Recipient

St Pancras Hospital

First report 4 Mar 2021•Latest report 17 Mar 2021

Recipient record

Reports, concerns and published responses

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

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from St Pancras Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

17 Mar2021
Inner North London
Concerns raised5
1. Failure to review medical-record alerts
2. Lack of a care co-ordinator or community mental health team member in overall charge of care
3. Failure to undertake a formal mental health assessment
1. Failure to ask patients for permission to contact family members
2. Failure to communicate that a review was not a formal mental health assessment
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

Benjamin Rajinder O’HARA · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Benjamin Rajinder O’Hara died after jumping from the fourth floor balcony of his home on 2 November 2020, following repeated contacts with mental health services and episodes of suicidal thoughts and psychosis. Concerns included that professionals did not ask permission to contact his family, an outdated hospital-admission alert was not reviewed, a review was not a formal mental health assessment, and he had no care co-ordinator or other community mental health team member overseeing his care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Pancras Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to review medical-record alerts
Wider context from the report
“2. There was an alert on Mr O’Hara’s medical record, saying that admission to hospital was unhelpful to him. However, this had been placed on the record 18 months before his death and had not been reviewed since. If it had been brought up to date, it could have affected the decision not to detain him on 3 October. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Pancras Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of a care co-ordinator or community mental health team member in overall charge of care
Wider context from the report
“4. Mr O’Hara did not have a care co-ordinator or other member of the community mental health team in overall charge of his care. This person would have been in a position to note his deterioration and the increasing frequency of his contacts with the mental health services in 2020. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Pancras Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake a formal mental health assessment
Wider context from the report
“3. The review undertaken on 3 October was with a s12 approved doctor and an approved mental health professional, but was not a formal mental health assessment. If the crisis team had been aware of this, they might have sought a formal mental health assessment when Mr O’Hara disengaged from their care on 4 October. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Pancras Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ask patients for permission to contact family members
Wider context from the report
“1. None of the healthcare professionals who assessed or treated Mr O’Hara in the period leading up to his death asked if he would give permission for his family to be contacted. If she had been told of his deterioration, his mother would have returned from abroad and stayed with him. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Pancras Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate that a review was not a formal mental health assessment
Wider context from the report
“3. The review undertaken on 3 October was with a s12 approved doctor and an approved mental health professional, but was not a formal mental health assessment. If the crisis team had been aware of this, they might have sought a formal mental health assessment when Mr O’Hara disengaged from their care on 4 October. ”
Open source report
4 Mar2021
Inner North London
Concerns raised2
1. Failure to complete investigation reports within 72 hours of death
2. Failure to routinely ask patients whether their families may be involved in their care
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

Grazyna WALCZAK · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Grazyna Walczak died after jumping three storeys from her flat on 25 or 26 September 2020 while suffering an acute depressive illness. Before her death, she was assessed as being at low to moderate risk, but was not asked whether her family could be notified. The report also raised concern that a required 72-hour investigation report was completed about five months after her death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Pancras Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete investigation reports within 72 hours of death
Wider context from the report
“2. The 72 hour investigation report that should be produced within 72 hours of death, to enable fast learning that may be of immediate benefit to other patients, was not completed until last week, some five months after Ms Walczak’s death. That is obviously not acceptable and could put others at risk by a potential failure to learn. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Pancras Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to routinely ask patients whether their families may be involved in their care
Wider context from the report
“1. Ms Walczak was seen by a psychological wellbeing practitioner from the Camden and Islington iCope service two or three days before her death. She was assessed as being at low to moderate risk to herself. However, she was not asked if she would agree to her family being notified of the situation and of her current mental ill health. Her son would dearly like to have been told what was happening and would have acted accordingly. I heard evidence that iCope does not routinely ask their patients if families may be involved. This seems to be a policy worthy of reconsideration. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to review medical-record alerts

Lack of a care co-ordinator or community mental health team member in overall charge of care

Failure to undertake a formal mental health assessment

Failure to ask patients for permission to contact family members

Failure to communicate that a review was not a formal mental health assessment

Concerns raised2

Failure to complete investigation reports within 72 hours of death

Failure to routinely ask patients whether their families may be involved in their care