Recipient

North London Mental Health Partnership

First report 27 Sep 2024•Latest report 18 Nov 2024

Recipient record

Reports, concerns and published responses

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

Reports: 2
Published responses: 100%
Concerns addressed: 3
Stated actions: 18

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

18stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from North London Mental Health Partnership linked to the concerns in each report. Select any concern, action or position to view the source wording.

18 Nov2024
Inner North London
Concerns raised4
1. Failure to assess the suitability of Olanzapine depot injections for in-patients who refuse vital signs checks
2. Failure to ensure continuous suitably qualified staff observation after Olanzapine depot injections
3. Failure to communicate the risk of death from Olanzapine depot injections to patients or their representatives
1. Failure of Lead Pharmacist approval to establish whether a SOAD has been obtained
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Yemisi Cielto-Opaleye · 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

Yemisi Cielto-Opaleye, a psychiatric inpatient at St Pancras Hospital, died on 13 December 2023 after receiving an Olanzapine depot injection and developing Olanzapine toxicity. The report identified concerns about inadequate pre- and post-injection vital-sign monitoring, unclear staff responsibilities, insufficient escalation and contingency planning, and failures to obtain required approval and provide adequate information about risks.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London Mental Health Partnership; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess the suitability of Olanzapine depot injections for in-patients who refuse vital signs checks
Wider context from the report
“(d) In cases where psychiatric in-patients are known to have a history of refusing vital signs checks, careful consideration and scrutiny should be given as to whether an Olanzapine depot injection is a suitable medication for such patients, especially in view of the crucial post-injection monitoring requirements. ”
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 London Mental Health Partnership; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure continuous suitably qualified staff observation after Olanzapine depot injections
Wider context from the report
“(b) In a psychiatric in-patient setting, there are many demands on staff who can become distracted from their expected duties. Unless there is a suitably qualified medical member of staff whose sole duty it is to remain in the company of a patient, who has had an Olanzapine depot injection at all times during the 3 hour post-injection observation period, there is a risk that vital signs checks will be missed and that Post Injection Syndrome will not be detected early enough if it occurs; ”
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 London Mental Health Partnership; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate the risk of death from Olanzapine depot injections to patients or their representatives
Wider context from the report
“I am concerned that: (a) The risk of death from the use of Olanzapine depot injection needs to be made clear to patients who are going to be given that injection. Although it is very small risk, the fact that the risk can be largely eradicated by vital signs checks at intervals within the 3-hour period every medical intervention, the risk needs to be stated to, and understood by, patients or those who represent their interests, before such a depot injection is given; ”
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 London Mental Health Partnership; that does not assign responsibility.
PFD Monitor interpretation
Failure of Lead Pharmacist approval to establish whether a SOAD has been obtained
Wider context from the report
“(c) There is a risk that approval from a Lead Pharmacist to initiate a non-formulary medicine such as an Olanzapine depot can occur without the Pharmacist knowing whether a SOAD has been obtained in relation to that medication and that patient; ”
Open source report
27 Sep2024
Inner North London
Concerns raised3
1. Delay in allocation of a replacement mental health care coordinator
2. Failure to escalate unsuccessful contact attempts for a welfare check
3. Failure to follow up repeated failed clinical encounters
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Maria Patricia Kelly · 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

Maria Patricia Kelly, who lived alone and was in poor health, was found deceased at home by police on 15 May 2024 after concerns were raised by neighbours and a housing officer. The report identifies prolonged lack of contact with primary care and mental health services, numerous failed encounters, and no welfare check until the neighbours’ concerns were raised; the inquest determined natural causes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London Mental Health Partnership; that does not assign responsibility.
PFD Monitor interpretation
Delay in allocation of a replacement mental health care coordinator
Wider context from the report
“Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past. She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024. From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening. Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023. It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts. Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London Mental Health Partnership; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate unsuccessful contact attempts for a welfare check
Wider context from the report
“Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past. She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024. From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening. Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023. It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts. Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London Mental Health Partnership; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow up repeated failed clinical encounters
Wider context from the report
“Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past. She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024. From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening. Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023. It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts. Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Failure to assess the suitability of Olanzapine depot injections for in-patients who refuse vital signs checks

Failure to ensure continuous suitably qualified staff observation after Olanzapine depot injections

Failure to communicate the risk of death from Olanzapine depot injections to patients or their representatives

Failure of Lead Pharmacist approval to establish whether a SOAD has been obtained

Concerns raised3

Delay in allocation of a replacement mental health care coordinator

Failure to escalate unsuccessful contact attempts for a welfare check

Failure to follow up repeated failed clinical encounters