PFD report

Emily VOUKELATOU · Prevention of Future Deaths report

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Issued 1 Nov 2016•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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised2

  1. Failure to route and return relatives’ calls
    Part of recurring concern: Failure to reliably telephone patients when follow-up or assessment requires it
  2. Failure to routinely involve family members in patient care
    Part of recurring concern: Failure to involve families and carers in mental health care planning and decisions
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.2

  1. Action

    Issue North Camden Crisis House staff guidance to provide families with clear contact details and direct access to a senior staff member.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
  2. Action

    Implement updated mandatory risk-assessment training reinforcing the importance of working with families, with monthly delivery to clinical staff.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Routine family-involvement assessment, patient consent considerations and mandatory training are considered sufficient without reconsidering the policy.

    Stated by North London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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 route and return relatives’ calls

Wider context from the report

“2. Ms Voukelatou’s sister telephoned Crisis House several times, very worried, both before and after Ms Voukelatou’s death (not having been informed that her twin had died), but her calls were never returned. Apparently, these were not passed on to the right people, but witnesses in court were not aware of the detail of this. Leaving relatives’ repeated calls unanswered cannot be right. It loses potentially valuable information, creates additional anxiety and is simply discourteous. ”

Is this part of a recurring concern?

Yes — Failure to reliably telephone patients when follow-up or assessment requires it.

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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 routinely involve family members in patient care

Wider context from the report

“1. I heard evidence from the consultant psychiatrist responsible for Ms Voukelatou’s care at Crisis House that it is not routine for the crisis team to involve family members in the care of a patient. I wonder whether that is a policy that would benefit from reconsideration? Otherwise potentially helpful input may be lost. One of the mental health nurses said that families are sometimes invited to meetings, but nobody thought about this for Ms Voukelatou. Her family live in Greece, but she was close to her mother and twin sister, and arrangements might have been made, perhaps for a telephone meeting. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in mental health care planning and decisions.

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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

Issue North Camden Crisis House staff guidance to provide families with clear contact details and direct access to a senior staff member.

Verbatim wording from the response

“In light of the information set out above we have unfortunately been unable to get to the bottom of what happened when ████████ tried to contact the Crisis House, and why her calls were not connected. From our enquiries with the switchboard supervisor, and ████████ however, we are satisfied that switchboard staff have the correct number for the crisis house. Nevertheless, given the significance of this issue, we have issued staff at North Camden Crisis House with clear guidance to ensure that numbers and contact details are clearly provided to families participating in a service user’s care so they are able to speak directly to a senior staff member.”

Source location

2017-0004-Response-by-Camden-and-Islington-NHS-Trust
Page 4 · response
Published 19 February 2017

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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

Implement updated mandatory risk-assessment training reinforcing the importance of working with families, with monthly delivery to clinical staff.

Verbatim wording from the response

“We have also reinforced the importance of working with families in our updated, risk assessment training which has been rolled out over the last 12 months. I have enclosed our updated risk assessment training for your information. Our risk assessment training is mandatory for all clinical staff. Our updated training has been implemented throughout the last year. It is run on a monthly basis, in partnership with Middlesex University. To date nearly 500 members of staff have been trained.”

Source location

2017-0004-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 19 February 2017

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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

Routine family-involvement assessment, patient consent considerations and mandatory training are considered sufficient without reconsidering the policy.

Verbatim wording from the response

“You heard evidence from the consultant psychiatrist responsible for Ms Voukelatou’s care that it is not routine practice for the crisis team to involve family members in a patient’s care. You have asked whether this policy would benefit from reconsideration to ensure that potentially helpful input from family members is not lost. You have also questioned whether arrangements might have been made for a telephone meeting with Ms Voukelatou’s family in Greece.”

Source location

2017-0004-Response-by-Camden-and-Islington-NHS-Trust
Page 1 · response
Published 19 February 2017

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

Existing switchboard arrangements are considered sufficient because staff have the correct Crisis House number and can transfer calls or provide direct contact details.

Verbatim wording from the response

“████████, Head of Facilities, has confirmed that switchboard staff have the number for all crisis houses, including North Camden Crisis House, and that staff would transfer an individual’s call to the crisis house, and also give them the direct”

Source location

2017-0004-Response-by-Camden-and-Islington-NHS-Trust
Page 3 · response
Published 19 February 2017

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