5 Mar 2026 Caroline Adeyelu · Prevention of Future Deaths report East London
View report summary
Concerns raised 9 Absence of safeguarding referrals for parents at risk of adult child to parent domestic abuse View source Lack of carer support View source Failure to provide prompt direct operational liaison between mental health services and police View source Failure to appreciate risks posed by mentally unwell adult children to parents View source Absence of multi-agency risk assessment and risk management View source Insufficient safeguarding training on adult child to parent domestic abuse View source Lack of home-based risk assessment View source Lack of information gathering from wider family members View source Lack of home visits by the clinical team View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Caroline Adeyelu · 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
Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the police.
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× 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of safeguarding referrals for parents at risk of adult child to parent domestic abuse
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of carer support
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support ; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prompt direct operational liaison between mental health services and police
Wider context from the report “2. The inquest heard concerns from multiple witnesses about the lack of effective communication systems in place between the mental health services and the Metropolitan Police Service , in circumstances where there are dual forensic and mental health concerns. Whilst there are clearly higher-level meetings that take place between the trusts and the MPS, these do not address the needs of psychiatrists and police officers working on the frontline who are having to address pressing risk issues – both in assessing and in managing risk. Such liaison needs to be prompt – in some cases immediate. Liaison may be from the MPS to the Trust (for example in risk assessing missing persons) or from the trust to the police (for both risk assessment and how to best manage risk). The inquest heard that communication both ways was challenging . The challenges have increased since the introduction of the Right Care, Right Person policy has been introduced. In some cases, communication was not attempted at all , because of the assumption that the appropriate professional was unlikely to be reached. Both trusts and the MPS are asked to consider a process for direct and immediate operational liaison between the police and NHS mental health staff for individuals presenting with a risk of violence compounded by mental ill health.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate risks posed by mentally unwell adult children to parents
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son . This poor appreciation of risk was observed at all levels of clinical staff . Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of multi-agency risk assessment and risk management
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management . It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient safeguarding training on adult child to parent domestic abuse
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case . In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of home-based risk assessment
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment ; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of information gathering from wider family members
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members ; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of home visits by the clinical team
Wider context from the report “1. The evidence at the inquest reflected very poor appreciation of the risks posed to Mrs Adeyelu by her mentally unwell adult son. This poor appreciation of risk was observed at all levels of clinical staff. Whilst I note that the safeguarding training within the trusts includes reference to the adult child to parent domestic abuse, I am concerned that the extent of training on this subject is insufficient to address the widespread concerns encountered in this case. In relation to the risk of domestic abuse in this case there was a lack of information gathering from wider family members; there was a lack of carer support; a lack of home-based risk-assessment; a lack of home visits by the clinical team ; an absence of safeguarding referrals for Mrs Adeyelu and an absence of multi-agency risk assessment/risk management. It has been brought to my attention that the Femicide Census (2000) found that for women killed by immediate family members, over 80% were mothers killed by their sons. Mental health of the perpetrator was a context of the violence in 58% of those cases. In light of this, and in light of the evidence heard at the inquest, I am concerned that the risk of adult child to parent domestic abuse is a matter that requires more substantive consideration in safeguarding training, than is currently provided.
” 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 Engage with the Metropolitan Police Service to review and agree strengthened operational liaison arrangements for high-risk situations involving mental ill health.
Verbatim wording from the response “In relation to the direct and immediate operational liaison between the Trust and the Metropolitan Police Service the Chief Executive Officers of both North East London NHS Foundation Trust (NELFT) and East London NHS Foundation Trust (ELFT) have written directly to Sir Mark Rowley of the Metropolitan Police Service to reset and strengthen our collective approach. Whilst we continue to engage at a Borough Command level (with the most recent collective review taking place on 14th April), we have advised that we would welcome the opportunity to work on and agree:” Source location Response from North East London Foundation Trust
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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 Deliver revised Safeguarding Level 3 training with dedicated adult child-to-parent abuse content and case studies across the mandatory rolling programme.
Verbatim wording from the response “In relation to the training that our staff are required to complete for safeguarding we are implementing the following:” Source location Response from North East London Foundation Trust
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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 Explore inclusion of adult child-to-parent abuse content in national Safeguarding Levels 1 and 2 e-learning packages with Health Education England.
Verbatim wording from the response “• Our Safeguarding lead has also contacted Health Education England to explore the inclusion of ACPA training within the national Safeguarding Levels 1 and 2 e-learning packages. These packages are available to all NHS bodies and therefore we await the outcome of these discussions and will be sharing the Regulation 28 report as part of the supporting evidence for inclusion.” Source location Response from North East London Foundation Trust
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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 Develop and disseminate a seven-minute adult child-to-parent abuse briefing through Safeguarding Assurance reports across Trust services and teams.
Verbatim wording from the response “• A 7-minute briefing on ACPA is now in development and will be incorporated into our Safeguarding Assurance reports for dissemination across all services and teams within the trust. This will support the dissemination of learning for all staff and will commence in May 2026.” Source location Response from North East London Foundation Trust
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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 Include adult child-to-parent abuse in regular Domestic Abuse awareness sessions for all staff and safeguarding practitioners.
Verbatim wording from the response “• The Trust safeguarding lead will be including ACPA in the regular Domestic Abuse awareness sessions at both the ‘All-staff webinar’ and the Trust Safeguarding Practitioners’ event. This will take place by the end of June 2026.” Source location Response from North East London Foundation Trust
Open published response
23 May 2025 George Kenneth Fraser · Prevention of Future Deaths report East London
View report summary
Concerns raised 6 Failure to review risk of harm when contact is lost View source Lack of structure in care provision View source Failure to maintain meaningful family contact about concerning loss of contact View source Failure to determine whether the missing person procedure should be activated View source Failure to carry out robust risk assessments View source Lack of a clear and documented care plan View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 8
Action
Recruit trainers to support delivery of the new risk-assessment and management training programme.
Stated completedThe respondent said that this action was complete when they made their response on 29 May 2025. View source
Action
Deliver care-planning workshops to strengthen staff skills in co-producing individualized, recovery-focused care plans.
Stated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025. View source
Action
Review zoning practice across four boroughs and produce a revised case-review template focused on recent face-to-face contact.
Stated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025. View source
Action
Implement the NICE-based risk-formulation approach through co-produced training, updated recording systems and team support.
Stated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025. View source
Action
Monitor compliance, patient and staff experience, and risk-formulation quality through supervision, meetings and the Risk Formulation Steering Group.
Stated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025. View source
Action
Use DIALOG assessments to co-produce and evaluate individualized care plans with service users.
Stated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025. View source
Action
Use the MaST electronic system in Havering to monitor caseloads, documentation, engagement, risk and care-planning reviews.
Stated completedThe respondent said that this action was complete when they made their response on 29 May 2025. View source
Action
Review and finalise the Missed Appointments Policy with stronger guidance for disengagement, unsuccessful contact and escalation of concerns.
Stated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025. View source See 5 more actions
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AI-generated summary
George Kenneth Fraser · 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
George Kenneth Fraser, aged 37, was found deceased at his home after mental health services had been unable to contact him and his family had last contacted him several weeks earlier. The cause and date of death were uncertain. Concerns included the absence of a clear care plan and robust risk assessment, and inadequate action and communication following failed contact and concerns raised by a friend and family.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review risk of harm when contact is lost
Wider context from the report “(3) The Mental Health and Wellness Team had been unable to reach Mr Fraser from the 16 July 2024. On the 18 July 2024 a friend contacted the mental health team to raise concern about his lack of contact with Mr Fraser. No action was taken at this time to review the risk of harm to Mr Fraser or to determine whether the Trust’s missing person procedure should be activated. There was no meaningful contact with the family to report the concerning lack of contact with Mr Fraser, until the 29 July 2024.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of structure in care provision
Wider context from the report “(1) There was no clear and documented care plan in place whilst Mr Fraser was under the care of the Mental Health and Wellness Team. There was a lack of structure to the care provided to Mr Fraser by the Mental Health and Wellness Team.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain meaningful family contact about concerning loss of contact
Wider context from the report “(3) The Mental Health and Wellness Team had been unable to reach Mr Fraser from the 16 July 2024. On the 18 July 2024 a friend contacted the mental health team to raise concern about his lack of contact with Mr Fraser. No action was taken at this time to review the risk of harm to Mr Fraser or to determine whether the Trust’s missing person procedure should be activated. There was no meaningful contact with the family to report the concerning lack of contact with Mr Fraser, until the 29 July 2024.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to determine whether the missing person procedure should be activated
Wider context from the report “(3) The Mental Health and Wellness Team had been unable to reach Mr Fraser from the 16 July 2024. On the 18 July 2024 a friend contacted the mental health team to raise concern about his lack of contact with Mr Fraser. No action was taken at this time to review the risk of harm to Mr Fraser or to determine whether the Trust’s missing person procedure should be activated . There was no meaningful contact with the family to report the concerning lack of contact with Mr Fraser, until the 29 July 2024.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out robust risk assessments
Wider context from the report “(2) There was no robust risk assessment carried out by the Mental Health and Wellness team.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear and documented care plan
Wider context from the report “(1) There was no clear and documented care plan in place whilst Mr Fraser was under the care of the Mental Health and Wellness Team. There was a lack of structure to the care provided to Mr Fraser by the Mental Health and Wellness Team.
” 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 Recruit trainers to support delivery of the new risk-assessment and management training programme.
Verbatim wording from the response “approach. The working group comprises staff from all professional groups, as well as service users and carers. To support implementation of this, new training has been developed, electronic recording systems reviewed and updated, trainers recruited, and team support designed to ensure that staff are equipped to embed this new way of working. This work programme has been co-produced with service users and carers, including involvement in training delivery, with every training day supported by a service user or carer to ensure their voice was heard throughout the process. This undertaking required considerable preparation before the rollout of the training began in 2024. The training programme has been delivered locality by locality, with three localities completed to date (July 2025).” Source location Response from North East London Foundation Trust
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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 Deliver care-planning workshops to strengthen staff skills in co-producing individualized, recovery-focused care plans.
Verbatim wording from the response “We are monitoring the use of this approach, and the number of plans being developed in this way is increasing as implementation progresses. Additionally, care planning workshops have been held throughout 2025 and are scheduled to continue. These workshops aim to support staff to use their skills to co-create individualised care plans with service users and their support networks. The workshops emphasise the importance of involving service users in the care planning process, focusing on their preferences and goals.” Source location Response from North East London Foundation Trust
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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 Review zoning practice across four boroughs and produce a revised case-review template focused on recent face-to-face contact.
Verbatim wording from the response “The patient safety investigation report into Mr Fraser’s sad death also highlighted learning outcomes in relation to team risk management. When Mr Fraser was not engaging with the Mental Health and Wellness Team, outcomes from the multidisciplinary zoning meeting were relatively passive, meaning that there was not an assertive response to support Mr Fraser. To support improvements in relation to this, we have established a Quality Improvement project to review zoning practice across the four boroughs. One outcome of this will be a revised template for teams to use to review cases, that maintains a focus on when the last face to face contact with a client took place. The implementation of the MaST tool also assists practitioners and supervisors in ensuring that face to face contact with clients is taking place appropriately.” Source location Response from North East London Foundation Trust
Open published response
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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 Implement the NICE-based risk-formulation approach through co-produced training, updated recording systems and team support.
Verbatim wording from the response “Since the publication of NICE Guidance NG225 on self-harm was published, focusing on assessment, management, and preventing recurrence, we have been working to change Trust practice in relation to the assessment and management of risk. In November 2023, NELFT's senior clinical leadership established a working group to plan for the full implementation of this” Source location Response from North East London Foundation Trust
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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 Monitor compliance, patient and staff experience, and risk-formulation quality through supervision, meetings and the Risk Formulation Steering Group.
Verbatim wording from the response “Compliance is monitored in teams through individual supervision, utilising the MaST tool, as well as team meetings and clinically focused groups, such as the team zoning meeting.” Source location Response from North East London Foundation Trust
Open published response
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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 Use DIALOG assessments to co-produce and evaluate individualized care plans with service users.
Verbatim wording from the response “Since 2024, we have been undertaking significant improvement work in relation to care planning. This has been driven by identified quality improvements, including those raised by patients and carers. In doing so, we have worked in close collaboration with patients and carers.” Source location Response from North East London Foundation Trust
Open published response
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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 Use the MaST electronic system in Havering to monitor caseloads, documentation, engagement, risk and care-planning reviews.
Verbatim wording from the response “Mental Health and Wellness Teams in Havering have also started using an electronic system, the Management and Supervision Tool (MaST). This enables clinicians and managers to manage caseloads and to monitor the quality of documentation, levels of engagement, and how documentation reflects risk and the complexity of a patient’s needs. This also enables monitoring of DIALOG and care planning, allowing staff to clearly identify, where review of the patient is required.” Source location Response from North East London Foundation Trust
Open published response
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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 Review and finalise the Missed Appointments Policy with stronger guidance for disengagement, unsuccessful contact and escalation of concerns.
Verbatim wording from the response “Missed Appointments Procedure” Source location Response from North East London Foundation Trust
Open published response
4 Dec 2024 Dean Martin Ford · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to audit risk assessments for referred patients not accepted by the team View source Failure to carry out holistic formulations of risk to self View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Dean Martin Ford · 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
Dean Martin Ford died by suicide on 10 March 2024 after leaving home, buying a length of rope, and being found hanging in Bedfords Park, Romford. Concerns included failures by two mental health teams to carry out a holistic risk formulation, an incorrect assessment of his risk as low, and the absence of audits for risk assessments of people referred but not accepted by the mental health and wellbeing team.
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× 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit risk assessments for referred patients not accepted by the team
Wider context from the report “(3) The Trust carries out risk assessment audits for clients who are accepted into the mental health and wellbeing team. There are no audits into risk assessments for those persons who are referred to the team, but not accepted by the team . As these patients who are safety net of ongoing mental healthcare, it is of concern that the quality of risk assessments for these patients is not audited .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out holistic formulations of risk to self
Wider context from the report “(1) Despite clear guidance from NICE in September 2022 relating to the need for a holistic formulation of risk to self, two NELFT teams involved in Mr Ford’s crisis care failed to carry out a holistic formulation of the risk he posed to himself .
(2) A clinical lead for the mental health and wellbeing team within NELFT, gave evidence at the inquest in December 2024 that Mr Ford’s risk was deemed to be low because “the main factor around risk is that he denied any risk to self and denied any suicidal thoughts”. This simplistic assessment of risk is not compliant with the NICE guidelines . It is of concern that a senior member - clinical lead - within the mental health and wellbeing team is not applying the correct risk formulation .
” 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 Deliver and expand face-to-face risk-formulation training across acute, rehabilitation and borough-based staff, including new starters.
Verbatim wording from the response “We have undertaken a very thorough review of all policies, procedures and associated training and worked closely with our experts by experience. We launched our Risk Formulation training in September 2024 and have been delivering a day-long face-to-face training. The training utilises videos we made of experts by experience and carers talking about their experience of risk and suicide. We have now trained some 80% of our acute and rehabilitation colleagues, and moved to Borough based training in January 2025 and have started training colleagues in Barking and Dagenham.” Source location Response from North East London Foundation Trust
Open published response
7 Oct 2024 James Warren Agius · Prevention of Future Deaths report Essex
View report summary
Concerns raised 4 Significant omissions in medical record documentation View source Differences of opinion in mental state assessments View source Failure to implement national training for assessing risk in patients with mental health concerns View source Incomplete risk assessments for patients with mental health concerns View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 6
Action
Require Home Treatment Team staff to use an agreed home-visit documentation template covering mental state, physical health, safeguarding, risk assessment, and follow-up planning, with fortnightly audits.
Stated completedThe respondent said that this action was complete when they made their response on 8 October 2024. View source
Action
Roll out risk-formulation training across the Trust, training Acute and Rehabilitation Directorate clinical staff first and achieving full Trust coverage by April 2026.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 October 2024. View source
Action
Require Home Treatment Team mental-state examinations to record speech abnormalities and psychotic symptoms where mood-disorder concerns arise.
Status unclearThe respondent did not make the status of this action clear when they made their response on 8 October 2024. View source
Action
Put revised good-record-keeping training packages into induction for all staff.
Stated completedThe respondent said that this action was complete when they made their response on 8 October 2024. View source
Action
Complete a thematic review of patient-safety incidents and establish Trust-wide workstreams to address identified record-keeping gaps and embed learning.
Stated completedThe respondent said that this action was complete when they made their response on 8 October 2024. View source
Action
Provide all staff with an intranet resource containing record-keeping guidance, escalation information, and quick access to related documentation standards.
Stated completedThe respondent said that this action was complete when they made their response on 8 October 2024. View source See 3 more actions
×
AI-generated summary
James Warren Agius · 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 Warren Agius was found deceased at home on 17 December 2022 after suspending himself, with the inquest concluding suicide by suspension by ligature. The concerns included significant omissions in his medical records, an incomplete risk assessment following a suicide attempt, differing views about whether he displayed hypomanic symptoms, and no evidence that new national risk-assessment training had been implemented by the Trust.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Significant omissions in medical record documentation
Wider context from the report “1. The medical record documentation for Mr Agius had significant omissions that included an incomplete risk assessment in February 2022 for Mr Agius following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr Agius attempted to take his own life.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Differences of opinion in mental state assessments
Wider context from the report “2. The evidence of assessments of Mr Agius’s mental state provided to the inquest indicated a difference of opinion as to whether Mr Agius was displaying hypomanic symptoms on 12 and 13 February 2022.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement national training for assessing risk in patients with mental health concerns
Wider context from the report “3. Evidence was heard that there is new national training for assessing risk for patients with mental health concerns but there was no evidence that the Trust has implemented this training .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete risk assessments for patients with mental health concerns
Wider context from the report “1. The medical record documentation for Mr Agius had significant omissions that included an incomplete risk assessment in February 2022 for Mr Agius following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr Agius attempted to take his own life.
” 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 Require Home Treatment Team staff to use an agreed home-visit documentation template covering mental state, physical health, safeguarding, risk assessment, and follow-up planning, with fortnightly audits.
Verbatim wording from the response “To support good record keeping practice in the Home Treatment Teams (HTT) in NELFT, all staff completing home visits to service users are expected to complete their records utilising an agreed template. This ensures that the visit and documentation of what took place will cover areas including (though not limited to), mental state examination, social situation, physical health concerns, risk assessment, safeguarding and that these lead to a clear plan to be followed by the team. Adherence to this is monitored within through a fortnightly progress note audit that is completed. The last audit that was completed for the Barking and Dagenham HTT was on 3rd November 2024, with the team scoring 100% for adherence to use of the correct template. All entries reviewed also included a full Mental State Examination and risk assessment.” Source location Response from NELFT
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 Roll out risk-formulation training across the Trust, training Acute and Rehabilitation Directorate clinical staff first and achieving full Trust coverage by April 2026.
Verbatim wording from the response “The final concern raised related to the risk assessment completed and NELFT’s progress in transitioning from the previous risk stratification model of assessing risk to that of risk formulation. As correctly referenced in your report, this change will reflect national recommendations on the most effective means of assessment of the risk suicide and self-harm (NICE NG225 Self Harm: assessment, management and preventing recurrence).” Source location Response from NELFT
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 Home Treatment Team mental-state examinations to record speech abnormalities and psychotic symptoms where mood-disorder concerns arise.
Verbatim wording from the response “When HTT staff complete their mental state examinations, where there is a potential concern regarding a mood disorder, staff will make reference to a service user’s speech and observation of any psychotic symptoms. This is completed as abnormalities within these domains can be common features of a manic episode (International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)).” Source location Response from NELFT
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 Put revised good-record-keeping training packages into induction for all staff.
Verbatim wording from the response “Revised training packages have also been put in place that cover the principles of good record keeping standards. These are essential training for all staff and are covered as part of the induction to NELFT.” Source location Response from NELFT
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 Complete a thematic review of patient-safety incidents and establish Trust-wide workstreams to address identified record-keeping gaps and embed learning.
Verbatim wording from the response “The Trust has completed a thematic review of patient safety incidents with the intention of identifying themes and patterns occurring within these. Resulting from this was the establishment of Trust wide workstreams aimed to address the identified gaps and then embed learning around these across the Trust. Of pertinence to the concerns raised in this instance, is the Improving Quality of Record Keeping and Clinical Documentation workstream.” Source location Response from NELFT
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 Provide all staff with an intranet resource containing record-keeping guidance, escalation information, and quick access to related documentation standards.
Verbatim wording from the response “The aim of this workstream is to establish any system weaknesses associated with poor record keeping, understand the behaviour associated with this and to improve recording keeping and create a healthy record keeping culture. The Quality Improvement initiatives around this workstream have so far been successful in creating a Trust wide intranet page accessible to all staff offering direction on the importance of accurate and good record keeping. In addition to this, the Trust has developed quick access to guidance and information on issues such as cut and paste and commonly used acronyms and clinical abbreviations. Readily accessible links to good record keeping practice are also available and consequences of failing to comply with this and guidance on how to escalate concerns are also captured and available to all staff within this platform.” Source location Response from NELFT
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The medical records indicate consistent staff opinions and do not support a difference of opinion about hypomanic symptoms.
Verbatim wording from the response “Mr Agius’ medical records would suggest that there was consistency in the opinion of the two staff members that visited, in as much that they both did not see evidence of an elated mood. Had Mr Agius been under the BDHTT for a period longer than the three days he was, he would have been reviewed by the medical team, in line with the HTT Standard Operating Procedure and greater clarity regarding his diagnosis would have been achieved.” Source location Response from NELFT
Open published response
24 Apr 2024 Olayemi Oluwarotimi Kodjo Kehinde · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure of staff authorised to supervise S.17 leave to identify serious incidents requiring meaningful intervention View source Failure of the Trust to identify matters requiring a full governance investigation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 6
Action
Implement the Patient Safety Incident Response Framework to guide compassionate incident responses, investigation decisions, learning and improvement.
Stated completedThe respondent said that this action was complete when they made their response on 30 April 2024. View source
Action
Perform two-monthly electronic dip-sample audits against the section 17 leave guidance and review outcomes to support improvements.
Stated plannedThe respondent said that this action was planned when they made their response on 30 April 2024. View source
Action
Review historic incidents through InPhase reporting, Incident Review Group discussion, directorate oversight and, where necessary, Patient Safety Incident Group consideration of a 72-hour report.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024. View source
Action
Prepare detailed guidance for safely escorting patients on section 17 leave and responding to serious incidents, reckless decisions, absconding or attempted absconding.
Stated completedThe respondent said that this action was complete when they made their response on 30 April 2024. View source
Action
Launch the section 17 leave guidance across the Trust and disseminate it through electronic communications, intranet publication, management channels, supervision and relevant training.
Stated plannedThe respondent said that this action was planned when they made their response on 30 April 2024. View source
Action
Establish and operate a weekly Patient Safety Incident Group to oversee qualifying incidents and determine appropriate learning responses.
Stated completedThe respondent said that this action was complete when they made their response on 30 April 2024. View source See 3 more actions
×
AI-generated summary
Olayemi Oluwarotimi Kodjo Kehinde · 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
Olayemi Oluwarotimi Kodjo Kehinde, a 34-year-old man with a history of schizophrenia illness, walked into fast-moving traffic on 26 October 2023, was struck by a van, and later died from his injuries. Concerns related to staff supervision of escorted leave and the Trust’s ability to identify incidents requiring meaningful intervention or a full governance investigation.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff authorised to supervise S.17 leave to identify serious incidents requiring meaningful intervention
Wider context from the report “1. In July 2011, Mr Kehinde was an inpatient subject to an order under S.3 Mental Health Act 1983. On 2nd July 2011, Mr Kehinde was granted escorted S.17 leave to return home to collect belongings. Mr Kehinde left the ward in the company of a mental health nurse and they both travelled to a tattoo parlour. Mr Kehinde’s face was tattooed with a large permanent tattoo. No action was taken by the nurse to prevent this act occurring. The incident was not investigated as a serious incident by the Trust. Whereas the court does not suggest that a facial tattoo constitutes a factor that would likely cause a future death, concerns arise regarding;
• The ability of staff authorised to supervise S.17 leave at identifying serious incidents that require meaningful intervention.
• The ability of the Trust to identify matters that require a full governance investigation.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Trust to identify matters requiring a full governance investigation
Wider context from the report “1. In July 2011, Mr Kehinde was an inpatient subject to an order under S.3 Mental Health Act 1983. On 2nd July 2011, Mr Kehinde was granted escorted S.17 leave to return home to collect belongings. Mr Kehinde left the ward in the company of a mental health nurse and they both travelled to a tattoo parlour. Mr Kehinde’s face was tattooed with a large permanent tattoo. No action was taken by the nurse to prevent this act occurring. The incident was not investigated as a serious incident by the Trust. Whereas the court does not suggest that a facial tattoo constitutes a factor that would likely cause a future death, concerns arise regarding;
• The ability of staff authorised to supervise S.17 leave at identifying serious incidents that require meaningful intervention.
• The ability of the Trust to identify matters that require a full governance investigation.
” 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 Implement the Patient Safety Incident Response Framework to guide compassionate incident responses, investigation decisions, learning and improvement.
Verbatim wording from the response “3. In 2023 the reporting and management of investigations changed with the implementation of the nationally mandated Patient Safety Incident Response Framework (PSIRF). PSIRF supports the development of an effective patient safety incident response system, that prioritises compassionate engagement and involvement of those affected by patient safety incidents (including patients, families and staff), and” Source location Response from NELFT
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 Perform two-monthly electronic dip-sample audits against the section 17 leave guidance and review outcomes to support improvements.
Verbatim wording from the response “Electronic dip-sample audits will be performed on a two-monthly basis, against the guidance, and the outcome of the audit will be reviewed by the relevant directorates to support any required improvements in this area.” Source location Response from NELFT
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 Review historic incidents through InPhase reporting, Incident Review Group discussion, directorate oversight and, where necessary, Patient Safety Incident Group consideration of a 72-hour report.
Verbatim wording from the response “6. Once the Trust is made aware of an incident that is historic, it reviews the historic incident utilising the current process in place, which consists of reporting it as an incident on InPhase, discussion of the incident at the IRG meeting, and following further directorate oversight, and where deemed necessary, preparation of a 72-hour report for presentation at the PSIG forum. This provides a robust decision-making mechanism, ensuring that the investigation of an historic incident is treated with the same care and attention as all incidents.” Source location Response from NELFT
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 Prepare detailed guidance for safely escorting patients on section 17 leave and responding to serious incidents, reckless decisions, absconding or attempted absconding.
Verbatim wording from the response “1. To ensure that staff who escort a patient on supervised leave under section 17 of the Mental Health Act 1983 (‘s. 17 leave’), are able to do so safely and are able to identify serious incidents that require meaningful intervention, and to provide appropriate and timely intervention, new guidance for leave from inpatient wards for mental health patients has been prepared. This guidance (attached) sets out in detail the process to be undertaken before, during, and after escorting a patient on s. 17 leave, and also covers actions to be taken if the patient intends what may be an ill-advised or reckless decision, and/or absconds or attempts to do so. The first page of this guidance contains on a single page an ‘At a glance guidance for escorted leave for mental health patients’ as a flowchart, to enable effective learning for staff involved in s.” Source location Response from NELFT
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 Launch the section 17 leave guidance across the Trust and disseminate it through electronic communications, intranet publication, management channels, supervision and relevant training.
Verbatim wording from the response “2. This guidance will go live across the Trust in June 2024 and will be communicated to all staff via the Trust electronic newsletter and a copy of this guidance will be placed on the Trust’s intranet. It will also feature in regular Mental Health Act (MHA) introductory and refresher training, and through wider learning at Trust-wide Learning & Development events. This guidance will also be circulated to the Integrated Care Directors, Directors of Nursing, Associate Directors of Nursing, the Directors, the Associate Medical Directors, and the matrons, some of whom were involved in the preparation of the guidance and disseminated through managers’ and matrons huddles, as well as in staff supervision.” Source location Response from NELFT
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 Establish and operate a weekly Patient Safety Incident Group to oversee qualifying incidents and determine appropriate learning responses.
Verbatim wording from the response “4. With the implementation of PSIRF, the Trust initiated a weekly Patient Safety Incident Group (PSIG) forum chaired by the Executive Chief Nursing Officer to oversee incidents that have met the threshold for a PSIRF learning response. There are several learning responses to incidents. Decisions about the type of investigation to undertake are decided at the weekly PSIG forum, and a learning response is decided, based on the local PSIRF plan, national PSIRF recommendations via NHS England (NHSE), and following presentations from clinical staff who share immediate learning outcomes.” Source location Response from NELFT
Open published response
11 Sep 2023 Amanda Jane Kramer · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to review Zopiclone use despite high-risk medication-taking behaviour View source Central nervous system depression risk from Zopiclone View source Dependency risk from Zopiclone View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 6
Action
Improve team handovers by documenting patient information, care plans and professional responsibilities, including primary-care prescribing arrangements, and audit effectiveness.
Stated completedThe respondent said that this action was complete when they made their response on 15 September 2023. View source
Action
Coordinate primary and secondary care medication monitoring through an established integrated-care-system workstream and improve information sharing.
Stated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023. View source
Action
Increase Crisis and Home Treatment team staffing through additional pharmacist posts.
Stated completedThe respondent said that this action was complete when they made their response on 15 September 2023. View source
Action
Train staff in the safe prescribing and management of Z-drugs and benzodiazepines through repeat sessions.
Stated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023. View source
Action
Use additional pharmacy capacity to improve discharge medication reconciliation, monitor and reconcile Zopiclone prescriptions, and provide medication education during transfers.
Stated plannedThe respondent said that this action was planned when they made their response on 15 September 2023. View source
Action
Review Zopiclone prescriptions within two weeks, identify existing patients for review, provide senior clinical oversight, and audit compliance six-monthly.
Stated completedThe respondent said that this action was complete when they made their response on 15 September 2023. View source See 3 more actions
×
AI-generated summary
Amanda Jane Kramer · 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
Amanda Jane Kramer, aged 56, was found unresponsive at home on 31 December 2022 and died from an overdose of prescribed zopiclone. The report raised concerns that zopiclone had been prescribed for approximately 18 years without clear evidence that its ongoing need, associated risks, or adherence to dosage instructions had been reviewed, including after previous deliberate overdoses of prescribed medication.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review Zopiclone use despite high-risk medication-taking behaviour
Wider context from the report “1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.
2. Mrs Kramer was prescribed Zopiclone for 18 years.
3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Central nervous system depression risk from Zopiclone
Wider context from the report “1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.
2. Mrs Kramer was prescribed Zopiclone for 18 years.
3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Dependency risk from Zopiclone
Wider context from the report “1. Zopiclone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it.
2. Mrs Kramer was prescribed Zopiclone for 18 years.
3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer's use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication.
” 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 Improve team handovers by documenting patient information, care plans and professional responsibilities, including primary-care prescribing arrangements, and audit effectiveness.
Verbatim wording from the response “3. The Trust has also worked with staff to ensure that there is effective handover of information between teams so that responsibilities are clear. In particular, there has been a focus on ensuring comprehensive documentation of patient information at the point of handover from one team to another. The effectiveness of this is being audited, and in the most recent audit undertaken (a random sample of 20 patients), all records were clear and reflected a comprehensive handover of the care plan and responsibilities for different professionals involved. This includes situations in which prescribing is taking place within primary care.” Source location Response from North East London Foundation Trust
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 Coordinate primary and secondary care medication monitoring through an established integrated-care-system workstream and improve information sharing.
Verbatim wording from the response “2. A workstream has been established across the primary and secondary care partners in the North East London Integrated Care System. This is overseeing improvements to the co-ordination of medication monitoring for patients receiving Benzodiazepines and Z-Drugs, including significant work on the co-ordination of information between primary and secondary care to ensure that accurate information is in place to enable the effective review and monitoring of patients who have been prescribed such medication.” Source location Response from North East London Foundation Trust
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 Increase Crisis and Home Treatment team staffing through additional pharmacist posts.
Verbatim wording from the response “4. Staffing in Crisis and Home Treatment teams has been increased, with the addition of extra pharmacist posts. This will enable improved medicine reconciliation at the point of discharge from hospital, and ensure that prescriptions for Zopiclone amongst other medication are effectively monitored and reconciled throughout the patient’s journey. This increased capacity will also give more pharmacy support to work with individual patients at this point of transfer and transition, including work on medication education for both patients and prescribers that will help to address risks associated with these medications.” Source location Response from North East London Foundation Trust
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 Train staff in the safe prescribing and management of Z-drugs and benzodiazepines through repeat sessions.
Verbatim wording from the response “In support of this work, staff have received training on the safe prescribing and management of Z-drugs and Benzodiazepines and this is being arranged on a repeat basis, with the next session taking place on 29 November 2023.” Source location Response from North East London Foundation Trust
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 Use additional pharmacy capacity to improve discharge medication reconciliation, monitor and reconcile Zopiclone prescriptions, and provide medication education during transfers.
Verbatim wording from the response “4. Staffing in Crisis and Home Treatment teams has been increased, with the addition of extra pharmacist posts. This will enable improved medicine reconciliation at the point of discharge from hospital, and ensure that prescriptions for Zopiclone amongst other medication are effectively monitored and reconciled throughout the patient’s journey. This increased capacity will also give more pharmacy support to work with individual patients at this point of transfer and transition, including work on medication education for both patients and prescribers that will help to address risks associated with these medications.” Source location Response from North East London Foundation Trust
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 Review Zopiclone prescriptions within two weeks, identify existing patients for review, provide senior clinical oversight, and audit compliance six-monthly.
Verbatim wording from the response “1. Patients who are initiated on Zopiclone now have a medical review of this medication within at least 2 weeks of the initial prescription date recorded in their care plan, whilst existing patients are being identified and reviewed. Senior clinical oversight has also been put in place to support this review for all patients prescribed this medication. The Trust has also put in place a 6 monthly audit process of this to help support this improvement in practice. The last of these audits was undertaken in October 2023, identifying one patient where a review was required, but that all other reviews had taken place. In circumstances where prescriptions remain in place for longer periods of time, the risks and rationale for this are discussed with patients and medical and care co-ordinator staff are keeping this under careful review.” Source location Response from North East London Foundation Trust
Open published response
31 Aug 2023 Donna Levy · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Failure to escalate care in response to deteriorating health and self-neglect risks View source Failure to undertake an adequately scoped serious investigation of community care incidents View source Domiciliary care visits failing to provide personal care View source Failure to undertake or consider a formal Mental Capacity Act assessment View source Failure to make formal mental health referrals for reluctance to accept offered care View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Donna Levy · 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
Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate care in response to deteriorating health and self-neglect risks
Wider context from the report “2. In the two months prior to her final admission into hospital Ms Levy was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake an adequately scoped serious investigation of community care incidents
Wider context from the report “6. The Trust responsible for community care did not undertake a Serious Investigation . The decision was justified on the basis that Ms Levy’s pressure sore was insufficiently significant to justify further inquiry. The decision was, in the view of the court flawed as evidence heard indicated that the pressure sore was in fact far more serious than appreciated at the time of community treatment. Further, restricting the scope of a serious incident report to the extent of a single pressure sore, neglected to take in the wider physical health problems suffered by Ms Levy that were obvious at that time .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Domiciliary care visits failing to provide personal care
Wider context from the report “1. Since 2020 Ms Levy had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken . Ms Levy was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided . Carers had escalated to the local authority Ms Levy’s reluctance to accept personal care and raised safeguarding reports regarding Ms Levy’s living conditions.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake or consider a formal Mental Capacity Act assessment
Wider context from the report “3. The inquest heard that as Ms Levy was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her.
4. No formal Mental Capacity Act assessment was ever undertaken or 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make formal mental health referrals for reluctance to accept offered care
Wider context from the report “5. No formal referral was made to mental health services regarding Ms Levy’s reluctance to take advantage of offered care .
” 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 Investigate all pressure ulcers associated with sepsis through full Patient Safety Incident Investigations.
Verbatim wording from the response “As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.” Source location Response from North East London Foundation Trust
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 Implement PSIRF governance processes, including PSIG review of whether incidents require investigation and the appropriate investigation form.
Verbatim wording from the response “With the introduction of the new Patient Safety Incident Response Framework, this has now changed. This framework includes new processes such as the Patient Safety Incident Report Group Forum (PSIG) that provides for greater and more detailed review of whether an investigation is needed and what form that will take. The PSIG is a NELFT wide meeting headed by the Executive Chief Nursing Officer and attended by, but not limited to, representatives at various levels from the different Directorates, Directors, Assistant Directors, Operational Leads, the Legal Team and the Patient Safety Team.” Source location Response from North East London Foundation Trust
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 Devise a standard operating procedure for district nurses’ daily handovers.
Verbatim wording from the response “• Devise a standardised operating procedure relating to how District Nurses conduct their daily handovers.” Source location Response from North East London Foundation Trust
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 Establish multidisciplinary pressure-ulcer review panels and thematic learning through PSIG and the Pressure Ulcer Assurance Group.
Verbatim wording from the response “As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.” Source location Response from North East London Foundation Trust
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 Ensure incident reports capture concerns across integrated services.
Verbatim wording from the response “• Ensure incident reports include concerns across integrated services.” Source location Response from North East London Foundation Trust
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 Provide mental-capacity assessment training to all health and social care staff.
Verbatim wording from the response “• Provide mental capacity assessment training for all health and social care staff.” Source location Response from North East London Foundation Trust
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 Provide Directorate oversight and expert review of category 2–4 pressure-ulcer incidents and stronger or deep-tissue injuries.
Verbatim wording from the response “As part of the new PSIRF governance process it is clear that all pressure ulcers related to sepsis will be investigated via a full Patient Safety Incident Investigation (PSII) by the patient safety incident team. The revised process in place in relation to pressure ulcers also ensures Directorate oversight and expert views of all incident reports for category 2, 3, and 4 pressure ulcers, as well as stronger and deep tissue injuries. In support of this, we are also establishing multidisciplinary review panels to address key themes in relation to pressure ulcer care, with themelining being reviewed through the PSIG and through the Trust’s pressure ulcer assurance group for wider learning.” Source location Response from North East London Foundation Trust
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 Review, revise and disseminate the risk-escalation process to health and social care staff.
Verbatim wording from the response “• Review, revise and disseminate the risk escalation process with health and social care staff.” Source location Response from North East London Foundation Trust
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 Complete mental-capacity assessments in complex cases.
Verbatim wording from the response “• Complete mental capacity assessments in complex cases.” Source location Response from North East London Foundation Trust
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 Review the case at the Pressure Ulcer Assurance Group to identify further care gaps and learning.
Verbatim wording from the response “• Undertake a review of this case at the Pressure Ulcer Assurance Group to identify any further gaps in care and learning.” Source location Response from North East London Foundation Trust
Open published response
Concerns raised 5 Lack of training for stepdown service teams on BDD diagnosis and associated risks View source Failure to share BDD diagnoses with clinics providing aesthetic dermatology treatment View source Failure to inform patients with BDD of the risks of seeking aesthetic dermatology treatment View source Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge View source Lack of national specialist resources for BDD View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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
×
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 Develop risk formulation to support robust risk assessment and risk management processes and improve patient safety.
Verbatim wording from the response “This approach could potentially standardise variation through testing a change package which includes evidence based approaches to ensure care provision meets those standards and teams have a realistic chance of providing the care that is required to avoid future untoward outcomes. There is also a workstream which is leading on the development of risk formulation to ensure the implementation of robust risk assessment and risk management process to improve patient safety and move away from the current risk stratification model.” Source location Response from NELFT
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 Share the joint working protocol with staff and discuss it in team business meetings.
Verbatim wording from the response “• Joint working protocol to be developed between the CADAT team and the stepdown services provided by NELFT. This should highlight the need for full information sharing around risk and joint risk/management planning and discharge.” Source location Response from NELFT
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 Undertake a quality improvement project to identify and address structural, process and cultural gaps in risk assessment and risk management.
Verbatim wording from the response “• The Trust is planning to undertake a Quality Improvement Project on understanding why there are gaps in risk assessment and risk management processes (a couple of examples of reoccurring themes), particularly when there are poor outcomes associated with care provided. The project will focus on working with users of service, clinical and operational teams, as well as senior leadership and other identified key stakeholders to understand the structural, process and cultural factors which contribute to poor outcomes and use improvement methodology and frameworks to address the areas which can result in process changes to improve outcomes. It may be that a break through series collaborative methodology could be used across various teams at NELFT.” Source location Response from NELFT
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 Deliver a learning event on completing and updating risk assessments, including relevant assessment parameters.
Verbatim wording from the response “• Learning event on completing risk assessments arranged for 05/07/2023. This learning event will cover updating risk, the parameters to consider when completing a risk assessment and when to update a risk assessment.” Source location Response from NELFT
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 Arrange BDD training for all staff in conjunction with SLAM’s specialised training provision.
Verbatim wording from the response “3) Body Dysmorphic (BDD) training to be offered to all staff” Source location Response from NELFT
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 Arrange a case-based learning event for staff addressing BDD and the importance of working with partner agencies.
Verbatim wording from the response “2) Learning event to be arranged on BDD for all staff” Source location Response from NELFT
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 Develop a joint working protocol between CADAT and NELFT step-down services covering risk information sharing, joint risk management and discharge planning.
Verbatim wording from the response “1) Improve working relationship between the highly specialised services of the CADAT team and the stepdown services provided by NELFT. This should include the need for full information sharing around risk and joint risk/management planning and discharge.” Source location Response from NELFT
Open published response
Concerns raised 15 Failure to provide accurate emergency-response information in incident reports View source Failure to incorporate available clinical information into self-harm risk assessments View source Failure to escalate suspension of patient observations through governance processes View source Failure to activate the ward emergency bell View source Failure of serious incident investigation to address risk-assessment and reporting deficiencies View source Failure to carry out prescribed patient observations View source Failure to maintain accurate and reliable observation records View source Failure to use the anti-barricade key to access a barricaded room View source Failure to align observation frequency decisions with policy guidance View source Unavailability of a ligature cutter for prompt emergency use View source Failure to provide paramedics with a clear and relevant patient history View source Delays in administering oxygen during emergencies View source Delays in calling duty doctors during emergencies View source Failure to identify and escalate observation suspension in the 72-hour report View source Failure to use the on-site defibrillator during an emergency View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 17
Action
Remind staff through daily roll call to sound the ERT alarm for all ward emergencies and ensure a timely ERT response.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Refresh observation training to make enhanced-observation requirements explicit and deliver it to relevant clinical staff.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Share observation guidance and discuss it in ward safety huddles, meetings and supervision.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Reinforce observation-record training, audit records and address compliance in supervision.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2023. View source
Action
Implement the new PSIRF framework, including panel review and sign-off of all 72-hour reports.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 May 2023. View source
Action
Review electronic-observation functionality.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Include anti-barricade-key use in resuscitation drills and audit staff awareness of its function.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Share the clarified observation-escalation process through leadership meetings, team meetings and individual supervision.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Commission an independent review of the MDT clinical decision about observation frequency.
Stated completedThe respondent said that this action was complete when they made their response on 5 May 2023. View source
Action
Use live RiO records for handovers, daily run-throughs and MDT ward rounds.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Audit compliance with live-record use and risk-assessment processes.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Review Serious Incident processes and revisit the adequacy of evidence and learning captured in reports.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Refresh staff training on ligature-cutter locations and use.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Review the Safe and Supportive Observations Policy to clarify escalation when staffing or other constraints challenge observation provision.
Stated completedThe respondent said that this action was complete when they made their response on 5 May 2023. View source
Action
Review original evidence and assess whether disciplinary action is warranted for inaccurate or misleading records and reports.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source
Action
Remind medical staff to respond to ERT alarms and alert the duty doctor promptly.
Stated plannedThe respondent said that this action was planned when they made their response on 5 May 2023. View source See 14 more actions
×
AI-generated summary
Winbourne Gregory Charles · 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
Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate emergency-response information in incident reports
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not .
b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action.
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate available clinical information into self-harm risk assessments
Wider context from the report “1. A failure to adequately assess risk of harm - Poor record keeping and a failure to read electronic records meant that important information was not considered at a Multi-Disciplinary Team (“MDT”) ward round on 6ᵗʰ April 2021. The MDT arrived at a conclusion that Mr Charles’ risk of self-harm was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles risk of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT discussion.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate suspension of patient observations through governance processes
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not.
b. The Datix failed to mention that observations had been suspended by the shift coordinator , a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action .
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to activate the ward emergency bell
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded ,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigation to address risk-assessment and reporting deficiencies
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not.
b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action.
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out prescribed patient observations
Wider context from the report “3. A failure to ensure that a treatment plan was followed - observations between 16.00 and 17.00 on the day of Mr Charles’ death were suspended by the ward shift co-ordinator . The decision meant all patients subject to general observation on the ward were ignored .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and reliable observation records
Wider context from the report “5. The credibility of evidence provided by Trust staff.
a. Two Trust witnesses declined to answer questions put to them regarding whether their observation records were truthful.
b. Observation records appeared to have been created utilising a “cut and paste” function .
c. Records often inaccurately recorded the prescribed frequency of observation.
d. Factually inaccurate entries were made in the record following Mr Charles’ death. On 11ᵗʰ April 2021 an entry stated that Mr Charles was, “awake in his bedroom sitting on his bed (sic)” at 07.21. On 12ᵗʰ April two entries made at 9.48 and 11.40 recorded that Mr Charles’ was alive and well. Senior Trust witnesses characterised these entries as dishonest.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the anti-barricade key to access a barricaded room
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door , instead the door was forced open causing a risk of harm to Mr Charles .
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to align observation frequency decisions with policy guidance
Wider context from the report “2. A decision to reduce observation frequency made by the MDT on 6/4/21 was not supported by the Trust Policy guidance which indicated that enhanced observations were appropriate .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a ligature cutter for prompt emergency use
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination ,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide paramedics with a clear and relevant patient history
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in administering oxygen during emergencies
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed ,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in calling duty doctors during emergencies
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly ,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and escalate observation suspension in the 72-hour report
Wider context from the report “6. Governance process failings.
a. A datix incident report created on the evening of 10ᵗʰ April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not.
b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action.
c. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021.
d. The Trust SI report was not prepared to fully address the poor risk assessment or inadequate datix & 72 hr reports.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the on-site defibrillator during an emergency
Wider context from the report “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include;
a. A ward emergency bell was not sounded,
b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles.
c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination,
d. Duty doctors were not called promptly,
e. Oxygen administration was delayed,
f. An on-site defibrillator was not used by staff
g. Staff could or would not provide a clear and relevant history to paramedics.
” 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 Remind staff through daily roll call to sound the ERT alarm for all ward emergencies and ensure a timely ERT response.
Verbatim wording from the response “6. The ERT alarm should be sounded in all ward emergency situations and the ERT team will respond” Source location NELFT NHS Foundation Trust Action Plan
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 Refresh observation training to make enhanced-observation requirements explicit and deliver it to relevant clinical staff.
Verbatim wording from the response “2. Risk management (inappropriate care plan) – the Coroner found that a decision to reduce observation frequency made by the MDT on 6 April 2021 was not supported by the Trust Policy guidance which indicated that | 3. | Observation training to be refreshed to ensure this is explicit” Source location NELFT NHS Foundation Trust Action Plan
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 Share observation guidance and discuss it in ward safety huddles, meetings and supervision.
Verbatim wording from the response “2. At a glance appendix from Safe and Supportive Observations to be shared again” Source location NELFT NHS Foundation Trust Action Plan
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 Reinforce observation-record training, audit records and address compliance in supervision.
Verbatim wording from the response “15. Record keeping training is available and audits take place” Source location NELFT NHS Foundation Trust Action Plan
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 Implement the new PSIRF framework, including panel review and sign-off of all 72-hour reports.
Verbatim wording from the response “2. Implementation of new PSIRF framework, all 72hr reports will be reviewed and signed off by the panel.” Source location NELFT NHS Foundation Trust Action Plan
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 Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.
Verbatim wording from the response “4. Risk management (shortcomings in responding to the emergency) – the Coroner found that the Trust did not respond to the | 5. | Resus drills which include all of these elements are taking place monthly. | 1. Resus drills to take place monthly” Source location NELFT NHS Foundation Trust Action Plan
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 Review electronic-observation functionality.
Verbatim wording from the response “3. Review of Electronic Observation functionality” Source location NELFT NHS Foundation Trust Action Plan
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 Include anti-barricade-key use in resuscitation drills and audit staff awareness of its function.
Verbatim wording from the response “7. All bunches of keys have an anti barricade key on them. Key audits have taken place in 2023” Source location NELFT NHS Foundation Trust Action Plan
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 Share the clarified observation-escalation process through leadership meetings, team meetings and individual supervision.
Verbatim wording from the response “1. Safe and Supportive Observations policy has been reviewed to make escalation of this clear, to be shared through Leadership Team meetings, team meetings and individual supervision” Source location NELFT NHS Foundation Trust Action Plan
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 Commission an independent review of the MDT clinical decision about observation frequency.
Verbatim wording from the response “enhanced observations were appropriate. | | Following the Inquest an independent review commissioned to review the clinical decision made by the MDT. | Independent Review commissioned by the Chief Nursing Officer | Chief Nursing Officer | October 2023” Source location NELFT NHS Foundation Trust Action Plan
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 Use live RiO records for handovers, daily run-throughs and MDT ward rounds.
Verbatim wording from the response “1. Risk assessment (lack of appropriate consideration of risks) – the Coroner found that poor | 1. | Handovers and daily run through to take place using live RiO | 1. Matrons, Ward Managers and Consultant Psychiatrists to be made aware that this needs to be in place” Source location NELFT NHS Foundation Trust Action Plan
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 Audit compliance with live-record use and risk-assessment processes.
Verbatim wording from the response “2. To be audited to ensure compliance | DON/AMD | June 2023” Source location NELFT NHS Foundation Trust Action Plan
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 Review Serious Incident processes and revisit the adequacy of evidence and learning captured in reports.
Verbatim wording from the response “17. Review of SI report and HR processes.” Source location NELFT NHS Foundation Trust Action Plan
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 Refresh staff training on ligature-cutter locations and use.
Verbatim wording from the response “a. [continued] 5. Refresh staff as part of the above on whereabouts of Ligature cutters (2 on each ward)” Source location NELFT NHS Foundation Trust Action Plan
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 Review the Safe and Supportive Observations Policy to clarify escalation when staffing or other constraints challenge observation provision.
Verbatim wording from the response “3. Risk management (lack of adherence to care plan) – the Coroner found that observations between 16.00 and 17.00 on the day of Mr Charles’ death were suspended by the ward shift co-ordinator. The decision meant all patients subject to general observation on the ward were ignored.3. Risk management and record keeping. | 4. | The Safe and Supportive Observations Policy does not allow for this to happen. However, if this becomes an issue due to teams being short staffed then escalation needs to be clearer | 1. Review of Policy to encompass escalation process” Source location NELFT NHS Foundation Trust Action Plan
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 Review original evidence and assess whether disciplinary action is warranted for inaccurate or misleading records and reports.
Verbatim wording from the response “1. Revisit original evidence provided to the SI report.” Source location NELFT NHS Foundation Trust Action Plan
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 Remind medical staff to respond to ERT alarms and alert the duty doctor promptly.
Verbatim wording from the response “9. Duty Dr should be alerted as a result of the ERT alarm” Source location NELFT NHS Foundation Trust Action Plan
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandatory ILS training already covers oxygen administration and defibrillator use, so these requirements do not need separate training arrangements.
Verbatim wording from the response “e. Oxygen administration was delayed.” Source location NELFT NHS Foundation Trust Action Plan
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SBARD and the Adult Cardiac Checklist already provide recognised frameworks for handing cardiac incident information to paramedics.
Verbatim wording from the response “g. Staff could or would not provide clear and relevant history to paramedics.” Source location NELFT NHS Foundation Trust Action Plan
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Safe and Supportive Observations Policy already prohibits suspending observations; the response limits further work to clarifying escalation.
Verbatim wording from the response “3. Risk management (lack of adherence to care plan) – the Coroner found that observations between 16.00 and 17.00 on the day of Mr Charles’ death were suspended by the ward shift co-ordinator. The decision meant all patients subject to general observation on the ward were ignored.3. Risk management and record keeping. | 4. | The Safe and Supportive Observations Policy does not allow for this to happen. However, if this becomes an issue due to teams being short staffed then escalation needs to be clearer | 1. Review of Policy to encompass escalation process” Source location NELFT NHS Foundation Trust Action Plan
Open published response
30 Mar 2023 Carol Ann Robinson · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to complete a comprehensive risk assessment before discharge View source Failure to communicate withdrawal of Home Treatment Team input to domiciliary care agencies or family View source Lack of multi-disciplinary team discussion to ensure a safe community plan following discharge View source Failure to provide medical review by a doctor within the Home Treatment Team before discharge View source See 1 more concern
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
Carol Ann Robinson · 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
Carol Ann Robinson died at Queen's Hospital on 8 May 2022 after taking an overdose of medication and being diagnosed with mixed drug toxicity. The principal concerns were that she was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multidisciplinary discussion, or communication with her domiciliary care agency and family about the withdrawal of support.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a comprehensive risk assessment before discharge
Wider context from the report “2. Mrs Robinson did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate withdrawal of Home Treatment Team input to domiciliary care agencies or family
Wider context from the report “3. There was no multi-disciplinary team discussion to ensure a safe community plan following discharge from the Home Treatment Team. There was no communication with regard to the withdrawal of the Home Treatment Team’s input, with the domiciliary care agency or family of Mrs Robinson.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of multi-disciplinary team discussion to ensure a safe community plan following discharge
Wider context from the report “3. There was no multi-disciplinary team discussion to ensure a safe community plan following discharge from the Home Treatment Team . There was no communication with regard to the withdrawal of the Home Treatment Team’s input, with the domiciliary care agency or family of Mrs Robinson.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medical review by a doctor within the Home Treatment Team before discharge
Wider context from the report “1. Mrs Robinson did not receive a medical review by a doctor within the Home Treatment Team prior to her discharge back to the care of her GP on the 25th April 2022.
” Open source report
Concerns raised 6 Lack of detailed risk assessment during transition between mental health teams View source Lack of detailed risk assessment when weaning Clonazepam medication View source Failure to provide at least weekly care co-ordinator reviews for amber-zoned patients View source Failure to establish a jointly agreed risk management plan during transition between mental health teams View source Failure to establish a risk management plan when weaning Clonazepam medication View source Failure to put additional safety measures in place during increased risk to self View source See 3 more concerns
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
Evelina Vilkiene · 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
Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed risk assessment during transition between mental health teams
Wider context from the report “1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed risk assessment when weaning Clonazepam medication
Wider context from the report “2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide at least weekly care co-ordinator reviews for amber-zoned patients
Wider context from the report “3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews . This was in contravention of the general requirement for amber zoned patients to be seen at least weekly .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a jointly agreed risk management plan during transition between mental health teams
Wider context from the report “1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a risk management plan when weaning Clonazepam medication
Wider context from the report “2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan . It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to put additional safety measures in place during increased risk to self
Wider context from the report “2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
” Open source report
Concerns raised 5 Lack of assessment of patients’ capacity to refuse physical observations View source Lack of agreed comprehensive care planning involving the multidisciplinary ward team, patients and relatives View source Failure to incorporate ways of supporting patients to engage in their recovery into holistic care plans View source Failure to respond to concerning clinical states with necessary urgency View source Failure to recognise acute clinical severity View source See 2 more concerns
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
Mary Ebere Nwanyonyiri · 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
Mary Ebere Nwanyonyiri was admitted to Goodmayes Hospital after deterioration in her mental state and was found unresponsive on 19 April 2021; post-mortem investigations found that she died from Covid-19 infection. The report raised concerns about the absence of a written care plan and completed risk assessment, the lack of clear assessment of her capacity to refuse physical observations, and failures to recognise and respond urgently to the severity of her condition.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assessment of patients’ capacity to refuse physical observations
Wider context from the report “1. Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved. The nursing staff did not acknowledge the value of a holistic care plan which incorporates the consideration of the many ways in which patients can be supported to engage in their recovery. Such a care plan could also incorporate assessments of capacity to refuse physical observations. There was no clear evidence of assessment of Mary’s capacity to refuse physical observations .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed comprehensive care planning involving the multidisciplinary ward team, patients and relatives
Wider context from the report “1. Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved . The nursing staff did not acknowledge the value of a holistic care plan which incorporates the consideration of the many ways in which patients can be supported to engage in their recovery. Such a care plan could also incorporate assessments of capacity to refuse physical observations. There was no clear evidence of assessment of Mary’s capacity to refuse physical observations.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate ways of supporting patients to engage in their recovery into holistic care plans
Wider context from the report “1. Senior nursing staff who gave evidence at the Inquest did not appear to appreciate the importance of an agreed comprehensive care plan in which the multi-disciplinary ward team, patient and relatives are involved. The nursing staff did not acknowledge the value of a holistic care plan which incorporates the consideration of the many ways in which patients can be supported to engage in their recovery . Such a care plan could also incorporate assessments of capacity to refuse physical observations. There was no clear evidence of assessment of Mary’s capacity to refuse physical observations.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to concerning clinical states with necessary urgency
Wider context from the report “2. A number of nurses failed to recognise the acute clinical severity of Mary’s condition on the morning of the 19th April 2021. They did not respond to her very concerning clinical state with the necessary urgency .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise acute clinical severity
Wider context from the report “2. A number of nurses failed to recognise the acute clinical severity of Mary’s condition on the morning of the 19th April 2021. They did not respond to her very concerning clinical state with the necessary urgency.
” Open source report
12 Jul 2022 Louise Asha Allen · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Non-comparable pay for care-coordinator posts View source Excessive caseloads for care co-ordinators View source Failure to provide continuity of care View source Insufficient number of care co-ordinators for clinical need View source High turnover of care-coordinator staff View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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
×
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 Recruit temporary staff to maintain continuity while permanent care-coordinator vacancies are filled.
Verbatim wording from the response “The service continuously recruits temporary staff, through the Trust’s temporary staffing service until all positions are permanently recruited to.” Source location Response from NHS Foundation Trust
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 Use non-recurrent funding to recruit additional staff for increased referral volume and patient acuity.
Verbatim wording from the response “NELFT has programmes in place to encourage staff to work in the organisation; the Trust has used non-recurrent funding to recruit additional staff to manage the real time increase of referrals and acuity of patients, following the pandemic. All new starters’ salaries are matched to their previous employment, so they do not lose out on their pay when they join NELFT. There is also a staff wellbeing service in place which is available to substantively and locum staff. In addition, the Trust is working to understand how staff can be supported through cost-of-living issues.” Source location Response from NHS Foundation Trust
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 Deliver a training and career-development programme enabling band 5 staff to progress into band 6 care-coordinator roles.
Verbatim wording from the response “A NELFT training programme has been developed for band 5 staff to help them develop the skills and competencies to take up the role of care coordinator at band 6 level. This will constitute an intensive and supportive career development programme designed to attract recently qualified staff who have the potential to progress rapidly and will also help with staff retention in the community recovery service.” Source location Response from NHS Foundation Trust
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 Match new starters’ salaries to their previous employment to support recruitment.
Verbatim wording from the response “NELFT has programmes in place to encourage staff to work in the organisation; the Trust has used non-recurrent funding to recruit additional staff to manage the real time increase of referrals and acuity of patients, following the pandemic. All new starters’ salaries are matched to their previous employment, so they do not lose out on their pay when they join NELFT. There is also a staff wellbeing service in place which is available to substantively and locum staff. In addition, the Trust is working to understand how staff can be supported through cost-of-living issues.” Source location Response from NHS Foundation Trust
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 Prioritise mental-health vacancies and use off-framework agencies to retain locum support and consistency during short-term vacancies.
Verbatim wording from the response “Temporary staffing has been advised to prioritise Mental Health posts and to use off-framework agencies to support retaining locum support, and consistency to manage short term vacancies.” Source location Response from NHS Foundation Trust
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 Continue the mental-health transformation programme to enhance service delivery and develop the care model.
Verbatim wording from the response “The Trust is undertaking a programme of mental health transformation, which once fully implemented will enhance the service offered to patients. Peer support workers have been given additional roles, with a focus on enhanced training in order that they can share their lived experiences with patients they manage. The Trust is re-designing care coordinator posts to increase the support available for professional development. Furthermore, the Trust continues to use Trust-wide work streams to have a zero-nursing vacancy; to use rolling advertisements to recruit and retain staff; utilise international recruitment to attract more professionals to work at NELFT; and to consider the use of financial incentives to attract and retain staff.” Source location Response from NHS Foundation Trust
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 Introduce the Management and Supervision Tool to support manageable caseloads, supervision and staff support.
Verbatim wording from the response “In the meantime, the Trust is introducing a Management and Supervision Tool (MaST) to support staff and their managers to ensure care coordinator caseloads are manageable and that appropriate supervision and support are in place; this is anticipated to be fully operational by December 2022.” Source location Response from NHS Foundation Trust
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 Audit care-coordinator caseloads and conduct a further scheduled audit to monitor caseload numbers.
Verbatim wording from the response “A recent quality audit of staff caseloads carried out on 19 July 2022 showed a reduction in care coordinator caseload from 27-30 patients per care coordinator to 19-27 patients. There is a further audit planned on 19 August 2022 to review the caseload numbers per care coordinator” Source location Response from NHS Foundation Trust
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 Consider financial incentives to attract and retain staff.
Verbatim wording from the response “The Trust is undertaking a programme of mental health transformation, which once fully implemented will enhance the service offered to patients. Peer support workers have been given additional roles, with a focus on enhanced training in order that they can share their lived experiences with patients they manage. The Trust is re-designing care coordinator posts to increase the support available for professional development. Furthermore, the Trust continues to use Trust-wide work streams to have a zero-nursing vacancy; to use rolling advertisements to recruit and retain staff; utilise international recruitment to attract more professionals to work at NELFT; and to consider the use of financial incentives to attract and retain staff.” Source location Response from NHS Foundation Trust
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 Provide a staff wellbeing service for substantive and locum staff.
Verbatim wording from the response “NELFT has programmes in place to encourage staff to work in the organisation; the Trust has used non-recurrent funding to recruit additional staff to manage the real time increase of referrals and acuity of patients, following the pandemic. All new starters’ salaries are matched to their previous employment, so they do not lose out on their pay when they join NELFT. There is also a staff wellbeing service in place which is available to substantively and locum staff. In addition, the Trust is working to understand how staff can be supported through cost-of-living issues.” Source location Response from NHS Foundation Trust
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 Recruit eight additional band 6 community psychiatric nurses to meet increased workload.
Verbatim wording from the response “The community mental health transformation programme will provide a better skill mix that will reduce the pressure on the care coordinator role. 8 additional Band 6 Community Psychiatric Nurses are being recruited to meet increased workload.” Source location Response from NHS Foundation Trust
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 Review resource and staffing levels through Trust executive and North East London system-wide work.
Verbatim wording from the response “The NELFT Waltham Forest leadership team continuously reviews the needs and risk of the service. Additional staff will continue to be placed in the service to manage the need and risk, efforts are made at Trust executive and North East London system wide level to review the resource and staffing levels deployed into the service.” Source location Response from NHS Foundation Trust
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 Continue reviewing service needs and risks and placing additional staff to manage them.
Verbatim wording from the response “The NELFT Waltham Forest leadership team continuously reviews the needs and risk of the service. Additional staff will continue to be placed in the service to manage the need and risk, efforts are made at Trust executive and North East London system wide level to review the resource and staffing levels deployed into the service.” Source location Response from NHS Foundation Trust
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 Work to understand how staff can be supported with cost-of-living issues.
Verbatim wording from the response “NELFT has programmes in place to encourage staff to work in the organisation; the Trust has used non-recurrent funding to recruit additional staff to manage the real time increase of referrals and acuity of patients, following the pandemic. All new starters’ salaries are matched to their previous employment, so they do not lose out on their pay when they join NELFT. There is also a staff wellbeing service in place which is available to substantively and locum staff. In addition, the Trust is working to understand how staff can be supported through cost-of-living issues.” Source location Response from NHS Foundation Trust
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 Use rolling advertisements and international recruitment to recruit and retain staff, while pursuing a zero-nursing-vacancy objective.
Verbatim wording from the response “The Trust is undertaking a programme of mental health transformation, which once fully implemented will enhance the service offered to patients. Peer support workers have been given additional roles, with a focus on enhanced training in order that they can share their lived experiences with patients they manage. The Trust is re-designing care coordinator posts to increase the support available for professional development. Furthermore, the Trust continues to use Trust-wide work streams to have a zero-nursing vacancy; to use rolling advertisements to recruit and retain staff; utilise international recruitment to attract more professionals to work at NELFT; and to consider the use of financial incentives to attract and retain staff.” Source location Response from NHS Foundation Trust
Open published response
27 Jun 2022 Michael John Vince · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to monitor the frequency of PRN medication administration View source Lack of meaningful review of insomnia medication prescriptions View source Failure to share dependence information with the mental health trust View source Failure to limit prolonged prescribing of insomnia medication View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael John Vince · 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
Michael John Vince, a patient of the community mental health team receiving treatment for schizo-affective disorder, was found deceased at home on 19 June 2021 after apparently taking an overdose. The concerns included prolonged prescribing of medication for insomnia, lack of meaningful prescription review, failure to share evidence of dependence, and failure to monitor the frequency of PRN administration.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor the frequency of PRN medication administration
Wider context from the report “4. The frequency with which Mr Vince was administering his PRN ████████ was never monitored .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful review of insomnia medication prescriptions
Wider context from the report “2. No evidence exists to support that Mr Vince’s GP or community mental health team meaningfully reviewed his prescription ████████ .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share dependence information with the mental health trust
Wider context from the report “3. Evidence of Mr Vince’s dependence upon ████████ was not shared by his GP with the mental health trust .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to limit prolonged prescribing of insomnia medication
Wider context from the report “1. The NICE guidelines for ████████ indicate that it is a suitable medication for the short term treatment of insomnia, it advises against prolonged use due to risk of tolerance and withdrawal symptoms . Mr Vince is said to have been prescribed ████████ for 20 years .
” 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 Update medication-monitoring practice and jointly monitor its implementation with the chief pharmacist.
Verbatim wording from the response “The current practice at NELFT is that whoever prescribes the medication, is responsible for monitoring the compliance with medication administration regime. However, in light of learning from this inquest we have updated our practice as highlighted within the attached action plan and will monitor implementation of the updated practice jointly with the chief pharmacist.” Source location Response from North East London Foundation Trust
Open published response
21 Oct 2021 David Ayontunde Walker · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to provide continuity of care coordination View source Failure to obtain collateral healthcare information from other trusts on hospital admission View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Ayontunde Walker · 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
David Ayontunde Walker died on 27 November 2020 after his mental health deteriorated following discharge from hospital. The report identified concerns about repeated changes of care co-ordinator and the failure to obtain and share important risk information between the mental health trusts, resulting in an incomplete discharge risk 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuity of care coordination
Wider context from the report “1. Between end of May 2020 to November 2020, Mr Walker was allocated four different care co-ordinators . There was evidence that only one of these care co-ordinators established a therapeutic relationship with Mr Walker . Many of the care co-ordinators were locum staff .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain collateral healthcare information from other trusts on hospital admission
Wider context from the report “2. On admission to hospital on the 10th November 2020 no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker . Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information that should have been available to the North East London Foundation Trust team . There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought .
” 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 Deploy semi-permanent agency staff to support community recovery teams during recruitment.
Verbatim wording from the response “High turnover of care coordinators and only one formed a therapeutic relationship
To act on the concerns immediately, agency staff have been sourced to support the Waltham Forest Community Recovery Teams. These staff have been recruited on a semi-permanent basis, whilst staff recruitment is taking place.” Source location Response from North East London NHS Foundation Trust
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 Provide induction training and clinical supervision for permanent and temporary staff managing risks and patient relationships.
Verbatim wording from the response “All staff, including temporary staff will be supported with training during induction and will be provided clinical supervision, to ensure that they are appropriately managing patients’ identified risks and are building relationship with patients they work with.” Source location Response from North East London NHS Foundation Trust
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 Send a further reminder to medical and nursing staff to obtain collateral information at the earliest opportunity.
Verbatim wording from the response “No evidence collateral healthcare information sought
Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.” Source location Response from North East London NHS Foundation Trust
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 Communicate to inpatient staff how to access external shared-link records for collateral information.
Verbatim wording from the response “No evidence collateral healthcare information sought
Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.” Source location Response from North East London NHS Foundation Trust
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 Recruit additional staff above establishment to reduce care-coordinator caseloads and support relationship building.
Verbatim wording from the response “High turnover of care coordinators and only one formed a therapeutic relationship
To act on the concerns immediately, agency staff have been sourced to support the Waltham Forest Community Recovery Teams. These staff have been recruited on a semi-permanent basis, whilst staff recruitment is taking place.” Source location Response from North East London NHS Foundation Trust
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 Provide clinical supervisors with a care-coordination prompt covering relationship building, risk management and caseload management.
Verbatim wording from the response “All clinical supervisors will be provided with a template / prompt that highlights the key elements of care coordination such as relationship building, risk management and caseload management, so staff are supported in their work with patients.” Source location Response from North East London NHS Foundation Trust
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 Amend the electronic admission checklist to prompt staff to identify other Trust involvement and obtain collateral information.
Verbatim wording from the response “No evidence collateral healthcare information sought
Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.” Source location Response from North East London NHS Foundation Trust
Open published response
11 Jul 2021 ELEANOR ROSE MURPHY-RICHARDS · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 6 Failure to update risk assessments after deviation from an agreed Safety Plan View source Failure to share all relevant information between Child and Adult Mental Health Teams for risk assessment View source Failure of risk management advice to account for absconding risk and inability to prevent leaving the centre View source Failure of Safety Plans to contain a contingency plan for agreement to attend Accident & Emergency View source Lack of a protocol for Mental Health Act assessment of people who will not voluntarily attend hospital Accident & Emergency View source Failure of Safety Plans to set out Child & Adolescent Mental Health Team responsibilities View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
ELEANOR ROSE MURPHY-RICHARDS · 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
Ellis died on 30 September 2020 after jumping from a footbridge onto a railway track in front of an oncoming train, intending to end his life. Concerns included gaps in the safety plan, a deviation from it without an updated risk assessment, incomplete sharing of information about a recent failed hanging attempt, and advice that did not account for the risk of Ellis leaving the centre.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk assessments after deviation from an agreed Safety Plan
Wider context from the report “(2) On 30ᵗʰ September 2020 there was a deviation from the agreed Safety Plan without an updated risk assessment .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share all relevant information between Child and Adult Mental Health Teams for risk assessment
Wider context from the report “(3) Not all relevant information was shared between the Child & Adult Mental Health Team about the circumstances disclosed of events on the night of 29ᵗʰ September of Ellis’s failed attempt at hanging as part of a risk assessment .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of risk management advice to account for absconding risk and inability to prevent leaving the centre
Wider context from the report “(4) Ellis was found to be in need of a Mental Health Act assessment. Management advice was sought about risk and what action should be taken should Ellis refuse to go to hospital, the advice was contact the police. This advice did not take into account that Ellis had a history of absconding and that he could not be prevented leaving the centre.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Safety Plans to contain a contingency plan for agreement to attend Accident & Emergency
Wider context from the report “(1) Ellis’s Safety Plan did not set out:
a. the responsibilities of the Child & Adolescent Mental Health Team
b. did not contain a contingency plan should Ellis agree to go to Accident & Emergency
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for Mental Health Act assessment of people who will not voluntarily attend hospital Accident & Emergency
Wider context from the report “The Child & Adolescent Mental Health Centre provides services to children and young people, some of whom may require Mental Health Act assessment. There is no protocol or policy for those that require Mental Health Act assessment and will not voluntarily attend hospital Accident & Emergency.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Safety Plans to set out Child & Adolescent Mental Health Team responsibilities
Wider context from the report “(1) Ellis’s Safety Plan did not set out:
a. the responsibilities of the Child & Adolescent Mental Health Team
b. did not contain a contingency plan should Ellis agree to go to Accident & Emergency
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing safety plan provided an A&E contingency, with police notification when attendance was refused.
Verbatim wording from the response “Ellis safety plan dated 22nd June 2020 (Page N.227 of the bundle) provides that, if he is unable to keep himself safe, even with the support of others, he is to attend A&E for further assessment in a place of safety.” Source location 2021-0237-Response-from-Trust-Head-Office_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Management advice accounted for refusal to attend A&E by instructing staff to contact the police.
Verbatim wording from the response ““My manager agreed regarding hospital admission and said that I should refer Ellis for this support from the Crisis Team and also said to ask Nan to take him to A&E immediately. I checked with my manager what I should do if Ellis did not get into the car with Nan and she advised to call the police.”” Source location 2021-0237-Response-from-Trust-Head-Office_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police Section 136 powers and attendance were contingent on statutory conditions and evidence of refusal to attend A&E.
Verbatim wording from the response “The police have powers under Section 136 of the Mental Health Act to detain a person who is in a public place and appears in immediate need of care or control; the police would thereby take them to a place of safety for assessment.” Source location 2021-0237-Response-from-Trust-Head-Office_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appropriate information was shared; the psychiatrist could not disclose the second incident because it was not known.
Verbatim wording from the response “It is my understanding that the psychiatrist contacted the care coordinator after the telephone assessment of Ellis. The psychiatrist shared the information that was available to them at the time. The psychiatrist informed the care coordinator about the incident the previous night involving a ligature. The psychiatrist was not aware at that time of the second incident at the Youth Club. The psychiatrist also discussed their assessment of Ellis’ suicide risk. They explained to the care coordinator that Ellis did not want to talk to them about the incident, which impacted on the ability to risk assess and establish if there were ongoing suicidal thoughts, intent or plans.” Source location 2021-0237-Response-from-Trust-Head-Office_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There was no deviation from the safety plan; a dynamic, though informal, risk assessment was undertaken.
Verbatim wording from the response “If you are referring to the risk assessment and safety plan effective on 30th September 2020 and the alleged deviation from the agreed Safety Plan by the psychiatrist. I note that there was no deviation from Ellis’ safety plan and the risk assessment was carried out by the psychiatrist.” Source location 2021-0237-Response-from-Trust-Head-Office_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing safety plans already specified CAMHS responsibilities and expected interventions.
Verbatim wording from the response “The purpose of a Safety Plan in Mental Health services is to document, communicate what interventions have been agreed to be provided by the health care teams to address the clinical needs of the patient. The Safety Plan (also referred to as Crisis & Safety Plan or Care Plan) can be used as an aide memoire in respect of care that the patient can expect to receive. The Safety Plan also assists the healthcare teams in ensuring the continuity of care.” Source location 2021-0237-Response-from-Trust-Head-Office_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust had no legal power to hold Ellis, and staff restraint or detention could constitute assault or unlawful imprisonment.
Verbatim wording from the response “In the circumstances the Trust acted within their remit as prescribed by law. The Trust had no legal power to hold Ellis. Given this, the Trust considers that it did comply with its safety plan for Ellis. The Trust also consider that the contingency plan would have been, at the correct time, to have called the police, which did occur. However as a learning organisation the Trust fully accepts that there are always elements of cases that can be used for learning and it will continue to reflect on its practice and procedures for all cases going forward.” Source location 2021-0237-Response-from-Trust-Head-Office_Published
Open published response
20 May 2021 Neil Challinor-Mooney · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to embed and follow the risk assessment and risk management policy View source Failure to make amendments to electronic records apparent View source Delays in validating electronic medical records View source
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
Neil Challinor-Mooney · 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
Neil Challinor-Mooney was admitted to hospital under the Mental Health Act after an acute relapse in his mental health. After disclosing suicidal thoughts and a plan to hang himself using his shoes, his trainers were not removed, and he was later found suspended by their laces; he died on 18 November 2018. Concerns included failures by nursing staff to follow risk assessment and management policy, and delays and amendments affecting the integrity of electronic medical 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed and follow the risk assessment and risk management policy
Wider context from the report “The Inquest heard evidence that the Trust policy in relation to risk assessment and risk management is sufficiently clear, however the Court was not fully satisfied that the said policy had been fully embedded into practice . A number of nursing staff, including senior nursing staff, during the course of the admission, failed to follow the policy .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make amendments to electronic records apparent
Wider context from the report “Another concern arising during the course of the Inquest related to the integrity of the electronic records. The Inquest heard that medical records should be validated very shortly after being entered into the system. The Court saw evidence of multiple entries where there was a significant delay between original entry and validation. Amendments were made to the records after Neil had passed away, but these were not apparent on the records disclosed to the Court . An audit of the records had to be carried out before the amendments were exposed .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in validating electronic medical records
Wider context from the report “Another concern arising during the course of the Inquest related to the integrity of the electronic records. The Inquest heard that medical records should be validated very shortly after being entered into the system . The Court saw evidence of multiple entries where there was a significant delay between original entry and validation . Amendments were made to the records after Neil had passed away, but these were not apparent on the records disclosed to the Court. An audit of the records had to be carried out before the amendments were exposed.
” Open source report
28 Apr 2021 Mr Paul Sartori · Prevention of Future Deaths report East London
View report summary
Concerns raised 8 Failure to document the decision-making process and rationale for redirecting patients from A&E View source Insufficient sensitivity of decision-making and risk-scoring tools for aortic dissection View source Failure to record a full set of observations, including a pain score, before diverting patients from A&E View source Insufficient access to CT scanning for suspected aortic dissection View source Failure to recognise and diagnose acute thoracic aortic dissection View source Failure to update streaming guidance in line with relevant learning and guidance View source Failure to embed THINK AORTA learning into emergency department practice at all levels View source Failures in transfer of patients with suspected aortic dissection to specialist centres View source See 5 more concerns
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
Mr Paul Sartori · 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
Paul Sartori sought emergency medical assistance for chest pain on 24 October 2019, was directed from A&E to an urgent care centre, diagnosed with costochondritis, and later died at home on 27 October 2019 after becoming unresponsive. A post-mortem examination found a ruptured dissecting aortic aneurysm. The report raised systemic concerns about awareness and diagnosis of aortic dissection in emergency departments, including the adequacy of current guidance and risk-scoring tools.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document the decision-making process and rationale for redirecting patients from A&E
Wider context from the report “2. The nurse making the decision to re-direct Mr Sartori from A&E did not record a full set of observations, to include a pain score, prior to diverting Mr Sartori from the A & E department. The nurse did not document her decision making process and rationale for redirecting Mr Sartori from A&E .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient sensitivity of decision-making and risk-scoring tools for aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record a full set of observations, including a pain score, before diverting patients from A&E
Wider context from the report “2. The nurse making the decision to re-direct Mr Sartori from A&E did not record a full set of observations, to include a pain score, prior to diverting Mr Sartori from the A & E department . The nurse did not document her decision making process and rationale for redirecting Mr Sartori from A&E.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient access to CT scanning for suspected aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and diagnose acute thoracic aortic dissection
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection . The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem .
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update streaming guidance in line with relevant learning and guidance
Wider context from the report “1. The Inquest heard evidence that the streaming guidance in place for Barts Health A & E staff and NELFT staff had not been updated to take into account the learning from the death of Mr Sartori and to take into account the guidance from the THINK AORTA Campaign (launched in 2016).
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed THINK AORTA learning into emergency department practice at all levels
Wider context from the report “3. A junior sister who provided evidence at the Inquest was not aware of the THINK AORTA campaign . The Inquest heard that the senior leadership team had recently agreed to embed the THINK AORTA learning into practice at all levels within the emergency department. This learning had not been embedded at the time of the Inquest hearing .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failures in transfer of patients with suspected aortic dissection to specialist centres
Wider context from the report “Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.
The expert confirmed that misdiagnosis of aortic dissection is a very common problem.
During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:
Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres
The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.
Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.
The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.
” Open source report
3 Mar 2021 Steven Paul David Gary Stout · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Failure to ensure effective referral from the ward to the community home treatment team View source Failure to accurately record and file important medical records View source
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
Steven Paul David Gary Stout · 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
Steven Paul David Gary Stout was detained under section 136 of the Mental Health Act after cutting both wrists while intoxicated by alcohol, and was later admitted to a mental health ward. He was discharged on 18 October 2019 without a referral to the home treatment team and was found unresponsive, suspended by his neck from a ligature, on 4 November 2019; he could not be resuscitated. The concerns included failures to accurately record and file important medical records and to ensure an effective referral to the home treatment team.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective referral from the ward to the community home treatment team
Wider context from the report “2. The failure of Turner Ward Goodmayes hospital to ensure the effective referral of a patient from the ward to the home treatment team within 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record and file important medical records
Wider context from the report “1. The failure of Turner Ward, Goodmayes hospital to accurately record and file important medical records including; decisions on discharge, risk assessments, and a crisis, relapse and contingency plan .
” Open source report
25 Nov 2020 Trinder Kaur Birdi · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to obtain and document a second psychiatric opinion before downgrading suicide risk View source Failure to consult the referring general practitioner before downgrading suicide risk View source Failure to safeguard downgrading of suicide risk by staff unfamiliar with the patient View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Trinder Kaur Birdi · 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
Trinder Kaur Birdi had a history of depression and personality disorder and was assessed as at high risk of suicide after reporting two paracetamol overdoses. Following assessment by a psychiatric nurse, the risk was reduced to low and a non-urgent Community Mental Health Team referral was made; she was later admitted with acute liver failure and died from the likely effect of self-administered drug toxicity. The principal concern was that her suicide risk was downgraded without consultation with the general practitioner, a documented second opinion, or assessment by a psychiatric doctor, and that safeguards were absent in these circumstances.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and document a second psychiatric opinion before downgrading suicide risk
Wider context from the report “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional .
It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult the referring general practitioner before downgrading suicide risk
Wider context from the report “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional.
It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner , second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to safeguard downgrading of suicide risk by staff unfamiliar with the patient
Wider context from the report “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional.
It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance , such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor.
” 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 Review Clinical Risk Advanced training to include differing clinical opinion scenarios and guidance on addressing them.
Verbatim wording from the response “5. A review of the Clinical Risk Advanced level training to include case scenarios that indicate a difference in clinical opinion, and to reiterate guidance how to address these scenarios.” Source location 2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
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 Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.
Verbatim wording from the response “1. A requirement will be introduced for a referral to the on-call psychiatrist to be completed where the presenting risk is significantly different to that of another clinician (including GP) who has reviewed the patient on the same day.” Source location 2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
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 Amend the Psychiatric Liaison Service assessment template to prompt documentation of concerns, protective factors and the risk management plan.
Verbatim wording from the response “2. The assessment template used within the Psychiatric Liaison Service will be amended to prompt the documentation of the consideration given to concerns raised by friends/family/healthcare staff, protective factors and risk management plan.” Source location 2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
Open published response
3 Mar 2020 Lee Leslie Carpenter · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Failure to document important clinical decisions and rationale in the triage of GP referrals View source Failure to discuss downgraded GP referral urgency with the patient or GP View source Failure to identify and make accountable the staff member making GP referral triage decisions View source
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
Lee Leslie Carpenter · 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
Lee Leslie Carpenter took his own life on 1 October 2019 after being referred by his GP to mental health services for an urgent review. Concerns included the referral being triaged as non-urgent without a documented rationale or discussion with Mr Carpenter or the GP, a lack of robust risk assessment, care planning and medication review, and the absence of a response when the Home Treatment Team visited his home on the day of his death. The report also identified no system for clearly documenting important clinical triage decisions or identifying the staff member responsible.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document important clinical decisions and rationale in the triage of GP referrals
Wider context from the report “The matter of concern during the course of the Inquest, was that a GP had made a referral to the mental health team requesting an urgent review of Mr Carpenter. This was sent on the 9th August 2019 to the Havering Access Assessment and Brief Intervention Team. The referral was received on the same date and appears to have been triaged for a non-urgent response. The decision determining the non-urgent response was not documented. There was no documented rationale for overriding the GP’s request for an urgent review. There was no discussion with the patient or the GP before the decision to downgrade the urgency. The member of staff who made the decision was not identified within the medical records. The first telephone assessment of Mr Carpenter did not take place until the 23rd August 2019.
As at the date of the Inquest, there is no system in place within the Trust for important clinical decision relating to the triage of GP referrals to be clearly documented within patient records and for the member of staff making the decision, to be clearly identified and accountable.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss downgraded GP referral urgency with the patient or GP
Wider context from the report “The matter of concern during the course of the Inquest, was that a GP had made a referral to the mental health team requesting an urgent review of Mr Carpenter. This was sent on the 9th August 2019 to the Havering Access Assessment and Brief Intervention Team. The referral was received on the same date and appears to have been triaged for a non-urgent response. The decision determining the non-urgent response was not documented. There was no documented rationale for overriding the GP’s request for an urgent review. There was no discussion with the patient or the GP before the decision to downgrade the urgency. The member of staff who made the decision was not identified within the medical records. The first telephone assessment of Mr Carpenter did not take place until the 23rd August 2019.
As at the date of the Inquest, there is no system in place within the Trust for important clinical decision relating to the triage of GP referrals to be clearly documented within patient records and for the member of staff making the decision, to be clearly identified and accountable.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and make accountable the staff member making GP referral triage decisions
Wider context from the report “The matter of concern during the course of the Inquest, was that a GP had made a referral to the mental health team requesting an urgent review of Mr Carpenter. This was sent on the 9th August 2019 to the Havering Access Assessment and Brief Intervention Team. The referral was received on the same date and appears to have been triaged for a non-urgent response. The decision determining the non-urgent response was not documented. There was no documented rationale for overriding the GP’s request for an urgent review. There was no discussion with the patient or the GP before the decision to downgrade the urgency. The member of staff who made the decision was not identified within the medical records. The first telephone assessment of Mr Carpenter did not take place until the 23rd August 2019.
As at the date of the Inquest, there is no system in place within the Trust for important clinical decision relating to the triage of GP referrals to be clearly documented within patient records and for the member of staff making the decision, to be clearly identified and accountable.
” Open source report
13 Dec 2019 Sammi Higgins · Prevention of Future Deaths report East London
View report summary
Concerns raised 3 Lack of overarching care plans for service users whose care requirements exceed brief intervention View source Failure to assign a key-worker to oversee AABIT service users’ care View source Delays in access to psychotherapy treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sammi Higgins · 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
Sammi Higgins had mental health conditions and a deteriorating mental state, including voices telling her to harm herself. On 3 February 2018, after presenting to mental health services following an overdose and self-harm and being discharged without weekend mental health support, she ingested a fatal combination of alcohol and tablets. Concerns included the absence of an overarching care plan or key-worker, failures in communicating and implementing a medication change, and lengthy delays in accessing psychotherapy.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of overarching care plans for service users whose care requirements exceed brief intervention
Wider context from the report “1. Sammi was cared for under the Access Assessment and Brief Intervention Team (AABIT). She was under the care of this team for almost three years. Her care requirements went beyond "brief intervention". Whilst under the care of this team, Sammi had no overarching care plan. No-one was appointed to oversee Sammi’s care. The evidence at the Inquest revealed that doctors working within the team were not aware of the possibility of service users under the AABIT having an overarching care plan or of service users having a key-worker assigned to them.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign a key-worker to oversee AABIT service users’ care
Wider context from the report “1. Sammi was cared for under the Access Assessment and Brief Intervention Team (AABIT). She was under the care of this team for almost three years. Her care requirements went beyond "brief intervention". Whilst under the care of this team, Sammi had no overarching care plan. No-one was appointed to oversee Sammi’s care. The evidence at the Inquest revealed that doctors working within the team were not aware of the possibility of service users under the AABIT having an overarching care plan or of service users having a key-worker assigned to them.
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in access to psychotherapy treatment
Wider context from the report “2. Sammi suffered from emotionally unstable personality disorder and mood congruent psychotic symptoms. She required psychotherapy treatment. She was referred to the psychotherapy services in March 2017. By the time of her death in February 2018, Sammi had not received psychotherapy. The Inquest heard that there could be delays of 17 months from referral to receipt of treatment. It is considered that these ongoing lengthy delays give rise to a risk of future deaths .
” 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 Use zoning meetings to verify completion of psychological-intervention actions and escalate outstanding clinical actions to case-holders.
Verbatim wording from the response “15. Audit – clinical risk management
Action: Each zoning meeting to ensure that actions regarding psychological interventions has been completed and clinical actions will be escalated to the relevant clinical case-holder. Any uncompleted actions will be escalated to the relevant clinical case-holder.
Deadline: 30.01.2020
Lead: ████████, Operational Lead AABIT” Source location Response from North East London NHS Foundation Trust
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 Review panel processes and internal referral points between AABIT and specialist psychological services.
Verbatim wording from the response “14. Service change in recommended best practice
Action: Review the psychological services panel process and internal referral points between the AABIT and the specialist psychological pathway to ensure that the correct clinical intervention/pathways are available to support release of clinical capacity for front line delivery as per action 12.
Deadline: 31.07.2020
Lead: ████████, Trust wide PS lead” Source location Response from North East London NHS Foundation Trust
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 Develop the multidisciplinary team function alongside the referral pathway to identify psychological interventions and reduce higher-intensity referrals.
Verbatim wording from the response “18. Service change – clinical risk management
Action: Develop the multidisciplinary team function in conjunction with the referral pathway – see Action 4 above (BFT pathway) – for the identification of psychological interventions as a way of reducing the need for higher intensity psychological interventions.
Deadline: 31.07.2020
Lead: Operational Lead AABIT; ████████, Trustwide PS lead” Source location Response from North East London NHS Foundation Trust
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 Implement RIO functionality displaying the named key worker alongside the clinical risk record.
Verbatim wording from the response “10. Policy/practice update – clinical risk management
Action: Implement functionality to display the named key worker alongside the clinical risk record (RIO) so that this is immediately visible to the clinician. This will ensure monitoring of action 8 above.
Deadline: 28.02.2020
Lead: ████████, RIO Clinical Systems Manager” Source location Response from North East London NHS Foundation Trust
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 Consult on and integrate the B&D MAP Specialist Psychological Service into BDAABIT as a single multidisciplinary service with clear pathways.
Verbatim wording from the response “13. Service change – clinical risk management
Action: Formally consult and integrate the B&D MAP Specialist Psychological Service into the BDAABIT service to ensure a single service, with clear pathways that are fully multi-disciplinary. The role of the managerial role (to be repeated for the Psychological Service in the Community Recovery Service). This is to streamline the delivery of psychological services and to ensure that capacity released (due to an expansion of capacity released) is used effectively to shorten the waiting times. The Trust will provide support and oversight in practice with determining best practice and Trust-wide learning.
Deadline: 30.09.2020
Lead: ████████, Director Adult Services; ████████, Trust wide PS lead; Operational Lead AABIT” Source location Response from North East London NHS Foundation Trust
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 Assess needs and risks of patients waiting more than 18 weeks and identify additional support required while they remain on the waiting list.
Verbatim wording from the response “16. Policy/practice update – clinical risk management
Action: In the meantime and while the development are being implemented, the service manager has been asked to contact the services waiting list for more than 18 weeks (national standard) to: 1. Assess the needs/risk of the patient to ensure that the person has not deteriorated and it is safe for the service user to remain on the waiting list. 2. Identify if any additional support is needed while the service user is on the waiting list. The above practice will be carried out until the required changes within the service will be completed.
Deadline: 30.01.2020
Lead: Service lead for MAP and Specialist Psychological Services” Source location Response from North East London NHS Foundation Trust
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 Produce and discuss monthly RIO reports demonstrating compliance with care and crisis plans on the correct pathway.
Verbatim wording from the response “7. Audit – care/crisis management plan compliance
Action: A RIO report demonstrating compliance with care plan/crisis plan on correct RIO pathway will be produced monthly basis and discussed at the AABIT team meeting.
Deadline: 31.01.2020
Lead: ████████, Operational Lead AA BIT” Source location Response from North East London NHS Foundation Trust
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 Issue clinical staff a reminder to record the named key worker or caseload manager in the designated RIO section.
Verbatim wording from the response “8. Policy/practice update – Compliance with terms of AABIT SOP
Action: A reminder will be issued to all clinical staff for the named key worker/caseload manager to be identified in the correct section of RIO clinical record – AAPI section of RIO clinical record.
Deadline: 31.01.2020
Lead: ████████, Operational Lead QAABIT” Source location Response from North East London NHS Foundation Trust
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 Prepare a psychological-services demand and capacity report and present an improvement plan to commissioners detailing service gaps.
Verbatim wording from the response “21. Service change – clinical risk management
Action: A Demand and capacity report to be prepared and relation to Psychological Services, and a plan to improve to be presented to the commissioners to ensure the service gaps in addition to any adverse service improvements are detailed in this action plan.
Deadline: 31.05.2020
Lead: ████████, Assistant Director Adult Services” Source location Response from North East London NHS Foundation Trust
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 Add MAP waiting-list times to the Trust risk register and monitor them monthly across mental health services.
Verbatim wording from the response “17. Audit – clinical risk management
Action: Waiting list times for MAP service to be added to the Trust risk register as a high risk and monitored on a monthly basis for all mental health services.
Deadline: 30.01.2020
Lead: Head of Service – Adult Mental Health services” Source location Response from North East London NHS Foundation Trust
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 Issue a reminder to maintain an up-to-date overarching care plan for every patient receiving AABIT care.
Verbatim wording from the response “6. Reminder – Care planning
Action: A reminder will be issued for a care plan template for each patient to be updated to ensure that the overarching care plan is up to date at all times when the service users are receiving care which meets their needs.
Deadline: 31.01.2020
Lead: ████████, Operational Lead AABIT” Source location Response from North East London NHS Foundation Trust
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 Review and collate outstanding vacancies across BDAABIT and Psychosis teams and service disciplines.
Verbatim wording from the response “19. Recruitment – clinical risk management
Action: Review the current vacancy levels in the BDAABIT and Psychosis teams to collate outstanding vacancies across the service disciplines in order to create additional 7 psychology posts. This will increase the BDAABIT capacity within Psychosis Services to meet the demands of the increasing caseload and to shorten waiting times for psychological interventions.
Deadline: 31.01.2020
Lead: Service – Adult Mental Health services S/SBT” Source location Response from North East London NHS Foundation Trust
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 Implement additional BIT pathway programmes, including group sessions and structured psychological interventions, within the AABIT service offer.
Verbatim wording from the response “3. Policy/practice update – Compliance with terms of AABIT SOP
Implement additional intervention pathway (BIT pathway) programmes (e.g. group sessions and structured term psychological interventions) as per the BDAABIT team’s development plan to ensure there is compliance with the AABIT SOP and that services are responsive to their users. The AABIT short-term support service will be responsive to their users. These programmes will form part of the whole service offer; patients will step up or down to alternative services or remain with their individual care plan.” Source location Response from North East London NHS Foundation Trust
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 Review monthly 18-week waiting reports and develop a time-tracked plan to monitor the maximum wait through divisional business meetings.
Verbatim wording from the response “20. Service change – clinical risk management
Action: Review the monthly 18 week wait report to ensure current configuration and develop a time-tracked development and monitor 18 week maximum wait of the 18 weeks will be maximum wait for achievement via the divisional business meeting.
Deadline: 28.02.2020
Lead: Head of Service – Adult Mental Health services” Source location Response from North East London NHS Foundation Trust
Open published response
20 Sep 2019 Karis Florence Braithwaite · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Failure to document verbal first-responder handovers in patient records View source Failure to ensure first-responder risk information is available to the assessing mental health team View source Failure to elicit relevant information from first responders during assessment View source Insufficient improvement of handover processes from first responders to Trust staff View source See 1 more concern
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
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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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
3 Jul 2019 John Patrick Doyle · Prevention of Future Deaths report East London
View report summary
Concerns raised 4 Lack of refresher training for occupational therapists as emergency equipment technology changes View source Training for occupational therapists not adequately covering the ordering process for emergency alarm equipment View source Training for occupational therapists not adequately covering available emergency alarm equipment View source Training for occupational therapists not adequately covering compatibility between alarm and home telephone systems View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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 North East London NHS Foundation Trust; 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
×
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 Add pendant-alarm ordering information, including clinical reasoning and equipment follow-up, to the occupational therapy induction checklist.
Verbatim wording from the response “Recommendation 3
To ensure that the training for pendant alarms is firmly embedded within the service.” Source location Response from North East London NHS Foundation Trust
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 Deliver an inpatient teaching session on pendant-alarm telephone compatibility requirements.
Verbatim wording from the response “Action 1
Patient safety alert distributed and an inpatient session to emphasise the following requirements:” Source location Response from North East London NHS Foundation Trust
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 Complete training on individual borough pendant-alarm ordering processes for inpatient and IRS staff.
Verbatim wording from the response “• This is to include any specific training related to assessment and provision of the pendant alarms as well as different types of equipment.” Source location Response from North East London NHS Foundation Trust
Open published response
24 Jan 2019 Mr Viswambaran · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to provide reliable telephone access to the IAPT team for initial triage View source Excessive waiting times for IAPT therapy View source
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
Mr Viswambaran · 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
Mr Viswambaran, aged 27, was found dead at home on 18 September 2018 after overdosing on co-dydramol tablets. The report raises concerns about lengthy waiting times for IAPT therapy and difficulties contacting the IAPT service, which could contribute to deterioration or disengagement from mental health support.
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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide reliable telephone access to the IAPT team for initial triage
Wider context from the report “2) Mr Viswambaran had problems making contact with the IAPT team by telephone in order to arrange the initial triage telephone call . I am concerned that this may discourage people from pursuing assistance from the service .
” 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 North East London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive waiting times for IAPT therapy
Wider context from the report “1) From the evidence of Mr Viswambaran’s GP, ████████, it transpired that the waiting time for IAPT therapy is in the region of 12 weeks but could be up to 18 weeks . I am concerned that individuals may experience a deterioration in their mental health pending an appointment or disengage from mental health services due to the length of waiting times for therapy .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations