PFD report

Agnes Stephanie LAMBERT · Prevention of Future Deaths report

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Issued 17 Dec 2018•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
6

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. Delays in interviewing witnesses to progress disciplinary hearings
    Part of recurring concern: Unreliable gathering of witness evidence for formal investigationsPart of recurring concern: Unreliable internal disciplinary proceedings
  2. Failure to enforce staff reassignment following recognition of a patient fixation
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

    Review the disciplinary policy to clarify which matters warrant full investigation and complete the refreshed policy.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 December 2018.
  2. Action

    Require a specially trained lay staff member to review disciplinary cases and provide assurance or challenge whether a formal hearing is required.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 December 2018.
  3. Action

    Add the risks of unnecessary and lengthy disciplinary processes to the HR and OD department risk register and monitor progress.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 December 2018.

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

Delays in interviewing witnesses to progress disciplinary hearings

Wider context from the report

“2. Following the allegations, it then took the trust four months (rather than the expected four weeks) to interview eight witnesses in order to progress to a disciplinary hearing. This was a distressing time for Ms Lambert and she finally went on sick leave. The service manager who gave evidence in court agreed that this was an unacceptable delay. ”

Is this part of a recurring concern?

Yes — Unreliable gathering of witness evidence for formal investigations; Unreliable internal disciplinary proceedings.

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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 enforce staff reassignment following recognition of a patient fixation

Wider context from the report

“1. Two weeks before the allegations were made and the investigation began (i.e. two weeks before the occasion of Nurse Lambert entering the patient’s room), the patient in question argued with another patient whom he thought was stealing his fiancée. He and Nurse Lambert were not engaged. They were not in a romantic relationship. The more senior member of staff who dealt with the matter, recognised the patient’s fixation and thought that Agnes Lambert should move to work on another ward. However, when Nurse Lambert declined because she did not regard the matter as serious, the manager, who had seniority and more experience, did not insist. The service manager who gave evidence in court accepted that the move should have been made regardless of the staff nurse’s wishes. If it had been, Nurse Lambert would not have been in a position to enter the patient’s room at night without later. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 disciplinary policy to clarify which matters warrant full investigation and complete the refreshed policy.

Verbatim wording from the response

“We absolutely recognise that unnecessary and lengthy disciplinary processes can have a serious detrimental impact on staff mental health and wellbeing. With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the”

Source location

2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 17 December 2018

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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

Require a specially trained lay staff member to review disciplinary cases and provide assurance or challenge whether a formal hearing is required.

Verbatim wording from the response

“We absolutely recognise that unnecessary and lengthy disciplinary processes can have a serious detrimental impact on staff mental health and wellbeing. With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby a specially-trained lay member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the”

Source location

2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 17 December 2018

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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

Add the risks of unnecessary and lengthy disciplinary processes to the HR and OD department risk register and monitor progress.

Verbatim wording from the response

“The risks posed by unnecessary and lengthy disciplinary processes have been added to the HR & OD department risk register to monitor and ensure progress is made.”

Source location

2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 3 · response
Published 17 December 2018

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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 Vital Conversations training for line managers as a professional requirement, initially prioritising nursing managers.

Verbatim wording from the response

“To support this, we are in the process of rolling out ‘vital conversations’ training which will form part of the professional requirements for all line managers in the Trust, though nursing managers will initially be prioritised.”

Source location

2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 17 December 2018

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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

Strengthen ward management and supervision by appointing a permanent ward manager.

Verbatim wording from the response

“Firstly, it is recognised that at the time that these events began, the ward where Ms Lambert worked did not have a permanent ward manager in post and the overall management and supervision structure on the ward was not as robust as it should have been. Significant steps have since been taken to address this and there is now a permanent ward manager. Further, we have recognised that there is a general need among managers for further support around how to have challenging conversations with staff, particularly in situations such as this, where the intention is not to punish the staff member, but to ensure their safety, whilst making it clear that staff are expected to follow reasonable management instructions.”

Source location

2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 17 December 2018

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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

Strengthen formal disciplinary investigations by emphasising managers’ responsibility to minimise delays and monitoring occupational health and Employee Assist referrals.

Verbatim wording from the response

“Vital Conversations training, will facilitate more issues being resolved informally through the supervision process. For those investigations that do proceed formally, there will be a greater focus on managers’ responsibility to minimise delay/keep to timeframes, and monitoring to ensure that managers have offered/referred staff to occupational health for support and also made them aware of our Employee Assist Programme. The refreshed policy is expected to complete in March 2019.”

Source location

2018-0410-Response-by-Camden-and-Islington-NHS-Trust
Page 3 · response
Published 17 December 2018

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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