27 Mar 2018 Maureen Anne CAMPBELL-SCOTT · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 6 Failure to address cross-practice recurrence of mental health care coordination concerns View source Delays in delivery of mental health clinic letters to GPs View source Inability of GPs to implement rapid and accurate specialist-directed medication changes View source Failure of mental health referral routing between teams View source Lack of joint coordination between mental health and primary care services View source Failure of GP prescribing to follow psychiatric team direction View source See 3 more concerns
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AI-generated summary
Maureen Anne CAMPBELL-SCOTT · 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
Maureen Anne Campbell-Scott died from multiple injuries after falling from a ledge at the Exchange Shopping Centre car park on 16 June 2017. The report identified concerns about delays and errors in mental health referrals, delayed communication of medication changes, prescribing that did not always follow specialist directions, and a lack of joint working between mental health services and the GP practice.
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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 address cross-practice recurrence of mental health care coordination concerns
Wider context from the report “(6) It is accepted that the concerns in this case are unlikely to be restricted to the Fulwell Cross Surgery . If a joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices.
” 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 delivery of mental health clinic letters to GPs
Wider context from the report “(2) There were often delays (in excess of 14 days) in the delivery to the GP of clinic letters from the mental health trust. Often, the clinic letters contained requests for the GP to make changes to 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 Inability of GPs to implement rapid and accurate specialist-directed medication changes
Wider context from the report “(4) In times of acute mental health crisis, medication if often rapidly changed/supplemented. Mrs Campbell-Scott had 7 changes in her medication regime between 21 November 2016 to 23 February 2017. It is challenging for GPs to be able to ensure rapid and accurate changes when medication changes are directed by the specialist 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 of mental health referral routing between teams
Wider context from the report “(1) The GP had sent the referral to the wrong team of the mental health trust. The referral then got lost between the receiving team and the correct team (the older age mental health team). This resulted in a 4 month delay in Maureen Campbell-Scott receiving an 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 Lack of joint coordination between mental health and primary care services
Wider context from the report “(5) At the time of the Inquest hearing, there had been no joint meeting between the mental health trust and the GP practice to consider the best way forward in terms of referrals to the service; prescribing during times of dynamic medication changes and general communication between the GP and the psychiatrist.
” 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 GP prescribing to follow psychiatric team direction
Wider context from the report “(3) The prescribing by the GP did not always follow the direction given by the psychiatric 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 Continue joint NELFT–Fullwell Cross meetings to agree the process for referrals, prescribing during medication changes and communication, including reconvening to resolve prescribing responsibilities.
Verbatim wording from the response “We have had two meetings with the Fullwell Cross Practice and believe that we had agreed a process regarding the prescribing of medication to our shared patients. It was only on Tuesday of this week that we were informed that the practice had some late reservations about this specific aspect of the joint action plan. As such we are reconvening a meeting with Primary Care Colleagues to discuss the position further and agree a way forward.” Source location 2018-0090-Response-by-NELFT
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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 Work with NELFT and the CCG to roll out the improved practices across Barking and Dagenham, Havering and Redbridge.
Verbatim wording from the response “It is accepted that the concerns in this case are unlikely to be restricted to the Fullwell Cross Surgery. If a joint protocol is agreed between the Trust and the Practice, this could be shared more widely with other practices.” Source location 2018-0090-Response-by-NELFT
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 Send NELFT correspondence electronically using the patient’s NHS number and initials as the email subject, and communicate this practice to Redbridge GPs and mental health services.
Verbatim wording from the response “2a | NELFT Action | All correspondence to be sent via email. Subject of emails to be patient NHS number and patient initials. | NELFT Dr Shweta Anand & Maria Thorn, Assistant Director | 18/05/18 | Completed” Source location 2018-0090-Response-by-NELFT
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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 Require doctors to include their telephone number on medication-change notifications sent to GPs.
Verbatim wording from the response “2c | NELFT Action | All Doctors to add their telephone number to the bottom of ‘change of medication notification’ | NELFT Dr Shweta Anand | 18/05/18 | Completed” Source location 2018-0090-Response-by-NELFT
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 Email medication changes to GPs within 24 working hours.
Verbatim wording from the response “2b | NELFT Action | Medication changes to be emailed to GP within 24 working hours. | NELFT Dr Shweta Anand | 18/05/18 | Completed” Source location 2018-0090-Response-by-NELFT
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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 Process every NELFT referral and redirect misrouted referrals to the correct team within two working days.
Verbatim wording from the response “1b | NELFT Action | All referrals into NELFT will be processed, if the referral is sent to the wrong team NELFT will ensure the referral goes to the correct team within 2 working days. | NELFT Bob Edwards, ICD for Redbridge | 18/05/18 | Completed” Source location 2018-0090-Response-by-NELFT
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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 Compile and redistribute NELFT consultant psychiatrists’ telephone numbers to Redbridge GPs so they can contact prescribing clinicians.
Verbatim wording from the response “We have already agreed to provide personal contact details of NELFT Consultant’s to GPs for additional support and this action is already in place to allow GP’s to access advice regarding the management of people who have mental health problems. NELFT attended a very successful event with all Redbridge GP’s last week, where our staff did a series of table presentation to the GP’s. The theme was around mental health services and the crisis care pathway. We believe this will aid our future joint working with GP’s within the borough. The event was coordinated by ████████ who is the BHR CCG Lead GP for Mental Health. At the event he briefed GP’s regarding future communication methods and that all communication will move to being electronic in line with the action plan in relation to this regulation 28.” Source location 2018-0090-Response-by-NELFT
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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 NELFT cannot facilitate compliance aids through local pharmacists, so medication for patients using them must be organised by GPs.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
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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 NELFT cannot undertake prescribing because it lacks arrangements with community pharmacists to ensure frail patients receive medication.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
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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 NELFT cannot use FP10 prescribing for many Older Adult Mental Health Team patients who lack capacity.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
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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 NELFT cannot undertake prescribing because prescribers lack an overview of patients’ full medication and may miss interactions or contraindications.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
Open published response
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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 NELFT cannot undertake FP10 prescribing for many patients in care or sheltered accommodation because those settings will not accept such prescriptions.
Verbatim wording from the response “We understand that Fullwell Cross Medical Centre are now of the view that NELFT should undertake the prescribing duty, whereas our clinicians advise this is not practical for a number of reason, these broadly being the following:” Source location 2018-0090-Response-by-NELFT
Open published response
2 Dec 2016 Peter Daniel Usher · Prevention of Future Deaths report East London
View report summary
Concerns raised 11 Poor quality of duty-doctor clinical and risk assessments View source Failure to inform the on-call doctor of Section 136 assessment arrivals and outcomes View source Failure of duty-doctor practice to demonstrate insight and reflection View source Failure to include a Home Treatment Team member in Section 136 assessments View source Inadequate medical staffing for Section 136 assessments View source Failure to conduct detailed Section 136 assessments using relevant information from professional and non-professional sources View source Delays in transferring clinical information for Section 136 assessments View source Unclear availability of audit of clinical decision making during Section 136 assessments View source Failure to notify an AMHP of planned Section 136 assessments View source Failure to obtain and communicate relevant police and family information during admission View source Potential pressure from six-hour assessment targets to proceed without all relevant evidence View source See 8 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.
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AI-generated summary
Peter Daniel Usher · 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
Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.
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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 Poor quality of duty-doctor clinical and risk assessments
Wider context from the report “6. The evidence during the course of the Inquest and the evidence received from the independent psychiatrist raised a number of concerns in relation to the quality of the overall assessment and risk assessment carried out by the duty doctor . No issues relating to the medical input were identified in the Trust's own Root Cause Analysis. Further concern was raised during the course of the Inquest by the apparent lack of insight by the duty doctor and by the apparent inability to reflect on practice.
” 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 the on-call doctor of Section 136 assessment arrivals and outcomes
Wider context from the report “2. The Trust policy requires that the assessment should be carried out by the duty doctor and member of the Home Treatment Team. The policy also requires that the doctor must inform the on-call doctor of the arrival and discuss the outcome of the assessment with them. The Home Treatment Team member was not present during the course of the assessment. He was gathering relevant clinical information from a previous Section 136 attendance. The information appears to have been requested shortly after 03:00 and not received until around 04:47. This was partly due to safe haven procedures which had to be complied with before a fax could be sent. The Home Treatment team member attended as the assessment was wrapping up. The on-call doctor was not informed of Mr Usher .
” 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 duty-doctor practice to demonstrate insight and reflection
Wider context from the report “6. The evidence during the course of the Inquest and the evidence received from the independent psychiatrist raised a number of concerns in relation to the quality of the overall assessment and risk assessment carried out by the duty doctor. No issues relating to the medical input were identified in the Trust's own Root Cause Analysis. Further concern was raised during the course of the Inquest by the apparent lack of insight by the duty doctor and by the apparent inability to reflect on practice .
” 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 include a Home Treatment Team member in Section 136 assessments
Wider context from the report “2. The Trust policy requires that the assessment should be carried out by the duty doctor and member of the Home Treatment Team. The policy also requires that the doctor must inform the on-call doctor of the arrival and discuss the outcome of the assessment with them. The Home Treatment Team member was not present during the course of the assessment . He was gathering relevant clinical information from a previous Section 136 attendance. The information appears to have been requested shortly after 03:00 and not received until around 04:47. This was partly due to safe haven procedures which had to be complied with before a fax could be sent. The Home Treatment team member attended as the assessment was wrapping up. The on-call doctor was not informed of Mr Usher.
” 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 Inadequate medical staffing for Section 136 assessments
Wider context from the report “5. The junior doctor gave evidence to confirm that he was the only doctor available for 11 wards and 200 patients . It would appear from information provided by the Trust, that the number of Section 136 assessments is increasing substantially and therefore there is a concern in relation to adequate medical staffing .
” 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 conduct detailed Section 136 assessments using relevant information from professional and non-professional sources
Wider context from the report “1. The assessing team did not carry out a detailed assessment of Mr Usher, to include not only a personal assessment but also to obtain relevant clinical information from both professional and non-professional sources . This would have included information from the family and GP. There was also relevant information available to the paramedics and police that was not elicited by the assessing 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 Delays in transferring clinical information for Section 136 assessments
Wider context from the report “9. There were inefficiencies in practice which resulted in the member of the Home Treatment Team missing the clinical assessment . He had to wait for approximately 1 hour 45 minutes for clinical information to be provided . He had to go through Safe Haven procedures and to wait for a fax . An email to a secure email address may have avoided these delays.
” 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 Unclear availability of audit of clinical decision making during Section 136 assessments
Wider context from the report “7. It is unclear from the evidence heard during the course of the Inquest whether there is any audit of clinical decision making during Section 136 assessments .
” 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 notify an AMHP of planned Section 136 assessments
Wider context from the report “3. The Trust policy requires that an AMHP (Approved Mental Health Professional) be notified of the planned assessment . This also did not take place .
” 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 and communicate relevant police and family information during admission
Wider context from the report “4. The police had received contact from family members whilst they were present at the hospital, confirming the concerns of family members due to the text received. This was not passed on to the hospital staff . 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 .
” 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 Potential pressure from six-hour assessment targets to proceed without all relevant evidence
Wider context from the report “8. The Section 136 policy contains a 6 hour target for assessments to be completed. Section 136 itself, allows a period of up to 72 hours. It is unclear from the evidence as to whether the 6 hour limit places undue pressure upon staff to carry out assessments without gathering all of the available relevant evidence .
” Open source report
13 Jun 2016 Laura McRory · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 3 Inadequate safety planning on discharge View source Lack of a system for prompt referral of staff to another Trust for mental healthcare View source Lack of a clear process for NELFT staff seeking mental healthcare while concerned about sharing information with colleagues 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
Laura McRory · 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
Laura McRory, who had a history of anxiety, depression and alcohol misuse, was assessed at hospital on 20 June 2015 after deterioration in her mental state and increased alcohol consumption. She was discharged without immediate follow-up or continued observation and was found unresponsive the following day; she died from alcohol and mixed drug consumption. The principal concerns were the adequacy of the discharge safety plan and the lack of a clear process for referring NELFT staff seeking mental healthcare to another Trust when they were unwilling to share information with colleagues.
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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 Inadequate safety planning on discharge
Wider context from the report “• The Trust’s investigation report found that there were no care or service delivery problems. The report however did not analyse to any degree the issues relating to the complexities surrounding NELFT employees seeking help for mental health conditions. The report also did not to any extent consider whether there was an adequate safety plan in place 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 a system for prompt referral of staff to another Trust for mental healthcare
Wider context from the report “• ████████ did not consider there to be an adequate safety plan in place for Mrs McRory. He also considered that there needed to be a system in place for staff to be promptly referred to a different Trust where they present with mental health difficulties and request services from a different Trust . ████████ did confirm that he was in the process of drafting a protocol to deal with this issue. A copy of the draft protocol was not 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 a clear process for NELFT staff seeking mental healthcare while concerned about sharing information with colleagues
Wider context from the report “• The evidence revealed a need for a clear process to be in place when NELFT staff require mental healthcare and express reservations about sharing information with colleagues .
” 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 Develop, publish and disseminate a protocol for staff requiring mental health care.
Verbatim wording from the response “Action to be taken:
A protocol on the process for staff requiring mental health care to be developed and published within NELFT. Managers and staff within NELFT to be made aware of the protocol via cascade, publication on the intranet and via NELFT’s Wellness Programme.” Source location Response from North East London NHS Foundation Trust
Open published response
9 Mar 2016 William Stanley Higgleton · Prevention of Future Deaths report East London
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Concerns raised 1 Lack of psychotherapy service provision for persons with anti-social personality disorder View source
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AI-generated summary
William Stanley Higgleton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Stanley Higgleton, who had anti-social personality disorder and mixed anxiety and depressive disorder and was considered at high risk of harm to himself, was found deceased at home on 22 July 2015. The cause of death was recorded as a multiple drug overdose. The principal concerns were the lack of psychotherapy provision for people with anti-social personality disorder and the absence of limits on his access to medication or community mental health support to assist with medication compliance and more frequent assessment.
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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 psychotherapy service provision for persons with anti-social personality disorder
Wider context from the report “████████ considered that Mr Higgleton's primary diagnosis was anti-social personality disorder. She confirmed that the primary treatment for this condition would be psychotherapy services. ████████ confirmed however that there is a lack of service provision for psychotherapy care to be provided to persons suffering from anti-social personality disorder . The lack of service provision in this regard was confirmed by ████████ (Assistant Director Adult Mental Health and Learning Disabilities).
I consider that the lack of provision of psychotherapy services to this group of patients presents a risk of future deaths occurring.
” Open source report
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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 care pathways for patients with antisocial personality disorder against NICE guidance, identify service gaps, and determine appropriate action.
Verbatim wording from the response “At the meeting, an agreement was reached to review the care pathways for the patients suffering with anti-social personality disorder, to ensure that they are supported to access the existing services in conjunction with National Institute for Health and Social Care Excellence (NICE) guidelines.” Source location William-Higgleton-Response
Open published response
16 Nov 2015 EMMA LOUISE BRAY · Prevention of Future Deaths report East London
View report summary
Concerns raised 17 Failure to refer patients from the Intake team to an appropriate service View source Absence of guidance on assessment information and its sources View source Failure to obtain a proper treatment and medication history from the patient and primary sources View source Lack of clarity about responsibility for communicating medication risks View source Failure to communicate medication risks to patients and families View source Lack of guidance on medication recommendations without a full medical history View source Lack of guidance on medication recommendations without seeing the patient in person View source Inadequate staff understanding and tools for self-harm risk assessment View source Lack of monitoring and auditing of patient progression through the service View source Failure to record emails from family members in patient notes View source Lack of clarity about retaining patients or referring them to other services View source Delays in psychiatric referral and assessment after initial assessment View source Failure to establish referral and treatment plans with timescales View source Lack of guidance for responding to concerns about patients not engaging with the Intake team View source Lack of clarity about the designated contact between patients and the Intake team View source Failure to provide timely and regular follow-up contact View source Failure to escalate family reports of changes in presentation for multidisciplinary review View source See 14 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
EMMA LOUISE BRAY · 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
Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.
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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 refer patients from the Intake team to an appropriate service
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Absence of guidance on assessment information and its sources
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 a proper treatment and medication history from the patient and primary sources
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Lack of clarity about responsibility for communicating medication risks
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 communicate medication risks to patients and families
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Lack of guidance on medication recommendations without a full medical history
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Lack of guidance on medication recommendations without seeing the patient in person
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Inadequate staff understanding and tools for self-harm risk assessment
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Lack of monitoring and auditing of patient progression through the service
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 record emails from family members in patient notes
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Lack of clarity about retaining patients or referring them to other services
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Delays in psychiatric referral and assessment after initial assessment
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 establish referral and treatment plans with timescales
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Lack of guidance for responding to concerns about patients not engaging with the Intake team
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 Lack of clarity about the designated contact between patients and the Intake team
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 provide timely and regular follow-up contact
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up . Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to 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 escalate family reports of changes in presentation for multidisciplinary review
Wider context from the report “During the evidence I was told that a number of things had not happened that ought to have done:
(a) A proper medication history was not taken on assessment
(b) EB’s treatment and medication history were not obtained from either public or private sector providers.
(c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days.
(d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition.
(e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team.
(f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring.
(g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment.
(h) There should have been regular contact with EB thereafter, initiated by IT.
(i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care.
(j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment.
(k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns.
(l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay.
On a systemic level, the following issues are of concern:
(a) Absence of guidelines about what information must be obtained on assessment, including the medication history.
(b) Absence of guidance about where that information should be obtained from: the patient / primary sources.
(c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services.
(d) Lack of clarity about who should be the person between patients and the IT.
(e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them.
(f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be.
(g) An absence of guidelines giving staff timescales within which referrals should take place.
(h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place.
(i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history.
(j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person.
(k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of.
(l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes.
(m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff.
” 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 record keeping standards in AABIT.
Verbatim wording from the response “The plan has five broad objectives within which your specific concerns have been addressed. These are:” Source location 2015-0438-Response-by-NELFT-NHS-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 AABIT staff are competent in risk assessment and escalation of risk.
Verbatim wording from the response “The plan has five broad objectives within which your specific concerns have been addressed. These are:” Source location 2015-0438-Response-by-NELFT-NHS-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 implement AABIT standard operating procedures.
Verbatim wording from the response “The plan has five broad objectives within which your specific concerns have been addressed. These are:” Source location 2015-0438-Response-by-NELFT-NHS-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 Improve the quality of assessment and treatment plans.
Verbatim wording from the response “The plan has five broad objectives within which your specific concerns have been addressed. These are:” Source location 2015-0438-Response-by-NELFT-NHS-Trust
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations