PFD report

Andrew James AITKEN · Prevention of Future Deaths report

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Issued 15 Dec 2014•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.

View original report
Concerns
5

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
3

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 safely secure medication brought into hospital
    Part of recurring concern: Failure to secure and control medication
  2. Failure to obtain relevant previous inpatient mental health records
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
  3. Failure to investigate and respond to complaints
    Part of recurring concern: Unreliable handling of safety-related complaints
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.1

  1. Action

    Finalise the RAID Operational Policy with explicit requirements to obtain collateral information.

    Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2014.

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

  1. Position

    A referral to secondary mental health services was considered unnecessary because comprehensive assessments found no indication that this level of input was required.

    Stated by East London NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.

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 safely secure medication brought into hospital

Wider context from the report

“1. When Mr Aitken was admitted to hospital on 10 June 2014, his girlfriend brought in the remainder of the tablets he had taken, hoping to assist those treating him. ████████ told me that a nurse took the tablets from her, of which there were still many remaining, and simply left them on the hospital bedside cabinet next to Mr Aitken. ”

Is this part of a recurring concern?

Yes — Failure to secure and control medication.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to obtain relevant previous inpatient mental health records

Wider context from the report

“2. Mr Aitken had been admitted to Prestwich Hospital Psychiatric Hospital when he was 16 years old. When he was admitted on 10 June 2014, no consideration was given to asking for any record of that inpatient stay. That was some 14 years earlier and may not have yielded anything useful but, as Mr Aitken was not registered with a general practitioner, it was the only source of history from healthcare professionals. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

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 investigate and respond to complaints

Wider context from the report

“4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes. I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter, and has been told that there is no ongoing investigation into her complaint. ”

Is this part of a recurring concern?

Yes — Unreliable handling of safety-related complaints.

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 ensure patients have appropriate clothing and footwear at discharge

Wider context from the report

“4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes. I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter, and has been told that there is no ongoing investigation into her complaint. ”

Is this part of a recurring concern?

Yes — Failure to provide fundamental personal care and welfare; Unreliable hospital discharge processes.

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 provide direct referral to community mental health services for patients without a GP

Wider context from the report

“3. The junior psychiatrist discharging Mr Aitken did strongly advise him to register with a GP and then to seek referral to mental health services, but it did not occur to her to refer him direct to the community mental health team, given that he had no GP. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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

Finalise the RAID Operational Policy with explicit requirements to obtain collateral information.

Verbatim wording from the response

“I am in complete agreement with you regarding the importance of gaining collateral information from any available sources. As you are aware the Trust undertook a Serious Incident Review (SIR) looking at the care and treatment of Mr Aitken and the Review considered this issue. Sources of collateral information in the absence of a GP can be: healthcare professionals previously involved with a patient and family and friends. Our SIR agreed that clinical staff had limited information and history regarding Mr Aitken in light of the fact that he did not have a GP. Senior staff in the RAID service are clear that they would expect staff to follow up and try to obtain all information available regarding an individual. The RAID Operational Policy is currently being finalised and the importance of obtaining collateral information will be included within this.”

Source location

2014-0561-Response-by-East-London-NHS-Trust
Page 2 · response
Published 15 December 2014

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 referral to secondary mental health services was considered unnecessary because comprehensive assessments found no indication that this level of input was required.

Verbatim wording from the response

“The SIR considered this point noting that the RAID Service is able to make direct referrals to secondary mental health services and where indicated can refer a patient to the Home Treatment Team, Crisis Services or the Community Mental Health Team. Community Mental Health Teams manage those patients with enduring mental health problems and the SIR found that the assessments undertaken had been comprehensive and that there had been no indication that this level of input was necessary for Mr Aitken.”

Source location

2014-0561-Response-by-East-London-NHS-Trust
Page 2 · response
Published 15 December 2014

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

Contacting historical psychiatric services was considered unnecessary because information was unlikely to be obtained during the short period of RAID involvement.

Verbatim wording from the response

“In considering this it was relevant to consider that RAID involvement with any patient is short term and the SIR concluded that it was highly unlikely that such historical information would have been obtained during the short time he was under their care to inform their assessment of him. It was therefore felt that the decision not to contact services in Prestwich had been reasonable. The Review was satisfied that staff had explored other potential sources of collateral information.”

Source location

2014-0561-Response-by-East-London-NHS-Trust
Page 2 · response
Published 15 December 2014

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 second and third concerns are being investigated and addressed separately by East London NHS Foundation Trust.

Verbatim wording from the response

“Your second and third concerns are being investigated and addressed separately by the East London NHS Foundation Trust.”

Source location

2014-0561-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 15 December 2014

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 ward had done everything possible regarding discharge without clothes or shoes, so the safeguarding alert was closed.

Verbatim wording from the response

“The investigation involved communicating with ████████ who is the senior sister on ward 11C. She told me that she remembered this man very well. She stated that he was medically fit and the psychiatry team had discharged him; he was willing to go home and so they could not keep him in hospital. He did not have any clothes with him and he told staff that no one could bring him any in. The Trust booked and paid for a taxi to take him home as they did not want him going home on public transport in hospital pyjamas. The ward did receive a complaint in June whereby a safeguarding alert was raised, although it was deemed that the ward had done everything it could at the time and so the safeguarding was closed.”

Source location

2014-0561-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 15 December 2014

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.2

  1. 1

    Inform RAID staff through regular business meetings that patients can self-refer to IAPT services.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2014.
  2. 2

    Consider how to ensure all Tower Hamlets staff have access to information about IAPT self-referral.

    Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2014.

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

  1. 1

    Psychiatric staff cannot register patients with a GP, so they could only remind patients to register or explain self-referral options.

    Stated by East London NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.

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 RAID staff through regular business meetings that patients can self-refer to IAPT services.

Verbatim wording from the response

“The SIR found that psychiatric staff are unable to register a patient with a GP and it was considered to have been good practice for a letter to be sent to Mr Aitken following his discharge to remind him to register with a GP. Whilst it is preferable for patients to be referred to IAPT services by their GP to ensure that appropriate support and follow up is available this is not compulsory and it is possible for patients to self-refer. Taking into account your concerns I believe that this information should be provided to patients who have been assessed would benefit from the IAPT service.”

Source location

2014-0561-Response-by-East-London-NHS-Trust
Page 3 · response
Published 15 December 2014

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

Consider how to ensure all Tower Hamlets staff have access to information about IAPT self-referral.

Verbatim wording from the response

“Whilst it is clear, with the benefit of hindsight, that Mr Aitken was unlikely to have self-referred I do think that it is important to ensure that our staff are aware that patients are able to do this and senior staff in the RAID team will ensure that this is brought to the attention of staff by way of their regular business meeting. In addition to this consideration is currently being given on the best way to ensure that all staff working in Tower Hamlets have access to information.”

Source location

2014-0561-Response-by-East-London-NHS-Trust
Page 3 · response
Published 15 December 2014

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

Psychiatric staff cannot register patients with a GP, so they could only remind patients to register or explain self-referral options.

Verbatim wording from the response

“The SIR found that psychiatric staff are unable to register a patient with a GP and it was considered to have been good practice for a letter to be sent to Mr Aitken following his discharge to remind him to register with a GP. Whilst it is preferable for patients to be referred to IAPT services by their GP to ensure that appropriate support and follow up is available this is not compulsory and it is possible for patients to self-refer. Taking into account your concerns I believe that this information should be provided to patients who have been assessed would benefit from the IAPT service.”

Source location

2014-0561-Response-by-East-London-NHS-Trust
Page 3 · response
Published 15 December 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026