The Evergreen Surgery, Wanstead

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First report 26 Mar 2024•Latest report 26 Mar 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 12

Concerns and recipient responses

Statements from The Evergreen Surgery, Wanstead linked to the concerns in each report. Select any concern, action or position to view the source wording.

26 Mar2024
East London
Concerns raised3
1. Lack of formal capacity assessment for nursing-home residents
2. Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
3. Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness
Actions described in response 3
1. Action
  Deliver an educational session for the clinical team on capacity assessments, including complex assessments.
2. Action
  Formally document capacity assessments in future similar cases.
3. Action
  Inform care staff that local mental health teams accept referrals from patients, carers and other medical professionals.
Respondent positions 4
1. Position
  Existing clinical and nursing-staff capacity assessments indicated capacity and no need for a further formal assessment.
  Existing arrangements considered sufficient
1. Position
  A mental-health referral required the consent of a patient assessed as having capacity, and depended on his willingness to consent.
  Unable to act
2. Position
  Placement decisions and assessments of nursing-home suitability are outside the Surgery’s authority and functions.
  Outside remit
3. Position
  Appropriate agencies are responsible for assessing and deciding nursing-home placement suitability.
  Redirects responsibility
AI-generated summary

Mark Wolfe Kinzley · Prevention of Future Deaths report

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

Report summary

Mark Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.

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 The Evergreen Surgery, Wanstead; that does not assign responsibility.
PFD Monitor interpretation
Lack of formal capacity assessment for nursing-home residents
Wider context from the report
“2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests. ”
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 The Evergreen Surgery, Wanstead; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
Wider context from the report
“3. During the same period, Mr Kinzley was not referred for a mental health assessment despite. a. His history of mental illness. b. His history of deliberate self-harm. c. His history of accidental self-harm when agitated. d. His deteriorating mental state during the month prior to his death. ”
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 The Evergreen Surgery, Wanstead; that does not assign responsibility.
PFD Monitor interpretation
Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness
Wider context from the report
“1. I have doubts that the location of Mr Kinzley’s care was appropriate. Mr Kinzley was a socially isolated adult suffering from a profound neurological disorder and mental illness. ”
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 an educational session for the clinical team on capacity assessments, including complex assessments.

Verbatim wording from the response
“We have also agreed that in any similar cases in future, we would formally document the capacity assessment. At our next practice Governance meeting (23 July 2024), we are providing an educational session to the whole clinical team on capacity assessments, with a particular focus on more complex capacity assessments.”

Source location
Response from Evergreen Surgery
Page 3 · response
Published 3 April 2024
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 document capacity assessments in future similar cases.

Verbatim wording from the response
“We have also agreed that in any similar cases in future, we would formally document the capacity assessment. At our next practice Governance meeting (23 July 2024), we are providing an educational session to the whole clinical team on capacity assessments, with a particular focus on more complex capacity assessments.”

Source location
Response from Evergreen Surgery
Page 3 · response
Published 3 April 2024
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
Inform care staff that local mental health teams accept referrals from patients, carers and other medical professionals.

Verbatim wording from the response
“Following the inquest, our named clinician, Dr Barker, for the care home has made the care staff aware that the local mental health teams, also accept referrals from patients, carers, and other medical professionals, in addition to referrals from a GP. This may be appropriate for any future cases as it would allow the care home to make a referral without waiting for a GP assessment, such as patients with fluctuating capacity or emergency situations.”

Source location
Response from Evergreen Surgery
Page 3 · response
Published 3 April 2024
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
Existing clinical and nursing-staff capacity assessments indicated capacity and no need for a further formal assessment.

Verbatim wording from the response
“Our clinical staff conducted multiple assessments of Mr Kinzley's capacity during his interactions with our Surgery. Capacity assessments are question and time specific. At the time of Mr Kinzley’s assessments by our clinicians, he was deemed to have capacity. There are various decisions that Mr Kinzley made regarding his physical and mental health detailed in the medical record. We detail these below:”

Source location
Response from Evergreen Surgery
Page 2 · response
Published 3 April 2024
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 mental-health referral required the consent of a patient assessed as having capacity, and depended on his willingness to consent.

Verbatim wording from the response
“Whilst we recognise the importance of mental health assessments and referrals for individuals with a history of mental health issues, we emphasise that any referral to mental health services in this situation would have required Mr. Kinzley's consent. He was deemed to have capacity at the times he was assessed, and therefore any referral would have been contingent upon his willingness to consent to such services.”

Source location
Response from Evergreen Surgery
Page 3 · response
Published 3 April 2024
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
Placement decisions and assessments of nursing-home suitability are outside the Surgery’s authority and functions.

Verbatim wording from the response
“We acknowledge the concerns regarding the suitability of the nursing home for Mr Kinzley's needs. We understand that his care needs were assessed by the appropriate agencies and Mr Kinzley consented to the placement in Cambridge Nursing Home. We wish to clarify that the Surgery does not have authority over the placement decisions of individuals in nursing homes. Likewise, the Surgery would not be involved in the assessment of placement suitability.”

Source location
Response from Evergreen Surgery
Page 1 · response
Published 3 April 2024
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
Appropriate agencies are responsible for assessing and deciding nursing-home placement suitability.

Verbatim wording from the response
“We acknowledge the concerns regarding the suitability of the nursing home for Mr Kinzley's needs. We understand that his care needs were assessed by the appropriate agencies and Mr Kinzley consented to the placement in Cambridge Nursing Home. We wish to clarify that the Surgery does not have authority over the placement decisions of individuals in nursing homes. Likewise, the Surgery would not be involved in the assessment of placement suitability.”

Source location
Response from Evergreen Surgery
Page 1 · response
Published 3 April 2024
Open published response

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 raised3

Lack of formal capacity assessment for nursing-home residents

Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state

Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness

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.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.4

Actions described in response 3

Respondent positions 4