Goodmayes Hospital

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First report 3 Jul 2019•Latest report 20 Sep 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

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.

  1. East London

    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

  2. East London

    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
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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