PFD report

Ella Colette La-India DAVID-FONG · Prevention of Future Deaths report

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Issued 30 Jun 2025•West 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
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised3

  1. Inadequate information for family and carers about consent, confidentiality and communicating concerns when consent is withdrawn
  2. Inadequate information for family and carers on consent, confidentiality and communication when consent is withdrawn
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and families
  3. Lack of an effective confidentiality-compliant channel for receiving communications when consent is withdrawn
    Part of recurring concern: Failure to reliably respond to patient and carer communications
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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

Inadequate information for family and carers about consent, confidentiality and communicating concerns when consent is withdrawn

Wider context from the report

“Ella had a very supportive and engaged family, but at times she withdrew consent from the agencies trying to provide care and support and refused for information to be shared with her family. As a capacious adult she was entirely able to make this decision, and the agencies had to respect this. The important information the family had was not therefore shared to assist with and improve Ella's care. Confidentiality and consent are key concepts in establishing the trust necessary to build effective therapeutic relationships as well as required under the legal framework. (1) It was acknowledged at inquest that there is currently inadequate information provided for family and carers regarding this challenging issue. The court was advised that it would be appropriate to provide further information at the commencement of treatment both by leaflets provided to the family and carers and on the website to set out the legal position of consent and confidentiality, together with information to assist family and carers in how they can share concerns and communicate information when consent is withdrawn. Currently there is no effective information of how communications can be received, without breaching the confidentiality requirements and this was stated to be a learning point for Ealing RISE at the inquest hearing. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Inadequate information for family and carers on consent, confidentiality and communication when consent is withdrawn

Wider context from the report

“Ella had a very supportive and engaged family, but at times she withdrew consent from the agencies trying to provide care and support and refused for information to be shared with her family. As a capacious adult she was entirely able to make this decision, and the agencies had to respect this. The important information the family had was not therefore shared to assist with and improve Ella's care. Confidentiality and consent are key concepts in establishing the trust necessary to build effective therapeutic relationships as well as required under the legal framework. (1) It was acknowledged at inquest that there is currently inadequate information provided for family and carers regarding this challenging issue. The court was advised that it would be appropriate to provide further information at the commencement of treatment both by leaflets provided to the family and carers and on the website to set out the legal position of consent and confidentiality, together with information to assist family and carers in how they can share concerns and communicate information when consent is withdrawn. Currently there is no effective information of how communications can be received, without breaching the confidentiality requirements and this was stated to be a learning point for Ealing RISE at the inquest hearing. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families.

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

Lack of an effective confidentiality-compliant channel for receiving communications when consent is withdrawn

Wider context from the report

“Ella had a very supportive and engaged family, but at times she withdrew consent from the agencies trying to provide care and support and refused for information to be shared with her family. As a capacious adult she was entirely able to make this decision, and the agencies had to respect this. The important information the family had was not therefore shared to assist with and improve Ella's care. Confidentiality and consent are key concepts in establishing the trust necessary to build effective therapeutic relationships as well as required under the legal framework. (1) It was acknowledged at inquest that there is currently inadequate information provided for family and carers regarding this challenging issue. The court was advised that it would be appropriate to provide further information at the commencement of treatment both by leaflets provided to the family and carers and on the website to set out the legal position of consent and confidentiality, together with information to assist family and carers in how they can share concerns and communicate information when consent is withdrawn. Currently there is no effective information of how communications can be received, without breaching the confidentiality requirements and this was stated to be a learning point for Ealing RISE at the inquest hearing. ”

Is this part of a recurring concern?

Yes — Failure to reliably respond to patient and carer communications.

Open source report
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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