Tamara HOLBOLL · Prevention of Future Deaths report

On 10 May 2014, one of my assistant coroners, William Dolman, commenced an investigation into the death of Tamara Holboll, aged 47 years. The investigation concluded at the end of the inquest on 20 April 2015. I made a narrative determination, which I attach to this letter.

Tamara Holboll died from stab wounds to the neck and chest. Her son, ████████, pleaded guilty to her manslaughter on the ground of diminished responsibility. He has been detained in a secure hospital for an unlimited period.

Two days before her death, the Holbolls uncharacteristically sought hospital admission from Camden & Islington NHS Trust, because they feared that ████████ would harm his mother. As you can see from the narrative attached, that admission was never effected.

I heard evidence at inquest of a great many changes being implemented by Camden & Islington since Ms Holboll’s death, and I have a copy of your 17 point action plan.

I shall not rehearse those matters now, but I want simply to re-iterate the overarching point that I discussed with your clinical director of acute services.

It seemed to me from the evidence I heard that, when a need for good communication (for example between clinician and bed manager) has been identified, there has been a lack of precision in your trust about exactly what that means and how it needs to be actioned.

Rather than simply talking about the need for better communication, it is necessary to identify that information A must be delivered on every occasion, by person B, at time C, and using method D. Without this level of detail, staff are left with a vague concept and the communication is unlikely to achieve the desired result.

I appreciate that this does not give you much in the way of specifics to work on, but your organisation has already identified these. What I hope to do is to share with you what I perceive to be a recurring theme in your organisation, that has been particularly highlighted by Ms Holboll’s death.