NHS Tower Hamlets Clinical Commissioning Group

Health and care · Clinical commissioning group

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First report 17 Oct 2014•Latest report 17 Oct 2014

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
1

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 NHS Tower Hamlets Clinical Commissioning Group linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Stephen Atherton · 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

    Stephen Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.

    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 Tower Hamlets Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in radiologist-recommended additional investigations when GPs cannot request them

    Wider context from the report

    “(3) Mr Atherton required multiple investigations of increasing complexity, at the recommendation of the reporting radiologists. I heard compelling evidence from Mr Atherton’s GP that this process results in delays. This is because the investigations could be undertaken more quickly if the radiologists themselves instigated the necessary additional investigations. This is particularly the case where the suggested investigations cannot actually be requested by GPs. The Trust gave evidence that this process is necessary because of the commissioning arrangements in place, which determine how payment is made for such tests. I am concerned that this process could increase the risk of future deaths occurring in similar circumstances to Mr Atherton’s case. ”
    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 Tower Hamlets Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a system at the GP practice to ensure successful receipt of important correspondence

    Wider context from the report

    “(1) It was clear from the evidence at the inquest that Mr Atherton’s GP was concerned that he should be seen for orthopaedic review more quickly than had been planned. However, was concerned that, given the importance of this further correspondence, there was no system in place at the GP practice to ensure successful receipt of the fax. ”
    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 Tower Hamlets Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to clinically triage routine orthopaedic referrals

    Wider context from the report

    “(2) I heard evidence that routine ‘choose and book’ orthopaedic referrals are not clinically triaged by the specialist to whom the referrals are made. As such, the concern was raised (which I share) that there is no potential for the triaging of apparently ‘routine’ appointments which, with specialist input might be expedited. It was clear from the evidence heard that other departments routinely triage referrals and no evidence was provided as to why this is not undertaken by the orthopaedic department. ”
    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 Tower Hamlets Clinical Commissioning Group; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment

    Wider context from the report

    “(4) The neurosurgical ward from which Mr Atherton self-discharged was not locked. This was despite the risk he posed to himself and the fact that the staff were clear he should not be free to leave, without medical assessment of his capacity to self-discharge. I heard evidence that the current legislative framework and case law means that locking of wards is not acceptable. Whilst it is clear that locking ward doors by default is not appropriate, I did not hear compelling evidence as to why mechanisms could not be put in place to facilitate temporary locking. I am concerned that the legal position is being interpreted so that no appropriate safeguards exist, which would have prevented Mr Atherton from absconding. This raises concerns that future deaths could result in such circumstances, if this issue is not addressed. ”
    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