PFD report

Lajos MANDRIK · Prevention of Future Deaths report

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Issued 1 Apr 2026•West 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
17

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. Failure to attempt engagement during patient observations
    Part of recurring concern: Unreliable observation of patients in specialist mental health unitsPart of recurring concern: Unreliable patient observation arrangements
  2. Failure to conduct general hourly observations beyond a headcount
    Part of recurring concern: Unreliable patient observation arrangements
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.9

  1. Action

    Implement the revised Observation and Engagement Policy, including clarified expectations for general and intermittent observations and an agreed staff code of conduct.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
  2. Action

    Pilot digital recording of general and intermittent observations across six inpatient wards, supported by PDSA cycles and evaluation.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
  3. Action

    Deliver organisation-wide webinars launching the revised observation policy for substantive, bank and agency staff.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.

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

  1. Position

    General observations are intended to locate patients and visually check wellbeing, while meaningful engagement applies to intermittent observations.

    Stated by South West London and St George'S Mental Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 attempt engagement during patient observations

Wider context from the report

“The Trust's policy - in common with that of other Trusts - is that all observations should include an attempt, at least, at engagement. The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations, in September 2023 or now. Intermittent observations may be recorded as, for example, 'Corridor - pacing' because the HCA has seen the patient but not attempted to engage with the patient. General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now). This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest. It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust's policy. If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward). ”

Is this part of a recurring concern?

Yes — Unreliable observation of patients in specialist mental health units; Unreliable patient observation arrangements.

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 conduct general hourly observations beyond a headcount

Wider context from the report

“The Trust's policy - in common with that of other Trusts - is that all observations should include an attempt, at least, at engagement. The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations, in September 2023 or now. Intermittent observations may be recorded as, for example, 'Corridor - pacing' because the HCA has seen the patient but not attempted to engage with the patient. General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now). This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest. It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust's policy. If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward). ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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

Implement the revised Observation and Engagement Policy, including clarified expectations for general and intermittent observations and an agreed staff code of conduct.

Verbatim wording from the response

“the Nurse in Charge as well as weekly assurance Audits. There was continuous work done on revising the policy and adjustments made in line with the existing training package to include an agreed code of conduct that clearly lays out expectation on roles and responsibility by staff who undertake observation.”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 2 · response
Published 29 April 2026

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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

Pilot digital recording of general and intermittent observations across six inpatient wards, supported by PDSA cycles and evaluation.

Verbatim wording from the response

“The Trust has an existing digital system that supports recording Constant and Enhanced Observation. To improve consistency, transparency and auditability of observations, the Trust will move general and intermittent observations to the same digital format. To enable this process, there is a plan to pilot the use of digital technology, ‘e-obs’ in 6 inpatient wards across the organisation, to ensure a collaborative approach to change in practice. This digital system will support a more detailed documentation which will include a safety and wellbeing check on patients during both general and intermittent observation. A set of PDSA cycles will be undertaken to ensure the change is supported and understood by staff. With a final evaluation of the pilot completed by 31 July 2026, with a planned phased roll-out across all inpatient wards by 31 October 2026, subject to evaluation findings.”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026

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

Deliver organisation-wide webinars launching the revised observation policy for substantive, bank and agency staff.

Verbatim wording from the response

“The governance process to support implementation of the revised policy will ensure a smooth transition for the implementation and the actions are as follows: - The revised policy was presented in the Quality Governance Group in May 2026, this will be ratified at the June 2026 meeting. - Webinars are scheduled for the launching of the policy from July through to September. This is across all inpatient services and includes both substantive and bank/agency staff. - The e-learning package has been updated to include the changes made in the policy and all staff will be expected to compete this with a new competency framework to demonstrate understanding and compliance with Observation. This will be reviewed by 30 December 2026 to ensure staff are compliant”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026

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

Increase leadership oversight through regular ward visits to support safe observation practice and policy compliance.

Verbatim wording from the response

“We will also increase visibility of leadership by regular ward visits to support staff in safe management of patients on observation and better oversight on whether the Observation Policy is being followed by staff. This oversight will:”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 4 · response
Published 29 April 2026

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

Provide staff with credit-card-sized observation memory cards distinguishing observation levels and minimum engagement expectations.

Verbatim wording from the response

“In addition, a new credit card sized memory Card has been created as an aid-memoir that can be kept on staff’s lanyard that will support staff at a glance to”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026

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

Create and deploy a dashboard showing the quality of observations to clinical staff.

Verbatim wording from the response

“The Trust also has a Nursing Optimisation & Workforce Programme that is focusing on compliance with observation and the quality of these. Having learned from the death of Mr Mandrik, the programme has reviewed the quality of observations and aims to ensure that all observations are supportive of the patient and are a therapeutic intervention. A dashboard to understand the quality of observation is being created and aim to be in use and visible to clinical staff in June 2026.”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 4 · response
Published 29 April 2026

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

Update observation e-learning and require staff to complete it alongside a new competency framework demonstrating understanding and compliance.

Verbatim wording from the response

“The governance process to support implementation of the revised policy will ensure a smooth transition for the implementation and the actions are as follows: - The revised policy was presented in the Quality Governance Group in May 2026, this will be ratified at the June 2026 meeting. - Webinars are scheduled for the launching of the policy from July through to September. This is across all inpatient services and includes both substantive and bank/agency staff. - The e-learning package has been updated to include the changes made in the policy and all staff will be expected to compete this with a new competency framework to demonstrate understanding and compliance with Observation. This will be reviewed by 30 December 2026 to ensure staff are compliant”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026

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 mandatory competency-based observation assessments and reinforce staff roles, responsibilities and expectations through training and regular supervision.

Verbatim wording from the response

“We acknowledge that HCAs were specifically referenced in HM Coroner’s concerns and recognising that sustainable improvement requires cultural as well as procedural change, the Trust is implementing a programme of workforce development for all disciplines across all inpatient wards including:”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 4 · response
Published 29 April 2026

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

Continue monitoring the effectiveness of observation improvements and embedding them into routine practice.

Verbatim wording from the response

“We will continue to monitor the effectiveness of these actions and ensure that they are embedded into routine practice.”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 5 · response
Published 29 April 2026

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

General observations are intended to locate patients and visually check wellbeing, while meaningful engagement applies to intermittent observations.

Verbatim wording from the response

“1. Trust Policy – Clarification of the observation model The Trust has undertaken a comprehensive review of the Observation and Engagement Policy in line with NICE guidelines with an increased focus on quality observations to improve patient’s experience as well as to provide greater clarity regarding expectations for all levels of observation. Specifically, the revised policy outlines the expectation for staff carrying out General and Intermittent Observation stating: General observations are the baseline observation applied within the trust, these low-level observations are performed hourly with the intention of locating a patient and visually checking their wellbeing.”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026

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.8

  1. 1

    Brief inpatient staff on the revised process through handovers, meetings and supervision, and record staff confirmation of understanding and adoption.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
  2. 2

    Update the Trust contraband policy to incorporate the revised form and interim SOP through the Quality Governance Group approval process.

    Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2026.
  3. 3

    Conduct monthly compliance audits, establish a rollout baseline, share results with ward teams, escalate performance below 95%, and provide Trust-wide assurance through the Quality Governance Group.

    Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2026.
  4. 4

    Use the interim Contraband Item SOP with daily forms across acute inpatient wards to standardize contraband issue, tracking, return and escalation during the trial.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
  5. 5

    Implement the revised Contraband Item Form with mandatory return recording, assigned responsibility, risk assessment and audit-supporting document storage across acute inpatient wards.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
  6. 6

    Incorporate the revised form and SOP into the Proactive Physical Intervention refresher training content at the next update cycle.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
  7. 7

    Share inquest and contraband-management learning across inpatient wards through nursing forums, ward managers’ meetings and a Patient Safety bulletin.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
  8. 8

    Conduct a formal review of the implementation plan and resulting observation practice improvements.

    Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.

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

Brief inpatient staff on the revised process through handovers, meetings and supervision, and record staff confirmation of understanding and adoption.

Verbatim wording from the response

“4. Communication and Staff Adoption”

Source location

Response from South West London and St George's Mental Health NHS Trust (2)
Page 3 · response
Published 29 April 2026

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

Update the Trust contraband policy to incorporate the revised form and interim SOP through the Quality Governance Group approval process.

Verbatim wording from the response

“3. Integration with Trust Policy”

Source location

Response from South West London and St George's Mental Health NHS Trust (2)
Page 2 · response
Published 29 April 2026

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

Conduct monthly compliance audits, establish a rollout baseline, share results with ward teams, escalate performance below 95%, and provide Trust-wide assurance through the Quality Governance Group.

Verbatim wording from the response

“6. Assurance, Audit and Escalation”

Source location

Response from South West London and St George's Mental Health NHS Trust (2)
Page 3 · response
Published 29 April 2026

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

Use the interim Contraband Item SOP with daily forms across acute inpatient wards to standardize contraband issue, tracking, return and escalation during the trial.

Verbatim wording from the response

“2. Standard Operating Procedure (Appendix 2)”

Source location

Response from South West London and St George's Mental Health NHS Trust (2)
Page 2 · response
Published 29 April 2026

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 Contraband Item Form with mandatory return recording, assigned responsibility, risk assessment and audit-supporting document storage across acute inpatient wards.

Verbatim wording from the response

“The existing form has been revised to establish clear expectations of responsibility and accountability in the management of contraband items in the inpatient setting.”

Source location

Response from South West London and St George's Mental Health NHS Trust (2)
Page 2 · response
Published 29 April 2026

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

Incorporate the revised form and SOP into the Proactive Physical Intervention refresher training content at the next update cycle.

Verbatim wording from the response

“5. Training”

Source location

Response from South West London and St George's Mental Health NHS Trust (2)
Page 3 · response
Published 29 April 2026

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

Share inquest and contraband-management learning across inpatient wards through nursing forums, ward managers’ meetings and a Patient Safety bulletin.

Verbatim wording from the response

“7. Shared Learning”

Source location

Response from South West London and St George's Mental Health NHS Trust (2)
Page 3 · response
Published 29 April 2026

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

Conduct a formal review of the implementation plan and resulting observation practice improvements.

Verbatim wording from the response

“Formal review will be undertaken in June 2027 to evaluate the implementation plan, and whether there has been an improvement in practice in line with observation.”

Source location

Response from South West London and St George's Mental Health NHS Trust
Page 5 · response
Published 29 April 2026

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