PFD report

Emanuel Kolade LADAPO · Prevention of Future Deaths report

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Issued 23 Apr 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
11

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. Insufficient staff awareness of the importance of exploring suicide risk
    Part of recurring concern: Inadequate mental health risk assessment
  2. Failure to ask patients whether they feel suicidal during psychiatric consultations
    Part of recurring concern: Inadequate mental health risk assessment
  3. Lack of engagement with families in 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.8

  1. Action

    Establish a Carer Partnership Board to provide assurance and monitor family and carer engagement.

    Stated by North London Mental Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
  2. Action

    Pilot Carer Peer Support Coach roles with Camden Carers and Islington Carers Hub, including testing and evaluation.

    Stated by North London Mental Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
  3. Action

    Deliver Carers Awareness Training for staff across the Partnership.

    Stated by North London Mental Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 29 April 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

Insufficient staff awareness of the importance of exploring suicide risk

Wider context from the report

“2. Mr Ladapo was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal. This was the error of an individual, but it too is an omission that I have observed and written to C&I about before. Furthermore, the initial management review did not identify the omission. I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I staff. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment.

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 ask patients whether they feel suicidal during psychiatric consultations

Wider context from the report

“2. Mr Ladapo was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal. This was the error of an individual, but it too is an omission that I have observed and written to C&I about before. Furthermore, the initial management review did not identify the omission. I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I staff. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment.

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 engagement with families in care

Wider context from the report

“1. Mr Ladapo lived with his sister, who wanted very much to be involved with his care. However, I did not hear any evidence of engagement with her by C&I, either: - generally, during his time with the early intervention service or the rehabilitation & recovery team; or - when in April 2022 he was found to have ordered a bolt gun on the internet that was only intercepted because it was discovered by the delivery driver; or - on transfer from the early intervention service to the rehabilitation & recovery team in June 2022. Lack of engagement with families is a story that I have heard often in inquests, and was the subject of prevention of future deaths reports that I sent to you on: - 04.03.21 regarding Grażyna Walczak; and - 17.03.21 regarding Ben O’Hara; and to your predecessor on: - 11.01.16 regarding Efstratios Voukelatos; and - 29.04.15 regarding Finnula Martin. ”

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

Failure of initial management reviews to identify omitted suicide-risk questioning

Wider context from the report

“2. Mr Ladapo was noted to have deteriorated by the time of his consultation on 19 January 2023, and he was still depressed on 16 February 2023, but the psychiatrist who saw him on each occasion omitted to ask him whether he felt suicidal. This was the error of an individual, but it too is an omission that I have observed and written to C&I about before. Furthermore, the initial management review did not identify the omission. I am concerned that the importance of exploring the suicide question does not feature highly enough in the consciousness of C&I staff. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Establish a Carer Partnership Board to provide assurance and monitor family and carer engagement.

Verbatim wording from the response

“There is also a specific workstream focused on Service User and Carer Engagement and Experience as part of our Quality Improvement programme, called ‘Brilliant Basics’, which seeks to ensure that the fundamentals of high quality care are fully embedded in areas needing attention. This programme helps us to provide the right care, first time, every time and is made up of a series of workstreams that create and track positive change. We held two workshops with Carers in December 2023 and February 2024 and engaged with a wider group of them through surveys. From this we have mapped the areas that families/carers feel will drive positive change in practice to improve engagement with them and their experience. Identifying patients’ support networks and recording this is a priority area. A Carers Partnership Board is being set up and will commence by August 2024.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 2 · response
Published 29 April 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

Pilot Carer Peer Support Coach roles with Camden Carers and Islington Carers Hub, including testing and evaluation.

Verbatim wording from the response

“We are currently undertaking a pilot project in partnership with Camden Carers and Islington Carers Hub, which introduces a couple of Carer Peer Support Coach roles. The project is designed to increase an awareness of carers amongst inpatient and community clients and staff. The testing and evaluation of this model will inform whether further utilisation of employees with explicit experience of unpaid caring can increase the quality of care being delivered within specific teams.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 2 · response
Published 29 April 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

Deliver Carers Awareness Training for staff across the Partnership.

Verbatim wording from the response

“Firstly I would like to say how very sorry we are that we did not explore engagement with Mr Ladapo’s sister; the team involved recognised this missed opportunity in their own reflections on what happened and will have it at the forefront of their minds going forward. We fully recognise the importance of high-quality engagement of families, or those identified people who are important to our service users, as equal partners in care and we are in the process of ensuring an organisation-wide commitment by creating a Carers Strategy, a Carer focused educational ‘Community of Practice’ and a programme of Carers Awareness Training for staff across the Partnership. We have an ‘involvement register’ which includes carers and is promoted as a way for them to positively influence the organisation both locally and at a wider partnership level.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 2 · response
Published 29 April 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

Map family and carer priorities for improving engagement and experience through the Brilliant Basics workstream.

Verbatim wording from the response

“There is also a specific workstream focused on Service User and Carer Engagement and Experience as part of our Quality Improvement programme, called ‘Brilliant Basics’, which seeks to ensure that the fundamentals of high quality care are fully embedded in areas needing attention. This programme helps us to provide the right care, first time, every time and is made up of a series of workstreams that create and track positive change. We held two workshops with Carers in December 2023 and February 2024 and engaged with a wider group of them through surveys. From this we have mapped the areas that families/carers feel will drive positive change in practice to improve engagement with them and their experience. Identifying patients’ support networks and recording this is a priority area. A Carers Partnership Board is being set up and will commence by August 2024.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 2 · response
Published 29 April 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

Create a carer-focused educational Community of Practice across the Partnership.

Verbatim wording from the response

“Firstly I would like to say how very sorry we are that we did not explore engagement with Mr Ladapo’s sister; the team involved recognised this missed opportunity in their own reflections on what happened and will have it at the forefront of their minds going forward. We fully recognise the importance of high-quality engagement of families, or those identified people who are important to our service users, as equal partners in care and we are in the process of ensuring an organisation-wide commitment by creating a Carers Strategy, a Carer focused educational ‘Community of Practice’ and a programme of Carers Awareness Training for staff across the Partnership. We have an ‘involvement register’ which includes carers and is promoted as a way for them to positively influence the organisation both locally and at a wider partnership level.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 2 · response
Published 29 April 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

Co-produce a carers leaflet template with carers for service-wide use.

Verbatim wording from the response

“For example, a group of Carers have been engaged in co-producing a carers leaflet template which all our services will be expected to implement and make available to families. Some were also recently involved in the development of our Partnership Clinical strategy as part of the coproduction working group.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 2 · response
Published 29 April 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

Create an organisation-wide Carers Strategy to strengthen family and carer engagement in care.

Verbatim wording from the response

“Firstly I would like to say how very sorry we are that we did not explore engagement with Mr Ladapo’s sister; the team involved recognised this missed opportunity in their own reflections on what happened and will have it at the forefront of their minds going forward. We fully recognise the importance of high-quality engagement of families, or those identified people who are important to our service users, as equal partners in care and we are in the process of ensuring an organisation-wide commitment by creating a Carers Strategy, a Carer focused educational ‘Community of Practice’ and a programme of Carers Awareness Training for staff across the Partnership. We have an ‘involvement register’ which includes carers and is promoted as a way for them to positively influence the organisation both locally and at a wider partnership level.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 2 · response
Published 29 April 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 and make the co-produced carers leaflet available to families across all services.

Verbatim wording from the response

“For example, a group of Carers have been engaged in co-producing a carers leaflet template which all our services will be expected to implement and make available to families. Some were also recently involved in the development of our Partnership Clinical strategy as part of the coproduction working group.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 2 · response
Published 29 April 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.3

  1. 1

    Establish a Partnership Shared Learning Collaborative to disseminate significant patient-safety learning across divisions and disciplines.

    Stated by North London Mental Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
  2. 2

    Review risk-assessment systems, processes and staff training.

    Stated by North London Mental Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
  3. 3

    Disseminate learning from the incident and inquests through the Shared Learning Collaborative, bulletins and reports.

    Stated by North London Mental Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 29 April 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

Establish a Partnership Shared Learning Collaborative to disseminate significant patient-safety learning across divisions and disciplines.

Verbatim wording from the response

“Whilst all service areas learn within their individual team governance meetings and across their divisions too, we have a Partnership ‘Weekly Incident Review Group’ meeting that is a forum for communicating recent incidents and risks alongside our Partnership weekly Safety Huddle. Any significant learning using the ‘Patient Safety Incident Response Framework’ (PSIRF) is presented at our newly set up (16th May 2024) ‘Shared Learning Collaborative’ that allows reflection of learning elements to disseminate across all divisions and disciplines within our Partnership. The sustained learning historically and more recently from this recent incident was presented at our 20th June 2024 collaborative meeting, for all our respective divisions and clinicians to understand further. Learning from inquests is also regularly featured in bulletins and reports.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 3 · response
Published 29 April 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 risk-assessment systems, processes and staff training.

Verbatim wording from the response

“More broadly, the trust is undertaking a review of risk assessment looking at systems and processes and also training for our staff.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 3 · response
Published 29 April 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

Disseminate learning from the incident and inquests through the Shared Learning Collaborative, bulletins and reports.

Verbatim wording from the response

“Whilst all service areas learn within their individual team governance meetings and across their divisions too, we have a Partnership ‘Weekly Incident Review Group’ meeting that is a forum for communicating recent incidents and risks alongside our Partnership weekly Safety Huddle. Any significant learning using the ‘Patient Safety Incident Response Framework’ (PSIRF) is presented at our newly set up (16th May 2024) ‘Shared Learning Collaborative’ that allows reflection of learning elements to disseminate across all divisions and disciplines within our Partnership. The sustained learning historically and more recently from this recent incident was presented at our 20th June 2024 collaborative meeting, for all our respective divisions and clinicians to understand further. Learning from inquests is also regularly featured in bulletins and reports.”

Source location

2024-0215 - Camden and Islington NHS Trust
Page 3 · response
Published 29 April 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