PFD report

Nonie Atshiki · Prevention of Future Deaths report

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Issued 12 Dec 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.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
16

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 raised4

  1. Lack of first aid training for night concierges
    Part of recurring concern: Inadequate staff competence to provide first aid
  2. Lack of naloxone-use training for night concierges
    Part of recurring concern: Failure to ensure naloxone is available and usable for opioid overdose emergencies
  3. Insufficient night staffing to support resuscitation while maintaining other essential duties
    Part of recurring concern: Unreliable on-site emergency medical and first-aid response 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.8

  1. Action

    Review potential expansion of defibrillator access, including locations, acquisition criteria, local-authority offers and possible purchases.

    Stated by St Mungo’s Community Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
  2. Action

    Review whether Overdose Prevention and Naloxone Training should become mandatory for first-stage hostels.

    Stated by St Mungo’s Community Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
  3. Action

    Provide regular Naloxone training for new staff and refresher training, supported by targeted communications to managers in first-stage hostels.

    Stated by St Mungo’s Community Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Financial constraints in commissioned contracts prevent adding a third night worker where preferable but not considered essential.

    Stated by St Mungo’s Community Housing AssociationUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Lack of first aid training for night concierges

Wider context from the report

“I heard evidence at inquest that the night concierge who found Ms Atshiki had not had any first aid training from St Mungo’s. He said that he had undergone first aid training elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not. Whilst not relevant in this case, I was told that the hostel does stock naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use. The evidence at inquest was that there are only ever two members of staff working at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms Atshiki. There is no evidence that if CPR had been performed it would have changed the outcome for Ms Atshiki. However, in another situation it might. And in another situation it might be the second member of staff who falls ill. That would only leave the night concierge to attempt resuscitation. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

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

Lack of naloxone-use training for night concierges

Wider context from the report

“I heard evidence at inquest that the night concierge who found Ms Atshiki had not had any first aid training from St Mungo’s. He said that he had undergone first aid training elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not. Whilst not relevant in this case, I was told that the hostel does stock naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use. The evidence at inquest was that there are only ever two members of staff working at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms Atshiki. There is no evidence that if CPR had been performed it would have changed the outcome for Ms Atshiki. However, in another situation it might. And in another situation it might be the second member of staff who falls ill. That would only leave the night concierge to attempt resuscitation. ”

Is this part of a recurring concern?

Yes — Failure to ensure naloxone is available and usable for opioid overdose emergencies.

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

Insufficient night staffing to support resuscitation while maintaining other essential duties

Wider context from the report

“I heard evidence at inquest that the night concierge who found Ms Atshiki had not had any first aid training from St Mungo’s. He said that he had undergone first aid training elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not. Whilst not relevant in this case, I was told that the hostel does stock naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use. The evidence at inquest was that there are only ever two members of staff working at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms Atshiki. There is no evidence that if CPR had been performed it would have changed the outcome for Ms Atshiki. However, in another situation it might. And in another situation it might be the second member of staff who falls ill. That would only leave the night concierge to attempt resuscitation. ”

Is this part of a recurring concern?

Yes — Unreliable on-site emergency medical and first-aid response 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

Unavailability of a defibrillator at the hostel

Wider context from the report

“I heard evidence at inquest that the night concierge who found Ms Atshiki had not had any first aid training from St Mungo’s. He said that he had undergone first aid training elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not. Whilst not relevant in this case, I was told that the hostel does stock naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use. The evidence at inquest was that there are only ever two members of staff working at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms Atshiki. There is no evidence that if CPR had been performed it would have changed the outcome for Ms Atshiki. However, in another situation it might. And in another situation it might be the second member of staff who falls ill. That would only leave the night concierge to attempt resuscitation. ”

Is this part of a recurring concern?

Yes — Unreliable availability and readiness of defibrillators for emergency response.

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

Review potential expansion of defibrillator access, including locations, acquisition criteria, local-authority offers and possible purchases.

Verbatim wording from the response

“Whilst it is my understanding that there is no legal requirement for housing associations to provide defibrillators, we will review the potential for expanding our access to defibrillators in key locations, particularly in 24-hour hostels where the risk of health emergencies is higher. This review will include where defibrillators are already located in our services, the criteria for a service obtaining a defibrillator, taking up offers of free defibrillators from Local Authorities where available, and considering whether to purchase them, where not. This review will be completed by May 2025.”

Source location

Response from St Mungo's
Page 11 · response
Published 18 December 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 whether Overdose Prevention and Naloxone Training should become mandatory for first-stage hostels.

Verbatim wording from the response

“We will conduct a review to determine whether it would be appropriate to add Overdose Prevention and Naloxone Training to our mandatory training list for first-stage hostels, where there is a higher prevalence of clients using substances. This review will be completed by October 2025.”

Source location

Response from St Mungo's
Page 12 · response
Published 18 December 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

Provide regular Naloxone training for new staff and refresher training, supported by targeted communications to managers in first-stage hostels.

Verbatim wording from the response

“ii. Short to Medium-term action: The Service Manager will ensure that regular Naloxone training is provided to all new staff, as well as refresher training either by the local drug”

Source location

Response from St Mungo's
Page 11 · response
Published 18 December 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

Arrange refresher Naloxone training for the Endell Street staff team.

Verbatim wording from the response

“i. Immediate action: We understand that the night concierge may have not received training in using Naloxone, which we accept may affect how a person responds in the case of an overdose. The Service Manager at Endell Street is arranging for the staff team to refresh their Naloxone training. Training is available as an on-line video recommended by the St Mungo’s Complex Needs Team that staff can watch. However, whilst we strongly encourage staff to use Naloxone in overdose situations, we do not make this mandatory. We accept that not all our staff (who are non-clinical and recruited to provide housing-related support) would feel comfortable or confident in administering an injection.”

Source location

Response from St Mungo's
Page 11 · response
Published 18 December 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 training completion for Endell Street staff, ensure Responding to Emergencies e-learning is completed, and provide annual CPR refreshers.

Verbatim wording from the response

“ii. Short to medium-term action: In addition to the actions related to First Aid Training (noted under Concern 1), the Service Manager at Endell Street will complete a review of training completion for all staff, including night staff, and will ensure that all staff have completed the Responding to Emergencies e-learning. The Service Manager will also ensure that staff”

Source location

Response from St Mungo's
Page 13 · response
Published 18 December 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

Update the First Aid Procedure to clarify qualification criteria and acceptance of externally obtained certificates.

Verbatim wording from the response

“We are updating our First Aid Procedure to include clear guidance on First Aid at Work and Emergency First Aid at Work qualification criteria, and to stipulate that only where a staff member is confident in delivering First Aid (including the use of defibrillators and delivery of CPR) in line with such criteria, will a previously obtained certificate prior to employment at St Mungo’s be considered and accepted.”

Source location

Response from St Mungo's
Page 10 · response
Published 18 December 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

Relaunch Solid Foundations with First Aid and Responding to Emergencies training tracked for compliance visibility and reporting.

Verbatim wording from the response

“In addition to the immediate actions related to First Aid Training (noted under Concern 1), as detailed above, we have relaunched our Solid Foundations process as of January 2025. First Aid training will be tracked in Solid Foundations to increase visibility and improve reporting. Responding to Emergencies e-learning has also been added to Solid Foundations for better compliance tracking and reporting. As noted above, First Aid Training and the Responding to Emergencies e-learning covers the provision of CPR.”

Source location

Response from St Mungo's
Page 13 · response
Published 18 December 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

Continue quarterly review of first-aid training compliance and assess interventions where compliance requires improvement.

Verbatim wording from the response

“ii. Short to Medium-term Action: The Learning and Development team and the Safety and Quality Assurance team will continue reviewing compliance with first aid training on a quarterly basis. They will ensure interventions to improve compliance are regularly assessed and will agree on actions if compliance needs improving.”

Source location

Response from St Mungo's
Page 10 · response
Published 18 December 2024

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

Financial constraints in commissioned contracts prevent adding a third night worker where preferable but not considered essential.

Verbatim wording from the response

“support the safe running of the service. We always ensure that our proposed staffing model will allow the service to be run safely, before bidding, accepting or delivering any service contract. However, it is also important to note that due to the nature of the financial environment within which we are commissioned, and the significant financial pressures that Local Authorities who often commission us face, there are significant and growing pressures to meet financial envelopes dictated by those commissioning our services. This sometimes means that in services where it might be preferable, but not necessarily essential, to have a third staff member on shift in the rota, we are unable to do so due to the financial constraints of the contract.”

Source location

Response from St Mungo's
Page 13 · response
Published 18 December 2024

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

Existing staffing models are considered sufficient to run services safely, with at least two waking night staff in many high-support services.

Verbatim wording from the response

“Response: In terms of staffing levels, it should be noted that we, St Mungo’s, develop and review our staffing models within each of our service contracts at the start and before any extension of a contract. In many of our high support services, we have a minimum of two staff members working at night, who undertake waking night shifts (on site and awake at all times), and who”

Source location

Response from St Mungo's
Page 12 · response
Published 18 December 2024

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

Naloxone administration is not mandatory because non-clinical staff may not feel comfortable or confident administering an injection.

Verbatim wording from the response

“i. Immediate action: We understand that the night concierge may have not received training in using Naloxone, which we accept may affect how a person responds in the case of an overdose. The Service Manager at Endell Street is arranging for the staff team to refresh their Naloxone training. Training is available as an on-line video recommended by the St Mungo’s Complex Needs Team that staff can watch. However, whilst we strongly encourage staff to use Naloxone in overdose situations, we do not make this mandatory. We accept that not all our staff (who are non-clinical and recruited to provide housing-related support) would feel comfortable or confident in administering an injection.”

Source location

Response from St Mungo's
Page 11 · response
Published 18 December 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.8

  1. 1

    Update the First Aid Policy and Procedure to reiterate CPR requirements for First Aiders and Emergency First Aiders.

    Stated by St Mungo’s Community Housing AssociationStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024.
  2. 2

    Finalise and publish Alcohol Management guidance.

    Stated by St Mungo’s Community Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
  3. 3

    Add the Drugs Policy and Procedure and Drug Awareness training to the Client Services Induction Checklist.

    Stated by St Mungo’s Community Housing AssociationStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024.
  4. 4

    Instruct Service Managers to direct staff to defibrillator guidance and add that information to the First Aid Policy and Procedure.

    Stated by St Mungo’s Community Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
  5. 5

    Continue Complex Needs Team support for incidents logged as overdoses.

    Stated by St Mungo’s Community Housing AssociationStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024.
  6. 6

    Publish Learning from Deaths Reviews to disseminate organisational learning.

    Stated by St Mungo’s Community Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
  7. 7

    Review Responding to Emergencies mandatory e-learning to ensure it clearly states emergency procedures and staff expectations.

    Stated by St Mungo’s Community Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
  8. 8

    Develop an accessible overdose and Naloxone guidance document and ensure staff know where to find it.

    Stated by St Mungo’s Community Housing AssociationStated plannedThe respondent said that this action was planned when they made their response on 18 December 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

Update the First Aid Policy and Procedure to reiterate CPR requirements for First Aiders and Emergency First Aiders.

Verbatim wording from the response

“We are also updating our First Aid Policy and Procedure to further reflect and reiterate the requirement for First Aiders and Emergency First Aiders to provide CPR when necessary.”

Source location

Response from St Mungo's
Page 14 · response
Published 18 December 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

Finalise and publish Alcohol Management guidance.

Verbatim wording from the response

“viii. We also created a 2024-25 forward plan, where we agreed on actions including: the Complex Needs Team will continue to provide support for incidents logged as overdoses; we will finalise and publish the Alcohol Management guidance; and we will publish Learning from Deaths Reviews to disseminate learnings within the organisation.”

Source location

Response from St Mungo's
Page 7 · response
Published 18 December 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

Add the Drugs Policy and Procedure and Drug Awareness training to the Client Services Induction Checklist.

Verbatim wording from the response

“As noted above, key policies are highlighted for client services within our Induction Checklist. We are adding the St Mungo’s Drugs Policy and Procedure and Drug Awareness training to the list of key policies and training to be completed by client services staff as part of the Induction Checklist.”

Source location

Response from St Mungo's
Page 12 · response
Published 18 December 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

Instruct Service Managers to direct staff to defibrillator guidance and add that information to the First Aid Policy and Procedure.

Verbatim wording from the response

“i. Immediate Action: Where a defibrillator is available at a service, we will instruct Service Managers to direct staff to the relevant guidance. This information will also be added to our First Aid Policy and Procedure.”

Source location

Response from St Mungo's
Page 10 · response
Published 18 December 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

Continue Complex Needs Team support for incidents logged as overdoses.

Verbatim wording from the response

“viii. We also created a 2024-25 forward plan, where we agreed on actions including: the Complex Needs Team will continue to provide support for incidents logged as overdoses; we will finalise and publish the Alcohol Management guidance; and we will publish Learning from Deaths Reviews to disseminate learnings within the organisation.”

Source location

Response from St Mungo's
Page 7 · response
Published 18 December 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

Publish Learning from Deaths Reviews to disseminate organisational learning.

Verbatim wording from the response

“viii. We also created a 2024-25 forward plan, where we agreed on actions including: the Complex Needs Team will continue to provide support for incidents logged as overdoses; we will finalise and publish the Alcohol Management guidance; and we will publish Learning from Deaths Reviews to disseminate learnings within the organisation.”

Source location

Response from St Mungo's
Page 7 · response
Published 18 December 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 Responding to Emergencies mandatory e-learning to ensure it clearly states emergency procedures and staff expectations.

Verbatim wording from the response

“We will conduct a review on our “Responding to Emergencies” mandatory e-learning to ensure that it clearly sets out our approach and what we expect from staff in an emergency situation. This review will be completed by June 2025.”

Source location

Response from St Mungo's
Page 10 · response
Published 18 December 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

Develop an accessible overdose and Naloxone guidance document and ensure staff know where to find it.

Verbatim wording from the response

“In addition to the abovementioned training and guidance that we already have in place regarding the administration of Naloxone, our Complex Needs Team will develop a short guidance document for services to keep accessible within services. This document will provide straightforward guidance on what to do in the event of an overdose, including administering Naloxone. Service Managers will ensure that all staff know where this document is located.”

Source location

Response from St Mungo's
Page 11 · response
Published 18 December 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