PFD report

Maria Patricia Kelly · Prevention of Future Deaths report

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Issued 27 Sep 2024•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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
19

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. Delay in allocation of a replacement mental health care coordinator
    Part of recurring concern: Insufficient staffing cover for mental health services during absencesPart of recurring concern: Unreliable care-coordinator provision and cover for mental health service users
  2. Failure to escalate unsuccessful contact attempts for a welfare check
    Part of recurring concern: Failure to conduct required welfare checks on people in distressPart of recurring concern: Failure to escalate welfare concerns after unsuccessful contactPart of recurring concern: Failure to take timely escalation action when safety thresholds are breached
  3. Failure to follow up repeated failed clinical encounters
    Part of recurring concern: Failure of case monitoring to identify cases requiring follow-upPart of recurring concern: Failure to maintain follow-up of patients who disengage from care
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.13

  1. Action

    Strengthen staff re-allocation and handover using a standardised handover template and clear successor contact information.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2024.
  2. Action

    Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2024.
  3. Action

    Implement the revised DNA policy through staff training and monitor its impact through a quality-improvement project.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2024.

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

Delay in allocation of a replacement mental health care coordinator

Wider context from the report

“Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past. She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024. From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening. Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023. It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts. Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024. ”

Is this part of a recurring concern?

Yes — Insufficient staffing cover for mental health services during absences; Unreliable care-coordinator provision and cover for mental health service users.

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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 escalate unsuccessful contact attempts for a welfare check

Wider context from the report

“Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past. She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024. From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening. Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023. It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts. Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024. ”

Is this part of a recurring concern?

Yes — Failure to conduct required welfare checks on people in distress; Failure to escalate welfare concerns after unsuccessful contact; Failure to take timely escalation action when safety thresholds are breached.

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

Failure to follow up repeated failed clinical encounters

Wider context from the report

“Ms Kelly’s medical records show that she suffered from a large number of medical conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, chronic kidney disease, iron deficiency anaemia, gastro-oesophageal reflux, hyperlipidaemia, simple schizophrenia, borderline personality disorder, recurrent depressive disorder and anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins Lymphoma in the past. She was prescribed repeat medications of Atorvastatin and Lansoprazole for her physical health problems, and Flupentixol (as directed by her consultant) and Mirtazapine for her mental health. A prescription appears to have been last issued by her GP on 1 August 2024. From 23 August 2023 until the practice was notified of her death, her GP summary showed 31 failed encounters for mental health reviews, as well as failed encounters for blood tests and bowel screening. Her last medical (mental health) review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a review of the team’s patient list found that there had been no contact with her since 11 August 2023. It was recorded that were “many attempts” (not quantified) to contact her. After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 failed telephone attempts. Despite this, no welfare check was undertaken, nor any request for a welfare made to her housing officer or police, until neighbours raised concerns on 14 May 2024. ”

Is this part of a recurring concern?

Yes — Failure of case monitoring to identify cases requiring follow-up; Failure to maintain follow-up of patients who disengage from care.

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

Strengthen staff re-allocation and handover using a standardised handover template and clear successor contact information.

Verbatim wording from the response

“1. Re-allocation and Handover Process We have reviewed and strengthened our re-allocation and handover processes to ensure continuity of care during staff transitions. A new handover template is now in use, standardising the transfer of key information when a staff member leaves. This ensures that service users and carers are promptly informed of any changes and are provided with clear contact details for their new care coordinator.”

Source location

Response from North London NHS Trust
Page 2 · response
Published 27 September 2024

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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

Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.

Verbatim wording from the response

“The MaST tool will play a key role in improving caseload management and prioritisation. Staff training is currently underway, with sessions delivered throughout October to enable the implementation of MaST. A MaST Champion has been appointed to guide the team through the implementation process. Training will be completed by November 2024, after which MaST will enable real-time tracking and prioritisation of high-risk service users. This will ensure close monitoring of service users on the waiting list, and timely follow-up.”

Source location

Response from North London NHS Trust
Page 2 · response
Published 27 September 2024

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

Implement the revised DNA policy through staff training and monitor its impact through a quality-improvement project.

Verbatim wording from the response

“5. DNA (Did Not Attend) Policy The DNA policy is currently under review to formalise new working processes in the management of DNA. The policy outlines clear steps for escalating cases after two consecutive missed appointments, ensuring disengaged service users are followed up promptly. The revised policy will be implemented through staff training to ensure consistent implementation. The impact of this policy will be monitored through a Quality Improvement (QI) project.”

Source location

Response from North London NHS Trust
Page 3 · response
Published 27 September 2024

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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 the DNA policy to formalise escalation after two consecutive missed appointments.

Verbatim wording from the response

“5. DNA (Did Not Attend) Policy The DNA policy is currently under review to formalise new working processes in the management of DNA. The policy outlines clear steps for escalating cases after two consecutive missed appointments, ensuring disengaged service users are followed up promptly. The revised policy will be implemented through staff training to ensure consistent implementation. The impact of this policy will be monitored through a Quality Improvement (QI) project.”

Source location

Response from North London NHS Trust
Page 3 · response
Published 27 September 2024

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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

Use RAG case tracking, weekly allocation meetings and interim manual audits to prioritise and follow up high-risk cases.

Verbatim wording from the response

“We have reinforced our case tracking procedures using the RAG-rating system which identifies levels of risk (Red, Amber, Green). Weekly allocation meetings are held to ensure that high-risk cases are prioritised for follow-up. While we await MaST full implementation,”

Source location

Response from North London NHS Trust
Page 2 · response
Published 27 September 2024

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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

Mobilise locality teams to collaborate with Integrated Community Teams and provide flexible staffing from February 2025.

Verbatim wording from the response

“Our new locality teams, set to be mobilised from February 2025, will work in collaboration with Integrated Community Teams to offer more flexible staffing options. This will enable us to manage resources more effectively during periods of reduced staffing, ensuring continued care for service users. We have also replaced two locum social workers with permanent social workers, ensuring greater stability in the team. A nursing Team Manager has been put in place to ensure effective nursing management and support.”

Source location

Response from North London NHS Trust
Page 2 · response
Published 27 September 2024

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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

Contact unallocated service users through a welfare-call system and escalate concerns under new guidance.

Verbatim wording from the response

“For service users who are still unallocated, we have implemented a welfare call system. These patients are regularly contacted to check in on their well-being. New guidance has also been put in place to ensure effective management of these patients, including clear instructions on when to escalate concerns. This initiative forms part of an ongoing Quality Improvement (QI) project aimed at improving care continuity and safety.”

Source location

Response from North London NHS Trust
Page 2 · response
Published 27 September 2024

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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

Provide staff guidance on RCRP protocols, including escalation within the police system when welfare-check requests are declined.

Verbatim wording from the response

“6. Right Care Right Person (RCRP) Guidance We have provided guidance to staff on the use of the Right Care Right Person (RCRP) protocols to ensure effective escalation to external agencies (specifically the Police) to support the management of welfare checks and missing persons. This includes escalating within the Police system when requests for support with welfare checks are declined by Police.”

Source location

Response from North London NHS Trust
Page 3 · response
Published 27 September 2024

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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

Recruit to address team vacancies, including targeted recruitment activity and continuing recruitment to remaining posts.

Verbatim wording from the response

“2. Staffing Challenges and Recruitment Between May and September 2023, there were a number of vacancies within the team (South Camden Rehabilitation and Recovery Team). This resulted in cases being added to the waiting list, impacting service continuity. The Trust has been actively recruiting to address this shortfall, including organising targeted recruitment events.”

Source location

Response from North London NHS Trust
Page 2 · response
Published 27 September 2024

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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 staffing capacity through experienced agency staff, permanent social workers, a Band 7 supervisory role and a nursing Team Manager.

Verbatim wording from the response

“All substantive social work posts have now been recruited to. We have successfully recruited into three nursing vacancies and put long term experienced agency staff in place to address current shortfall. Additionally, we have introduced new roles, such as a Band 7 position to supervise Band 4 Assistant Practitioners, reducing the reliance on harder-to-recruit Band 6 nurse posts. Recruitment to these posts will continue.”

Source location

Response from North London NHS Trust
Page 2 · response
Published 27 September 2024

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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

Organise additional London Care Record training to improve information sharing and notification of GPs when concerns or disengagement arise.

Verbatim wording from the response

“8. Communication with GPs and LCR (London Care Record) Improving communication with GPs is a priority to ensure coordinated care for service users. We are organising additional training on the use of the London Care Record (LCR) to enhance information sharing between our teams and primary care providers. This will ensure that GPs are promptly notified if concerns arise or if service users disengage from care. The integration of our teams into the new Integrated Community Teams will strengthen collaboration with GPs and other community services, enabling a more coordinated, collaborative and effective approach to care.”

Source location

Response from North London NHS Trust
Page 3 · response
Published 27 September 2024

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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

Clarify whether reported welfare-check arrangements have been completed in future cases.

Verbatim wording from the response

“However, we will of course endeavour to clarify if things have been sorted in future, and if not, possibly call Adult Social Care (we have recently been told by police about other cases that they do not do welfare checks anymore). We have discussed this with practice management here and the clinical lead - myself.”

Source location

Response from Gray's Inn Medical Group
Page 1 · response
Published 27 September 2024

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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

Discuss welfare-check clarification arrangements with practice management and the clinical lead.

Verbatim wording from the response

“However, we will of course endeavour to clarify if things have been sorted in future, and if not, possibly call Adult Social Care (we have recently been told by police about other cases that they do not do welfare checks anymore). We have discussed this with practice management here and the clinical lead - myself.”

Source location

Response from Gray's Inn Medical Group
Page 1 · response
Published 27 September 2024

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.6

  1. 1

    Train team social workers as AMHPs to improve interface working.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2024.
  2. 2

    Strengthen escalation of declined AMHP requests to senior management and discuss cases in multidisciplinary meetings.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2024.
  3. 3

    Enhance and standardise divisional governance meetings to prioritise urgent cases and share incident learning.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2024.
  4. 4

    Appoint a MaST Champion to guide the team through implementation.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2024.
  5. 5

    Maintain regular staff wellbeing check-ins, support initiatives and workload-management measures.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2024.
  6. 6

    Review and update client contact details in RiO through administration-led work and allocated Care Coordinator time.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2024.

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

Train team social workers as AMHPs to improve interface working.

Verbatim wording from the response

“7. Escalation of Declined AMHP Referrals We are strengthening our procedures for managing situations where AMHP (Approved Mental Health Professional) service requests, such as Section 135(1) warrant applications, are declined. When a request is refused, staff are required to escalate the matter to senior management for further review. These cases are also discussed during Multi-Disciplinary Team (MDT) meetings to explore alternative actions and ensure the safety and wellbeing of the service user are prioritised. Social workers in the team are being trained as AMHPs to improve interface working.”

Source location

Response from North London NHS Trust
Page 3 · response
Published 27 September 2024

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

Strengthen escalation of declined AMHP requests to senior management and discuss cases in multidisciplinary meetings.

Verbatim wording from the response

“7. Escalation of Declined AMHP Referrals We are strengthening our procedures for managing situations where AMHP (Approved Mental Health Professional) service requests, such as Section 135(1) warrant applications, are declined. When a request is refused, staff are required to escalate the matter to senior management for further review. These cases are also discussed during Multi-Disciplinary Team (MDT) meetings to explore alternative actions and ensure the safety and wellbeing of the service user are prioritised. Social workers in the team are being trained as AMHPs to improve interface working.”

Source location

Response from North London NHS Trust
Page 3 · response
Published 27 September 2024

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

Enhance and standardise divisional governance meetings to prioritise urgent cases and share incident learning.

Verbatim wording from the response

“10. Clinical Governance We are enhancing and standardising governance meetings across the division to ensure staff are kept informed and have opportunities to discuss cases requiring urgent attention. These governance meetings will prioritise attendance and focus on sharing key learning from incidents, promoting a culture of continuous improvement.”

Source location

Response from North London NHS Trust
Page 4 · response
Published 27 September 2024

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

Appoint a MaST Champion to guide the team through implementation.

Verbatim wording from the response

“The MaST tool will play a key role in improving caseload management and prioritisation. Staff training is currently underway, with sessions delivered throughout October to enable the implementation of MaST. A MaST Champion has been appointed to guide the team through the implementation process. Training will be completed by November 2024, after which MaST will enable real-time tracking and prioritisation of high-risk service users. This will ensure close monitoring of service users on the waiting list, and timely follow-up.”

Source location

Response from North London NHS Trust
Page 2 · response
Published 27 September 2024

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

Maintain regular staff wellbeing check-ins, support initiatives and workload-management measures.

Verbatim wording from the response

“9. Staff Wellbeing We are prioritising staff wellbeing through regular check-ins and support initiatives. These include reminding staff about Trust-wide initiatives such as weekly mindfulness sessions and access to mental health support services. We are also focused on workload management, ensuring staff have the necessary resources and support to prevent burnout and maintain a healthy work-life balance.”

Source location

Response from North London NHS Trust
Page 3 · response
Published 27 September 2024

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

Review and update client contact details in RiO through administration-led work and allocated Care Coordinator time.

Verbatim wording from the response

“11. Client Contact Information Accuracy To address ongoing challenges with service users being unreachable due to outdated contact details, we have instructed team administration to lead an initiative to ensure all client contact details are accurate and up to date in RiO (the Trust’s electronic patient records system). Care Coordinators are being allocated time slots to review and update their client contact details. This proactive step is expected to improve contact and engagement, reducing risk associated with missed appointments or service disengagement.”

Source location

Response from North London NHS Trust
Page 4 · response
Published 27 September 2024

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