Concerns raised 7 Lack of clinical direction in crisis care View source Lack of cohesion in crisis care View source Failure of communication within the crisis team and with crisis houses View source Failure to consider hospital admission for a patient presenting significant suicide risk View source Delays in progressing referrals to a crisis house View source Failure to record reasons when twice-daily crisis team visits are not attempted View source Failure to conduct twice-daily crisis team visits in accordance with the care plan View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Patrick DANIELS · 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
Mark Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.
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 clinical direction in crisis care
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction .
” 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 cohesion in crisis care
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” 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 communication within the crisis team and with crisis houses
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses ;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” 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 consider hospital admission for a patient presenting significant suicide risk
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house .
I gained the impression of a lack of cohesion and clinical direction.
” 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 progressing referrals to a crisis house
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly ;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” 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 record reasons when twice-daily crisis team visits are not attempted
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted ;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” 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 conduct twice-daily crisis team visits in accordance with the care plan
Wider context from the report “You will see from the determination attached, that I found there was a failure by the crisis team:
- to visit Mr Daniels twice a day, despite a plan so to do ;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.
I gained the impression of a lack of cohesion and clinical direction.
” 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 measures across all Crisis Teams and Crisis Houses to address the identified concerns.
Verbatim wording from the response “████████ Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them – the action plan is appended at the end of this letter. As you can see from the action plan updates, several” Source location 2015-0208-Response-by-Camden-and-Islington-NHS-Trust
Open published response
Concerns raised 2 Failure to make potentially important CANDI service information accessible to other services within the Trust View source Lack of an out-of-hours process for obtaining and transferring iCope notes to Rio View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keith Gallimore · 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
Keith Gallimore, who had discussed plans to commit suicide with a clinical psychologist, was found deceased at home on 4 December 2014. The medical cause of death was the combined toxic effects of heroin and cocaine, and suicidal or accidental intent could not be established to the required standard. Concern was raised that potentially important iCope information was not accessible to other services within the same Trust without a proactive request, including in out-of-hours settings.
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 make potentially important CANDI service information accessible to other services within the Trust
Wider context from the report “(1) I am concerned that potentially important information, documented by a service provided by CANDI, is not accessible by other services within the same Trust, without a proactive request being made . It was not clear why this restriction is in place, nor what steps could be taken if information were required in an ‘out-of-hours’ setting, at which time the iCope service would not be available to copy notes to Rio.
Although there was no evidence that, had the iCope notes been available to the Crisis Team, the outcome of Mr Gallimore's case would have been different, I am concerned that future deaths could result because of this issue.
” 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 an out-of-hours process for obtaining and transferring iCope notes to Rio
Wider context from the report “(1) I am concerned that potentially important information, documented by a service provided by CANDI, is not accessible by other services within the same Trust, without a proactive request being made. It was not clear why this restriction is in place, nor what steps could be taken if information were required in an ‘out-of-hours’ setting , at which time the iCope service would not be available to copy notes to Rio .
Although there was no evidence that, had the iCope notes been available to the Crisis Team, the outcome of Mr Gallimore's case would have been different, I am concerned that future deaths could result because of this issue.
” 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 Maintain a protocol for checking new referrals against IAPTUS and recording relevant current or recent ICope contacts on RiO.
Verbatim wording from the response “I agree that there is a gap in information sharing between ICope and rest of the Trust, this is because of the use of different electronic patient record systems. ICope is obliged to use electronic patient records system called IAPTUS because of national data reporting requirements, whilst all other services in the Trust use electronic patient records system called RIO. ICope has an established protocol for checking all new referrals against the RIO system and for making entries on RIO where patients have either current or recent contact with the service.” Source location 2015-0184-Response-by-Camden-and-Islington-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train designated acute-assessment staff across liaison, crisis-resolution and bed-management teams to check IAPTUS records and access clinical notes.
Verbatim wording from the response “One possible solution would be for all ICope staff to enter all their patient data on RIO as well as IAPTUS. Given the number of referrals to the service (some 17,000 in the last year) this is impractical and would mostly be of little benefit. Following discussion between leads in our Acute Division and ICope it was agreed that the most effective solution would be to provide IAPTUS training to a small number of front-line staff (who provide services 7 days a week/ 24 hours a day) in the Acute Division. This means that staff working in the acute assessment teams will be able to make routine checks on all new patients against the IAPTUS system and have immediate access to the full clinical notes. All IAPT staff are already trained on the use of RiO electronic system and have access to RiO.” Source location 2015-0184-Response-by-Camden-and-Islington-NHS-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 Entering all ICope patient data in both systems is impractical and would provide little benefit because of the service’s referral volume.
Verbatim wording from the response “One possible solution would be for all ICope staff to enter all their patient data on RIO as well as IAPTUS. Given the number of referrals to the service (some 17,000 in the last year) this is impractical and would mostly be of little benefit. Following discussion between leads in our Acute Division and ICope it was agreed that the most effective solution would be to provide IAPTUS training to a small number of front-line staff (who provide services 7 days a week/ 24 hours a day) in the Acute Division. This means that staff working in the acute assessment teams will be able to make routine checks on all new patients against the IAPTUS system and have immediate access to the full clinical notes. All IAPT staff are already trained on the use of RiO electronic system and have access to RiO.” Source location 2015-0184-Response-by-Camden-and-Islington-NHS-Trust
Open published response
Concerns raised 13 Failure to obtain the triage record before patient assessment View source Unavailability of triage records of patient attendance View source Failure to ask patients about thoughts of suicide View source Failure to establish the circumstances leading to police involvement and the identity of the caller View source Lack of clarity about protocols for receiving information from police officers accompanying voluntary patients View source Delays in passing family information to the psychiatry liaison team View source Confusion about voluntary attendance of patients with mental health needs accompanied by police View source Failure to record calls from family members to the emergency department View source Failure to characterise urgent police contact as an emergency after a patient leaves hospital View source Failure to obtain collateral history from family members before concluding the interview View source Confusion about voluntary attendance of patients with mental health needs accompanied by police View source Failure to record critical information disclosed to police call handlers View source Failure to ask patients about thoughts of harming another person View source See 10 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
Finnulla Catherine MARTIN · 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
Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.
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 obtain the triage record before patient assessment
Wider context from the report “2. The team then saw a patient without waiting to obtain the triage record created by Whittington Hospital Trust 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 Unavailability of triage records of patient attendance
Wider context from the report “2. I was told at inquest by Camden & Islington that the Whittington had been unable to locate the Whittington triage record of Ms Martin’s attendance , and I did not discover any record of the call made by Ms Martin’s sister to the emergency department that night.
” 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 about thoughts of suicide
Wider context from the report “3. The doctor did not ask Ms Martin about thoughts of suicide within the context of her earlier declaration that she would die that night.
” 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 establish the circumstances leading to police involvement and the identity of the caller
Wider context from the report “5. He did not address his mind to what had led up to the police being called for Ms Martin, nor who had called them .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about protocols for receiving information from police officers accompanying voluntary patients
Wider context from the report “1. It seemed from the evidence I heard that the Camden and Islington Trust psychiatry liaison team (doctor and nurse) operating at Whittington Hospital on the night of 15 November 2015, were not wholly clear about the protocols for receipt of information from police officers bringing patients into hospital on a voluntary basis .
” 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 passing family information to the psychiatry liaison team
Wider context from the report “8. The crisis team did not pass on information received from Ms Martin’s sister to the psychiatry liaison team with a sufficient degree of urgency to ensure that this was taken into consideration before the interview with Ms Martin was concluded.
” 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 Confusion about voluntary attendance of patients with mental health needs accompanied by police
Wider context from the report “2. As I have indicated above, the confusion surrounding voluntary attendance of a patient with mental health needs accompanied by the police , suggests a multi agency discussion and agreement would be beneficial.
” 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 record calls from family members to the emergency department
Wider context from the report “2. I was told at inquest by Camden & Islington that the Whittington had been unable to locate the Whittington triage record of Ms Martin’s attendance, and I did not discover any record of the call made by Ms Martin’s sister to the emergency department that night .
” 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 characterise urgent police contact as an emergency after a patient leaves hospital
Wider context from the report “7. When they obtained this afterwards and then realised that Ms Martin had left the hospital, they contacted the police but did not characterise this as an emergency .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain collateral history from family members before concluding the interview
Wider context from the report “6. Neither doctor nor nurse obtained a collateral history of events from a family member before concluding their interview with Ms 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 Confusion about voluntary attendance of patients with mental health needs accompanied by police
Wider context from the report “1. There seemed to be some degree of confusion surrounding the voluntary attendance of a patient with mental health needs accompanied by the police , that suggests a multi agency discussion and agreement would be beneficial.
” 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 record critical information disclosed to police call handlers
Wider context from the report “1. The police call handler who spoke to Ms Martin did not record that she said: “I need to jump a balcony” . This was important information.
” 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 about thoughts of harming another person
Wider context from the report “4. He did not ask her about any thoughts of harming another person , regardless of the fact he was not aware that she had threatened this.
” Open source report
Concerns raised 1 Lack of precise specification of communication requirements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tamara HOLBOLL · 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
Tamara Holboll died from stab wounds to the neck and chest after she and her son had sought hospital admission because they feared he would harm her, but the admission was not effected. The principal concern was a recurring lack of precision in communication within Camden & Islington NHS Trust, including insufficient clarity about what information should be delivered, by whom, when, and how.
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 precise specification of communication requirements
Wider context from the report “It seemed to me from the evidence I heard that, when a need for good communication (for example between clinician and bed manager) has been identified, there has been a lack of precision in your trust about exactly what that means and how it needs to be actioned .
Rather than simply talking about the need for better communication, it is necessary to identify that information A must be delivered on every occasion, by person B, at time C, and using method D . Without this level of detail, staff are left with a vague concept and the communication is unlikely to achieve the desired result .
I appreciate that this does not give you much in the way of specifics to work on, but your organisation has already identified these. What I hope to do is to share with you what I perceive to be a recurring theme in your organisation , that has been particularly highlighted by Ms Holboll’s death.
” 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 Amend the action-plan template and author guidance to require specific, concrete actions linked to each recommendation.
Verbatim wording from the response “1. We have amended the action plan template and revised our guidance to authors writing recommendations and action plans.” Source location 2015-0171-Response-by-Camden-and-Islington-NHS-Trust
Open published response
Concerns raised 2 Transfer of acute psychiatric patients when no bed is available View source Use of CRHTT as a filter preventing patients in need of a bed from accessing a bed 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
Ronald Gittens · 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
Ronald Gittens was taken to hospital, assessed for an informal psychiatric admission and transferred while waiting for a bed, but left before admission. He was later found at home having hanged himself. The principal concerns were the transfer of acute psychiatric patients when no bed is available and the use of CRHTT as a filter for patients needing a bed.
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 Transfer of acute psychiatric patients when no bed is available
Wider context from the report “The transfer of acute psychiatric patients when no bed is available and
The use of CRHTT as a filter to prevent patients in need of a bed from having access to a bed.
” 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 Use of CRHTT as a filter preventing patients in need of a bed from accessing a bed
Wider context from the report “The transfer of acute psychiatric patients when no bed is available and
The use of CRHTT as a filter to prevent patients in need of a bed from having access to a bed.
” Open source report
Concerns raised 3 Failure to complete steps in the Haringey Crisis Resolution Team action plan View source Delays in completing outstanding action-plan steps View source Failure to complete steps in the first action plan 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
Huseyin Hasan Erdogan · 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
Huseyin Hasan Erdogan hanged himself on 4 June 2014 and died on 13 June 2014 from cerebral hypoxia resulting directly from the hanging. The inquest identified a failure by mental health practitioners to conduct and act upon a fully informed assessment of his mental state, contributing to no steps being taken to prevent the hanging. Concerns were also raised that action-plan steps intended to address recommendations had not been completed by the inquest and that further deaths might not be prevented without their completion.
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 steps in the Haringey Crisis Resolution Team action plan
Wider context from the report “(2) Although the Haringey Crisis Resolution Team (SUI) Action plan likewise set out nine steps to be taken (some of which corresponded very closely with those set out in the first Action Plan), and likewise set a “Date to be completed” of “November 2014”, there was, again, no evidence before me at the inquest that items numbers 1, and 3 to 9 had been completed .
” 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 completing outstanding action-plan steps
Wider context from the report “(3) The risk of further deaths not being prevented will not be diminished if all outstanding steps have not already been completed, and if they are not completed without avoidable 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 complete steps in the first action plan
Wider context from the report “(1) Although the first Action Plan set out six steps to be taken as “Action in Response to recommendations” and, although the “Date to be completed” for items 1 to 5 was stated to be “November 2014” there was, by the date of the inquest (over two months later) no evidence before me that any of those five steps had been completed .
” Open source report
Concerns raised 5 Failure of crisis team records to capture valuable information received during referrals View source Lack of shared understanding between crisis teams and general practitioners about crisis team capabilities and limitations View source Insufficient information captured by the crisis team pager messaging service View source Lack of shared understanding between referrers and crisis teams about crisis team capabilities and limitations View source Lack of specific training and education for general practitioners about crisis team services and limitations View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Andrew Elliot FROST · 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
Andrew Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.
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 crisis team records to capture valuable information received during referrals
Wider context from the report “2. The crisis team’s records did not reflect some valuable information that was passed to them.
For example, that police and paramedics were with Mr Frost at the time of the GP’s call. This information was communicated by the GP and by Mr Frost’s partner. If the crisis team had considered this information, they could have advised Mr Frost’s partner he should tell the paramedics that the crisis team were not coming out that day, which may have assisted paramedics’ 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 Lack of shared understanding between crisis teams and general practitioners about crisis team capabilities and limitations
Wider context from the report “1. There was no shared understanding between the crisis team and the GP about what the crisis team could and could not do.
The GP thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.
The GP regarded the crisis team as an emergency service, which the team leader told me in court is not the case.
It seems that this GP, his partners, and the other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis team about their service, including its limitations.
” 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 information captured by the crisis team pager messaging service
Wider context from the report “3. The pager messaging service used by the crisis team simply takes the name of the patient and a telephone number to call, nothing more.
This means that valuable time was wasted by the crisis team, trying to track down the police officer who had rung to find out more detail, most especially Mr Frost’s address.
This is time that could be used treating patients.
” 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 shared understanding between referrers and crisis teams about crisis team capabilities and limitations
Wider context from the report “During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone.
You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him.
However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do .
You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.
You regarded the crisis team as an emergency service, which the team leader told me in court is not the case.
It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations.
I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else.
” 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 specific training and education for general practitioners about crisis team services and limitations
Wider context from the report “During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone.
You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him.
However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do.
You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day.
You regarded the crisis team as an emergency service, which the team leader told me in court is not the case.
It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations.
I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else.
” Open source report
Concerns raised 1 Failure to promptly communicate critical self-harm risk information between wards 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
Tanya Christine PAGE · 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
Tanya Christine PAGE took her own life by hanging while detained under a section of the Mental Health Act on Opal Ward of Highgate Mental Health Unit. A principal concern was that staff did not promptly communicate her disclosure of a recent attempted hanging on Sapphire Ward, apparently because of concern that this might be perceived as criticism of Sapphire staff.
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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 promptly communicate critical self-harm risk information between wards
Wider context from the report “1. When Ms Page was transferred from Sapphire to Opal Ward, she disclosed that she had tried to hang herself whilst on Sapphire a few days before. Opal Ward staff members were shocked at this but, though they recorded the disclosure in the medical notes, they did not alert any staff member from Sapphire until after Ms Page’s death .
From the evidence given by the consultant psychiatrist on Opal Ward, there appeared to be a reluctance to draw attention to this information, because of the perception that it carried with it a criticism of the staff on Sapphire.
However, it was important that staff on Sapphire were told, both from the point of view of Ms Page herself, and because this was a valuable piece of learning for them that could affect how they cared for other patients. The worry about perceived blame should not have prevented prompt discussion .
There were other learning points discussed during the inquest, such as the necessity to search the laundry room as well as bedroom of a patient feared to be at risk of self harm; the potential for wardrobe doors to act as a ligature point and the desirability of sharing that learning nationally; and the training issues around use of alarms, ligatures, general patient safety and resuscitation techniques. However, evidence was given that steps have already been taken by the trust to act upon these and so I do not need to comment on them further.
” Open source report
Concerns raised 4 Failure to arrange Mental Health Act assessment when the responsible psychiatrist is unavailable View source Failure to secure timely inpatient admission when no NHS bed is available View source Failure to inform families of the route to obtain an immediate Mental Health Act assessment View source Delays in arranging urgent Mental Health Act assessments View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sandra Bodrožič’ · 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
Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such assessments.
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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 arrange Mental Health Act assessment when the responsible psychiatrist is unavailable
Wider context from the report “2. The consultant psychiatrist treating Ms Bodrožič’ formed the view on the evening of 18 June 2014 that Ms Bodrožič’ should have a Mental Health Act assessment. However, the psychiatrist was going on holiday the following day and so decided to leave this until her return, rather than asking colleagues .
” 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 secure timely inpatient admission when no NHS bed is available
Wider context from the report “1. Ms Bodrožič’ agreed on 23 May 2014 to the recommendation of those treating her that she be admitted to hospital on an informal basis. However, no bed was found for her until 30 May , by which time she had changed her mind.
There was no exploration of the possibility of purchasing a bed from the private sector when no NHS bed was available.
” 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 of the route to obtain an immediate Mental Health Act assessment
Wider context from the report “3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožič’ on Wednesday, 25 June 2014, decided that she needed a Mental Health Act assessment and immediately made the appropriate referral.
However, once the referral was made, it took until the following week for this to be arranged, and Ms Bodrožič’ had killed herself in the meantime, on Sunday, 29 June.
Healthcare professionals explained in court that Mental Health Act assessments are, by their very nature, urgent, yet there seemed to be a general acceptance by the team that they will usually take several days to take place, in this case from a Wednesday until the following Tuesday.
The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family.
Ms Bodrožič’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit.
” 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 urgent Mental Health Act assessments
Wider context from the report “3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožič’ on Wednesday, 25 June 2014, decided that she needed a Mental Health Act assessment and immediately made the appropriate referral.
However, once the referral was made, it took until the following week for this to be arranged , and Ms Bodrožič’ had killed herself in the meantime, on Sunday, 29 June.
Healthcare professionals explained in court that Mental Health Act assessments are, by their very nature, urgent, yet there seemed to be a general acceptance by the team that they will usually take several days to take place , in this case from a Wednesday until the following Tuesday.
The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family .
Ms Bodrožič’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit.
” 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 Escalate delays caused by unavailable external agencies to senior management and add recurrent delays to the Trust risk register.
Verbatim wording from the response “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:” Source location 2014-0560-Camden-Islington-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record in the electronic patient record how risks from delays in Mental Health Act assessments will be mitigated.
Verbatim wording from the response “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:” Source location 2014-0560-Camden-Islington-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Alert commissioners to London Ambulance Service delays and poor GP attendance at Mental Health Act assessments.
Verbatim wording from the response “d) An alert to delays by the London Ambulance Service to attend MHA assessments have been made to the Joint Commissioner in Camden, and also of the poor attendance of GP’s to MHA assessments with the Joint Commissioners in the London Borough of Islington.” Source location 2014-0560-Camden-Islington-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify and disseminate the bed management policy, emphasising admission offers regardless of Mental Health Act status.
Verbatim wording from the response “The Serious Incident Report in relation to Ms Bodrozic’s death noted that the Trust’s bed management policy was not followed correctly. Consequently, the Clinical Director for the Acute Division has clarified and disseminate the Trust’s bed management policy to its employees emphasising that, ‘any patient requiring a bed will be offered admission regardless of their Mental Health Act status’. This should ensure that private beds are available to informal patients promptly.” Source location 2014-0560-Camden-Islington-NHS-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 Delaying the mental health assessment until the psychiatrist’s return was considered clinically reasonable because established cover arrangements were in place.
Verbatim wording from the response “2. The Consultant Psychiatrist treating Ms Bodrozic had established a good rapport with her and her family and had made stringent efforts to engage Ms Bodrozic in her care. She felt that it was a reasonable clinical decision to carry out the MHA assessment following her period of leave. Whilst on leave, clinical cover arrangements were in place with another Consultant Psychiatrist, which is the usual procedure in order to continue to provide support to Ms Bodrozic and her family should she need arise. Ms Bodrozic brother contacted the team on 24th June expressing concerns about his sister’s mental health and following a home visit by the social worker, a referral for a MHA assessment was made.” Source location 2014-0560-Camden-Islington-NHS-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 A private bed was not considered necessary because Trust bed availability was changing and a bed was expected within the required timeframe.
Verbatim wording from the response “1. When ████████ took the decision to admit Ms Bodrozic to hospital on an informal basis on 23rd May 2014 she spoke to the duty nurse at the Highgate Mental Health Centre (the Centre) to make the referral. They discussed the urgency of the referral and although there was no bed available at the Centre it was anticipated that a bed would become available within the next few days. This was appropriate given the clinical urgency of the case at the time. Therefore, a private bed was not considered to be necessary. The family had been advised that they could take Ms Bodrozic to the Accident & Emergency department over the bank holiday weekend if there were any changes in her state of mind or behaviour.” Source location 2014-0560-Camden-Islington-NHS-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 A specific agreed timeframe for mental health act assessments was not possible because coordinating multiple agencies with competing priorities can be difficult.
Verbatim wording from the response “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:” Source location 2014-0560-Camden-Islington-NHS-Trust
Open published response
Concerns raised 4 Failure to directly assess thoughts of taking one's life View source Shortened clinical specialist sessions View source Failure to assess and address ongoing excessive use of illicit amitriptyline View source Failure to explore therapeutic input from an alternative healthcare professional View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Noleen Mary McPHARLANE · 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
Noleen Mary McPHARLANE had longstanding contact with mental health services and a history of overdoses and self-inflicted wounds. She died after ingesting an excess of a drug purchased on the internet, although her intentions were unclear. Concerns included that her suicide thoughts and continued illicit amitriptyline use were not directly explored, and that there was no consideration of input from an alternative healthcare professional despite limited therapeutic engagement.
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 directly assess thoughts of taking one's life
Wider context from the report “1. Ms McPharlane had a long history of overdoses and self inflicted wounds, her last admission to hospital for treatment for the consequent physical injuries being in May 2013. However, in the year following that until her death, the clinical specialist who looked after never once asked her directly if she had thoughts of taking her life .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortened clinical specialist sessions
Wider context from the report “3. The clinical specialist, ████████, by profession a mental health nurse, saw Noleen McPharlane once a fortnight. The sessions were scheduled to last 50 minutes, but frequently only lasted 20 or 30 minutes.
He told me that this was because she did not initiate conversation and responded to questions only briefly. He did not feel he had a good rapport with her.
No other health professional from Highgate Hospital saw her. ████████ did speak to his manager, another clinical specialist (by profession a social worker) about Ms McPharlane, and twice over the year to a psychiatrist. However, there was never any exploration of the possible therapeutic benefit of direct input from an alternative healthcare professional. ████████ now thinks that would have been appropriate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and address ongoing excessive use of illicit amitriptyline
Wider context from the report “2. The medical records made clear that Ms McPharlane had a history of buying illicit amitriptyline from the internet and taking this to excess. However, in the last year of her life, her clinical specialist never once asked her if this was ongoing, or advised her about this, or explored the issue with her in any way . He now regards this as 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 explore therapeutic input from an alternative healthcare professional
Wider context from the report “3. The clinical specialist, ████████, by profession a mental health nurse, saw Noleen McPharlane once a fortnight. The sessions were scheduled to last 50 minutes, but frequently only lasted 20 or 30 minutes.
He told me that this was because she did not initiate conversation and responded to questions only briefly. He did not feel he had a good rapport with her.
No other health professional from Highgate Hospital saw her. ████████ did speak to his manager, another clinical specialist (by profession a social worker) about Ms McPharlane, and twice over the year to a psychiatrist. However, there was never any exploration of the possible therapeutic benefit of direct input from an alternative healthcare professional . ████████ now thinks that would have been appropriate.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the clinical risk assessment and management policy.
Verbatim wording from the response “The Trust has a clinical risk assessment and management policy in place. It has been reviewed and updated in September 2014 and is currently being consulted upon. The Trust believes that effective risk assessment and management is crucial to the delivery of high quality services across all parts of the Trust and is a core component of mental” Source location 2014-0370-Response-by-Camden-Islington-NHS
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 Instruct clinical staff to assess risks to self and others and address identified risks in care plans.
Verbatim wording from the response “The Director of Nursing & People and the Interim Medical Director will ensure that all clinical staff are instructed to ensure that the risk assessments of all services users include asking about risks to self and others and, if risks are identified, that these are addressed in care plans. The deadline for this is November 2014.” Source location 2014-0370-Response-by-Camden-Islington-NHS
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 Raise with supervisors that risk-assessment content must be checked during supervision.
Verbatim wording from the response “The Head of the Personality Disorders Service will raise with supervisors in the service that the content of risk assessments are checked during supervision.” Source location 2014-0370-Response-by-Camden-Islington-NHS
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 Instruct clinical staff to discuss known self-harm methods, monitor related practices and medication risks, and set preventive care-plan actions.
Verbatim wording from the response “The Interim Medical Director will ensure that all clinical staff are instructed that where it is known the methods of self-harm service users employ, including the purchase of non-prescribed medication through the internet, they must have these practices discussed with them regularly. A plan should be set in place to include monitoring the frequency of these practices, e.g. the medication purchased and consideration given to the impact of this on their prescribed medication and the likelihood of overdosing. The care plan should set out clear actions to be taken to prevent self-harming practices where possible. The deadline for this is November 2014.” Source location 2014-0370-Response-by-Camden-Islington-NHS
Open published response
Concerns raised 1 Failure to follow up police welfare-check requests when no response is received View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Anthony WARD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Anthony Ward, who had a long history of depression and other mental health problems, was found hanging by a close friend on 28 February. The principal concern was that, after the crisis team contacted police to request a welfare check, nobody followed up when police did not call back within one or two hours; the police later said they could not locate his flat, by which time Mr Ward had been found hanging.
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 follow up police welfare-check requests when no response is received
Wider context from the report “However, at around 7.30pm on Thursday, 27 February, a member of the crisis team placed a call to police asking for a welfare check to be carried out. What concerns me is that, when the police did not call back within an hour or two, nobody from the crisis team followed this up with the police .
The next contact was at around 8.15am on the morning of Friday, 28 February, when the police rang the crisis team to say that they were outside Mr Ward’s building and could not locate his flat.
In fact, Mr Ward’s friend had by this time found him hanging.
Mr Ward did not have any personal contact with anyone after Tuesday, 25 February, so by the time the alarm was raised on Thursday evening, he might well have already died. However, he might not. In any event, following up with the police might be critical for another person in his position.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a full organisational protocol for police-contact follow-up, including further work with Metropolitan Police colleagues.
Verbatim wording from the response “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.” Source location 2014-0248-Response-by-Camden-Islington-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish guidance requiring requests for checks to be followed up within six hours across community mental health teams.
Verbatim wording from the response “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.” Source location 2014-0248-Response-by-Camden-Islington-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue the check-follow-up guidance to staff across the organisation.
Verbatim wording from the response “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.” Source location 2014-0248-Response-by-Camden-Islington-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review existing community mental health service practice to inform safer police-requested check arrangements.
Verbatim wording from the response “Further to your report the Trust has considered the issues raised. Attached is a guidance note that has been drawn up to clarify arrangements across all community mental health teams. This has been developed following a review of practice already in place within services. It requires that requests for checks should be followed up within six hours of them being made. This guidance note is now to be developed into a full protocol for use across the organisation. The process of developing this will include further work with colleagues from the Metropolitan Police.” Source location 2014-0248-Response-by-Camden-Islington-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain Trust Quality Committee ratification and formally issue the full protocol as a Trust protocol.
Verbatim wording from the response “The guidance is due to be issued to staff across the organisation on 21st July 2014, with the ratification of the full protocol due at the Trust Quality Committee in September 2014 for formal issuing as a Trust Protocol by 1st October 2014.” Source location 2014-0248-Response-by-Camden-Islington-NHS-Trust
Open published response
Concerns raised 1 Limited availability of psychological therapy for transferred patients 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
Michael Harry WORRALL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Harry Worrall had longstanding mental health issues and was admitted to secure forensic units before being discharged to community services in July 2013. He died after falling from a bridge in October 2013. The principal concern was the limited availability of psychological therapy at Avesbury House and the possible adverse consequences of discontinuing psychological input before discharge into the community; the report states there was no evidence that this lack of treatment 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 Limited availability of psychological therapy for transferred patients
Wider context from the report “(1) The limited availability of psychological therapy at Avesbury House could be significant for patients who, prior to transfer there, were receiving such input. The concern was raised by Mr Worrall’s family, which I share, that this period of discontinuation of psychological input might have adverse consequences on subsequent discharge into the community.
” Open source report
Concerns raised 4 Failure of emergency-response policy to require requesting duty doctor attendance View source Failure of nursing staff to respond to collapses in a calm coordinated manner View source Failure of nursing staff to apply basic life-support training View source Lack of clear staff-response guidance for collapses View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adrian Anthony Cowan · 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
Adrian Anthony Cowan, who was detained under the Mental Health Act 1983, had a seizure on 14 June 2012 and was later found unresponsive in his room after being observed breathing normally. The inquest recorded natural causes, with pulmonary thromboembolism and deep vein thrombosis as the medical cause of death, alongside epilepsy and diabetes. Concerns related to unclear emergency-response guidance, including the failure to require the duty doctor to attend, and staff difficulties in responding calmly and applying basic life-support training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of emergency-response policy to require requesting duty doctor attendance
Wider context from the report “(1) That the trust policy dealing with the staff response did not include a clear set of guidance to those staff members responding to Mr Cowan’s collapse nor did the policy include the need, as part of the emergency response, to request the duty doctor to attend .
” 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 nursing staff to respond to collapses in a calm coordinated manner
Wider context from the report “(2) Some of the nursing staff were not able, when responding to Mr Cowan being found collapsed, act in a calm coordinated manner and were not able to apply the training they had received in basic life support.
” 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 nursing staff to apply basic life-support training
Wider context from the report “(2) Some of the nursing staff were not able, when responding to Mr Cowan being found collapsed, act in a calm coordinated manner and were not able to apply the training they had received in basic life support .
” 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 clear staff-response guidance for collapses
Wider context from the report “(1) That the trust policy dealing with the staff response did not include a clear set of guidance to those staff members responding to Mr Cowan’s collapse nor did the policy include the need, as part of the emergency response, to request the duty doctor to attend.
” 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 Revise and regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.
Verbatim wording from the response “In order to improve the confidence and competence of staff’s application of resuscitation techniques, regular assessments and practical sessions have been implemented using a lifelike manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This approach is being revised and will in future be run regularly across all wards within the Forensic Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability to respond in an emergency situation.” Source location 2014-0111-Response
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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 the Trust resuscitation policy to address emergency response guidance.
Verbatim wording from the response “I would like to assure you that we have taken immediate action to review the Trust’s resuscitation policy, which at the time of Mr Cowan’s Death was up to date and was not due to be reviewed until 2015.” Source location 2014-0111-Response
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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 Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.
Verbatim wording from the response “I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.” Source location 2014-0111-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 the step-by-step emergency-response guide in all other inpatient areas.
Verbatim wording from the response “I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.” Source location 2014-0111-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 Conduct unannounced resuscitation scenarios across Forensic wards to strengthen emergency response.
Verbatim wording from the response “In order to improve the confidence and competence of staff’s application of resuscitation techniques, regular assessments and practical sessions have been implemented using a lifelike manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This approach is being revised and will in future be run regularly across all wards within the Forensic Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability to respond in an emergency situation.” Source location 2014-0111-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 Update the resuscitation policy with deteriorating-patient actions, an expanded NEWS Score, and a requirement to contact the duty doctor during medical emergencies.
Verbatim wording from the response “The update to the policy will incorporate additional action to be taken in the future in response to the “deteriorating patient”, and we will update and expand the “NEWS” Score, which is a nationally recognised tool for assessing patients whose physical health may be deteriorating. The revised policy will make clear the need to contact the duty doctor in the event of a medical emergency.” Source location 2014-0111-Response
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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 resuscitation policy already listed actions for determining whether a collapsed patient was breathing and responding to such events.
Verbatim wording from the response “I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.” Source location 2014-0111-Response
Open published response
Concerns raised 3 Failure to provide effective airway ventilation during resuscitation View source Failure to maintain continuous responsibility for the airway during resuscitation View source Failure to ask patients about thoughts of taking their life 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
Abdullahi Sharif ABOKAR · 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
Abdullahi Sharif Abokar, a 22-year-old patient detained under section 3 of the Mental Health Act, was found hanging from smoke alarm wires on a secure mental health ward on 16 June 2012 and died five days after being taken to hospital. Concerns included staff not asking him about suicidal thoughts and significant shortcomings in the conduct of resuscitation, including compromised ventilatory support and uncertainty about airway management.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to North London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective airway ventilation during resuscitation
Wider context from the report “2. Resuscitation
The psychiatry doctor who attended the resuscitation in progress (approximately seven minutes after Mr Abokar was discovered), found an ambubag mask on Mr Abokar’s face, but no ambubag connected and no person holding the mask.
The nurse who had been in charge of Mr Abokar’s airway said that she had been giving him mouth to mouth resuscitation, though no other witness in the room saw this. No explanation was provided as to why she would have given mouth to mouth rather than use the ambubag present (even if the ambubag was not connected to a flow of oxygen).
The nurse had left Mr Abokar in the middle of resuscitation, simply to go out into the corridor and ascertain the whereabouts of the paramedic.
She said that she had left Mr Abokar’s airway in the care of another member of staff, but she did not know who that person was, and all other members of staff in the room denied that his airway was ever left in their charge. She was out of the room for 50 seconds.
The paramedic attending Mr Abokar after resuscitation had been ongoing for quite some minutes, said that Mr Abokar’s head was not tilted back sufficiently, and the ambubag reservoir was not inflated because the oxygen cylinder, whilst connected, was not switched on.
Neither of the paramedic’s observations was accepted by the nurse with control of the airway, though he clearly has a great deal more experience of resuscitation than she.
The nurse also said that a colleague, though she did not know who, had connected the ambubag to the first oxygen cylinder; and then a colleague, either the same colleague or a different one, she did not know, had connected the ambubag to a second cylinder; though all other members of staff in the room denied that they had done this.
It appears that Mr Abokar’s ventilatory support was significantly compromised by the way in which it was conducted. It was entirely unclear what impact, if any, this had on Mr Abokar’s potential recovery, though that would not necessarily be the case for another patient in a similar position.
” 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 maintain continuous responsibility for the airway during resuscitation
Wider context from the report “2. Resuscitation
The psychiatry doctor who attended the resuscitation in progress (approximately seven minutes after Mr Abokar was discovered), found an ambubag mask on Mr Abokar’s face, but no ambubag connected and no person holding the mask.
The nurse who had been in charge of Mr Abokar’s airway said that she had been giving him mouth to mouth resuscitation, though no other witness in the room saw this. No explanation was provided as to why she would have given mouth to mouth rather than use the ambubag present (even if the ambubag was not connected to a flow of oxygen).
The nurse had left Mr Abokar in the middle of resuscitation, simply to go out into the corridor and ascertain the whereabouts of the paramedic.
She said that she had left Mr Abokar’s airway in the care of another member of staff, but she did not know who that person was, and all other members of staff in the room denied that his airway was ever left in their charge. She was out of the room for 50 seconds.
The paramedic attending Mr Abokar after resuscitation had been ongoing for quite some minutes, said that Mr Abokar’s head was not tilted back sufficiently, and the ambubag reservoir was not inflated because the oxygen cylinder, whilst connected, was not switched on.
Neither of the paramedic’s observations was accepted by the nurse with control of the airway, though he clearly has a great deal more experience of resuscitation than she.
The nurse also said that a colleague, though she did not know who, had connected the ambubag to the first oxygen cylinder; and then a colleague, either the same colleague or a different one, she did not know, had connected the ambubag to a second cylinder; though all other members of staff in the room denied that they had done this.
It appears that Mr Abokar’s ventilatory support was significantly compromised by the way in which it was conducted. It was entirely unclear what impact, if any, this had on Mr Abokar’s potential recovery, though that would not necessarily be the case for another patient in a similar position.
” 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 about thoughts of taking their life
Wider context from the report “1. Asking the suicide question
Several members of staff looking after him did not ask Mr Abokar if he had thoughts of taking his life.
Some, including his ward manager, gave evidence that they thought that asking the question might give a patient the idea of taking his life , though evidence was given by the assistant director of nursing that this thinking is not in accordance with training or accepted practice.
One mental health nurse said that, although he would ask the suicide question of a patient who appeared isolated or in low mood, he could not ever remember asking that question, despite his work on a secure mental health ward.
” 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 Transfer resuscitation-scene coordination to the most senior nurse on duty until attending paramedics assume responsibility.
Verbatim wording from the response “e) Management of the resuscitation scene will no longer be with the attending doctor, but with the most senior nurse on duty at the time. This will be the duty nurse or site matron who will have responsibility for coordinating staff actions, and handing over information to attending paramedics. Until the paramedic lead accepts responsibility, the duty nurse or site matron will maintain the lead for managing the resuscitation.” Source location 2013-0323-Response-by-Camden-Islington-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 Approve and implement a revised Trust Resuscitation Policy aligned with national guidance and learning from the inquest.
Verbatim wording from the response “a) A revised Trust Resuscitation Policy was approved by the Trust’s Quality Committee in November 2013, containing changes in line with national guidance and also directly related to learning from this inquest’s findings.” Source location 2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide specialist oxygen-use training using live oxygen cylinders during training sessions.
Verbatim wording from the response “f) Training in use of oxygen will now be provided by an independent company contracted to provide this for the Trust. This is a specialist Health and Safety firm. The Trust will ensure that live oxygen cylinders are provided for each training session for this purpose, which will enable staff undergoing training to familiarise themselves fully with the cylinder and how it functions, including the sound it makes when activated. The Deputy Director of Nursing has responsibility for organising this. The Trust will also recommend to the National Resuscitation Council that this should be a component of in-hospital Life support training, as it is not currently stipulated as” Source location 2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require clinical staff to ask every patient about suicidal thoughts or plans, reinforced through supervision and monitoring of clinical standards.
Verbatim wording from the response “The Trust has implemented the following plan to ensure patient safety through staff having competence and confidence in the assessment of suicidal risk in patients. The Trust expects all its clinical staff to regularly ask every patient about suicide, in terms of thoughts or plans and this issue is explored in clinical supervision and through regular monitoring of clinical standards.” Source location 2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission acute inpatient suicide-prevention training from King’s College London for all inpatient services.
Verbatim wording from the response “d) The Trust will commission Acute In-patient Suicide Prevention training from Kings College, London by March 2014 for all inpatient services.” Source location 2013-0323-Response-by-Camden-Islington-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 Introduce six-monthly CPR simulation exercises across inpatient units, with committee monitoring.
Verbatim wording from the response “d) Due to the infrequent occurrences of CPR within mental health hospital settings, our inpatient units will now perform simulation exercises every 6 months to ensure staff get practice in performing CPR. The matron from each unit has responsibility for organising these, under the guidance of the Deputy Director of Nursing. The first such exercises will take place in April 2014. The exercises will be monitored through our committee structure.” Source location 2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
Open published response
Concerns raised 4 Failure to ensure complete retrieval of medical and nursing records View source Lack of clarity in nursing observation records View source Possible drowning hazard associated with patient bathing in baths View source Lack of consistent nursing staff understanding of intermittent observation requirements during patient bathing 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.
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AI-generated summary
John Frank Henry LANSDOWNE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Frank Henry Lansdowne, who had schizophrenia and a history of serious suicide attempts, was admitted to St Pancras Hospital under section 3 of the Mental Health Act after talking about taking his life. He was found submerged in a bath on 18 May 2012 and died shortly afterwards. Concerns included unclear observation timings, an unrecovered observation sheet, inconsistent staff understanding of observations while a patient was bathing, and the use of baths rather than walk-in showers.
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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 ensure complete retrieval of medical and nursing records
Wider context from the report “2. There was confusion regarding the retrieval of the entirety of the medical/nursing records after Mr Lansdowne’s death, and one observation sheet was never recovered .
” 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 in nursing observation records
Wider context from the report “1. The jury found that the times observations of Mr Lansdowne took place in the 45 minutes preceding his discovery were unclear , despite a nursing observation record setting these out .
” 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 Possible drowning hazard associated with patient bathing in baths
Wider context from the report “4. Mr Lansdowne died in the bath, it is possible as a result of drowning . Mr Lansdowne’s family explained at inquest that in other hospitals where he had been treated, only walk in showers are used .
” 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 consistent nursing staff understanding of intermittent observation requirements during patient bathing
Wider context from the report “3. At inquest, there was a lack of consistency in the understanding of nursing staff on Laffan Ward at St Pancras Hospital, as to the exact requirements of intermittent observations when a patient is bathing .
” Open source report
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Addressed to Camden and Islington NHS Foundation 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