19 May 2026 Catherine Mary MORGAN · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 10 Failure to use a viable welfare-check pathway when the resident is not known to be at the address View source Overly rigid application of deployment policy and affinity protocol View source Failure to inform the nurse in charge about leave decisions and circumstances View source Failure to include a patient photograph in the grab pack View source Inadequate monitoring and escalation of patients on leave who do not return View source Lack of a voluntary-patient checklist for measures taken to locate the patient View source Failure to conduct leave risk assessments consistently with NICE Guidelines View source Inadequate communication and recording of leave decisions View source Training that restricts professional judgement in deployment decisions View source Inconsistent approach to leave and return for detained and voluntary patients View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Issue and disseminate a Blue Light Bulletin reinforcing prompt checks and escalation when patients fail to return from leave.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source
Action
Replace paper hourly observation checks with electronic well-being checks linked to leave monitoring and audit processes.
Stated plannedThe respondent said that this action was planned when they made their response on 28 July 2026. View source
Action
Provide reflective learning on nurse-in-charge responsibilities for leave management, risk escalation and patient safety.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source
Action
Develop a standardised leave log suitable for detained and informal patients.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source
Action
Develop a replacement electronic patient record system incorporating redesigned risk assessment, safety planning, leave documentation and monitoring capabilities.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026. View source
Action
Adopt a personalised, NICE- and NHSE-aligned approach to risk formulation, management planning and safety planning.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source
Action
Update mandatory clinical risk training to reflect the revised risk assessment and harm management policy.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source
Action
Review and update the leave, informal-patient leave, and absent-or-missing-person policies to align practice, NICE guidance and legal requirements, including photographs and voluntary-patient checklists.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026. View source
Action
Publish and disseminate patient-safety learning on informal leave management, documentation and failure to return to relevant staff.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source
Action
Investigate and explore producing the leave form electronically, including with the new EPR provider, to improve access, recording and monitoring.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026. View source
Action
Introduce and maintain a ward whiteboard recording patient leave and expected return times.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source
Action
Implement electronic ward-round templates for documenting leave discussions, risk considerations, plans and actions and sharing them across multidisciplinary teams and shifts.
Stated completedThe respondent said that this action was complete when they made their response on 28 July 2026. View source See 9 more actions
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AI-generated summary
Catherine Mary MORGAN · 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
Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a viable welfare-check pathway when the resident is not known to be at the address
Wider context from the report “2. A call handler informed SLAM to call London Ambulance Service to do a welfare check at
the home address of the patient in circumstances where the ambulance service will only
attend an address if the resident is known to be there ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Overly rigid application of deployment policy and affinity protocol
Wider context from the report “1. An overly rigid approach to the Right Care Right Person policy and affinity protocol resulted
in a delayed deployment . Even where call handlers have real concerns that someone not
returning to a mental health unit is a high risk missing person, the outcome of the toolkit not to
deploy is the same if the individual's address has not been visited, even when told that they
would not go there. The way in which the policy was applied removed any discretion by call
handlers and dispatchers to deploy whilst checks at the address were being conducted .
Evidence was given at the inquest that the call handler in the second call to MPS attempted to
convey her concerns that there should be immediate deployment to her supervisors in
despatch and was advised the police would not deploy;
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the nurse in charge about leave decisions and circumstances
Wider context from the report “2. The systems in place for safeguarding voluntary patients in respect of leave and recording
the decisions was inadequate and decisions were largely communicated by word of mouth
which led to differences of understanding what had been agreed, the basis on which it had
been agreed and by whom it was agreed. Documentation in respect of leave was incomplete
and did not comply with policy. The nurse in charge was not informed of the decision for leave
or the circumstances in which leave was granted ;
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include a patient photograph in the grab pack
Wider context from the report “5. A photograph of the patient was not included in the grab pack . Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring and escalation of patients on leave who do not return
Wider context from the report “3. The system for monitoring leave was inadequate , reliance being placed on hourly checks.
The nurse conducting the hourly check at 12.00 when Catherine was due to return was not
aware that she was on unescorted leave and did not escalate the matter to the nurse in charge
with the result that the ward only became aware that she had not returned when her mother
arrived at 12.50. Consideration was not given to the appropriate amount of leeway to be given
to the patient before escalating the fact of them not having returned , with patients being given
30 minutes or more;
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a voluntary-patient checklist for measures taken to locate the patient
Wider context from the report “5. A photograph of the patient was not included in the grab pack. Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct leave risk assessments consistently with NICE Guidelines
Wider context from the report “1. Evidence was given at the inquest that although dynamic risk assessments were undertaken
in advance of leave being authorised, risk assessments were not consistent with NICE
Guidelines ;
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication and recording of leave decisions
Wider context from the report “2. The systems in place for safeguarding voluntary patients in respect of leave and recording
the decisions was inadequate and decisions were largely communicated by word of mouth
which led to differences of understanding what had been agreed, the basis on which it had
been agreed and by whom it was agreed . Documentation in respect of leave was incomplete
and did not comply with policy . The nurse in charge was not informed of the decision for leave
or the circumstances in which leave was granted;
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Training that restricts professional judgement in deployment decisions
Wider context from the report “It was recognised by MPS at the inquest that there was an overly rigid approach to the Right
Care Right Person policy and Affinity Protocol resulting from the robust application of the
policy and protocol (see above). Some changes have been made within MPS within the
parameters allowed given national guidance and standards, but evidence was given to the
effect that training as to the application of the policy, protocol and toolkit could result in the
professional judgement of call handlers/despatchers/supervisors being restricted resulting in
delays to deployment
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent approach to leave and return for detained and voluntary patients
Wider context from the report “4. Ward staff appeared to take a different approach to leave and return depending upon the
status of the patient as a detained or voluntary patient ;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue and disseminate a Blue Light Bulletin reinforcing prompt checks and escalation when patients fail to return from leave.
Verbatim wording from the response “The aforementioned Patient Safety article circulated to staff on 5 March 2026 reinforced the following:” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace paper hourly observation checks with electronic well-being checks linked to leave monitoring and audit processes.
Verbatim wording from the response “Since the incident, the hourly observation checks (which were completed incorrectly for Catherine at 12pm on 4 September 2024) have also been made electronic as part of the Trust’s work in respect of its new Enhanced Care policy. The introduction of the checks (now known as ‘well-being checks’) in an electronic form (Appendix C) will make it easier for them to be cross referenced with the Leave Log to assist with monitoring patients on leave. It will also make it easier to audit the checks to ensure they have been correctly completed by staff.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide reflective learning on nurse-in-charge responsibilities for leave management, risk escalation and patient safety.
Verbatim wording from the response “In addition, there was a Lewisham Quality Meeting held on 13 April 2026 chaired by ████████, Deputy Head of Nursing and Quality with attendance by front line clinical staff, including Band 5 and 6 nurses who carry out nurse in charge role. Learning and discussion was held in relation to the nurse in charge role, including the key role they play in relation to leave, expectations of those in that role and in light of the clearly set parameters of the role set out within the Trust policies and procedures.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised leave log suitable for detained and informal patients.
Verbatim wording from the response “• The Ward Risk Assessment for Section 17/Informal Leave form that was in use when Ms Morgan was a patient on the ward was not included in any Trust policy but was produced by the ward by combining the Section 17 leave risk assessment checklist and the Daily Leave Log to produce a new form. Because of the reference to section 17 leave it was not felt that this was appropriate to both detained and informal patients and thus a new standardised Leave Log has been developed that is appropriate to both detained and informal patients (Appendix D). With respect to the Section 17 leave risk assessment checklist, it has been identified that this is not in accordance with NICE guidance 2022 which does not recommend the use of risk assessment tools to predict the risk of suicide or to decide which patients receive treatment or are discharged.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a replacement electronic patient record system incorporating redesigned risk assessment, safety planning, leave documentation and monitoring capabilities.
Verbatim wording from the response “The Trust has recently completed a procurement in relation to a new Electronic Patient Record (“EPR”) system and work is underway with the appointed provider to develop a new EPR system with a plan for this to be in place by 2028.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt a personalised, NICE- and NHSE-aligned approach to risk formulation, management planning and safety planning.
Verbatim wording from the response “However, the Trust has now fully adopted NICE and NHSE guidance on individualised risk formulation and management planning. The Trust’s move to a personalised approach to risk has been launched in four phases:” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update mandatory clinical risk training to reflect the revised risk assessment and harm management policy.
Verbatim wording from the response “The Trust has mandatory training for all clinicians on the management of Clinical Risk, which must be completed every 3 years. As part of Phase 2, this internal training was updated to include the revised Clinical Risk Assessment and Management of Harm Policy.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the leave, informal-patient leave, and absent-or-missing-person policies to align practice, NICE guidance and legal requirements, including photographs and voluntary-patient checklists.
Verbatim wording from the response “The Trust continues to evaluate its transition towards a personalised approach to risk assessment and suicide prevention. In respect of the Inquest process, it was identified there is still some work to be done with respect to aligning all other policies with the transformed Clinical Risk Assessment and Management of Harm policy. In particular, there are aspects within the AWOL, Absent and Missing Persons policy which retain “old” low/medium/high classifications, i.e. the checklist used to guide decision making where a patient is identified as AWOL. This policy has now been marked as under review as was previously indicated in the Trust’s evidence in this case.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and disseminate patient-safety learning on informal leave management, documentation and failure to return to relevant staff.
Verbatim wording from the response “On the 5 March 2026 this matter, along with broader considerations regarding management of informal leave and failure to return from planned leave were addressed within a Patient Safety learning article which has been published centrally and has been disseminated by Directorate governance teams to all relevant staff. A copy of this has previously been shared with the Coroner. As a point of clarity, it is not Trust policy (and it would also be contrary to the legal framework) to mandate time limits for informal leave given the legal right of informal patients to take time off the ward as they choose.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Investigate and explore producing the leave form electronically, including with the new EPR provider, to improve access, recording and monitoring.
Verbatim wording from the response “• The Trust is currently investigating options for producing the Leave Form electronically potentially within the Trust’s “Enhanced Care on E-Obs” system, which is an electronic platform integrated with ePJS to enable recording wellbeing checks. Enhanced Care on eObs is a secure digital system that helps hospital staff record wellbeing checks and engagement during periods of enhanced care.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and maintain a ward whiteboard recording patient leave and expected return times.
Verbatim wording from the response “In the meantime, additional measures are in place on the ward to which Ms Morgan was admitted where they have now introduced a whiteboard in the main nursing office with leave and return times written on it. This means that it is now much easier for nursing staff to keep track of whether a patient has returned from leave at the expected time. The board is updated when a patient is signed out and then on their return. This aspect of learning from the incident was part of the presentation at the Patient Safety Committee so that other wards within the Trust can consider implementing the same system.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement electronic ward-round templates for documenting leave discussions, risk considerations, plans and actions and sharing them across multidisciplinary teams and shifts.
Verbatim wording from the response “Since Ms Morgan’s death, the Trust has made significant changes to the way in which discussion and plans from ward rounds, including in relation to patient leave, are noted within EPJS and how these are shared through EPJS template documents to assist with robust handover throughout the MDT and between shifts. There is a Ward Round template (Appendix A) which guides clinicians in noting the discussion and outcomes from ward round meetings. Of note, there is a specifically a space under the “Safety” tab for clinicians to record agreement and discussions around leave, however it is also anticipated that discussion and planning of leave will feature prominently in ward round discussions and to this extent they should also be reflected within the recorded considerations around risk as well as plans and actions for the patient arising from the ward round review.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot mandate time limits for informal leave because doing so would be contrary to the legal framework governing informal patients’ leave.
Verbatim wording from the response “On the 5 March 2026 this matter, along with broader considerations regarding management of informal leave and failure to return from planned leave were addressed within a Patient Safety learning article which has been published centrally and has been disseminated by Directorate governance teams to all relevant staff. A copy of this has previously been shared with the Coroner. As a point of clarity, it is not Trust policy (and it would also be contrary to the legal framework) to mandate time limits for informal leave given the legal right of informal patients to take time off the ward as they choose.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental Health Code guidance requiring patient photographs in grab packs applies to detained patients, not voluntary patients.
Verbatim wording from the response “The requirement in the Trust's AWOL policy for there to be a current photograph associated with a patient's grab pack derives from the Mental Health Code of Practice’s guidance that detained patients should have a photograph included in their notes (27.22). The Trust acknowledges that its policy does not make clear that this guidance relates to detained patients rather than voluntary patients.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
24 Apr 2026 Edward Muwanga · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation View source Lack of awareness of the section 135 MHA 1980 process View source Fragmented healthcare record systems limiting the visibility and communication of important patient safety information View source Failure to locate and identify information about a section 135 MHA 1980 warrant View source Failure to make a detailed and measured assessment of a person’s situation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Edward Muwanga · 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
Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the application of section 136 MHA 1980 powers in communal spaces within private accommodation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the section 135 MHA 1980 process
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980 , and a lack of inquiry by the more experienced officer as to the existence of such a warrant, together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmented healthcare record systems limiting the visibility and communication of important patient safety information
Wider context from the report “(3) The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the treating Trust (SLAM) and NHS 111, and between the Ambulance Service (not NHS 111) and the treating Trust (SLAM). ████████ from London Ambulance Service NHS Trust writes to me in her PFD statement that “it is recognised that there remain challenges with the visibility of information from healthcare settings across London. While advances have been made, the visibility of pertinent information depends on technological developments and the coordination of a complex healthcare system.” In her written evidence to me dated 19th March 2026 ████████ Chief Medical Officer of LAS NHS Trust, writes that “..there is currently no single, comprehensive system that provides universal access to all patient records across NHS organisations. Access is influenced by information governance requirements, system interoperability, commissioning arrangements, and the extent to which partner organisations upload information to shared platforms." Whilst this fragmented situation persists with a multiplicity of systems, platforms, screens, and process in which important patient safety information is embedded the risk such information is not identified or communicated to practitioners making healthcare decisions remains and as such gives rise to a risk of death due to decisions being made on incomplete information where more complete information exists .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to locate and identify information about a section 135 MHA 1980 warrant
Wider context from the report “(2) A lack of awareness by the two less experienced officers about the process under section 135 MHA 1980, and a lack of inquiry by the more experienced officer as to the existence of such a warrant , together with a concern that it was not clear from the evidence where information about the warrant could be obtained by officers .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make a detailed and measured assessment of a person’s situation
Wider context from the report “(1) A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie’s situation
” 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 Adopt and operate London Care Record sharing to provide authorised clinicians with near-real-time access to relevant mental health information.
Verbatim wording from the response “Since March 2023, SLaM has adopted a London-wide sharing approach to ensure that appropriate information is available to clinicians at the point of need, regardless of where the patient presents.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an internal review of recorded information and its availability to other organisations.
Verbatim wording from the response “1.1 Approach to the review
In response to the concerns identified by you, Sir, SLaM undertook a comprehensive internal review. The purpose of the review was to examine:” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the electronic Mental Health Act system to complete, process and securely share statutory documentation across organisations.
Verbatim wording from the response “The eMHA by Thalamos is a digital platform used by five Mental Health Trusts in London to complete, process, and securely share statutory Mental Health Act documentation across organisations involved in a patient’s care. It was implemented locally in SLaM from 24 March 2025, as part of a London-wide programme to improve the accuracy, timeliness and accessibility of MHA documentation.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with system partners to strengthen information sharing, improve shared-record consistency and usability, and support coordinated care.
Verbatim wording from the response “While no single system currently provides a fully integrated, real-time view of all patient information, these developments represent meaningful progress in improving visibility of key information and supporting safer decision-making across organisations. The Trust recognises that safe clinical decision-making depends not only on the availability of information, but also on the ability of clinicians to identify and interpret it, alongside effective communication between services in crisis situations.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
15 Oct 2025 Tony Montana Duncan · Prevention of Future Deaths report City of London
View report summary
Concerns raised 6 Failure to recognise and assess an identified suicide risk View source Failure to alert relevant services, the GP, or family about a high-risk patient’s departure View source Failure to involve Crisis or Home Treatment teams for immediate safeguarding follow-up View source Failure to document risk assessments View source Failure to review medication, consider admission, or escalate care for an acutely deteriorating patient View source Failure to retain and re-assess a high-risk patient before departure View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Tony Montana Duncan · 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
Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.
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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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and assess an identified suicide risk
Wider context from the report “2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent ; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to alert relevant services, the GP, or family about a high-risk patient’s departure
Wider context from the report “3. The Deceased was subsequently seen in the Accident and Emergency Department by a Social Worker from the homelessness team. The Deceased insisted that he was not homeless and that he had attended the hospital for help with his mental health, without which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric liaison team who he found, together, in their office. Subsequently, whilst still in the department, the Deceased became agitated and abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or was escorted out as he was being abusive; the records show that at least one member of the psychiatric liaison team was aware of this development but took no action to prevent the Deceased from leaving or to encourage him to stay in order to re-assess him, nor to alert the Crisis and/or Home Treatment teams, the GP, or the Deceased’s family as to the situation .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve Crisis or Home Treatment teams for immediate safeguarding follow-up
Wider context from the report “2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding . Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document risk assessments
Wider context from the report “2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor, nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others , both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review medication, consider admission, or escalate care for an acutely deteriorating patient
Wider context from the report “2. When the Deceased attended the hospital, the Accident and Emergency team’s triage notes included express reference to his specific suicide plan and attached the GP’s letter of referral. The Deceased was then assessed by a psychiatric liaison nurse who concluded that his presentation was as a result of psycho-social stressors rather than mental illness; she was not concerned about the risk of suicide because he had no plan or intent; and she referred the Deceased to the homelessness team and discharged him back to the care of his GP. The nurse did not take any steps to review the Deceased’s medication or consider admission, or escalate these matters to a doctor , nor did she involve the Crisis or Home Treatment teams for follow up / immediate safeguarding. Despite there being a recognised risk to self and to others, both of which the Deceased himself said he could not control, there is no evidence of any risk assessment documentation being 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and re-assess a high-risk patient before departure
Wider context from the report “3. The Deceased was subsequently seen in the Accident and Emergency Department by a Social Worker from the homelessness team. The Deceased insisted that he was not homeless and that he had attended the hospital for help with his mental health, without which he would jump from London Bridge. The Social Worker immediately passed this information to members of the psychiatric liaison team who he found, together, in their office. Subsequently, whilst still in the department, the Deceased became agitated and abusive, which behaviour was a recognised aspect of his behaviour when he was unwell. It seems he later left the department and/or was escorted out as he was being abusive; the records show that at least one member of the psychiatric liaison team was aware of this development but took no action to prevent the Deceased from leaving or to encourage him to stay in order to re-assess him , nor to alert the Crisis and/or Home Treatment teams, the GP, or the Deceased’s family as to the situation.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.
Verbatim wording from the response “Since Mr Duncan’s death the Trust has introduced several new systems to address the challenges raised by patients presenting to ED. The Liaison Psychiatry team carries out multiple clinical safety huddles in ED each day. These are brief, daily, multi-disciplinary team meetings to quickly review patient safety, share urgent information, identify risks (like high-risk behaviour or medication issues), plan care, improve teamwork, and resolve problems. This follows the team handover which facilitates rapid risk review and shared decision making between ED and Liaison Psychiatry teams.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a 24/7 Emergency Department Low Intensity Area at King’s College Hospital with capacity for six patients.
Verbatim wording from the response “KCH has also launched a new ED Low Intensity Area (LIA) in partnership with SLAM. The LIA space offers a calm and supportive environment for suitable patients who would otherwise wait in the busy environment of the main ED. Operating 24/7, it currently has capacity for six patients. The LIA is a continuum of the ED, but patients are kept in a less stimulating environment. Patients who are moved into LIA have already been assessed and have a plan in place, but they need to wait to have it enacted. These plans may include referral for a psychiatric admission, referral to an associated team such as the homeless team or addictions care team, with ongoing care planning following the assessment, or referral to Recovery House in Lewisham, where they can be offered a maximum of 7 nights stay, as an alternative to admission for people who feel unable to return home.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.
Verbatim wording from the response “Ideally, the PLN would have sought Mr Duncan’s consent to contact a named person/carer, ideally his mother with whom he lived, but did not do this; the AAR has made a recommendation to address this omission by embedding ‘carer contact’ in the Liaison Psychiatry departmental handover board; this must be done and documented before patients can be discharged. The Trust is accredited under the Triangle of Care initiative led by the Carers Trust and endorsed by NHS England, which seeks to implement six key standards required to achieve better collaboration and partnership with carers, including identification of carers at first contact; the implementation of this in the ED can be difficult for reasons outlined in the AAR, and this extra flag is intended to provide further operational support for future patient cases.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the national Culture of Care Programme pilot on personalised approaches to suicide risk.
Verbatim wording from the response “Training on personalised risk assessment and management was released by NHSE in September 2025, and the AAR recommends that such training should be mandatory for clinicians. The Trust is one of ten mental health organisations taking part in a national pilot through the NHS England and Royal College of Psychiatrists Culture of Care Programme – Personalised Approach to Risk. The pilot aims to enhance how we approach, assess, and manage the risk of suicide. This work aligns with the NICE guidance for Self-harm, which states that risk assessment tools should not be used to predict suicide. Further information can be found here: Culture of Care Programme and here: NCISH | Implementing a personalised approach to risk.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.
Verbatim wording from the response “The AAR did note that adult patients with mental capacity to make the relevant decision may well decline or refuse a request to contact their family, but in this case there is no documentation that this discussion took place. Family members are often able to provide useful collateral information which can assist in care planning, even if the patient does not permit the clinician to share information about them. However, if a patient refuses to allow contact, it may not be possible to make this contact. This should be noted in the electronic record.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.
Verbatim wording from the response “Referral by the PLN to a doctor was not clearly indicated, as this pathway is for those who may require admission under the Mental Health Act, or changes to their medication, or for other complexities as deemed by the assessing clinician. The AAR explored onward referral to doctors by PLNs and this was thought to be working well, with senior psychiatric doctors available 24 hours a day. Mr Duncan initially presented as calm and without signs or symptoms of affective disorder or psychosis. Later, when Mr Duncan became agitated, referral to a doctor to consider next steps (including potential referral to a crisis team) may have been indicated, and his self-discharge without further review or discussion was a lost opportunity to review the assessment and offer further support.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recovery House was unsuitable for homeless patients and therefore unavailable as an alternative to admission in this case.
Verbatim wording from the response “KCH has also launched a new ED Low Intensity Area (LIA) in partnership with SLAM. The LIA space offers a calm and supportive environment for suitable patients who would otherwise wait in the busy environment of the main ED. Operating 24/7, it currently has capacity for six patients. The LIA is a continuum of the ED, but patients are kept in a less stimulating environment. Patients who are moved into LIA have already been assessed and have a plan in place, but they need to wait to have it enacted. These plans may include referral for a psychiatric admission, referral to an associated team such as the homeless team or addictions care team, with ongoing care planning following the assessment, or referral to Recovery House in Lewisham, where they can be offered a maximum of 7 nights stay, as an alternative to admission for people who feel unable to return home.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A patient with capacity could not lawfully be detained or prevented from leaving when insisting on self-discharge.
Verbatim wording from the response “Had Mr Duncan been found to have capacity to make decisions around treatment and care, as he was in the initial assessment, there would have been no grounds to detain him and stop him if he insisted on leaving. However, it would have been useful to review his mental state again, given that his presentation appeared to change while he was in the ED. It does not appear that the Liaison Psychiatry team were informed by the ED team that Mr Duncan was trying to leave the ED and self-discharge, until such time as he was being escorted out by security. The AAR recommends that potential self-discharges must be flagged to the Liaison Psychiatry Team by Emergency Department colleagues early and there must be consideration whether further assessment is warranted to ensure self-discharge is safe.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medication discontinuation was not clearly the main cause of relapse, and the presentation did not indicate medication review by liaison psychiatry.
Verbatim wording from the response “It is not clear discontinuation of medication was the main causative factor in Mr Duncan’s relapse as one might suspect in a psychotic illness. During the Psychiatric Liaison Nurse’s (PLN) assessment in KCH Emergency Department (ED), Mr Duncan did not present with signs or symptoms of psychotic or mood disorder, or with agitation or sleep disturbance which might indicate the need for medication. We acknowledge the GP requested a medication review in the referral letter and that the PLN did not address this. Medication review is often more usefully carried out with a full treatment history, and this is more suitable for the Community Mental” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Admission was not clearly beneficial for this condition, so community treatment was considered an appropriate alternative when the patient initially engaged.
Verbatim wording from the response “Mr Duncan had last been admitted to hospital in 2016; this was initially a voluntary admission, subsequently an emergency Section 5(2) was used to detain him until a full Mental Health Act assessment could be organised. He was found not to be detainable and self-discharged against medical advice. Shortly after this he requested to be readmitted and when this could not be accommodated, he caused damage to Trust property by smashing the windows of the ward. When in the community, he was less agitated than on the ward and was subsequently managed by a CMHT and then primary care without further intervention from acute services. It is therefore not clear admission had been helpful, and this is not uncommon in patients with personality disorder and one of the reasons why the benefits of admission should be weighed against potential harms of admission to hospital.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
19 Sep 2025 Mr Luke John Chatterton · Prevention of Future Deaths report South London
View report summary
Concerns raised 4 Lack of a national formal guideline for management of bowel obstruction View source Delays in accessing advanced life support resuscitation for detained patients View source Failure of mental health hospitals to provide advanced life support resuscitation without acute hospital co-location View source Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Luke John Chatterton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a national formal guideline for management of bowel obstruction
Wider context from the report “2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction, including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics. There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in accessing advanced life support resuscitation for detained patients
Wider context from the report “1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards, and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of mental health hospitals to provide advanced life support resuscitation without acute hospital co-location
Wider context from the report “1. The delays in accessing advanced life support (ALS) resuscitation in the MH hospital were worse than expected in the community. London Ambulance Service target for Category 1 calls is 7 minutes and yet it took 37 minutes before the paramedics arrived. Despite concerns that resuscitation skills were better to maintain in a MH Trust, Adrenaline and IV lines were part of the system at the time. Initially no IV line could be found, then none could be inserted. 25 minutes of asystole elapsed before Adrenaline was administered. Evidence was heard that MH Trusts cannot safely provide advanced life support resuscitation unless they are co-located with an acute hospital site. The National Quality Standards in mental health in patient care requires calling 999 immediately and strongly recommends provision of IV-line insertion and drug administration and a team leader with ALS skills, but the Resuscitation Council has apparently approved the Trust policy. Thus, the safety of a patient detained by the State, who has a cardio-respiratory arrest, would seem to vary according to post code, some not being close to acute hospital standards , and might even be worse than in the community. Given that those who suffer psychosis have increased risks of premature death, including suicide and cardiovascular deaths, in part related to treatment, the State would seem to have a responsibility to mitigate these risks, when compulsorily detaining them. It raises the question as to whether patients with high risk should have the right to choose a site where there is co-location of acute services and whether units with high concentration of detained psychotics should and can be safely equipped to provide Advanced 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the risks of deterioration and death from suspected acute obstruction in patients chronically on Clozapine
Wider context from the report “2. The acute Trust has taken a number of steps to facilitate identifying the risks of a patient who is referred with suspected obstruction. Outstanding is the development with the mental health Trust of an educational package and guidelines for managing suspected acute obstruction , including pseudo-obstruction (a complication of Clozapine) and recognizing the rare but potentially fatal risks of anti-psychotics . There is currently no national formal guideline on management of bowel obstruction. Given the rarity of antipsychotic induced acute obstruction, there seems to be merit in alerting national professional bodies to enable consideration to be given to the development of a guideline, which might identify the use of red flags to escalate and investigate those at most risk.
” Open source report
7 Apr 2025 Christopher McDonald · Prevention of Future Deaths report South London
View report summary
Concerns raised 4 Failure to accompany police when returning a patient from their home View source Lack of staff knowledge and understanding of the AWOL, missing and absent persons policy View source Failure to draw up a joint police and Trust staff action plan when police are likely to return a patient to hospital View source Failure to individually assess whether to suspend section 17 leave when a patient goes AWOL 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
Christopher McDonald · 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
Christopher McDonald, who had been detained under section 3 of the Mental Health Act and was receiving care at Bethlem Royal Hospital, died by strangulation by a ligature he had applied around his neck. Concerns included shortcomings in the individualised assessment and management of his leave after he went AWOL, failure to follow the AWOL policy, inadequate review of observation levels, and avoidable delay in identifying the ligature and communicating his relevant medical history to ambulance staff.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accompany police when returning a patient from their home
Wider context from the report “The evidence heard at the inquest demonstrated that staff working on the NPU did not have knowledge or a clear understanding of the “AWOL - Missing & Absent Persons Policy” of South London and Maudsley NHS Foundation Trust (“SLAM”) Specifically:
(1) Whilst there should be an individualised assessment of whether it is appropriate to suspend section 17 when a patient goes AWOL: (a) one member of staff at the inquest gave evidence that it was “standard practice” and “protocol” that leave would be suspended; and (b) there was no evidence of any individualised assessment in Mr McDonald’s case.
(2) The policy provides that SLAM staff should always accompany the police if the patient is to be returned from their home . This was not done in this case, and there was no evidence that any member of NPU staff considered this once Mr McDonald was located at his mother’s address on 24 February 2023.
(3) The policy provides that if the police are likely to be involved in returning the patient to hospital then an action plan – jointly drafted between the police and Trust staff - needs to be drawn up. This was not done in this case, and there was no evidence that this was considered or completed by SLAM 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge and understanding of the AWOL, missing and absent persons policy
Wider context from the report “The evidence heard at the inquest demonstrated that staff working on the NPU did not have knowledge or a clear understanding of the “AWOL - Missing & Absent Persons Policy” of South London and Maudsley NHS Foundation Trust (“SLAM”) Specifically:
(1) Whilst there should be an individualised assessment of whether it is appropriate to suspend section 17 when a patient goes AWOL: (a) one member of staff at the inquest gave evidence that it was “standard practice” and “protocol” that leave would be suspended; and (b) there was no evidence of any individualised assessment in Mr McDonald’s case.
(2) The policy provides that SLAM staff should always accompany the police if the patient is to be returned from their home. This was not done in this case, and there was no evidence that any member of NPU staff considered this once Mr McDonald was located at his mother’s address on 24 February 2023.
(3) The policy provides that if the police are likely to be involved in returning the patient to hospital then an action plan – jointly drafted between the police and Trust staff - needs to be drawn up. This was not done in this case, and there was no evidence that this was considered or completed by SLAM 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to draw up a joint police and Trust staff action plan when police are likely to return a patient to hospital
Wider context from the report “The evidence heard at the inquest demonstrated that staff working on the NPU did not have knowledge or a clear understanding of the “AWOL - Missing & Absent Persons Policy” of South London and Maudsley NHS Foundation Trust (“SLAM”) Specifically:
(1) Whilst there should be an individualised assessment of whether it is appropriate to suspend section 17 when a patient goes AWOL: (a) one member of staff at the inquest gave evidence that it was “standard practice” and “protocol” that leave would be suspended; and (b) there was no evidence of any individualised assessment in Mr McDonald’s case.
(2) The policy provides that SLAM staff should always accompany the police if the patient is to be returned from their home. This was not done in this case, and there was no evidence that any member of NPU staff considered this once Mr McDonald was located at his mother’s address on 24 February 2023.
(3) The policy provides that if the police are likely to be involved in returning the patient to hospital then an action plan – jointly drafted between the police and Trust staff - needs to be drawn up . This was not done in this case, and there was no evidence that this was considered or completed by SLAM 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to individually assess whether to suspend section 17 leave when a patient goes AWOL
Wider context from the report “The evidence heard at the inquest demonstrated that staff working on the NPU did not have knowledge or a clear understanding of the “AWOL - Missing & Absent Persons Policy” of South London and Maudsley NHS Foundation Trust (“SLAM”) Specifically:
(1) Whilst there should be an individualised assessment of whether it is appropriate to suspend section 17 when a patient goes AWOL : (a) one member of staff at the inquest gave evidence that it was “standard practice” and “protocol” that leave would be suspended ; and (b) there was no evidence of any individualised assessment in Mr McDonald’s case.
(2) The policy provides that SLAM staff should always accompany the police if the patient is to be returned from their home. This was not done in this case, and there was no evidence that any member of NPU staff considered this once Mr McDonald was located at his mother’s address on 24 February 2023.
(3) The policy provides that if the police are likely to be involved in returning the patient to hospital then an action plan – jointly drafted between the police and Trust staff - needs to be drawn up. This was not done in this case, and there was no evidence that this was considered or completed by SLAM staff.
” 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 Mandate MDT risk assessment after every AWOL incident and prompt Responsible Clinician review of leave status.
Verbatim wording from the response “Action:” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the AWOL Policy to require a jointly agreed police and Trust action plan when police involvement in a hospital return is anticipated.
Verbatim wording from the response “3. Joint Action Planning with Police” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind wards that staff must accompany police returning patients and issue guidance and briefings on collaborative working.
Verbatim wording from the response “Actions:” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade the AWOL safety measures through Trust-wide bulletins and briefings, obtaining formal directorate confirmation of implementation.
Verbatim wording from the response “• These actions will be shared and cascaded via Trust-wide through a blue light bulletin. Each directorate will be required to provide formal confirmation of full implementation to ensure accountability.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver bespoke AWOL Policy refresher training to the National Psychosis Unit and monitor attendance.
Verbatim wording from the response “• Bespoke Refresher training on all aspects of the AWOL Policy will be delivered to the National Psychosis Unit. Attendance will be monitored to ensure consistent understanding and application of the policy.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
23 May 2024 Jada Monoja · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to clearly date and signpost revisions within compound risk assessments View source Failure to systematically review and update risk indicators at relevant patient events View source Failure to maintain detailed patient risk assessments as clear, well-signposted and dated assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jada Monoja · 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
Jada Monoja, who had a history of chronic paranoid and delusional thinking, disclosed suicidal thoughts on 15 November 2020 and was assessed by mental health services before being accepted by the Home Treatment Team. In the early hours of 17 November 2020, he was found unresponsive after leaving home and could not be resuscitated; the inquest concluded that he died by suicide, likely while experiencing delusional and paranoid thoughts. The principal concerns relate to the use of the online risk assessment tool, including assessments being incomplete, insufficiently dated or signposted, and difficult to identify within chronological records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly date and signpost revisions within compound risk assessments
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event, it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to systematically review and update risk indicators at relevant patient events
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc. ), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event , it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered , then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information ; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain detailed patient risk assessments as clear, well-signposted and dated assessments
Wider context from the report “Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment.
Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event, it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated.
Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that:
(1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information; and
(2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based
(3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading;
(4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ;
(5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes , the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost , requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient .
” 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 Conduct regular audits of risk assessments to ensure completion in accordance with requirements.
Verbatim wording from the response “Teams will ensure this is being completed through regular audits of risk assessments on the Trust Audit Systems ‘Tenable’. From June 2024, the Trust has made changes to the auditing system of Risk assessments for inpatients, crisis and community services to ensure that this is a now stand-alone audit tool to ensure the quality and accuracy of risk assessments for patients within our care.” Source location Response from South London and Maudsley 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 a blue light bulletin reminding clinical staff to update risk assessment documents at appropriate intervals and during assessment.
Verbatim wording from the response “As a result, we will be issuing a blue light bulletin to all clinical staff by Friday 9th August 2024 reminding them of the need to ensure risk assessment documents are updated at appropriate intervals including at the time of assessment in line with the Trust risk assessment policy.” Source location Response from South London and Maudsley 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 Adapt the risk assessment and formulation tool with the National Culture of Care team, train staff and embed sustained practice change.
Verbatim wording from the response “As you have noted, following the investigation into this very sad death, the Trust is committed to improving our approach to assessment, formulation and safety planning. To this effect, leads have been appointed to start this work and last month the Trust was successful in a bid to be one of the second wave pilot sites to work with the National Culture of Care team to adapt our risk assessment and formulation tool. The purpose of this is to train staff in current best practice with regards to risk, and to embed sustained change in practice across the Trust. This is a major piece of work over the next 18 months, with significant service user involvement and using quality improvement methodology. Progress will be tracked by regular meetings and review of data with the culture of care team.” Source location Response from South London and Maudsley 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 Operate a standalone risk-assessment audit tool for inpatient, crisis and community services to improve assessment quality and accuracy.
Verbatim wording from the response “Teams will ensure this is being completed through regular audits of risk assessments on the Trust Audit Systems ‘Tenable’. From June 2024, the Trust has made changes to the auditing system of Risk assessments for inpatients, crisis and community services to ensure that this is a now stand-alone audit tool to ensure the quality and accuracy of risk assessments for patients within our care.” Source location Response from South London and Maudsley NHS Trust
Open published response
25 Mar 2024 Jacqueline Anne Cobain · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Failure of the questionnaire system to recognise cancelled assessment appointments View source Lack of a system or protocol for timely clinical review and escalation of concerning questionnaire responses when assessment appointments are delayed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Anne Cobain · 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
Jacqueline Anne Cobain deliberately jumped in front of a moving train at Vauxhall London Underground station on 11 September 2021, suffering multiple injuries and dying at the scene. Her questionnaire responses to mental health services contained concerning responses, but the questionnaire was not reviewed until after her death because the system did not recognise that her appointment had been cancelled. The principal concern was the absence of a system or protocol to alert a clinician to review concerning responses when an assessment appointment was delayed by several days or weeks.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the questionnaire system to recognise cancelled assessment appointments
Wider context from the report “1. When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by email on Saturday 4 September 2021, the system nevertheless generated an automatic questionnaire which is normally is sent 24 hours prior to a scheduled assessment appointment . The system had not recognised that Mrs Cobain had cancelled her appointment . She completed the questionnaire.
2. Mrs Cobain’s responses to the questionnaire contained what were accepted to be concerning responses.
3. Due to the cancellation the questionnaire was not reviewed by a clinician until after Mrs Cobain’s sad death.
4. Changes have been made to the protocols around cancellation, and language has been added to the assessment template.
5. However, there is no system or protocol to alert a clinician to review concerning responses and to consider appropriate next steps, where (outside the usual protocol and time frame of submission and review within 24 hours of the assessment appointment) the patient has completed the questionnaire, and for whatever reason, the assessment appointment with the clinician is not for a period of several days/weeks as was the case in Mrs Cobain’s case.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system or protocol for timely clinical review and escalation of concerning questionnaire responses when assessment appointments are delayed
Wider context from the report “1. When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by email on Saturday 4 September 2021, the system nevertheless generated an automatic questionnaire which is normally is sent 24 hours prior to a scheduled assessment appointment. The system had not recognised that Mrs Cobain had cancelled her appointment. She completed the questionnaire.
2. Mrs Cobain’s responses to the questionnaire contained what were accepted to be concerning responses .
3. Due to the cancellation the questionnaire was not reviewed by a clinician until after Mrs Cobain’s sad death .
4. Changes have been made to the protocols around cancellation, and language has been added to the assessment template.
5. However, there is no system or protocol to alert a clinician to review concerning responses and to consider appropriate next steps , where (outside the usual protocol and time frame of submission and review within 24 hours of the assessment appointment) the patient has completed the questionnaire, and for whatever reason, the assessment appointment with the clinician is not for a period of several days/weeks as was the case in Mrs Cobain’s case.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation PHQ-9 responses are not diagnostic or predictive of suicidality and should not be used as a suicide risk assessment.
Verbatim wording from the response “Mrs Cobain completed a number of short questionnaires. The questionnaire completed by Mrs Cobain which has caused some concern was the Patient Health Questionnaire-9. This is a measure used to give an indication of possible symptoms of depression experienced by an individual over the past two weeks. It is not a diagnostic tool nor is it a risk assessment. The questions are intended only to help inform and structure an in-person assessment. They are also used to provide a quantitative baseline against which progress in later treatment can be measured. Clinical research indicates that these types of measures have no predictive value as an assessment of suicidality and, indeed, recently published NICE guidance confirms that they must not be used in this way.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
26 May 2023 Conrad Richard James Colson · Prevention of Future Deaths report East London
View report summary
Concerns raised 5 Lack of training for stepdown service teams on BDD diagnosis and associated risks View source Failure to share BDD diagnoses with clinics providing aesthetic dermatology treatment View source Failure to inform patients with BDD of the risks of seeking aesthetic dermatology treatment View source Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge View source Lack of national specialist resources for BDD View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Conrad Richard James Colson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training for stepdown service teams on BDD diagnosis and associated risks
Wider context from the report “3. The Inquest heard that there is a need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with it .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share BDD diagnoses with clinics providing aesthetic dermatology treatment
Wider context from the report “2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients with BDD of the risks of seeking aesthetic dermatology treatment
Wider context from the report “2. Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge
Wider context from the report “1. A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT . There was a lack of full information sharing around risk and risk assessment/risk management planning on discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national specialist resources for BDD
Wider context from the report “4. The inquest heard that there is a lack of national resources for BDD . The highly specialised service at South London and Maudsley has a very long waiting list (several months) . This is on a background of concerns of a likely increase in BDD. In light of this concern, I am also providing this report to the Royal College of Psychiatrists, to the Department for Health & Social Care and to NHSE.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer BDD training to local step-down and other referring services.
Verbatim wording from the response “It would not be possible for the CADAT to provide training on BDD to all referring services nationwide due to the logistics and capacity within the clinic itself. The CADAT clinic is in the process of offering training on BDD to local services. In addition, the CADAT has agreed to provide more support to local services who have referred patients. The CADAT will now include a detailed one page BDD information guide (enclosed with this letter) prepared by Professor David Veale, Consultant Psychiatrist in Cognitive Behaviour Therapy at the CADAT, to referring services in their communication following referral.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and ratify the CADAT discharge policy to require liaison, joint risk planning, and communication with skin clinics about aesthetic treatment.
Verbatim wording from the response “The Centre for Anxiety Disorders and Trauma (‘CADAT’) has updated its discharge policy (enclosed with this letter), to explicitly state the expectations of liaison between local teams and CADAT. The updates to this policy confront the issues faced in Conrad’s case. The updated policy was circulated to all team members at CADAT and was discussed in the clinic’s team meeting on 1 June 2023. This” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nationwide BDD training cannot be provided because the clinic lacks the necessary logistical capacity.
Verbatim wording from the response “It would not be possible for the CADAT to provide training on BDD to all referring services nationwide due to the logistics and capacity within the clinic itself. The CADAT clinic is in the process of offering training on BDD to local services. In addition, the CADAT has agreed to provide more support to local services who have referred patients. The CADAT will now include a detailed one page BDD information guide (enclosed with this letter) prepared by Professor David Veale, Consultant Psychiatrist in Cognitive Behaviour Therapy at the CADAT, to referring services in their communication following referral.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
Concerns raised 5 Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points View source Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients View source Failure to print medical notes and other documents from the Trust IT system in shared premises View source Failure to upload PDF medical records and important information promptly in original form to the electronic notes system View source Limited coverage of the Bed Manager function to one Trust region 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
Mina TOPLEY-BIRD · 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
Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points
Wider context from the report “3. The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given . One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients
Wider context from the report “5. The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still 'a work in progress' and further work was required . It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to print medical notes and other documents from the Trust IT system in shared premises
Wider context from the report “2. It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT . This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to upload PDF medical records and important information promptly in original form to the electronic notes system
Wider context from the report “1. Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form . This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited coverage of the Bed Manager function to one Trust region
Wider context from the report “4. Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust . On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it .
” Open source report
Concerns raised 2 Omission of Lamotrigine self-harm or suicide risk from pharmacological information resources View source Failure to provide patients with information about Lamotrigine side effects 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
Viktor John Anthony Scott-Brown · 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
Viktor John Anthony Scott-Brown, aged 23, was found hanging at his home overnight on 14/15 December 2018 and pronounced dead at the scene; the inquest concluded that his death was suicide. He had been prescribed Lamotrigine without being warned about its potential association with thoughts of self-harm or suicide, and concerns were raised that reputable prescribing resources were inconsistent or silent about this potential side effect.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of Lamotrigine self-harm or suicide risk from pharmacological information resources
Wider context from the report “Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.
The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.
Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.
Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.
From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with information about Lamotrigine side effects
Wider context from the report “Mr Scott-Brown was prescribed Lamotrigine by an NHS Foundation Trust Consultant Psychiatrist. The prescribing consultant did not give Mr Scott-Brown a Trust information sheet about Lamotrigine and a Patient Information Leaflet about Lamotrigine from the drug manufacturer, GlaxoSmithKline. It was common ground that the consultant should have done so. Both documents record as a side effect of using Lamotrigine a risk that the patient may begin to experience thoughts of self-harm or suicide. Mr Scott-Brown was never given that information.
The consultant gave evidence that he was not aware of that particular side effect of Lamotrigine, and that his prescribing practice was informed by the British National Formulary and The Maudsley Prescribing Guidelines. Neither the online BNF viewable via the NICE website nor the 10th Edition of The Maudsley Guidelines (to which the court was referred) refer to that side effect in their respective entries for Lamotrigine.
Subsequent to the conclusion of the Inquest, I have learned from the Oxleas NHS Foundation Trust that when Mr Scott-Brown was prescribed Lamotrigine, then the current edition of the Maudsley Guidelines was the 13th Edition. The Inquest heard no evidence about the 13th Edition of the Maudsley Guidelines and information therein concerning Lamotrigine.
Quite apart from any issue regarding the consultant’s knowledge about Lamotrigine (and the existence of the 13th Edition of the Maudsley Guidelines) and his not having given Mr Scott-Brown the Trust’s prepared information about the drug and its side effects, I am concerned that two obviously reputable sources of pharmacological information are apparently silent, or have been silent, on a potentially significant side effect of this particular drug.
From a lay perspective, there is apparent potential for harm to patients depending upon which resources a prescriber consults before prescribing Lamotrigine. That potential for harm might be ameliorated were the advice about Lamotrigine consistent across all such resources.
” Open source report
10 Feb 2020 Ms Kerry Aldridge · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency View source Insufficient mental health training for Sexual Offences Investigation Trained officers View source Lack of established links between police Safeguarding teams and NHS mental health teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms Kerry Aldridge · 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
Ms Kerry Aldridge was a student police officer who died by suicide after jumping into the path of a train at Sydenham Railway Station on 6 April 2019. The report raised concerns about the lack of established links between police Safeguarding Teams and NHS mental health teams, and about the need for further mental health training and access to non-urgent advice for officers.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency
Wider context from the report “During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support.
It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent , which may be a difficult judgment for officers, without professional mental health advice .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training for Sexual Offences Investigation Trained officers
Wider context from the report “During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health . ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support.
It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of established links between police Safeguarding teams and NHS mental health teams
Wider context from the report “During the course of the inquest, the local MPS investigation by Directorate of Professional Standards reported the view of the Central Mental Health Team that Sexual Offences Investigation Trained officers require further training in mental health. ████████ the investigating officer, gave evidence that it would be beneficial to have a mental health single point of contact within the local mental health team who could be contacted for non-urgent advice by Safeguarding Teams concerning victims that they are most concerned about. The investigation found no misconduct by officers, who provided a good level of care and support.
It appears that the police Safeguarding team have no established links with NHS MH team and that referral to a Crisis Resolution and Home Treatment Team depends on an officer recognising the need was urgent, which may be a difficult judgment for officers, without professional mental health advice.
” 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 Operate a 24-hour mental-health advice and support line for the public, police and ambulance service, staffed by mental-health professionals who can initiate rapid joint assessment.
Verbatim wording from the response “South London & Maudsley NHS Trust has, since 2017, worked in partnership with the Metropolitan Police to provide a crisis and assessment service. The service enables mental health staff to work jointly with metropolitan police officers in the provision of early assessment and intervention. ████████, allocates officers to work within the Crisis and Assessment Team. The service also provides a 24 hour advice and support line to the public, 111 service, the police and London Ambulance Service. The advice line is staffed by mental health professionals who will advise officers and instigate rapid joint assessment if required. This joint arrangement between the police and South London & Maudsley NHS Foundation Trust offers a proactive joint response to the concerns that may face police officers who may have limited knowledge in relation to mental illness.” Source location 2020-0055-Response-from-South-London-and-Maudsley-NHS-Foundation-Redacted
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 Employ two Metropolitan Police officers within main SLaM hospital sites to provide information, advice and support and liaise with borough safeguarding officers.
Verbatim wording from the response “Mental Health Support to Metropolitan Police Officers
████████ identified that the Metropolitan Police do not have a Safeguarding Adult Team, however, there are safeguarding strands attached to all 12 of the Borough Command Units. South London & Maudsley NHS Trust Foundation Trust employ two full time Metropolitan Police officers who work within our main hospital sites and liaise on a three monthly basis with the borough command safeguarding officers who all have mental health knowledge and experience. The officers employed within our mental health trust would usually act as a conduit for information, advice and support within our service but also their fellow officers in the borough command units” Source location 2020-0055-Response-from-South-London-and-Maudsley-NHS-Foundation-Redacted
Open published response
8 May 2018 WILLIAM DICKENS · Prevention of Future Deaths report London Inner (South)
View report summary
Concerns raised 2 Failure to make contemporaneous observation-log entries View source Failure to conduct required ward patient observations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
WILLIAM DICKENS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
WILLIAM DICKENS, who was assessed as at high risk of repeat self-harm, died on 10 May 2017 after being discovered hanging by a belt from the bed in his room at a mental health unit. The report raises concerns that required intermittent observations were not carried out, that observation-log entries were made after the event, and that defects in the logging process could create a risk of future deaths.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make contemporaneous observation-log entries
Wider context from the report “(1) From 10 am on the morning of 10 May 2017 the observation regime for the ward was not complied with. While there are notes on the observation log suggesting that some patients had been seen in the period between 10 am and 11 am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation log shows that several other patients were unaccounted for during the same period.
(2) During the inquest the nurse in charge of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and 11 am were not made contemporaneously but after Mr Dickens had died . No note had been made on the log to indicate that the entries were being made after the event .
(3) While the observation log may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks on the patients were in fact conducted; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe.
(4) Those purposes are plainly frustrated if entries are made on the log at times that are different to the actual observations, and after the event .
(5) Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required ward patient observations
Wider context from the report “(1) From 10 am on the morning of 10 May 2017 the observation regime for the ward was not complied with . While there are notes on the observation log suggesting that some patients had been seen in the period between 10 am and 11 am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation log shows that several other patients were unaccounted for during the same period .
(2) During the inquest the nurse in charge of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and 11 am were not made contemporaneously but after Mr Dickens had died. No note had been made on the log to indicate that the entries were being made after the event.
(3) While the observation log may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks on the patients were in fact conducted ; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe.
(4) Those purposes are plainly frustrated if entries are made on the log at times that are different to the actual observations, and after the event.
(5) Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver annual Learning the Lessons presentations on timely observation and recording to nurses in training years one to three, using the case as teaching material.
Verbatim wording from the response “5) From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for.
Commencing September 2018 and annual thereafter.” Source location 2018-0137-Response-by-South-London-Maudsley-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 Develop a timeline for transforming mental health safety and engagement observations into the e-observation framework, beginning with scoping.
Verbatim wording from the response “7) The Director of Nursing as Chair of the E-observation Project Group to develop the timeline for transforming mental health safety and engagement observations into the e-observation framework.
This is a long term project that is complex to deliver, a time frame is difficult to reliably commit to, the aim will be scoping from January 2019.” Source location 2018-0137-Response-by-South-London-Maudsley-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 Deliver annual Learning the Lessons presentations on timely observation and recording to newly registered nurses, using the case as teaching material.
Verbatim wording from the response “4) From September 2018 the cohort of newly registered nurses to receive a “Learning the Lessons” presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for.
Commencing September 2018 and annual thereafter.” Source location 2018-0137-Response-by-South-London-Maudsley-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 Conduct six-monthly snap audits of compliance with observation standards, report results through quality governance meetings, and take necessary improvement steps.
Verbatim wording from the response “8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance.
Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate.” Source location 2018-0137-Response-by-South-London-Maudsley-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 an internal Blue Light Bulletin to registered nurses using the case to reinforce observation and recording practice standards.
Verbatim wording from the response “1) The Director of Nursing to use the case as the basis of an internal safety alert ‘Blue Light Bulletin’ to be sent out to all registered nurses to reinforce the practice standards.
To be completed by 6/07/18” Source location 2018-0137-Response-by-South-London-Maudsley-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 Direct ward managers to hold learning conversations with inpatient registered and non-registered nurses about observation practice.
Verbatim wording from the response “2) All Ward Managers to be directed to have a learning conversation with inpatient registered and non-registered nurses about the practice.
To be completed by 31/07/18” Source location 2018-0137-Response-by-South-London-Maudsley-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 the Therapeutic Engagement and Observation Policy, focusing on practice-standard clarity and policy implementation.
Verbatim wording from the response “3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to the clarity of practice standards and the implementation of the policy.” Source location 2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Open published response
27 Apr 2018 Katy Roberts · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 3 Failure to expressly communicate in writing all routes for raising concerns and seeking help View source Failure to provide a clear route or opportunity to challenge or appeal Care Plan changes View source Failure to communicate in writing a Care Plan and changes to it View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Katy Roberts · 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
Katy Roberts, who was aged 16, was under the care of CAMHS at SLAM when she died; the inquest concluded that her death was suicide. The report describes concerns that changes to her care plan were not confirmed in writing, that there was no clear route to challenge or appeal them, and that written routes for seeking help in emergencies and non-emergencies were not clearly communicated.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to expressly communicate in writing all routes for raising concerns and seeking help
Wider context from the report “(3) Failure to expressly communicate in writing all routes by which, to raise concerns and seek help on a non-emergency or emergency 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clear route or opportunity to challenge or appeal Care Plan changes
Wider context from the report “(2) Failure to provide a clear route or opportunity to challenge or appeal these changes to the Care Plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate in writing a Care Plan and changes to it
Wider context from the report “(1) Failure to communicate in writing a Care Plan and changes to it .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to routinely provide written guidance explaining how young people and families can seek emergency and non-emergency help.
Verbatim wording from the response “3. Guidance to Young People, their Parents and Carers
All CAMHS community services provide clear written guidance to Young People, their families and other agencies on how to seek help from CAMHS and other services. We will remind all staff to make this information available routinely and will conduct a survey with service user, carers and parents in January 2019 to assure the CAMHS Directorate operational management teams that the information is being made available.” Source location 2018-0136-Response-by-South-London-and-Maudsley
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an implementation plan to introduce the Community Care Plan across CAMHS community teams.
Verbatim wording from the response “1. Written Care Plan
All CAMHS community practitioners, working with Young People with complex mental health difficulties, will complete a Community Care Plan with the Young Person concerned. While this has been our practice for some time, we have not adopted a consistent way of writing and sharing care plans and risk assessments. The Trust completed the testing of the Community Care Plan in June 2018 and CAMHS is now developing an implementation plan for its introduction across community teams. A Community Care Plan summary document is attached with this response.” Source location 2018-0136-Response-by-South-London-and-Maudsley
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure young people and families review proposed Community Care Plans and agree or change them within four working weeks.
Verbatim wording from the response “CAMHS community practitioners will ensure that the Community Care Plan proposed is reviewed by the Young Person and their family and then either agreed, or changed, within 4 working weeks. The number of Community Care Plans changed, following challenge or appeal will be audited and performance considered by CAMHS Directorate Operational Governance meeting each Quarter.” Source location 2018-0136-Response-by-South-London-and-Maudsley
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 Monitor Community Care Plan implementation and communication through patient-led reports, supervision, monthly performance meetings and quarterly governance reviews.
Verbatim wording from the response “Monitoring of implementation and communication of the plans, at individual practitioner and team leader level, will be enabled by patient led reports and supervision. CAMHS Borough Community Services will include this new” Source location 2018-0136-Response-by-South-London-and-Maudsley
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Southwark Emergency and Developing Crisis Protocol with GPs, school counsellors, young people and their families.
Verbatim wording from the response “Southwark now has an Emergency and Developing Crisis Protocol, which has been widely shared with GPs, schools counsellors, Young People and their families; a copy is attached.” Source location 2018-0136-Response-by-South-London-and-Maudsley
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 Survey service users, carers and parents in January 2019 to assess whether help-seeking information is being made available.
Verbatim wording from the response “3. Guidance to Young People, their Parents and Carers
All CAMHS community services provide clear written guidance to Young People, their families and other agencies on how to seek help from CAMHS and other services. We will remind all staff to make this information available routinely and will conduct a survey with service user, carers and parents in January 2019 to assure the CAMHS Directorate operational management teams that the information is being made available.” Source location 2018-0136-Response-by-South-London-and-Maudsley
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit Community Care Plans changed after challenge or appeal and consider performance quarterly through CAMHS Directorate Operational Governance.
Verbatim wording from the response “CAMHS community practitioners will ensure that the Community Care Plan proposed is reviewed by the Young Person and their family and then either agreed, or changed, within 4 working weeks. The number of Community Care Plans changed, following challenge or appeal will be audited and performance considered by CAMHS Directorate Operational Governance meeting each Quarter.” Source location 2018-0136-Response-by-South-London-and-Maudsley
Open published response
21 Mar 2018 Edward Arthur Lundy · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 5 Failure to clearly communicate when psychiatric assessment is believed necessary in referrals View source Failure to maintain continuity of care when patients have contact with multiple professionals View source Failure to document discharge consultation and explicitly discuss risks with families View source Lack of evidence of compliance with recommended safety actions View source Failure to provide independent consultation with families on discharge to family care View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Edward Arthur Lundy · 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
Edward Arthur Lundy, who had a history of depression, was found hanging in a barn on 23 August 2016 and could not be revived. The concerns identified included a lack of continuity in his care, no psychiatric assessment despite a referral indicating this was needed, and insufficient documentation and discussion of care options and risks with his family. The report also states that evidence had not been produced showing that the proposed actions had been implemented or shared nationally.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly communicate when psychiatric assessment is believed necessary in referrals
Wider context from the report “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced.
2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings.
3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist . Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission.
There has been no evidence produced as to compliance with the recommended actions.
There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts.
That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continuity of care when patients have contact with multiple professionals
Wider context from the report “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care . Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced.
2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings.
3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission.
There has been no evidence produced as to compliance with the recommended actions.
There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts.
That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document discharge consultation and explicitly discuss risks with families
Wider context from the report “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced.
2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed . Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings.
3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission.
There has been no evidence produced as to compliance with the recommended actions.
There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts.
That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence of compliance with recommended safety actions
Wider context from the report “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced.
2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings.
3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission.
There has been no evidence produced as to compliance with the recommended actions.
There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts.
That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide independent consultation with families on discharge to family care
Wider context from the report “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced.
2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings.
3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission.
There has been no evidence produced as to compliance with the recommended actions.
There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts.
That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure.
” Open source report
28 Jun 2017 Olaseni Lewis · Prevention of Future Deaths report South London
View report summary
Concerns raised 8 Inadequate definition of prolonged restraint and restraint danger in ABD training View source Lack of defined and understood respective roles and responsibilities between healthcare and police staff View source Failure of ABD training to provide clear and understood recognition guidance View source Lack of guidance and training for failure to achieve control within a given period View source Lack of trained and physically able medical staff View source Lack of clarity about responsibility for assessing compliance View source Failure to follow the policy for closing wards or placing them in special measures when training levels fall below the required level View source Lack of required reading and ready reference on restraint techniques and dangers View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Olaseni Lewis · 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
Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate definition of prolonged restraint and restraint danger in ABD training
Wider context from the report “(3) Police were taught that prolonged restraint was dangerous, but had no idea what “prolonged” meant, and were left to use their own judgement . They also seemed to think that prolonged restraint referred to time spent in a prone position and that as long as the detainee was held on his/her side the danger was ameliorated or removed . The pathological and psychiatric expert evidence clearly indicated that restraint in any position can lead to sudden death in patients who are highly agitated . The jury found that the police training was inadequate in its definition of “prolonged restraint” for people exhibiting signs of ABD .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined and understood respective roles and responsibilities between healthcare and police staff
Wider context from the report “(5) There was no training or understanding about the respective roles and responsibilities of healthcare and police staff . There was (and still is) no Memorandum of Understanding .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ABD training to provide clear and understood recognition guidance
Wider context from the report “(2) Officers had been taught about Acute Behavioural Disturbance (ABD) but most did not recognise that Mr Lewis was suffering from ABD . The training on ABD appeared unnecessarily complicated and was not fully understood by officers . They incorrectly assumed that it was a formal diagnosis of some sort and that healthcare professionals would be able to recognise and treat the condition . An expert psychiatrist indicated that the description might be helpful for police in the community, particularly when the condition is caused by drugs, but it causes difficulty when police and mental health services work together and where the underlying cause is related to mental illness. The question that arose was whether it is necessary to attach a label at all. It might be more easily understood if officers are taught that people who resist restraint and appear to be suffering from mental illness may not respond as expected, and are therefore more vulnerable to die suddenly during restraint.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance and training for failure to achieve control within a given period
Wider context from the report “(4) Police officers were given no advice or training what they could or should do if control was not achieved within a given period of time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of trained and physically able medical staff
Wider context from the report “(6) The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff . The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was not followed and there was a lack of clarity around who was responsible for assessing compliance
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for assessing compliance
Wider context from the report “(6) The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff. The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was not followed and there was a lack of clarity around who was responsible for assessing compliance
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy for closing wards or placing them in special measures when training levels fall below the required level
Wider context from the report “(6) The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff. The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was not followed and there was a lack of clarity around who was responsible for assessing compliance
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of required reading and ready reference on restraint techniques and dangers
Wider context from the report “(1) The court was told that officers are not expected to read Standing Operating Procedures and the Officer Safety Manual , and there is little “required reading” or ready reference for police officers regarding restraint techniques and dangers .
” 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 Deliver Trust-wide training on Operation Metallah, multi-agency emergency roles, and responsibilities for police assistance.
Verbatim wording from the response “Training has been implemented across the Trust which teaches staff about the protocols of Operation Metallah. In addition, a training DVD called "Safety in Mind" has been and is being shown to staff. The film aims to demonstrate successful ways of working together, the roles, relationships and expectations that should feature when working in a multi-agency mental health emergency. Staff have also been and are continuing to be trained in their respective roles and responsibilities relating to police assistance at one of the Trust's hospital sites as a matter of routine.” Source location 2017-0205-Response-by-South-London-and-Maudsley-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 Audit clinical-team training compliance monthly and apply improvement targets and formal performance management where required levels are not achieved.
Verbatim wording from the response “Every member of a clinical team is allocated to a level of Promoting Safer and Therapeutic Services ('PSTS') training appropriate to their role. This allocation then forms part of their training requirements and is captured within our education and training database ('LEAP'). The LEAP system and the training delivery is the responsibility of the Trust's Education and Training Department.” Source location 2017-0205-Response-by-South-London-and-Maudsley-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 Conduct recurring police liaison meetings to discuss interface issues, review incidents, monitor trends, and undertake thematic section 136 reviews.
Verbatim wording from the response “Local police liaison meetings, chaired by local clinical service managers with local police representation present, occur every 2 months. In these meetings any local interface issues are discussed and all Operation Metallah incidents for that specific borough are reviewed. In addition, there is a Trust-wide police liaison meeting which is chaired by one of our service directors which brings the four borough representatives from both the police and the Trust together to discuss issues that cut across the four boroughs. Monitoring of all Operation Metallah incidents and relevant trends takes place at this meeting and they also undertake thematic reviews of section 136 use. This meeting occurs every three months.” Source location 2017-0205-Response-by-South-London-and-Maudsley-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 Implement formal Operation Metallah protocols for police responses to hospital emergencies.
Verbatim wording from the response “Following the death of Olaseni Lewis, the Trust and police have worked very closely together to develop formal working protocols when the police are called. This is currently called Operation Metallah and was described in my witness statement for the inquest dated 1 February 2017. Any emergency call received by the Central Control Centre ('CCC') originating from the Bethlem Royal Hospital, Maudsley Hospital, or Lambeth Hospital sites is” Source location 2017-0205-Response-by-South-London-and-Maudsley-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 Monitor staff unable to undertake PSTS physical-intervention training and redeploy unable staff to other work areas.
Verbatim wording from the response “Through ward managers, directorate and Clinical Academic Group Leads and the Trust's Education and Training Department, the Trust is closely monitoring whether any of its staff members are unable to take part in any level of PSTS training either temporarily or in the long term. The Trust seeks to ensure that its services always have the minimum number of staff available to provide safe and therapeutic care to its patients which includes the ability of staff members to use PSTS physical interventions in the correct manner. The Trust has redeployed staff to other work areas on the basis that they are unable to perform PSTS physical interventions.” Source location 2017-0205-Response-by-South-London-and-Maudsley-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 Formally discuss and sign off the Memorandum of Understanding with the Metropolitan Police at the scheduled 5 September 2017 meeting.
Verbatim wording from the response “There is also a quarterly meeting with borough commanders which is chaired by our Chief Operating Officer where any significant issues are raised. The Memorandum of Understanding will be formally discussed and signed off at the next quarterly meeting on 5 September 2017, as issues have been clarified between the two organisations in the intervening period since the release of the draft document for comment in the early part of this year.” Source location 2017-0205-Response-by-South-London-and-Maudsley-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 The decision to place a service on special measures for inadequate mandatory training rests with the relevant directorate and Clinical Academic Group leads.
Verbatim wording from the response “I enclose a copy of Appendix 2 of the Trust's up-to-date Mandatory Training Policy entitled 'Escalation procedure for mandatory training levels. Escalation and action procedure should Tier 1 training levels fall below agreed standards', to be enacted by Directorate E&T committee or Directorate Performance management. It can be seen from this that it remains open to the Trust to place a service on special measures in relation to mandatory training levels and the decision to take this step rests in the hands of the relevant directorate and Clinical Academic Group Leads.” Source location 2017-0205-Response-by-South-London-and-Maudsley-NHS-Trust
Open published response
28 May 2017 Jamie Pashley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Failure to make telephone contact between discharge and first appointment review View source Reliance on individuals to proactively manage their rehabilitation after discharge View source Limited availability of hospital alcohol liaison nurse support View source Failure to provide fixed post-discharge appointments after detoxification View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jamie Pashley · 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
Jamie Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make telephone contact between discharge and first appointment review
Wider context from the report “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed:
(1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment;
(2) whether telephone contact should also be made with an individual between discharge and first appointment review ;
(3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on individuals to proactively manage their rehabilitation after discharge
Wider context from the report “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed:
(1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment;
(2) whether telephone contact should also be made with an individual between discharge and first appointment review;
(3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited availability of hospital alcohol liaison nurse support
Wider context from the report “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed:
(1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment;
(2) whether telephone contact should also be made with an individual between discharge and first appointment review;
(3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide fixed post-discharge appointments after detoxification
Wider context from the report “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed:
(1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment ;
(2) whether telephone contact should also be made with an individual between discharge and first appointment review;
(3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient.
” Open source report
5 Dec 2016 Christopher Brennan · Prevention of Future Deaths report South London
View report summary
Concerns raised 2 Unavailability of laryngoscopes in emergency equipment on the unit View source Lack of adequate policy or guidance for assessing and managing self-harm risks from items on adolescent psychiatric units 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
Christopher Brennan · 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
Christopher Brennan, aged 15, was a patient at an adolescent psychiatric unit and died on 31 August 2014 after swallowing the lid of a roll-on deodorant, causing acute upper airway obstruction and cardiac arrest. The report identified concerns about the lack of clear and consistent guidance for managing items that could be used for self-harm and the absence of a laryngoscope from the unit’s emergency equipment.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of laryngoscopes in emergency equipment on the unit
Wider context from the report “(2) With regard to resuscitation: the emergency equipment on the unit did not include a laryngoscope . The item obstructing Christopher’s airway was subsequently used by ambulance personnel using Magill forceps with a laryngoscope, and this combination had been successfully used on a previous occasion when Christopher had swallowed a bottle top.
Laryngoscopes are not part of the standardised items on the unit , and are not included in the Resuscitation Council guidance for mental healthcare settings. It has been suggested that this is because they are complex devices that require intense training and competency assessments before staff can use them, and that it may be counterproductive to make them available. However, in view of the circumstances of Christopher’s death, and the apparent prevalence of self harm in adolescent units, the matter is reported for consideration, both in relation to the laryngoscope itself and the access to staff trained in its use.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate policy or guidance for assessing and managing self-harm risks from items on adolescent psychiatric units
Wider context from the report “(1) In respect of the in-patient management: that there was no separate policy or guidance, other than a partial wall chart, regarding the assessment and management of risks posed by items that might be used to cause self harm . The complexities of managing these risks on an adolescent in-patient psychiatric unit were not therefore adequately considered , and this led to a lack of clarity and consistency .
” Open source report
14 Jun 2016 Christina O'Brien · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Lack of non-hospital respite care options for mentally ill people in the community View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christina O'Brien · 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
Christina O'Brien died by suicide on 17 September 2015 after hanging herself outside her flat; she also had injuries to her arms and legs. She had a long-term mental illness and was receiving treatment and care from SLAM. The principal concern was that community respite options for people experiencing mental health crises were limited, particularly after the withdrawal of Dove House, a non-hospital respite facility that had previously benefited her.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of non-hospital respite care options for mentally ill people in the community
Wider context from the report “(1) I am concerned that the options for mentally ill people in the community needing respite care through SLAM are limited solely to attendance by the Home Treatment team as the alternative to hospital admission . In this particular case I found that the availability of Dove House did, in the past, provide respite for the deceased. I also find, on the evidence I heard, that if this option had been available in 2015 the death might have been prevented. Whilst the Home Treatment team could provide support by way of medication and counselling it could not deal with the source of the distress the deceased was suffering from building work.
(2) Given the unpredictability of the perceptions of people with mental illness in the community I also found that having a further option of respite residence in a non hospital setting could prevent future self-inflicted deaths. Examples that spring to mind, in a high density area like Lambeth, might be bullying by neighbours or sources of excessive noise from neighbouring residences as well as building work.
(3) I am concerned the Dove House facility was withdrawn in about 2008 without any provision being made for alternative respite care when it appeared to have had a beneficial effect for the deceased and, by reasonable inference, other SLAM patients.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review crisis-house provision to assess appropriate crisis accommodation and alternatives.
Verbatim wording from the response “The Trust undertook a review of crisis house provision during 2014 and this review was led by the living well collaborative. This report is attached for your further information. The view taken following this review was that a residential option was problematic in that typically bed based crisis beds tend to get tilted up quickly so took the position we should trial out an on-bed based model. The outcome was to pilot the evening sanctuary from April 2015 for two to three days per week. This provision has been commissioned full time from the week beginning 11 July 2016 and provides an out of hour’s alternative to people experiencing crisis.” Source location 2016-0221-South-London-and-Maudsley-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 Commission the evening sanctuary full time as an out-of-hours alternative for people experiencing crisis.
Verbatim wording from the response “The Trust undertook a review of crisis house provision during 2014 and this review was led by the living well collaborative. This report is attached for your further information. The view taken following this review was that a residential option was problematic in that typically bed based crisis beds tend to get tilted up quickly so took the position we should trial out an on-bed based model. The outcome was to pilot the evening sanctuary from April 2015 for two to three days per week. This provision has been commissioned full time from the week beginning 11 July 2016 and provides an out of hour’s alternative to people experiencing crisis.” Source location 2016-0221-South-London-and-Maudsley-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 The former crisis house was decommissioned because demand for this type of facility was considered low.
Verbatim wording from the response “Dove House was not a crisis house and it was decommissioned with joint agreement between the Trust and the former Lambeth PCT in 2009 due to there being low demand for a facility of this type. The Trust closed the Emergency Clinic at the Maudsley Hospital approximately eight years ago for clinical reasons.” Source location 2016-0221-South-London-and-Maudsley-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 Expanded crisis services and an evening sanctuary were considered preferable to reintroducing a residential crisis-house option.
Verbatim wording from the response “The Trust undertook a review of crisis house provision during 2014 and this review was led by the living well collaborative. This report is attached for your further information. The view taken following this review was that a residential option was problematic in that typically bed based crisis beds tend to get tilted up quickly so took the position we should trial out an on-bed based model. The outcome was to pilot the evening sanctuary from April 2015 for two to three days per week. This provision has been commissioned full time from the week beginning 11 July 2016 and provides an out of hour’s alternative to people experiencing crisis.” Source location 2016-0221-South-London-and-Maudsley-NHS-Trust
Open published response
9 Jul 2015 Michael George · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 5 Failure to provide appropriate care plans addressing the risks of refused urine and blood glucose testing View source Failure to provide domiciliary consultant physician visits to mental health wards View source Insufficient senior management attention to Regulation 28 reports and the physical health care of mentally ill patients View source Failure to follow up refused glucose and urine testing for patients on antipsychotics View source Failure to ensure immediate ambulance transfer when abnormal blood results require urgent transfer View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael George · 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 George died after developing a life-threatening hyperglycaemic condition while receiving long-term Olanzapine treatment. The report identified concerns about inadequate monitoring for diabetes, delays and insufficient urgency in transfer to A&E, incomplete referral information, and gaps in the subsequent oversight and care arrangements for the physical health of mental health inpatients.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate care plans addressing the risks of refused urine and blood glucose testing
Wider context from the report “(2) Although there was now systematic recording of urine and blood glucose of patients on antipsychotics on the wards, the audit conducted and presented in court showed a number of patients who had refused these tests, but not demonstrated whether in subsequent weeks testing was conducted or whether these same patients, like Mr George, never had their glucose measured, noting that urine measurement was non invasive, and had an appropriate care plan to address these risks .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide domiciliary consultant physician visits to mental health wards
Wider context from the report “(3) The Trust response to 2654-11 in September 2014 was that a research bid was being mounted and discussions held with commissioners and Kings College Hospital (KCH). Progress on this was not provided to the court and there had apparently not been action to reduce risks of deaths by ensuring there were domiciliary visits from consultant physicians at KCH (which is across the road from the Maudsley) to mental health wards , as reported to the Trust in 2014. The need to implement such a service was again reiterated by a different expert in this inquest . It is inferred from the expert opinion that failure to do so would mean that patients in SLAM in-patient units would be more at risk than those mental health patients in a district general hospital.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient senior management attention to Regulation 28 reports and the physical health care of mentally ill patients
Wider context from the report “(1) The management spokesperson on the Action Plan at the inquest was unaware that the Trust had received these two court Regulation 28 reports , suggesting that senior management attached insufficient importance to them and the issue of physical health care of mentally ill 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up refused glucose and urine testing for patients on antipsychotics
Wider context from the report “(2) Although there was now systematic recording of urine and blood glucose of patients on antipsychotics on the wards, the audit conducted and presented in court showed a number of patients who had refused these tests, but not demonstrated whether in subsequent weeks testing was conducted or whether these same patients, like Mr George, never had their glucose measured , noting that urine measurement was non invasive, and had an appropriate care plan to address these risks.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediate ambulance transfer when abnormal blood results require urgent transfer
Wider context from the report “(4) Whilst there had been individual learning and changes in training and note keeping and recording, it was unclear whether, in the absence of consultant physician advice, that the serious untoward incident investigation conclusion on urgent transfer would be heeded . It advised that there should have been immediate action to call an ambulance to effect transfer, despite lack of consent, when the blood results were known .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue collaboration with Kings College Hospital to improve access to medical care and support rapid access from the Maudsley site.
Verbatim wording from the response “6. We have linked with KCH to continue to improve access to care and demonstrated in a pilot study how this affects length of stay in the acute hospital – an indirect indicator of medical need. (Appendix III) I also attach the pathway for rapid access to medical care from the Maudsley site. (Appendix IV)” Source location 2015-0264-Response-by-South-London-and-Maudsley-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Physical Health Committee with consultant diabetology input to improve diabetes management on inpatient wards.
Verbatim wording from the response “1. The Trust has established a Physical Health Committee chaired by two consultant psychiatrists, ████████ and ████████. The committee has been working closely with ████████, Consultant Diabetologist in improving the management of Diabetes Mellitus on our wards.” Source location 2015-0264-Response-by-South-London-and-Maudsley-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 Lobby for resources to establish an inpatient medical liaison service.
Verbatim wording from the response “5. In relation to the previous recommendation of Inreach medicine into the system, the Trust collaborated with KCH to put in a bid for a Medical Liaison Team to consult on the medical management of our inpatients. After repeated revisions, this was turned down. This was unfortunate as we had clearly demonstrated the need as evidenced in Appendix II, where we show that over 10% of our admissions are medically unstable enough to require a night in a general hospital as part of their SLAM inpatient stay. However, to my knowledge, no Mental Health Trusts have Inreach medical care on their general psychiatry wards, although many forensic units have GPs who visit (in keeping with the long length of stay). We plan tp continue to lobby for resources to establish such a service.” Source location 2015-0264-Response-by-South-London-and-Maudsley-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 Submit and revise a bid with Kings College Hospital for a Medical Liaison Team providing medical-management advice to inpatients.
Verbatim wording from the response “5. In relation to the previous recommendation of Inreach medicine into the system, the Trust collaborated with KCH to put in a bid for a Medical Liaison Team to consult on the medical management of our inpatients. After repeated revisions, this was turned down. This was unfortunate as we had clearly demonstrated the need as evidenced in Appendix II, where we show that over 10% of our admissions are medically unstable enough to require a night in a general hospital as part of their SLAM inpatient stay. However, to my knowledge, no Mental Health Trusts have Inreach medical care on their general psychiatry wards, although many forensic units have GPs who visit (in keeping with the long length of stay). We plan tp continue to lobby for resources to establish such a service.” Source location 2015-0264-Response-by-South-London-and-Maudsley-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 Testing patients who refuse blood or urine samples is constrained by the practical difficulty and unpleasantness of restraint.
Verbatim wording from the response “10. CQUINs (commissioning for quality and innovation) have optimised the requesting of tests on the wards but the management of patients refusing tests is very difficult. It is possible to take glucose under restraint under the MHA. The MCA may be used but, restraint for bloods is technically difficult and if someone has a treatment responsive illness, in the absence of an acute deterioration, people often wait for their mental health to settle and try again once, they regain capacity. If someone is refusing bloods, it is rare for them to agree to urine testing – urine is usually more difficult to get than blood. However with respect to sugar, a BM Stix under restraint is feasible – though not pleasant.” Source location 2015-0264-Response-by-South-London-and-Maudsley-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 medical liaison service could not be established because the funding bid was rejected; resource lobbying will continue.
Verbatim wording from the response “5. In relation to the previous recommendation of Inreach medicine into the system, the Trust collaborated with KCH to put in a bid for a Medical Liaison Team to consult on the medical management of our inpatients. After repeated revisions, this was turned down. This was unfortunate as we had clearly demonstrated the need as evidenced in Appendix II, where we show that over 10% of our admissions are medically unstable enough to require a night in a general hospital as part of their SLAM inpatient stay. However, to my knowledge, no Mental Health Trusts have Inreach medical care on their general psychiatry wards, although many forensic units have GPs who visit (in keeping with the long length of stay). We plan tp continue to lobby for resources to establish such a service.” Source location 2015-0264-Response-by-South-London-and-Maudsley-NHS-Trust
Open published response
2 Dec 2014 Moses Andrew Arthur McDonald · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1 Lack of mandatory and regular glucose testing for people on antipsychotic medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Moses Andrew Arthur McDonald · 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
Moses Andrew Arthur McDonald, who had paranoid schizophrenia and was taking Clozapine, was found deceased at home on 2 April 2013 after experiencing frequent urination and extreme thirst. He had not undergone glucose testing since May 2012. The principal concern was the lack of mandatory and regular glucose testing by the Clozapine clinic while he was receiving antipsychotic medication; the inquest concluded that diabetic ketoacidosis 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and regular glucose testing for people on antipsychotic medication
Wider context from the report “(1) The lack of mandatory and regular glucose testing while on antipsychotic medication by the Clozapine clinic .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with physical-health monitoring recommendations and provide feedback to clinical services.
Verbatim wording from the response “In order to monitor compliance with the Maudsley Prescribing Guidelines, specifically relating to the physical health monitoring recommendations the Trust pharmacy team carry out regular audits and feedback to clinical services.” Source location 2014-0524-Response-by-South-London-Maudsley-NHS-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 Update the physical healthcare policy to define staff responsibilities and reference Maudsley guidance for patients prescribed Clozapine.
Verbatim wording from the response “The current physical healthcare policy has recently been updated and outlines the responsibility of each member of clinical staff to address the physical health needs of all patients.” Source location 2014-0524-Response-by-South-London-Maudsley-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Clozapine clinics across four boroughs to assess operations, resources, responsibilities and functions, define core functions and standards, and clarify management and reporting structures.
Verbatim wording from the response “In order to improve consistency of care provision and clarity of roles and responsibilities of physical health monitoring for patients attending the clinic the following actions will be taken within the next 6 months.” Source location 2014-0524-Response-by-South-London-Maudsley-NHS-Trust
Open published response
31 Oct 2014 CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Lack of adequate training and support for Care Coordinators View source Lack of audit and assurance of departmental safety changes View source Failure to ensure post-discharge follow-up visits View source Inconsistent supervision of Care Coordinators View source Failure to comprehensively plan discharge arrangements View source Failure to secure appropriate accommodation and care support at discharge View source Failure to identify and act on high-risk patient needs View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
CHRISTOPHER TOKE AJAYI · 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
Christopher Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate training and support for Care Coordinators
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of audit and assurance of departmental safety changes
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively , and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure post-discharge follow-up visits
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent supervision of Care Coordinators
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision , which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to comprehensively plan discharge arrangements
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure appropriate accommodation and care support at discharge
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and act on high-risk patient needs
Wider context from the report “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death.
In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day.
On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge.
Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him.
To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society.
It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators.
I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing.
I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop capacity within community caseloads with primary-care and third-sector stakeholders to support lower care-coordinator caseloads.
Verbatim wording from the response “• Case load management: Southwark community psychosis teams have active case-loads between 250-300 patients, resulting in average Care Co-ordinator case-loads of 25-30; the Trust continues to work with stakeholders in Primary care and the Third sector to develop capacity within the active case load, aiming ideally to reduce the average Care Co-ordinator case load to facilitate enhanced delivery of evidence based interventions; case loads are monitored on an ongoing basis, both within 1:1 supervision, and across the community as a whole.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Audit implementation of discharge planning, follow-up and care-coordinator support, then report and review results through safeguarding and Trust governance committees.
Verbatim wording from the response “Robust discharge planning and follow up and support to care coordinators are supported by the actions outlined in this report. However, the Trust will undertake an audit in March 2015 to assure itself and partners that implementation has been effective.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Prioritise community physical-health support in the next CQUIN commissioning round and consider primary-care outreach pilots.
Verbatim wording from the response “• Commissioning intentions (2015/16): appropriately supporting community patients to manage their physical health are being prioritised in the next round of CQUINs; there is a range of collaborative initiatives including consideration of pilots with GPs undertaking outreach clinics in community team bases to increase the numbers of patients receiving appropriate physical health assessments, investigations and interventions.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Work with partners to secure community district-nurse provision for safe diabetes management.
Verbatim wording from the response “• Community District Nurses: the Trust is working with our partners to ensure District Nurse provision to ensure safe community diabetes management.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Debrief involved staff and remind Trust and local-authority staff about discharge planning, documentation and physical-health guidance.
Verbatim wording from the response “• All Trust and London Borough of Southwark (LBS) staff involved in this specific case gave evidence, learnt lessons and have been de-briefed on the Coroner’s conclusions.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 housing and community-support needs with partners for patients managing physical health independently in the community.
Verbatim wording from the response “• Partnership working around social care and support: discussions are currently underway reviewing housing and community support needs for patients to appropriately address physical health once living independently in the community” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Develop an ICT portal enabling mutual access to key clinical information across Trust and acute electronic patient-record systems.
Verbatim wording from the response “• ICT harmony: there have been significant developments in increasing mutual access between the Trust and Acute electronic patient record systems, with the development of an ICT ‘Portal’ to review key clinical information; further developments are underway to link these secondary care systems with Primary care ICT (EMIS) systems; this work is further being supported by the Southwark CCG.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Revise, disseminate and publish the Trust supervision policy with clearer expectations for clinical and social-work staff.
Verbatim wording from the response “• Trust revised Supervision policy (Sept 2014); this recent policy update which covers Trust and LBS staff, has been sent out to all staff and available on the Trust intranet for reference, sets out clear expectations of staff supervision, recognising effective supervision as an integral aspect of the working lives of all NHS clinical and social work staff to support them to deliver the best care to patients and their carers, provide opportunity to develop competent parishioners and to develop their skills.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Implement updated action plans producing more robust systems and structures between Southwark inpatient and community teams.
Verbatim wording from the response “• The breakdown in effective clinical communication and collaborative care planning was noted in the Trust’s SI investigation report (together with action plans) and further acknowledged and discussed in supporting evidence given at Inquest.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Discuss scaling the diabetic liaison service for patients with severe mental-health disorders and develop additional community mental-health staff training.
Verbatim wording from the response “• Southwark Diabetic services; discussions are underway to scale up the award winning Diabetic Liaison service currently running at KCH to assist patients with severe mental health disorders, with additional training being developed for community mental health staff.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Identify and support community multidisciplinary-team staff to lead physical-health assessment, treatment and patient support.
Verbatim wording from the response “• MDT Physical Health leads within community MDTs: teams are being encouraged to identify and support individual team staff members to lead on developing support for patients to engage with the assessment, treatment and support around their physical health.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.
Verbatim wording from the response “• The community team involved have undertaken two specific audits: (a) Team 7 day follow-up performance (Oct-Dec 2014) showed no missed reviews; (b) Discharge of two patients with unstable diabetes (Dec 2014) demonstrated extensive communication and forward planning prior to discharge, appropriately involving all partners.” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 Complete discharge notification proformas routinely and send them to community teams or team managers on the discharge day, with ongoing audit.
Verbatim wording from the response “• Discharge proforma (discharge notification): this is now routinely completed and copies sent to community team/team manager on the day of discharge (compliance is monitored through ongoing audit).” Source location 2014-0558-Response-by-South-London-and-Maudsley-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 There are no systemic problems with discharge and community follow-up for patients with complex mental and physical health needs.
Verbatim wording from the response “The Trust acknowledges that important lessons have been learnt from this specific case that are being taken forward in improving integrated working; the Trust is otherwise confident that there is no systemic problems with regard to discharge and community follow up of similar patients with complex mental and physical health problems.” Source location 2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
Open published response
26 Jun 2014 Sadik Miah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Lack of consultant physician input into management of in-patients with physical health problems View source Lack of national guidance for addressing physical health matters in psychiatric care View source Failure to ensure ECG findings are monitored by psychiatrists View source Unavailability of timely medical opinions for non-emergency physical illness View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sadik Miah · 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
Sadik Miah, who had schizophrenia and was detained in hospital, collapsed suddenly and died in Lambeth Hospital on 15 October 2011 despite resuscitation. Concerns included the monitoring of ECG abnormalities and antipsychotic-related arrhythmia risk, delays in obtaining specialist advice about hyponatraemia, and the lack of regular physician support for psychiatric in-patients with physical health problems.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant physician input into management of in-patients with physical health problems
Wider context from the report “(1) ████████ said that consultant psychiatrists caring for in-patients with physical health problems did not have the benefit of a fellow consultant physician visiting, examining and advising on management , as would occur in a DGH. This did create a risk of other deaths occurring and should be a concern for the coroner.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for addressing physical health matters in psychiatric care
Wider context from the report “(2). It was reported that the Trust had been developing a Physical Health Policy and building corporate relationships, but that there was no national guidance about how organizations should address these matters . The court was not informed of the extent to which there was resolution of the areas of concern of the coroner.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure ECG findings are monitored by psychiatrists
Wider context from the report “During the inquest it was heard that antipsychotics, including Olanzapine, may cause arrhythmias and that a cardiologist's opinion may be needed from time to time. In this case the ECG done available was done in 2010 and showed a prolonged QT interval of 440, prior to transfer. ████████ said that he had an ECG in A&E but that this was not monitored by psychiatrists .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely medical opinions for non-emergency physical illness
Wider context from the report “During the inquest evidence was heard that he developed hyponatraemia from excessive drinking but the aetiology was not clear, although he was thought to have psychogenic polydipsia. A referral was made to an endocrinologist for a routine out patient appointment, for which there would be a 6-12 week wait. One of the possibilities of the cause was that it was medication related and it was agreed that such a delay was not appropriate. The court heard that there was a facility for emergency treatment for a physical illness, but apparently no facility for a medical opinion that was not an emergency but should not wait several weeks .
” Open source report
9 May 2014 Gary Richards · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to complete identified clinical pathway and interagency service improvements View source Lack of clarity of responsibility for risk assessment View source Failure to ensure reliable communication pathways for follow-up View source Failure to communicate patient risk and vulnerability to relevant agencies View source Failure to properly assess and record self-harm and suicide risk View source Inadequate support for patients when no mental illness is identified View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gary Richards · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete identified clinical pathway and interagency service improvements
Wider context from the report “(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients.
(3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity of responsibility for risk assessment
Wider context from the report “(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients.
(3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment , inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure reliable communication pathways for follow-up
Wider context from the report “(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients .
(3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patient risk and vulnerability to relevant agencies
Wider context from the report “(1) Psychiatric staff did not properly assess his risk of self harm, nor communicate his vulnerability to others . At discharge on 10/05 his risk of self harm was not fully measured. On being seen on 14/06 his risk assessment was not recorded and the risk plan not sent to the GP . The consultant explained that the risk was not mitigatable as no mental illness was found. Evidence was heard that his forensic history indicated that he belonged to a group of patients with 80 times the risk of suicide compared with the general population, yet he was considered at low risk. The value of performing a proper risk assessment to demonstrate the risks and vulnerabilities of the patient to other agencies, such as housing and social services , does not seem to have been considered, although it was reluctantly conceded by the consultant to be of value especially as homelessness presented as the primary problem.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly assess and record self-harm and suicide risk
Wider context from the report “(1) Psychiatric staff did not properly assess his risk of self harm , nor communicate his vulnerability to others. At discharge on 10/05 his risk of self harm was not fully measured . On being seen on 14/06 his risk assessment was not recorded and the risk plan not sent to the GP. The consultant explained that the risk was not mitigatable as no mental illness was found. Evidence was heard that his forensic history indicated that he belonged to a group of patients with 80 times the risk of suicide compared with the general population, yet he was considered at low risk. The value of performing a proper risk assessment to demonstrate the risks and vulnerabilities of the patient to other agencies, such as housing and social services, does not seem to have been considered, although it was reluctantly conceded by the consultant to be of value especially as homelessness presented as the primary problem.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate support for patients when no mental illness is identified
Wider context from the report “(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients.
(3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness . A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to record risk assessments in the correct electronic patient-record section.
Verbatim wording from the response “The Trust’s policy on risk assessment is clear in its documentation and staff have been reminded to ensure that when risk is assessed, that this is documented in the correct fashion in the relevant section of the electronic patient record to ensure that this is easily accessible by all clinical staff.” Source location 2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secure £250,000 funding to pilot a mental-health-specific homeless project linked to an established homeless support scheme.
Verbatim wording from the response “Homelessness features highly amongst the patients that the Trust cares for. However, I am pleased to inform you that we have been successful in obtaining funding in the sum of £250,000 from the Guys and St Thomas’ Hospital Charity to pilot a mental health specific homeless project working with those who present to our services. This will be linked to an existing scheme which is in place across King’s and St Thomas’ Hospitals for those who enter our services who are homeless, and where our staff will have direct access to the expertise in an already established homeless scheme. I am sure that this will lead to an improvement in the service we can provide to patients who are in this unfortunate situation.” Source location 2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Follow-up was attempted using the patient’s recorded telephone number and messages through A&E, rather than wholly failing through absent communication pathways.
Verbatim wording from the response “A further review of Mr Richards’ records indicates that when he was seen in the outpatient clinic in June, the service was aware of his mobile phone number. In fact, he had been called the day before by a social worker at the community team and asked to attend the outpatient appointment on 14 June as his GP had been concerned that he had again reported suicidal ideation.” Source location 2014-0212-Response-by-South-London-Maudsley-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 Referring the homeless patient to SHIP was considered the correct and only available way to mitigate his suicide risk.
Verbatim wording from the response “I believe that the clinicians involved in Mr Richards’ care were aware of the impact of his homelessness on his risk of suicide and that their focus on ensuring that he received the help that he required, by referring him to the Single Homeless Intervention and Prevention agency (SHIP) was the correct course of action to follow. This was, in reality, all that they could do to mitigate the suicide risk.” Source location 2014-0212-Response-by-South-London-Maudsley-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 Risk was assessed during admission but recorded in the wrong electronic-record location, rather than not being assessed.
Verbatim wording from the response “It is correct that there is no formal documentation of risk in the correct location on the PJS (our electronic patient record system) either at the point of his presentation under Section 136 or whilst on the Triage Ward. This was noted in the Trust’s investigators in their report. However, there is clear evidence in the clinical records that risk was assessed and is documented in the detailed entries made by the ward medical staff during his admission. It was acknowledged that there was a risk of suicide but this was not linked to mental illness but rather the difficult circumstances he found himself in, in particular, his homelessness.” Source location 2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further contact was constrained because the patient remained homeless and his sole recorded telephone number became unobtainable.
Verbatim wording from the response “She tried, using the number on file, but it was unobtainable. There was no other way of making contact with Mr Richards, so she left a message at the A&E department asking him to make contact with her should he re-present as he had booked an appointment to see her on 2 October.” Source location 2014-0212-Response-by-South-London-Maudsley-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 The method of threatened suicide was considered insignificant to this case because staff addressed the risk through accommodation support.
Verbatim wording from the response “Although Mr Richards did not have a mental illness, staff did acknowledge his suicidal intent and were aware that this was directly related to his homelessness. It is clear from his records that there was recurrent mention of committing suicide by jumping in front of a train. Although this may not have been noted specifically by the clinical team, his recurrent mention of suicide was. I do not feel that the method by which he said he would commit suicide is significant in this particular case. The way of addressing this was through assisting him in finding accommodation through SHIP. In order to obtain help through SHIP, he needed to be officially homeless and could not be considered as such, as long as his name was on the tenancy of the property he had shared with his wife.” Source location 2014-0212-Response-by-South-London-Maudsley-NHS-Trust
Open published response
6 Mar 2014 Natasha Raghoo · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 13 Sporadic and insufficient physical observations View source Delays in obtaining records from community services View source Inconsistent shift handover communication View source Lack of staff training in cardiopulmonary resuscitation and defibrillator use View source Failure to provide timely electrocardiograms View source Unclear policy for involving family in care planning View source Failure to check agency staff prior work before deployment View source Haphazard communication between staff and family View source Unclear responsibility for stopping physical observations View source Failure to use an available ward defibrillator View source Unclear policy on the duration of patient observations View source Unclear policy for access to GP services View source Poor-quality staff handovers 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
Natasha Raghoo · 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
Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Sporadic and insufficient physical observations
Wider context from the report “2. Physical observations of blood pressure, pulse and temperature were sporadic and few in number . This was cause for concern as Natasha had a raised blood pressure and had been commenced on treatment, Observations stopped two days prior to death and no member of staff was able to explain who was responsible for this action.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining records from community services
Wider context from the report “8. Obtaining records particularly from community services involved with the care of the patient was difficult and slow .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent shift handover communication
Wider context from the report “4. Staff handovers occur twice daily in the morning and evening. Those finishing a shift hand over information about the patients to the incoming shift. It was apparent that communication was inconsistent, particularly when bank or agency staff were involved .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in cardiopulmonary resuscitation and defibrillator use
Wider context from the report “1. During the course of the evidence, concern was expressed concerning the training that staff had received in the techniques of cardio pulmonary resuscitation and the use of the defibrillator . The latter was reported not to have been used by hospital staff although available on the ward.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely electrocardiograms
Wider context from the report “3. Whilst under the care of the Dene,and on antipsychotic drugs and with a raised blood pressure an electrocardiogram was not carried out because all routine ECGs are performed by a visiting nurse from a General Practitioners surgery on a set day of the week . An ECG machine is available within the hospital but is not routinely 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear policy for involving family in care planning
Wider context from the report “5. Communications between staff and family were haphazard the policy of involving family in care planning was not clear .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check agency staff prior work before deployment
Wider context from the report “7. Unclear as to whether checking to ensure that when using agency staff they have not already worked a shift elsewhere that day .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Haphazard communication between staff and family
Wider context from the report “5. Communications between staff and family were haphazard the policy of involving family in care planning was not clear.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for stopping physical observations
Wider context from the report “2. Physical observations of blood pressure, pulse and temperature were sporadic and few in number. This was cause for concern as Natasha had a raised blood pressure and had been commenced on treatment, Observations stopped two days prior to death and no member of staff was able to explain who was responsible for this action .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use an available ward defibrillator
Wider context from the report “1. During the course of the evidence, concern was expressed concerning the training that staff had received in the techniques of cardio pulmonary resuscitation and the use of the defibrillator. The latter was reported not to have been used by hospital staff although available on the ward .
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear policy on the duration of patient observations
Wider context from the report “9. The policy on length of time staff are expected to conduct observations , and the quality of handover from one member of staff to another.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear policy for access to GP services
Wider context from the report “6. The policy of access to GP services was not clear leading to misunderstanding by the Princess Royal as to where to send a report.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor-quality staff handovers
Wider context from the report “9. The policy on length of time staff are expected to conduct observations, and the quality of handover from one member of staff to another .
” Open source report
20 Aug 2013 Nicola Matthews · Prevention of Future Deaths report South London
View report summary
Concerns raised 3 Incomplete documentation of important clinical decisions View source Failure to provide discharging staff with clear information about medication supplied at discharge View source Unclear and undocumented follow-up arrangements for discharged 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.
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AI-generated summary
Nicola Matthews · 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
Nicola Matthews took an overdose of medication after leaving hospital on 15 October 2010 and was found unrousable at her partner’s home in the early hours of 16 October, later being pronounced dead in hospital. The principal concern was that decisions about her discharge, including follow-up arrangements and the nature and quantity of medication supplied, were unclear and inadequately documented or communicated.
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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete documentation of important clinical decisions
Wider context from the report “My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented. The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round. Nicola had a long-standing history of borderline personality disorder and was constantly at risk of self-harm. Her acts were frequently impulsive. Whilst she had been sectioned on 12 October, the Section 5 order was rescinded on 15 October at the ward round. Nicola was then insistent on being allowed to leave the hospital.
The follow-up arrangements made for her continuing care were not clear and were not documented. Evidence at my inquest suggested that there was no clarity as to what the follow-up arrangements were and whether or not they were made clear either to Nicola or to her partner.
In the event, Nicola went home and later that evening took an overdose of medication which resulted in her death. Whilst it is not possible to state that better arrangements for follow-up would probably have made a difference to the outcome, I am concerned to ensure that in future patients who are discharged have a clear understanding of follow-up arrangements. It is important that staff members on the ward who have to handle the departure of the patient from the ward have clarity as to what is to happen. In the case of Nicola, with the period of time between the decision being made and her actually leaving, staff had changed and the contemporaneous documents did not allow the member of staff who escorted Nicola off the ward to have a clear understanding of follow-up arrangements or indeed of the nature of and quantity of medication with which she was being discharged.
I suggest that consideration should be given to formulating better advice and ensuring that important decisions are better documented and that follow-up arrangements are made clear and adequately documented.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide discharging staff with clear information about medication supplied at discharge
Wider context from the report “My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented. The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round. Nicola had a long-standing history of borderline personality disorder and was constantly at risk of self-harm. Her acts were frequently impulsive. Whilst she had been sectioned on 12 October, the Section 5 order was rescinded on 15 October at the ward round. Nicola was then insistent on being allowed to leave the hospital.
The follow-up arrangements made for her continuing care were not clear and were not documented. Evidence at my inquest suggested that there was no clarity as to what the follow-up arrangements were and whether or not they were made clear either to Nicola or to her partner.
In the event, Nicola went home and later that evening took an overdose of medication which resulted in her death. Whilst it is not possible to state that better arrangements for follow-up would probably have made a difference to the outcome, I am concerned to ensure that in future patients who are discharged have a clear understanding of follow-up arrangements. It is important that staff members on the ward who have to handle the departure of the patient from the ward have clarity as to what is to happen. In the case of Nicola, with the period of time between the decision being made and her actually leaving, staff had changed and the contemporaneous documents did not allow the member of staff who escorted Nicola off the ward to have a clear understanding of follow-up arrangements or indeed of the nature of and quantity of medication with which she was being discharged.
I suggest that consideration should be given to formulating better advice and ensuring that important decisions are better documented and that follow-up arrangements are made clear and adequately documented.
” 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 South London and Maudsley NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear and undocumented follow-up arrangements for discharged patients
Wider context from the report “My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented. The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round. Nicola had a long-standing history of borderline personality disorder and was constantly at risk of self-harm. Her acts were frequently impulsive. Whilst she had been sectioned on 12 October, the Section 5 order was rescinded on 15 October at the ward round. Nicola was then insistent on being allowed to leave the hospital.
The follow-up arrangements made for her continuing care were not clear and were not documented. Evidence at my inquest suggested that there was no clarity as to what the follow-up arrangements were and whether or not they were made clear either to Nicola or to her partner.
In the event, Nicola went home and later that evening took an overdose of medication which resulted in her death. Whilst it is not possible to state that better arrangements for follow-up would probably have made a difference to the outcome, I am concerned to ensure that in future patients who are discharged have a clear understanding of follow-up arrangements . It is important that staff members on the ward who have to handle the departure of the patient from the ward have clarity as to what is to happen. In the case of Nicola, with the period of time between the decision being made and her actually leaving, staff had changed and the contemporaneous documents did not allow the member of staff who escorted Nicola off the ward to have a clear understanding of follow-up arrangements or indeed of the nature of and quantity of medication with which she was being discharged.
I suggest that consideration should be given to formulating better advice and ensuring that important decisions are better documented and that follow-up arrangements are made clear and adequately documented .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations