Ralph Stephen Goslin · Prevention of Future Deaths report

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Issued 25 Jun 2014•Inner North London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

Described in responses

Recipients and published responses

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 raised1

  1. Failure of sodium valproate blood test reference ranges to clearly indicate the therapeutic range
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable medication-specific blood-level monitoring

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.13

  1. North London NHS Foundation Trust

    Increase leadership capacity through changed Montague Ward staffing arrangements.

  2. North London NHS Foundation Trust

    Review Montague Ward care plans weekly to ensure they reflect individual needs.

  3. North London NHS Foundation Trust

    Develop and implement an epilepsy wellbeing resource pack across inpatient areas for staff, patients, families and carers.

  4. North London NHS Foundation Trust

    Audit Montague Ward care-plan arrangements to verify that required reviews and risk controls are in place.

  5. North London NHS Foundation Trust

    Issue a Trust-wide epilepsy safety alert and review care plans for people with epilepsy or seizure risk, adding individualized risk-mitigation plans.

  6. North London NHS Foundation Trust

    Follow up group dissemination of investigation, complaint and Coroner findings with every member in writing.

  7. North London NHS Foundation Trust

    Roll out specialist epilepsy training and advice across inpatient and residential services, led by a specialist epilepsy nurse.

  8. North London NHS Foundation Trust

    Review all bathrooms and shower rooms independently for suitability, patient needs and disability requirements to inform service-specific decisions.

  9. North London NHS Foundation Trust

    Convert communal bathroom and shower rooms at the Huntley Centre into wet rooms.

  10. North London NHS Foundation Trust

    Revise the observation policy and issue observation sheets requiring clearer locations, rationale for enhanced observations and more frequent reviews.

  11. North London NHS Foundation Trust

    Issue a bathing-safety alert and establish bathroom and shower-room protocols covering access, supervision and seizure-related needs.

  12. North London NHS Foundation Trust

    Address identified ligature risks in the Montague Ward bathroom.

  13. North London NHS Foundation Trust

    Complete the environmental ligature-risk review to inform bathroom and shower-room requirements.

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 of sodium valproate blood test reference ranges to clearly indicate the therapeutic range

Wider context from the report

“1. The junior doctor at St Pancras Hospital who first reviewed the UCH blood test result giving Mr Goslin’s sodium valproate level as less than 3, did not realise that this was sub therapeutic, because the reference range was given as less than 100, rather than 50-100 as it is in some other hospitals. This meant that Mr Goslin’s failure to take his anti epilepsy medication was not recognised as quickly as it could have been. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable medication-specific blood-level monitoring.

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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

Increase leadership capacity through changed Montague Ward staffing arrangements.

Verbatim wording from the response

“• Changes to the staffing arrangements on Montague to increase the leadership capacity in the services.”

Source location

2014-0282-Response
Page 2 · response
Published 25 June 2014

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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

Review Montague Ward care plans weekly to ensure they reflect individual needs.

Verbatim wording from the response

“• Review of all care plans on Montague Ward to ensure these are reviewed on a weekly basis and are reflective of individual need.”

Source location

2014-0282-Response
Page 2 · response
Published 25 June 2014

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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

Develop and implement an epilepsy wellbeing resource pack across inpatient areas for staff, patients, families and carers.

Verbatim wording from the response

“In addition to the training programme, a well-being resource pack to support people living with epilepsy is being developed. This will be implemented across all in-patient areas and enable staff to engage with patients, families and carer’s to raise their awareness and knowledge of the risks people with epilepsy face, and provide practical steps to take on a day to day basis. This will also ensure staff have the particular issues of risks associated with bathing for people with epilepsy in their minds.”

Source location

2014-0282-Response
Page 2 · response
Published 25 June 2014

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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

Audit Montague Ward care-plan arrangements to verify that required reviews and risk controls are in place.

Verbatim wording from the response

“• Programmes of audits on Montague Ward to ensure the above arrangements are in place.”

Source location

2014-0282-Response
Page 2 · response
Published 25 June 2014

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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 a Trust-wide epilepsy safety alert and review care plans for people with epilepsy or seizure risk, adding individualized risk-mitigation plans.

Verbatim wording from the response

“The programme will be led by a Specialist Consultant Nurse in Epilepsy and will roll out across the Trust during September and October 2014. In support of the programme the Trust has taken a range of immediate steps to ensure management of people at risk of epilepsy are effectively managed in the interim. These actions include:”

Source location

2014-0282-Response
Page 2 · response
Published 25 June 2014

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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

Follow up group dissemination of investigation, complaint and Coroner findings with every member in writing.

Verbatim wording from the response

“The Trust also shared with staff the findings of the inquest touching the death of Mr JL However following the inquest touching the death of Mr RG and the evidence of the Ward Manager on Montague ward that he had not been aware of the inquest findings, the Trust has reviewed the case and how the learning was disseminated.”

Source location

2014-0282-Response
Page 3 · response
Published 25 June 2014

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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

Roll out specialist epilepsy training and advice across inpatient and residential services, led by a specialist epilepsy nurse.

Verbatim wording from the response

“Specialist training and advice has been commissioned from the National Neurological Commissioning Support Unit, working in conjunction with the National Epilepsy Society to undertake a programme of training across all our inpatient and residential services. This will draw on national best practice and address matters including:”

Source location

2014-0282-Response
Page 2 · response
Published 25 June 2014

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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

Review all bathrooms and shower rooms independently for suitability, patient needs and disability requirements to inform service-specific decisions.

Verbatim wording from the response

“Currently the Trust provides services over a number of sites, from a range of different building, of which a small number are purpose built but many have been adapted from a previous use or inherited following organisational change. The Trust has therefore commissioned an independent review of all bathrooms and shower rooms to determine their”

Source location

2014-0282-Response
Page 2 · response
Published 25 June 2014

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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

Convert communal bathroom and shower rooms at the Huntley Centre into wet rooms.

Verbatim wording from the response

“suitability for the current patient group and how they meet the needs of patients and disability requirements. This review alongside a review of environmental ligature risks (already completed) will inform decisions about the type of bathroom / shower rooms required for each particular service. This review is due to complete at the end of August 2014. As indicated in court, the Trust has already made the decision to convert communal bathroom/shower rooms in the Huntley Centre at St Pancras Hospital to wet rooms and the programme of work has already commenced. This programme will conclude in September 2014.”

Source location

2014-0282-Response
Page 3 · response
Published 25 June 2014

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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

Revise the observation policy and issue observation sheets requiring clearer locations, rationale for enhanced observations and more frequent reviews.

Verbatim wording from the response

“• A review of the observation policy, issuing new observation sheets on 19th December 2013, which provide greater detail about patient’s location on the ward and a clear rational for enhanced observations, leading to greater interaction with the patient and more frequent reviews.”

Source location

2014-0282-Response
Page 3 · response
Published 25 June 2014

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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 a bathing-safety alert and establish bathroom and shower-room protocols covering access, supervision and seizure-related needs.

Verbatim wording from the response

“2. Risks associated with bathing The Trust has issued a second Patient Safety Alert (appendix 2) ensuring all in-patient services and community houses have protocols in place for the use of bathroom and shower rooms. These protocols ensure:”

Source location

2014-0282-Response
Page 2 · response
Published 25 June 2014

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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

Address identified ligature risks in the Montague Ward bathroom.

Verbatim wording from the response

“As with all serious untoward incidents in the Trust, our policy requires an internal investigation. One of the findings from the Internal Investigation, shared prior to the inquest was that the identified ligature risks in the bathroom on Montague Ward were of a level that meant the room should not be used until these issues had been addressed. It was upon this basis that the bathroom was temporarily closed. The timing of the closure was governed by the completion of the internal investigation report and was not done in preparation for the inquest. These ligature risks are programmed to be addressed in September 2014.”

Source location

2014-0282-Response
Page 3 · response
Published 25 June 2014

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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

Complete the environmental ligature-risk review to inform bathroom and shower-room requirements.

Verbatim wording from the response

“suitability for the current patient group and how they meet the needs of patients and disability requirements. This review alongside a review of environmental ligature risks (already completed) will inform decisions about the type of bathroom / shower rooms required for each particular service. This review is due to complete at the end of August 2014. As indicated in court, the Trust has already made the decision to convert communal bathroom/shower rooms in the Huntley Centre at St Pancras Hospital to wet rooms and the programme of work has already commenced. This programme will conclude in September 2014.”

Source location

2014-0282-Response
Page 3 · response
Published 25 June 2014

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