Recipient

NHS North East London Integrated Care Board

First report 9 Mar 2016•Latest report 18 Sep 2025

Recipient record

Reports, concerns and published responses

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

Reports: 6
Published responses: 33%
Concerns addressed: 1
Stated actions: 5

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.

33%published responses found

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from NHS North East London Integrated Care Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

18 Sep2025
East London
Concerns raised2
1. Failure to ensure prominent and accurate filing of critical respiratory action plans in online clinical records
2. Lack of a coordinated process for producing and storing critical respiratory action plans in online clinical records
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

Kwabena Amoateng · 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

Kwabena Amoateng, a 17-year-old boy with congenital central hypoventilation syndrome, became ill on 16 September 2024 and died in hospital on 23 September 2024 after developing severe respiratory complications. A Paediatric Respiratory Action Plan for his condition was mislabelled and misfiled, so it was unavailable to emergency healthcare professionals assessing him. The report identified the absence of a coordinated process for producing and storing such documents in online clinical records as a substantive concern.

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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure prominent and accurate filing of critical respiratory action plans in online clinical records
Wider context from the report
“1. The inquest found that a critically important document had been produced by his specialist respiratory doctors to assist emergency healthcare professionals in understanding his rare and potentially dangerous condition - CCHS. The document, A Paediatric Respiratory Action Plan (‘PRAP’) set out the necessary steps to be considered should Kwabena fall ill. 2. During Kwabena’s final illness, those assessing him from 16ᵗʰ-21ˢᵗ September 2024 were unaware of this vital document as it had been mislabelled and misfiled within the online records available to them. 3. Had the PRAP been more prominently filed it is likely that those assessing Kwabena would have escalated his treatment to admission to hospital far earlier, which may have resulted in Kwabena’s life being saved. 4. An investigation into why the PRAP was not visible to emergency services in this case has highlighted that there is no coordinated process to ensure a consistent approach in producing and storing such documents in online clinical records. ”
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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of a coordinated process for producing and storing critical respiratory action plans in online clinical records
Wider context from the report
“1. The inquest found that a critically important document had been produced by his specialist respiratory doctors to assist emergency healthcare professionals in understanding his rare and potentially dangerous condition - CCHS. The document, A Paediatric Respiratory Action Plan (‘PRAP’) set out the necessary steps to be considered should Kwabena fall ill. 2. During Kwabena’s final illness, those assessing him from 16ᵗʰ-21ˢᵗ September 2024 were unaware of this vital document as it had been mislabelled and misfiled within the online records available to them. 3. Had the PRAP been more prominently filed it is likely that those assessing Kwabena would have escalated his treatment to admission to hospital far earlier, which may have resulted in Kwabena’s life being saved. 4. An investigation into why the PRAP was not visible to emergency services in this case has highlighted that there is no coordinated process to ensure a consistent approach in producing and storing such documents in online clinical records. ”
Open source report
26 Mar2024
East London
Concerns raised3
1. Lack of formal capacity assessment for nursing-home residents
2. Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
3. Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness
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

Mark Wolfe Kinzley · 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

Mark Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.

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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of formal capacity assessment for nursing-home residents
Wider context from the report
“2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests. ”
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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
Wider context from the report
“3. During the same period, Mr Kinzley was not referred for a mental health assessment despite. a. His history of mental illness. b. His history of deliberate self-harm. c. His history of accidental self-harm when agitated. d. His deteriorating mental state during the month prior to his death. ”
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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness
Wider context from the report
“1. I have doubts that the location of Mr Kinzley’s care was appropriate. Mr Kinzley was a socially isolated adult suffering from a profound neurological disorder and mental illness. ”
Open source report
12 Jul2022
East London
Concerns raised5
1. Non-comparable pay for care-coordinator posts
2. Excessive caseloads for care co-ordinators
3. Failure to provide continuity of care
1. Insufficient number of care co-ordinators for clinical need
2. High turnover of care-coordinator 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

Louise Asha Allen · 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

Louise Asha Allen, who had bipolar disorder and emotionally unstable personality disorder, was discharged from hospital in December 2020 and was regarded as a very high risk to herself. Between February and June 2021, she did not receive necessary mental state assessments or sufficient support, and inaccurate clinical details contributed to unreliable risk assessments. On 12 June 2021, she placed herself in front of a train. The principal concerns related to inadequate care coordination, including insufficient continuity of care, excessive caseloads, staff turnover and insufficient numbers of care coordinators.

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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Non-comparable pay for care-coordinator posts
Wider context from the report
“Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include: 1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff. 2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts. 3. Care Co-ordinators within the Trust are currently carrying excessive caseloads. 4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators. 5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators. ”
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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Excessive caseloads for care co-ordinators
Wider context from the report
“Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include: 1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff. 2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts. 3. Care Co-ordinators within the Trust are currently carrying excessive caseloads. 4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators. 5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators. ”
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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide continuity of care
Wider context from the report
“Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include: 1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff. 2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts. 3. Care Co-ordinators within the Trust are currently carrying excessive caseloads. 4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators. 5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators. ”
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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Insufficient number of care co-ordinators for clinical need
Wider context from the report
“Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include: 1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff. 2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts. 3. Care Co-ordinators within the Trust are currently carrying excessive caseloads. 4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators. 5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators. ”
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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
High turnover of care-coordinator staff
Wider context from the report
“Louise Allen did not receive a care plan that was adequate to address the high-risk of harm to herself. This was largely due to failings in the co-ordination of her care. The Inquest heard that care co-ordinators are fundamental to the safe provision of care for high-risk service users. Concerns heard during the evidence at the inquest include: 1. There is a need within the Trust for better continuity of care. There are not enough care co-ordinators to ensure that continuity of care is provided. There are high turnovers of staff. 2. Efforts need to be made to make the post of care co-ordinator more attractive. The evidence heard that the pay within North East London Foundation Trust is not comparable to other Trusts. 3. Care Co-ordinators within the Trust are currently carrying excessive caseloads. 4. There has been an increase in the number of referrals coming into the service. There has been no commensurate increase in the number of care co-ordinators. 5. Whilst the Trust has over recruited in terms of the financial budgets, it is still under recruited in terms of the clinical need for care co-ordinators. ”
Open source report
21 Dec2020
East London
Concerns raised1
1. Lack of care summaries when complex patients transfer between GP surgeries
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

James Alexander David Taylor · 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

James Alexander David Taylor died as a result of suicide after sustaining life-changing injuries in a road traffic collision, which led to refractory pain, sensory disturbances, psychological distress and suicidal ideation. The inquest heard that required long-term psychological therapy was not provided and that his participation in a functional neurological disorder programme ended after four days because of pain. Concerns were also raised about repeated changes of GP surgery, lack of continuity of care, and the absence of a clear transfer summary for his complex medical needs.

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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of care summaries when complex patients transfer between GP surgeries
Wider context from the report
“As a result of his complex health needs, Mr Taylor changed address on a number of occasions. This required a number of changes of general practitioner surgeries. In 4 years, Mr Taylor had changed surgeries 4 times. The Inquest heard evidence from his final general practitioner who confirmed that there was a large volume of records relating to Mr Taylor. The GP confirmed that no summary of care is provided to GP practices when transfer of patients take place. He confirmed the dangers of this, in that important clinical matters can be missed where a patient has a large volume of records. The general practitioner indicated that handover summaries should be provided to GPs when complex patients are transferred from surgery to surgery. Such transfer summaries could include a summary of past medical history and highlight acute, ongoing clinical conditions, together with any safeguards around prescribing of medication. Such summaries could ensure safety in the continuity of care ”
Open source report
8 Dec2020
East London
Concerns raised1
1. Failure to authorise 1:1 care for a person at high risk of falls
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Route all one-to-one care requests to the Head of Service and senior nurse assessor for a response within two hours.
  Stated completed
2. Action
  Escalate care-home one-to-one requests made directly to brokerage staff to a senior clinician and embed this escalation in CHC electronic processes.
  Stated in progress
3. Action
  Require supporting risk and care evidence, with reassessment before extending one-to-one care beyond the usual 14-day authorisation.
  Stated completed
AI-generated summary

Ann Doris Stillwell · 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

Ann Doris Stillwell, who was at high risk of falls, sustained a left-sided neck of femur fracture after a fall in her care home on 3 July 2020 and died from complications of her injuries on 5 July 2020. The principal concern was that 1:1 care was not authorised despite the identified risk, and the report states that this would have been the only way to mitigate the particular risk she presented to herself.

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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to authorise 1:1 care for a person at high risk of falls
Wider context from the report
“1. Mrs Stillwell was at high risk of falls during the entirety of the period of 25th May 2020 until the 3rd July 2020. During that period the Commissioner for her care did not authorise 1:1 care. 1:1 care would have been the only way in which the particular risk presented by Mrs Stillwell to herself could have been mitigated. ”
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
Route all one-to-one care requests to the Head of Service and senior nurse assessor for a response within two hours.

Verbatim wording from the response
“4. We have identified that requests for 1 to 1s come through to different people in the CHC Team and the level of information given is sometimes variable. We have now introduced a requirement for requests for 1 to 1s to be sent to the Head of Service and a senior nurse assessor who will provide a response to the request within 2 hours.”

Source location
2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
Page 2 · response
Published 31 March 2021
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
Escalate care-home one-to-one requests made directly to brokerage staff to a senior clinician and embed this escalation in CHC electronic processes.

Verbatim wording from the response
“7. We are introducing an additional safeguard to ensure that any requests for 1 to 1s submitted to the brokerage team directly by a care home are brought to the attention of a senior clinician. The following actions have been agreed:”

Source location
2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
Page 2 · response
Published 31 March 2021
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 supporting risk and care evidence, with reassessment before extending one-to-one care beyond the usual 14-day authorisation.

Verbatim wording from the response
“5. If the information is not complete, then the hospital discharge team is asked to forward all falls risk assessments, care diaries and behaviour charts as appropriate to the Head of Service or senior nurse assessor so that they can confirm a decision. Evidence is needed as to whether this level of support is required during the daytime only or the full 24 hours. Many people are nursed on enhanced observations or in a cohort /bay in hospital do not go on to require this level of support in the care home.”

Source location
2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
Page 2 · response
Published 31 March 2021
Open published response
9 Mar2016
East London
Concerns raised1
1. Lack of psychotherapy service provision for persons with anti-social personality disorder
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

William Stanley Higgleton · 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

William Stanley Higgleton, who had anti-social personality disorder and mixed anxiety and depressive disorder and was considered at high risk of harm to himself, was found deceased at home on 22 July 2015. The cause of death was recorded as a multiple drug overdose. The principal concerns were the lack of psychotherapy provision for people with anti-social personality disorder and the absence of limits on his access to medication or community mental health support to assist with medication compliance and more frequent 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 NHS North East London Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of psychotherapy service provision for persons with anti-social personality disorder
Wider context from the report
“████████ considered that Mr Higgleton's primary diagnosis was anti-social personality disorder. She confirmed that the primary treatment for this condition would be psychotherapy services. ████████ confirmed however that there is a lack of service provision for psychotherapy care to be provided to persons suffering from anti-social personality disorder. The lack of service provision in this regard was confirmed by ████████ (Assistant Director Adult Mental Health and Learning Disabilities). I consider that the lack of provision of psychotherapy services to this group of patients presents a risk of future deaths occurring. ”
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 raised2

Failure to ensure prominent and accurate filing of critical respiratory action plans in online clinical records

Lack of a coordinated process for producing and storing critical respiratory action plans in online clinical records

Concerns raised3

Lack of formal capacity assessment for nursing-home residents

Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state

Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness

Concerns raised5

Non-comparable pay for care-coordinator posts

Excessive caseloads for care co-ordinators

Failure to provide continuity of care

Insufficient number of care co-ordinators for clinical need

High turnover of care-coordinator staff

Concerns raised1

Lack of care summaries when complex patients transfer between GP surgeries

Concerns raised1

Failure to authorise 1:1 care for a person at high risk of falls

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.3

Concerns raised1

Lack of psychotherapy service provision for persons with anti-social personality disorder

Actions described in response 3