PFD report

Tony Mark DUNNE · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 20 Aug 2019•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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.

Open published report

Concerns and recipient responses

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

Concerns raised1

  1. Failure to ask Crisis Line callers about current suicidal feelings
    Part of recurring concern: Inadequate mental health risk assessment
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

    Provide crisis-line clinicians with training on risk-assessment competencies and required medical-record standards.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.

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 ask Crisis Line callers about current suicidal feelings

Wider context from the report

“Mr Dunne rang the Crisis Line a little over an hour after he had been discharged from the emergency department. He had been seen at the emergency department because he had been found by police standing by an 8th floor window intending to jump. The Crisis Line call taker read his medical notes and so knew this history, but nevertheless did not ask him if he was now feeling suicidal. If she had asked him and he had said yes, she could have asked him to come in to the hospital again or she could have called an ambulance for him. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment.

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

Provide crisis-line clinicians with training on risk-assessment competencies and required medical-record standards.

Verbatim wording from the response

“The importance of good quality, full, complete and appropriate risk assessments is a key skill for all our clinical staff at the Trust. In order to reinforce this, the City and Hackney HTT will be providing additional training during its away days scheduled for 4 and 5 December 2019. This will include:”

Source location

2019-0265_Response-by-East-London-NHS-Trust
Page 2 · response
Published 17 October 2019

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

    Provide training on handover of patient care during sudden staff illness.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.
  2. 2

    Roll out a protocol requiring immediate line managers to review outstanding caseload actions after sudden clinician illness and document completion in medical notes.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.

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

Provide training on handover of patient care during sudden staff illness.

Verbatim wording from the response

“Good quality handover of patient care is also expected of our clinical staff at the Trust, including in cases of sudden illness. The City and Hackney HTT will also be providing training in relation to this topic, in accordance with the Trust’s Managing Sickness Absence Policy on its away days on 4 and 5 December 2019.”

Source location

2019-0265_Response-by-East-London-NHS-Trust
Page 2 · response
Published 17 October 2019

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

Roll out a protocol requiring immediate line managers to review outstanding caseload actions after sudden clinician illness and document completion in medical notes.

Verbatim wording from the response

“Additionally, the Trust appreciates that in cases of sudden illness, circumstances may arise beyond staff members’ control impacting the quality of their handover. In order to ensure continuity of care for all of its patients, the City and Hackney HTT will be rolling out a new protocol on checking outstanding work following sickness. Going forward, if a clinician manning the crisis line is suddenly ill, at the first opportunity, that staff members’ immediate line manager will review their case load for that shift and ensure that all appropriate actions have been taken and that this is reflected in the medical notes.”

Source location

2019-0265_Response-by-East-London-NHS-Trust
Page 2 · response
Published 17 October 2019

Open published response
Back to top

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