12 Feb 2015 Andrew Elliot FROST · Prevention of Future Deaths report Inner North London
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Concerns raised 5 Failure of crisis team records to capture valuable information received during referrals View source Lack of shared understanding between crisis teams and general practitioners about crisis team capabilities and limitations View source Insufficient information captured by the crisis team pager messaging service View source Lack of shared understanding between referrers and crisis teams about crisis team capabilities and limitations View source Lack of specific training and education for general practitioners about crisis team services and limitations View source See 2 more concerns
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Andrew Elliot FROST · 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 Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.
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 Killick Street Health Centre; that does not assign responsibility.
PFD Monitor interpretation Failure of crisis team records to capture valuable information received during referrals
Wider context from the report “2. The crisis team’s records did not reflect some valuable information that was passed to them.
For example, that police and paramedics were with Mr Frost at the time of the GP’s call. This information was communicated by the GP and by Mr Frost’s partner. If the crisis team had considered this information, they could have advised Mr Frost’s partner he should tell the paramedics that the crisis team were not coming out that day, which may have assisted paramedics’ decision making.
” 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 Killick Street Health Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between crisis teams and general practitioners about crisis team capabilities and limitations
Wider context from the report “1. There was no shared understanding between the crisis team and the GP about what the crisis team could and could not do.
The GP thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.
The GP regarded the crisis team as an emergency service, which the team leader told me in court is not the case.
It seems that this GP, his partners, and the other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis team about their service, including its limitations.
” 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 Killick Street Health Centre; that does not assign responsibility.
PFD Monitor interpretation Insufficient information captured by the crisis team pager messaging service
Wider context from the report “3. The pager messaging service used by the crisis team simply takes the name of the patient and a telephone number to call, nothing more.
This means that valuable time was wasted by the crisis team, trying to track down the police officer who had rung to find out more detail, most especially Mr Frost’s address.
This is time that could be used treating patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Killick Street Health Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of shared understanding between referrers and crisis teams about crisis team capabilities and limitations
Wider context from the report “During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone.
You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him.
However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do .
You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.
You regarded the crisis team as an emergency service, which the team leader told me in court is not the case.
It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations.
I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else.
” 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 Killick Street Health Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of specific training and education for general practitioners about crisis team services and limitations
Wider context from the report “During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone.
You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him.
However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do.
You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.
You regarded the crisis team as an emergency service, which the team leader told me in court is not the case.
It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations.
I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else.
” 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 Establish regular meetings between practice GPs and the Crisis Team to discuss service provision and individual clients.
Verbatim wording from the response “Following your requirement for our service to meet with the Crisis Team, I can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. I met up with ████████ both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients.” Source location 2015-0119-Response-by-Killick-Street-Health-Centre
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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 Meet with Crisis Team managers to discuss service provision.
Verbatim wording from the response “Following your requirement for our service to meet with the Crisis Team, I can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. I met up with ████████ both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients.” Source location 2015-0119-Response-by-Killick-Street-Health-Centre
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations