PFD report

Evan Amon DANDOU-DAMBELLE · Prevention of Future Deaths report

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Issued 29 Oct 2025•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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

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Concerns raised1

  1. Failure to automatically consider significant medication changes when setting mental-health service contact levels
    Part of recurring concern: Failure to reassess safety risks during significant mental-health medication changes
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.3

  1. Action

    Reinforce the guidance through Operational Lead-led shared learning and scheduled service and team business-meeting discussions and review.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 October 2025.
  2. Action

    Include significant medication changes as a factor for multidisciplinary consideration in the Tower Hamlets Early Intervention Service RAG guidance.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
  3. Action

    Communicate the learning about significant medication changes to the Tower Hamlets consultant psychiatrist body by email.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.

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 automatically consider significant medication changes when setting mental-health service contact levels

Wider context from the report

“When Mr Dandou-Dambelle was discussed at an ELFT multi disciplinary meeting on 9 April 2025, his level of contact was changed from red (weekly) to amber (fortnightly). This was the last MDT before his death. This was also the point when the consultant psychiatrist decided to stop his olanzapine that day and commence risperidone, titrating it up gradually. However, the psychiatrist did not suggest that, in deciding the level of contact (red being weekly; amber fortnightly; and green monthly), the medication change was worthy of particular consideration. Even if the consultant had raised the medication change for particular consideration, the team might still have decided to move Mr Dandou-Dambelle to amber, and even if they had kept him on red, it might not have impacted on the outcome. However, in deciding level of contact from the mental health services, it does seem worthy of automatic consideration that the patient’s medication has been altered significantly. ”

Is this part of a recurring concern?

Yes — Failure to reassess safety risks during significant mental-health medication changes.

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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

Reinforce the guidance through Operational Lead-led shared learning and scheduled service and team business-meeting discussions and review.

Verbatim wording from the response

“I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026.”

Source location

Response from East London NHS Foundation Trust
Page 2 · response
Published 31 October 2025

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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

Include significant medication changes as a factor for multidisciplinary consideration in the Tower Hamlets Early Intervention Service RAG guidance.

Verbatim wording from the response

“I can also confirm that the guidance for the RAG (red / amber / green) rating system in use in Tower Hamlets Early Intervention Service highlights significant medication changes as a factor for MDT consideration. This will be further reinforced within the team through shared learning led by the Operational Lead for the service. It is due to be discussed at the service business meeting on 6th January 2026 and will also be reviewed at the team business meeting on 7th April 2026.”

Source location

Response from East London NHS Foundation Trust
Page 2 · response
Published 31 October 2025

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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

Communicate the learning about significant medication changes to the Tower Hamlets consultant psychiatrist body by email.

Verbatim wording from the response

“Since receiving your Regulation 28 report, this learning has already been communicated by email to the Tower Hamlets consultant psychiatrist body, and Clinical Directors in other Trust Directorates have been asked to relay it to their consultant bodies too.”

Source location

Response from East London NHS Foundation Trust
Page 2 · response
Published 31 October 2025

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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.1

  1. 1

    Ask Clinical Directors in other Trust Directorates to relay the learning about significant medication changes to their consultant bodies.

    Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.

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

Ask Clinical Directors in other Trust Directorates to relay the learning about significant medication changes to their consultant bodies.

Verbatim wording from the response

“Since receiving your Regulation 28 report, this learning has already been communicated by email to the Tower Hamlets consultant psychiatrist body, and Clinical Directors in other Trust Directorates have been asked to relay it to their consultant bodies too.”

Source location

Response from East London NHS Foundation Trust
Page 2 · response
Published 31 October 2025

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