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First report 19 Aug 2016•Latest report 19 Aug 2016

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Addressed to Keats House Consulting Rooms (Drs S.M and P Pereira LLP), now represented here by The Foundry.

    Inner North London

    AI-generated summary

    John Richard William JONES · Prevention of Future Deaths report

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

    Report summary

    John Jones, aged 48, died instantaneously after jumping in front of a moving train at West Hampstead Railway Station on 18 April 2016. During his month-long admission to the Nightingale Hospital, he largely remained alone in his room and did not engage with the available group therapy. The principal concern was that the hospital environment appeared suboptimal for addressing his difficulty accepting help and providing effective treatment.

    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 Foundry; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to address inpatients’ inability to engage with offered therapy

    Wider context from the report

    “I heard at inquest that, during his month long residence at the Nightingale, Mr Jones declined to engage with any of the 35 hours per week of group therapy on offer. He did see his consultant psychiatrist for a one to one session three times a week, and he went for a short walk with his parents most days. However, for the majority of his time in hospital, this extremely bright and able but very unwell man, simply stayed in his room alone. He engaged with nurses who popped in to see him on a polite but only ever superficial level. Sometimes he used his computer, but he did not even come out for meals with the other patients. He had a good appetite, but asked for meals to be brought to his room, which they were. This seems a very sub optimal therapeutic environment, most particularly as Mr Jones’s psychiatrist said that the reason for admitting him to hospital was to enable him to access the therapy on offer. I appreciate that Mr Jones himself declined the therapy, but the difficulty he had in accepting help was surely part and parcel of the reason for this episode of mental ill health, and had to be addressed. Whether a patient’s engagement is made a condition of stay at the hospital, whether it is secured by offering a different form of therapy e.g. on a one to one basis, or whether there is some other way of ensuring better treatment, is of course a matter for you. ”
    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

Data last updated 7 September 2026