appropriate. All MDT meetings are attended by the team Consultant, Operational Lead, Depot Clinic Lead, Care Coordinator, Psychologist, Occupational Therapist and wider MDT members. Risk is reviewed, RAG rated, and monitored weekly until resolved or stabilised. Managers and senior clinicians have reiterated the requirement that all discussions, decisions and responsibilities are clearly recorded in the electronic clinical system, including the named clinician responsible for agreed actions.” Source location Response from East London Foundation Trust
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 Deliver mandatory risk-assessment and safety-planning training across Community Mental Health Teams, covering disengagement, relapse prevention, escalation, legal frameworks and multi-agency working.
Verbatim wording from the response “In parallel, risk assessment and safety planning training are being delivered across Community Mental Health Teams. This training strengthens staff skills in formulation-based risk assessment, relapse prevention, recognition of disengagement, and appropriate use of escalation processes, including legal frameworks and multi-agency working. Attendance is mandatory for all CMHT clinical staff.” Source location Response from East London Foundation Trust
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 enhanced monitoring and documented risk-management plans when service users with capacity decline medication, including documented consideration of family involvement.
Verbatim wording from the response “Where a service user with capacity declines medication, enhanced monitoring and documented risk management plans are implemented. If non-compliance persists and risk increases, the case is reviewed to consider the need for a formal Mental Capacity Assessment, involvement of crisis services, or application of Mental Health Act powers where clinically appropriate. Clinicians are also required to have documented discussions regarding family involvement, recognising the important role carers may play in identifying early signs of relapse.” Source location Response from East London Foundation Trust
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 Routine Summary Care Record checks, enhanced monitoring and escalation processes are considered sufficient; no further action is required.
Verbatim wording from the response “Response:
To address this gap, all relevant clinical staff have now been trained to access and use the NHS Summary Care Record (SCR). This enables clinicians to verify prescription issues and collection, thereby reducing reliance solely on self-report. The SCR is now routinely checked, where medication adherence forms a significant component of risk management.” Source location Response from East London Foundation Trust
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 Strengthened medication non-concordance procedures, auditing, monitoring and training are considered sufficient; no further action is required.
Verbatim wording from the response “Response:
The Trust has reviewed and reinforced its operational policy and standard operating procedures regarding medication non-concordance. These now require that missed depot injections or concerns about adherence be formally discussed in the weekly multidisciplinary team (MDT) meeting and documented comprehensively in the electronic patient record.” Source location Response from East London Foundation Trust
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 Weekly MDT review, risk-register oversight, escalation and documented accountability are considered sufficient; no further action is required.
Verbatim wording from the response “Response:
The MDT has reflected on this learning and strengthened processes accordingly. Where a service user misses a depot injection or demonstrates medication non-adherence, the matter is now formally raised within the weekly MDT and added to the MDT risk register where appropriate. All MDT meetings are attended by the team Consultant, Operational Lead, Depot Clinic Lead, Care Coordinator, Psychologist, Occupational Therapist and wider MDT members. Risk is reviewed, RAG rated, and monitored weekly until resolved or stabilised. Managers and senior clinicians have reiterated the requirement that all discussions, decisions and responsibilities are clearly recorded in the electronic clinical system, including the named clinician responsible for agreed actions.” Source location Response from East London Foundation Trust
Open published response
29 Oct 2025 Evan Amon DANDOU-DAMBELLE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to automatically consider significant medication changes when setting mental-health service contact levels View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Evan Amon DANDOU-DAMBELLE · 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
Evan Dandou-Dambelle was at home on the evening of 2 May 2025 while experiencing symptoms of psychosis and command hallucinations. The concerns relate to a change in his mental-health service contact from weekly to fortnightly at the same time that his olanzapine was stopped and risperidone commenced, without the medication change being specifically considered when setting the level of contact. The inquest determined that he died by suicide.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to automatically consider significant medication changes when setting mental-health service contact levels
Wider context from the report “When Mr Dandou-Dambelle was discussed at an ELFT multi disciplinary meeting on 9 April 2025, his level of contact was changed from red (weekly) to amber (fortnightly). This was the last MDT before his death.
This was also the point when the consultant psychiatrist decided to stop his olanzapine that day and commence risperidone, titrating it up gradually. However, the psychiatrist did not suggest that, in deciding the level of contact (red being weekly; amber fortnightly; and green monthly), the medication change was worthy of particular consideration .
Even if the consultant had raised the medication change for particular consideration, the team might still have decided to move Mr Dandou-Dambelle to amber, and even if they had kept him on red, it might not have impacted on the outcome.
However, in deciding level of contact from the mental health services, it does seem worthy of automatic consideration that the patient’s medication has been altered significantly .
” 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 Reinforce the guidance through Operational Lead-led shared learning and scheduled service and team business-meeting discussions and review.
Verbatim wording from the response “I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026.” Source location Response from East London NHS Foundation Trust
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 Include significant medication changes as a factor for multidisciplinary consideration in the Tower Hamlets Early Intervention Service RAG guidance.
Verbatim wording from the response “I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026.” Source location Response from East London NHS Foundation Trust
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 Communicate the learning about significant medication changes to the Tower Hamlets consultant psychiatrist body by email.
Verbatim wording from the response “Since receiving your Regulation 28 report, this learning has already been communicated by email to the Tower Hamlets consultant psychiatrist body, and Clinical Directors in other Trust Directorates have been asked to relay it to their consultant bodies too.” Source location Response from East London NHS Foundation Trust
Open published response
1 Sep 2025 Name not published · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 10 Lack of an effective contingency response to door-locking system failure View source Failure to complete comprehensive patient risk assessments and associated safety documentation View source Failure to complete allocated clinical tasks within the responsible shift View source Failure of clinical governance to respond to escalated serious patient-safety concerns View source Failure to maintain effective 1:1 or within-eyesight observations View source Failure of auditing of nursing and clinical record keeping to produce measurable improvement View source Failure to conduct and record patient observations accurately, sufficiently and therapeutically View source Failure of staff to recognise serious risks to patients View source Delays in consultant review of patients View source Inconsistent staff understanding of risk assessment requirements View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Name not published · 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
████████ was detained under the Mental Health Act and admitted to psychiatric wards at the Tower Hamlets Centre for Mental Health before being found unresponsive in a patient room on 7 June 2022; her death was verified later that day. The jury identified several contributing factors, including a non-functioning door-locking system and shortcomings in patient observations. Further concerns included risk assessment, staff understanding and attitudes towards risk, auditing, and clinical oversight.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective contingency response to door-locking system failure
Wider context from the report “4) The door-locking / ‘fob’ system
This was not working at the time of ████████ death and the jury found this to have been a contributory factor in her death, in that it allowed her access to other patient’s bedrooms. There was evidence to suggest that the system is now working as intended, which is positive. However, the cause for concern is whether there is a sufficient system in place to guide and assist staff in what to do if the door locking system were to fail again . The evidence was that, at the material time, staff were aware that this was an issue that put patients at increased risk; however, there was evidence that staff did not fully appreciate the nature and extent of the increased risk or deploy measures to sufficiently reduce the risk .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete comprehensive patient risk assessments and associated safety documentation
Wider context from the report “5) Risk assessment of patients
The Trust accepted that there were issues in the risk assessment of ████████ in that: what documentation there was stated there were risks but did not fully assess the risks; there was no ‘My Safety Plan’ in place; and ‘Dialog+’ had not completed . At the time, staff said that they had been trained regarding risk assessment and its importance. However, when giving evidence at the inquest, numerous members of staff were vague in their understanding of risk assessment. For example, a senior member of staff said that it was possible to complete the ‘My Safety Plan’ documentation even if a patient did not want to engage with the process, whereas other members of staff were insistent that if a patient doesn’t engage then the document should not be completed.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete allocated clinical tasks within the responsible shift
Wider context from the report “7) Attitudinal concerns
There was a recurrent theme in the evidence provided by nursing and support staff that certain clinical tasks (including, but not limited to, the completion of risk assessment documentation) could simply be left for the next shift to complete. The net result of this was that such tasks were not completed, allowing the risks associated with non-completion to be perpetuated .
The court was told that all shifts (on Rosebank Ward in particular) were busy and staff often did not have time to complete the tasks allocated to them. However, CCTV footage showed, for example, a member of staff (allocated to complete observations and not on a designated break at the material times) checking their mobile telephone and sitting in the lounge reading the newspaper instead of undertaking their clinical role.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical governance to respond to escalated serious patient-safety concerns
Wider context from the report “8) Effective clinical oversight at THCMH
There was clear evidence at the inquest that, following an extended bank holiday weekend period, there was a lack of consultant cover on Rosebank Ward and the male PICU ward, which led to one consultant attempting to cover both wards. This, in itself, is not the concern for the purposes of this report, but it puts the matter into some context.
The consultant that was providing the cover to both wards gave evidence at the inquest, as did other senior nursing staff. The consultant’s own evidence raised questions about their own professional judgment in providing that cover to the wards and assessing the risks. The evidence of a senior nurse was that specific concerns had previously been raised about the consultant in question, including that consultant not being a “very responsive consultant” and there having been “a pattern” with this consultant not reviewing patients in a timely manner. The court was told that those concerns had previously been raised with the Trust’s Clinical Director and Associate Clinical Director and, despite this, no discernible change had been noted. The Trust’s response to this during the inquest was to say that the consultant in question no longer works for the Trust and therefore the risk has been addressed. In my opinion, this is a misunderstanding of the risk. I consider that the risk is that senior nursing staff raised a serious issue with very senior (director level) clinicians about a pattern of issues creating risk to patients (some relating to other patient deaths and / or other serious untoward incidents) and little, if any, evidence was provided about how the Trust dealt with this serious issue from a clinical governance and oversight point of view . As such, the concern remains.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain effective 1:1 or within-eyesight observations
Wider context from the report “2) 1:1 or ‘within eyesight’ Observations
The CCTV footage played at inquest showed a member of staff who was allocated to ‘within eyesight’ observations of another patient sat on the back of a chair (with their back facing the patient’s bedroom door) and engaged on their mobile telephone . That member of staff initially told the court that they were conducting the ‘within eyesight’ observations correctly and could see the patient in question. This raises significant concern, not only about the quality of 1:1 observation but also about staff attitudes and approach to observations that are integral to keeping patients safe (see below at para 7)).
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of auditing of nursing and clinical record keeping to produce measurable improvement
Wider context from the report “3) Auditing of record keeping
The Trust’s evidence regarding auditing nursing / clinical records provided little, if any, reassurance that the system in place is bringing about a truly measurable or meaningful change .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct and record patient observations accurately, sufficiently and therapeutically
Wider context from the report “1) Patient Observations (generally)
I am aware that, prior to ████████ final admission under the care of the Trust in 2022, other concerns had been raised by a coroner regarding patient observations within the Trust. Those concerns were first raised in 2021 (following a patient death in 2018). Concerns included the quality of observations and the falsification of observations. Despite assurances from the Trust in numerous action plans since, the evidence in this inquest revealed widespread concerns across two wards at THCMH (Brick Lane Ward and Rosebank Ward) about observations that were carried out. Such concerns included: the level of detail in observation records not meeting the expectations of the Trust’s own policy; the accuracy of timing’s in some observations was questionable; observations were often not used as a tool to aid therapeutic engagement with patients; and some observations were inaccurate or possibly falsified .
The evidence received and heard during the inquest did not reassure me that this matter has been adequately addressed. Given the importance of observations in keeping patients safe, I remain concerned that significant risks remain.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to recognise serious risks to patients
Wider context from the report “6) Understanding of risk
Some Trust witnesses who gave evidence appeared to lack an appreciable understanding of what could constitute serious risks to patients . In some instances, this seemed to go beyond possible training issues and raised potential questions about suitability for being in a caring role.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in consultant review of patients
Wider context from the report “8) Effective clinical oversight at THCMH
There was clear evidence at the inquest that, following an extended bank holiday weekend period, there was a lack of consultant cover on Rosebank Ward and the male PICU ward, which led to one consultant attempting to cover both wards. This, in itself, is not the concern for the purposes of this report, but it puts the matter into some context.
The consultant that was providing the cover to both wards gave evidence at the inquest, as did other senior nursing staff. The consultant’s own evidence raised questions about their own professional judgment in providing that cover to the wards and assessing the risks. The evidence of a senior nurse was that specific concerns had previously been raised about the consultant in question, including that consultant not being a “very responsive consultant” and there having been “a pattern” with this consultant not reviewing patients in a timely manner . The court was told that those concerns had previously been raised with the Trust’s Clinical Director and Associate Clinical Director and, despite this, no discernible change had been noted . The Trust’s response to this during the inquest was to say that the consultant in question no longer works for the Trust and therefore the risk has been addressed. In my opinion, this is a misunderstanding of the risk. I consider that the risk is that senior nursing staff raised a serious issue with very senior (director level) clinicians about a pattern of issues creating risk to patients (some relating to other patient deaths and / or other serious untoward incidents) and little, if any, evidence was provided about how the Trust dealt with this serious issue from a clinical governance and oversight point of view. As such, the concern remains.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent staff understanding of risk assessment requirements
Wider context from the report “5) Risk assessment of patients
The Trust accepted that there were issues in the risk assessment of ████████ in that: what documentation there was stated there were risks but did not fully assess the risks; there was no ‘My Safety Plan’ in place; and ‘Dialog+’ had not completed. At the time, staff said that they had been trained regarding risk assessment and its importance. However, when giving evidence at the inquest, numerous members of staff were vague in their understanding of risk assessment . For example, a senior member of staff said that it was possible to complete the ‘My Safety Plan’ documentation even if a patient did not want to engage with the process, whereas other members of staff were insistent that if a patient doesn’t engage then the document should not be completed .
” 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 Provide monthly Dialog+, My Safety Plan and risk-assessment training for staff.
Verbatim wording from the response “There is a rolling programme of monthly Dialog+, my safety plan and risk assessment training for staff, with each member of staff completing this as a one-off.” Source location Response from East London NHS Foundation Trust
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 Use daily unit huddles to report new admissions and monitor completion of initial assessments and care planning.
Verbatim wording from the response “The daily unit huddle meeting in the Tower Hamlets Center for Mental Health requires ward managers to feedback on each new admission and the completion of their initial assessments and care planning. This is monitored until it is reported that all tasks have been completed. There is a record kept of this.” Source location Response from East London NHS Foundation Trust
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 Use board relays to improve observation practices and therapeutic engagement.
Verbatim wording from the response “I would like to draw your attention to an article published in the International Journal for Quality in Healthcare shortly after ████████ inquest took place, where the results of some of the Trust’s interventions to improve observation practices have been quantified. Observation completion and therapeutic engagement were shown to have improved following the introduction of zonal observations, a board relay, and life skills activities led by recovery workers. Sustained improvements were seen in all 10 measures used in this work, as evidenced by shifts in statistical process control charts. General observation completion increased by 1.2% (to 99.57%), and intermittent observation completion rose by 1.9% (to 98.25%). Incidents of physical violence were reduced by 23%, verbal aggression by 38% and racial aggression by 60%.” Source location Response from East London NHS Foundation Trust
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 a longer electronic training package for the nurse-in-charge role.
Verbatim wording from the response “All qualified nursing staff are undergoing brief initial training around the role of the nurse in charge which includes allocation of outstanding tasks (assessments, care plans etc) and monitoring the completion of these. A longer electronic training package is being developed. This has already been completed in Tower Hamlets.” Source location Response from East London NHS Foundation Trust
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 Introduce CCTV auditing of recorded observations after completing staff training on footage access.
Verbatim wording from the response “The Trust is moving towards using CCTV to objectively audit whether observations have been made as recorded. This is anticipated to commence in January 2026 to allow for staff training to download and access CCTV footage.” Source location Response from East London NHS Foundation Trust
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 Deliver shared learning to unit staff on mobile-phone use while on duty.
Verbatim wording from the response “The member of staff in question has had their knowledge refreshed about the expectations of the Trust’s observations policy and the Trust’s mobile phone policy. The latter was updated in 2024 to include material on staff use of mobile phones, making it clear that they are not allowed in clinical areas unless there is an exceptional reason agreed with a local manager. There has been shared learning with all staff across the unit on the use of mobile phones whilst on duty, in 2024.” Source location Response from East London NHS Foundation Trust
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 Update mobile-phone policy requirements for staff working in clinical areas.
Verbatim wording from the response “The member of staff in question has had their knowledge refreshed about the expectations of the Trust’s observations policy and the Trust’s mobile phone policy. The latter was updated in 2024 to include material on staff use of mobile phones, making it clear that they are not allowed in clinical areas unless there is an exceptional reason agreed with a local manager. There has been shared learning with all staff across the unit on the use of mobile phones whilst on duty, in 2024.” Source location Response from East London NHS Foundation Trust
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 Require completion and review of Dialog+ and My Safety Plan documentation within 72 hours of admission, including weekly case-note audits.
Verbatim wording from the response “In terms of the Trust’s expectations regarding whether staff should commence the My Safety Plan and Dialog+ documents in the absence of patient engagement, staff are expected to complete the Dialog+ and My Safety Plan within 72 hours of admission; where patients are not able to engage in this process staff will revisit and obtain their input. Staff are also encouraged to obtain collateral information from family, friends and carers. There are weekly case note audits to look at the quality of dialog+ including patients’ views, which provides opportunities for clarity of processes and expectations related to this documentation to be reinforced.” Source location Response from East London NHS Foundation Trust
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 Use a standardised handover template to identify and allocate outstanding nursing and medical tasks, with senior nursing oversight.
Verbatim wording from the response “A standardised handover template has been introduced which facilitates the identification of outstanding nursing and medical tasks to be allocated. The lead nurse and matrons are attending nursing handovers to monitor and embed this practice.” Source location Response from East London NHS Foundation Trust
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 Review ward locking systems through safety huddles, escalate faults to Estates, and brief staff on door-closing procedures during failures.
Verbatim wording from the response “The ward environment - including the locking systems / fobs - has been added as an agenda item onto Ward Safety Huddles. A representative of the Trust Estates team normally attends these huddles and any issues with the system can be escalated directly to them. In the event of failure, staff are briefed to proactively close doors themselves and encourage patients to close their own doors. I understand that there has been an occasion since ████████ death when a malfunction has been successfully rectified in the space of a single day, indicating that the revised system is working effectively.” Source location Response from East London NHS Foundation Trust
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 Train qualified nursing staff in nurse-in-charge responsibilities, including allocation and monitoring of outstanding tasks.
Verbatim wording from the response “All qualified nursing staff are undergoing brief initial training around the role of the nurse in charge which includes allocation of outstanding tasks (assessments, care plans etc) and monitoring the completion of these. A longer electronic training package is being developed. This has already been completed in Tower Hamlets.” Source location Response from East London NHS Foundation Trust
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 No further action is considered necessary because considerable work has addressed the identified concerns.
Verbatim wording from the response “I have addressed these in turn below. Please note that in respect of Concerns 2, 4, 5, 6, 7 and 8 the Trust entirely acknowledges the reasons for your concerns and has considered them extremely” Source location Response from East London NHS Foundation Trust
Open published response
28 Oct 2024 Kashim ALI · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to escalate National Early Warning Scores for review View source Failure to maintain continuous sight of patients during one-to-one observations View source Inaccurate record-keeping of patient observations View source
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Standardise the nursing handover process across Tower Hamlets to communicate patient risks and physical-health observation requirements.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Update the mobile phone policy to prohibit personal mobile phone use during clinical shifts.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Roll out the standardised nursing handover process across the Trust’s other directorates.
Stated plannedThe respondent said that this action was planned when they made their response on 1 November 2024. View source
Action
Introduce a Nurse in Charge training tool requiring confirmation that NEWS2 monitoring and escalation responsibilities have been understood.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Increase lead Nurse or Matron night-shift visits to twice monthly for three months and observe compliance with clinical standards and the mobile phone policy.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Amend daily ward spot-check audits to review observation records, documentation timeliness, completeness, accuracy, and actions taken in response to patient deterioration.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Continue reviewing and enhancing record-keeping and auditing processes.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2024. View source
Action
Require all inpatient nursing staff to complete a mandatory two-day physical health and NEWS2 training course.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Introduce the updated Observations and Therapeutic Engagement Policy, including documentation standards, missed-observation procedures, improvement ideas, and Honesty in Documentation training.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Generate a daily NEWS2 report identifying scores of three or above, review ward responses and escalation, and record the process for audit.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Continue reinforcing record-keeping standards through regular audits, continuous training, and checks of timely, accurate, and complete documentation.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2024. View source
Action
Include NEWS2 escalation training in the annual mandatory online programme and monitor completion.
Stated completedThe respondent said that this action was complete when they made their response on 1 November 2024. View source
Action
Introduce an e-observations system linking observation care plans to records, time-stamping entries, and requiring documentation of observation-level changes and escalation decisions.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 November 2024. View source See 10 more actions
×
AI-generated summary
Kashim ALI · 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
Kashim Ali was detained under section 3 of the Mental Health Act 1983 at Mile End Hospital and died on 21 May 2024 after being found unresponsive in bed; attempts at resuscitation were unsuccessful. The concerns identified included failures to escalate NEWS2 scores, shortcomings in one-to-one observation practices, and inaccurate observation records, which were considered to create risks to patient safety and future patients.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate National Early Warning Scores for review
Wider context from the report “1) Any National Early Warning Score (‘NEWS2’) should always be escalated . However, during Mr Ali’s time on Millharbour Ward he achieved a NEWS2 score on more than one occasion, which was not escalated to the nurse in charge for review .
While this was not a causative factor in Mr Ali’s death, I consider that it creates significant risk for other patients in future, if not addressed.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuous sight of patients during one-to-one observations
Wider context from the report “2) During part of his on Millharbour Ward, Mr Ali was on one-to-one observations, requiring him to always be within the sight of a dedicated member of staff . Following Mr Ali’s death, it transpired that during this period of observations, designated members of staff were noted to preoccupied with the use of their personal mobile telephones at times , and on one occasion, the designated member of staff was sat on a chair with their back to Mr Ali’s door .
While this was not a causative factor in Mr Ali’s death, I consider that such practices undermine patient safety and would place future patients at considerable risk.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate record-keeping of patient observations
Wider context from the report “3) The Trust noted, during its own serious incident investigation, that the quality of record keeping in relation to Mr Ali’s observations was not always accurate . Given the key role that accurate record-keeping plays in patient care within any healthcare setting , I formed the view that this also creates significant risk.
” 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 Standardise the nursing handover process across Tower Hamlets to communicate patient risks and physical-health observation requirements.
Verbatim wording from the response “8. The nursing handover process has been standardised in Tower Hamlets and is set to be rolled out across other directorates in the Trust to ensure that the care needs and risks for each patient are clearly communicated at the start of each shift. This includes a thorough review of physical health issues, with a particular emphasis on the frequency and appropriateness of physical health observations, including NEWS2 scores. The handover is designed to ensure that all staff are aware of the specific needs of each patient, including any concerns related to their vital signs or deterioration.” Source location Response from East London NHS Foundation Trust
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 Update the mobile phone policy to prohibit personal mobile phone use during clinical shifts.
Verbatim wording from the response “14. We recognise that the inappropriate use of personal mobile phones by staff during clinical shifts can be detrimental to patient safety and the quality of care. In response to this concern, the Trust has reviewed and updated its mobile phone policy to establish clear guidelines on the acceptable use of personal phones within clinical settings, with the effect that staff are completely prohibited from using personal mobile phones during shifts. This policy is designed to ensure that staff remain fully engaged with their patients and the clinical environment, minimising distractions and maintaining focus on patient care.” Source location Response from East London NHS Foundation Trust
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 Roll out the standardised nursing handover process across the Trust’s other directorates.
Verbatim wording from the response “8. The nursing handover process has been standardised in Tower Hamlets and is set to be rolled out across other directorates in the Trust to ensure that the care needs and risks for each patient are clearly communicated at the start of each shift. This includes a thorough review of physical health issues, with a particular emphasis on the frequency and appropriateness of physical health observations, including NEWS2 scores. The handover is designed to ensure that all staff are aware of the specific needs of each patient, including any concerns related to their vital signs or deterioration.” Source location Response from East London NHS Foundation Trust
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 Introduce a Nurse in Charge training tool requiring confirmation that NEWS2 monitoring and escalation responsibilities have been understood.
Verbatim wording from the response “11. As part of the directorate’s inpatient unit’s new handover process, there is now a specific training tool for the Nurse in Charge, which covers the importance of monitoring and escalating physical health observations, including NEWS2 scores. Section 11 of this tool directly addresses the importance of overseeing physical health observations and ensuring they are carried out and acted upon. Each Nurse in Charge is required to confirm they have reviewed and understood this process, ensuring that they are fully aware of their responsibilities in managing and escalating NEWS2 scores.” Source location Response from East London NHS Foundation Trust
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 Increase lead Nurse or Matron night-shift visits to twice monthly for three months and observe compliance with clinical standards and the mobile phone policy.
Verbatim wording from the response “15. To further ensure that these issues are being addressed at the local level, the frequency of visits by a lead Nurse or a Matron on night shifts has been increased to twice a month from once a month for three months. These visits are focused on maintaining high standards of care and ensuring that all clinical practices, including the monitoring of physical health observations, are being consistently followed. As part of these visits, any use of mobile phones by staff is specifically observed to ensure compliance with the updated policy. These increased visits are also an opportunity to address any concerns directly with staff and to reinforce the Trust’s expectations regarding clinical standards.” Source location Response from East London NHS Foundation Trust
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 Amend daily ward spot-check audits to review observation records, documentation timeliness, completeness, accuracy, and actions taken in response to patient deterioration.
Verbatim wording from the response “18. In response to the concerns raised, the Directorate has amended the daily spot check audit process on all wards, including Millharbour Ward, to ensure that the quality of patient records is closely monitored. The daily spot check now specifically includes a detailed review of the records kept during patient observations, including physical health observations and any clinical actions taken in response to changes in a patient’s condition. This enhancement to the audit process is designed to ensure that any gaps or inaccuracies in record-keeping are identified early and addressed promptly.” Source location Response from East London NHS Foundation Trust
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 Continue reviewing and enhancing record-keeping and auditing processes.
Verbatim wording from the response “23. The Trust will continue to review and enhance its processes for record-keeping and auditing as part of our ongoing commitment to improving the quality of care we provide. By ensuring that all documentation is accurate and up to date, we can better support clinical decision-making, improve patient outcomes, and ensure that our practices remain aligned with the highest standards of care.” Source location Response from East London NHS Foundation Trust
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 Require all inpatient nursing staff to complete a mandatory two-day physical health and NEWS2 training course.
Verbatim wording from the response “6. All in-patient nursing staff across the Trust are now required to attend a two-day physical health training course. This course includes comprehensive instruction on NEWS2, its significance, and the appropriate escalation procedures. This training is mandatory and forms part of the Trust’s ongoing commitment to ensure that inpatient clinical staff have the knowledge and skills required to respond effectively to physical health concerns.” Source location Response from East London NHS Foundation Trust
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 Introduce the updated Observations and Therapeutic Engagement Policy, including documentation standards, missed-observation procedures, improvement ideas, and Honesty in Documentation training.
Verbatim wording from the response “Updated Observations and Therapeutic Engagement Policy” Source location Response from East London NHS Foundation Trust
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 Generate a daily NEWS2 report identifying scores of three or above, review ward responses and escalation, and record the process for audit.
Verbatim wording from the response “10. A further safeguard is in place with the directorate’s inpatient unit’s midday huddle, where a report is generated from the RIO system to identify any patient who has a NEWS2 score of 3 or above (3 or above being the level that requires escalation) within the previous 24 hours. If such a score is identified, the ward teams’ interventions and escalation process are reviewed to ensure that appropriate actions have been taken. This process is recorded for audit purposes and provides a clear trail to confirm that physical health concerns have been addressed.” Source location Response from East London NHS Foundation Trust
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 Continue reinforcing record-keeping standards through regular audits, continuous training, and checks of timely, accurate, and complete documentation.
Verbatim wording from the response “22. The Trust recognises that accurate record-keeping is not only crucial for the continuity of care but also for accountability and auditing purposes. As such, the Trust is committed to reinforcing these standards through regular audits, continuous training, and a robust system of checks to ensure that patient records are always completed in a timely, accurate, and thorough manner.” Source location Response from East London NHS Foundation Trust
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 Include NEWS2 escalation training in the annual mandatory online programme and monitor completion.
Verbatim wording from the response “7. In addition to the initial physical health training, NEWS2 training is also included in the Trust’s annual mandatory online training programme. This ensures that all inpatient nursing staff are refreshed on the key aspects of NEWS2, including recognising deteriorating physical health and the correct process for escalating concerns to senior staff. Completion of this training is monitored.” Source location Response from East London NHS Foundation Trust
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 Introduce an e-observations system linking observation care plans to records, time-stamping entries, and requiring documentation of observation-level changes and escalation decisions.
Verbatim wording from the response “17. As the Trust PSII set out, work is progressing on introducing an e-observations system which will prompt staff to enter both their observations and engagement with the patient (rather than just the location of the patient), and this will be time-stamped. On the app each patient’s observation care plan will be linked to their record of observation. This ensures continuity of care. Any reviews in level of observations will require an entry to be made verifying the escalation and decision making process.” Source location Response from East London NHS Foundation Trust
Open published response
12 Aug 2024 Nimo OSMAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 8 Failure of nursing staff to call ambulances without prior senior clinician approval View source Failure to complete VTE risk assessments on admission to the in-patient unit View source Delays in recognising that patients are unrousable View source Ambiguity in the venous thromboembolism policy View source Failure to activate the emergency alarm system to summon the rapid response team promptly View source Failure to consider physical illness as an explanation for patients’ behaviour View source Venous thromboembolism policy failing to align with NICE guidelines View source Delays in calling emergency ambulances View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nimo OSMAN · 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
Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to call ambulances without prior senior clinician approval
Wider context from the report “Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner.
The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events.
I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital.
I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future.
However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition . Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician . Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’.
While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete VTE risk assessments on admission to the in-patient unit
Wider context from the report “I heard evidence from Nurse A, in the absence of the jury, about East London NHS Foundation Trust’s ‘Patient Safety Serious Incident Review Report’ (the SI Report). I was taken through the detailed ‘Action Plan’ that was devised as a result of the various ‘service delivery problems’ (SDP), ‘care delivery problems’ (CDP), and ‘additional lessons learned’ (ALL) that were identified as a result of the SI Report.
Not all of the SDPs, CDPs or ALLs are of such seriousness that I consider that they create a risk of future deaths unless action is taken. However, some of them do, in my opinion, reach that threshold.
While the evidence of Nurse A and the accompanying Action Plan did provide prima facie reassurance that action has been taken, the evidence of Nurse B (who, as previously stated is relatively senior and experienced) has significantly undermined what I heard from Nurse A. The undermining of that evidence and reassurance from Nurse A, leads me to conclude that there is, at the very least, a realistic possibility that the learning and apparent changes put in place have not necessarily been fully embedded with all relevant personnel within East London NHS Foundation Trust. As such those concerns and risks persist.
For this reason, I consider that further reassurance is required in relation to the following matters of concern:
(a) CDP2 – ‘Staff should consider whether patients’ behaviour might be due to being physically unwell and not assume that this is due to their mental health condition.’ This concern relates, in part to the delay in calling for an ambulance (as per (1) above), but in my view it also has potentially wider implications for other patients.
(b) CDP3 – ‘As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit. ’ While in Ms Osman’s case the expert evidence from a consultant histopathologist was that pulmonary thromboembolism was not a causative factor in her death, I consider that this matter does raise potentially significant risks for other patients .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising that patients are unrousable
Wider context from the report “Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable . A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner.
The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events.
I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital.
I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future.
However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’.
While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in the venous thromboembolism policy
Wider context from the report “With regard to the East London NHS Foundation Trust’s policy in relation to Venous Thromboembolism, I noted during the course of the evidence that this appeared to possibly conflict with NICE guidelines in some respects. There also appeared to be aspects of the policy that were ambiguous and open to different interpretations . I was told the policy remains in force and unchanged. The concern here is that possible ambiguity may lead to a non-universal interpretation of the policy, thereby putting patients at risk .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to activate the emergency alarm system to summon the rapid response team promptly
Wider context from the report “Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner .
The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called. I also viewed the CCTV evidence covering this course of events.
I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk, if repeated in the case of another patient requiring emergency treatment at hospital.
I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future.
However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’.
While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider physical illness as an explanation for patients’ behaviour
Wider context from the report “I heard evidence from Nurse A, in the absence of the jury, about East London NHS Foundation Trust’s ‘Patient Safety Serious Incident Review Report’ (the SI Report). I was taken through the detailed ‘Action Plan’ that was devised as a result of the various ‘service delivery problems’ (SDP), ‘care delivery problems’ (CDP), and ‘additional lessons learned’ (ALL) that were identified as a result of the SI Report.
Not all of the SDPs, CDPs or ALLs are of such seriousness that I consider that they create a risk of future deaths unless action is taken. However, some of them do, in my opinion, reach that threshold.
While the evidence of Nurse A and the accompanying Action Plan did provide prima facie reassurance that action has been taken, the evidence of Nurse B (who, as previously stated is relatively senior and experienced) has significantly undermined what I heard from Nurse A. The undermining of that evidence and reassurance from Nurse A, leads me to conclude that there is, at the very least, a realistic possibility that the learning and apparent changes put in place have not necessarily been fully embedded with all relevant personnel within East London NHS Foundation Trust. As such those concerns and risks persist.
For this reason, I consider that further reassurance is required in relation to the following matters of concern:
(a) CDP2 – ‘Staff should consider whether patients’ behaviour might be due to being physically unwell and not assume that this is due to their mental health condition. ’ This concern relates, in part to the delay in calling for an ambulance (as per (1) above), but in my view it also has potentially wider implications for other patients .
(b) CDP3 – ‘As per Physical Healthcare Policy, v.14.1, Feb 2021, 7.6, all patients should have a VTE risk assessment form completed and a VTE assessment on admission to the in-patient unit.’ While in Ms Osman’s case the expert evidence from a consultant histopathologist was that pulmonary thromboembolism was not a causative factor in her death, I consider that this matter does raise potentially significant risks for other patients.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Venous thromboembolism policy failing to align with NICE guidelines
Wider context from the report “With regard to the East London NHS Foundation Trust’s policy in relation to Venous Thromboembolism, I noted during the course of the evidence that this appeared to possibly conflict with NICE guidelines in some respects . There also appeared to be aspects of the policy that were ambiguous and open to different interpretations. I was told the policy remains in force and unchanged. The concern here is that possible ambiguity may lead to a non-universal interpretation of the policy, thereby putting patients at risk.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in calling emergency ambulances
Wider context from the report “Following the discovery of Ms Osman’s collapse on Rosebank Ward on 21 April 2022, it took staff a significant number of minutes to recognise that instead of just lying on the floor, Ms Osman was actually unrousable. A few minutes later a nurse arrived on the scene, who decided to summon the duty senior nurse (DSN) by radio, rather than activating the alarm system, which would have summoned the rapid response team sooner.
The DSN contacted the duty doctor to inform them that there was a medical emergency, prior to calling an ambulance. In total, Ms Osman had been on the floor and unresponsive for over half an hour before an ambulance was called . I also viewed the CCTV evidence covering this course of events.
I heard evidence from a consultant neurosurgeon and a consultant neuroradiologist. Their evidence was such that, in Ms Osman’s case this delay would not have made a difference because she had suffered a catastrophic brain injury and her condition was likely to have been unsalvageable from the moment she was found unresponsive on the floor. However, I consider that a delay of circa 30 minutes in calling an emergency ambulance raises a considerable risk , if repeated in the case of another patient requiring emergency treatment at hospital.
I was initially reassured by the evidence of a very senior member of nursing staff (Nurse A) about the work that has been done to educate all staff that anyone can call 999 for an ambulance if they consider it necessary, without seeking the advice of colleagues or the specific approval of a doctor. I was told by Nurse A that they were confident that the education and training undertaken with staff had had a positive impact and that a delay of this kind was unlikely to be repeated in the future.
However, a senior nurse (Nurse B) who was on duty at the time of Ms Osman’s collapse told me in their evidence (over two years after Ms Osman’s death) that nursing staff cannot and would not call an ambulance of their own volition. Nurse B told me that she would only ever call an ambulance if told to do so by a more senior clinician. Nurse B went on to tell me that it was often the case that by the time an ambulance had been called and arrived, a patient would die; the manner in which this evidence was given led me to form the view that the Nurse B seemed to think that this was ‘just one of those things that happens’.
While I was told by Nurse A (who seemed genuinely concerned) that this matter would be escalated and addressed, I was concerned that over two years since Ms Osman’s death this view was still held by a senior and experienced member of the nursing team who led a team of more junior nurses. My concern was such that I am not reassured that sufficient steps have been taken to prevent the recurrence of such a risk in the future.
” 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 Add a mandatory VTE-risk screening question to the Observations and Measurements form, preventing electronic-record completion until answered.
Verbatim wording from the response “12. Since August 2024, the nurses’ Observations and Measurements form incorporates a screening question for VTE risk. It is a mandatory box to complete on the form and cannot be saved on RiO (the Trust’s electronic record system) until the question has been responded to.” Source location Response from East London Foundation Trust
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 Disseminate to nursing staff that emergency services may be called without senior permission and physical health may contribute to behaviour.
Verbatim wording from the response “6. This matter was also brought up with all the Lead Nurses at the Trust shortly after the inquest to ensure that the message that ‘permission from senior staff is NOT required to call emergency services’ was disseminated to all nursing staff. As a reminder, this was followed up at the Lead Nurses meeting on 28 August 2024.” Source location Response from East London Foundation Trust
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 Reinforce the importance of completing VTE assessments through staff communications.
Verbatim wording from the response “10. I understand that the BLN’s oral evidence was that VTE assessments form part of the two-day physical health training outlined in paragraph 8 above. Additionally, both the BLN and Clinical Director for Tower Hamlets circulated an email in January 2023 about the importance of undertaking VTE assessments. This was resent on 1 October 2024 to ensure that staff remain aware of the importance of these assessments.” Source location Response from East London Foundation Trust
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 Remove unclear VTE assessment information from the Physical Healthcare Policy and publish an update directing staff to the VTE policy.
Verbatim wording from the response “the Physical Healthcare Policy is not clearly set out. Therefore, the VTE information has been removed from the aforementioned policy in a soon to be published update and it has been made clear that the VTE policy is the appropriate reference. The changes to the Physical Healthcare Policy are expected to be agreed through the Physical Health in Mental Health Committee in November 2024.” Source location Response from East London Foundation Trust
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 Deliver mandatory physical-health training for Tower Hamlets inpatient nursing staff and social therapists, including recognition of physical causes of concerning behaviour.
Verbatim wording from the response “8. It is important that all staff are aware of the impact that physical health as well as mental health can have on a service user’s behaviour. As outlined in the BLN’s oral evidence, to ensure this information is embedded, all Tower Hamlets in-patient nursing staff and social therapists undertake a mandatory two-day physical health training course. It includes content on service users presenting as unwell and whether this may be related to their mental or physical health. This course started on 03 May 2023 and is delivered regularly. Further training courses will take place on:” Source location Response from East London Foundation Trust
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 Complete refresher Intermediate Life Support training for the nurse involved.
Verbatim wording from the response “5. I can confirm, that at the time of Ms Osman’s death and at the inquest, Nurse B’s Intermediate Life Support (ILS) training was up to date. This training is clear in highlighting the expectations of a staff member attending a medical emergency. These expectations include that the staff member will undertake an initial check of the service user, summons help internally, and ensure an ambulance is called. No permission is required from a senior staff member. Following the inquest, the BLN spoke to Nurse B and Nurse B confirmed that she recognised the need for escalation immediately in medical emergencies as opposed to waiting for senior input. The BLN and Nurse B agreed that Nurse B will complete refresher ILS training. In the meantime, Nurse B has also completed a reflective piece in relation to this matter.” Source location Response from East London Foundation Trust
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 Review admissions daily or during weekend huddles to confirm VTE risk assessments, and audit those assessments fortnightly.
Verbatim wording from the response “11. Additionally, all service user admissions are reviewed every morning between Monday-Friday. The Ward Manager or Matron in attendance confirms that a VTE risk assessment is completed. During the weekend and bank holidays, the weekend huddle will consider any admissions and a doctor clerks the patients in. These assessments are audited bi-weekly as part of the service’s physical health assessment audits.” Source location Response from East London Foundation Trust
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 Introduce simulations addressing whether clinical concerns are physical-health or mental-health related.
Verbatim wording from the response “9. Additionally, Tower Hamlets clinical staff already engage in once weekly emergency scenarios that include when it is appropriate to call 999. By30 November 2025 simulations will take place which include considerations whether something is a physical health verse mental health concern.” Source location Response from East London Foundation Trust
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 Nursing staff do not require senior permission to call emergency services; this is not agreed Trust practice.
Verbatim wording from the response “4. I share your concerns that one of the Trust’s nurses was under the impression that an ambulance could only be called if under the instruction of a more senior nurse. This is” Source location Response from East London Foundation Trust
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 The separate VTE policy is unambiguous and aligned with NICE guidelines, although VTE information in the Physical Healthcare Policy is unclear.
Verbatim wording from the response “13. It has come to my attention that the inquest only considered the VTE assessment information as provided in the Trust’s Physical Healthcare Policy v.14.1, February 2021. The Trust has a more recent and separate Venous Thromboembolism (VTE) Reducing Risk policy v. 3, March 2023. The information in the VTE policy is unambiguous and in-line with NICE guidelines. It is accepted that the VTE assessment information contained in” Source location Response from East London Foundation Trust
Open published response
22 Jul 2024 Omar Abdi Ahmed · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure of district nursing staff to identify risks when patients disengage from treatment View source Failure to challenge refusal to use central heating View source Under-resourcing of the district nursing team View source Failure of domiciliary care to provide essential cleaning, personal care and meal support View source Failure of communication between care providers and public services to identify deterioration in living conditions and health View source Failure to challenge unsafe budgeting decisions affecting access to food and cleaning materials View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Omar Abdi Ahmed · 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
Omar Abdi Ahmed, who had significant comorbidity and bilateral lower-limb amputations, was found unresponsive and severely hypothermic at home on 15 November 2023 after receiving domiciliary and district nursing care. He died in hospital on 20 November 2023; the inquest concluded that hypothermia, with pneumonia and ischaemic heart disease contributing, was the medical cause of death. Concerns included poor communication between care organisations, shortcomings in district nursing oversight, and domiciliary care arrangements that did not adequately address his personal care, nutrition, cleaning, and heating needs.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of district nursing staff to identify risks when patients disengage from treatment
Wider context from the report “2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge refusal to use central heating
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating , a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death .
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of the district nursing team
Wider context from the report “2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of domiciliary care to provide essential cleaning, personal care and meal support
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between care providers and public services to identify deterioration in living conditions and health
Wider context from the report “1. Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr Ahmed’s living conditions and health .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to challenge unsafe budgeting decisions affecting access to food and cleaning materials
Wider context from the report “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged , this led to a lack of nutritious food and cleaning materials in his home . Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.
Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.
” 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 Meet with Newham safeguarding teams to review current pathways and organisational interfaces for improving communication about high-risk service users.
Verbatim wording from the response “7. Since the receipt of the Report, two meetings have taken place between the Trust’s Director of Nursing, Community Health Service’s Medical Director and LBN’s Senior Safeguarding Adviser and Interim Service Manager for Access to Adult Social Care and hospital discharge. It was explored how to further improve escalation and communication between the services in relation to high risk service groups. The outcome of both of these meetings is that both the Trust and LBN’s teams will meet in October 2024 to review the current pathways and organisational interface to ensure better communication relating to patient care.” Source location Response from ELFT
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 Review the process for responding to high-risk service-user concerns with Trust staff, reinforcing responsibilities to arrange multi-agency professionals’ meetings.
Verbatim wording from the response “8. Communication between domiciliary care providers and Community Health Newham (the Trust) is done on an individual service user basis. The system is designed so that a General Practitioner is the gate keeper of care and manages and coordinates communication between the public bodies. That said, if a high risk service user presents as a concern to Trust staff members, they are proactive and will arrange a professionals meeting for all agencies involved. We plan to review this process with all staff over the next two months to ensure that they are aware of their responsibilities and understand the importance of acting on concerns.” Source location Response from ELFT
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 Staff the dressing clinic with a substantive band 6 nurse under senior Trust community district nursing line management.
Verbatim wording from the response “12. Since the sad death of Mr Ahmed, some further changes were introduced to the dressing clinic. It is now staffed by a substantive band 6 nurse (as opposed to temporary staff) whose clinical and professional line management is provided by senior nursing within the Trust’s Community District Nursing Team. I expect this will improve the accountability of clinical staff on the team as well as allow them to receive more consistent supervision and improve clinical skills and enhance curiosity.” Source location Response from ELFT
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 a dressing-clinic standard operating procedure providing 30-minute service-user appointment slots instead of 10-minute slots.
Verbatim wording from the response “13. On 24 July, a new standard operating procedure was put into place for dressing clinic staff. The key change is that the time slots allocated to attend to service users has increased from 10 minutes to 30 minutes. It is anticipated that the provision of additional time to complete work should improve care planning and allow more meaningful communications with other services as well as improve staff morale.” Source location Response from ELFT
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 The commissioner and General Practitioner are expected to manage concerns about domiciliary care and the service user’s poor decision-making.
Verbatim wording from the response “The local authority, not the Trust commissioned the domiciliary care providers. Consequently, it is expected that the commissioner and the General Practitioner would manage concerns. However, as outlined in paragraph 8, Trust staff should be proactive when they witness concerns and arrange professionals’ meetings between agencies. This will be reviewed with staff over the next two months.” Source location Response from ELFT
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 The Trust cannot comment on behalf of the local authority or domiciliary care company regarding their communication and care arrangements.
Verbatim wording from the response “4. The Trust is unable to comment on behalf of London Borough of Newham (‘LBN’) or the domiciliary care company. However, it can confirm that LBN and the Trust have systems in place which facilitate joint working to improve care for service users under both services.” Source location Response from ELFT
Open published response
18 Jul 2024 Anna Vivien Elliott · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 10 Failure to conduct an adequate risk assessment before ending a safety plan View source Failure to complete safe and supportive observation charts to the required standard View source Failure to record and pass on safety-relevant information View source Failure of written handover records to capture vital information View source Failure of audit staff to produce adequate observation records View source Failure to complete safe and supportive observations View source Failure of spot checks to identify and address falsified observation records View source Falsification of safe and supportive observation records View source Failure to keep patient records accurate and correctly attributed View source Failure to maintain secure individual account access View source See 7 more concerns
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 18
Action
Use escalation protocols to guide staff when resources are insufficient to meet care needs.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Continue using Safety Huddles and document discussions on the handover template.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Deliver face-to-face Honesty in Documentation training across inpatient services.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Increase staffing on each shift by one unregistered Band 3 member and add a weekday Band 4 Life Skills Recovery Worker.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Recruit to eliminate registered vacancies, review unregistered workforce skills, and maintain safer staffing rota approval and monitoring.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Introduce observation relay boards to reduce missed observations and improve clinical-information handover.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Deliver monthly Tower Hamlets training on Dialog+ care planning, safety plans and risk formulations using group scenarios.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Pilot the Microsoft PowerApps observation-documentation application on four wards and plan wider inpatient rollout.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Adjust observation spot-check data to focus specifically on observation quality and begin collecting it.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Cover the administrators’ office during handover and allocate the patient/carer phone to a named, logged staff member.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Develop and roll out a standardised 24-hour handover template with daily and quarterly audits.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Continue reviewing escalation protocols to support task prioritisation, rapid resource deployment and reporting of compromised care.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Continue work promoting honesty in documentation.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source See 15 more actions
×
AI-generated summary
Anna Vivien Elliott · 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
Anna Vivien Elliott, who had severe recurrent depression with psychotic features and autism spectrum disorder, was detained under the Mental Health Act after having thoughts and plans to end her life. She was found deceased in her room on 24 November 2021 after safe and supportive observations were missed and her safety plan was ended without an adequate risk assessment. Concerns included inadequate handover and staffing, missed and falsified observation records, poor record keeping, and uncertainty about the management of safety plans.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an adequate risk assessment before ending a safety plan
Wider context from the report “Concern 5
A safety plan had been agreed with Anna and put in place in the afternoon of 24 November 2021. This worked well and was a good example of staff thinking about Anna’s safety and the best strategy in the context of least restrictive practice. However, during the night shift, that safety plan was ended without a formal (or any adequate) risk assessment taking place . In accordance with the Trust’s policy, safe and supportive observation levels cannot be decreased without the input of a doctor. I remain unclear whether the same applies to other measures contained in safety plans and the PFD witness was unable to confirm the position.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete safe and supportive observation charts to the required standard
Wider context from the report “Concern 2
The Trust’s policy is very clear on what should be recorded on the safe and supportive observation charts. In addition, all of the witnesses could explain in evidence, the expectation and what good practice looks like. However, only one staff member’s entries met this expectation . All of the other entries that I was taken to simply recorded Anna’s location at the time of the observation . I heard evidence that observation records are audited for quality and entries raised with staff if they do not meet expectations. However, this process of auditing was in place at the time of Anna’s death and the observation entries of the senior nurses responsible for that auditing were of the same poor quality.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and pass on safety-relevant information
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on ; an entry relating to a different patient was recorded in Anna’s records; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of written handover records to capture vital information
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on; an entry relating to a different patient was recorded in Anna’s records; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of audit staff to produce adequate observation records
Wider context from the report “Concern 2
The Trust’s policy is very clear on what should be recorded on the safe and supportive observation charts. In addition, all of the witnesses could explain in evidence, the expectation and what good practice looks like. However, only one staff member’s entries met this expectation. All of the other entries that I was taken to simply recorded Anna’s location at the time of the observation. I heard evidence that observation records are audited for quality and entries raised with staff if they do not meet expectations. However, this process of auditing was in place at the time of Anna’s death and the observation entries of the senior nurses responsible for that auditing were of the same poor quality .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete safe and supportive observations
Wider context from the report “Concern 3
In Anna’s case, safe ad supportive observations were missed . This is, at least, in part due to high acuity on the unit as a whole on the night of Anna’s death, a support worker undertaking those observations being called away to an emergency and her colleagues reporting being unaware that she had left the ward . I heard evidence about steps that have been put in place to prevent observations being missed but the data provided by the Trust appeared to show that missed observations are rising and not decreasing. However, the data provided was out of date and the PFD witness was unable to interpret what was provided. I heard evidence about a strong focus on safety, openness and honesty following Anna’s death. I am therefore unclear whether the data reflects a true rise in missed observations or whether it is the result of more honest reporting of missed observations by staff on the ground.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of spot checks to identify and address falsified observation records
Wider context from the report “Concern 4
In Anna’s case, observation records were backfilled despite the observations not having been conducted. All of the witnesses who gave evidence had received training, were aware of a previous PFD on missed and falsified observations, could tell me the purpose and importance of the observations, knew that observations should not be falsified and knew that if observations were missed, this should be reported that to the nurse in charge. I was also provided with screenshots of training which included a message from the Chief Nurse appearing to be dated May 2024 which refer to “an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done”. As the spot checks described to me only look at the quality and timings of the written observations , I am not reassured that records are not still being falsified or about how this is being identified and addressed .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Falsification of safe and supportive observation records
Wider context from the report “Concern 4
In Anna’s case, observation records were backfilled despite the observations not having been conducted . All of the witnesses who gave evidence had received training, were aware of a previous PFD on missed and falsified observations, could tell me the purpose and importance of the observations, knew that observations should not be falsified and knew that if observations were missed, this should be reported that to the nurse in charge. I was also provided with screenshots of training which included a message from the Chief Nurse appearing to be dated May 2024 which refer to “an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done ”. As the spot checks described to me only look at the quality and timings of the written observations, I am not reassured that records are not still being falsified or about how this is being identified and addressed.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep patient records accurate and correctly attributed
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on; an entry relating to a different patient was recorded in Anna’s records ; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain secure individual account access
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on; an entry relating to a different patient was recorded in Anna’s records; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information.
” 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 Use escalation protocols to guide staff when resources are insufficient to meet care needs.
Verbatim wording from the response “Escalation protocols have been developed for use to guide staff when there are not sufficient resources in place to meet care needs.” Source location Response from ELFT
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 Continue using Safety Huddles and document discussions on the handover template.
Verbatim wording from the response “14. In addition, the Trust will continue to use Safety Huddles as a way of discussion and decision making during a shift. Safety Huddle discussions will be documented on the handover template. This will ensure vital information during a shift is captured in the handover documentation.” Source location Response from ELFT
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 Deliver face-to-face Honesty in Documentation training across inpatient services.
Verbatim wording from the response “Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.” Source location Response from ELFT
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 Increase staffing on each shift by one unregistered Band 3 member and add a weekday Band 4 Life Skills Recovery Worker.
Verbatim wording from the response “Staffing/ resource availability | Staff establishment reviews were undertaken in 22/23 and 23/24. Correct and agreed investments have gone into teams, increasing staff on each shift by one unregistered Band 3. Additional investment has been made for a Band 4 Life Skills Recovery Worker on Mondays to Fridays 9am to 5pm to increase the delivery of activities and opportunities for meaningful engagement.” Source location Response from ELFT
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 Recruit to eliminate registered vacancies, review unregistered workforce skills, and maintain safer staffing rota approval and monitoring.
Verbatim wording from the response “A proactive recruitment campaign has been ongoing with services moving to zero registered vacancies and a review of the unregistered workforce (correct band and skill). Staffing rotas for the wards have been reviewed and updated to reflect safer staffing requirements; senior approval of rotas is required six weeks in advance of the current period and quarterly rota monitoring meetings are in place.” Source location Response from ELFT
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 the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
Verbatim wording from the response “The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.” Source location Response from ELFT
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 Introduce observation relay boards to reduce missed observations and improve clinical-information handover.
Verbatim wording from the response “A Trust-wide Quality Improvement programme which involved all inpatient teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:” Source location Response from ELFT
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 Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
Verbatim wording from the response “Communication
To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.” Source location Response from ELFT
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 Deliver monthly Tower Hamlets training on Dialog+ care planning, safety plans and risk formulations using group scenarios.
Verbatim wording from the response “25. In Tower Hamlets the Trust has introduced Dialog+ Plus and Safety Planning training facilitated by Trust Matrons. We have a monthly schedule where inpatient staff in Tower Hamlets must attend Training covering Dialog+ care planning, safety plans and risk formulations. Staff have an opportunity to practice using scenarios in groups.” Source location Response from ELFT
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 Pilot the Microsoft PowerApps observation-documentation application on four wards and plan wider inpatient rollout.
Verbatim wording from the response “A digital application to document observations (using Microsoft PowerApps) has been developed and is in the testing phase. It is planned that this will be piloted from October 2024 on four wards and then scaled across all inpatient units.” Source location Response from ELFT
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 a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
Verbatim wording from the response “Standardised processes
To develop a consistent approach to supporting staff to learn from their observations practice through reflection, personal accountability and if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.” Source location Response from ELFT
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 Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
Verbatim wording from the response “Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.” Source location Response from ELFT
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 Adjust observation spot-check data to focus specifically on observation quality and begin collecting it.
Verbatim wording from the response “17. The Directorate has now adjusted spot check data to be specific around quality of observations. It will begin collecting data from September 2024.” Source location Response from ELFT
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 Cover the administrators’ office during handover and allocate the patient/carer phone to a named, logged staff member.
Verbatim wording from the response “6. Steps are now in place to ensure calls are not missed: the administrators’ office will now be covered with admin staff during the team handover from 14:00 to 16:00 to ensure calls are not missed.” Source location Response from ELFT
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 and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
Verbatim wording from the response “19. The Trust is currently developing a new E-observations (e-obs) platform which has in-built prompts to ensure staff capture the location of a patient, what they observe and their interactions with a patient. Daily spot checks will be undertaken by the clinical nurse manager or the most senior nurse on shift out of hours. It is hoped that this will be in place in the coming six months.” Source location Response from ELFT
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 and roll out a standardised 24-hour handover template with daily and quarterly audits.
Verbatim wording from the response “13. Tower Hamlets is currently working on creating a standardised handover template. This project is being led by the Deputy Borough Lead Nurse. The aim is to have a running document over a 24-hour period. The handover template has been tested on some of the wards and is currently being rolled out to the remaining wards. Roll out should be completed by the end of September 2024. The Matron responsible for ward will be responsible for the initial audit daily, this will be audited by the Lead Nurses quarterly.” Source location Response from ELFT
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 Continue reviewing escalation protocols to support task prioritisation, rapid resource deployment and reporting of compromised care.
Verbatim wording from the response “Staffing/resource availability
Continue to review escalation protocols to senior staff on site in response to changes in acuity or demand or if there are staff shortages on a shift. This is to include:” Source location Response from ELFT
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 Continue work promoting honesty in documentation.
Verbatim wording from the response “Continued work on honesty in documentation.” Source location Response from ELFT
Open published response
10 Jul 2024 Mahamoud Hussain Ali · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to conduct required observations View source Failure to accurately record required observations View source
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 22
Action
Develop and deliver Honesty in Documentation training face to face across all inpatient services.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Develop a learning system linking internal incident and improvement learning with national observation-practice work.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Implement twilight shifts that add staffing during reduced activity periods and provide therapeutic activities.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Conduct senior-staff night visits with spot-check audits and observation of practice.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Review and update ward rotas for safer staffing, with advance senior approval and quarterly monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Implement zonal observations to support continuous patient engagement and monitoring across wards.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Continue reviewing escalation protocols for acuity, demand and staffing shortages, including task allocation, rapid resource deployment and reporting compromised care.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Develop a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Test and pilot a Microsoft PowerApps application for documenting observations before planned inpatient-wide scaling.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Implement the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Implement observation board relay to reduce missed observations and improve handover between staff.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Increase each ward shift by one unregistered Band 3 staff member and add a weekday Band 4 Life Skills Recovery Worker.
Stated completedThe respondent said that this action was complete when they made their response on 31 July 2024. View source
Action
Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Continue work on honesty in documentation.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Review the Human Factors Analysis findings and suggested improvements through senior leadership.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source
Action
Continue Trust-wide communications discouraging falsification, encouraging honest reporting and clarifying missed-observation reporting requirements.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024. View source
Action
Review and relaunch use of the Standard Observation Measurement tool and its outputs to influence practice.
Stated plannedThe respondent said that this action was planned when they made their response on 31 July 2024. View source See 19 more actions
×
AI-generated summary
Mahamoud Hussain Ali · 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
Mahamoud Hussain Ali fell twice in the street on 19 August 2020 and was later detained under the Mental Health Act and transferred to Lea Ward. On 21 August 2020 he was found unresponsive and died in hospital on 26 August 2020. The principal concern was that required 15-minute observations were not conducted or were falsely recorded, and that subsequent Trust action had not been sufficient to ensure observations were conducted and recorded as required.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required observations
Wider context from the report “(1) Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep.
East London NHS Foundation Trust (the Trust) has acknowledged that the deliberate falsification of observation records is not acceptable.
Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted . One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained.
Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation.
The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022.
I have been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorate’s in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…”
Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done. ”
Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record required observations
Wider context from the report “(1) Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep.
East London NHS Foundation Trust (the Trust) has acknowledged that the deliberate falsification of observation records is not acceptable .
Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted . One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained.
Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation.
The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022.
I have been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorate’s in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…”
Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done. ”
Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur.
” 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 Develop and deliver Honesty in Documentation training face to face across all inpatient services.
Verbatim wording from the response “Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.” Source location Response from ELFT
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 a learning system linking internal incident and improvement learning with national observation-practice work.
Verbatim wording from the response “Learning system
To develop a learning system that includes learning from incidents and improvement work internally, but that also links in with national work in relation to observations practice.” Source location Response from ELFT
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 Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.
Verbatim wording from the response “Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.” Source location Response from ELFT
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 twilight shifts that add staffing during reduced activity periods and provide therapeutic activities.
Verbatim wording from the response “Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:” Source location Response from ELFT
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 Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.
Verbatim wording from the response “Safety discussion sessions are facilitated weekly in directorates for all inpatient staff to review observation data, reflect on gaps in practice and disseminate learning.” Source location Response from ELFT
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 Conduct senior-staff night visits with spot-check audits and observation of practice.
Verbatim wording from the response “Night visits are undertaken by senior staff in directorates to monitor practice through spot check audits and observing work as it happens.” Source location Response from ELFT
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 Review and update ward rotas for safer staffing, with advance senior approval and quarterly monitoring.
Verbatim wording from the response “Staffing rotas for the wards have been reviewed and updated to reflect safer staffing requirements; senior approval of rotas is required six weeks in advance of the current period and quarterly rota monitoring meetings are in place.” Source location Response from ELFT
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 zonal observations to support continuous patient engagement and monitoring across wards.
Verbatim wording from the response “Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:” Source location Response from ELFT
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 Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.
Verbatim wording from the response “Audit and monitoring
The Standard Observation Measurement (SOM) Tool was developed for oversight of rates of completion of all observations. Individual ward teams and directorates can access and use their data to drive continued improvement.” Source location Response from ELFT
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 Continue reviewing escalation protocols for acuity, demand and staffing shortages, including task allocation, rapid resource deployment and reporting compromised care.
Verbatim wording from the response “Staffing/resource availability
Continue to review escalation protocols to senior staff on site in response to changes in acuity or demand or if there are staff shortages on a shift. This is to include:” Source location Response from ELFT
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 Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.
Verbatim wording from the response “To design an internal governance process for the review of reported cases of missed observations and learning that arises from this, that will report into the Patient Safety and Quality Assurance committees.” Source location Response from ELFT
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 a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.
Verbatim wording from the response “Standardised processes
To develop a consistent approach to supporting staff to learn from incidents involving poor observations practice through reflection, personal accountability and, if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.” Source location Response from ELFT
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 Test and pilot a Microsoft PowerApps application for documenting observations before planned inpatient-wide scaling.
Verbatim wording from the response “A digital application to document observations (using Microsoft PowerApps) has been developed and is in the testing phase. It is planned that this will be piloted from October 2024 on four wards and then scaled across all inpatient units.” Source location Response from ELFT
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 the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.
Verbatim wording from the response “Staff competency | The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.” Source location Response from ELFT
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 observation board relay to reduce missed observations and improve handover between staff.
Verbatim wording from the response “Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:” Source location Response from ELFT
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 Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.
Verbatim wording from the response “Standards of professional practice | Expected standards of practice have been communicated to staff, with frequent updates on improvement work since 2021 to date. In 2023, this specifically addressed accountability and responsibility for accurately documenting observations. It included the importance of honesty in documentation and gave guidelines for staff to follow for occasions when observations were missed. The Trust-wide Quality Improvement programme described above has introduced the observation relay board to reduce incidents of observations being left or not handed over.” Source location Response from ELFT
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 Increase each ward shift by one unregistered Band 3 staff member and add a weekday Band 4 Life Skills Recovery Worker.
Verbatim wording from the response “Overarching theme | Therapeutic engagement and observation improvement work undertaken
Staffing/resource availability | Staff establishment reviews were undertaken in 22/23 and 23/24. Correct and agreed investments have gone into teams, increasing staff on each shift by one unregistered Band 3. Additional investment has been made for a Band 4 Life Skills Recovery Worker on Mondays to Fridays 9am to 5pm to increase the delivery of activities and opportunities for meaningful engagement.” Source location Response from ELFT
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 Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.
Verbatim wording from the response “Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,” Source location Response from ELFT
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 Continue work on honesty in documentation.
Verbatim wording from the response “Continued work on honesty in documentation.” Source location Response from ELFT
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 Review the Human Factors Analysis findings and suggested improvements through senior leadership.
Verbatim wording from the response “Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,” Source location Response from ELFT
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 Continue Trust-wide communications discouraging falsification, encouraging honest reporting and clarifying missed-observation reporting requirements.
Verbatim wording from the response “Communication
To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.” Source location Response from ELFT
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 Review and relaunch use of the Standard Observation Measurement tool and its outputs to influence practice.
Verbatim wording from the response “Professional practice
Review and relaunch use of SOM tool and outputs to impact on practice.” Source location Response from ELFT
Open published response
22 Mar 2024 Regina Olufunmilola Ademiluyi · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to formally assess mental capacity View source Insufficiently detailed safeguarding reports failing to trigger further investigation View source Failure to offer a carers assessment in response to concerns about carer capacity View source Failure of the local authority to seek further information or clarification from the Trust View source Failure of the local authority to undertake meaningful significant event analysis of care failings View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Regina Olufunmilola Ademiluyi · 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
Regina Olufunmilola Ademiluyi was an 83-year-old woman who was bed-bound following surgery for a broken hip and died in March 2024 after declining cognition and physical health, malnutrition, a grade 4 sacral pressure ulcer and an aspiration incident. The report raised concerns that state-funded domiciliary care was not provided, and that the NHS Trust and local authority did not adequately assess or respond to safeguarding, mental-capacity and carer-support concerns.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess mental capacity
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity , had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently detailed safeguarding reports failing to trigger further investigation
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to offer a carers assessment in response to concerns about carer capacity
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the local authority to seek further information or clarification from the Trust
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the local authority to undertake meaningful significant event analysis of care failings
Wider context from the report “2. Despite the death of Mrs Ademiluyi’s occurring in the spring of 2023 no meaningful reflection or remediation had been undertaken by the Local Authority into the failings in care by the time of the inquest almost a year later. It was suggested by the legal representative of local authority that the inquest hearing itself was the extent of the significant event analysis undertaken by their professional client.
” 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 Use established joint-working forums for practitioners to discuss service-user mental-capacity concerns.
Verbatim wording from the response “12. I asked the Trust’s Mental Capacity Act Lead to explore issues surrounding Ms Ademiluyi’s capacity. They confirmed that in-line with the provisions of the Mental Capacity Act 2005 (the ‘MCA’) the Trust is only the decision-maker in relation to decisions pertaining to her health care. The social care provider (LBN) is responsible for assessing capacity in relation to care and support needs.” Source location Response from East London NHS Foundation Trust
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 Remind staff to discuss carer self-referral or make carer-assessment referrals on carers’ behalf when concerns arise.
Verbatim wording from the response “Carer’s Assessment” Source location Response from East London NHS Foundation Trust
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 Remind Newham Community Health Services staff to follow the internal safeguarding escalation pathway and escalate barriers without waiting for monthly forums.
Verbatim wording from the response “11. Additionally, Newham Community Health Services staff have been reminded of the Trust’s internal escalation pathway which they are expected to follow when there are concerns about the safeguarding process between public bodies during supervision. The escalation pathway is a tool to support staff with recognising their” Source location Response from East London NHS Foundation Trust
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 monthly joint safeguarding meetings, safeguarding forums and escalation processes between Trust and local authority services.
Verbatim wording from the response “8. The Named Professional, the Lead Nurse and LBN have implemented arrangements to improve collaborative working and developed processes to escalate any drifting delays and/or cases with significant level of risk. These are as follows:” Source location Response from East London NHS Foundation Trust
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 Deliver quarterly safeguarding adults training for Newham Community Health Services staff, including guidance on completing high-quality referrals.
Verbatim wording from the response “9. Whilst the detail in the safeguarding referral was not the reason the safeguarding concern was not investigated further; the Named Professional agrees that it provided insufficient information. To ensure this does not occur again, the following training and supervision has been arranged for Community Health Services staff in Newham area:” Source location Response from East London NHS Foundation Trust
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 The safeguarding referral’s insufficient detail did not cause the investigation failure; LBN’s backlog delayed the safeguarding enquiry.
Verbatim wording from the response “6. According to LBN, the referral was screened according to their own internal safeguarding policy and the Trust was advised that it met threshold for the Section 42 safeguarding enquiry. However, LBN is managing a backlog of such referrals. Therefore, it was not addressed before Ms Ademiluyi’s sad death. Please refer to LBN’s response to this Regulation 28 report.” Source location Response from East London NHS Foundation Trust
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 LBN, not the Trust, is responsible for assessing capacity concerning social care and support needs.
Verbatim wording from the response “12. I asked the Trust’s Mental Capacity Act Lead to explore issues surrounding Ms Ademiluyi’s capacity. They confirmed that in-line with the provisions of the Mental Capacity Act 2005 (the ‘MCA’) the Trust is only the decision-maker in relation to decisions pertaining to her health care. The social care provider (LBN) is responsible for assessing capacity in relation to care and support needs.” Source location Response from East London NHS Foundation Trust
Open published response
4 Dec 2023 Angela Dawn COLLINS · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Lack of support for vulnerable adults at risk of prescription drug overdose or mental health crisis View source
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Engage administrative staff to clarify distress-support responsibilities, training needs, escalation pathways, reflection, and debrief arrangements.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2023. View source
Action
Develop a detailed action plan with colleagues to strengthen care for vulnerable adults at risk of overdose or mental health crisis.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023. View source
Action
Provide all teams with clear escalation routes to partner agencies through the system-wide Cooperation between Teams protocol.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2023. View source
Action
Review the multi-agency protocol to clarify communication, roles, responsibilities, and timely, accurate recordkeeping as circumstances evolve.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2023. View source
Action
Assess learning from this and previous cases, embed resulting practice changes, and provide ongoing staff support.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023. View source
Action
Review the Community Mental Health Team duty function, including resourcing, training, practice standards, and senior oversight.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2023. View source See 3 more actions
×
AI-generated summary
Angela Dawn COLLINS · 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
Angela Dawn COLLINS died after taking an overdose of prescription drugs while experiencing severe mental and emotional distress. The report describes limited or no support for vulnerable adults at risk of overdose or mental health crisis despite being under secondary mental health services, alongside missed or unsuccessful contacts before her death.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of support for vulnerable adults at risk of prescription drug overdose or mental health crisis
Wider context from the report “Vulnerable adults at risk of accidental/intentional prescription drug overdose and potentially suffering mental health crisis (such as Angie) appear to receive very limited or no support even though they are under the care of secondary mental health services provided by East London NHS Foundation Trust.
” 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 Engage administrative staff to clarify distress-support responsibilities, training needs, escalation pathways, reflection, and debrief arrangements.
Verbatim wording from the response “2. Engage with administrative staff (who are usually the first people to talk to a service user and/or their carer) to clarify the purpose of their role in terms of supporting people over the phone who may be in distress and providing robust/timely support. This will include clarifying and getting their feedback on training needs and clear escalation pathways, plus ensuring that opportunities for reflection and de-briefs are made available.” Source location Response from East London NHS Foundation Trust
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 a detailed action plan with colleagues to strengthen care for vulnerable adults at risk of overdose or mental health crisis.
Verbatim wording from the response “In light of HM Coroner’s observations, the Trust has further reflected on the details of this case to see if there are actions that can be taken to further strengthen care in such circumstances. The Trust is now assessing the impact of the learning from this case and related previous cases to ensure that changes to practice are properly embedded and support is provided to staff on an ongoing basis. In doing so, the Trust believes vulnerable adults at risk of accidental/intentional prescription drug overdose and potentially suffering a mental health crisis (such as Ms Collins) will be supported appropriately. A detailed action plan is being developed with colleagues and will include items listed below. Please note that references to staff and managers are to CMHT staff in the London and Bedfordshire Directorate.” Source location Response from East London NHS Foundation Trust
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 all teams with clear escalation routes to partner agencies through the system-wide Cooperation between Teams protocol.
Verbatim wording from the response “7. That all teams provide clear routes of escalation to partner agencies if there is discourse or disagreement about how a case is being managed utilising the system wide Cooperation between Teams protocol.” Source location Response from East London NHS Foundation Trust
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 Review the multi-agency protocol to clarify communication, roles, responsibilities, and timely, accurate recordkeeping as circumstances evolve.
Verbatim wording from the response “6. Review the appropriate multi-agency protocol to ensure that staff are clear on the need for clear communication when supporting a person alongside other agencies and that roles and responsibilities are clearly articulated and where necessary reviewed to respond to ongoing and evolving circumstances. That records are both accurate, detailed, and timely and reflect the situation as it unfolds.” Source location Response from East London NHS Foundation Trust
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 Assess learning from this and previous cases, embed resulting practice changes, and provide ongoing staff support.
Verbatim wording from the response “In light of HM Coroner’s observations, the Trust has further reflected on the details of this case to see if there are actions that can be taken to further strengthen care in such circumstances. The Trust is now assessing the impact of the learning from this case and related previous cases to ensure that changes to practice are properly embedded and support is provided to staff on an ongoing basis. In doing so, the Trust believes vulnerable adults at risk of accidental/intentional prescription drug overdose and potentially suffering a mental health crisis (such as Ms Collins) will be supported appropriately. A detailed action plan is being developed with colleagues and will include items listed below. Please note that references to staff and managers are to CMHT staff in the London and Bedfordshire Directorate.” Source location Response from East London NHS Foundation Trust
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 Review the Community Mental Health Team duty function, including resourcing, training, practice standards, and senior oversight.
Verbatim wording from the response “1. A robust review of the Duty Function including how it is resourced, training requirements, practice standards, and senior oversight, across all Community Mental Health Teams in Bedfordshire and Luton. This work will commence in February 2024.” Source location Response from East London NHS Foundation Trust
Open published response
12 Jun 2023 Heather FINDLAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 15 Omissions from serious incident investigations View source Failure to communicate the appropriate level of suicide risk to police View source Lack of ward assistance and contingency planning for retrieval of an absconded patient View source Lack of instructions for staff following an absconded patient View source Failure to prepare clinical staff to maintain line of sight when a patient absconds View source Failure to recognise imminent suicide risk after a patient absconds View source Failure to volunteer the trust's risk grading when reporting a patient to police View source Confusion about police contact when a patient is missing View source Lack of training for doctors and nurses in street restraint and patient transport View source Unavailability of police assistance for clinicians responding to an absconded patient View source Failure of police and health-trust partnership working to allocate responsibility for patient retrieval View source Lack of learning culture at ELFT View source Inconsistent terminology and definitions between police and mental-health services View source Failure of police reporting information to align with local policies View source Failure to routinely record all useful risk information in police reports View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Heather FINDLAY · 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
Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omissions from serious incident investigations
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation .
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the appropriate level of suicide risk to police
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide . Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection .
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward assistance and contingency planning for retrieval of an absconded patient
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task . I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of instructions for staff following an absconded patient
Wider context from the report “2. By the time the HCA rang the duty senior nurse for advice Ms Findlay was out of sight, and so the HCA was instructed to return to the ward.
I heard evidence that an email is to be sent out shortly to explain that a new ELFT absent without leave policy will be in place by the end of June 2023. The new policy will confirm that, if it is safe to do so an escort may follow a patient who has absconded, keeping them in line of sight whilst ringing the duty senior nurse for instructions.
However, there is no ELFT policy for what those instructions should be or even what they could include . No member of ELFT gave evidence of any organisational thought having gone into how then to progress such a situation, other than the ward calling the police to report a missing person. No member of ELFT giving evidence was able to set out what the staff member following should do .
This appears to be a significant omission.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare clinical staff to maintain line of sight when a patient absconds
Wider context from the report “1. When Ms Findlay ran off, the HCA escorting her was so panicked that she did not even think of following. Ms Findlay had run across a road and so chasing her at speed did present safety considerations. However, the ELFT policy, training, culture and expectation was such, that there the HCA did not at any point consider attempting to walk after her to keep her in sight . Clinical staff must be adequately prepared for such an eventuality .
That means more than simply a change in policy wording.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise imminent suicide risk after a patient absconds
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff .
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to volunteer the trust's risk grading when reporting a patient to police
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it .
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion about police contact when a patient is missing
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves ; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing .
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for doctors and nurses in street restraint and patient transport
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward .
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of police assistance for clinicians responding to an absconded patient
Wider context from the report “3. Moreover, one of the MPS policy leads in this area gave evidence that in such a situation the police would not necessarily attend , even if called direct by a hospital staff member in the street following a patient about whom they are worried.
I spent some time examining the police regarding this point, and I was left with the impression that a clinician calling the police in what the clinician perceived to be an emergency situation might not be assisted by the police .
That concerned me.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police and health-trust partnership working to allocate responsibility for patient retrieval
Wider context from the report “4. I heard that Right Care, Right Person is an operational model developed by Humberside Police that changes the way the emergency services respond to calls involving concerns about mental health. I understand that it is in the process of being rolled out across the UK as part of ongoing work between police forces, health providers and government.
I heard that the MPS has already created a similar model under the resource and demand team. The protocol is called Affinity. It attempts to target preventable demand from the mental health trusts.
I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if an escort is following a patient who has run away and about whom the escort is worried.
I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other hospital staff have the same powers as the police under section 18 of the Mental Health Act. Hospital employees have the legal authority to take a sectioned patient into custody and return them to hospital.
However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to assist an escort who already following a patient. I heard nothing of a trust contingency plan that would allow a ward to function without the doctors and nurses needed to undertake such a task. I heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of the street and to transport them back to the ward.
From the evidence I heard, the police / health trust partnership working allows each agency to regard such a situation as the other’s responsibility , whilst nobody is on the ground attempting to retrieve a seriously ill patient who is meant to be inside a locked ward for their own safety.
Whether this is a matter of policy or practice, the result is the same. If partner agency working is to be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear understanding by all those involved, from the highest policy maker to the most junior member of a team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing what.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of learning culture at ELFT
Wider context from the report “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident.
At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself.
It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future.
However,
• the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and
• any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection.
So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff.
I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020.
This position seems lacking the necessary reflection.
I draw your attention to earlier prevention of future deaths reports (PFDs) as follows:
• Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing.
• Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation.
• Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent terminology and definitions between police and mental-health services
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions .
It seems that this would benefit from consideration.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police reporting information to align with local policies
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies , whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine, and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely record all useful risk information in police reports
Wider context from the report “5. Evidence was given that the police classify a person at high risk as: the risk is immediate and there are substantial grounds for believing immediate risk of self harm.
I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own grading of the patient’s risk. The police said that they will not necessarily following the trust grading, but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses told me that if the police did not ask for the trust’s grading then the trust would not offer it.
I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was printed out and handed to police if & when the police attended the ward. It is now filled out on a portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns with local policies, whether all useful information (including the trust’s grading of risk) is recorded as a matter of routine , and how far the police and the trust are using the same terminology with the same definitions.
It seems that this would benefit from consideration.
” 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 Review the AWOL Grab Pack’s alignment with local policies, including its information content.
Verbatim wording from the response “The author of the AWOL policy has been tasked with reviewing how the Grab Pack aligns with local polices, including what information is included. The expected timescale for this is three months.” Source location Response from East London NHS Foundation Trust
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 Review the Risk Assessment policy in light of recent NICE guidance.
Verbatim wording from the response “In relation to your fifth and sixth concerns, risk assessment and prediction in relation to suicide are complex areas that the Trust is determined to address appropriately and robustly. The National Institute for Health and Care Excellence (NICE) published guidance in 2022 suggesting that risk stratification (e.g. medium and high risk) should not be used to predict future suicide or self-harm, and that risk assessment tools and scales should not be used for those purposes either. The emphasis should be on supporting the person’s immediate and long-term psychological and physical safety, and on risk formulation.” Source location Response from East London NHS Foundation Trust
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 Add escorted-leave AWOL scenarios to relevant staff induction and provide two-yearly refresher training.
Verbatim wording from the response “The Trust intends to incorporate scenarios involving patients going AWOL on escorted leave into its induction training for new staff in the relevant services. In addition there will be a 2-yearly refresher for Section 17 and Escort training. The scenario training will incorporate such situations and include reference to the information that needs to be considered by the escorting staff and fed back to staff on the wards to help in making a decision around risk and level of escalation needed. The Trust expects this to be in place in the next 3-6 months.” Source location Response from East London NHS Foundation Trust
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 Revise the Missing and AWOL Policy to clarify safe responses when patients abscond from escorted leave.
Verbatim wording from the response “Although this was the practice in operation at the time, the Trust has taken action to review the relevant part of its Missing and Absent Without Leave (AWOL) Policy to reflect this practice. The updated version will read as below:” Source location Response from East London NHS Foundation Trust
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 Seek external expert opinion on proposed changes to risk assessment policy and procedures before implementation work begins.
Verbatim wording from the response “ELFT intends to review its policy for Risk Assessment and will consider recent NICE guidance in so doing. We will also be seeking an expert opinion from outside of the Trust about changes we propose for our policy and procedures before a programme of work to implement changes is undertaken, with consideration given to the implications for other organisations at that point. The expected timescale for this programme of work is six months.” Source location Response from East London NHS Foundation Trust
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 Continue joint discussions with the MPS and local health stakeholders on AWOL responses and respective organisational roles.
Verbatim wording from the response “The Trust notes that you are aware of the Affinity protocol which is already in place between the Metropolitan Police Service (MPS) and the Trust.” Source location Response from East London NHS Foundation Trust
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 Off-site mobilisation of multiple staff would have significant resource implications and could compromise the safety of patients remaining on the ward.
Verbatim wording from the response “Furthermore, it should be noted that mobilising a group of staff to travel off-site to take a patient into custody and return them to the ward would have significant resource implications and could impinge on the safety of patients on the ward.” Source location Response from East London NHS Foundation Trust
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 Section 18 does not give Trust staff police powers to divert members of the public during a patient's return to hospital.
Verbatim wording from the response “In relation to your third and fourth concerns, the Trust respectfully notes that it is an oversimplification to say that hospital staff have the same powers as the Police via section 18 of the Mental Health Act. Although s18 does confer legal authority on Trust staff to return a sectioned patient to hospital, it does not endow them with any authority to divert members of the public away who might attempt to intervene (on either a malevolent or well-intentioned basis) in the process of taking a patient into custody and returning them to a ward. The absence of such wider powers could put patients, members of the public and staff at risk if Trust staff were to exercise s18 MHA powers.” Source location Response from East London NHS Foundation Trust
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 Senior nurses should use clinical judgement and existing principles rather than follow a prescribed response in line-of-sight scenarios.
Verbatim wording from the response “In relation to your second concern, the Trust believes that the appropriate response from a senior nurse in the envisaged ‘line of sight’ advice-giving scenario should be driven by that senior nurse’s clinical judgement at the time of the event, and that attempting to prescribe a response in advance in a policy document would be unhelpful given the number of dynamic factors that could be relevant.” Source location Response from East London NHS Foundation Trust
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 The Trust will not adopt police-style mechanical restraints or protective equipment because doing so would conflict with its healthcare-provider values.
Verbatim wording from the response “Furthermore, it should be noted that healthcare staff do not have the range of mechanical restraints (e.g. handcuffs) or personal protective equipment (e.g. stab vests) available to the MPS, which are occasionally needed. The Trust would find it contrary to its values as a healthcare provider to adopt such equipment.” Source location Response from East London NHS Foundation Trust
Open published response
8 Jun 2023 Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 11 Failure to make proper efforts to contact a missing patient's family View source Failure to communicate leave restrictions to all unit staff View source Delays in notifying police and ambulance services when a patient is missing View source Insufficient staffing levels in the unit View source Failure to consult medical notes and records during leave risk assessment View source Failure to record service-user movements in the unit sign-in/sign-out book View source Failure to communicate relevant ward-round risk information to all unit staff View source Failure to communicate a missing patient's serious suicide risk to police and ambulance services View source Failure to follow the missing-patient response policy and identify required contacts and methods View source Failure to prevent unescorted leave from a secure unit when prohibited by clinical risk assessment View source Lack of a proper system for identifying whether service users may leave the unit View source See 8 more concerns
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 19
Action
Run a City and Hackney recruitment drive for Band 5 and Band 6 nurses.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 June 2023. View source
Action
Provide Twilight Shifts staffed by Band 6 community nursing colleagues during peak evening periods.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.
Stated plannedThe respondent said that this action was planned when they made their response on 22 June 2023. View source
Action
Include leave-recording and information-sharing requirements in the junior doctor induction programme.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Maintain and review a live spreadsheet weekly to identify recruitment gaps and support recruitment.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Document inpatient leave arrangements on ward nursing-office whiteboards, reassess them at handover, and require staff to check them before authorising leave.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Reinforce correct escalation processes for missing service users through the Gardner Ward Time to Think forum.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Review Trust recruitment strategy and processes following the inpatient activity and staffing review.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Add explicit family-contact instructions to the updated missing-patient policy and discuss them with Gardner Ward staff.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Require junior staff to consult the shift coordinator before permitting patient leave.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Conduct daily multidisciplinary Safety Huddles on City and Hackney inpatient wards to share critical clinical, risk and leave information.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Ratify the reviewed Missing and Absent Without Leave policy.
Stated plannedThe respondent said that this action was planned when they made their response on 22 June 2023. View source
Action
Assign a Band 5 registered nurse to report rota shortages and enhanced-observation demand for staffing responses.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Review staffing levels daily through multidisciplinary huddles and take actions such as redeployment and booking temporary or bank staff.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Send ward staff a memo reinforcing requirements to record and communicate clinical decisions about patient leave.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Relocate and revise inpatient Sign In/Sign Out books to capture leave, return, documentation, belongings and search information.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source
Action
Engage senior-level Metropolitan Police partners to develop a coordinated response strategy for missing inpatients.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 June 2023. View source
Action
Spot-check each Sign In/Sign Out book once per shift and develop a more robust audit system.
Stated in progressThe respondent said that this action was in progress when they made their response on 22 June 2023. View source
Action
Provide £800,000 Safer Staffing investment to City and Hackney inpatient services based on identified staffing needs.
Stated completedThe respondent said that this action was complete when they made their response on 22 June 2023. View source See 16 more actions
×
AI-generated summary
Hilary Clare (Billy) Guedalla · 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
Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make proper efforts to contact a missing patient's family
Wider context from the report “9. No proper efforts were made to contact members of the deceased’s family once the deceased was found to be missing.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate leave restrictions to all unit staff
Wider context from the report “2. The decision that the deceased should not be allowed unescorted leave was not communicated to all members of staff working in the unit such that the person who allowed the deceased to leave was unaware that the decision had been made .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in notifying police and ambulance services when a patient is missing
Wider context from the report “7. Once the deceased was found to be missing from the unit, there was an unexplained delay in informing the police and ambulance service , a failure to inform either of the serious suicide risk which the deceased posed to themselves and a lack of appreciation of the urgency of the situation by staff generally.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels in the unit
Wider context from the report “10. The unit was short-staffed and this affected the care provided to the deceased, the assessment of the deceased whilst in the unit and record keeping generally.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult medical notes and records during leave risk assessment
Wider context from the report “6. The member of staff who allowed the deceased to leave the unit made a brief risk assessment of them before deciding whether they should be allowed to leave. That person did not consult any medical notes or records about the deceased when making that assessment . Had that member of staff consulted the deceased’s medical notes and records, the serious suicide risk which they posed would have been evident .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record service-user movements in the unit sign-in/sign-out book
Wider context from the report “4. The “Sign in/Sign out” book which was supposed to record the movements of service users in the unit was frequently not completed , particularly when service users went out for short periods .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant ward-round risk information to all unit staff
Wider context from the report “3. The relevant information gathered during the Ward Round on the 28th October 2021, which included the fact that the deceased had attempted to take their own life, the night before, was not adequately communicated to all staff on the unit .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate a missing patient's serious suicide risk to police and ambulance services
Wider context from the report “7. Once the deceased was found to be missing from the unit, there was an unexplained delay in informing the police and ambulance service, a failure to inform either of the serious suicide risk which the deceased posed to themselves and a lack of appreciation of the urgency of the situation by staff generally.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the missing-patient response policy and identify required contacts and methods
Wider context from the report “8. The hospital policy which applied to missing patients was not properly adhered to by staff and there was confusion about who should be contacted and in what manner , once a patient was found to be missing.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent unescorted leave from a secure unit when prohibited by clinical risk assessment
Wider context from the report “1. The deceased was allowed to leave Gardener Ward (“the unit”) which was part of a secure facility of the hospital, alone , when a clinical decision had been taken that they should not be allowed to leave the unit unaccompanied by staff , because they posed a serious risk of suicide.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a proper system for identifying whether service users may leave the unit
Wider context from the report “5. There was no proper system for identifying whether a service user should be permitted to leave the unit .
” 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 Run a City and Hackney recruitment drive for Band 5 and Band 6 nurses.
Verbatim wording from the response “e) There is a recruitment drive in City and Hackney for band 5 and 6 nurses.” Source location Response from East London NHS Foundation Trust
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 Twilight Shifts staffed by Band 6 community nursing colleagues during peak evening periods.
Verbatim wording from the response “c) Twilight Shifts have been introduced. Band 6 nursing colleagues from the community teams attend between 5.30 to 9 pm when the wards are busiest to ensure smooth transitions to night shifts.” Source location Response from East London NHS Foundation Trust
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 Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.
Verbatim wording from the response “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.” Source location Response from East London NHS Foundation Trust
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 Include leave-recording and information-sharing requirements in the junior doctor induction programme.
Verbatim wording from the response “Additionally, the Clinical Director for City and Hackney has updated the junior doctor induction programme to include this information.” Source location Response from East London NHS Foundation Trust
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 Maintain and review a live spreadsheet weekly to identify recruitment gaps and support recruitment.
Verbatim wording from the response “d) A live spreadsheet is maintained and reviewed weekly by the ward matrons to highlight recruitment gaps and support the recruitment process” Source location Response from East London NHS Foundation Trust
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 Document inpatient leave arrangements on ward nursing-office whiteboards, reassess them at handover, and require staff to check them before authorising leave.
Verbatim wording from the response “Additionally, all inpatient leave arrangements (for both formal and informal service users) are now documented on the relevant nursing office whiteboard in each City and Hackney inpatient ward. The leave arrangements are reassessed at every shift handover and the whiteboard is updated accordingly. It is expected that all staff members check the whiteboard before allowing leave of any type.” Source location Response from East London NHS Foundation Trust
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 Reinforce correct escalation processes for missing service users through the Gardner Ward Time to Think forum.
Verbatim wording from the response “a. On the 13 July 2022, staff from Gardner Ward attended the “Time to Think” forum. There, the Trust’s Health, Safety and Security Planning Manager led the meeting and reinforced the correct escalation processes to use when a service user is missing.” Source location Response from East London NHS Foundation Trust
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 Review Trust recruitment strategy and processes following the inpatient activity and staffing review.
Verbatim wording from the response “A recent Trust-wide review of the Trust’s inpatient activity (clinical demand and benchmarking against national standards for comparable services) was undertaken in January 2023. This review contributes to ensuring the Trust meets Safer Staffing expectations for services. In particular, that the right staff with the right skills are in the right place at the right time. The review has resulted in an increased investment in inpatient staffing based on the identified needs of the services. Since April 2023, an £800,000 investment for Safer Staffing has been provided to the City and Hackney directorate within ELFT. The benefits of the increased investment will be reduced reliance on temporary staffing at times of high acuity and better resourced teams to meet the needs of service users. In addition to this we have reviewed our recruitment strategy and processes.” Source location Response from East London NHS Foundation Trust
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 Add explicit family-contact instructions to the updated missing-patient policy and discuss them with Gardner Ward staff.
Verbatim wording from the response “I can confirm that explicit information about contacting family members is provided in the updated policy and was discussed with Gardner Ward staff during its review of the policy.” Source location Response from East London NHS Foundation Trust
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 Require junior staff to consult the shift coordinator before permitting patient leave.
Verbatim wording from the response “Further, junior staff members are now required to speak to the shift co-ordinator (the most senior staff member) prior to allowing patient leave.” Source location Response from East London NHS Foundation Trust
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 Conduct daily multidisciplinary Safety Huddles on City and Hackney inpatient wards to share critical clinical, risk and leave information.
Verbatim wording from the response “In order to provide an additional safety net to ensure that appropriate information sharing occurs, a daily Safety Huddle comprised of the entire multi-disciplinary team now takes place on all City and Hackney inpatient wards each morning. Critical clinical information about all service users is shared during the Safety Huddles. Important clinical decisions and risk information discussed at the Safety Huddles are expected to be documented on RIO (this expectation will also be further reinforced at the away day and junior doctor induction).” Source location Response from East London NHS Foundation Trust
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 Ratify the reviewed Missing and Absent Without Leave policy.
Verbatim wording from the response “b. In June 2023, the Trust’s Missing and Absent without Leave policy was reviewed and it is now awaiting ratification.” Source location Response from East London NHS Foundation Trust
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 Assign a Band 5 registered nurse to report rota shortages and enhanced-observation demand for staffing responses.
Verbatim wording from the response “b) A Band 5 registered nurse is currently responsible for ‘red flag’ reporting (reviewing staff shortages on the daily rota and the numbers of service users” Source location Response from East London NHS Foundation Trust
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 Review staffing levels daily through multidisciplinary huddles and take actions such as redeployment and booking temporary or bank staff.
Verbatim wording from the response “a) Staffing levels across the directorate are discussed face to face at a daily Huddle every Monday – Friday at a designated venue. The Duty Senior Nurse, Borough Lead Nurse, Ward Managers and matrons are present. The Psychiatric Liaison Teams and Home Treatment Team also feed into the Huddle. Safe staffing levels are considered alongside appropriate actions such as redeployment, booking temporary staff and block booking Trust bank staff.” Source location Response from East London NHS Foundation Trust
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 Send ward staff a memo reinforcing requirements to record and communicate clinical decisions about patient leave.
Verbatim wording from the response “In order to ensure that this does not occur again, at the next Gardner Ward away day on 23 August 2023 all staff will be reminded again of the importance of properly recording clinical decisions (whether made by themselves or in Ward Management Meetings or Ward Rounds). As well as reviewing the RIO notes prior to making important clinical decisions. This same discussion will be repeated at the next away days for all City and Hackney inpatient wards. Considerations about the differences in recording such information between formal and informal service users will be discussed. A memo has been sent out to all ward staff on 27 July 2023 by the Clinical Director reinforcing these expectations too.” Source location Response from East London NHS Foundation Trust
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 Relocate and revise inpatient Sign In/Sign Out books to capture leave, return, documentation, belongings and search information.
Verbatim wording from the response “I have been provided with assurances that the process for managing the Sign In/Sign Out book (the “book”) on all inpatient units in City and Hackney has been improved. The book is now located at the nursing office to enhance completion. It has been revised to include the following information: service user name, whether leave is escorted (and by whom) or not, location of planned leave, time left and time returned, the validity of Section 17 leave papers for detained patients, description of items taken, and whether search on return was completed.” Source location Response from East London NHS Foundation Trust
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 Engage senior-level Metropolitan Police partners to develop a coordinated response strategy for missing inpatients.
Verbatim wording from the response “c. The Trust is now engaged at a senior level with the Metropolitan Police to develop a strategy around, “Right Care, Right Person” which is anticipated to lead to improvements in the coordination of response to missing inpatients by both organisations.” Source location Response from East London NHS Foundation Trust
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 Spot-check each Sign In/Sign Out book once per shift and develop a more robust audit system.
Verbatim wording from the response “Presently, either the nurse in charge or the shift coordinator spot checks the book to ensure completion one time per shift. However, work is being done to develop a more robust audit system.” Source location Response from East London NHS Foundation Trust
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 £800,000 Safer Staffing investment to City and Hackney inpatient services based on identified staffing needs.
Verbatim wording from the response “A recent Trust-wide review of the Trust’s inpatient activity (clinical demand and benchmarking against national standards for comparable services) was undertaken in January 2023. This review contributes to ensuring the Trust meets Safer Staffing expectations for services. In particular, that the right staff with the right skills are in the right place at the right time. The review has resulted in an increased investment in inpatient staffing based on the identified needs of the services. Since April 2023, an £800,000 investment for Safer Staffing has been provided to the City and Hackney directorate within ELFT. The benefits of the increased investment will be reduced reliance on temporary staffing at times of high acuity and better resourced teams to meet the needs of service users. In addition to this we have reviewed our recruitment strategy and processes.” Source location Response from East London NHS Foundation Trust
Open published response
25 Jan 2023 Andrew Mark Largin · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Lack of shared understanding of neighbourhood team patient-contact response times View source Failure to identify decision makers’ reasoning and shared misconceptions after safety incidents View source Delays in neighbourhood team allocation after discharge View source Lack of clarity about neighbourhood team referral back to the crisis team View source Failure to document hot debriefs in notes or medical records View source Failure of the crisis team to reassess patients and reopen crisis-team cases when clinically indicated View source Failure of ELFT managers to discuss crisis-team decision making with the decision maker View source Failure to record reasons for crisis-team pathway decisions View source Failure of serious incident investigations to interview relevant decision makers and provide feedback View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Mark Largin · 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
Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding of neighbourhood team patient-contact response times
Wider context from the report “8. The SI review also did not identify that members of the crisis team and the neighbourhood team did not share an understanding of how quickly the neighbourhood team aims to make contact with patients , to assist in their decision making about the correct pathway for a patient. In fact, a member of the neighbourhood team itself gave evidence about the response times that, I was told later, was not correct .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify decision makers’ reasoning and shared misconceptions after safety incidents
Wider context from the report “7. Thus, nobody from ELFT found out what the decision maker’s thinking had been, or what misconceptions she might have had that other staff members might share . The former crisis team member who made the decision still works for ELFT. As far as I could ascertain, her decision making concerning Mr Largin has never been discussed with her by ELFT managers.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in neighbourhood team allocation after discharge
Wider context from the report “1. The ELFT serious incident (SI) review report identified that, although Mr Largin was discharged to the Woodberry Wetlands neighbourhood rehabilitation team from the crisis (i.e. home treatment) team on 25 January 2022, the neighbourhood team did not allocate him to a team member until 3 February .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about neighbourhood team referral back to the crisis team
Wider context from the report “9. Finally, the operations lead for the neighbourhood team had great difficulty in giving me clear evidence about whether his team would or could refer a patient back to the crisis team if they felt the circumstances warranted . He demonstrated a lack of clarity on the point that I found very concerning.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document hot debriefs in notes or medical records
Wider context from the report “6. It is believed, I was told, that there was a hot de-brief after Mr Largin’s death. However, no notes were made of that and no entry was made on Mr Largin’s medical record .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the crisis team to reassess patients and reopen crisis-team cases when clinically indicated
Wider context from the report “2. The report also identified that, despite receiving an email from the Homerton University Hospital community rehabilitation team on 2 February, saying that Mr Largin had been seen on 1 February and was still very depressed, the crisis team failed to reassess him or to re-open his case to the crisis team , but instead referred the community team to the neighbourhood team.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ELFT managers to discuss crisis-team decision making with the decision maker
Wider context from the report “7. Thus, nobody from ELFT found out what the decision maker’s thinking had been, or what misconceptions she might have had that other staff members might share. The former crisis team member who made the decision still works for ELFT. As far as I could ascertain, her decision making concerning Mr Largin has never been discussed with her by ELFT managers .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record reasons for crisis-team pathway decisions
Wider context from the report “3. However, the SI report did not identify that the crisis team member who made the decision on 2 February simply to advise that Mr Largin should be dealt with by the neighbourhood team failed to record any reasons for her decision .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to interview relevant decision makers and provide feedback
Wider context from the report “4. The SI reviewer giving evidence in court said that the SI reviewing team had not even spoken to that crisis team member as part of their investigation, let alone fed back to her .
5. He said they did not at the time realise that she still worked for ELFT, though he accepted that it would have been an extremely straightforward matter to find out. The crisis team member’s manager gave evidence that she thought the relevant decision maker had left the team before Mr Largin’s death, so between 3 and 6 February 2022. When I invited that manager to make a call while the inquest was ongoing to check, she later told me that the team member had not left the crisis team until 29 April 2022.
” 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 Resume regular Neighbourhood Team and Crisis Pathway meetings and produce an action plan to communicate shared referral processes and criteria.
Verbatim wording from the response “Additionally, the Deputy Borough Director for City and Hackney has confirmed that the Neighbourhood Teams and Crisis Pathway teams (which includes HTT) are resuming their regular pathways meeting on 7 April 2023. They will produce an action plan around communicating a shared understanding of referral process and criteria.” Source location Response from East London NHS Foundation Trust
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 Require Serious Incident reviewers to consider integrated working practices between different services during quality assurance.
Verbatim wording from the response “I have considered that the Trust SI review failed to highlight that there was no shared understanding between the HTT and the WWNT about referral timelines and I agree that this should have been explored.” Source location Response from East London NHS Foundation Trust
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 a six-month rolling training programme for Neighbourhood Teams on clinical risk, referral processes, and risk indicators.
Verbatim wording from the response “Further, the Trust is implementing a training programme for all Neighbourhood Teams to highlight issues of clinical risk when triaging incoming referrals. This programme, due to start on 22 March 2023, will run monthly for 6 months in a rolling fashion. Its aim is to train staff and maintain a constant discussion in how to think about complex issues of risk for patients referred to the Neighbourhood Teams, whether that is from Crisis Pathway Teams (which include HTT), GPs, or elsewhere. It will use didactic teaching, role play with actors, sample cases, discussion, and reflection, and will be facilitated by an experienced Consultant Psychiatrist, as well as the Associate Clinical Director for the Neighbourhood Teams. An important part of this training will be to improve understanding of referrals and risk signifiers from the Crisis Team to the Neighbourhood Team.” Source location Response from East London NHS Foundation Trust
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 Review how learning from incidents is investigated and recorded through implementation of the Patient Safety Incident Response Framework.
Verbatim wording from the response “5. HOT DE-BRIEF RECORD” Source location Response from East London NHS Foundation Trust
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 Amend the Serious Incident reviewer responsibilities document to require relevant staff to be contacted through Human Resources for review involvement.
Verbatim wording from the response “I was troubled that the Trust’s SI review did not highlight that the relevant crisis team member did not record their rationale explaining why Mr Largin should remain with WWNT. I asked the Trust’s Associate Director of Governance and Risk to explore this further.” Source location Response from East London NHS Foundation Trust
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 Existing procedures are considered sufficient for neighbourhood team clinicians to refer service users back to the crisis team when necessary.
Verbatim wording from the response “7. Referral to Crisis Team” Source location Response from East London NHS Foundation Trust
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 Hot debriefs are not recorded in clinical notes because they are informal staff-support processes; learning is captured through 48-hour and serious incident reports.
Verbatim wording from the response “Following serious incidents such as violence, aggression or death, clinical teams at the Trust hold a debrief as soon after the incident as is practicable. The debrief is usually facilitated by the manager or the team psychologist to explore thoughts and feelings around the incident, the impact on staff, the service user and the team. These incidents are not documented in the clinical notes as it is focused on initial staff reactions and is not a formal process to look at lessons learned.” Source location Response from East London NHS Foundation Trust
Open published response
20 Jan 2023 Sophia Ayuk · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to assess inpatient patients for venous thromboembolism risk View source Failure to adequately monitor and record patients’ food and fluid intake View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sophia Ayuk · 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
Sophia Ayuk, who had treatment-resistant schizophrenia and was an inpatient, became motionless and unresponsive on 18 March 2022, later deteriorated and died despite resuscitation. The inquest narrative attributed her death to a pulmonary embolism following a deep vein thrombosis, and recorded that she had not taken food or drink for at least two days. The principal concerns were that VTE risk was not assessed during either period of inpatient care and that food and fluid intake monitoring was not adequately followed.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess inpatient patients for venous thromboembolism risk
Wider context from the report “1. At no time during the two periods of Ms Ayuk’s inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately monitor and record patients’ food and fluid intake
Wider context from the report “2. Instructions given to monitor and record Ms Ayuk’s food and fluid intake were not adequately followed .
” 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 Disseminate a VTE screening and assessment clinical alert across the Trust.
Verbatim wording from the response “2) A VTE Screening and Assessment Clinical Alert was disseminated across the Trust;” Source location Response from East London NHS Foundation Trust
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 Add VTE assessment information to new-doctor induction and the junior doctors’ handbook.
Verbatim wording from the response “3) Changes were made to the new doctors’ induction and junior doctors handbook to include information on VTE assessments;” Source location Response from East London NHS Foundation Trust
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 Review the Trust’s VTE policy.
Verbatim wording from the response “I understand that you heard oral evidence at inquest that the Trust proposed the following actions to ensure that VTE risk assessments are undertaken in accordance with the Trust’s policy and best clinical practice:” Source location Response from East London NHS Foundation Trust
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 Trial Power BI and use it to monitor compliance with VTE risk assessments.
Verbatim wording from the response “7) The Trust has been trialling Power BI (a data analytics tool) in order to monitor compliance with VTE risk assessments.” Source location Response from East London NHS Foundation Trust
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 Employ an Advanced Clinical Practitioner as Consultant Nurse in Physical Health to review in-patient physical health and address concerns in daily safety huddles.
Verbatim wording from the response “1) An Advanced Clinical Practitioner (ACP) has started in the role of Consultant Nurse in Physical Health at NCFMH. She reviews physical health on the in-patient wards. If she has concerns about the physical health of in-patients, including around VTE assessments, she addresses them with staff during daily, morning safety huddles.” Source location Response from East London NHS Foundation Trust
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 Add antipsychotic medication as a consideration in the VTE assessment tool.
Verbatim wording from the response “4) Anti-psychotic medication has been added as a consideration on the Trust’s VTE assessment tool;” Source location Response from East London NHS Foundation Trust
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 Conduct weekly matron night checks including review of food and fluid charts.
Verbatim wording from the response “2) Matrons now do weekly night checks that include review of food/fluid charts.” Source location Response from East London NHS Foundation Trust
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 Add RiO pop-up reminders prompting VTE risk assessment when patients’ presentations change.
Verbatim wording from the response “2) The Trust’s electronic medical records system (RiO) was updated to include a pop-up reminder to seek a VTE risk assessment if someone’s presentation changes every time nurses update the Observations and Measurements Form.” Source location Response from East London NHS Foundation Trust
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 Include food and fluid charts in the monthly physical health training programme.
Verbatim wording from the response “3) The Trust introduced a series of training measures in relation to nutrition on in-patient wards:” Source location Response from East London NHS Foundation Trust
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 Use a new decision-making template for commencing or terminating food and fluid chart monitoring.
Verbatim wording from the response “3) A new template for decision making for commencing/terminating food and fluid chart monitoring has been developed and is in use.” Source location Response from East London NHS Foundation Trust
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 Include VTE risk in the monthly physical health training programme.
Verbatim wording from the response “5) The Trust’s monthly two day physical health training programme now includes a session on VTE risk; and” Source location Response from East London NHS Foundation Trust
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 Conduct daily senior-nurse checks of food and fluid charts for completion.
Verbatim wording from the response “Since you expressed your concerns in the Regulation 28 report, NCFMH has undertaken the following additional steps to address the issue of staff compliance with food and fluid chart completion:” Source location Response from East London NHS Foundation Trust
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 a nutrition policy emphasizing food and fluid monitoring for in-patients.
Verbatim wording from the response “1) The Trust implemented a new nutrition policy that highlights the importance of food and fluid monitoring for in-patients;” Source location Response from East London NHS Foundation Trust
Open published response
28 Sep 2022 Donna Neill · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to put risk management plans in place for identified medication-taking risks View source Failure to fully assess identified medication-taking risks View source Failure to document identified medication-taking risks in mental health records View source Failure of internal investigations to identify and address deficiencies in risk assessment and management systems View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Donna Neill · 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
Donna Neill was found deceased at home on 10 December 2018 after an overdose involving medication prescribed to her husband. The report identified that the risk of her taking medication not prescribed to her was not fully assessed, documented, or managed, and that no risk management plan was put in place.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to put risk management plans in place for identified medication-taking risks
Wider context from the report “A clear risk was raised at the CPA meeting on the 4th December 2018. This was the risk of Donna taking medications prescribed to her husband. This risk was not documented in the Trust’s mental health records, not fully assessed and no risk management plan was put in place to protect Donna from harm .
The absence of a risk assessment and management plan was not identified as a failing within the Trust’s internal investigation report and no steps have been taken by the Trust to improve the systems in place.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully assess identified medication-taking risks
Wider context from the report “A clear risk was raised at the CPA meeting on the 4th December 2018. This was the risk of Donna taking medications prescribed to her husband. This risk was not documented in the Trust’s mental health records, not fully assessed and no risk management plan was put in place to protect Donna from harm.
The absence of a risk assessment and management plan was not identified as a failing within the Trust’s internal investigation report and no steps have been taken by the Trust to improve the systems in place.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document identified medication-taking risks in mental health records
Wider context from the report “A clear risk was raised at the CPA meeting on the 4th December 2018. This was the risk of Donna taking medications prescribed to her husband. This risk was not documented in the Trust’s mental health records , not fully assessed and no risk management plan was put in place to protect Donna from harm.
The absence of a risk assessment and management plan was not identified as a failing within the Trust’s internal investigation report and no steps have been taken by the Trust to improve the systems in place.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to identify and address deficiencies in risk assessment and management systems
Wider context from the report “A clear risk was raised at the CPA meeting on the 4th December 2018. This was the risk of Donna taking medications prescribed to her husband. This risk was not documented in the Trust’s mental health records, not fully assessed and no risk management plan was put in place to protect Donna from harm.
The absence of a risk assessment and management plan was not identified as a failing within the Trust’s internal investigation report and no steps have been taken by the Trust to improve the systems in place .
” Open source report
Concerns raised 7 Failure to ensure medical review of escalated chest pain View source Failure to assess inpatients for venous thromboembolism risk View source Failure to disclose the DNACPR error to investigating police officers View source Failure of nursing cardiac-arrest response to follow resuscitation guidelines View source Failure to record the DNACPR error in the incident report View source Failure to disclose the DNACPR error to the family under the Duty of Candour View source Failure to escalate episodes of raised blood pressure for medical review View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Delina Etienne · 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
Delina Etienne, who had schizo-affective disorder and was an inpatient receiving treatment, was found unresponsive in bed on 7 May 2021 and was declared deceased at the scene. The report identifies concerns about the chaotic response to her cardiac arrest, including failure to follow resuscitation procedures and an erroneous assumption that a DNACPR order was in place. It also identifies concerns about failures to escalate raised blood pressure and chest pain, assess VTE risk, and disclose the resuscitation error.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical review of escalated chest pain
Wider context from the report “4. An episode of chest pain identified by nursing staff on 21st April 2021 was escalated for medical review, no evidence of such a review exists .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess inpatients for venous thromboembolism risk
Wider context from the report “3. At no time during the two periods of Mrs Etienne’s inpatient care was she assessed for venous thromboembolism (VTE) risk in contravention of trust policy.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose the DNACPR error to investigating police officers
Wider context from the report “5. When nursing staff discovered that they had fallen into error by asserting that Mrs Etienne had a DNACPR in place the matter was discussed with ward management on the morning of 7th May 2022. Despite that, the error was not admitted ;
A. To officers of the Metropolitan Police who investigated the circumstances of the death that morning ,
B. To the Trust’s governance team – an incident report (DATIX) failed to mention the error,
C. To Mrs Etienne’s family who, subject to the Trust’s statutory “Duty of Candour” were communicated with by telephone and in person on 7th May 2021 and in written correspondence on 10th May 2021
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing cardiac-arrest response to follow resuscitation guidelines
Wider context from the report “1. The response of the nursing team to a cardiac arrest was chaotic , and failed to follow trust and national guidelines designed to maximise the effectiveness of resuscitation .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the DNACPR error in the incident report
Wider context from the report “5. When nursing staff discovered that they had fallen into error by asserting that Mrs Etienne had a DNACPR in place the matter was discussed with ward management on the morning of 7th May 2022. Despite that, the error was not admitted;
A. To officers of the Metropolitan Police who investigated the circumstances of the death that morning,
B. To the Trust’s governance team – an incident report (DATIX) failed to mention the error ,
C. To Mrs Etienne’s family who, subject to the Trust’s statutory “Duty of Candour” were communicated with by telephone and in person on 7th May 2021 and in written correspondence on 10th May 2021
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose the DNACPR error to the family under the Duty of Candour
Wider context from the report “5. When nursing staff discovered that they had fallen into error by asserting that Mrs Etienne had a DNACPR in place the matter was discussed with ward management on the morning of 7th May 2022. Despite that, the error was not admitted ;
A. To officers of the Metropolitan Police who investigated the circumstances of the death that morning,
B. To the Trust’s governance team – an incident report (DATIX) failed to mention the error,
C. To Mrs Etienne’s family who, subject to the Trust’s statutory “Duty of Candour” were communicated with by telephone and in person on 7th May 2021 and in written correspondence on 10th May 2021
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate episodes of raised blood pressure for medical review
Wider context from the report “2. Whilst Mrs Etienne was an inpatient, the ward failed to escalate episodes of raised blood pressure for medical review in contravention of trust policy.
” 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 Include chest-pain management in annual staff competency training.
Verbatim wording from the response “paramedics. This training will become part of the year updated competency training for staff.” Source location Response from East London NHS Foundation Trust
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 Train Cazaubon Ward staff to escalate chest pain as a medical emergency and manage it using monitoring, oxygen and paramedic preparation.
Verbatim wording from the response “Training was undertaken regarding the correct escalation of a patient with chest pain at the Cazaubon Ward away day on 23.06.2022. A separate training programme was completed for all staff on an individual basis. This covered the requirement for a staff member to stay with the patient and manage chest pain like any other medical emergency, calling for the immediate attendance of a doctor or emergency services, continual monitoring of vital signs, the use of oxygen and preparing information for” Source location Response from East London NHS Foundation Trust
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 Amend resuscitation policy to emphasise RiO recording, CPR communication and early defibrillator use.
Verbatim wording from the response “The author of the Trust policy for resuscitation will amend the policy to emphasise the correct procedure for recording in RiO and communicating CPR, and the use of a defibrillator at the earliest opportunity.” Source location Response from East London NHS Foundation Trust
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 further Immediate Life Support training to the two staff members involved in the incident.
Verbatim wording from the response “The Trust identified particular concerns about two members of staff involved in the incident. The two members of staff have subsequently attended further Immediate Life Support Training. The training highlights the action to be taken by a staff member who finds a patient/person in a physical health emergency including a person with no pulse or other life signs. It teaches staff how to start compressions, get help, apply, and use an automated defibrillator machine (AED), check the paper copy of any do not attempt resuscitation prescription, call for an emergency ambulance and continuing resuscitation until paramedics take over and make any decision about discontinuing that attempt.” Source location Response from East London NHS Foundation Trust
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 Amend physical-health policy to require admission VTE screening and correct RiO recording.
Verbatim wording from the response “The author of the Trust policy for physical healthcare will amend the policy to emphasise that all patients need to have a VTE risk screening assessment undertaken on admission and the correct procedure for recording this in RiO.” Source location Response from East London NHS Foundation Trust
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 Amend nurses’ physical-health assessment to include VTE screening and complete screens through weekly audit processes.
Verbatim wording from the response “The nurses’ physical health assessment is being amended to include a VTE screening assessment which would require a medical assessment to be completed if a risk was identified. Once this has been amended Cazaubon wards nursing staff will complete a screen for each patient as part of the wards weekly audit programme.” Source location Response from East London NHS Foundation Trust
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 Train staff on NEWS2 blood-pressure updates and revise NEWS2 scoring and recording templates in RiO.
Verbatim wording from the response “NEWS 2-update training on blood pressure has been undertaken by 62 staff, and NEWS 2 scores template and recording within the RiO medical records has now been revised.” Source location Response from East London NHS Foundation Trust
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 Undertake VTE assessments for all Cazaubon Ward admissions and audit completion weekly.
Verbatim wording from the response “All patients have a VTE assessment undertaken on admission to Cazaubon Ward. This was audited on 03.11.22 and will continue to be audited weekly. A request has been made to have the Trust’s automated reporting system updated to facilitate the ability to run a report on each wards VTE screening assessments.” Source location Response from East London NHS Foundation Trust
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 Discuss resuscitation policy and emergency-management topics during Cazaubon Ward staff away days.
Verbatim wording from the response “The existing Trust policy on ‘Resuscitation’ has been discussed at Cazaubon Ward staff away days organised by the Cazaubon ward Matron and the following topics were discussed:” Source location Response from East London NHS Foundation Trust
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 Enable automatic RiO alerts for physical-health observations outside expected limits, including action guidance.
Verbatim wording from the response “The electronic recording system for NEWS 2 now has automatic alerts for all physical health observations recorded which are outside expected limits. This highlights any concern and advises on action to be taken by the person entering the readings.” Source location Response from East London NHS Foundation Trust
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 Conduct monthly physical-health simulation training across inpatient units and continue emergency simulations on Cazaubon Ward.
Verbatim wording from the response “Physical health simulations training is facilitated across the ELFT Trust inpatient units. Simulation training sessions are being undertaken at least monthly in all units. Emergency simulations have also taken place on Cazaubon Ward on the following dates and are ongoing.” Source location Response from East London NHS Foundation Trust
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 Add a weekly ward-managers agenda item to plan East Ham Care Centre simulation exercises.
Verbatim wording from the response “From 10.10.22 a weekly ward managers meeting now has an agenda item to plan a simulation exercise for that week within the East Ham Care Centre unit.” Source location Response from East London NHS Foundation Trust
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 Include CPR status formally in every Cazaubon Ward nursing-shift handover.
Verbatim wording from the response “CPR status is now a formal part of the handover for each nursing shift on Cazaubon Ward.” Source location Response from East London NHS Foundation Trust
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 Cazaubon Ward staff training on elevated blood-pressure assessment and repeat measurement.
Verbatim wording from the response “A training template was created and reviewed with each Cazaubon Ward staff member in May 2022.” Source location Response from East London NHS Foundation Trust
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 Request an automated reporting-system update to enable ward-level VTE screening reports.
Verbatim wording from the response “All patients have a VTE assessment undertaken on admission to Cazaubon Ward. This was audited on 03.11.22 and will continue to be audited weekly. A request has been made to have the Trust’s automated reporting system updated to facilitate the ability to run a report on each wards VTE screening assessments.” Source location Response from East London NHS Foundation Trust
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 an electronic DNACPR alert in RiO as a secondary aid.
Verbatim wording from the response “A DNACPR electronic alert is now available within the RiO medical records as a secondary aid.” Source location Response from East London NHS Foundation Trust
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 Advise Cazaubon Ward staff to use the DNACPR forms red folder as the first emergency reference.
Verbatim wording from the response “All Cazaubon Ward staff have been advised on the location of the DNACPR forms red folder, and that this is the first point of reference in a medical emergency.” Source location Response from East London NHS Foundation Trust
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 Cazaubon Ward blood-pressure management monthly.
Verbatim wording from the response “Monthly audits of the ward in relation to management of blood pressure started in May 2022 and are ongoing.” Source location Response from East London NHS Foundation Trust
Open published response
25 May 2022 Ian Michael Cockfield · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure to review falls risk assessments on arrival at a mental health ward View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ian Michael Cockfield · 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
Ian Michael Cockfield died in hospital on 12 July 2021 after collapsing and sustaining a cardiac arrest despite resuscitative efforts. The report raised concern that, after transfer to a mental health ward, his falls risk assessment was not reviewed and he subsequently fell while mobilising unsupervised, sustaining a serious head laceration.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review falls risk assessments on arrival at a mental health ward
Wider context from the report “1. On Sunday 11th July 2021, Mr Cockfield was discharged from hospital after treatment. The patient was discharged to a mental health ward at a different hospital. Upon arrival at the mental health ward at 16.00hrs, a review of the patient’s falls risk assessment was not undertaken . The following day, Mr Cockfield suffered a fall whilst mobilising, unsupervised by staff. Mr Cockfield sustained a serious laceration to his head.
” 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 Review and update the Physical Health Care and Slips, Trips and Falls policies to clarify falls-assessment requirements and timeframes.
Verbatim wording from the response “As a consequence of your specific concern about the falls assessment not being completed, the Trust is reviewing its Physical Health Care Policy and its Slips, Trips and Falls Policy.” Source location Response from East London NHS Foundation Trust
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 Open adult mental-health multidisciplinary huddles to occupational therapists and monitor completion of identified falls assessments.
Verbatim wording from the response “Daily Multi-Disciplinary Team huddles on the adult mental health wards in Newham have been opened to Occupational Therapists to ensure that falls risk assessments are being undertaken in more complex cases. There is a daily process of monitoring actions from the huddles which ensures the completion of the falls assessments that were identified to be undertaken.” Source location Response from East London NHS Foundation Trust
Open published response
16 May 2022 Mr Thomas Antony Smith · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure to ensure escorting staff receive and review patient-specific risk information before s.17 leave View source Lack of staff knowledge and training about substance-related dangers and presentations in detained mental health settings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Thomas Antony Smith · 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
Mr Thomas Antony Smith died in a drugs-related death after serious failings in his care on Coral Ward during the night of 29–30 December 2020. The principal concerns were inadequate staff knowledge about the dangers and presentation of drugs, insufficient observation and escalation after a positive drugs test and signs of deterioration, and weaknesses in the system for assessing risks associated with Section 17 leave.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure escorting staff receive and review patient-specific risk information before s.17 leave
Wider context from the report “2) The system for assessing risks associated with s.17 leave
I was told that, when a staff member is escorting a service user out of the ward, there is an expectation for that staff member to be aware of the location, general mental state and wellbeing of the service user; and that a ‘mental state assessment’ should be carried out on the ward prior to leave taking place, as a further safeguard once s.17 leave had been granted.
However, the evidence of the healthcare assistant who took Mr Smith out on leave, on the occasion (29 December 2020) that the jury concluded it was possible that he was able to buy the ████████ the misuse of which caused his death, was that:
(i) He would not necessarily read a patient’s RiO (electronic continuous) notes before taking a patient out on leave;
(ii) He had not read Mr Smith’s care plan before taking him on leave;
(iii) There had been no handover from other staff to him of Mr Smith’s presentation on 28 December 2020 presentation (when he was suspected of being ‘under the influence’ of a substance); and
(iv) Although he had read the form authorising Mr Smith’s leave (i.e. the s.17 form), that form – a statutory document – does not contain information about particular risks posed to a patient by or when out on s.17 leave.
As a result of the above, this particular healthcare assistant was unaware that:
(i) On 28 December 2020 Mr Smith had been suspected of being under the influence of drugs;
(ii) Mr Smith’s care plan of 20 December 2020 set out as a ‘risk issue’ the fact that “Thomas has a history of using illicit substances”; and
(iii) The care plan set out as an ‘intervention’ for Mr Smith: “Nursing staff to do random urine drug screening and breathalysing upon return to the ward.”
The healthcare assistant therefore appears to have been in a position of escorting a patient on leave without knowledge of a patient’s very recent potential drug-related presentation, or of a specified intervention aimed at reducing the risk posed to that patient by drugs as set out in his care plan.
There was, however, no suggestion in the evidence of any witness during Mr Smith’s inquest that the situation in which the escorting healthcare assistant found himself represented a failure to follow policy or expected procedure. In the event that this is correct there appears to be a wider issue – and this Report is therefore directed to NHS England and NHS Improvement.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge and training about substance-related dangers and presentations in detained mental health settings
Wider context from the report “1) Knowledge of the dangers of ████████ in detained mental health patient settings
There was evidence of steps having been taken by the ELFT at a local level to remedy the apparent lack of knowledge amongst its staff regarding the dangers of ████████ and ████████ after Mr Smith’s death, including its own substance misuse training and inviting local substance misuse charities back onto its wards to work with its patients and staff as Covid restrictions lift.
There was, however, various evidence which suggested a lack of knowledge from ELFT staff around ████████ and it’s potentially fatal effects , including that several witnesses:
(i) Did not know what ████████ or ████████ could look like;
(ii) Were unaware of how a person under the influence of ████████ or ████████ might present; and
(iii) Had received no training on the dangers of ████████ or ████████
There was some evidence that this might be a wider issue of concern, both locally and nationally, than only with ELFT staff. In the event that is correct, this report is directed to NHS England and NHS Improvement.
” Open source report
18 Mar 2022 Gary OTTWAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 8 Failure to report poor visibility through a seclusion-room observation panel View source Failure to perform chest compressions on the chest during resuscitation View source Unavailability of the emergency grab bag at the resuscitation location View source Failure of nursing staff to enter the seclusion room without a doctor present during an emergency View source Delays in calling the rapid response team when non-respiration is suspected View source Failure to provide constant and effective nursing observation View source Inadequate resuscitation training and emergency-equipment familiarity among the only available doctor View source Failure to enter a seclusion room promptly when non-respiration is suspected View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gary OTTWAY · 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
Gary Ottway, aged 41, died after being found in cardiac arrest while detained alone in a seclusion room under constant nursing observation during a severe mental health episode. The report raised concerns about whether observation was constant or effective, delays in entering the room and obtaining emergency equipment, gaps in available medical training and resources, and ineffective chest compressions. The inquest determined that he died from natural causes involving two heart conditions.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report poor visibility through a seclusion-room observation panel
Wider context from the report “3. The senior duty nurse also told me that the visibility through the Perspex panel was poor , though he had never brought this to anyone’s attention and did not do so after Mr Ottway’s death .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform chest compressions on the chest during resuscitation
Wider context from the report “8. When paramedics arrived, they found that chest compressions were being given (by nursing staff) to Mr Ottway’s abdomen instead of his chest , thus rendering them ineffective .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the emergency grab bag at the resuscitation location
Wider context from the report “6. In the six and a half to seven minutes before the junior doctor arrived at the seclusion room, the emergency grab bag had not . That took another 30 seconds , though to retrieve it was only a three minute round trip from the room where the nurses who had first identified the lack of respiration were waiting.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to enter the seclusion room without a doctor present during an emergency
Wider context from the report “5. The junior doctor was the last person to attend the resuscitation and told me he did so after the rapid response team, yet no one had entered the seclusion room by the time he arrived .
It may be that there was a (perhaps unconscious) reluctance to enter the room without a doctor, despite the presence of the rapid response (nursing) team . But by the time the junior doctor got to the door (and immediately identified that Mr Ottway was not breathing, at least six and a half to seven minutes had elapsed since the first two nurses saw no evidence of respiration. This was well outside the three to four minute window of opportunity for resuscitation without inevitable brain damage or death.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in calling the rapid response team when non-respiration is suspected
Wider context from the report “4. The senior duty nurse told me that the nurses would not enter the seclusion room until the rapid response team was present, but he did not call the rapid response team as soon as he suspected that Mr Ottway was not breathing . Instead, he started by going to get one of the other nurses, which took a couple of minutes; then he rang the duty doctor; and only after that did he radio for the rapid response team .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide constant and effective nursing observation
Wider context from the report “1. Though Mr Ottway was meant to be under constant nursing observation, not only was he in cardiac arrest but he was also cold and exhibiting hypostasis when he was found. This appears to indicate that either the nursing observation was not constant, or it was not effective. I appreciate that the trust is putting in place a new IT system to monitor signs of life, but nevertheless basic nursing observations must be performed competently .
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate resuscitation training and emergency-equipment familiarity among the only available doctor
Wider context from the report “7. The junior (and only) doctor called to assist in the attempted resuscitation was not familiar with the contents of the emergency grab bag , told me that it would not have occurred to him to ask for any equipment to assist with ventilations other than a pocket mask , and explained that he was not trained in giving adrenaline or any other medicines for resuscitation .
As he was the only medical resource available in the case of an emergency, these seem significant gaps.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enter a seclusion room promptly when non-respiration is suspected
Wider context from the report “When the senior duty nurse and the nurse undertaking continuous observation noted that they could not see evidence of respiration, they did not immediately enter the seclusion room where Mr Ottway lay, because they deemed that unsafe following his earlier violent behaviour .
” Open source report
15 Feb 2022 Mr Jason Lennon · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure to effectively review medical records before assessment View source CRT staff performance falling below regulator standards View source Failure to adequately document important information arising from assessment View source Failure to monitor whether patients are on care pathways appropriate to their needs View source Failure of governance processes to complete serious incident investigation action plans View source Failure to evidence consideration of necessary referrals to a regulator View source Failure to communicate important clinical information between CRT staff and external stakeholders View source Failure to assess mental state, relapse and risk of harm View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Jason Lennon · 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
Jason Lennon, a 37-year-old man living in supported accommodation, died on 31 July 2019 after being found unresponsive while restrained in a prone position by security officers at the Excel Centre; resuscitation efforts later ceased in hospital. The concerns included failures in community mental health care, including inadequate monitoring, assessment, communication and documentation, and the extent and manner of the restraint used by security officers. The report also identified deficiencies in the Trust’s serious incident action plan and uncertainty about whether regulatory referral had been considered.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively review medical records before assessment
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation CRT staff performance falling below regulator standards
Wider context from the report “4. Accepted individual failings by staff within the CRT fall below standards set by their regulator. There is no evidence before the court to assess whether ELFT have considered the necessity to make a referral to a regulator.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately document important information arising from assessment
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor whether patients are on care pathways appropriate to their needs
Wider context from the report “1. Expert psychiatric evidence indicated that Mr Lennon was a suitable candidate for the Care Programme Approach mental health pathway and that the use of this pathway would have reduced the risk of an acute deterioration in his mental state. The CRT failed to effectively monitor whether Mr Lennon was on a care pathway appropriate to his needs.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of governance processes to complete serious incident investigation action plans
Wider context from the report “3. The Trust undertook a serious incident investigation report into the events leading to Mr Lennon’s death in November 2019 which made a series of recommendations for action. The action plan was found to have been incomplete by 6/2/22 due to errors attributable to the Trust’s governance team.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to evidence consideration of necessary referrals to a regulator
Wider context from the report “4. Accepted individual failings by staff within the CRT fall below standards set by their regulator. There is no evidence before the court to assess whether ELFT have considered the necessity to make a referral to a regulator.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate important clinical information between CRT staff and external stakeholders
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess mental state, relapse and risk of harm
Wider context from the report “2. The CRT undertook a flawed review of Mr Lennon’s mental state on 29/7/19 which failed to assess that, Jason was in relapse and was a risk of harm to himself and others.
Factors which contributed to this failure included;
a. CRT staff did not effectively review medical records prior to assessing Jason,
b. The CRT did not communicate important clinical information between themselves and external stakeholders.
c. The CRT did not adequately document important information arising from the assessment.
” Open source report
Concerns raised 2 Inadequate transition arrangements for individuals with high functioning autism reaching adulthood View source National gap in transition services for individuals with high functioning autism View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Richard WILDEN · 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
Luke Richard WILDEN was a vulnerable adult with high functioning autism and ADHD who, after turning 18, was not effectively transitioned from child to adult mental health services or provided with an appropriate social care package. He moved to independent living on 2 January 2020, experienced declining mental health and drug misuse, and was found deceased in his flat on 22 May 2020 after being discharged from psychiatric inpatient care. The principal concerns were inadequate transition arrangements within ELFT and a possible wider national gap in services.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate transition arrangements for individuals with high functioning autism reaching adulthood
Wider context from the report “Transition arrangements within ELFT for individuals with high functioning autism were inadequate when Luke turned 18 and, as a result, he was not transferred to the appropriate adult mental health team for continued treatment and to enable provision of an appropriate adult social care package, including suitable accommodation for him . Whilst I understand that changes have been made within ELFT in order to address this gap in services, I am concerned that these may still not be sufficient . Furthermore, I am concerned that this gap in services may also exist on a national level.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation National gap in transition services for individuals with high functioning autism
Wider context from the report “Transition arrangements within ELFT for individuals with high functioning autism were inadequate when Luke turned 18 and, as a result, he was not transferred to the appropriate adult mental health team for continued treatment and to enable provision of an appropriate adult social care package, including suitable accommodation for him. Whilst I understand that changes have been made within ELFT in order to address this gap in services, I am concerned that these may still not be sufficient. Furthermore, I am concerned that this gap in services may also exist on a national level .
” 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 Participate in the multi-agency task group identifying transition gaps across local authority and health services.
Verbatim wording from the response “There is currently a safeguarding adults review (SAR) taking place in relation to Mr Wilden’s case. Bedford Borough Council safeguarding has requested a specific joint multi-agency, task and finish group (Task Group) to identify gaps in transitions across local authority and health. The findings will be fed back to the safeguarding board. The Trust is taking an active role in the SAR and the Task Group. Any significant findings will be fed into Trust Policy.” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
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 Outline a proposal to establish a strategic multi-agency transitions forum to the three named local authorities by 31 March.
Verbatim wording from the response “As part of the newly appointed Strategic Transitions Lead’s role, ELFT will propose a strategic multi-agency forum be established with all key partners, particularly its local authority partners, to ensure that transitions retains a system wide focus and that leadership can be provided on a collaborative basis, to the many teams and services that have the potential to interface with a young person and their family carers during their journey to adulthood.” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
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 Review the serious incident report and transition policy and protocols with relevant CAMHS staff.
Verbatim wording from the response “I understand that you heard oral evidence at the inquest into Mr Wilden’s death that the Trust’s Bedford and Luton Directorate have already taken measures to reinforce its transition policy and protocols.” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
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 Increase transition-support staffing for autistic young people through a dedicated worker, an additional worker and two further support workers.
Verbatim wording from the response “To assist staff in reinforcing the transition policies and protocols outlined above, the Trust has also increased its capacity for supporting transitions from CAMHS to adult mental health and social care services. I understand that at the inquest you received submissions outlining various changes that the Trust had already undertaken specifically in relation to transition arrangements for individuals with high-functioning autism.” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
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 Revamp the Bedford and Luton Transition Policy with current protocols and joint CAMHS and adult mental health input, then review and reinforce it after completion.
Verbatim wording from the response “Additionally, Bedford and Luton’s Transition Policy has come up for review. A decision has been made that the policy be revamped to include the latest transition protocols with both CAMHS and Adult Mental Health services feeding into the final document. It is anticipated that this will be complete on 14 April 2022. The new policy will be reviewed at the first CAMHS away day following completion and reinforced through supervisors via monthly supervision.” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
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 Identify CAMHS service users approaching adulthood monthly and discuss their transition planning at multidisciplinary team meetings.
Verbatim wording from the response “Additionally, since 31 December 2020, the administrator within each CAMHS team, pulls a list of all existing service users on a monthly basis. Those age 17.5 (6 months from their” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
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 Conduct quarterly transition audits, including cross-team audits, to identify improvements, share learning and promote better transitions.
Verbatim wording from the response “An audit was also undertaken. A sample of 5 patients were reviewed over a period of 3 months to assess services’ compliance with the protocols. All cases reviewed met the required targets.” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
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 Appoint a Strategic Transitions Lead to provide cross-agency leadership and maintain robust transition pathways.
Verbatim wording from the response “The Trust has just appointed a Strategic Transitions Lead. This role will provide system leadership across all agencies, including ensuring that robust transitions systems between children’s (CAMHS) and Adult Mental Health Care are maintained. They will also work with the relevant local authorities to ensure that robust transition pathways are in place across mental health services. They will ensure that the experience of the young person is at the heart of how the systems and processes develop and operate.” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
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 Include transition-policy performance monitoring in CAMHS supervisors’ monthly clinical supervision.
Verbatim wording from the response “CAMHS supervisors were also reminded of the importance of the transition policy and protocols and their monthly clinical supervision with staff members now includes performance monitoring of the transition policy and protocols.” Source location 2022-0015-Response-from-NHS-East-London-NHS-Foundation-Trust_Published
Open published response
5 Jan 2022 James EMMERSON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure to provide AMHP assessment before discharge from section 136 detention View source Ambiguity in guidance on required AMHP assessment under section 136 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
James EMMERSON · 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
James Emmerson, known as Jamie, was detained under section 136 of the Mental Health Act on 1 February 2019 but was discharged without being interviewed by an Approved Mental Health Professional. He was later detained at a police custody suite and died by hanging at home on 3 February 2019. The principal concern was confusion in the Code of Practice, which led to an interpretation that an Approved Mental Health Professional assessment was not required before discharge, exposing patients to significant risk including self-harm or suicide.
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. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide AMHP assessment before discharge from section 136 detention
Wider context from the report “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”).
The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders.
Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital.
Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”.
“The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment.
“The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.”
Jamie was never examined by an AMPH only by a lone section 12 approved
junior doctor and he was discharged from his s.136.
In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.”
This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises.
I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to.
” 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 East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguity in guidance on required AMHP assessment under section 136
Wider context from the report “1. Confusion generated by the Department of Health Guide “Mental Health Act 1983 Code of Practice” (“The Code”).
The Mental Health Act 1983 is the relevant Act under which persons may be assessed or detained when they are suspected or diagnosed as having one of a number of mental disorders.
Section 136 of the Mental Health Act 1983 is a power which allows police officers to remove a person who is in a place to which the public have access to a place of safety. Many mental health facilities have designated “section 136 suites” where the detained person can be taken for assessment. Jamie was in a public place when his psychiatric needs assessed by police were such that he needed to be taken to a place of safety. He was taken to the section 136 suite at the Luton and Dunstable University Hospital.
Section 136 (2) MHA 1983 provides that “A person removed to or kept at a place of safety under this section may be detained there for ........ the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an approved mental health professional and of making any necessary arrangements for his treatment or care”.
“The Code” (s 16.25) states: “The purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment.
“The Code” (s16.27) states: “The person should be assessed by a doctor and interviewed by an AMHP as soon as possible after the person is brought to the place of safety.”
Jamie was never examined by an AMPH only by a lone section 12 approved
junior doctor and he was discharged from his s.136.
In answer to the question as to why he was not examined by an AMPH s 16.50 of “The Code” was relied on which states: “If a doctor assesses the person and concludes that the person is not suffering from a mental disorder then the person must be discharged, even if not seen by an AMHP.”
This was interpreted as meaning that assessment by an AMPH was not a required formality. This was a deeply flawed interpretation but it is possible to see where the ambiguity arises.
I was told that this arrangement was “custom and practice” in Bedfordshire and Luton and also in other areas. Whether it was custom and practice or not I consider that the arrangement contravened both the spirit and the letter of the Mental Health Act 1983. It exposed patients to significant risk, including that of self harm or suicide by failing to provide adequate assessment prior to discharge from s. 136 detention. I was told that the position in Bedfordshire and Luton had been regularised by the time of the Inquest but I have no knowledge as to practice in the “other areas” referred to.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations