20 Oct 2021 Freeda GLAUSIUSZ · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to provide prompt and candid cooperation with coronial inquiries View source Failure to provide respectful, empathic listening during crisis-line conversations View source Failure to elicit clear risks during crisis-line conversations View source Failure to record crisis-line calls in the medical record View source Failure to assure appropriate action following serious crisis-line 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.
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AI-generated summary
Freeda GLAUSIUSZ · 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
Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.
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 prompt and candid cooperation with coronial inquiries
Wider context from the report “2. I heard at inquest that the clinician and his manager had listened to the recording of the call within days of the death and had recognised very significant shortcomings. However, the recording was not volunteered to my coroner’s officer . I was aware of the existence of the call only because ████████ told my officer about it.
• I received a copy of the recording of the call (without a transcript) the day before the inquest .
• I received a statement from the clinician who took the call the day before the inquest.
• I received statements from other ELFT clinicians in dribs and drabs earlier this month .
• I received a copy of the SI report the day before the inquest .
• I never received a copy of the 48 hour hot de-brief .
• Freeda Glausiusz died five months ago. My officer first requested witness statements and a copy of any internal investigation on 7 June, over four months ago, and asked for the statements to be provided by 20 August.
This chronology does not demonstrate an eagerness to promote a learning culture by ELFT. The failure to provide prompt and candid co-operation with my office obstructs the coronial inquiry , an inquiry that includes the function of learning from deaths. And it does not demonstrate respect for the family of the deceased.
” 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 respectful, empathic listening during crisis-line conversations
Wider context from the report “1. I was shocked when I listened to the recording of the call that █
████████ made to the crisis line the day before his daughter died.
The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation; did not listen to ████████; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis.
In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. ████████ was not taken seriously, he was not treated respectfully and he was not treated kindly . He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled .
The clinician then made no note of the call in the medical records, even retrospectively.
I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts.
• This is not the first time that I have made a PFD report to ELFT about its crisis line.
• Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record. He said that he had made a note on a piece of paper, but he did not now have that piece of paper.
• When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance.
” 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 elicit clear risks during crisis-line conversations
Wider context from the report “1. I was shocked when I listened to the recording of the call that █
████████ made to the crisis line the day before his daughter died.
The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation ; did not listen to ████████; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis.
In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. ████████ was not taken seriously, he was not treated respectfully and he was not treated kindly. He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled.
The clinician then made no note of the call in the medical records, even retrospectively.
I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts.
• This is not the first time that I have made a PFD report to ELFT about its crisis line.
• Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record. He said that he had made a note on a piece of paper, but he did not now have that piece of paper.
• When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance.
” 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 crisis-line calls in the medical record
Wider context from the report “1. I was shocked when I listened to the recording of the call that █
████████ made to the crisis line the day before his daughter died.
The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation; did not listen to ████████; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis.
In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. ████████ was not taken seriously, he was not treated respectfully and he was not treated kindly. He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled.
The clinician then made no note of the call in the medical records, even retrospectively.
I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts.
• This is not the first time that I have made a PFD report to ELFT about its crisis line.
• Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record . He said that he had made a note on a piece of paper, but he did not now have that piece of paper.
• When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance.
” 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 assure appropriate action following serious crisis-line failings
Wider context from the report “1. I was shocked when I listened to the recording of the call that █
████████ made to the crisis line the day before his daughter died.
The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation; did not listen to ████████; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis.
In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. ████████ was not taken seriously, he was not treated respectfully and he was not treated kindly. He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled.
The clinician then made no note of the call in the medical records, even retrospectively.
I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts.
• This is not the first time that I have made a PFD report to ELFT about its crisis line.
• Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record. He said that he had made a note on a piece of paper, but he did not now have that piece of paper.
• When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance .
” Open source report
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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 a larger Trust-wide Crisis Line call-quality audit from January 2022.
Verbatim wording from the response “From January 2022, a larger Trust-wide Crisis Line call quality audit will take place. The audit tool has already been devised.
Finally, there is a plan for the Crisis Line to change its crisis line provider to a service which allows staff supervisors in-call listening so that supervision can occur in real-time.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce standardised assessment and care-planning tools across the Crisis Pathway and specified linked services.
Verbatim wording from the response “Part of the transformation involves reviewing all job descriptions, operational policies and introducing a training programme tailored specifically to the needs of Crisis Practitioners. Standardised assessment and care planning tools will be introduced across the pathway, including the Psychiatric Liaison Team in the Emergency Department and the Crisis Café. A crisis hub will be established as an alternative to the Emergency Department. It is hoped staff will be able to work flexibly across the pathway in order to increase staffing in a specific area in the immediate demand becomes high. The Crisis Pathway services will work more closely with our voluntary sector colleagues to improve access to crisis services and care which is better focussed around the needs of specific communities.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise Serious Incident investigations with inquest dates and provide realistic due dates for late reports.
Verbatim wording from the response “I have sought assurance from the Associate Director of Governance and Risk that until that time, SI investigations with inquest dates will be prioritised and that HM Coroner is provided with realistic due dates if SI reports are going to be submitted to the Coroner’s Court late.” Source location Response from East London NHS Foundation Trust
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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 supervisory listening to sampled Crisis Line calls to assess care quality.
Verbatim wording from the response “Now, senior staff supervisors (registered mental health nurses, social workers or occupational therapists at a Band 7 level) listen to a sample of each Crisis Line clinician’s calls (with them) on a monthly basis to assess the quality of their care.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the Coroner with the 48-hour report when Serious Incident reports are late.
Verbatim wording from the response “Additionally, in the instance that SI reports are late, HM Coroner will be provided with the 48 Hour report.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employ four additional Serious Incident investigators to increase investigation capacity and address the backlog.
Verbatim wording from the response “The Trust has hired four new SI investigators. They start work beginning in November and are tasked with clearing the current backlog of SI reports that have accumulated throughout the pandemic. It is estimated that this will be completed by the end of 2021.” Source location Response from East London NHS Foundation Trust
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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 specialised Samaritans training for Crisis Line call handlers.
Verbatim wording from the response “With this in mind, the Crisis Line call handlers will be attending specialised training provided by the Samaritans. Training sessions are taking place between 29 November and 16 December 2021. Further, a Quality Improvement Project addressing issues of Crisis Line Staff well-being was commenced in October. It will focus on increasing staff resilience with a focus on skills, process, workload and stress management and supervision.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Chase witness statements and evidence promptly and provide realistic deadlines when delays affect progress.
Verbatim wording from the response “In the interim, the Interim Associate Director of Legal Affairs has assured me the Legal Affairs Team will be tasked with diligently chasing up witness statements and evidence such as recordings in a timely manner and provide realistic deadlines to the Coroner’s Officers if issues such as clinician sick leave hinder progress.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide medical-records training for senior nurses and Trust managers on record keeping, observations and retrospective entries.
Verbatim wording from the response “To address this matter, medical records training for all senior nurses was provided on 24 November 2021 to all senior nurses and managers at the Trust. The focus of the training was good record keeping, observations and retrospective record keeping.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Liaise with the Coroner’s Officer to discuss providing transcripts of recorded calls.
Verbatim wording from the response “I note, the Trust has not previously been requested to provide transcripts of recordings of calls. Going forward, the Interim Associate Director of Legal Affairs will liaise with your Coroner’s Officer’s to discuss how the Trust will provide such a transcript to you.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hire an additional solicitor to increase Legal Affairs Team capacity by late March.
Verbatim wording from the response “The Trust has also agreed to hire an additional solicitor in order to increase the Legal Affairs Team’s capacity which has been affected by long term sickness absence and the increase in inquests. A new solicitor will join the team by late March.” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clear the accumulated Serious Incident report backlog by the end of 2021.
Verbatim wording from the response “The Trust has hired four new SI investigators. They start work beginning in November and are tasked with clearing the current backlog of SI reports that have accumulated throughout the pandemic. It is estimated that this will be completed by the end of 2021.” Source location Response from East London NHS Foundation Trust
Open published response
30 Apr 2021 Rohan Dayal Singh · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to maintain accurate records of clinical observations View source Tolerance of inaccurate and misleading clinical record keeping View source Failure of searches to detect and remove dangerous contraband View source Failure to undertake required intermittent observations View source Failure to complete relevant documentation after rapid tranquillisation View source Failure to monitor patients following rapid tranquillisation View source See 3 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. 13
Action
Implement daily observation audits and a directorate data-reporting structure for reliable monitoring, governance review and local remedial action.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021. View source
Action
Overhaul rapid-tranquilisation training, including interim policy-change content and a standalone annual module for Registered Nurses and Nursing Associates.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021. View source
Action
Require all inpatient nursing staff to complete and annually renew the observations competency checklist, with completion recorded and reported for oversight.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2021. View source
Action
Create and deliver a search training course, record completion in ESR, provide it at induction and every two years, and monitor compliance.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021. View source
Action
Create an observations training module and ESR compliance record, deliver training annually, and report completion data for management and Board review.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021. View source
Action
Develop and roll out an electronic observations system enabling real-time recording of patient observations in RIO.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021. View source
Action
Make a rapid-tranquilisation e-learning package available on ESR and monitor uptake in real time.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2021. View source
Action
Use a RIO rapid-tranquilisation monitoring pack as an interim standardised guide and documentation tool for pre-, during- and post-administration monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 5 May 2021. View source
Action
Revise the search policy to govern search-information handover and review, and the disposal or storage of seized items, then disseminate the changes.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021. View source
Action
Provide medical-record-keeping training to Borough Lead Nurses and cascade the learning to staff during induction and away days.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2021. View source
Action
Review observation practice daily and through weekly night ward visits, discuss findings with Ward Matrons, and escalate compliance information through nursing leadership.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021. View source
Action
Require rapid-tranquilisation monitoring by Registered Nurses and place recipients on Registered Nurse eyesight observations during the first post-administration hour.
Stated completedThe respondent said that this action was complete when they made their response on 5 May 2021. View source
Action
Review and update the rapid-tranquilisation policy to clarify definitions, health limits, monitoring terminology, paper charts and a ward grab pack.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2021. View source See 10 more actions
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AI-generated summary
Rohan Dayal Singh · 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
Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor 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 maintain accurate records of clinical observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable , staff accepted that they had failed to undertake observations and made false records , further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” 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 Tolerance of inaccurate and misleading clinical record keeping
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” 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 searches to detect and remove dangerous contraband
Wider context from the report “1. Rohan Singh died on a mental health ward, following his death he was found to be in possession of number of prohibited items including controlled drugs and a bracelet consisting of a ligature and a blade. Before admission into hospital, Rohan had been subject to a personal search by police officers when the bracelet was seized. During Rohan’s admission his property was subjected to a search and later he himself was searched for contraband, despite these steps he retained dangerous contraband.
” 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 undertake required intermittent observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” 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 relevant documentation after rapid tranquillisation
Wider context from the report “3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation . The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
” 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 patients following rapid tranquillisation
Wider context from the report “3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation. The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
” Open source report
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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 daily observation audits and a directorate data-reporting structure for reliable monitoring, governance review and local remedial action.
Verbatim wording from the response “A new system for auditing observations is being implemented. Templates for monitoring auditing observation practice were sent to the Borough Lead Nurses as of 30 May 2021 to be cascaded down to their respective teams. Ward Managers will complete the audits daily and report to Ward Matrons on the numbers of observations being undertaken properly and any patterns of failures or concerns.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
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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 Overhaul rapid-tranquilisation training, including interim policy-change content and a standalone annual module for Registered Nurses and Nursing Associates.
Verbatim wording from the response “In order to ensure that Nurses are fully aware of both the importance and the content of the Trust’s RT policy, processes and procedures the Trust is overhauling its program of training.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
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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 and annually renew the observations competency checklist, with completion recorded and reported for oversight.
Verbatim wording from the response “One of the first steps being taken to address this problem is that all nursing staff (including new staff members and bank staff) working in Trust in-patient services must complete the observations competency checklist that forms part of the Trust’s Observation Policy by 30 June 2021. This is irrespective of whether they have completed the checklist in the past. Local Ward Matrons managing this process have been identified. They will send the staff records showing completed competency training to the Trust’s Learning and Development Team, who will upload the information on each Nurse’s ESR. The Matrons will then feed the information about compliance back to the Director of Nursing for senior oversight.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
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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 and deliver a search training course, record completion in ESR, provide it at induction and every two years, and monitor compliance.
Verbatim wording from the response “To ensure that nursing staff are equipped to carry out robust searches the Trust’s Director of Nursing and the Learning and Development Team are creating a ‘search’ training course. The course will reflect the Trust’s updated policy. Completion of the course will be monitored using the Trust’s Electronic Staff Record (ESR) data base.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Open published response
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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 an observations training module and ESR compliance record, deliver training annually, and report completion data for management and Board review.
Verbatim wording from the response “Nurse Observation Training Modules” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
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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 an electronic observations system enabling real-time recording of patient observations in RIO.
Verbatim wording from the response “The Trust is developing an e-observation (e-obs) recording system to replace the current paper-based system. The intention is that, staff will carry an iPad with direct links to RIO so they can enter patient records in real time. It is expected that this will improve the timeliness and accuracy of observations. A full project plan will be completed by the end of July with anticipated roll out throughout each hospital site from early Autumn 2021.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Open published response
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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 Make a rapid-tranquilisation e-learning package available on ESR and monitor uptake in real time.
Verbatim wording from the response “The more substantial stand-alone training module in relation to the administration and post-administration monitoring of RT is expected to be completed by 31 August 2021. It will be undertaken alongside the SAME training annually.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Open published response
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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 RIO rapid-tranquilisation monitoring pack as an interim standardised guide and documentation tool for pre-, during- and post-administration monitoring.
Verbatim wording from the response “Finally, since the e-obs platform outlined above will only be available later this year, as of June 2021 a RIO RT monitoring pack is being used as an interim measure to reinforce the Trust’s RT policy.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Open published response
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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 search policy to govern search-information handover and review, and the disposal or storage of seized items, then disseminate the changes.
Verbatim wording from the response “In order to address the issue of contraband being handed back to Mr Dayal Singh, the Trust is revising its search policy to explicitly include guidance on:” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
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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 medical-record-keeping training to Borough Lead Nurses and cascade the learning to staff during induction and away days.
Verbatim wording from the response “Two half day training sessions will be provided to the Borough Lead Nurses on medical record keeping by the Trust’s external solicitors within the next 6 months. The training will focus on the legal standard expected for documenting medical practice (especially in relation to observations) and will ensure staff understand when retrospective entries are and are not appropriate and what comprises a misleading record.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Open published response
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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 observation practice daily and through weekly night ward visits, discuss findings with Ward Matrons, and escalate compliance information through nursing leadership.
Verbatim wording from the response “Clinical Nurse Managers have already started reviewing nurses’ observation practice daily. They are also undertaking weekly night visits on the wards to observe compliance with the observation policy at night - as this has traditionally been overlooked.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Open published response
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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 rapid-tranquilisation monitoring by Registered Nurses and place recipients on Registered Nurse eyesight observations during the first post-administration hour.
Verbatim wording from the response “Given the serious implications of the above findings, the Chief Nurse made immediate changes to the substance of the Trust’s RT policy. On 10 May 2021 (via email), she instructed all Lead Borough Nurses that as of 17 May 2021, RT Monitoring will only be undertaken by Registered Nurses. Further, patients receiving RT medicines will be placed on eyesight observations with a Registered Nurse, only for the first hour, post-administration.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
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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 rapid-tranquilisation policy to clarify definitions, health limits, monitoring terminology, paper charts and a ward grab pack.
Verbatim wording from the response “Additionally, the following areas of the Trust’s policy are scheduled to be reviewed by a Subject Matter Expert Group led by Director of Nursing. It will be updated on 19 July 2021 with a specific focus on:” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Open published response
18 Sep 2020 PAULINE VIOLET OAKLEY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to provide monitoring of the fire alarm in the flats View source Failure to assess the safety or suitability of the home and appliances as part of hospital discharge planning View source Failure to assess the safety or suitability of the home and appliances as part of the Co-ordinate My Care Plan View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
PAULINE VIOLET OAKLEY · 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
Pauline Oakley fell onto an electric heater at her home on 3 April 2020, causing a fire. She sustained burns covering 60% of her body and died later that day in hospital. The concerns included the absence of assessments of the safety and suitability of her home and appliances, and the apparent lack of monitoring of the building’s fire alarm.
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 monitoring of the fire alarm in the flats
Wider context from the report “(3) The fire alarm in the flats was apparently not monitored by East End Homes, the police or the London Fire Brigade. When an alarm was activated it was dependent upon a resident in the flats or a member of the public to call the emergency services. Residents in the flats may have thought that the alarm was monitored and therefore there was no need for any resident to call the emergency services.
” 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 the safety or suitability of the home and appliances as part of hospital discharge planning
Wider context from the report “(1) There was no assessment of the safety or suitability of Pauline Oakley’s flat, or the appliances within the flat arranged by the NHS Trust Foundation responsible for her discharge home as part of the hospital discharge plan . The evidence was that she had fallen on a modern electric heater, with a built in safety mechanism, there would have been no fire.
” 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 the safety or suitability of the home and appliances as part of the Co-ordinate My Care Plan
Wider context from the report “(2) There was no assessment of the safety or suitability of Pauline Oakley’s flat, or the appliances within the flat arranged by as part of the Co-ordinate My Care Plan .
” Open source report
×
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 Responsibility for environmental risk assessments after discharge lay with the Reablement Team within the London Borough of Tower Hamlets.
Verbatim wording from the response “████████, Legal Affairs Manager was present at the Inquest and informed you that it was her understanding that responsibility for environmental risk assessment following Ms Oakley’s discharge from hospital, would lie with the Reablement Team. The Reablement Team falls within the remit of the London Borough of Tower Hamlets. The Trust understands that the Reablement Team were providing Ms Oakley with regular support following her discharge in order to help her with everyday tasks and ensure that she could live as independently as possible.” Source location 2020-0304-Response-from-East-London-NHS-Foundation-Trust_Redacted
Open published response
20 Aug 2019 Tony Mark DUNNE · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to ask Crisis Line callers about current suicidal feelings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tony Mark DUNNE · 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
Tony Mark Dunne, who had alcohol dependence disorder, extreme anxiety and mild depression, died after jumping from a seventh-floor window on 20 February 2019. Earlier that evening, he had been found by police intending to jump and was assessed in an emergency department, but was discharged after refusing informal admission and being deemed not detainable. The principal concern was that, when he later called the Crisis Line, the call taker knew this history but did not ask whether he was feeling suicidal or arrange further hospital support.
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 ask Crisis Line callers about current suicidal feelings
Wider context from the report “Mr Dunne rang the Crisis Line a little over an hour after he had been discharged from the emergency department.
He had been seen at the emergency department because he had been found by police standing by an 8th floor window intending to jump.
The Crisis Line call taker read his medical notes and so knew this history, but nevertheless did not ask him if he was now feeling suicidal.
If she had asked him and he had said yes, she could have asked him to come in to the hospital again or she could have called an ambulance for him.
” 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 crisis-line clinicians with training on risk-assessment competencies and required medical-record standards.
Verbatim wording from the response “The importance of good quality, full, complete and appropriate risk assessments is a key skill for all our clinical staff at the Trust. In order to reinforce this, the City and Hackney HTT will be providing additional training during its away days scheduled for 4 and 5 December 2019. This will include:” Source location 2019-0265_Response-by-East-London-NHS-Trust
Open published response
13 Mar 2019 Mr Mohammed Hussain · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure of staff to understand and apply risk assessment training View source Failure to pass and sufficiently highlight important risk assessment information in communications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Mohammed Hussain · 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 Mohammed Hussain died after setting fire to himself inside a car in Luton on 12 March 2018, following deterioration in his mental health and previous overdoses. Concerns included shortcomings in mental health risk assessments, inadequate application of risk assessment training, and failures to share or highlight important information between staff and care providers.
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 staff to understand and apply risk assessment training
Wider context from the report “(1) The Trust had carried out a Serious Incident Investigation (SII) into the circumstances of the Mr Hussain’s death which was critical of both the mental health assessments of Mr Hussain carried out by staff on 30 April and 1 May 2018. This meant that 3 individual staff members had misunderstood or misapplied their risk assessment training.
(2) I was informed by the Trust that further risk assessment training was carried out by the Trust following Mr Hussain’s death and yet, at the Inquest, both members of staff (although, one has now moved to another Trust) showed little insight into their actions despite the SII ‘s findings and the further training.
(3) It was also apparent at the Inquest that important information required for the risk assessment process had not necessarily been passed and/or sufficiently highlighted in communications both between individual Trust staff members and with other care providers
” 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 pass and sufficiently highlight important risk assessment information in communications
Wider context from the report “(1) The Trust had carried out a Serious Incident Investigation (SII) into the circumstances of the Mr Hussain’s death which was critical of both the mental health assessments of Mr Hussain carried out by staff on 30 April and 1 May 2018. This meant that 3 individual staff members had misunderstood or misapplied their risk assessment training.
(2) I was informed by the Trust that further risk assessment training was carried out by the Trust following Mr Hussain’s death and yet, at the Inquest, both members of staff (although, one has now moved to another Trust) showed little insight into their actions despite the SII ‘s findings and the further training.
(3) It was also apparent at the Inquest that important information required for the risk assessment process had not necessarily been passed and/or sufficiently highlighted in communications both between individual Trust staff members and with other care providers
” 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 Maintain additional risk-assessment training for staff following the Serious Incident Review.
Verbatim wording from the response “I am aware that you heard evidence during the course of the Inquest that the Trust has mandatory training in Clinical Risk Assessment in place and that as a result of the concerns highlighted in the Serious Incident Review additional risk assessment training had been put into place and would continue to be delivered on an ongoing basis. However, having heard the evidence of staff, you were concerned that they had potentially misunderstood or misapplied both the mandatory and additional risk assessment training.” Source location 2019-0122-Response-by-East-London-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 Deliver further Bedfordshire crisis-service training on risk assessment and suicide prevention.
Verbatim wording from the response “Within the crisis services in Bedfordshire further training has now been organised and is currently being delivered to staff specifically looking at assessment of risk and suicide prevention training.” Source location 2019-0122-Response-by-East-London-NHS-Trust
Open published response
27 Jun 2018 Dudley Vincent Brown · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Delays in AMHPS referral and assessment across weekends and bank holidays View source Delays in AMHPS assessment caused by unavailable property information View source Failure to arrange welfare checks pending mental health assessment View source Unclear allocation of responsibility for initiating emergency procedures under the Mental Health Act View source Incorrect understanding of referral routes to the Approved Mental Health Practitioner Service 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
Dudley Vincent Brown · 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
Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk assessment.
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 Delays in AMHPS referral and assessment across weekends and bank holidays
Wider context from the report “(4) Mr Brown’s referral to the AMHPS and subsequent assessment was delayed due to intervening weekends (including a 3 day bank holiday weekend).
” 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 AMHPS assessment caused by unavailable property information
Wider context from the report “(5) Mr Brown’s assessment by the AMHPS team was delayed due to the need for information regarding the nature of his property being required by the Metropolitan Police as part of their risk 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 arrange welfare checks pending mental health assessment
Wider context from the report “(2) Mr Brown’s care package was withdrawn on 27 December 2017. No arrangements were put into place for Mr Brown’s welfare to be checked in the period pending a mental health 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 Unclear allocation of responsibility for initiating emergency procedures under the Mental Health Act
Wider context from the report “(1) Following the incident on 29 December 2017, the incident was reported to police the same day. The social work team leader dealing with the case was of the view that the police were the best placed to initiate emergency procedures under the Mental Health Act.
” 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 Incorrect understanding of referral routes to the Approved Mental Health Practitioner Service
Wider context from the report “(3) The social work team leader dealing with this case was under the impression that referrals to the Approved Mental Health Practitioner Service (AMPHS) had to be made by a GP.
” Open source report
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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 Improve staff and manager fluency in routes and response expectations for general mental health and Mental Health Act assessments.
Verbatim wording from the response “This is a joint response between the Council and East London Foundation Trust. We acknowledge and accept your recommendations in this case, and have worked together to address the concerns, by way of formulating and implementing a multi-agency action plan which is attached for your reference.” Source location 2018-0211-Response-by-Hackney-Borough-Council
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 AMHP referral risk-assessment process, including timely collection of information needed to progress cases.
Verbatim wording from the response “This is a joint response between the Council and East London Foundation Trust. We acknowledge and accept your recommendations in this case, and have worked together to address the concerns, by way of formulating and implementing a multi-agency action plan which is attached for your reference.” Source location 2018-0211-Response-by-Hackney-Borough-Council
Open published response
11 Sep 2017 Janet WILLIAMS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 11 Failure to respond to or act on family concerns View source Failure to conduct reviews in accordance with CPA protocol View source Failure to identify retrospective medical-record entries View source Failure to investigate conflicting reports about mental health symptoms View source Failure to detect missing computer records of CPA care plans View source Failure to record CPA care plans in the computer system View source Failure to maintain care-coordinator meetings View source Insufficient monitoring of patients with serious mental health conditions View source Delays in arranging required medical reviews View source Failure to maintain timely medical review arrangements View source Failure to arrange psychiatrist medical reviews 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
Janet WILLIAMS · 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
Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.
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 respond to or act on family concerns
Wider context from the report “7. When Ms Williams’ family attempted to raise concerns with her care co-ordinator, at times their calls were not returned and at other times their concerns were simply not acted upon . She had recently been diagnosed with a very serious mental health condition, but she was not monitored with sufficient care or in some instances at all, and she was therefore not assessed or treated appropriately.
” 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 reviews in accordance with CPA protocol
Wider context from the report “3. Ms Williams was not reviewed in accordance with the protocol for a person on a CPA . A medical review with her consultant psychiatrist scheduled for 12 May 2016 was cancelled by her care co-ordinator. The reason given was that the psychiatrist was unwell, though in fact she 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 identify retrospective medical-record entries
Wider context from the report “8. Finally, as I know you are aware, the care co-ordinator made several retrospective entries in the medical records that she did not record as being made retrospectively . These entries were made up to eleven months after events, and were made after Ms Williams’ death and mostly after my request for a statement from the care co-ordinator in preparation for the inquest.
” 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 investigate conflicting reports about mental health symptoms
Wider context from the report “2. Ms Williams told her care co-ordinator that she was no longer hearing voices, but her daughter raised concerns that this was not true . Ms Williams’ care co-ordinator did not at any point in April 2016 or afterwards raise this with Ms Williams , but instead accepted Ms Williams’ narrative as accurate .
” 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 detect missing computer records of CPA care plans
Wider context from the report “1. Ms Williams’ care plan approach (CPA) was not recorded on the computer system and so there were no automatic alerts generated when she was not seen for review at the appropriate times. The lack of computer record of her CPA was never noted .
” 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 CPA care plans in the computer system
Wider context from the report “1. Ms Williams’ care plan approach (CPA) was not recorded on the computer system and so there were no automatic alerts generated when she was not seen for review at the appropriate times . The lack of computer record of her CPA was never noted.
” 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 care-coordinator meetings
Wider context from the report “5. Between 11 October 2016 when Ms Williams was discharged by the home treatment team, to 21 February 2017 when she saw her general practitioner and her care co-ordinator together, Ms Williams’ care co-ordinator did not meet with her .
” 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 monitoring of patients with serious mental health conditions
Wider context from the report “7. When Ms Williams’ family attempted to raise concerns with her care co-ordinator, at times their calls were not returned and at other times their concerns were simply not acted upon. She had recently been diagnosed with a very serious mental health condition, but she was not monitored with sufficient care or in some instances at all , and she was therefore not assessed or treated appropriately .
” 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 arranging required medical reviews
Wider context from the report “4. A meeting was then scheduled three months’ away, for 9 August 2016 , despite the need for medical review and the lack of any alternative arrangement in the meantime .
” 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 timely medical review arrangements
Wider context from the report “3. Ms Williams was not reviewed in accordance with the protocol for a person on a CPA. A medical review with her consultant psychiatrist scheduled for 12 May 2016 was cancelled by her care co-ordinator . The reason given was that the psychiatrist was unwell, though in fact she 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 arrange psychiatrist medical reviews
Wider context from the report “6. Between 11 October 2016 when Ms Williams was discharged by the home treatment team, and her death on 8 March 2017, Ms Williams’ care co-ordinator did not arrange for a medical review by the psychiatrist .
” Open source report
8 Aug 2017 Fallon Alphonsine ABBY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to contact social workers and obtain collateral history View source Failure to invite the social worker to ward rounds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Fallon Alphonsine ABBY · 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
Fallon Alphonsine ABBY died by suicide after jumping from the balcony of her sixth-floor bedroom on 18 February 2017, following recent hospital attendances and discharge to a home treatment team. The report raised concerns that the Roman Ward team did not contact her social worker, meaning potentially valuable information was not shared and social-work support was not available on discharge.
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 contact social workers and obtain collateral history
Wider context from the report “I heard at inquest that no member of the team on Roman Ward contacted Fallon’s social worker . There was no protocol for this .
If they had sought a collateral history from the social worker, they would have discovered that Fallon’s mum was not dead as Fallon had told them, but was alive and living in a hostel . The social worker had been rung by a nurse at the Royal London Hospital, but she was waiting to be invited to a ward round at Mile End Hospital and such invitation was never made.
It seems unlikely that proper discussion with the social worker would have changed the outcome for Fallon, but it would have meant that valuable information would have been shared, and it would have meant that Fallon would have had the benefit of her social worker on hand upon discharge. This might be very important for another patient.
” 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 invite the social worker to ward rounds
Wider context from the report “I heard at inquest that no member of the team on Roman Ward contacted Fallon’s social worker. There was no protocol for this.
If they had sought a collateral history from the social worker, they would have discovered that Fallon’s mum was not dead as Fallon had told them, but was alive and living in a hostel. The social worker had been rung by a nurse at the Royal London Hospital, but she was waiting to be invited to a ward round at Mile End Hospital and such invitation was never made .
It seems unlikely that proper discussion with the social worker would have changed the outcome for Fallon, but it would have meant that valuable information would have been shared, and it would have meant that Fallon would have had the benefit of her social worker on hand upon discharge . This might be very important for another patient.
” Open source report
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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 Work with admitted young people to negotiate their social worker’s involvement after informing the Leaving Care Team.
Verbatim wording from the response “In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.” Source location 2017-0288-Response-by-East-London-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 Review the ward Operational Policy to include contacting the Leaving Care Team when a previously looked-after young person is admitted.
Verbatim wording from the response “In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.” Source location 2017-0288-Response-by-East-London-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 Planned training and policy changes are considered to have adequately addressed concerns about involving Leaving Care Team social workers.
Verbatim wording from the response “In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.” Source location 2017-0288-Response-by-East-London-NHS-Trust
Open published response
26 Jul 2017 Songul BOZDAG · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to arrange mandatory post-discharge reviews View source Failure to update drug cards to reflect increased prescriptions View source Absence of a system safety net for detecting individual care errors View source Failure to maintain records supporting individual consultations View source Failure to record mandatory monthly care reviews View source Failure to record the need for a care plan approach on the computer system 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
Songul BOZDAG · 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
Songul Bozdag, who had schizophrenia and other mental health conditions, died after jumping from a tenth-floor window on 9 February 2017. Concerns included missed mandatory reviews, incomplete recording of consultations, failure to record a required care plan approach, an incorrect drug card that left her under-medicated, and the absence of a system safety net to identify these errors.
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 arrange mandatory post-discharge reviews
Wider context from the report “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016 .
2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory.
3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error.
4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system.
5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg. Ms Bozdag was therefore under medicated on an ongoing basis.
These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life.
” 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 update drug cards to reflect increased prescriptions
Wider context from the report “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016.
2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory.
3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error.
4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system.
5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg . Ms Bozdag was therefore under medicated on an ongoing basis .
These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life.
” 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 a system safety net for detecting individual care errors
Wider context from the report “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016.
2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory.
3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error.
4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system.
5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg. Ms Bozdag was therefore under medicated on an ongoing basis.
These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life .
” 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 records supporting individual consultations
Wider context from the report “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016.
2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory.
3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error.
4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description . However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system.
5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg. Ms Bozdag was therefore under medicated on an ongoing basis.
These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life.
” 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 mandatory monthly care reviews
Wider context from the report “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016.
2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory .
3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions . She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error.
4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system.
5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg. Ms Bozdag was therefore under medicated on an ongoing basis.
These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life.
” 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 need for a care plan approach on the computer system
Wider context from the report “1. Ms Bozdag’s care co-ordinator did not arrange for what was a mandatory say review of Ms Bozdag after discharge from hospital in August/September 2016.
2. She recorded monthly reviews of Ms Bozdag on only half of the months from September 2016 to Ms Bozdag’s death in February 2017, though monthly reviews were mandatory.
3. The care co-ordinator gave evidence at inquest that she had actually reviewed Ms Bozdag once a fortnight when Ms Bozdag came for her depot injections, but in the main did not record these discussions. She did include in her statement for the court one note recording the nature of a discussion had on 10 February. This was in fact the day after death. She said this was an error.
4. She described having a very good recollection of individual consultations with Ms Bozdag, such as one on 6 September 2016 though there was no record supporting this description. However, she had not had a sufficient recollection of Ms Bozdag’s treatment during her life to notice that the need for a care plan approach (CPA) had not been recorded on the computer system .
5. Finally, the care co-ordinator did not ensure that the drug card in use reflected the psychiatrist’s increased prescription of 50mg of risperidone rather than the original one of 37.5mg. Ms Bozdag was therefore under medicated on an ongoing basis.
These were the errors of an individual, but there is an additional point that they were not captured by any sort of system safety net during Ms Bozdag’s life.
” 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 supervision for all care coordinators, covering care-plan delivery, reviews, CPA status and record-keeping, with regular compliance audits.
Verbatim wording from the response “The key system for monitoring the ongoing support provided to service users by a care coordinator is monthly supervision. This had not been robustly undertaken within the CMHT and I am pleased to report that this is now working in line with Trust procedures with all care coordinators receiving monthly supervision. Standing agenda items in supervision include CPA status, delivery of the care plan including monitoring of visits and medical reviews and the standard to record keeping. Regular audits are being undertaken to maintain a robust oversight on the process and also actively respond to any gaps in the system in a timely way and to provide assurance that staff are working to agreed record keeping standards and 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 Implement a central referrals inbox for communicating hospital discharge plans to CMHT staff, with daily administrative review and senior oversight.
Verbatim wording from the response “There is now a new Operational Team Lead in post and this member of staff has imbedded robust systems within the CMHT. The first change is the implementation of an Inbox based system to communicate discharge care plans to CMHT 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 Review internal monitoring processes to identify gaps in CPA reviews and regular contact.
Verbatim wording from the response “In addition to the above a review of internal monitoring process has been undertaken to assure the Trust that systems are sufficiently robust and will flag up any cases where service users on CPA are not being seen regularly or reviewed by their consultant. Teams have access to live reports which allows real time activity by the Team and can be drilled down to provide data on an individual service user. The Team administrator also sends out weekly prompts around key performance indicators to the Operational Team Lead and this includes activity for patients on CPA.” 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 Extend seven-day post-discharge follow-up to everyone discharged from hospital, not only people under the Care Programme Approach.
Verbatim wording from the response “A seven day follow up following discharge from hospital is a key intervention and has now been extended to include all individuals following discharge from hospital, not just those under the Care Programme Approach.” 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 care coordinators’ caseloads against agreed record-keeping standards and practice.
Verbatim wording from the response “Before setting out the steps that the Trust is taken in relation to improving systems I would like to reassure you that the issues highlighted in relation to the conduct of the care co-ordinator. One of the first actions taken was an audit of the care coordinators case load to ascertain if she was working to agreed record keeping standards and practice. The gaps in the care that she provided to Ms Bozdag are currently being dealt with by her employer, the London Borough of Tower Hamlets, through formal processes with the full support of the Trust and the individual in question is not working with patients whilst these processes 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 Provide teams with live activity reports and weekly performance prompts covering CPA patients.
Verbatim wording from the response “In addition to the above a review of internal monitoring process has been undertaken to assure the Trust that systems are sufficiently robust and will flag up any cases where service users on CPA are not being seen regularly or reviewed by their consultant. Teams have access to live reports which allows real time activity by the Team and can be drilled down to provide data on an individual service user. The Team administrator also sends out weekly prompts around key performance indicators to the Operational Team Lead and this includes activity for patients on CPA.” 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 Senior Practitioners to allocate and monitor discharge-plan actions, using duty workers when care coordinators are unavailable.
Verbatim wording from the response “Senior Practitioners are now responsible for ensuring that actions arising from discharge plans are allocated to care coordinators and monitored to ensure they have been followed up. This will include seven day follow ups, medical reviews and changes in medication. This new process will also allow senior practitioners to allocate actions to a duty worker if the care coordinator is absent from work or unable to undertake an intervention for any reason.” 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 London Borough of Tower Hamlets is handling formal processes addressing the care coordinator’s conduct, with Trust support.
Verbatim wording from the response “Before setting out the steps that the Trust is taken in relation to improving systems I would like to reassure you that the issues highlighted in relation to the conduct of the care co-ordinator. One of the first actions taken was an audit of the care coordinators case load to ascertain if she was working to agreed record keeping standards and practice. The gaps in the care that she provided to Ms Bozdag are currently being dealt with by her employer, the London Borough of Tower Hamlets, through formal processes with the full support of the Trust and the individual in question is not working with patients whilst these processes are ongoing.” 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 Implemented CMHT systems are considered sufficient to address concerns about monitoring care coordinators.
Verbatim wording from the response “With the systems that are now implemented at the CMHT I hope you will be content that the Trust has taken these issues seriously and adequately addressed your concerns.” Source location Response from East London NHS Foundation Trust
Open published response
23 Jun 2017 ANDREW STUART CODLING · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1 Failure to communicate the availability of alternative support before Monday morning View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
ANDREW STUART CODLING · 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 Stuart Codling, aged 39, was found hanging at Old Warden Tunnel Woods near Cardington, Bedfordshire, on 26 November 2016. He had previously attempted suicide and was under the care of the Biggleswade Community Health Team. Concerns were raised about the content and timing of the Team’s final call, including that it did not reinforce the availability of other sources of help before Monday morning.
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 communicate the availability of alternative support before Monday morning
Wider context from the report “(3) That call missed the opportunity to re-inforce the fact that there were other means of help should the deceased require it, including the crisis numbers already provided by the Service.
(4) Reminding the deceased that there was provision to provide support before Monday morning may have been all the deceased required to avoid taking the decision to hang himself particularly, bearing in mind it was the deceased who had initiated the call
” 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 service users with an explanatory letter, including alternative contact arrangements, whenever staff give them a mobile-phone number.
Verbatim wording from the response “In response to the concerns raised, a new protocol has been developed and implemented within the CMHTs. The protocol provides guidance to staff in relation to the use of mobile phones in communication with service users. Where a member of staff provides a service user with their mobile phone number an explanatory letter is now provided. This includes information on who can be contacted should the call not be answered, depending on the nature of the call and what assistance is required.” Source location 2017-0339-Response-by-East-London-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 Develop and implement a CMHT protocol governing mobile-phone communication and requiring staff to provide urgent-support contacts when service users do not answer calls.
Verbatim wording from the response “In response to the concerns raised, a new protocol has been developed and implemented within the CMHTs. The protocol provides guidance to staff in relation to the use of mobile phones in communication with service users. Where a member of staff provides a service user with their mobile phone number an explanatory letter is now provided. This includes information on who can be contacted should the call not be answered, depending on the nature of the call and what assistance is required.” Source location 2017-0339-Response-by-East-London-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 The Trust considers that its action adequately addresses the concern and that no further safety work is necessary.
Verbatim wording from the response “I hope that the action taken provides you with assurance that the Trust has taken appropriate action and that your concern has been adequately addressed.” Source location 2017-0339-Response-by-East-London-NHS-Trust
Open published response
25 Apr 2017 Jamie Neil Elliott · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to verify treatment information with external mental health service providers View source Failure to provide timely face-to-face psychiatric assessment after worsened-condition referral View source Lack of Consultant Psychiatrist assessment for worsened conditions referred to the Home Treatment Team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jamie Neil 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
Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.
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 verify treatment information with external mental health service providers
Wider context from the report “1. Mental health clinicians from the Trust should be required to contact external providers of mental health services, if possible, when a patient is receiving treatment elsewhere , particularly when consideration is being given to compulsorily detain that individual. They should not simply take the patient’s account at face value .
” 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 timely face-to-face psychiatric assessment after worsened-condition referral
Wider context from the report “2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric 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 Lack of Consultant Psychiatrist assessment for worsened conditions referred to the Home Treatment Team
Wider context from the report “2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric assessment.
” 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 Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.
Verbatim wording from the response “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:” Source location 2017-0135-Response-by-East-London-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 Distribute guidance to City and Hackney clinical staff on contacting external mental health providers.
Verbatim wording from the response “In relation to contact with external providers I can confirm that a memo has been distributed to all clinical staff in City and Hackney highlighting the issue.” Source location 2017-0135-Response-by-East-London-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 routine doctor review within 72 hours for Home Treatment referrals without prior professional assessment, with out-of-hours emergency review by on-call psychiatry.
Verbatim wording from the response “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:” Source location 2017-0135-Response-by-East-London-NHS-Trust
Open published response
13 Apr 2017 LUKE ALF EDWARD MOULDING · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 2 Failure to send required opt-in letters View source Reliance on typed opt-in letters instead of readily available information formats 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
LUKE ALF EDWARD MOULDING · 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
On 25 November 2016, Luke Alf Edward Moulding entered a railway line near his home after consuming alcohol and drugs, collided with a train, and died from severe traumatic injuries. The report raised concerns that an “opt in” letter following a mental-health consultation was not sent, and that the process for sending such letters could be made more effective.
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 send required opt-in letters
Wider context from the report “(1) The Deceased saw ████████, Speciality Doctor in Psychiatry, at Beacon House Community Mental Health Team on 11th November 2016. The deceased left part way through the consultation. ████████ decided an “opt in” letter was required. It was not sent.
(2) The evidence is that “opt in” letters are “normally typed and sent by 10 working days.
(3) There seems to be no reason why a typed letter is required. A pre-printed letter/brochure/card would suffice and give the service users sufficient information, should they require it.
” 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 Reliance on typed opt-in letters instead of readily available information formats
Wider context from the report “(1) The Deceased saw ████████, Speciality Doctor in Psychiatry, at Beacon House Community Mental Health Team on 11th November 2016. The deceased left part way through the consultation. ████████ decided an “opt in” letter was required. It was not sent.
(2) The evidence is that “opt in” letters are “normally typed and sent by 10 working days.
(3) There seems to be no reason why a typed letter is required. A pre-printed letter/brochure/card would suffice and give the service users sufficient information, should they require it.
” Open source report
10 Apr 2017 Christiana Pelle · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Lack of a clearly understood system for communicating concerns and relevant information between the Community District Nurses Team and a community patient’s care provider agency View source Lack of clear guidance for Community District Nursing team nurses on when to involve a community patient’s GP View source Absence of a clearly understood system for sharing relevant community patient information and escalating care-quality concerns between the Community District Nursing Team and partner agencies 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
Christiana Pelle · 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
Christiana Pelle developed a grade 4 sacral pressure ulcer while living at home under the care of community nursing and a planned care package. The ulcer became infected, and she later died in hospital after contracting pneumonia while receiving inpatient treatment. The principal concerns were unclear guidance about when nurses should involve a GP and inadequate systems for sharing information and escalating concerns between community nursing, other agencies, and the care provider.
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 clearly understood system for communicating concerns and relevant information between the Community District Nurses Team and a community patient’s care provider agency
Wider context from the report “(3) The lack of a clearly understood system for communicating concerns and/or other relevant information between the Community District Nurses Team and the care provider agency for a community patient .
” 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 clear guidance for Community District Nursing team nurses on when to involve a community patient’s GP
Wider context from the report “(1) Lack of clear guidance and thus ongoing uncertainty on the part of the nurses in Homerton’s Community District Nursing team as to when they should seek the involvement of a community patient’s GP ;
” 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 a clearly understood system for sharing relevant community patient information and escalating care-quality concerns between the Community District Nursing Team and partner agencies
Wider context from the report “(2) An ongoing absence of any / any clearly understood system for sharing relevant information relating to a community patient and/or escalating concerns about the quality of the care they were receiving , between Homerton’s Community District Nursing Team and other partner agencies involved - in this instance the Community Mental Health Team from the East London NHS Foundation Trust’s City and Hackney Mental Health Care for Older People and the London Borough of Hackney’s Integrated Independence Team;
” Open source report
14 Mar 2017 Mariana Hungria Bayam Veiga PINTO · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to clearly communicate crisis team limitations to families and friends View source Failure to communicate expected illness progression and clear action plans to families View source Failure of crisis line nurses to contact emergency services when callers may be unable to do so View source Failure to advise callers to contact emergency services during urgent mental health crises View source Failure to escalate urgent crisis calls internally to expedite home visits 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
Mariana Hungria Bayam Veiga PINTO · 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
Mariana Pinto jumped from the third-floor balcony of her home as a deliberate act, without a proper understanding of what she was doing, after attending the emergency department the previous day. The concerns included whether the crisis team’s limitations and possible symptom worsening had been adequately communicated to her family, and whether the urgent crisis-line call was escalated appropriately.
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 clearly communicate crisis team limitations to families and friends
Wider context from the report “1. It seemed to me at inquest that, when Ms Pinto left the emergency department the day before her death, the limitations of the crisis team were not made clear to her family and friends .
” 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 expected illness progression and clear action plans to families
Wider context from the report “2. The view of the psychiatrists treating Ms Pinto in the emergency department was that she was suffering cannabis withdrawal, which I heard is generally at its worst during the first three days.
Her symptoms were now quiescent, but it would have been very helpful for her family to know that, most particularly as she had taken cannabis the night before, once the lorazepam wore off she might well have a resurgence of symptoms though these were not expected to be as severe as they had been. Worsening advice could then have been delivered in this context, with a clear plan of action.
It is a theme I have noticed in deaths such as Ms Pinto’s, that clinicians’ expectations of illness progression are not necessarily communicated effectively to families, to enable families to identify unexpected deterioration and then to act swiftly and appropriately .
” 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 crisis line nurses to contact emergency services when callers may be unable to do so
Wider context from the report “3. The band 7 mental health nurse who took the call to the crisis line at 3.32pm on 16 October, did not suggest to Ms Pinto’s husband that ████████ call the emergency services while the nurse rang Ms Pinto and spoke to her to offer what support he could.
When ████████ told him that the situation was now urgent, the nurse responded that the time for home visits was 5-7pm.
After the call had ended, the nurse did not discuss with colleagues the potential to bring the home visit forward.
The nurse did not ring the emergency services himself in case ████████ had been unable to make the call.
” 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 advise callers to contact emergency services during urgent mental health crises
Wider context from the report “3. The band 7 mental health nurse who took the call to the crisis line at 3.32pm on 16 October, did not suggest to Ms Pinto’s husband that ████████ call the emergency services while the nurse rang Ms Pinto and spoke to her to offer what support he could.
When ████████ told him that the situation was now urgent, the nurse responded that the time for home visits was 5-7pm.
After the call had ended, the nurse did not discuss with colleagues the potential to bring the home visit forward.
The nurse did not ring the emergency services himself in case ████████ had been unable to make the call.
” 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 urgent crisis calls internally to expedite home visits
Wider context from the report “3. The band 7 mental health nurse who took the call to the crisis line at 3.32pm on 16 October, did not suggest to Ms Pinto’s husband that ████████ call the emergency services while the nurse rang Ms Pinto and spoke to her to offer what support he could.
When ████████ told him that the situation was now urgent, the nurse responded that the time for home visits was 5-7pm.
After the call had ended, the nurse did not discuss with colleagues the potential to bring the home visit forward.
The nurse did not ring the emergency services himself in case ████████ had been unable to make the call.
” 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 Implement and provide written discharge care plans to service users and relatives after psychiatric assessment in A&E.
Verbatim wording from the response “It is obviously important to ensure that both the patient and relatives/carers are aware of the steps to take should there be a serious deterioration in an individual’s mental state. Having considered your concern I am confident that this will be addressed by the formulation of a written discharge care plan which is currently being developed and will in future be provided to all service users/relatives prior to discharge from A&E following a psychiatric assessment.” Source location response-Pinto
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 consult service users and carers on a written discharge care plan template.
Verbatim wording from the response “It is obviously important to ensure that both the patient and relatives/carers are aware of the steps to take should there be a serious deterioration in an individual’s mental state. Having considered your concern I am confident that this will be addressed by the formulation of a written discharge care plan which is currently being developed and will in future be provided to all service users/relatives prior to discharge from A&E following a psychiatric assessment.” Source location response-Pinto
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 HTT flexibility to bring forward visits for service users whose mental health deteriorates between scheduled visits.
Verbatim wording from the response “I understand that you heard evidence during the course of the Inquest that additional funding had been secured for the HTT and from October 2017 the team will have increased flexibility to bring forward visits to those service users who experience a deterioration in their mental health between scheduled visits. From October 2017 the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service. The City and Hackney Home Treatment Team had previously operated one shift only each day of the weekend, with a morning shift on a Saturday and an evening on Sunday. This has since been changed to providing both a morning and an evening shift to improve provision of visits on the weekend.” Source location response-Pinto
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 Reconfigure the HTT to provide 24-hour face-to-face contact when required and an enhanced urgent response service.
Verbatim wording from the response “I understand that you heard evidence during the course of the Inquest that additional funding had been secured for the HTT and from October 2017 the team will have increased flexibility to bring forward visits to those service users who experience a deterioration in their mental health between scheduled visits. From October 2017 the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service. The City and Hackney Home Treatment Team had previously operated one shift only each day of the weekend, with a morning shift on a Saturday and an evening on Sunday. This has since been changed to providing both a morning and an evening shift to improve provision of visits on the weekend.” Source location response-Pinto
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 Directing callers to Police and Ambulance services is considered an appropriate and robust response in emergencies.
Verbatim wording from the response “In relation to your final point regarding the handling of the call made by Mr Parra-Braun on the afternoon of 16th October it is important to confirm that in an emergency situation advice to contact Police and Ambulance is an appropriate and robust response. I believe that your specific concern related to what support the HTT could have provided in the interim, for example the member of staff attempting to speak to the service user to deescalate the situation and/or personally contacting the emergency services.” Source location response-Pinto
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 Mental health staff cannot readily contact emergency services when relatives or carers are present because responders require information from them.
Verbatim wording from the response “Direct contact with the emergency services by mental health staff is not straight forward where family or friends are in attendance at the scene, as Police and Ambulance services require as much information as possible in relation to access and a description of the current situation from relatives or carers. However, in the event that a service user is on their own at a time of crisis then staff could intervene to call an ambulance or request that the Police attend to conduct a welfare check.” Source location response-Pinto
Open published response
2 Dec 2016 Peter Daniel Usher · Prevention of Future Deaths report East London
View report summary
Concerns raised 11 Poor quality of duty-doctor clinical and risk assessments View source Failure to inform the on-call doctor of Section 136 assessment arrivals and outcomes View source Failure of duty-doctor practice to demonstrate insight and reflection View source Failure to include a Home Treatment Team member in Section 136 assessments View source Inadequate medical staffing for Section 136 assessments View source Failure to conduct detailed Section 136 assessments using relevant information from professional and non-professional sources View source Delays in transferring clinical information for Section 136 assessments View source Unclear availability of audit of clinical decision making during Section 136 assessments View source Failure to notify an AMHP of planned Section 136 assessments View source Failure to obtain and communicate relevant police and family information during admission View source Potential pressure from six-hour assessment targets to proceed without all relevant evidence 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
Peter Daniel Usher · 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
Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.
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 Poor quality of duty-doctor clinical and risk assessments
Wider context from the report “6. The evidence during the course of the Inquest and the evidence received from the independent psychiatrist raised a number of concerns in relation to the quality of the overall assessment and risk assessment carried out by the duty doctor . No issues relating to the medical input were identified in the Trust's own Root Cause Analysis. Further concern was raised during the course of the Inquest by the apparent lack of insight by the duty doctor and by the apparent inability to reflect on practice.
” 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 inform the on-call doctor of Section 136 assessment arrivals and outcomes
Wider context from the report “2. The Trust policy requires that the assessment should be carried out by the duty doctor and member of the Home Treatment Team. The policy also requires that the doctor must inform the on-call doctor of the arrival and discuss the outcome of the assessment with them. The Home Treatment Team member was not present during the course of the assessment. He was gathering relevant clinical information from a previous Section 136 attendance. The information appears to have been requested shortly after 03:00 and not received until around 04:47. This was partly due to safe haven procedures which had to be complied with before a fax could be sent. The Home Treatment team member attended as the assessment was wrapping up. The on-call doctor was not informed of Mr Usher .
” 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 duty-doctor practice to demonstrate insight and reflection
Wider context from the report “6. The evidence during the course of the Inquest and the evidence received from the independent psychiatrist raised a number of concerns in relation to the quality of the overall assessment and risk assessment carried out by the duty doctor. No issues relating to the medical input were identified in the Trust's own Root Cause Analysis. Further concern was raised during the course of the Inquest by the apparent lack of insight by the duty doctor and by the apparent inability to reflect on practice .
” 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 include a Home Treatment Team member in Section 136 assessments
Wider context from the report “2. The Trust policy requires that the assessment should be carried out by the duty doctor and member of the Home Treatment Team. The policy also requires that the doctor must inform the on-call doctor of the arrival and discuss the outcome of the assessment with them. The Home Treatment Team member was not present during the course of the assessment . He was gathering relevant clinical information from a previous Section 136 attendance. The information appears to have been requested shortly after 03:00 and not received until around 04:47. This was partly due to safe haven procedures which had to be complied with before a fax could be sent. The Home Treatment team member attended as the assessment was wrapping up. The on-call doctor was not informed of Mr Usher.
” 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 medical staffing for Section 136 assessments
Wider context from the report “5. The junior doctor gave evidence to confirm that he was the only doctor available for 11 wards and 200 patients . It would appear from information provided by the Trust, that the number of Section 136 assessments is increasing substantially and therefore there is a concern in relation to adequate medical staffing .
” 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 detailed Section 136 assessments using relevant information from professional and non-professional sources
Wider context from the report “1. The assessing team did not carry out a detailed assessment of Mr Usher, to include not only a personal assessment but also to obtain relevant clinical information from both professional and non-professional sources . This would have included information from the family and GP. There was also relevant information available to the paramedics and police that was not elicited by the assessing 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 Delays in transferring clinical information for Section 136 assessments
Wider context from the report “9. There were inefficiencies in practice which resulted in the member of the Home Treatment Team missing the clinical assessment . He had to wait for approximately 1 hour 45 minutes for clinical information to be provided . He had to go through Safe Haven procedures and to wait for a fax . An email to a secure email address may have avoided these delays.
” 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 Unclear availability of audit of clinical decision making during Section 136 assessments
Wider context from the report “7. It is unclear from the evidence heard during the course of the Inquest whether there is any audit of clinical decision making during Section 136 assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify an AMHP of planned Section 136 assessments
Wider context from the report “3. The Trust policy requires that an AMHP (Approved Mental Health Professional) be notified of the planned assessment . This also did not take 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 obtain and communicate relevant police and family information during admission
Wider context from the report “4. The police had received contact from family members whilst they were present at the hospital, confirming the concerns of family members due to the text received. This was not passed on to the hospital staff . It became apparent during the course of the Inquest that the police also had access to information which was relevant to the circumstances of the preceding events which would have been relevant to the mental state of the deceased. It would appear that inadequate questions were asked by the receiving hospital team in relation to the circumstances leading to admission .
” 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 Potential pressure from six-hour assessment targets to proceed without all relevant evidence
Wider context from the report “8. The Section 136 policy contains a 6 hour target for assessments to be completed. Section 136 itself, allows a period of up to 72 hours. It is unclear from the evidence as to whether the 6 hour limit places undue pressure upon staff to carry out assessments without gathering all of the available relevant evidence .
” Open source report
6 May 2016 Komang Jack SUSIANTA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to communicate clinical expectations to patients and families before discharge View source Failure to communicate that recurrence of psychotic symptoms requires significant concern and potentially immediate action View source Failure to communicate when and how to seek urgent professional help 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
Komang Jack SUSIANTA · 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
Jack was a 17-year-old boy who developed a drug-related psychotic episode after taking cannabis and ecstasy, was detained by police and taken to hospital, and was discharged after assessment. His condition deteriorated after discharge; he later entered a river while being pursued by police and drowned. The principal concern was that the hospital did not communicate to his family the expected recovery, warning signs of recurrence, or when and how to seek urgent professional help.
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 communicate clinical expectations to patients and families before discharge
Wider context from the report “The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode.
However, she did not communicate to his family:
- first and foremost, the fact that she expected him now to be free from all psychotic symptoms ;
- second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action;
- thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this.
Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before.
By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice.
I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge .
” 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 that recurrence of psychotic symptoms requires significant concern and potentially immediate action
Wider context from the report “The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode.
However, she did not communicate to his family:
- first and foremost, the fact that she expected him now to be free from all psychotic symptoms;
- second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action ;
- thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this.
Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before.
By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice.
I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge.
” 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 when and how to seek urgent professional help
Wider context from the report “The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode.
However, she did not communicate to his family:
- first and foremost, the fact that she expected him now to be free from all psychotic symptoms;
- second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action;
- thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this.
Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before.
By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice.
I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge.
” Open source report
19 Feb 2016 Brenda Elizabeth MORRIS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Lack of routine consideration of family feedback after weekend leave View source Failure to communicate the basis for weekend leave to the supervising partner View source Substandard nursing-record documentation of risk assessments before weekend leave View source Failure to routinely obtain required medical authorisation for unplanned leave of informal patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Brenda Elizabeth MORRIS · 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
Brenda Elizabeth Morris, aged 66, died by drowning herself in the bath at home after being admitted to Larch Lodge as an informal patient and granted weekend leave. Concerns included inadequate communication with her partner about the basis for leave, limited routine feedback from family after leave, confusion about authorisation of unplanned leave, and substandard nursing documentation affecting the recording of risk assessments.
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 routine consideration of family feedback after weekend leave
Wider context from the report “2. The weekend before the weekend of her death, Ms Morris’s partner felt that she had not been well during the weekend leave. I appreciate that care must be taken not to override a patient’s autonomy, but it might be useful for staff routinely to consider whether they are able to obtain feedback from family members after such leave .
” 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 basis for weekend leave to the supervising partner
Wider context from the report “1. Brenda Morris was allowed weekend leave on the basis that her partner was at home to keep an eye on her, but no member of staff told him this . This was not a situation where she needed 24 hour supervision. Nevertheless, it would have been helpful for him to know the basis for the leave, because he would then have modified his own behaviour accordingly.
” 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 Substandard nursing-record documentation of risk assessments before weekend leave
Wider context from the report “4. Substandard documentation in the nursing records had already been identified before the inquest by your serious incident review. Without improvement in the records, it is not possible to determine whether and if so by whom a necessary risk assessment is undertaken , e.g. immediately before weekend leave is taken.
” 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 obtain required medical authorisation for unplanned leave of informal patients
Wider context from the report “3. There appears to be confusion about whether a doctor is needed to authorise unplanned leave of an informal patient (not relevant in this case because the leave had already been authorised). Your serious incident review of this matter indicates that this is necessary, but I heard evidence that such medical authorisation is not routinely sought .
” 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 Implement and roll out the inpatient leave checklist requiring risk assessment, family discussions, contingency plans, return feedback, and RIO documentation.
Verbatim wording from the response “In addition to the above an ‘In-patient leave checklist for informal and detained patients’ has been developed. It is also a requirement for this checklist to be completed for all leave. The checklist requires staff to assess risk prior to any period of leave, discuss with family or friends issues of risk and provide relatives/carers with a copy of an individualised contingency care plan. On return from leave staff will need to confirm that they have obtained feedback from family on the patient’s return from leave. The detail of all assessments and discussions will be fully documented on RIO.” Source location 2016-0065-Response-by-East-London-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 Implement and roll out the Informal patient leave agreement documenting doctor-approved leave, conditions, contingency plans, and signatures.
Verbatim wording from the response “However, in light of the importance of this issue the Trust has taken the decision to implement the use of template documentation to ensure that any leave has been appropriately agreed by a doctor. A new ‘Informal patient leave agreement’ has been developed. This document details the agreement of leave following assessment by a doctor. The template includes a box detailing any leave conditions along with any expectations from staff, patients, relatives and carers. A separate box deals with contingency plans. The agreement is then signed by the doctor, the patient and the relative. This document is expected to be in place before a patient goes on leave.” Source location 2016-0065-Response-by-East-London-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 Conduct quarterly audits of leave forms and corresponding RIO entries from July 2016 through January 2017.
Verbatim wording from the response “Both forms are currently being piloted on one of our Mental Health Care for Older Persons wards with the aim of full introduction across all of our Older Persons wards by the end of this month. Use of the forms and the corresponding RIO entries will be the subject to quarterly audits starting from the end of July 2016 until January 2017 and will be subject to further review thereafter if necessary.” Source location 2016-0065-Response-by-East-London-NHS-Trust
Open published response
5 Feb 2016 Chentoоri Chanthirakumar · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to consider personal meetings when communicating significant academic decisions View source Failure to distinguish receiving and acting on third-party concerns from disclosing patient details 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
Chentoоri Chanthirakumar · 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
Chentoоri Chanthirakumar, a 24-year-old medical student, died by suicide after being discharged from a period of inpatient mental health treatment. The concerns included the university communicating by email about her examinations rather than arranging a personal meeting, and mental health staff not fully absorbing concerns raised by others because of confidentiality 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 consider personal meetings when communicating significant academic decisions
Wider context from the report “The decision that Ms Chanthirakumar could re-take the fourth year of her medical degree was seen by the medical school as a helpful decision. The re-take was allowed on the basis of her ill health and was not a criticism of her academic achievement.
That she would not be able to take her fourth year examinations in August 2015 came to be regarded as almost self evident, because she had not been able to attend the majority of her recent clinical placement and had been so recently so unwell.
However, unbeknown to the university staff, Ms Chanthirakumar appears to have lacked some insight at this point, and was actually hoping not to have to re-take the year, but instead to take her fourth year exams in August 2015.
Given the very particular course of very recent events leading up to the medical school’s decision, I wonder whether a personal meeting to discuss matters with her could have been arranged, rather than communicating this by email. A face to face meeting may not necessarily have had any impact on the outcome, but nevertheless I think would be a helpful consideration for the process 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 distinguish receiving and acting on third-party concerns from disclosing patient details
Wider context from the report “After the medical school was alerted to Ms Chanthirakumar’s illness by two of her friends on 17 June 2015, a senior lecturer working in student support services (and, as it happens, herself a general practitioner) rang Globe Ward of Mile End Hospital and spoke to a treating nurse.
Her intention in making this call was to deliver information, most specifically to relay concerns that Ms Chanthirakumar was not being wholly open with staff about the extent of her distress. However, such was the ward nurse’s anxiety not to breach patient confidentiality, the conversation was not as meaningful or as productive as it might otherwise have been.
It seems to me that nurses and doctors working in mental health particularly, would benefit from a reminder of the difference between absorbing (and, if appropriate, acting upon) concerns raised by a patient’s relatives, friends, tutors etc., and divulging a patient’s private details .
” Open source report
15 Dec 2014 Andrew James AITKEN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to safely secure medication brought into hospital View source Failure to obtain relevant previous inpatient mental health records View source Failure to investigate and respond to complaints View source Failure to ensure patients have appropriate clothing and footwear at discharge View source Failure to provide direct referral to community mental health services for patients without a GP 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
Andrew James AITKEN · 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 Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.
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 safely secure medication brought into hospital
Wider context from the report “1. When Mr Aitken was admitted to hospital on 10 June 2014, his girlfriend brought in the remainder of the tablets he had taken, hoping to assist those treating him.
████████ told me that a nurse took the tablets from her, of which there were still many remaining, and simply left them on the hospital bedside cabinet next to Mr Aitken .
” 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 obtain relevant previous inpatient mental health records
Wider context from the report “2. Mr Aitken had been admitted to Prestwich Hospital Psychiatric Hospital when he was 16 years old. When he was admitted on 10 June 2014, no consideration was given to asking for any record of that inpatient stay .
That was some 14 years earlier and may not have yielded anything useful but, as Mr Aitken was not registered with a general practitioner, it was the only source of history from healthcare professionals.
” 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 investigate and respond to complaints
Wider context from the report “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes.
I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter , and has been told that there is no ongoing investigation into her complaint .
” 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 ensure patients have appropriate clothing and footwear at discharge
Wider context from the report “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes .
I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter, and has been told that there is no ongoing investigation into her complaint.
” 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 direct referral to community mental health services for patients without a GP
Wider context from the report “3. The junior psychiatrist discharging Mr Aitken did strongly advise him to register with a GP and then to seek referral to mental health services, but it did not occur to her to refer him direct to the community mental health team, given that he had no GP .
” 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 Finalise the RAID Operational Policy with explicit requirements to obtain collateral information.
Verbatim wording from the response “I am in complete agreement with you regarding the importance of gaining collateral information from any available sources. As you are aware the Trust undertook a Serious Incident Review (SIR) looking at the care and treatment of Mr Aitken and the Review considered this issue. Sources of collateral information in the absence of a GP can be: healthcare professionals previously involved with a patient and family and friends. Our SIR agreed that clinical staff had limited information and history regarding Mr Aitken in light of the fact that he did not have a GP. Senior staff in the RAID service are clear that they would expect staff to follow up and try to obtain all information available regarding an individual. The RAID Operational Policy is currently being finalised and the importance of obtaining collateral information will be included within this.” Source location 2014-0561-Response-by-East-London-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 A referral to secondary mental health services was considered unnecessary because comprehensive assessments found no indication that this level of input was required.
Verbatim wording from the response “The SIR considered this point noting that the RAID Service is able to make direct referrals to secondary mental health services and where indicated can refer a patient to the Home Treatment Team, Crisis Services or the Community Mental Health Team. Community Mental Health Teams manage those patients with enduring mental health problems and the SIR found that the assessments undertaken had been comprehensive and that there had been no indication that this level of input was necessary for Mr Aitken.” Source location 2014-0561-Response-by-East-London-NHS-Trust
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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 Contacting historical psychiatric services was considered unnecessary because information was unlikely to be obtained during the short period of RAID involvement.
Verbatim wording from the response “In considering this it was relevant to consider that RAID involvement with any patient is short term and the SIR concluded that it was highly unlikely that such historical information would have been obtained during the short time he was under their care to inform their assessment of him. It was therefore felt that the decision not to contact services in Prestwich had been reasonable. The Review was satisfied that staff had explored other potential sources of collateral information.” Source location 2014-0561-Response-by-East-London-NHS-Trust
Open published response
24 Jul 2014 Graham Darby · Prevention of Future Deaths report Inner North London
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Concerns raised 1 Failure to clearly flag direct suicide threats to agencies responsible for housing and eviction 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.
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AI-generated summary
Graham Darby · 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
Graham Darby, who had alcohol dependence, was found dead at his home the day after being evicted and forcibly re-entering the property; the inquest concluded that the cause of death was suspension by ligature and that his death was a suicide. A significant concern was that a reported threat to take his own life using a knife and rope if evicted was not passed on to the housing agency, and was therefore not sufficiently flagged between agencies.
Read the report on judiciary.uk
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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 clearly flag direct suicide threats to agencies responsible for housing and eviction
Wider context from the report “That there were a number of agencies involved in both trying to assist Mr Darby and to deal with his anti-social behaviour (which led to the eviction). That although information was passed on generally between agencies and that communication was ongoing about Mr Darby, the evidence disclosed that one significant piece of information was not flagged up as it was not made sufficiently clear to Family Mosaic who were responsible for his housing and eviction . This was that the psychiatrist from ARC made a specific observation that Mr Darby had said that he had a knife and a rope in his property and would take his own life if evicted . The witness from Family Mosaic said that this particular piece of information was not passed on and that if it had been different actions may have been taken. Such direct threats should be flagged up in similar circumstances.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations