PFD report

Matthew Marc GROOM · Prevention of Future Deaths report

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Issued 12 Nov 2015•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
18

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to convey the need for urgent police intervention in a welfare-check request
    Part of recurring concern: Failure of police operational communications to reliably share safety-critical informationPart of recurring concern: Unreliable welfare-check request handling and follow-up
  2. Delays in arranging immediate mental health assessment
    Part of recurring concern: Unreliable assessment of patients’ mental state
  3. Failure to administer prescribed medication
    Part of recurring concern: Unsafe medication administration
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.12

  1. Action

    Arrange for liaison-team prescribers to receive honorary contracts enabling them to prescribe medication in the emergency department.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 November 2015.
  2. Action

    Adapt regular audit to check whether prescribed medication has been administered.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.
  3. Action

    Strengthen the direct mental-health referral protocol, including patient-triggered referrals and a disseminated frontline flowchart.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    The patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to convey the need for urgent police intervention in a welfare-check request

Wider context from the report

“5. The nurse who then contacted the police did not then convey this to them, but requested a welfare check that would be satisfied by knowing he was with a family member. ”

Is this part of a recurring concern?

Yes — Failure of police operational communications to reliably share safety-critical information; Unreliable welfare-check request handling and follow-up.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in arranging immediate mental health assessment

Wider context from the report

“1. Most importantly, Matt Groom waited four hours in the emergency unit before he saw a mental healthcare professional for the first time. I heard that, at the time in these circumstances, it was not possible for a triage nurse to arrange for immediate mental health assessment. ”

Is this part of a recurring concern?

Yes — Unreliable assessment of patients’ mental state.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to administer prescribed medication

Wider context from the report

“2. Diazepam was prescribed but never administered. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to plan action if a mental health assessment is interrupted by a patient leaving

Wider context from the report

“3. The mental health nurse who then saw him did not consider what action to take if he should suddenly decide to leave, most particularly given that she felt unable to conclude the assessment without waiting for a doctor to come in from home to assist. ”

Is this part of a recurring concern?

Yes — Unreliable completion of mental health assessments when patients leave or disengage.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to seek urgent hospital security assistance when detention under the Mental Health Act is considered necessary

Wider context from the report

“4. When Matt did leave the department, the assessing doctor asked the nurse to call the police, but neither doctor nor nurse considered seeking urgent assistance from hospital security, given that they were by now both of the view that he would probably now have to be detained under section of the Mental Health Act. ”

Is this part of a recurring concern?

Yes — Failure to take timely escalation action when safety thresholds are breached; Unreliable Mental Health Act detention arrangements.

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

Arrange for liaison-team prescribers to receive honorary contracts enabling them to prescribe medication in the emergency department.

Verbatim wording from the response

“d) We are making arrangements to reduce the risk of psychiatric or anxiolytic medication being inadvertently omitted, we are making arrangements to ensure that Camden and Islington Mental Health Liaison Team prescribers can prescribe in Whittington ED. The Camden and Islington liaison psychiatry consultant is providing the details of Mental Health Liaison Team prescribers who will then be issued with honorary Whittington contracts in order that they can then prescribe medication in Whittington ED.”

Source location

Matthew-Groom-Response
Page 3 · response
Published 12 November 2015

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 regular audit to check whether prescribed medication has been administered.

Verbatim wording from the response

“b) This protocol will be monitored through regular audit, which has been adapted to incorporate checking for medication administration.”

Source location

Matthew-Groom-Response
Page 2 · response
Published 12 November 2015

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

Strengthen the direct mental-health referral protocol, including patient-triggered referrals and a disseminated frontline flowchart.

Verbatim wording from the response

“a) We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr Groom’s death, but has since been significantly strengthened in that the patient themselves can now trigger a prompt and direct referral to the Mental Health Liaison Team simply by requesting this.”

Source location

Matthew-Groom-Response
Page 2 · response
Published 12 November 2015

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

Strengthen handover between emergency-department and liaison teams to explicitly check prescribed, refused, outstanding and administered medications.

Verbatim wording from the response

“c) We have strengthened handover of patient information between Whittington ED and Camden and Islington Mental Health Liaison Team so that this now involves explicit checking between the teams as to whether:”

Source location

Matthew-Groom-Response
Page 2 · response
Published 12 November 2015

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

Refresh and embed the emergency-department medication protocol defining prescriber and nursing responsibilities for checking and administering prescriptions.

Verbatim wording from the response

“a) We have refreshed and embedded a Whittington ED departmental protocol that clearly defines the responsibility of prescribers to inform the assigned nurse once a prescription has been issued. It also directs the nurses to regularly check patient’s drug charts to check for any medications prescribed. In circumstances such as Mr Groom’s, where the patient is not in a defined cubicle with an assigned nurse, prescribers should highlight the prescription to the nurse-in-charge of the area.”

Source location

Matthew-Groom-Response
Page 2 · response
Published 12 November 2015

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

Prepare a joint emergency-department framework and reference document covering risk assessment, capacity, security, observation, documentation and inter-service communication when patients leave.

Verbatim wording from the response

“Improvement in response to Concern To improve the reliability of assessments made by the Whittington and Camden and Islington frontline staff to consider and plan what action to take should a patient suddenly decide to leave, both organisations are jointly preparing a joint framework and reference document that will be used in the ED to outline and further reinforce clear steps with regard to:”

Source location

Matthew-Groom-Response
Page 4 · response
Published 12 November 2015

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 regular audit to check whether prescribed medication has been administered.

Verbatim wording from the response

“b) This protocol will be monitored through regular audit, which has been adapted to incorporate checking for medication administration.”

Source location

2015-0503-Response
Page 2 · response
Published 12 November 2015

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

Refresh and embed the emergency-department medication protocol requiring prescribers to notify nurses and nurses to check prescribed medicines.

Verbatim wording from the response

“a) We have refreshed and embedded a Whittington ED departmental protocol that clearly defines the responsibility of prescribers to inform the assigned nurse once a prescription has been issued. It also directs the nurses to regularly check patient’s drug charts for any medications prescribed. In circumstances such as Mr Groom’s, where the patient is not in a defined cubicle with an assigned nurse, prescribers should highlight the prescription to the nurse-in-charge of the area.”

Source location

2015-0503-Response
Page 2 · response
Published 12 November 2015

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

Strengthen handover between emergency-department and mental-health liaison teams by explicitly checking medication status and recording findings in patient records.

Verbatim wording from the response

“c) We have strengthened handover of patient information between Whittington ED and Camden and Islington Mental Health Liaison Team so that this now involves explicit checking between the teams as to whether:”

Source location

2015-0503-Response
Page 2 · response
Published 12 November 2015

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

Prepare a joint emergency-department framework and reference document covering risk, capacity, security, observation, documentation and inter-service communication when patients may leave.

Verbatim wording from the response

“Both Trusts have committed to improving staff awareness of their legal duties, what the options are associated with the various circumstances and clinical contingency planning in line with legal options. These are detailed under point 4.”

Source location

2015-0503-Response
Page 3 · response
Published 12 November 2015

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

Arrange honorary contracts enabling mental-health liaison prescribers to prescribe medication in the emergency department.

Verbatim wording from the response

“d) We are making arrangements to reduce the risk of psychiatric or anxiolytic medication being inadvertently omitted, we are making arrangements to ensure that Camden and Islington Mental Health Liaison Team prescribers can prescribe in Whittington ED. The Camden and Islington liaison psychiatry consultant is providing the details of Mental Health Liaison Team prescribers who will then be issued with honorary Whittington contracts in order that they can then prescribe medication in Whittington ED.”

Source location

2015-0503-Response
Page 3 · response
Published 12 November 2015

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

Strengthen the direct mental-health referral protocol so patients can promptly trigger referral from emergency-department triage, supported by a disseminated frontline flowchart.

Verbatim wording from the response

“a) We have strengthened the direct mental health referral protocol from Whittington Emergency (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr Groom’s death, but has since been significantly strengthened in that the patient themselves can now trigger a prompt and direct referral to the Mental Health Liaison Team simply by requesting this.”

Source location

2015-0503-Response
Page 2 · response
Published 12 November 2015

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 patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.

Verbatim wording from the response

“The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this the assessors have to consider the persons capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.”

Source location

Matthew-Groom-Response
Page 3 · response
Published 12 November 2015

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

Informal patients cannot lawfully be prevented from leaving without sufficient grounds for detention or proportionate physical intervention.

Verbatim wording from the response

“Individuals who have attended the ED voluntarily are informal patients and are not subject to any form of legal detention such as the Mental Health Act. For informal patients staff may try and persuade patients not to leave, but cannot in any manner prevent them leaving. A general duty of care can be applied in circumstances where someone is actively violent or is actively trying to hurt themselves or others, and then a physical intervention can be applied by NHS staff. This was not the case for Mr Groom.”

Source location

Matthew-Groom-Response
Page 3 · response
Published 12 November 2015

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 joint police protocols already govern communication about people who abscond or go missing, including conveying immediate-risk information.

Verbatim wording from the response

“Improvement in response to concern For the reasons described above (in response to concern 3) Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that indicated that he was at immediate risk of harm to himself or others to require that the police perform an active search for him. Had this been the case then the Trusts practice is to convey this information to the police. Camden & Islington NHS FT already has joint protocols with the Police, concerning people who have absconded and / or go missing. As I understand it the police were alerted that if they were to see Mr Groom, they should consider bringing him back to hospital if the family members he left with were concerned. As we understand it, this would also normally entail the police’s consideration of the use of section 136 legislation if thought appropriate.”

Source location

2015-0503-Response
Page 5 · response
Published 12 November 2015

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

Informal patients cannot lawfully be prevented from leaving unless applicable legal grounds for detention or physical intervention exist.

Verbatim wording from the response

“Individuals who have attended the ED voluntarily are informal patients and are not subject to any form of legal detention such as the Mental Health Act. For informal patients staff may try and persuade patients not to leave, but cannot in any manner prevent them leaving. A general duty of care can be applied in circumstances where someone is actively violent or is actively trying to hurt themselves or others, and then a physical intervention can be applied by NHS staff. This was not the case for Mr Groom.”

Source location

2015-0503-Response
Page 3 · response
Published 12 November 2015

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 patient was not considered an immediate risk requiring detention, restraint, or an active police search.

Verbatim wording from the response

“The Mental Health Act enables appropriately trained staff to deprive someone of their liberty and enforce treatment; rightly this assessment requires a high threshold to be met. Alongside this assessment, staff have to consider the person’s capacity to make this decision. Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display behaviour that was sufficiently concerning that it required Mr Groom to be immediately detained under the Mental Health Act or any other Act.”

Source location

2015-0503-Response
Page 3 · response
Published 12 November 2015

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Add a monthly joint meeting with Whittington, liaison services and a named police inspector to agree further joint-working actions.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.
  2. 2

    Introduce a Standard Operating Procedure for Section 136 patients brought to the emergency department.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.
  3. 3

    Install a dedicated emergency-department telephone for police pre-alerts about Section 136 patients and other urgent information.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.
  4. 4

    Introduce a standard operating procedure for emergency-department patients brought under Section 136 of the Mental Health Act.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.
  5. 5

    Add a monthly meeting with Whittington, Camden and Islington, and an Islington Police inspector to agree further joint-working improvements.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.
  6. 6

    Install a dedicated emergency-department telephone for police pre-alerts about Section 136 patients and other urgent information.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Trust found no significant clinical competency concerns regarding the mental health nurse’s clinical judgment.

    Stated by North London NHS Foundation Trust and Whittington Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Add a monthly joint meeting with Whittington, liaison services and a named police inspector to agree further joint-working actions.

Verbatim wording from the response

“c) The Trusts regular meetings with the police have been supplemented by an additional monthly meeting between Whittington, Camden and Islington and a named inspector from Islington Police to agree further actions to improve joint working.”

Source location

Matthew-Groom-Response
Page 5 · response
Published 12 November 2015

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

Introduce a Standard Operating Procedure for Section 136 patients brought to the emergency department.

Verbatim wording from the response

“b) We have a new Standard Operating Procedure for patients brought to the Whittington ED under Section 136 of the Mental Health Act.”

Source location

Matthew-Groom-Response
Page 5 · response
Published 12 November 2015

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

Install a dedicated emergency-department telephone for police pre-alerts about Section 136 patients and other urgent information.

Verbatim wording from the response

“a) We have a new black phone in Whittington Health ED specifically for the police to pre-alert us to patients who are being brought to WH ED under Section 136 of the Mental Health Act, and to communicate any other urgent information.”

Source location

Matthew-Groom-Response
Page 5 · response
Published 12 November 2015

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

Introduce a standard operating procedure for emergency-department patients brought under Section 136 of the Mental Health Act.

Verbatim wording from the response

“b) We have a new Standard Operating Procedure for patients brought to the Whittington ED under Section 136 of the Mental Health Act.”

Source location

2015-0503-Response
Page 5 · response
Published 12 November 2015

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

Add a monthly meeting with Whittington, Camden and Islington, and an Islington Police inspector to agree further joint-working improvements.

Verbatim wording from the response

“c) The Trusts regular meetings with the police have been supplemented by an additional monthly meeting between Whittington, Camden and Islington and a named inspector from Islington Police to agree further actions to improve joint working.”

Source location

2015-0503-Response
Page 5 · response
Published 12 November 2015

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

Install a dedicated emergency-department telephone for police pre-alerts about Section 136 patients and other urgent information.

Verbatim wording from the response

“a) We have a new black phone in Whittington Health ED specifically for the police to pre-alert us to patients who are being brought to WH ED under Section 136 of the Mental Health Act, and to communicate any other urgent information.”

Source location

2015-0503-Response
Page 5 · response
Published 12 November 2015

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 Trust found no significant clinical competency concerns regarding the mental health nurse’s clinical judgment.

Verbatim wording from the response

“he leave the assessment setting. At the point at which the nurse stopped her assessment to speak with the on call SpR doctor for advice, she did not consider it appropriate to document a contingency plan about what action to take were Mr Groom to leave. This was based on the fact that Mr Groom was not considered to pose an immediate risk of absconding or a risk to himself or others. In this respect Mr Groom did not qualify for detention under the Mental Health Act (or the Mental Capacity Act) and therefore there would have been no legal powers to prevent him from leaving. (Although the assessment was incomplete, this in itself would not have been grounds for preventing him from leaving either.) The Trust did not establish that there were any significant clinical competency concerns in relation to the mental health nurse’s clinical judgment.”

Source location

Matthew-Groom-Response
Page 4 · response
Published 12 November 2015

Open published response
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Data last updated 7 September 2026