19 May 2026 Najib Ahmed NAAGI · Prevention of Future Deaths report Inner North London
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Concerns raised 3 Failure to conduct patient observations at scheduled times View source Failure to provide accurate evidence in court View source Failure to accurately and contemporaneously record patient observations View source
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AI-generated summary
Najib Ahmed NAAGI · 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
Najib Naagi was found unresponsive in his mental health hospital bed on 3 January 2025, was resuscitated, and died in intensive care the following day from natural causes. The report raises concerns that observations were not conducted at the required times and that the clinical support worker’s records did not accurately reflect the observations made, misleading the court and undermining confidence in patient records.
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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 London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct patient observations at scheduled times
Wider context from the report “The clinical support worker who had been tasked with conducting Mr Naagi’s observations recorded that she had observed Mr Naagi at the following times:
• 4.30am
• 5.30am
• 6.30am
She reiterated that in her statement and in her oral evidence at inquest. She did not volunteer the fact that her record was wrong. It was only when I put it to her in quite robust terms that she accepted this.
In fact, the ward CCTV showed that she looked through the observation panel at the following times:
• 4.48am
• 6.18am
Thus, the record she made did not reflect the actions she took. The consequences of this are as follows:
1. A patient’s medical record was wrong. Any healthcare professional seeking to understand when Mr Naagi had been observed to be well by reading the record would have been given the wrong information.
2. The fact that this record was wrong casts doubt on the remainder of the record, both in terms of this individual (was he actually well at the times recorded?) and the other patients (were they observed when the record indicates that they were observed?).
3. The court was misled.
Observations should be conducted when they are meant to be conducted , but if they are not then this fact must be recorded contemporaneously.
It was put to me by the trust’s solicitor that because the clinical support worker later looked through the observation panel at 6.36am, this meant that the number of observations recorded was accurate and so the later observation somehow made good the lack of earlier observation and corrected the wrong recording. That is simply not the case. Proper patient care demands that patient records are accurate and not in any way fabricated.
Regarding the giving of inaccurate evidence in court, this may amount to a contempt of court, it may amount to perjury, it may be punishable by a fine or even by a term of imprisonment. For your patients, it obstructs learning from deaths.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate evidence in court
Wider context from the report “The clinical support worker who had been tasked with conducting Mr Naagi’s observations recorded that she had observed Mr Naagi at the following times:
• 4.30am
• 5.30am
• 6.30am
She reiterated that in her statement and in her oral evidence at inquest. She did not volunteer the fact that her record was wrong. It was only when I put it to her in quite robust terms that she accepted this.
In fact, the ward CCTV showed that she looked through the observation panel at the following times:
• 4.48am
• 6.18am
Thus, the record she made did not reflect the actions she took. The consequences of this are as follows:
1. A patient’s medical record was wrong. Any healthcare professional seeking to understand when Mr Naagi had been observed to be well by reading the record would have been given the wrong information.
2. The fact that this record was wrong casts doubt on the remainder of the record, both in terms of this individual (was he actually well at the times recorded?) and the other patients (were they observed when the record indicates that they were observed?).
3. The court was misled.
Observations should be conducted when they are meant to be conducted, but if they are not then this fact must be recorded contemporaneously.
It was put to me by the trust’s solicitor that because the clinical support worker later looked through the observation panel at 6.36am, this meant that the number of observations recorded was accurate and so the later observation somehow made good the lack of earlier observation and corrected the wrong recording. That is simply not the case. Proper patient care demands that patient records are accurate and not in any way fabricated.
Regarding the giving of inaccurate evidence in court, this may amount to a contempt of court, it may amount to perjury , it may be punishable by a fine or even by a term of imprisonment. For your patients, it obstructs learning from deaths.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately and contemporaneously record patient observations
Wider context from the report “The clinical support worker who had been tasked with conducting Mr Naagi’s observations recorded that she had observed Mr Naagi at the following times:
• 4.30am
• 5.30am
• 6.30am
She reiterated that in her statement and in her oral evidence at inquest. She did not volunteer the fact that her record was wrong. It was only when I put it to her in quite robust terms that she accepted this.
In fact, the ward CCTV showed that she looked through the observation panel at the following times:
• 4.48am
• 6.18am
Thus, the record she made did not reflect the actions she took. The consequences of this are as follows:
1. A patient’s medical record was wrong. Any healthcare professional seeking to understand when Mr Naagi had been observed to be well by reading the record would have been given the wrong information.
2. The fact that this record was wrong casts doubt on the remainder of the record, both in terms of this individual (was he actually well at the times recorded?) and the other patients (were they observed when the record indicates that they were observed?).
3. The court was misled.
Observations should be conducted when they are meant to be conducted, but if they are not then this fact must be recorded contemporaneously.
It was put to me by the trust’s solicitor that because the clinical support worker later looked through the observation panel at 6.36am, this meant that the number of observations recorded was accurate and so the later observation somehow made good the lack of earlier observation and corrected the wrong recording. That is simply not the case. Proper patient care demands that patient records are accurate and not in any way fabricated.
Regarding the giving of inaccurate evidence in court, this may amount to a contempt of court, it may amount to perjury, it may be punishable by a fine or even by a term of imprisonment. For your patients, it obstructs learning from deaths.
” 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 Amend the supportive observations policy and observation form to require and record each patient’s exact observation time.
Verbatim wording from the response “As explained, the Trust recognises that the existing observation record form does not support staff to record observations contemporaneously. As a result, the Supportive Observations Policy has been amended to state that ‘staff must record the exact time that each patient is observed on every check, rather than relying solely on the hourly observation column. Accurate timings provide an auditable record of when observations took place and are essential for patient safety, incident investigations, CCTV reviews and other reviews of care. Recording a time that does not reflect when the observation occurred may constitute falsification of records and could result in disciplinary action’. In conjunction, the general observation form has been amended to allow staff to record the exact time they check each patient.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the case across inpatient services and management teams, and remind staff of responsibilities when providing evidence.
Verbatim wording from the response “To reinforce a culture of openness, transparency, and accountability at all times, learning from this case has been shared across all inpatient services and management teams. In addition, staff have been reminded of their professional responsibilities when providing witness statements and evidence during investigations and legal processes.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor observation practice and documentation through audits, quality visits, safety huddles, senior reviews, and governance reporting.
Verbatim wording from the response “Compliance with observation practice and documentation standards will be reviewed through monthly observation audits, Matron quality visits and daily safety huddles, out-of-hours senior manager reviews and reporting through the Care Group Quality and Safety governance structure. Any themes and findings will be escalated further through the Trust’s governance arrangements where required.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review observation competency compliance across substantive and temporary staff.
Verbatim wording from the response “As part of the investigation undertaken by NHSP, the CCTV was reviewed. This shows that no observations were conducted at 05:30. The Trust understands the importance of observations to support safe, person-centred care and the formulation of risk assessment. The Trust has reviewed observation competency compliance across substantive and temporary staff and has reinforced the requirement that all staff undertaking supportive observations complete observation training, competency assessment, and ward induction before undertaking observation duties.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce requirements for observation training, competency assessment, and ward induction before staff undertake observation duties.
Verbatim wording from the response “As part of the investigation undertaken by NHSP, the CCTV was reviewed. This shows that no observations were conducted at 05:30. The Trust understands the importance of observations to support safe, person-centred care and the formulation of risk assessment. The Trust has reviewed observation competency compliance across substantive and temporary staff and has reinforced the requirement that all staff undertaking supportive observations complete observation training, competency assessment, and ward induction before undertaking observation duties.” Source location Response from North London NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust did not endorse treating later observations as correcting missed observations; the information offered a possible explanation for the worker’s timing error.
Verbatim wording from the response “The Trust acknowledges that there are no circumstances in which the completion of an observation at 06:18 can ever be interpreted to represent the completion of an observation required at 05:30 and nowhere in Trust policy is this accepted to represent acceptable practice. By referring the court to the number of observations completed, the Trust’s Solicitor was not seeking to suggest that the Trust endorses any such approach, or in any way makes light of this situation. This information was provided only to offer a possible” Source location Response from North London NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing procedures ensure suspected dishonesty is investigated and referred to regulators, DBS or police, preventing continued risk to patient safety.
Verbatim wording from the response “As explained at the outset of this Response, the Trust fully accepts the gravity of this situation and that incidents involving significant departures from professional standards of conduct and / or, most significantly, dishonesty can have regulatory and / or legal consequences. Please be assured that the Trust has in place procedures to ensure that, following appropriate investigation, where incidents of this nature are established or strongly suspected referrals to regulators, the DBS and / or the police are completed as required. This is to ensure that conduct of this nature is appropriately sanctioned and does not represent a continued risk to patient safety.” Source location Response from North London NHS Foundation Trust
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23 Jun 2025 Louise Elizabeth Amy Crane · Prevention of Future Deaths report Inner North London
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Concerns raised 9 Failure to conduct patient observations in accordance with observation policy View source Failure to implement identified risk-reduction actions View source Failure of staff to recognise when a patient is becoming withdrawn View source Lack of communication between staff at all levels View source Failure of step-down and discharge systems to facilitate identified risks and needs View source Failure of audits to identify and address compliance concerns View source Failure of senior clinical leadership to recognise identified care issues View source Lack of staff understanding of therapeutic engagement in mental health care View source Failure to ensure that staff make records using their own identification and accurately identify the author View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Louise Elizabeth Amy Crane · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Louise Elizabeth Amy Crane, who had a history of mental health diagnoses and was detained in hospital under the Mental Health Act, was found suspended by a ligature at Highgate Mental Health Centre on 19 September 2024. The jury found that factors contributing to her death included chronic suicide risk, unsatisfactory information sharing and recording, inadequate risk management, staffing, and insufficient care and treatment on Topaz Ward. The report also raised concerns about record keeping, therapeutic engagement and professional curiosity, ward observations, communication, transitions between wards, and outstanding actions in the Trust’s action plan.
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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 London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct patient observations in accordance with observation policy
Wider context from the report “5) Observations on Topaz Ward
The Trust’s own internal investigation highlighted issues regarding the review of required observation levels. However, the evidence at inquest, in relation to the observation round at or about 11:30 on 19 September raised a further concern, albeit this did not cause / contribute to Ms Crane’s death in the particular circumstances.
The evidence was that the support worker conducting this check did not see any part of Ms Crane , and on trying to open the door there was some resistance. As such, the assumption was made that Ms Crane was sat with her back to the door, and the support worker marked Ms Crane as being in her room and moved on to the next room . This raises the concern that observations being undertaken do not always comply with the Trust’s own observation policy and that there may be a staff training / knowledge gap in this regard.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement identified risk-reduction actions
Wider context from the report “7) Trust Action Plan
Some of the matters contained within the Trust’s action plan, which stems from its own internal investigation, remain outstanding and / or are still awaiting Board level approval. As such, there is some extent, a lack of reassurance (at present) regarding the actions that will actually be taken to address the risks the Trust itself has already identified .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to recognise when a patient is becoming withdrawn
Wider context from the report “4) Therapeutic Engagement / Professional Curiosity – Generally
The jury heard evidence from numerous members of Topaz Ward staff who were taken through the care records, that Ms Crane had become withdrawn from around 12 September 2024 onwards. Many of the witnesses denied this, despite the evidence to the contrary. The fact of Ms Crane becoming withdrawn had been identified by staff in PICU as a significant risk factor for Ms Crane. While this may not have been picked up by all staff due to record keeping issues (already identified by the Trust), the concern here is that there appears to have been a general inability among staff to recognise when a patient is becoming withdrawn , which raises concern about underlying professional curiosity .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between staff at all levels
Wider context from the report “6) Communication and Culture
While the Trust’s internal investigation highlighted issues with documentation and record keeping, which is key tool for communication, the evidence revealed a lack of general communication between staff at all levels . Aside from documentation matters, a lack of good communication more generally raises significant patient care risks and could undermine patient safety .
The substantive consultant psychiatrist for Topaz Ward said that they would change nothing about the care that was provided. This raises concerns that the senior clinician for the Ward does not accept or appreciate the issues identified by the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of step-down and discharge systems to facilitate identified risks and needs
Wider context from the report “3) Step down / discharge from PICU to acute ward
There was evidence that the Trust’s systems were unable to accommodate the needs of Ms Crane in ensuring that her transition from an intensive care to an acute setting was as safe as possible for her . Numerous risks and needs were identified for the step down / discharge process, but most of these (which significantly impacted Ms Crane’s risk to self) were not facilitated.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of audits to identify and address compliance concerns
Wider context from the report “2) Lack of Professional Curiosity / Therapeutic Engagement – Audits
This was a matter picked up during the Trust’s own investigation. The Trust’s action plan includes audits to monitor compliance with certain aspects of Trust policy etc. However, the Topaz Ward manager gave evidence that there had been issues with audits in the past, which had been escalated (prior to Ms Crane’s death) but no response received . I was not reassured that further audits would be sufficient to address the concerns already identified .
In addition to the above, numerous members of staff from Topaz Ward gave evidence during the inquest and it appeared that many of them struggled with the concept of ‘therapeutic engagement’. Some maintained that Ms Crane had received a sufficient level of therapeutic engagement from Ward staff, contrary to the findings of the Trust’s own investigation and the subsequent findings of the jury. This suggests a potentially widespread lack of understanding, and underlying knowledge of ‘therapeutic engagement’ and its importance in mental health care.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinical leadership to recognise identified care issues
Wider context from the report “6) Communication and Culture
While the Trust’s internal investigation highlighted issues with documentation and record keeping, which is key tool for communication, the evidence revealed a lack of general communication between staff at all levels. Aside from documentation matters, a lack of good communication more generally raises significant patient care risks and could undermine patient safety.
The substantive consultant psychiatrist for Topaz Ward said that they would change nothing about the care that was provided. This raises concerns that the senior clinician for the Ward does not accept or appreciate the issues identified by the Trust .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding of therapeutic engagement in mental health care
Wider context from the report “2) Lack of Professional Curiosity / Therapeutic Engagement – Audits
This was a matter picked up during the Trust’s own investigation. The Trust’s action plan includes audits to monitor compliance with certain aspects of Trust policy etc. However, the Topaz Ward manager gave evidence that there had been issues with audits in the past, which had been escalated (prior to Ms Crane’s death) but no response received. I was not reassured that further audits would be sufficient to address the concerns already identified.
In addition to the above, numerous members of staff from Topaz Ward gave evidence during the inquest and it appeared that many of them struggled with the concept of ‘therapeutic engagement’ . Some maintained that Ms Crane had received a sufficient level of therapeutic engagement from Ward staff, contrary to the findings of the Trust’s own investigation and the subsequent findings of the jury. This suggests a potentially widespread lack of understanding, and underlying knowledge of ‘therapeutic engagement’ and its importance in mental health care .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that staff make records using their own identification and accurately identify the author
Wider context from the report “1) Record Keeping / Professional Standards
There was evidence that staff on Topaz Ward would sometimes use the ID card of another member of staff to makes notes on the records system, without making it clear who the entry was actually made by . In this case there were two entries that appeared to have been made by a support worker, that were actually made by a nurse. Such misleading and inaccurate record keeping risks significant confusion in the provision of care and potentially creates significant risk in relation to the continuity of care.
” 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 ward staff access daily and reinforce requirements against sharing Smart Cards or misattributing electronic records.
Verbatim wording from the response “Ward managers are expected to complete a daily review of staff attending their wards to check access and ability to record accurately.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Realign matrons under the Associate Director of Nursing and remove operational duties so they focus on clinical quality and safety.
Verbatim wording from the response “a. Matron line management has been moved from operational service managers to the Associate Director of Nursing to re-establish their role as one of quality and standards.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review improvement actions through executive-chaired Mandated Support meetings reporting to the Executive Management Committee.
Verbatim wording from the response “4) Ongoing review of all actions at the Mandated Support meetings that are chaired by executives and report to the Executive Management Committee (EMC)” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Perfect Day model with standardized ward timetables, daily electronic handover templates and documentation of multidisciplinary and observation decisions.
Verbatim wording from the response “4) It is also acknowledged that some of the therapeutic engagement with patients/actions which would evidence professional curiosity were not being captured within our clinical documentation. To support improvement, the Division has rolled out the ‘Perfect Day’ model which essentially standardises the inpatient ward day timetable across all our wards. The Perfect Day model provides a timetable for the day which is predictable and understandable by all staff, patients and visitors. It also provides a standardised digital template for handovers that is completed daily and uploaded to the electronic patient record (EPR) system every day before 11am evidencing key information such as risk, barriers to discharge etc.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit Perfect Day documentation fidelity using a standardized checklist and continue monitoring implementation through the discharge facilitation team.
Verbatim wording from the response “Audit is considered a vital tool in monitoring and providing assurance that the Perfect Day model improvements around documentation are being implemented consistently. The role out of the model was initially supported by a band 8c Director of Operations working in the division and auditing the results. This has now been handed over to the newly formed discharge facilitation team to continue with the audits.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress ward Culture of Care recommendations arising from multidisciplinary away days and senior leadership review.
Verbatim wording from the response “Between November 2024 and January 2025 the Trust delivered 15 full away days for the wards on the Highgate campus. These away days used the new NHS ‘Culture of Care’¹ standards as their focus and included all the ward multidisciplinary teams and senior management. Discussions around the importance of therapeutic engagement and professional curiosity were central to these sessions, focusing on identifying barriers and implementing strategies for improvement. They were facilitated by Organisational Development colleagues who compiled reports on the learning from the away days about the different cultures on our wards and reported back to the senior leadership group to support each individual ward with developing their approach to patient care. A set of overarching recommendations was also made and these are currently being progressed as part of the ongoing programme of work.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide bank-shift induction covering ward procedures and observation requirements, while prioritizing trained regular bank staff.
Verbatim wording from the response “Use of bank staff presents a challenge as they may not receive the same training as substantive staff. We are addressing this through the recruitment referred to earlier which will reduce our reliance on bank staff, and where we do use bank staff, wherever possible these will be from a regular pool of staff who are trained on Trust policies and procedures. We are also ensuring all staff working a bank shift receive an induction to the ward which includes how to carry out observations.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing a cross-ward approach to PICU step-down through a women’s PICU workshop and planned care-group structure.
Verbatim wording from the response “Additionally, we are in the early stages of a further conversation about this with a workshop recently commenced on the women’s PICU ward. In November the Trust is moving to a new structure with the current divisions to be replaced by care groups, bringing all inpatient wards for adults of working age across the organisation under the same management structure. This will support us to make best use of all our available beds across the entire Trust.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor observation sheets daily and reconcile weekly CCTV and documentation reviews, with increased nurse-leader visibility.
Verbatim wording from the response “Observation sheets are now monitored daily by the Nurse in Charge, Ward Manager, Matron, and out of hours via the Senior Site Coordinators. In addition, the Division has initiated a weekly CCTV and documentation review and reconciling these. This is undertaken by the Ward Managers and Matrons to ensure that documentation is accurate and up to date. We have also increased visibility of Nurse Leaders (Ward Managers, Matrons and members of the Senior Leadership Team) to support this work. As of August, the role of the Matrons has changed so that they are now focussed on clinical, rather than operational duties, with an emphasis on improving nursing standards and the quality of care.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Streamline Smart Card access and require bank staff to hold cards and complete Rio training before booking shifts.
Verbatim wording from the response “Record Keeping / Professional Standards
The Trust recognises the vital importance of accurate record keeping in supporting safe patient care. It is acknowledged that access to Smart Cards to support the use of Rio (the Trust’s Electronic Patient Record system) has been an issue, particularly for staff working via our bank staff provider NHS Professionals (NHSP). As part of the EMS program, this was investigated and processes streamlined so that all existing and new staff are now able to apply for a Smart Card and complete RIO training. Going forward, in order to be booked onto a bank shift, NHSP staff must have a Smart Card. As a result, all staff (substantive and NHSP) can now make their own records on the RIO System thereby reducing any reliance on using other colleagues’ accounts.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress Topaz ward’s quality-improvement programme on therapeutic engagement through the division-wide improvement programme.
Verbatim wording from the response “In addition, Topaz ward specifically engaged in an additional Quality Improvement programme of working on ‘Improving Therapeutic Engagement on the ward’. Although this is still in its initial stages, it will be progressed with the wider programme of work being undertaken by the division.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a discharge facilitation team comprising network navigators, discharge coordinators and a team manager to reduce nursing administrative workload.
Verbatim wording from the response “In addition, a discharge facilitation team has been introduced which works with all our inpatient wards to support with some of the practical and administrative tasks around discharge planning which were previously being undertaken by nursing staff, with subsequent impact on time available to provide care. Current feedback is that this team is having a significant positive impact on capacity.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit 24 additional Registered Nurses and implement a three-nurse, two-support-worker day-shift staffing ratio across acute inpatient wards.
Verbatim wording from the response “1) A Safe Staffing skill mix review was completed by the Nursing Directorate and approved by the Executive Management Committee to upgrade the staffing model of all acute inpatient wards within the Hospital Division. This means that an additional 24 Registered Nurses will be recruited by October 2025 to initiate the new staffing ratio of 3 Nurses and 2 Health care support workers on day shift (previously 2 nurses and 3 Health care support workers). The increased number of qualified clinical staff will support with dedicated quality time to engage in therapeutic engagement time on the wards. We have also reviewed the input from other allied health professionals (Occupational Therapists, Activity Coordinators and ward Psychologists) to improve engagement via a range of professionals on the inpatient wards.” Source location Response from North London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out a supportive-observation template requiring staff to check and record signs of life, and incorporate it into Trust policy.
Verbatim wording from the response “Observations on Topaz Ward
We recognise that observations are an area that have presented challenges for the organisation but we are committed to getting this right; observations are central to ensuring patient safety on our wards. There is also a need for consideration of patients’ privacy and dignity and to ensure that they are conducted in a way which is not unnecessarily intrusive. Following a review of observations as part of the EMS and learning from the BLPI, a new template has been piloted on three wards. This specifically prompts staff undertaking observations to check for and record Signs of Life. Staff are expected to enter the patient’s room and check their level of alertness/breathing where this is not immediately apparent, for example, by looking for chest movement when a patient is sleeping.” Source location Response from North London NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Staff understand therapeutic engagement and professional curiosity, although staffing, time and documentation barriers have affected implementation.
Verbatim wording from the response “Following the inquest, the staff team on Topaz ward have been supported to further reflect on the care provided to Ms Crane, in particular in regard to the findings around lack of professional curiosity and therapeutic engagement. We are satisfied that there is understanding amongst staff about what this is, but it is recognised that there have been barriers to implementing it effectively. Factors involved include staffing levels and skill mix, lack of time due to number of tasks staff are responsible for and standards of clinical documentation. One of the overarching aims of the ongoing improvements is to support staff so that they have time to ensure that every individual’s clinical needs are met. As part of the on-going mandated support program, the Division has initiated several actions to address this:” Source location Response from North London NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Severe bed-capacity pressures mean step-down from PICU cannot currently be planned in the way ideally required.
Verbatim wording from the response “Bed capacity remains challenging with there being a very high level of demand for beds across the area the Trust serves. This means that there are frequently long waits, both for people to be initially admitted to a bed (for example, from A&E) and for step down from PICU to the acute wards. Realistically, this is not likely to change in the near future and it means that we are not able to plan step down in the way that we might ideally wish to. However, all the other areas of work set out in this response that are ongoing to release time to care and make patients safer are expected to impact positively on this process and improve the experience for patients. There will be increased time to spend with patients when they are first admitted; to ensure that every individual’s needs are incorporated into their care plan so they can be effectively supported through this period of transition.” Source location Response from North London NHS Foundation Trust
Open published response
Concerns raised 2 Failure to support and discuss positive drug test results with prisoners View source Failure to ensure clear and followed pathways for action after a positive drug test View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Samuel Anthony Donald STEWART · 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
Samuel Stewart was found deceased in his cell at HMP Wormwood Scrubs on 15 July 2023, with drugs paraphernalia in the cell. His death was due to drugs in combination with long-term cardiac damage. A positive drug test on 6 March 2023 was not followed by discussion, support, or a multidisciplinary meeting, and the pathways after a positive result were unclear or not followed.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to support and discuss positive drug test results with prisoners
Wider context from the report “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare.
(1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines
(2) pathways after a positive test result were either not followed or unclear
(3) An opportunity was missed to support Sam and discuss this with him
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear and followed pathways for action after a positive drug test
Wider context from the report “Sam had elected to have a place on a "drug free" wing and accepted the conditions of this placement. He accessed non-prescribed drugs (amphetamines) as his test on 6 March 2023 yielded a positive result. No action was taken by either the prison or healthcare.
(1) consideration should be given as to what actions should have been taken, and if this is set out in the national or local policy guidelines
(2) pathways after a positive test result were either not followed or unclear
(3) An opportunity was missed to support Sam and discuss this with him
” Open source report
20 Feb 2025 Duncan HOLLOWAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Lack of a mechanism preventing psychotherapists unable to deal with suicidality from practising with clients who may experience it View source Failure to provide joined-up care between different agencies View source Omission of suicidality from BCAP-accredited psychotherapy training View source Lack of a minimum standard for psychotherapy consultation note keeping View source Failure to teach police contact in psychotherapy planning for missing or suicidal clients View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Duncan HOLLOWAY · 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
Duncan Holloway died after jumping from a bridge at approximately 5am on 18 July 2024, being killed by the impact with the railway tracks below. The concerns included psychotherapy note-keeping, training and response to suicidality, whether psychotherapists unable to manage suicidality should practise with at-risk clients, and a lack of joined-up care between agencies.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism preventing psychotherapists unable to deal with suicidality from practising with clients who may experience it
Wider context from the report “4. The psychotherapist explained in court that she was angry that Mr Holloway’s friend disclosed to her that Mr Holloway had died, asking the friend: “Do you have any idea how this impacts me and my ability to do my job going forward?” The psychotherapist said that she (the psychotherapist) was in distress and shock.
In hindsight, the psychotherapist said that she wished she had referred Mr Holloway to a psychotherapist with more experience in suicidality, she said at inquest because she did not want to be in this situation again with this responsibility.
Should there be a mechanism of ensuring that a psychotherapist who is unable to deal with suicidality does not practise with clients who may experience this ?
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide joined-up care between different agencies
Wider context from the report “5. Mr Holloway was seen and fully assessed by North West London clinicians when he was taken to hospital by police following an episode of self harm on 30 June 2024. Police attendance had been prompted by Mr Holloway’s brother, calling from abroad.
Mr Holloway’s brother was particularly disappointed that it seemed as if Mr Holloway’s care was not joined up between the different agencies .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of suicidality from BCAP-accredited psychotherapy training
Wider context from the report “2. The psychotherapist said that she had never before had a client who was suicidal. She said that this is not taught at university, though she had completed a post graduate course in working with suicidal ideation.
Can it be right that suicidality is completely omitted from BCAP accredited psychotherapy training ?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a minimum standard for psychotherapy consultation note keeping
Wider context from the report “1. Mr Holloway’s BCAP accredited psychotherapist did not make any notes of her consultations with him, because he had asked her not to. She gave evidence that she is not bound by law or ethics to keep any notes.
Is it appropriate that there is no minimum standard of note keeping following psychotherapy consultations ?
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to teach police contact in psychotherapy planning for missing or suicidal clients
Wider context from the report “3. When Mr Holloway’s friend contacted the psychotherapist to say that he was missing, knowing that he had neither attended nor cancelled their last consultation the psychotherapist was very concerned for his safety. She instructed the friend to go round to his home, but it did not occur to her to call the police.
The friend did this, but can it be right that contacting the police in such a situation is not taught as part of psychotherapy planning ?
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing processes require enquiries about support networks and promptly sending mental health assessment summaries to service users’ GPs.
Verbatim wording from the response “The Trust entirely recognises the importance of communication between its services and service users’ professional and personal support networks to support joined up care and manage risks. Service users are vital partners in their own care. However, with the exception of key support networks (such as those offered by a service user’s GP or next of kin), and although we enquire, the Trust relies on service users to expressly alert it to the involvement of any other networks. In accordance with our standard process when anyone is brought to A&E and a mental health assessment is carried out, a summary was promptly sent to Mr Holloway’s GP.” Source location Response from North London NHS
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot involve other relevant parties without the service user’s consent and relies on the service user identifying those parties.
Verbatim wording from the response “The Trust was not aware that Mr Holloway had sought the support of a private therapist and was only made aware of this involvement during the inquest hearing. It appears that the therapist’s involvement postdates the Trust’s assessment of Mr Holloway at A&E. The Trust always seeks to involve all relevant parties in a patient’s care. However, this only possible with their consent and, although we enquire, the Trust is reliant on service users making it aware of who the relevant parties are. It is therefore difficult to see what the Trust could have done differently in this case. Notwithstanding this, the Trust will continue to reflect on this incident, which it will share through its various governance forums as part of its commitment to learning and improvement.” Source location Response from North London NHS
Open published response
20 Feb 2025 Hayley Joanne BEAVINGTON · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Failure to provide instructions for challenging an inappropriate crisis-house placement decision View source Failure to account for identified suicide and cuckooing risks in crisis-house placement decisions View source Delays in reattempting crisis-house placement after a disputed refusal View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hayley Joanne BEAVINGTON · 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
Slightly before 1am on 21 September 2024, Hayley Joanne Beavington jumped from the fifth-floor balcony of her home and died by suicide after being discharged from hospital the previous day. The substantive concerns relate to the failure to secure a place for her at a local crisis house despite concerns about cuckooing and a view that she was definitely at risk of suicide, and the lack of instructions to challenge that decision.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide instructions for challenging an inappropriate crisis-house placement decision
Wider context from the report “When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house.
Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because:
- Ms Beavington had secure accommodation; and
- she was no longer actively suicidal.
This was despite the fact that:
- there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and
- the team view was that she was definitely at risk of suicide.
The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instructions as to how to challenge the decision that the consultant believed was wrong.
Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made.
Ms Beavington was discharged home and killed herself at 1am the next morning.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for identified suicide and cuckooing risks in crisis-house placement decisions
Wider context from the report “When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house.
Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because:
- Ms Beavington had secure accommodation; and
- she was no longer actively suicidal.
This was despite the fact that:
- there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and
- the team view was that she was definitely at risk of suicide.
The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instructions as to how to challenge the decision that the consultant believed was wrong.
Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made.
Ms Beavington was discharged home and killed herself at 1am the next morning.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reattempting crisis-house placement after a disputed refusal
Wider context from the report “When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house.
Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because:
- Ms Beavington had secure accommodation; and
- she was no longer actively suicidal.
This was despite the fact that:
- there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and
- the team view was that she was definitely at risk of suicide.
The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instructions as to how to challenge the decision that the consultant believed was wrong.
Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made.
Ms Beavington was discharged home and killed herself at 1am the next morning.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require senior clinical review, an alternative plan, documented accountability and formal escalation before finalising any declined crisis house referral.
Verbatim wording from the response “• All declined referrals must now be escalated for senior clinical review before a final decision is made; this will ensure that no referral is left without further review and will seek to reduce the risk of missed opportunities for intervention.” Source location Response from North London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require referring teams to agree alternative plans and Tactical On-Call staff to maintain risk-management arrangements when crisis houses are closed.
Verbatim wording from the response “• The pathway has been reviewed to make it clear that in the event of a referral being declined it is the responsibility of the referring team to review and agree an alternative plan.” Source location Response from North London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require senior clinicians to review risk assessments at key points and schedule follow-up reviews within agreed timeframes.
Verbatim wording from the response “• Senior clinicians are now required to review risk assessments at key points to reduce the chance of missed warning signs.” Source location Response from North London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinicians with 24/7 Crisis Hub access to senior clinical advice for urgent escalation and referral guidance.
Verbatim wording from the response “• The Crisis Hub Health Professional Line now provides 24/7 access for clinicians needing urgent escalation or referral guidance. This guarantees that immediate support is available, reducing the risk of delays.” Source location Response from North London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record declined referrals, referral outcomes, escalation calls, risk reassessments, follow-up reviews and capacitous admission refusals in required systems and documentation.
Verbatim wording from the response “• All declined referrals must now be clearly recorded on RiO to ensure that decisions are transparent, and risks are reassessed at every stage.” Source location Response from North London NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The referring team is responsible for reviewing declined referrals and agreeing an alternative plan.
Verbatim wording from the response “• The pathway has been reviewed to make it clear that in the event of a referral being declined it is the responsibility of the referring team to review and agree an alternative plan.” Source location Response from North London NHS Foundation Trust
Open published response
Concerns raised 1 Failure of mental health in-reach staff to follow guidance when deciding whether prisoners require suicide watch or ACCT View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
George Kyriacos Petrou · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George Kyriacos Petrou was found deceased in his cell at HMP Pentonville on 1 March 2021 after partially suspending himself by ligature in the bathroom of his cell. The report raised concerns that some mental health in-reach staff placed significant weight on prisoners declining suicide watch or ACCT measures, contrary to guidance, policy and procedures, and that insufficient reassurance was provided that this had been addressed.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health in-reach staff to follow guidance when deciding whether prisoners require suicide watch or ACCT
Wider context from the report “1) Evidence from members of staff at the Trust, working in the prison at that time, gave the distinct impression that there were a number of members of the mental health in-reach team that placed significant weight on a prisoner telling them that they did not want to be placed on any form of suicide watch and/or ACCT . This was contrary to the guidance, policy and procedures in place . While not being placed on an ACCT was not a causative factor in Mr Petrou’s case, it nonetheless raises a risk of death in the future . In my view, witnesses from the Trust provided insufficient reassurance that this matter has been addressed .
” Open source report
Concerns raised 1 Excessively long waiting lists for first appointments at Gender Dysphoria clinics View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leia Dorothy Pandora Sampson-Grimbly · 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
Leia Dorothy Pandora Sampson-Grimbly, aged 17, jumped from London Bridge into the Thames on 6 November 2024 and died in hospital later that day despite treatment. The report describes her being without preventative treatment amid lengthy waiting lists for a Gender Dysphoria clinic, alongside low mood, gender dysphoria, hostility from some sections of the community and social media links inciting suicide. The principal concern identified was that waiting lists were too long for a first appointment at a Gender Dysphoria clinic.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Excessively long waiting lists for first appointments at Gender Dysphoria clinics
Wider context from the report “Waiting lists are far too long for first appointment at a Gender Dysphoria clinic.
” 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 Work with NHS England and other providers to develop ways to reduce GIC waiting lists and support patients while waiting.
Verbatim wording from the response “England and other providers to develop innovative ways of reducing the waiting list and providing support to patients while on the waiting list.” Source location Response from Tavistock and Portman NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England, as commissioner of specialised gender dysphoria services, is responsible for commissioning sufficient service capacity.
Verbatim wording from the response “The waiting times for such GIC assessments is currently around 2.5 years, which is broadly in keeping with the national picture, though there is some variation in waiting times. NHS England (NHSE) is the direct commissioner of specialised services for individuals with a diagnosis of gender dysphoria. Prior to 2019/20, seven specialist centres were commissioned in England, based in or near Newcastle, Leeds, Sheffield, Northampton, Nottingham, London and Exeter.” Source location Response from Tavistock and Portman NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Insufficient specialist clinical staff and increasing demand have prevented NHS England from commissioning enough capacity to meet waiting-time expectations.
Verbatim wording from the response “The consultant-led services provided by the GDCs when adult patients are referred to them are amongst those intended to commence within 18 weeks of referral. Unfortunately, NHSE has been unable to commission sufficient capacity to meet that expectation because of the lack of specialist clinical staff (recruitment and retention) – against a backdrop of significant increasing demand, reflecting an international trend. Unfortunately, waiting times for a first appointment at a GDC remain very high. The Trust will continue to engage with its commissioners, NHS England, to develop provisions to reduce waiting times where possible.” Source location Response from Tavistock and Portman NHS Foundation Trust
Open published response
Concerns raised 4 Insufficient staff awareness of the importance of exploring suicide risk View source Failure to ask patients whether they feel suicidal during psychiatric consultations View source Lack of engagement with families in care View source Failure of initial management reviews to identify omitted suicide-risk questioning View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Emanuel Kolade LADAPO · 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
Emanuel Kolade Ladapo had paranoid schizophrenia and depression and was receiving treatment from Camden & Islington services. He died by suicide, with the medical cause recorded as asphyxiation via a plastic bag and inhalation of nitrogen gas. Concerns included a lack of engagement with his sister, and failures to ask about suicidal feelings when he had deteriorated and remained depressed, including a failure of the initial management review to identify the omission.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff awareness of the importance of exploring suicide risk
Wider context from the report “2. Mr Ladapo was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal.
This was the error of an individual, but it too is an omission that I have observed and written to C&I about before. Furthermore, the initial management review did not identify the omission.
I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I 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 London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients whether they feel suicidal during psychiatric consultations
Wider context from the report “2. Mr Ladapo was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal .
This was the error of an individual, but it too is an omission that I have observed and written to C&I about before . Furthermore, the initial management review did not identify the omission.
I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I 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 London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of engagement with families in care
Wider context from the report “1. Mr Ladapo lived with his sister, who wanted very much to be involved with his care. However, I did not hear any evidence of engagement with her by C&I , either:
- generally, during his time with the early intervention service or the rehabilitation & recovery team; or
- when in April 2022 he was found to have ordered a bolt gun on the internet that was only intercepted because it was discovered by the delivery driver; or
- on transfer from the early intervention service to the rehabilitation & recovery team in June 2022.
Lack of engagement with families is a story that I have heard often in inquests , and was the subject of prevention of future deaths reports that I sent to you on:
- 04.03.21 regarding Grażyna Walczak; and
- 17.03.21 regarding Ben O’Hara;
and to your predecessor on:
- 11.01.16 regarding Efstratios Voukelatos; and
- 29.04.15 regarding Finnula Martin.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of initial management reviews to identify omitted suicide-risk questioning
Wider context from the report “2. Mr Ladapo was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal.
This was the error of an individual, but it too is an omission that I have observed and written to C&I about before. Furthermore, the initial management review did not identify the omission .
I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I staff.
” Open source report
Concerns raised 2 Lack of routine cross-referencing between prescribed and collected medication View source Failure to update prescribing GPs about medication non-adherence and stockpiling risks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mohammed Zeeshan Akram (Zee) · 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
Mohammed Zeeshan Akram, known as Zee, had a history of suicidal ideation and a psychotic disorder. He died at Whittington Hospital on 21 March 2023 after being found unresponsive at his flat. The principal concern was that GPs were not routinely informed when patients stopped taking prescribed medication, including where suicidal ideation or a risk of stockpiling might be present.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of routine cross-referencing between prescribed and collected medication
Wider context from the report “I heard evidence that there was no routine mechanism to cross reference what people are prescribed and what medication they are actually collecting , and no automatic notification to GPs who are responsible for the medication prescribing. Zee informed BEH that he had not taken his olanzapine and fluoxetine for two weeks. His GP, who was prescribing that medication, was not informed.
I am concerned that GPs are not updated, particularly where patients have expressed suicidal ideation, and may not be aware that people are not taking medication and/or that there may be a risk of stockpiling.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update prescribing GPs about medication non-adherence and stockpiling risks
Wider context from the report “I heard evidence that there was no routine mechanism to cross reference what people are prescribed and what medication they are actually collecting, and no automatic notification to GPs who are responsible for the medication prescribing . Zee informed BEH that he had not taken his olanzapine and fluoxetine for two weeks. His GP, who was prescribing that medication, was not informed.
I am concerned that GPs are not updated, particularly where patients have expressed suicidal ideation , and may not be aware that people are not taking medication and/or that there may be a risk of stockpiling .
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing medication-review procedures and subsequent GP notification were considered sufficient; no additional GP communication was expected before the review.
Verbatim wording from the response “This medication review by the prescribing clinician will automatically lead to the GP being notified when there are any changes to the client’s prescription or treatment plan, including whether the client has stopped taking the medication and any steps the service is taking to provide additional support. The expected standard is the GP would receive this correspondence via email within 48 hours of the medical review. In cases where a rapid medical review is arranged, the service will usually wait until the review before updating the GP, to ensure the GP is provided with the most up to date treatment plan.” Source location Response from Barnet Enfield and Haringey Mental Health NHS Trust
Open published response
Concerns raised 2 Lack of robust protocols for patients who deteriorate during staff leave without initially requiring handover care View source Lack of robust protocols when both key points of contact are on leave simultaneously View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Claire Elizabeth HOMER · 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
Claire Elizabeth Homer, aged 46, was found dead at home on 5 May 2023. The cause of death was unascertained. Concerns were raised about a delayed response to a GP’s email regarding Claire’s worsening condition and whether more robust protocols were needed when staff or key contacts are on leave.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust protocols for patients who deteriorate during staff leave without initially requiring handover care
Wider context from the report “On the 27 April 2023 Claire’s GP, ████████, wrote an email to ████████ sharing concerns around her worsening, querying the CDAT referral and suggesting family involvement in the formulation of a management plan.
Unfortunately there was no reply to this email until 5th May 2023, by which time it was too late. I do not criticise ████████ for this, as she was on holiday and thereafter catching up with what was no doubt an avalanche of emails. This does raise the question, however, of whether more robust protocols need to be in place to address the scenarios of (a) patients who are not initially deemed to require handover care but deteriorate during a member of staff’s leave and (b) both key points of contact being on leave at the same time.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust protocols when both key points of contact are on leave simultaneously
Wider context from the report “On the 27 April 2023 Claire’s GP, ████████, wrote an email to ████████ sharing concerns around her worsening, querying the CDAT referral and suggesting family involvement in the formulation of a management plan.
Unfortunately there was no reply to this email until 5th May 2023, by which time it was too late. I do not criticise ████████ for this, as she was on holiday and thereafter catching up with what was no doubt an avalanche of emails. This does raise the question, however, of whether more robust protocols need to be in place to address the scenarios of (a) patients who are not initially deemed to require handover care but deteriorate during a member of staff’s leave and (b) both key points of contact being on leave at the same time.
” Open source report
Concerns raised 11 Lack of mental health care for patients on waiting lists View source Lack of a single, named point of contact available to patients when needed View source Failure of assessment protocols to require consideration of dissociation and psychosis risks and effects View source Failure to provide initial and annual training for staff caring for trans persons View source Lack of quality assurance scrutiny of staff training delivery and implementation View source Failure to set and implement criteria for treatment prioritisation View source Failure to direct patients to specialist carers View source Failure of assessment protocols to require consideration of previous diagnoses, treatment and available care information View source Failure of liaison among clinicians involved in patient care and treatment View source Lack of a helpline available to patients when needed View source Failure of assessment protocols to require obtaining and considering the views of people close to patients View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Monitor training through monthly management meetings, clinical supervision, case discussions, electronic-record compliance checks and annual appraisals.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source
Action
Deliver training on working with trans people and gender-affirming care to Personality Disorder Service staff.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source
Action
Seek internal and external records of previous engagements and treatments, and incorporate relevant information from service users and permitted supporters into assessment and treatment planning.
Stated plannedThe respondent said that this action was planned when they made their response on 10 March 2023. View source
Action
Require clinicians to invite family members, carers, supporters and advocates to assessments and record their contact details and involvement in Rio.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source
Action
Require initial assessments to examine previous diagnoses and treatments in consultation with the service user.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source
Action
Provide every service user with a named point of contact from referral and identify that person in the referral acknowledgement letter.
Stated plannedThe respondent said that this action was planned when they made their response on 10 March 2023. View source
Action
Deliver scheduled diversity identity training covering diverse identity, micro-affirmation, transgender documentation and inequalities, with attendance follow-up.
Stated plannedThe respondent said that this action was planned when they made their response on 10 March 2023. View source
Action
Require assessment of dissociation and psychosis, including consideration of self-harm and suicidality risks.
Stated completedThe respondent said that this action was complete when they made their response on 10 March 2023. View source
Action
Discuss with commissioners whether a national protocol can support patients moving between clinics before their first appointment.
Stated plannedThe respondent said that this action was planned when they made their response on 10 March 2023. View source See 6 more actions
×
AI-generated summary
Sophie Gwen Williams · 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
Sophie Gwen Williams died at home in the early hours of 20 May 2021 after taking a fatal overdose of prescription medications while in a psychotic or dissociative state. The report identifies concerns about the lack of assessment and management of her overdose and self-harm risk, continuity of care and crisis support, staff training and gender-affirming care, and coordination between mental health and gender-identity services.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health care for patients on waiting lists
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a single, named point of contact available to patients when needed
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient ;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of assessment protocols to require consideration of dissociation and psychosis risks and effects
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide initial and annual training for staff caring for trans persons
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of quality assurance scrutiny of staff training delivery and implementation
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance .
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to set and implement criteria for treatment prioritisation
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to direct patients to specialist carers
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of assessment protocols to require consideration of previous diagnoses, treatment and available care information
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of liaison among clinicians involved in patient care and treatment
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a helpline available to patients when needed
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of assessment protocols to require obtaining and considering the views of people close to patients
Wider context from the report “for trans persons on a Personality Disorder Pathway, arise out of the lack of provision of the following:
(A) by local NHS Trusts:
(1) The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient;
(2) The training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:
(a) the needs of trans persons
(b) gender-affirming care
(c) dissociation and psychosis
(3) Scrutiny of the delivery and implementation of such training, by way of quality assurance.
(4) The absence from the assessment protocol of a provision to ensure that the full account is taken of:
(a) any previous diagnosis and treatment
(b) all other information (including information from those who have previously provided care and treatment to the patient) available to members of the team
(c) the risks to (and effects on) patients with (or likely to develop) conditions of dissociation and/or psychosis including, in particular, the risks of self-harm and loss of life
(d) the views of those who are close to the patient, including the patient’s carers, family and advocates (both formal and informal), who should be contacted, for that purpose
(B) By clinics providing gender-identity treatment (and in relation to both current and prospective patients):
(1) a help-line, available when needed by patients
(2) the direction of patients to specialist carers
(3) provision of mental health care for those patients on waiting-lists
(4) liaison (at both local and national levels) among all clinicians concerned (or expected to be concerned) in the care and treatment of such patients
(5) the setting and implementation (where practicable) of criteria for deciding whether (and, if so, which) patients (other than those terminally ill) should be given priority for receiving treatment
” 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 Monitor training through monthly management meetings, clinical supervision, case discussions, electronic-record compliance checks and annual appraisals.
Verbatim wording from the response “3. Scrutiny of the delivery and implementation of such training, by way of Quality Assurance” Source location Response from Barnet, Enfield and Haringey Mental Health Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver training on working with trans people and gender-affirming care to Personality Disorder Service staff.
Verbatim wording from the response “2. the training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:” Source location Response from Barnet, Enfield and Haringey Mental Health 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 Seek internal and external records of previous engagements and treatments, and incorporate relevant information from service users and permitted supporters into assessment and treatment planning.
Verbatim wording from the response “b. all other information (including information from those who have previously provided care and treatment to the patient) available to the member of the team” Source location Response from Barnet, Enfield and Haringey Mental Health 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 Require clinicians to invite family members, carers, supporters and advocates to assessments and record their contact details and involvement in Rio.
Verbatim wording from the response “d. the views of those who are close to the patient, including the patient’s carers, family, and advocates (both formal and informal), who should be contacted, for that purpose.” Source location Response from Barnet, Enfield and Haringey Mental Health 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 Require initial assessments to examine previous diagnoses and treatments in consultation with the service user.
Verbatim wording from the response “4. The absence from the assessment protocol of a provision to ensure that a full account is taken of:” Source location Response from Barnet, Enfield and Haringey Mental Health Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide every service user with a named point of contact from referral and identify that person in the referral acknowledgement letter.
Verbatim wording from the response “1. The assignment of a single, named point of contact, available (aside from holiday and sickness absence) when needed by the patient.” Source location Response from Barnet, Enfield and Haringey Mental Health Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver scheduled diversity identity training covering diverse identity, micro-affirmation, transgender documentation and inequalities, with attendance follow-up.
Verbatim wording from the response “2. the training of staff assigned to provide care and treatment to such persons, both at the time of their appointment, and annually thereafter, with a focus on:” Source location Response from Barnet, Enfield and Haringey Mental Health 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 Require assessment of dissociation and psychosis, including consideration of self-harm and suicidality risks.
Verbatim wording from the response “c. the risks to (and effects on) patients with (or likely to develop) conditions of dissociation” Source location Response from Barnet, Enfield and Haringey Mental Health 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 Discuss with commissioners whether a national protocol can support patients moving between clinics before their first appointment.
Verbatim wording from the response “Regarding the setting and implementation of criteria for prioritising patients for treatment, it is deeply regrettable that Ms. Williams could not maintain her existing place on the waiting list following a previous referral to a different GIC (as she had not yet been reviewed at the first clinic to which she was referred). Any change in this approach would have to be agreed nationally, not unilaterally by the GIC, to ensure equity and consistency for service users. The Trust will also discuss this arrangement with its commissioners in order to see if there is any scope for a different, national protocol for those patients moving between clinics before they have had their first appointment.” Source location Response from The Tavistock and Portman NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental healthcare for GIC patients is provided through GPs or secondary mental health services, with information sharing as needed.
Verbatim wording from the response “Addressing the specific concerns at 5B of your Report, the condition the GIC is commissioned to treat is Gender Incongruence, coded HA60 in the International Classification of Diseases version 11; this is ‘a condition related to sexual health’ and not a mental health diagnosis. Accordingly, the provision of mental health care for those both on the waiting list, and those who are actively being treated by the GIC, continues to be dealt with either through their GP or secondary mental health services, as was the case for Ms. Williams. The GIC works closely with colleagues from primary care or secondary mental health services, including sharing information to facilitate patient care as required.” Source location Response from The Tavistock and Portman NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Any change to waiting-list prioritisation for patients moving between clinics must be agreed nationally rather than by the GIC alone.
Verbatim wording from the response “Regarding the setting and implementation of criteria for prioritising patients for treatment, it is deeply regrettable that Ms. Williams could not maintain her existing place on the waiting list following a previous referral to a different GIC (as she had not yet been reviewed at the first clinic to which she was referred). Any change in this approach would have to be agreed nationally, not unilaterally by the GIC, to ensure equity and consistency for service users. The Trust will also discuss this arrangement with its commissioners in order to see if there is any scope for a different, national protocol for those patients moving between clinics before they have had their first appointment.” Source location Response from The Tavistock and Portman NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot provide services for patients waiting for GIC assessment because those services are not currently commissioned.
Verbatim wording from the response “The service specification states that “Gender Dysphoria Clinics assess and diagnose individuals; directly provide some interventions and arrange referrals to other services, including for medical and surgical treatments.” The Trust is inevitably restricted to providing” Source location Response from The Tavistock and Portman NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England commissioners must decide whether waiting-list services should be commissioned and funded.
Verbatim wording from the response “The Trust however is keen to engage in a dialogue with its commissioners, NHS England, to discuss the provisions proposed in your Report and whether these services should be commissioned and funded in the future, and thus able to be provided by the Trust or other providers.” Source location Response from The Tavistock and Portman NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GIC treats gender incongruence, which is not classified as a mental health diagnosis.
Verbatim wording from the response “Addressing the specific concerns at 5B of your Report, the condition the GIC is commissioned to treat is Gender Incongruence, coded HA60 in the International Classification of Diseases version 11; this is ‘a condition related to sexual health’ and not a mental health diagnosis. Accordingly, the provision of mental health care for those both on the waiting list, and those who are actively being treated by the GIC, continues to be dealt with either through their GP or secondary mental health services, as was the case for Ms. Williams. The GIC works closely with colleagues from primary care or secondary mental health services, including sharing information to facilitate patient care as required.” Source location Response from The Tavistock and Portman NHS Foundation Trust
Open published response
Concerns raised 3 Failure to identify patients requiring service review for multidisciplinary discussion and follow-up View source Failure to produce clear and sufficient clinical notes View source Failure to implement steps to prevent recurrence of documentation and follow-up errors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Demet AKCICEK · 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
Demet Akcicek was found dead in bed beside her sleeping seven-year-old son on the morning of 27 May 2022. The inquest determined that she died after taking an excess of prescribed and online-obtained medication, and that she did not intend to take her life. Concerns included a failure by a mental health service worker to arrange follow-up after a welfare call, and an insufficiently clear record of that call.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify patients requiring service review for multidisciplinary discussion and follow-up
Wider context from the report “When the duty worker from Islington complex depression, anxiety and trauma (CDAT) service rang Ms Akcicek for a welfare check on 25 November 2021, Ms Akcicek reported feeling “quite bad” and that she wanted to cry. She explained that she had difficulty performing everyday activities such as cooking and taking her child to school. She said that two nights earlier, her son reported that she had woken chanting, “I don’t want to die, I don’t want to die”.
The duty worker (a registered mental health nurse) formed the view that Ms Akcicek needed to be seen by the service, but failed to put her name on the board, and so she was not discussed at the multi disciplinary team meeting and no follow up was arranged . In addition, the duty worker accepted in court that her note of the conversation was insufficient. I found the note difficult to understand and the duty worker was not able fully to explain its meaning.
The duty worker told me that she will not make such mistakes again. However, I did not hear evidence of what steps, if any, Camden & Islington Trust has taken to avoid such a situation arising in future.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce clear and sufficient clinical notes
Wider context from the report “When the duty worker from Islington complex depression, anxiety and trauma (CDAT) service rang Ms Akcicek for a welfare check on 25 November 2021, Ms Akcicek reported feeling “quite bad” and that she wanted to cry. She explained that she had difficulty performing everyday activities such as cooking and taking her child to school. She said that two nights earlier, her son reported that she had woken chanting, “I don’t want to die, I don’t want to die”.
The duty worker (a registered mental health nurse) formed the view that Ms Akcicek needed to be seen by the service, but failed to put her name on the board, and so she was not discussed at the multi disciplinary team meeting and no follow up was arranged. In addition, the duty worker accepted in court that her note of the conversation was insufficient . I found the note difficult to understand and the duty worker was not able fully to explain its meaning .
The duty worker told me that she will not make such mistakes again. However, I did not hear evidence of what steps, if any, Camden & Islington Trust has taken to avoid such a situation arising in future.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement steps to prevent recurrence of documentation and follow-up errors
Wider context from the report “When the duty worker from Islington complex depression, anxiety and trauma (CDAT) service rang Ms Akcicek for a welfare check on 25 November 2021, Ms Akcicek reported feeling “quite bad” and that she wanted to cry. She explained that she had difficulty performing everyday activities such as cooking and taking her child to school. She said that two nights earlier, her son reported that she had woken chanting, “I don’t want to die, I don’t want to die”.
The duty worker (a registered mental health nurse) formed the view that Ms Akcicek needed to be seen by the service, but failed to put her name on the board, and so she was not discussed at the multi disciplinary team meeting and no follow up was arranged. In addition, the duty worker accepted in court that her note of the conversation was insufficient. I found the note difficult to understand and the duty worker was not able fully to explain its meaning.
The duty worker told me that she will not make such mistakes again. However, I did not hear evidence of what steps, if any, Camden & Islington Trust has taken to avoid such a situation arising in future .
” 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 Include the new duty-tracking process in induction for new CDAT staff.
Verbatim wording from the response “This new process has been discussed at the team business meeting and was officially started on 24th October. It will be reviewed in 6 weeks’ time and monitored going forward through audit and governance processes, to ensure that it is embedded in the team’s usual business practice and is working effectively. It will be included in the induction of new staff who join the team.” Source location Response from Camden and Islington NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff of clinical record-keeping requirements and monitor compliance through supervision and record-keeping audits.
Verbatim wording from the response “In regard to record keeping, the team has been reminded that in accordance with both Trust policy and professional obligations, clinical records should be full, accurate and entered in a timely manner. This will continue to be monitored through individual staff supervision and record keeping audits.” Source location Response from Camden and Islington NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and monitor the new duty-tracking process through scheduled review, audit and governance processes to ensure effective embedding.
Verbatim wording from the response “This new process has been discussed at the team business meeting and was officially started on 24th October. It will be reviewed in 6 weeks’ time and monitored going forward through audit and governance processes, to ensure that it is embedded in the team’s usual business practice and is working effectively. It will be included in the induction of new staff who join the team.” Source location Response from Camden and Islington NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the updated CDAT operational policy and daily duty tracker, with same-day logging and senior daily cross-checks for follow-up.
Verbatim wording from the response “Firstly I would like to offer sincere apologies to Ms Akcicek’s family on behalf of both the CDAT team and the Trust for this error which led to her not being followed up by the team. In order to address this and prevent it happening again, the team manager and service manager have updated the CDAT Operational Policy and have implemented a daily duty sheet/tracker. All matters dealt with on duty are logged immediately on this sheet which are then cross checked at 4.30pm daily by the senior on duty to handover and ensure appropriate follow up for all issues logged. A copy of the amended Operational policy incorporating this new process is enclosed with this response.” Source location Response from Camden and Islington NHS Foundation Trust
Open published response
Concerns raised 2 Lack of a process to triage referral acuity and expedite clinical assessments where necessary View source Delays in arranging clinical assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Stuart Tokam · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Stuart Tokam, who had a documented history of depressive illness and two previous attempts to take his own life, died after hanging himself from railings at Dalaman Airport, Turkey, on 18 September 2020. Concerns included an unacceptable delay in arranging a clinical assessment and the apparent absence of a process to triage referral acuity and expedite assessment where necessary.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a process to triage referral acuity and expedite clinical assessments where necessary
Wider context from the report “2. There appears to have been no process in place to triage the acuity of a referral and expedite a clinical assessment where necessary .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging clinical assessments
Wider context from the report “1. There was an unacceptable delay in arranging a clinical assessment of Mr Tokam.
” Open source report
Concerns raised 6 Failure to maintain accurate records of clinical observations View source Tolerance of inaccurate and misleading clinical record keeping View source Failure of searches to detect and remove dangerous contraband View source Failure to undertake required intermittent observations View source Failure to complete relevant documentation after rapid tranquillisation View source Failure to monitor patients following rapid tranquillisation View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rohan Dayal Singh · 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
Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate records of clinical observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable , staff accepted that they had failed to undertake observations and made false records , further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Tolerance of inaccurate and misleading clinical record keeping
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of searches to detect and remove dangerous contraband
Wider context from the report “1. Rohan Singh died on a mental health ward, following his death he was found to be in possession of number of prohibited items including controlled drugs and a bracelet consisting of a ligature and a blade. Before admission into hospital, Rohan had been subject to a personal search by police officers when the bracelet was seized. During Rohan’s admission his property was subjected to a search and later he himself was searched for contraband, despite these steps he retained dangerous contraband.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake required intermittent observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete relevant documentation after rapid tranquillisation
Wider context from the report “3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation . The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients following rapid tranquillisation
Wider context from the report “3. Mr Singh was subject to rapid tranquillisation, following administration of this medication, staff failed to follow the Trust’s monitoring process or complete relevant documentation. The failure to monitor Rohan was found by the jury to have contributed to his death. Trust evidence demonstrates that beyond this incident, throughout the organisation the processes are not being universally followed.
” Open source report
Concerns raised 5 Failure to review medical-record alerts View source Lack of a care co-ordinator or community mental health team member in overall charge of care View source Failure to undertake a formal mental health assessment View source Failure to ask patients for permission to contact family members View source Failure to communicate that a review was not a formal mental health assessment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin Rajinder O’HARA · 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
Benjamin Rajinder O’Hara died after jumping from the fourth floor balcony of his home on 2 November 2020, following repeated contacts with mental health services and episodes of suicidal thoughts and psychosis. Concerns included that professionals did not ask permission to contact his family, an outdated hospital-admission alert was not reviewed, a review was not a formal mental health assessment, and he had no care co-ordinator or other community mental health team member overseeing his care.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review medical-record alerts
Wider context from the report “2. There was an alert on Mr O’Hara’s medical record, saying that admission to hospital was unhelpful to him. However, this had been placed on the record 18 months before his death and had not been reviewed since . If it had been brought up to date, it could have affected the decision not to detain him on 3 October.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a care co-ordinator or community mental health team member in overall charge of care
Wider context from the report “4. Mr O’Hara did not have a care co-ordinator or other member of the community mental health team in overall charge of his care . This person would have been in a position to note his deterioration and the increasing frequency of his contacts with the mental health services in 2020.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a formal mental health assessment
Wider context from the report “3. The review undertaken on 3 October was with a s12 approved doctor and an approved mental health professional, but was not a formal mental health assessment . If the crisis team had been aware of this, they might have sought a formal mental health assessment when Mr O’Hara disengaged from their care on 4 October.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ask patients for permission to contact family members
Wider context from the report “1. None of the healthcare professionals who assessed or treated Mr O’Hara in the period leading up to his death asked if he would give permission for his family to be contacted . If she had been told of his deterioration, his mother would have returned from abroad and stayed with him.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate that a review was not a formal mental health assessment
Wider context from the report “3. The review undertaken on 3 October was with a s12 approved doctor and an approved mental health professional, but was not a formal mental health assessment. If the crisis team had been aware of this , they might have sought a formal mental health assessment when Mr O’Hara disengaged from their care on 4 October.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review carers policy, benchmark family-engagement standards, and agree an action plan with training.
Verbatim wording from the response “The Trust recognises the vital role that carers have in supporting their loved ones/our service users and is committed to working in partnership with carers. In order to address these issues around contact with next of kin in this case, the report has recommended that the Crisis Teams review carers policy and benchmark quality standards for carer/family/sibling engagement against the national Triangle of Care self-assessment. An action plan, including a training package, will be agreed following this self-assessment. This should be completed by August 2021.” Source location 2021-0077-Response-from-St-Pancras-Hospital-Redacted
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 communication between crisis and other Trust teams by requiring further discussion of concerning decisions.
Verbatim wording from the response “Despite ICRT feeling like the option of MHAA was closed to them, they did not explore this further with the duty team who advised on these matters. The report has made a recommendation to improve communication between the crisis teams and other teams in the Trust, so that in future the crisis team ensure they discuss further any decisions by other teams which are of concern to them. Progress against this action will be reviewed in August 2021.” Source location 2021-0077-Response-from-St-Pancras-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind acute-division teams through business meetings about the importance of family engagement.
Verbatim wording from the response “In addition, all teams within the acute division of Trust services have been reminded at team business meetings of the importance of family engagement.” Source location 2021-0077-Response-from-St-Pancras-Hospital-Redacted
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 update the Carenotes alert process, including agreed wording protocols linked to risk-assessment and suicide-prevention processes.
Verbatim wording from the response “Alerts should be reviewed regularly to ensure the information remains relevant. If the information in the alert suggests contacting a secondary care team, the secondary care team should review the alert accordingly on discharge to incorporate this change. In this instance the alert was not reviewed on discharge. Alerts should also provide important information and should refrain from being opinion orientated. On interview, numerous staff assessing Mr. O’Hara indicated that the alert on Carenotes influenced their review.” Source location 2021-0077-Response-from-St-Pancras-Hospital-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust states that the clerical error would have had limited impact on the decision made during the assessment.
Verbatim wording from the response “By holding interviews with clinicians, the investigation found that this would have limited impact on the decision made on the day of the assessment. If the section 12 approved doctor or duty AMHP had further concerns and felt admission was necessary, they could have completed a first recommendation and requested a second opinion doctor. However, it does appear that it impacted Islington crisis team (ICRT) views on their available courses of action. ICRT were under the impression that a formal Mental Health Act Assessment (MHAA) had been completed, and when Mr. O’Hara disengaged from ICRT almost immediately after being discharged, they felt they had no grounds to request another MHAA as nothing had changed in his presentation, and therefore opted for discharge.” Source location 2021-0077-Response-from-St-Pancras-Hospital-Redacted
Open published response
Concerns raised 2 Failure to complete investigation reports within 72 hours of death View source Failure to routinely ask patients whether their families may be involved in their care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Grazyna WALCZAK · 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
Grazyna Walczak died after jumping three storeys from her flat on 25 or 26 September 2020 while suffering an acute depressive illness. Before her death, she was assessed as being at low to moderate risk, but was not asked whether her family could be notified. The report also raised concern that a required 72-hour investigation report was completed about five months after her death.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete investigation reports within 72 hours of death
Wider context from the report “2. The 72 hour investigation report that should be produced within 72 hours of death , to enable fast learning that may be of immediate benefit to other patients, was not completed until last week, some five months after Ms Walczak’s death .
That is obviously not acceptable and could put others at risk by a potential failure to learn.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely ask patients whether their families may be involved in their care
Wider context from the report “1. Ms Walczak was seen by a psychological wellbeing practitioner from the Camden and Islington iCope service two or three days before her death. She was assessed as being at low to moderate risk to herself.
However, she was not asked if she would agree to her family being notified of the situation and of her current mental ill health . Her son would dearly like to have been told what was happening and would have acted accordingly.
I heard evidence that iCope does not routinely ask their patients if families may be involved . This seems to be a policy worthy of reconsideration.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement 72-hour reporting through the Datix patient-safety incident reporting system.
Verbatim wording from the response “The following key recommendations were made and are being implemented” Source location 2021-0063-Response-from-St-Pancras-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare and deliver training for divisional staff on the Datix 72-hour reporting process.
Verbatim wording from the response “The following key recommendations were made and are being implemented” Source location 2021-0063-Response-from-St-Pancras-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop 72-hour reporting process maps for users to improve compliance and reporting quality.
Verbatim wording from the response “The following key recommendations were made and are being implemented” Source location 2021-0063-Response-from-St-Pancras-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Trust-wide 72-hour reporting process and analyse report timeliness to identify improvements.
Verbatim wording from the response “This Trust has undertaken a review of the timeliness of 72-hour reporting to ensure adherence to meeting the requirements of the National SI Framework and to implement improvements in light of the prevention of future deaths report. This will ensure more timely reporting and organisational learning takes place.” Source location 2021-0063-Response-from-St-Pancras-Hospital-Redacted
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 Evaluate the new 72-hour reporting process and the effectiveness of its training, reporting progress to the Quality and Safety Programme Board.
Verbatim wording from the response “6. To evaluate the training package with the divisions after 3 months.” Source location 2021-0063-Response-from-St-Pancras-Hospital-Redacted
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 72-hour report submission process using quality-improvement methods, with progress monitored through existing executive and quality-safety governance arrangements.
Verbatim wording from the response “The following key recommendations were made and are being implemented” Source location 2021-0063-Response-from-St-Pancras-Hospital-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Next-of-kin information will not be mandatory because patient confidentiality must be protected and access to the service should remain unrestricted.
Verbatim wording from the response “The iCope service has reviewed the policy on contact with clients’ families in light of the PFD report. Up to now the service has not routinely collected information on ‘Next of Kin’ and would contact the person’s GP if that information was needed. iCope does, however, quite often involve relatives or partners in aspects of treatment if appropriate and with the consent of the patient. The service takes the confidentiality of its patients very seriously, so would not want to make it mandatory for people to give NOK information in order to access the service.” Source location 2021-0063-Response-from-St-Pancras-Hospital-Redacted
Open published response
Concerns raised 6 Lack of support or education for families and carers managing emotionally unstable personality disorder View source Failure to make arrangements to address risks when closing crisis team referrals View source Lack of a process for families to escalate concerns to prevent delivery of hazardous packages View source Failure to inform families about the facility for reopening crisis team support View source Delays of 14 days in securing mental health act assessments View source Failure to act on an inpatient admission plan following identification of acute suicide risk View source See 3 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
Thiago Araujo · 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
Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.
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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 London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of support or education for families and carers managing emotionally unstable personality disorder
Wider context from the report “3. Family and carers of patients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diagnosis from Camden and Islington NHS Trust, unless the patient has been received for treatment by the personality disorder service .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make arrangements to address risks when closing crisis team referrals
Wider context from the report “1. On 24 January 2020 Mr Araujo had discharged himself from psychiatric inpatient care he was to be supervised by the Camden and Islington NHS trust crisis team. Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo’s referral . In the course of this closure no arrangements were made to address the risks presented by Mr Araujo .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for families to escalate concerns to prevent delivery of hazardous packages
Wider context from the report “6. In the days leading to Mr Araujo’s death his family became aware that he had made an online purchase of ████████ which was to be delivered to his father’s home address. Despite raising these issues with Camden and Islington NHS trust, the Metropolitan police and employees of the post office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform families about the facility for reopening crisis team support
Wider context from the report “2. Following Mr Araujo’s death it has become clear that the closure of his case by the crisis team was not permanent, and had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support . Mr Araujo’s family were unaware of this facility .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays of 14 days in securing mental health act assessments
Wider context from the report “5. In evidence the community recovery team indicated that a factor in their inaction was the knowledge that arranging a section 135 mental health act 1983 warrant assessment would take two weeks . Such an assessment requires actions by an approved mental health practitioner from the local authority, two section 12 mental health act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant. A delay of 14 days in securing a mental health act assessment is in my opinion unacceptable .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on an inpatient admission plan following identification of acute suicide risk
Wider context from the report “4. By 4 February 2020 the Camden and Islington community recovery team identified an acute risk of suicide in Mr Araujo, faced with his non-compliance with community treatment they considered an admission into inpatient care . No actions were taken to affect this plan .
” 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 Conduct six-monthly community-team audits of carer assessments, support plans, information, and psychoeducation, with plans to address identified gaps.
Verbatim wording from the response “The Trust recognised that a key theme in the report was that carers had lost confidence in the teams working with the deceased and did not feel that their views were taken on board. As a result of this feedback the Trust has revised the action plan with an additional recommendation relevant to carers involvement. To provide assurance that this is consistently happening, the strengthened action plan includes a requirement for community teams to carry out 6 monthly audits, checking that carers are routinely offered an assessment and support plan, and that information, support and psychoeducation are available. Plans will be developed to address any gaps identified as a result of these audits which are now underway within the teams.” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 Remind crisis team staff to provide self-referral information and relevant contact details on discharge.
Verbatim wording from the response “On discharge it is the crisis team’s standard practice to advise service users that they may re-refer themselves, or be re-referred, should the need arise. We can only sincerely apologise to Mr Araujo’s family if this was not made clear to them in this case. All crisis team staff have been reminded of the need to ensure that this information plus relevant contact details is passed on. This is also covered by the recommendation at point 1, where the updating of crisis and contingency plans is required.” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 Circulate staff guidance on responding to potentially dangerous packages and access to means of self-harm.
Verbatim wording from the response “It was apparent from the evidence given at the inquest that at the time of this incident Trust staff were unsure how to respond to this situation and what actions if any were available to them. The Trust has since sought advice from its legal team and guidance to staff on this issue, as well as reiteration of previous advice around access to means to self-harm generally, has been circulated across the organisation.” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 Require senior multidisciplinary review, documented communication, and updated crisis and contingency plans before closing non-engagement referrals.
Verbatim wording from the response “Additional Recommendation: Any service user of the Crisis Team who is being considered for discharge because of non-engagement must be discussed in the Crisis Service Multi-Disciplinary Meeting with senior overview of the decision to discharge. The decision and rationale to discharge because of non-engagement must be clearly communicated to the” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 Obtain legal advice on responding to potentially dangerous packages and access to means of self-harm.
Verbatim wording from the response “It was apparent from the evidence given at the inquest that at the time of this incident Trust staff were unsure how to respond to this situation and what actions if any were available to them. The Trust has since sought advice from its legal team and guidance to staff on this issue, as well as reiteration of previous advice around access to means to self-harm generally, has been circulated across the organisation.” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 Monitor community Mental Health Act assessment waiting times through the Mental Health Law Committee under the CQC action plan.
Verbatim wording from the response “The average wait for a community assessment at the moment is around 14 days. In February 2020 when the incident took place the average wait time was closer to 18 days, so we are seeing some improvement but acknowledge further is required. This issue is part of our CQC action plan and ongoing monitoring is in place as part of this via our Mental Health Law Committee.” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 Liaise with local-authority partners to address delays in community Mental Health Act assessments.
Verbatim wording from the response “The AMHP service, which coordinates and carries out assessments under the Mental Health Act, is a local authority service, although physically based on Trust premises. The Trust has liaised with our local authority partners in regard to this important issue and we can report as follows:” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 Mental Health Act assessments are coordinated and carried out by the Local Authority’s AMHP service, not the Trust.
Verbatim wording from the response “The AMHP service, which coordinates and carries out assessments under the Mental Health Act, is a local authority service, although physically based on Trust premises. The Trust has liaised with our local authority partners in regard to this important issue and we can report as follows:” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 When the Personality Disorder Service is not involved, carers are directed to Local Authority services for assessment and support.
Verbatim wording from the response “The Trust has a duty to assess carers need for support as part of its responsibilities under the Section 75 Agreement with the Local Authority. When the Personality Disorder Service identify a carer who may be in need of support, either at the point of referral, assessment or during the treatment of a patient, a Carers Assessment at the service is offered. A Carers Lead is employed to fulfil this role. When the Personality Disorder Service is not directly involved carers are directed to Local Authority services - Support for carers | Camden & Islington Carers Hub | Supporting unpaid carers in Islington. Carers assessments are also carried out by other community teams within the Trust, including the community rehab team, who can support carers to access appropriate support.” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
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 Royal Mail and police are the bodies to report potentially dangerous packages to for possible interception or other action.
Verbatim wording from the response “The legal advice we have received is that the Royal Mail do potentially have powers to intercept and destroy packages containing items which are either prohibited or restricted from being sent in the mail. Therefore, as part of the response to concerns of this nature, teams should consider reporting any concerns about potentially dangerous packages to the Royal Mail (via the local sorting office) and also to the police and must ensure that discussions and actions taken are documented in the clinical records.” Source location 2021-0132-Response-from-St-Pancras-Hospital-Redacted.pdf
Open published response
Concerns raised 8 Lack of a practical ward plan for taking escalation action with available resources View source Lack of clarity between the MPS and trusts about required information and ensuing police action View source Lack of ward staff understanding of actions required to prompt police progression View source Lack of ward staff understanding of key information required by the MPS View source Failure to promptly and fully utilise patients’ friends in missing-person searches View source Lack of ward staff understanding of MPS actions in response to absent-without-leave reports View source Failure to account for different organisational definitions of the same terms View source Failure to provide MPS decision makers with all information held by the MPS View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Nimo Younis · 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
Nimo Younis was detained in a psychiatric intensive care unit and was granted unescorted leave on 24 January 2019, but did not return. She was found at a friend's home the following day after hanging herself. The concerns included shortcomings in communication and understanding between ward staff and the police, the escalation and handling of the missing-person enquiry, the information provided to police decision-makers, and the use of the patient's friends in searching for her.
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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 London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a practical ward plan for taking escalation action with available resources
Wider context from the report “3. C&I ward staff did not have a practical plan as to how to take that action with the resources at their disposal .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity between the MPS and trusts about required information and ensuing police action
Wider context from the report “7. Whether or not there is agreement between the MPS and any trust about who should be doing what, there must be a clarity about what information the MPS needs in order to make the best decisions and what action the MPS will then take .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward staff understanding of actions required to prompt police progression
Wider context from the report “2. C&I ward staff did not have a proper understanding of what action the MPS required others to take in order to prompt the police to progress the matter further .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward staff understanding of key information required by the MPS
Wider context from the report “4. C&I ward staff did not have a proper understanding of what key information they needed to provide the MPS in order to trigger a police missing person enquiry, or to escalate an existing enquiry.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly and fully utilise patients’ friends in missing-person searches
Wider context from the report “5. C&I ward staff did not promptly or fully utilise the significant potential of their patient’s friends , who were ultimately the route by which Nimo Younis was found, and who would certainly have acted sooner if they had appreciated the lack of action being taken - whatever the reason for that lack of action.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ward staff understanding of MPS actions in response to absent-without-leave reports
Wider context from the report “1. C&I ward staff did not have a proper understanding of what action the MPS would take in what circumstances , following the report of a patient absent without leave.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to account for different organisational definitions of the same terms
Wider context from the report “This needs to include a recognition that different organisations may have different definitions of the same terms .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide MPS decision makers with all information held by the MPS
Wider context from the report “6. The MPS decision makers, particularly the night time duty inspector, did not have all the information that the MPS held when they were making decisions . Evidence was given that this was a resourcing issue on that particular night and of course it is difficult to legislate for that, but creative thinking may be utilised to address such an issue.
” Open source report
Concerns raised 2 Delays in interviewing witnesses to progress disciplinary hearings View source Failure to enforce staff reassignment following recognition of a patient fixation 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
Agnes Stephanie LAMBERT · 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
Agnes Stephanie Lambert was a mental health nurse who died after an investigation into allegations concerning her contact with a patient who was fixated on her. The inquest determined that her death was suicide, with the medical cause recorded as suspension by ligature. Concerns included the failure to move her to another ward despite recognising the patient’s fixation, and an allegedly unacceptable delay in progressing the disciplinary investigation.
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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 London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in interviewing witnesses to progress disciplinary hearings
Wider context from the report “2. Following the allegations, it then took the trust four months (rather than the expected four weeks) to interview eight witnesses in order to progress to a disciplinary hearing . This was a distressing time for Ms Lambert and she finally went on sick leave.
The service manager who gave evidence in court agreed that this was an unacceptable delay .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enforce staff reassignment following recognition of a patient fixation
Wider context from the report “1. Two weeks before the allegations were made and the investigation began (i.e. two weeks before the occasion of Nurse Lambert entering the patient’s room), the patient in question argued with another patient whom he thought was stealing his fiancée. He and Nurse Lambert were not engaged. They were not in a romantic relationship.
The more senior member of staff who dealt with the matter, recognised the patient’s fixation and thought that Agnes Lambert should move to work on another ward. However, when Nurse Lambert declined because she did not regard the matter as serious, the manager, who had seniority and more experience, did not insist .
The service manager who gave evidence in court accepted that the move should have been made regardless of the staff nurse’s wishes . If it had been, Nurse Lambert would not have been in a position to enter the patient’s room at night without later.
” 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 the disciplinary policy to clarify which matters warrant full investigation and complete the refreshed policy.
Verbatim wording from the response “We absolutely recognise that unnecessary and lengthy disciplinary processes can have a serious detrimental impact on staff mental health and wellbeing. With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the” Source location 2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require a specially trained lay staff member to review disciplinary cases and provide assurance or challenge whether a formal hearing is required.
Verbatim wording from the response “We absolutely recognise that unnecessary and lengthy disciplinary processes can have a serious detrimental impact on staff mental health and wellbeing. With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the” Source location 2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add the risks of unnecessary and lengthy disciplinary processes to the HR and OD department risk register and monitor progress.
Verbatim wording from the response “The risks posed by unnecessary and lengthy disciplinary processes have been added to the HR & OD department risk register to monitor and ensure progress is made.” Source location 2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out Vital Conversations training for line managers as a professional requirement, initially prioritising nursing managers.
Verbatim wording from the response “To support this, we are in the process of rolling out ‘vital conversations’ training which will form part of the professional requirements for all line managers in the Trust, though nursing managers will initially be prioritised.” Source location 2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen ward management and supervision by appointing a permanent ward manager.
Verbatim wording from the response “Firstly, it is recognised that at the time that these events began, the ward where Ms Lambert worked did not have a permanent ward manager in post and the overall management and supervision structure on the ward was not as robust as it should have been. Significant steps have since been taken to address this and there is now a permanent ward manager. Further, we have recognised that there is a general need among managers for further support around how to have challenging conversations with staff, particularly in situations such as this, where the intention is not to punish the staff member, but to ensure their safety, whilst making it clear that staff are expected to follow reasonable management instructions.” Source location 2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen formal disciplinary investigations by emphasising managers’ responsibility to minimise delays and monitoring occupational health and Employee Assist referrals.
Verbatim wording from the response “Vital Conversations training, will facilitate more issues being resolved informally through the supervision process. For those investigations that do proceed formally, there will be a greater focus on managers’ responsibility to minimise delay/keep to timeframes, and monitoring to ensure that managers have offered/referred staff to occupational health for support and also made them aware of our Employee Assist Programme. The refreshed policy is expected to complete in March 2019.” Source location 2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Open published response
Concerns raised 7 Failure to review relevant historical mental health records View source Failure to distinguish denial of a suicide plan from refusal to answer View source Disjointed coordination of care between crisis house and crisis team services View source Unavailability of mental health records to crisis house staff View source Risk assessment plans failing to be enforceable in an open crisis facility View source Insufficient detail in written risk assessments provided to the crisis house View source Failure to arrange crisis team follow-up meetings View source See 4 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
Siân Louise WITHERIDGE · 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
Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review relevant historical mental health records
Wider context from the report “3. The crisis team staff (as opposed to the crisis house staff) did have access to Ms Witheridge’s mental health records, but they did not read them any further back than the first call to crisis house during that last episode, i.e. 25 May 2017, despite her very extensive past medical history .
There seemed a lack of recognition of the importance of the notes, particularly the older notes .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish denial of a suicide plan from refusal to answer
Wider context from the report “5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan .
False reassurance appeared to have been drawn from the latter . No arrangement was made for the crisis team to meet Ms Witheridge on 30 May.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Disjointed coordination of care between crisis house and crisis team services
Wider context from the report “6. The care offered to service users of Highbury Grove Crisis House and the Islington Crisis Team seemed disjointed and not dovetailed between OneHousing and Camden & Islington NHS Trust .
For example, the crisis team members who gave evidence did not have any knowledge of the crisis house procedure for risk assessing before allowing leave .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health records to crisis house staff
Wider context from the report “1. While Ms Witheridge was staying in Crisis House, her mental health records were not available to the OneHousing staff there .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk assessment plans failing to be enforceable in an open crisis facility
Wider context from the report “4. One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms Witheridge took any leave.
However, this was an unenforceable plan, because Highbury Grove is an open facility .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in written risk assessments provided to the crisis house
Wider context from the report “2. I was told that the written risk assessment provided to Highbury Grove Crisis House was not as detailed as it should have been .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange crisis team follow-up meetings
Wider context from the report “5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.
False reassurance appeared to have been drawn from the latter. No arrangement was made for the crisis team to meet Ms Witheridge on 30 May .
” 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 Reinforce detailed feedback to OneHousing staff and agreement of a written action plan when crisis team staff complete risk assessments.
Verbatim wording from the response “We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&I staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&I staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient.” Source location 2017-0305-Response
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 Check clinical-history review practice during regular staff supervision.
Verbatim wording from the response “The Assistant Practitioner acknowledged at the inquest that she should have read further back in the clinical records than she did. To ensure that the learning from this case is embedded within the teams, the operational manager and team manager of the crisis team have reinforced the importance of undertaking a comprehensive review of the clinical records, including reading the risk assessment, before seeing a patient. The practice of reading the history will be checked in regular supervisions.” Source location 2017-0305-Response
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 Reinforce comprehensive clinical-record review, including the risk assessment, before staff see patients.
Verbatim wording from the response “The Assistant Practitioner acknowledged at the inquest that she should have read further back in the clinical records than she did. To ensure that the learning from this case is embedded within the teams, the operational manager and team manager of the crisis team have reinforced the importance of undertaking a comprehensive review of the clinical records, including reading the risk assessment, before seeing a patient. The practice of reading the history will be checked in regular supervisions.” Source location 2017-0305-Response
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 Work with OneHousing to establish shared access to clinical records and risk assessments for Highbury Grove staff.
Verbatim wording from the response “We agree that Highbury Grove Crisis House staff should have access to our clinical records. To this end, we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.” Source location 2017-0305-Response
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 Introduce joint risk assessments completed by OneHousing and Camden and Islington staff.
Verbatim wording from the response “We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&I staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&I staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient.” Source location 2017-0305-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the risk assessment to ensure it contains comprehensive risk history, previous suicide attempts and current risk factors.
Verbatim wording from the response “We have reviewed our risk assessment and I have enclosed a copy for your information. We are satisfied that it contains a comprehensive risk history and that it includes sufficient detail about previous suicide attempts and risk factors.” Source location 2017-0305-Response
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 Information-sharing problems have been rectified through ready access to relevant clinical information and established communication channels.
Verbatim wording from the response “We are aware that Highbury Grove has sent you our ‘Working Protocol’ setting out how our teams work together. As set out earlier, we accept that there have been challenges with information sharing. We are confident however that this has been rectified and Highbury Grove and staff will in the future have ready access to all the relevant clinical information.” Source location 2017-0305-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The reviewed risk assessment contains sufficient detail about previous suicide attempts and current risk factors.
Verbatim wording from the response “We have reviewed our risk assessment and I have enclosed a copy for your information. We are satisfied that it contains a comprehensive risk history and that it includes sufficient detail about previous suicide attempts and risk factors.” Source location 2017-0305-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The nurse’s plan to check the patient’s mental state before leave was not inappropriate because staff could take emergency action if necessary.
Verbatim wording from the response “The nurse in question was unable to attend the inquest to explain his plan. However, he was certainly aware that Highbury Grove is an open facility and that Ms Witheridge could not have forcibly been prevented from leaving the premises. The nurse’s intention in asking Highbury Grove staff to check in with Ms Witheridge before she took any leave was for them to obtain an impression of her mental state and to make an assessment as to whether she was safe to leave. If staff considered that Ms Witheridge was at immediate risk of self-harm before leaving the premises then immediate action could have been taken such as trying to persuade Ms Witheridge to stay or calling emergency services. As such, whilst staff were aware that Ms Witheridge could not be detained at Highbury Grove, he was ensuring that an additional check was undertaken before she left the premises.” Source location 2017-0305-Response
Open published response
Concerns raised 6 Failure to reconcile and challenge contradictory suicide-risk information View source Failure to recognise impaired insight in the context of recurrent unexplained physical symptoms View source Failure to tailor discharge support to the patient’s reported lack of benefit from crisis-team care View source Failure to provide timely and appropriately urgent access to a mental health bed View source Failure to complete and communicate general-practitioner referrals View source Failure to obtain team consultation before mental health discharge clearance View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jonathan Anthony MEANEY · 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
Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reconcile and challenge contradictory suicide-risk information
Wider context from the report “2. When the mental nurse assessed Mr Meaney before discharge on Wednesday, 15 March, he did not question Mr Meaney’s assertion that he had not intended to take an overdose two days before . This was despite the fact that Mr Meaney had told the assessing doctor that he had been trying to kill himself and he had written notes of intent .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise impaired insight in the context of recurrent unexplained physical symptoms
Wider context from the report “3. The mental health nurse assessed Mr Meaney as rational and having good insight , despite the fact that Mr Meaney once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found . In court, the mental health nurse told me that he knew that Mr Meaney’s illness was mental rather than physical.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to tailor discharge support to the patient’s reported lack of benefit from crisis-team care
Wider context from the report “5. The mental health nurse who saw Mr Meaney decided to refer Mr Meaney to his general practitioner for counselling, though Mr Meaney had already said that he had not found the crisis team helpful . Then having made that decision, I heard that there was no evidence that the mental health nurse did go on to make the referral. He told me that all he would do in such a situation would be to send the GP a discharge summary, never with a short accompanying note of request.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and appropriately urgent access to a mental health bed
Wider context from the report “1. Mr Meaney waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home.
A mental health nurse from the C&I psychiatry liaison team called the bed manager on the morning of Tuesday, 14 March, and then saw Mr Meaney briefly to explain that no bed was available . The same nurse called the bed manager again the following morning, Wednesday, 15 March, and then saw Mr Meaney once again with no news about admission. It was at that point that Mr Meaney expressed a wish to leave.
There seemed no urgency about the need for a bed for such a seriously ill man.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and communicate general-practitioner referrals
Wider context from the report “5. The mental health nurse who saw Mr Meaney decided to refer Mr Meaney to his general practitioner for counselling, though Mr Meaney had already said that he had not found the crisis team helpful. Then having made that decision, I heard that there was no evidence that the mental health nurse did go on to make the referral . He told me that all he would do in such a situation would be to send the GP a discharge summary, never with a short accompanying note of request .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain team consultation before mental health discharge clearance
Wider context from the report “4. The mental health nurse did not consult any other member of the team before clearing Mr Meaney as fit for discharge from a mental health point of view . (The assessing doctor gave evidence that, if Mr Meaney had not agreed to admission to hospital when she saw him, she would have sought an assessment under the Mental Health Act with a view to detaining Mr Meaney for treatment.)
” 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 Complete a serious incident review examining the sequence of events and contributory factors in the case.
Verbatim wording from the response “We are undertaking a serious incident review of this case. Part of its scope is to undertake an in-depth analysis to ascertain in further detail exactly what steps were taken as Trust to secure Mr Meaney a bed. We will forward you our serious incident review on its completion. We are aiming to complete our review in November.” Source location 2017-0244-Response2
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 Write GPs an accompanying note identifying any specific action required of them when the mental health liaison team sends a referral or discharge summary.
Verbatim wording from the response “Going forwards, if there is any specific action that we need a GP to carry out, the mental health liaison team will now write an accompanying note to alert the GP to the specific action and what they are required to do.” Source location 2017-0244-Response2
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require agency or bank staff changing another clinician’s decision to de-escalate an outcome to obtain senior agreement and record it in the patient’s notes.
Verbatim wording from the response “- Any decision taken by agency or bank staff to change the original decision made by another full time clinician whereby they are de-escalating the outcome, must be discussed and agreed with a senior member of the team and this must be clearly recorded in the patients notes;” Source location 2017-0244-Response2
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bed allocation urgency was assessed against clinical risk and safety, with priority given to patients not in places of safety.
Verbatim wording from the response “The allocation of a bed is a centralised task, undertaken by the bed management team, managed by Camden and Islington NHS Foundation Trust. The bed management team received the referral from psychiatric liaison psychiatry, requesting a psychiatric bed for Mr Meaney at 04.46am on 14 March. Patients are prioritised according to both their clinical need, and the assessment of risk, for example, whether the patient is in a safe place. Patients who are not in places of safety i.e. at home or in police custody would take priority for acute beds. The referrals list is something that can change rapidly depending on the priority of the new referrals and whether the risk of an existing referral has changed. Senior staff meet daily to review all pending referrals and to estimate when a bed will become available.” Source location 2017-0244-Response2
Open published response
Concerns raised 2 Inadequate clinical decision-making for granting leave to detained patients at risk of absconding View source Failure to ensure that all relevant personnel are aware of the patient’s mental health observation level View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dominic Michael WHITE · 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
Dominic White, who had bipolar affective disorder and psychosis, rapidly deteriorated over several days and was assessed as requiring detention under section 2 of the Mental Health Act. Before he could be conveyed to a mental health hospital, he left the emergency unit and was found the following day at an electricity substation with injuries consistent with a fall from height. The concerns included whether mental health observation levels were communicated effectively and the clinical decision-making involved in allowing him to leave after detention had been decided.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical decision-making for granting leave to detained patients at risk of absconding
Wider context from the report “2. The C&I approved mental health professional (AMHP) who gave Mr White permission to leave the hospital to go to McDonald’s, after the decision had been made to detain him under section 2 of the Mental Health Act, acknowledged that she should have discussed this first with a colleague.
However, she remained of the view at inquest that the decision itself had been the right one. Proof of this, she explained, was the fact that Mr White did return to the hospital from this visit.
Allowing leave in these circumstances was a very unusual step I am concerned at the lack of recognition, even so long after the event, that allowing a person to leave the hospital in these circumstances:
- was not necessarily the right one simply because the patient returned on this occasion (he left again within half an hour and never returned); and
- had the potential to lull others into a false sense of security about his risk of absconding .
The trust’s root cause analysis action plan merely describes the need to have legally authorised permission to leave, without addressing any question of how to shape clinical decision making .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all relevant personnel are aware of the patient’s mental health observation level
Wider context from the report “1. I heard that, following Mr White’s death, the level of (mental health) observations of a patient at the Whittington Hospital Emergency Unit is now clearly documented.
However, I am not sure that there is yet a robust protocol in place to ensure that all relevant personnel (Whittington EU doctors, nurses and security officers; also visiting independent s12 doctors, BEH and C&I staff) are aware of the level .
My concern arises because sometimes, when anyone can look at a record, that nobody actually does .
” 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 Conduct five daily senior-staff situation reports and follow-up reviews covering mental health patients’ risks, observation compliance, care quality and confirmed plans.
Verbatim wording from the response “8. To ensure that the level of observations is being complied with and that the clinical decision making regarding Mental Health patients is robust Senior Whittington ED staff members (nurse in charge, site team, ED registrar or consultant) conduct a situation report 5 times per day in which the status of the department including” Source location 2017-0177-Response-by-Whittington-Hospital-NHS2-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Display Emergency Department signage showing the observation process and responsible nursing and special-staff assignments.
Verbatim wording from the response “6. As part of improving communication between organisations signage has been introduced in Whittington ED, which is prominently placed around the nurses’ station, to ensure that visiting doctors and AMHPs are aware of this process and that the name of the patient’s allocated nurse and any 1:1 or ‘special’ staff member is visible outside the patient’s cubicle (see images).” Source location 2017-0177-Response-by-Whittington-Hospital-NHS2-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update mental health policies and the joint observation protocol to define roles, responsibilities and decision-making case studies.
Verbatim wording from the response “We set out below our agreed approach for ensuring that all relevant personnel are aware of a mental health patient’s level of observation. In order to address both concerns identified in the PFD, the Whittington and Camden & Islington have reviewed their mental health policies. These are being updated to ensure the roles and responsibilities are explicit and will also include case studies to assist in decision making. This will be included in Camden & Islington NHS Foundation Trust’s Mental Health Liaison Operational Policy and the Whittington Health NHS policy for mental health patients in the Emergency Department which is currently being updated.” Source location 2017-0177-Response-by-Whittington-Hospital-NHS2-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The London Borough of Islington is responsible for responding to concerns about Approved Mental Health Professional decision-making.
Verbatim wording from the response “The second matter concerns the decision making of the Approved Mental Health Professional. The AMHP is employed by the London Borough of Islington. When AMHPs are carrying out their duties, they act on behalf of the Local Authority. The London Borough of Islington will therefore provide you with a separate response to this issue.” Source location 2017-0177-Response-by-Whittington-Hospital-NHS2-Trust
Open published response
Concerns raised 2 Failure to consider specifically described risks during risk assessment View source Failure of investigations to reflect identified risk issues for further learning View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Demi Williams · 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
Demi Williams was detained under the Mental Health Act after developing psychotic symptoms and disclosed that she had purchased helium gas intending to kill herself. She was later found deceased in her flat from helium inhalation; the principal concerns were that her specific risk of access to helium was not assessed and that this issue was not reflected in the Trust’s investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider specifically described risks during risk assessment
Wider context from the report “(1) The method that Ms Williams later used to take her own life was specifically described to CANDI during the assessment process in January 2016. I am concerned that, although a general risk assessment was undertaken on several occasions, there was no consideration of the specific risk which Ms Williams had previously described .
Furthermore, I am concerned that, as it stands, the Trust’s own investigation does not reflect this issue and that the potential for further learning from Ms Williams’ death could be missed.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to reflect identified risk issues for further learning
Wider context from the report “(1) The method that Ms Williams later used to take her own life was specifically described to CANDI during the assessment process in January 2016. I am concerned that, although a general risk assessment was undertaken on several occasions, there was no consideration of the specific risk which Ms Williams had previously described.
Furthermore, I am concerned that, as it stands, the Trust’s own investigation does not reflect this issue and that the potential for further learning from Ms Williams’ death could be missed .
” Open source report
Concerns raised 2 Failure to route and return relatives’ calls View source Failure to routinely involve family members in patient care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily VOUKELATOU · 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
Emily Voukelatou left North Camden Crisis House after writing notes of intent, travelled to Beachy Head on 30 June 2016, and jumped from the cliff. Concerns included the lack of routine involvement of family members in care and Crisis House’s failure to return her sister’s repeated calls before and after her death.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to route and return relatives’ calls
Wider context from the report “2. Ms Voukelatou’s sister telephoned Crisis House several times, very worried, both before and after Ms Voukelatou’s death (not having been informed that her twin had died), but her calls were never returned . Apparently, these were not passed on to the right people , but witnesses in court were not aware of the detail of this.
Leaving relatives’ repeated calls unanswered cannot be right. It loses potentially valuable information, creates additional anxiety and is simply discourteous.
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely involve family members in patient care
Wider context from the report “1. I heard evidence from the consultant psychiatrist responsible for Ms Voukelatou’s care at Crisis House that it is not routine for the crisis team to involve family members in the care of a patient .
I wonder whether that is a policy that would benefit from reconsideration? Otherwise potentially helpful input may be lost.
One of the mental health nurses said that families are sometimes invited to meetings, but nobody thought about this for Ms Voukelatou . Her family live in Greece, but she was close to her mother and twin sister, and arrangements might have been made, perhaps for a telephone meeting.
” 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 Issue North Camden Crisis House staff guidance to provide families with clear contact details and direct access to a senior staff member.
Verbatim wording from the response “In light of the information set out above we have unfortunately been unable to get to the bottom of what happened when ████████ tried to contact the Crisis House, and why her calls were not connected. From our enquiries with the switchboard supervisor, and ████████ however, we are satisfied that switchboard staff have the correct number for the crisis house. Nevertheless, given the significance of this issue, we have issued staff at North Camden Crisis House with clear guidance to ensure that numbers and contact details are clearly provided to families participating in a service user’s care so they are able to speak directly to a senior staff member.” Source location 2017-0004-Response-by-Camden-and-Islington-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement updated mandatory risk-assessment training reinforcing the importance of working with families, with monthly delivery to clinical staff.
Verbatim wording from the response “We have also reinforced the importance of working with families in our updated, risk assessment training which has been rolled out over the last 12 months. I have enclosed our updated risk assessment training for your information. Our risk assessment training is mandatory for all clinical staff. Our updated training has been implemented throughout the last year. It is run on a monthly basis, in partnership with Middlesex University. To date nearly 500 members of staff have been trained.” Source location 2017-0004-Response-by-Camden-and-Islington-NHS-Trust
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 Routine family-involvement assessment, patient consent considerations and mandatory training are considered sufficient without reconsidering the policy.
Verbatim wording from the response “You heard evidence from the consultant psychiatrist responsible for Ms Voukelatou’s care that it is not routine practice for the crisis team to involve family members in a patient’s care. You have asked whether this policy would benefit from reconsideration to ensure that potentially helpful input from family members is not lost. You have also questioned whether arrangements might have been made for a telephone meeting with Ms Voukelatou’s family in Greece.” Source location 2017-0004-Response-by-Camden-and-Islington-NHS-Trust
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 Existing switchboard arrangements are considered sufficient because staff have the correct Crisis House number and can transfer calls or provide direct contact details.
Verbatim wording from the response “████████, Head of Facilities, has confirmed that switchboard staff have the number for all crisis houses, including North Camden Crisis House, and that staff would transfer an individual’s call to the crisis house, and also give them the direct” Source location 2017-0004-Response-by-Camden-and-Islington-NHS-Trust
Open published response
Concerns raised 5 Failure to convey the need for urgent police intervention in a welfare-check request View source Delays in arranging immediate mental health assessment View source Failure to administer prescribed medication View source Failure to plan action if a mental health assessment is interrupted by a patient leaving View source Failure to seek urgent hospital security assistance when detention under the Mental Health Act is considered necessary View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Arrange for liaison-team prescribers to receive honorary contracts enabling them to prescribe medication in the emergency department.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 November 2015. View source
Action
Adapt regular audit to check whether prescribed medication has been administered.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2015. View source
Action
Strengthen the direct mental-health referral protocol, including patient-triggered referrals and a disseminated frontline flowchart.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2015. View source
Action
Strengthen handover between emergency-department and liaison teams to explicitly check prescribed, refused, outstanding and administered medications.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2015. View source
Action
Refresh and embed the emergency-department medication protocol defining prescriber and nursing responsibilities for checking and administering prescriptions.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2015. View source
Action
Prepare a joint emergency-department framework and reference document covering risk assessment, capacity, security, observation, documentation and inter-service communication when patients leave.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 November 2015. View source
Action
Adapt regular audit to check whether prescribed medication has been administered.
Stated plannedThe respondent said that this action was planned when they made their response on 12 November 2015. View source
Action
Refresh and embed the emergency-department medication protocol requiring prescribers to notify nurses and nurses to check prescribed medicines.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2015. View source
Action
Strengthen handover between emergency-department and mental-health liaison teams by explicitly checking medication status and recording findings in patient records.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2015. View source
Action
Prepare a joint emergency-department framework and reference document covering risk, capacity, security, observation, documentation and inter-service communication when patients may leave.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 November 2015. View source
Action
Arrange honorary contracts enabling mental-health liaison prescribers to prescribe medication in the emergency department.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 November 2015. View source
Action
Strengthen the direct mental-health referral protocol so patients can promptly trigger referral from emergency-department triage, supported by a disseminated frontline flowchart.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2015. View source See 9 more actions
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AI-generated summary
Matthew Marc GROOM · 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
Matthew Marc Groom stood in front of a lorry after spending seven hours in the emergency unit of Whittington Hospital, where he was seen by emergency medicine and mental health staff. Concerns included delays in his mental health assessment, prescribed diazepam not being administered, inadequate planning for his possible departure, failure to seek urgent hospital security assistance, and incomplete communication with police.
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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convey the need for urgent police intervention in a welfare-check request
Wider context from the report “5. The nurse who then contacted the police did not then convey this to them , but requested a welfare check that would be satisfied by knowing he was with a family member .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging immediate mental health assessment
Wider context from the report “1. Most importantly, Matt Groom waited four hours in the emergency unit before he saw a mental healthcare professional for the first time . I heard that, at the time in these circumstances, it was not possible for a triage nurse to arrange for immediate mental health 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 London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed medication
Wider context from the report “2. Diazepam was prescribed but never administered .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to plan action if a mental health assessment is interrupted by a patient leaving
Wider context from the report “3. The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave , most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist .
” 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 NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek urgent hospital security assistance when detention under the Mental Health Act is considered necessary
Wider context from the report “4. When Matt did leave the department, the assessing doctor asked the nurse to call the police, but neither doctor nor nurse considered seeking urgent assistance from hospital security , given that they were by now both of the view that he would probably now have to be detained under section of the Mental Health Act .
” 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 Arrange for liaison-team prescribers to receive honorary contracts enabling them to prescribe medication in the emergency department.
Verbatim wording from the response “d) We are making arrangements to reduce the risk of psychiatric or anxiolytic medication being inadvertently omitted, we are making arrangements to ensure that Camden and Islington Mental Health Liaison Team prescribers can prescribe in Whittington ED. The Camden and Islington liaison psychiatry consultant is providing the details of Mental Health Liaison Team prescribers who will then be issued with honorary Whittington contracts in order that they can then prescribe medication in Whittington ED.” Source location Matthew-Groom-Response
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 Adapt regular audit to check whether prescribed medication has been administered.
Verbatim wording from the response “b) This protocol will be monitored through regular audit, which has been adapted to incorporate checking for medication administration.” Source location Matthew-Groom-Response
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 Strengthen the direct mental-health referral protocol, including patient-triggered referrals and a disseminated frontline flowchart.
Verbatim wording from the response “a) We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr Groom’s death, but has since been significantly strengthened in that the patient themselves can now trigger a prompt and direct referral to the Mental Health Liaison Team simply by requesting this.” Source location Matthew-Groom-Response
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 Strengthen handover between emergency-department and liaison teams to explicitly check prescribed, refused, outstanding and administered medications.
Verbatim wording from the response “c) We have strengthened handover of patient information between Whittington ED and Camden and Islington Mental Health Liaison Team so that this now involves explicit checking between the teams as to whether:” Source location Matthew-Groom-Response
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 Refresh and embed the emergency-department medication protocol defining prescriber and nursing responsibilities for checking and administering prescriptions.
Verbatim wording from the response “a) We have refreshed and embedded a Whittington ED departmental protocol that clearly defines the responsibility of prescribers to inform the assigned nurse once a prescription has been issued. It also directs the nurses to regularly check patient’s drug charts to check for any medications prescribed. In circumstances such as Mr Groom’s, where the patient is not in a defined cubicle with an assigned nurse, prescribers should highlight the prescription to the nurse-in-charge of the area.” Source location Matthew-Groom-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 Prepare a joint emergency-department framework and reference document covering risk assessment, capacity, security, observation, documentation and inter-service communication when patients leave.
Verbatim wording from the response “Improvement in response to Concern
To improve the reliability of assessments made by the Whittington and Camden and Islington frontline staff to consider and plan what action to take should a patient suddenly decide to leave, both organisations are jointly preparing a joint framework and reference document that will be used in the ED to outline and further reinforce clear steps with regard to:” Source location Matthew-Groom-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 Adapt regular audit to check whether prescribed medication has been administered.
Verbatim wording from the response “b) This protocol will be monitored through regular audit, which has been adapted to incorporate checking for medication administration.” Source location 2015-0503-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 Refresh and embed the emergency-department medication protocol requiring prescribers to notify nurses and nurses to check prescribed medicines.
Verbatim wording from the response “a) We have refreshed and embedded a Whittington ED departmental protocol that clearly defines the responsibility of prescribers to inform the assigned nurse once a prescription has been issued. It also directs the nurses to regularly check patient’s drug charts for any medications prescribed. In circumstances such as Mr Groom’s, where the patient is not in a defined cubicle with an assigned nurse, prescribers should highlight the prescription to the nurse-in-charge of the area.” Source location 2015-0503-Response
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 Strengthen handover between emergency-department and mental-health liaison teams by explicitly checking medication status and recording findings in patient records.
Verbatim wording from the response “c) We have strengthened handover of patient information between Whittington ED and Camden and Islington Mental Health Liaison Team so that this now involves explicit checking between the teams as to whether:” Source location 2015-0503-Response
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 Prepare a joint emergency-department framework and reference document covering risk, capacity, security, observation, documentation and inter-service communication when patients may leave.
Verbatim wording from the response “Both Trusts have committed to improving staff awareness of their legal duties, what the options are associated with the various circumstances and clinical contingency planning in line with legal options. These are detailed under point 4.” Source location 2015-0503-Response
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 Arrange honorary contracts enabling mental-health liaison prescribers to prescribe medication in the emergency department.
Verbatim wording from the response “d) We are making arrangements to reduce the risk of psychiatric or anxiolytic medication being inadvertently omitted, we are making arrangements to ensure that Camden and Islington Mental Health Liaison Team prescribers can prescribe in Whittington ED. The Camden and Islington liaison psychiatry consultant is providing the details of Mental Health Liaison Team prescribers who will then be issued with honorary Whittington contracts in order that they can then prescribe medication in Whittington ED.” Source location 2015-0503-Response
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 Strengthen the direct mental-health referral protocol so patients can promptly trigger referral from emergency-department triage, supported by a disseminated frontline flowchart.
Verbatim wording from the response “a) We have strengthened the direct mental health referral protocol from Whittington Emergency (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr Groom’s death, but has since been significantly strengthened in that the patient themselves can now trigger a prompt and direct referral to the Mental Health Liaison Team simply by requesting this.” Source location 2015-0503-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 The patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.
Verbatim wording from the response “The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this the assessors have to consider the persons capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.” Source location Matthew-Groom-Response
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 Informal patients cannot lawfully be prevented from leaving without sufficient grounds for detention or proportionate physical intervention.
Verbatim wording from the response “Individuals who have attended the ED voluntarily are informal patients and are not subject to any form of legal detention such as the Mental Health Act. For informal patients staff may try and persuade patients not to leave, but cannot in any manner prevent them leaving. A general duty of care can be applied in circumstances where someone is actively violent or is actively trying to hurt themselves or others, and then a physical intervention can be applied by NHS staff. This was not the case for Mr Groom.” Source location Matthew-Groom-Response
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 Existing joint police protocols already govern communication about people who abscond or go missing, including conveying immediate-risk information.
Verbatim wording from the response “Improvement in response to concern
For the reasons described above (in response to concern 3) Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that indicated that he was at immediate risk of harm to himself or others to require that the police perform an active search for him. Had this been the case then the Trusts practice is to convey this information to the police. Camden & Islington NHS FT already has joint protocols with the Police, concerning people who have absconded and / or go missing.
As I understand it the police were alerted that if they were to see Mr Groom, they should consider bringing him back to hospital if the family members he left with were concerned. As we understand it, this would also normally entail the police’s consideration of the use of section 136 legislation if thought appropriate.” Source location 2015-0503-Response
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 Informal patients cannot lawfully be prevented from leaving unless applicable legal grounds for detention or physical intervention exist.
Verbatim wording from the response “Individuals who have attended the ED voluntarily are informal patients and are not subject to any form of legal detention such as the Mental Health Act. For informal patients staff may try and persuade patients not to leave, but cannot in any manner prevent them leaving. A general duty of care can be applied in circumstances where someone is actively violent or is actively trying to hurt themselves or others, and then a physical intervention can be applied by NHS staff. This was not the case for Mr Groom.” Source location 2015-0503-Response
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 The patient was not considered an immediate risk requiring detention, restraint, or an active police search.
Verbatim wording from the response “The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this assessment, staff have to consider the person’s capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.” Source location 2015-0503-Response
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Addressed to Barnet, Enfield and Haringey Mental Health NHS Trust, now represented here by North London NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations