Recipient

Goodmayes Hospital

First report 3 Jul 2019•Latest report 20 Sep 2019

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Goodmayes Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

20 Sep2019
East London
Concerns raised4
1. Failure to document verbal first-responder handovers in patient records
2. Failure to ensure first-responder risk information is available to the assessing mental health team
3. Failure to elicit relevant information from first responders during assessment
1. Insufficient improvement of handover processes from first responders to Trust staff
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

Karis Florence Braithwaite · 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

Karis Florence Braithwaite, aged 24, died after stepping in front of a fast train on 24 September 2018 following discharge from a Section 136 mental health assessment. The concerns included important risk information from the paramedic and police not being available to the assessment team, and handover information not being adequately documented or transferred into the Trust’s 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 Goodmayes Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to document verbal first-responder handovers in patient records
Wider context from the report
“1. Important risk information was provided to the Trust by a first responder (paramedic) but was not available to the MHA assessment team. 2. A copy of the PRF form was left with staff but does not appear to have been uploaded to the electronic records or a paper copy provided to the assessing team. 3. The paramedic provided a verbal handover to staff which does not appear to have been documented in the patient’s records. 4. The police officer who attended with Karis also gave evidence as to difficulties in providing a handover to the receiving mental health team. 5. A PFD report was written to the Trust on the 2nd December 2016 noting: There was also relevant information available to the paramedics and police that was not elicited by the assessing team. 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. In light of the evidence heard at Ms Braithwaite’s inquest, there is a concern that insufficient steps have been taken by the Trust to improve the handover process from first responders to Trust staff following serious incidents in the community. ”
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 Goodmayes Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure first-responder risk information is available to the assessing mental health team
Wider context from the report
“1. Important risk information was provided to the Trust by a first responder (paramedic) but was not available to the MHA assessment team. 2. A copy of the PRF form was left with staff but does not appear to have been uploaded to the electronic records or a paper copy provided to the assessing team. 3. The paramedic provided a verbal handover to staff which does not appear to have been documented in the patient’s records. 4. The police officer who attended with Karis also gave evidence as to difficulties in providing a handover to the receiving mental health team. 5. A PFD report was written to the Trust on the 2nd December 2016 noting: There was also relevant information available to the paramedics and police that was not elicited by the assessing team. 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. In light of the evidence heard at Ms Braithwaite’s inquest, there is a concern that insufficient steps have been taken by the Trust to improve the handover process from first responders to Trust staff following serious incidents in the community. ”
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 Goodmayes Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to elicit relevant information from first responders during assessment
Wider context from the report
“1. Important risk information was provided to the Trust by a first responder (paramedic) but was not available to the MHA assessment team. 2. A copy of the PRF form was left with staff but does not appear to have been uploaded to the electronic records or a paper copy provided to the assessing team. 3. The paramedic provided a verbal handover to staff which does not appear to have been documented in the patient’s records. 4. The police officer who attended with Karis also gave evidence as to difficulties in providing a handover to the receiving mental health team. 5. A PFD report was written to the Trust on the 2nd December 2016 noting: There was also relevant information available to the paramedics and police that was not elicited by the assessing team. 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. In light of the evidence heard at Ms Braithwaite’s inquest, there is a concern that insufficient steps have been taken by the Trust to improve the handover process from first responders to Trust staff following serious incidents in the community. ”
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 Goodmayes Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient improvement of handover processes from first responders to Trust staff
Wider context from the report
“1. Important risk information was provided to the Trust by a first responder (paramedic) but was not available to the MHA assessment team. 2. A copy of the PRF form was left with staff but does not appear to have been uploaded to the electronic records or a paper copy provided to the assessing team. 3. The paramedic provided a verbal handover to staff which does not appear to have been documented in the patient’s records. 4. The police officer who attended with Karis also gave evidence as to difficulties in providing a handover to the receiving mental health team. 5. A PFD report was written to the Trust on the 2nd December 2016 noting: There was also relevant information available to the paramedics and police that was not elicited by the assessing team. 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. In light of the evidence heard at Ms Braithwaite’s inquest, there is a concern that insufficient steps have been taken by the Trust to improve the handover process from first responders to Trust staff following serious incidents in the community. ”
Open source report
3 Jul2019
East London
Concerns raised4
1. Lack of refresher training for occupational therapists as emergency equipment technology changes
2. Training for occupational therapists not adequately covering the ordering process for emergency alarm equipment
3. Training for occupational therapists not adequately covering available emergency alarm equipment
1. Training for occupational therapists not adequately covering compatibility between alarm and home telephone systems
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

John Patrick Doyle · 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

John Patrick Doyle was found deceased at home after a likely fall, having previously been identified as needing a panic alarm that was not in place. He died from starvation ketoacidosis, and concerns were raised about occupational therapists’ training on emergency alarm equipment, ordering processes, compatibility with home telephone systems, and refresher training.

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 Goodmayes Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of refresher training for occupational therapists as emergency equipment technology changes
Wider context from the report
“the evidence heard around the training provided to occupational therapists in relation to the emergency equipment available from Telecare. It is requested that the training for occupational therapists is reviewed to consider: I. The emergency alarm equipment available II. The order process required for such equipment, and III. The compatibility between the alarm system and the telephone systems within the home setting. It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered. ”
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 Goodmayes Hospital; that does not assign responsibility.
PFD Monitor interpretation
Training for occupational therapists not adequately covering the ordering process for emergency alarm equipment
Wider context from the report
“the evidence heard around the training provided to occupational therapists in relation to the emergency equipment available from Telecare. It is requested that the training for occupational therapists is reviewed to consider: I. The emergency alarm equipment available II. The order process required for such equipment, and III. The compatibility between the alarm system and the telephone systems within the home setting. It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered. ”
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 Goodmayes Hospital; that does not assign responsibility.
PFD Monitor interpretation
Training for occupational therapists not adequately covering available emergency alarm equipment
Wider context from the report
“the evidence heard around the training provided to occupational therapists in relation to the emergency equipment available from Telecare. It is requested that the training for occupational therapists is reviewed to consider: I. The emergency alarm equipment available II. The order process required for such equipment, and III. The compatibility between the alarm system and the telephone systems within the home setting. It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered. ”
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 Goodmayes Hospital; that does not assign responsibility.
PFD Monitor interpretation
Training for occupational therapists not adequately covering compatibility between alarm and home telephone systems
Wider context from the report
“the evidence heard around the training provided to occupational therapists in relation to the emergency equipment available from Telecare. It is requested that the training for occupational therapists is reviewed to consider: I. The emergency alarm equipment available II. The order process required for such equipment, and III. The compatibility between the alarm system and the telephone systems within the home setting. It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Failure to document verbal first-responder handovers in patient records

Failure to ensure first-responder risk information is available to the assessing mental health team

Failure to elicit relevant information from first responders during assessment

Insufficient improvement of handover processes from first responders to Trust staff

Concerns raised4

Lack of refresher training for occupational therapists as emergency equipment technology changes

Training for occupational therapists not adequately covering the ordering process for emergency alarm equipment

Training for occupational therapists not adequately covering available emergency alarm equipment

Training for occupational therapists not adequately covering compatibility between alarm and home telephone systems