PFD report

Komang Jack SUSIANTA · Prevention of Future Deaths report

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Issued 6 May 2016•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
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised3

  1. Failure to communicate clinical expectations to patients and families before discharge
    Part of recurring concern: Failure to involve families and carers in discharge planning and decisionsPart of recurring concern: Unreliable hospital discharge processes
  2. Failure to communicate that recurrence of psychotic symptoms requires significant concern and potentially immediate action
    Part of recurring concern: Inadequate safety-netting advice for patients and carers
  3. Failure to communicate when and how to seek urgent professional help
    Part of recurring concern: Inadequate safety-netting advice for patients and carers
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 communicate clinical expectations to patients and families before discharge

Wider context from the report

“The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode. However, she did not communicate to his family: - first and foremost, the fact that she expected him now to be free from all psychotic symptoms; - second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action; - thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this. Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before. By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice. I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in discharge planning and decisions; Unreliable hospital discharge processes.

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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 communicate that recurrence of psychotic symptoms requires significant concern and potentially immediate action

Wider context from the report

“The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode. However, she did not communicate to his family: - first and foremost, the fact that she expected him now to be free from all psychotic symptoms; - second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action; - thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this. Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before. By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice. I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge. ”

Is this part of a recurring concern?

Yes — Inadequate safety-netting advice for patients and carers.

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 communicate when and how to seek urgent professional help

Wider context from the report

“The consultant psychiatrist who assessed Jack on the morning of Tuesday, 28 July, fully expected him now to continue to improve. Whilst she was concerned that he might take drugs again, she thought that he had recovered from this psychotic episode. However, she did not communicate to his family: - first and foremost, the fact that she expected him now to be free from all psychotic symptoms; - second, that any recurrence of these symptoms would be a cause for significant concern and potentially immediate action; - thirdly, in exactly what circumstances professional help should be sought on an urgent basis and how to go about this. Jack’s family were very worried indeed about his condition. However, because they had not been given the clinical expectation, they did not know that they could/should take him back to hospital, even though he had been discharged only hours before. By the time they rang police that afternoon, Jack was on the point of leaving the house. However, they had felt something was wrong from the evening before. His brother had even trawled the internet looking for appropriate advice. I am aware that new systems have been put in place by the East London Foundation Trust at Homerton University Hospital. The one point that I would like most especially to bring to your attention is the need to communicate clinical expectations (preceding return advice) to patients and their families before discharge. ”

Is this part of a recurring concern?

Yes — Inadequate safety-netting advice for patients and carers.

Open source report
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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