PFD report

Hayley Joanne BEAVINGTON · Prevention of Future Deaths report

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Issued 20 Feb 2025•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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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. Failure to provide instructions for challenging an inappropriate crisis-house placement decision
    Part of recurring concern: Failure to provide effective consultant psychiatrist oversight in mental health care
  2. Failure to account for identified suicide and cuckooing risks in crisis-house placement decisions
  3. Delays in reattempting crisis-house placement after a disputed refusal
    Part of recurring concern: Insufficient and unsafe crisis-house provision for patients needing crisis carePart of recurring concern: Unreliable mental health referral pathways
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.5

  1. Action

    Require senior clinical review, an alternative plan, documented accountability and formal escalation before finalising any declined crisis house referral.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  2. Action

    Require referring teams to agree alternative plans and Tactical On-Call staff to maintain risk-management arrangements when crisis houses are closed.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  3. Action

    Require senior clinicians to review risk assessments at key points and schedule follow-up reviews within agreed timeframes.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.

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

  1. Position

    The referring team is responsible for reviewing declined referrals and agreeing an alternative plan.

    Stated by North London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 provide instructions for challenging an inappropriate crisis-house placement decision

Wider context from the report

“When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house. Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because: - Ms Beavington had secure accommodation; and - she was no longer actively suicidal. This was despite the fact that: - there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and - the team view was that she was definitely at risk of suicide. The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instructions as to how to challenge the decision that the consultant believed was wrong. Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made. Ms Beavington was discharged home and killed herself at 1am the next morning. ”

Is this part of a recurring concern?

Yes — Failure to provide effective consultant psychiatrist oversight in mental health care.

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 account for identified suicide and cuckooing risks in crisis-house placement decisions

Wider context from the report

“When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house. Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because: - Ms Beavington had secure accommodation; and - she was no longer actively suicidal. This was despite the fact that: - there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and - the team view was that she was definitely at risk of suicide. The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instructions as to how to challenge the decision that the consultant believed was wrong. Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made. Ms Beavington was discharged home and killed herself at 1am the next morning. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Delays in reattempting crisis-house placement after a disputed refusal

Wider context from the report

“When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house. Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because: - Ms Beavington had secure accommodation; and - she was no longer actively suicidal. This was despite the fact that: - there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and - the team view was that she was definitely at risk of suicide. The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instructions as to how to challenge the decision that the consultant believed was wrong. Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made. Ms Beavington was discharged home and killed herself at 1am the next morning. ”

Is this part of a recurring concern?

Yes — Insufficient and unsafe crisis-house provision for patients needing crisis care; Unreliable mental health referral pathways.

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

Require senior clinical review, an alternative plan, documented accountability and formal escalation before finalising any declined crisis house referral.

Verbatim wording from the response

“• All declined referrals must now be escalated for senior clinical review before a final decision is made; this will ensure that no referral is left without further review and will seek to reduce the risk of missed opportunities for intervention.”

Source location

Response from North London NHS Foundation Trust
Page 2 · response
Published 25 February 2025

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

Require referring teams to agree alternative plans and Tactical On-Call staff to maintain risk-management arrangements when crisis houses are closed.

Verbatim wording from the response

“• The pathway has been reviewed to make it clear that in the event of a referral being declined it is the responsibility of the referring team to review and agree an alternative plan.”

Source location

Response from North London NHS Foundation Trust
Page 3 · response
Published 25 February 2025

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

Require senior clinicians to review risk assessments at key points and schedule follow-up reviews within agreed timeframes.

Verbatim wording from the response

“• Senior clinicians are now required to review risk assessments at key points to reduce the chance of missed warning signs.”

Source location

Response from North London NHS Foundation Trust
Page 3 · response
Published 25 February 2025

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 clinicians with 24/7 Crisis Hub access to senior clinical advice for urgent escalation and referral guidance.

Verbatim wording from the response

“• The Crisis Hub Health Professional Line now provides 24/7 access for clinicians needing urgent escalation or referral guidance. This guarantees that immediate support is available, reducing the risk of delays.”

Source location

Response from North London NHS Foundation Trust
Page 2 · response
Published 25 February 2025

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

Record declined referrals, referral outcomes, escalation calls, risk reassessments, follow-up reviews and capacitous admission refusals in required systems and documentation.

Verbatim wording from the response

“• All declined referrals must now be clearly recorded on RiO to ensure that decisions are transparent, and risks are reassessed at every stage.”

Source location

Response from North London NHS Foundation Trust
Page 3 · response
Published 25 February 2025

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

The referring team is responsible for reviewing declined referrals and agreeing an alternative plan.

Verbatim wording from the response

“• The pathway has been reviewed to make it clear that in the event of a referral being declined it is the responsibility of the referring team to review and agree an alternative plan.”

Source location

Response from North London NHS Foundation Trust
Page 3 · response
Published 25 February 2025

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.4

  1. 1

    Require same-day communication of hospital admissions to relevant community teams through updated standard practice.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  2. 2

    Review declined referrals through governance processes, track decisions, identify systemic trends and report issues for targeted improvement.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  3. 3

    Standardise referral processes and practices across the seven crisis houses and five boroughs under a dedicated crisis house lead.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 February 2025.
  4. 4

    Share and discuss the changes and learning through team, governance, leadership and shared-learning forums, and include them in new-staff induction.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 February 2025.

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 same-day communication of hospital admissions to relevant community teams through updated standard practice.

Verbatim wording from the response

“The NLFT Standard Practice for Community Teams and Wards on Hospital Admissions (2025) strengthens Out of Hours (OOH) escalation by requiring that hospital admissions be communicated to the relevant community teams the same day to ensure that hospital and community services work together seamlessly.”

Source location

Response from North London NHS Foundation Trust
Page 3 · response
Published 25 February 2025

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 declined referrals through governance processes, track decisions, identify systemic trends and report issues for targeted improvement.

Verbatim wording from the response

“• All declined referrals are now reviewed in routine governance meetings to ensure that trends and patterns are identified early and actions taken to prevent repeated incidents.”

Source location

Response from North London NHS Foundation Trust
Page 3 · response
Published 25 February 2025

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

Standardise referral processes and practices across the seven crisis houses and five boroughs under a dedicated crisis house lead.

Verbatim wording from the response

“By way of context, crisis houses at the Trust exist as an informal alternative to inpatient admission. We have 7 crisis houses available across the Trust and since we merged as a single organisation on 1st November 2024, we are working hard to standardise referral processes and practices across the 7 houses and 5 boroughs. This is being led by a newly appointed band 7 crisis house lead dedicated to this work.”

Source location

Response from North London NHS Foundation Trust
Page 2 · response
Published 25 February 2025

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 and discuss the changes and learning through team, governance, leadership and shared-learning forums, and include them in new-staff induction.

Verbatim wording from the response

“To ensure staff awareness of these changes they will be shared and discussed at team meetings and governance meetings across our services, as well as at senior leadership and shared learning forums, with the expectation that the improvements and learning are supported at senior level and cascaded effectively. For new staff, we have agreed to include these updates as part of their induction to help maintain momentum and continue building a culture of openness and shared responsibility around risk, escalation, and documentation.”

Source location

Response from North London NHS Foundation Trust
Page 4 · response
Published 25 February 2025

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