PFD report

Claire Elizabeth HOMER · Prevention of Future Deaths report

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Issued 10 Nov 2023•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
7

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 raised2

  1. Lack of robust protocols for patients who deteriorate during staff leave without initially requiring handover care
  2. Lack of robust protocols when both key points of contact are on leave simultaneously
    Part of recurring concern: Failure to provide continuity of care staffing
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.6

  1. Action

    Discuss and circulate robust out-of-office requirements, including urgent escalation routes, across the Early Intervention Service.

    Stated by North London Mental Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.
  2. Action

    Reiterate pre-leave patient handovers and require deterioration-related concerns to follow out-of-office escalation routes.

    Stated by North London Mental Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.
  3. Action

    Reiterate requirements for doctor cover arrangements to be established, communicated to teams and signposted through out-of-office messages.

    Stated by North London Mental Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 21 November 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Patient handover before staff leave is already robustly in place, so no additional handover arrangement is identified.

    Stated by North London Mental Health PartnershipExisting 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

Lack of robust protocols for patients who deteriorate during staff leave without initially requiring handover care

Wider context from the report

“On the 27 April 2023 Claire’s GP, ████████, wrote an email to ████████ sharing concerns around her worsening, querying the CDAT referral and suggesting family involvement in the formulation of a management plan. Unfortunately there was no reply to this email until 5th May 2023, by which time it was too late. I do not criticise ████████ for this, as she was on holiday and thereafter catching up with what was no doubt an avalanche of emails. This does raise the question, however, of whether more robust protocols need to be in place to address the scenarios of (a) patients who are not initially deemed to require handover care but deteriorate during a member of staff’s leave and (b) both key points of contact being on leave at the same time. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Lack of robust protocols when both key points of contact are on leave simultaneously

Wider context from the report

“On the 27 April 2023 Claire’s GP, ████████, wrote an email to ████████ sharing concerns around her worsening, querying the CDAT referral and suggesting family involvement in the formulation of a management plan. Unfortunately there was no reply to this email until 5th May 2023, by which time it was too late. I do not criticise ████████ for this, as she was on holiday and thereafter catching up with what was no doubt an avalanche of emails. This does raise the question, however, of whether more robust protocols need to be in place to address the scenarios of (a) patients who are not initially deemed to require handover care but deteriorate during a member of staff’s leave and (b) both key points of contact being on leave at the same time. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of care staffing.

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

Discuss and circulate robust out-of-office requirements, including urgent escalation routes, across the Early Intervention Service.

Verbatim wording from the response

“1) The importance of ensuring robust ‘Out of Office’ responses when on leave was discussed with staff in an Early Intervention Service-wide meeting on 24/11/2023. This meeting was chaired by ████████, Service Manager. Minutes have since been sent to the whole service. Staff were asked to ensure their automated ‘Out of Office’ replies clearly signpost if the matter is urgent or requires an urgent response a) how to escalate a concern and b) to whom.”

Source location

Response from Barnet, Enfield and Haringey, Camden and Islington NHS FT
Page 1 · response
Published 21 November 2023

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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

Reiterate pre-leave patient handovers and require deterioration-related concerns to follow out-of-office escalation routes.

Verbatim wording from the response

“7) The service manager has reiterated the necessity to provide the team with a clear handover of patients prior to taking leave. This practice is robustly in place already. However, when a patient deteriorates whilst they are away, the expectation is that the person alerting the team to this follows the signposting indicated on their ‘Out of Office’ reply and escalates to the team inbox and/or duty phone.”

Source location

Response from Barnet, Enfield and Haringey, Camden and Islington NHS FT
Page 2 · response
Published 21 November 2023

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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

Reiterate requirements for doctor cover arrangements to be established, communicated to teams and signposted through out-of-office messages.

Verbatim wording from the response

“5) With regards key contacts being on leave at the same time, the need for cover arrangements for doctors to be in place and communicated clearly with the team has been reiterated. These cover arrangements should always be clearly signposted via ‘Out of Office’ messages.”

Source location

Response from Barnet, Enfield and Haringey, Camden and Islington NHS FT
Page 2 · response
Published 21 November 2023

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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

Request robust use of equivalent escalation signposting in staff voicemail messages during absences.

Verbatim wording from the response

“3) The service manager has also requested this same practice is robustly followed for voicemail messages when a member of staff is absent from work.”

Source location

Response from Barnet, Enfield and Haringey, Camden and Islington NHS FT
Page 2 · response
Published 21 November 2023

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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

Reiterate the need to balance service requirements and cover when considering annual leave requests.

Verbatim wording from the response

“6) The service manager has reiterated to team managers the importance of balancing service need and cover with requests for annual leave.”

Source location

Response from Barnet, Enfield and Haringey, Camden and Islington NHS FT
Page 2 · response
Published 21 November 2023

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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

Update online EIS contact information to include both teams’ duty mobile numbers alongside existing switchboard and inbox details.

Verbatim wording from the response

“4) The service manager has checked that the information is correct for both EIS teams online and has had this amended to include the duty mobile numbers of the two EIS teams, in addition to the switchboard number and team Inboxes which were already present.”

Source location

Response from Barnet, Enfield and Haringey, Camden and Islington NHS FT
Page 2 · response
Published 21 November 2023

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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

Patient handover before staff leave is already robustly in place, so no additional handover arrangement is identified.

Verbatim wording from the response

“7) The service manager has reiterated the necessity to provide the team with a clear handover of patients prior to taking leave. This practice is robustly in place already. However, when a patient deteriorates whilst they are away, the expectation is that the person alerting the team to this follows the signposting indicated on their ‘Out of Office’ reply and escalates to the team inbox and/or duty phone.”

Source location

Response from Barnet, Enfield and Haringey, Camden and Islington NHS FT
Page 2 · response
Published 21 November 2023

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.1

  1. 1

    Share and implement the learning across the Camden division and wider Partnership.

    Stated by North London Mental Health PartnershipStated plannedThe respondent said that this action was planned when they made their response on 21 November 2023.

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

Share and implement the learning across the Camden division and wider Partnership.

Verbatim wording from the response

“For the record we wish for it to be noted that in this case staff email accounts have been checked and robust Out of Office messages were in place signposting recipients to the EIS duty team. Whilst the above actions are now in place within the EIS team, we will also be ensuring that this learning is shared and implemented across the Camden division and the wider Partnership.”

Source location

Response from Barnet, Enfield and Haringey, Camden and Islington NHS FT
Page 2 · response
Published 21 November 2023

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