London OfficeIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Multi-service care provider

Pin Request correction

First report 11 Aug 2022•Latest report 30 Aug 2023

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
3

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 London Office linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: ████████ President, Royal College of Psychiatrists, London Office, 21 Prescot Street, London, E1 8BB.

    East London

    AI-generated summary

    Allison Vivian Jacome Aules · 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

    Allison Aules was referred to a child and adolescent mental health service in May 2021 following concerns including self-harm, low mood and anxiety, but her referral was delayed and the eventual assessment was incomplete. She was discharged without a documented risk management plan, and was found suspended in her bedroom on 18 July 2022; the investigation states that she died on 19 July 2022 as a result of suicide, contributed to by neglect. The principal concerns were failings in care and the under-resourcing of CAMHS services, including delays in assessment and concern that continuing under-resourcing amid rising demand could result in similar deaths.

    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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Under-resourcing of CAMHS services

    Wider context from the report

    “The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced. The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern. The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country. There was very little evidence of any consultant psychiatrist leadership within the CAMHS team. The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams. The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor. The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week. There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase), will result in future similar deaths. ”
    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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of consultant psychiatrist leadership within CAMHS teams

    Wider context from the report

    “The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced. The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern. The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country. There was very little evidence of any consultant psychiatrist leadership within the CAMHS team. The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams. The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor. The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week. There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase), will result in future similar deaths. ”
    Open source report

  2. Addressed to: ████████, President, Royal College of Psychiatrists, London Office, 21 Prescot Street, London, E1 8BB.

    East London

    AI-generated summary

    Conrad Richard James Colson · 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

    Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.

    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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training for stepdown service teams on BDD diagnosis and associated risks

    Wider context from the report

    “3. The Inquest heard that there is a need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with 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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share BDD diagnoses with clinics providing aesthetic dermatology treatment

    Wider context from the report

    “2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis. ”
    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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform patients with BDD of the risks of seeking aesthetic dermatology treatment

    Wider context from the report

    “2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis. ”
    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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge

    Wider context from the report

    “1. A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT. There was a lack of full information sharing around risk and risk assessment/risk management planning on 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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of national specialist resources for BDD

    Wider context from the report

    “4. The inquest heard that there is a lack of national resources for BDD. The highly specialised service at South London and Maudsley has a very long waiting list (several months). This is on a background of concerns of a likely increase in BDD. In light of this concern, I am also providing this report to the Royal College of Psychiatrists, to the Department for Health & Social Care and to NHSE. ”
    Open source report

  3. Addressed to: ████████, President, Royal College of Psychiatrists, London Office, 21 Prescot Street, London, E1 8BB.

    East London

    AI-generated summary

    Lily May Girton · 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

    Lily May Girton, who had anxiety, depression and emotional dysregulation, died after taking her own life while suffering from mental illness. The inquest found that her death was contributed to by failures in the community CAMHS team concerning psychiatric assessment, risk management and titration of antidepressant medication. It also raised concerns that inadequate staffing and resources in CAMHS services pose a risk of future deaths of young people.

    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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of adequate numbers of suitably trained CAMHS staff

    Wider context from the report

    “The Inquest heard that CAMHS services nationally have a lack of adequate staffing levels in the form of doctors, in the form of psychiatrists, registered mental health nurses and psychotherapy staff. The Inquest heard that consultants often have an average of 130 to 150 active cases on their caseloads. This is substantially higher than the recommended caseloads by the Royal College of Psychiatrists. The lack of staffing and resources contributed to Lily’s death and there is a concern that the ongoing shortages of suitably trained staff within CAMHS teams poses a risk of future deaths of young people. ”
    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 London Office; that does not assign responsibility.

    PFD Monitor interpretation

    Excessive consultant caseloads in CAMHS

    Wider context from the report

    “The Inquest heard that CAMHS services nationally have a lack of adequate staffing levels in the form of doctors, in the form of psychiatrists, registered mental health nurses and psychotherapy staff. The Inquest heard that consultants often have an average of 130 to 150 active cases on their caseloads. This is substantially higher than the recommended caseloads by the Royal College of Psychiatrists. The lack of staffing and resources contributed to Lily’s death and there is a concern that the ongoing shortages of suitably trained staff within CAMHS teams poses a risk of future deaths of young people. ”
    Open source report
Back to top

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