PFD report

James Warren Agius · Prevention of Future Deaths report

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Issued 7 Oct 2024•Essex

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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. Significant omissions in medical record documentation
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Differences of opinion in mental state assessments
    Part of recurring concern: Unreliable assessment of patients’ mental state
  3. Failure to implement national training for assessing risk in patients with mental health concerns
    Part of recurring concern: Inadequate mental health risk assessment
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.6

  1. Action

    Require Home Treatment Team staff to use an agreed home-visit documentation template covering mental state, physical health, safeguarding, risk assessment, and follow-up planning, with fortnightly audits.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 October 2024.
  2. Action

    Roll out risk-formulation training across the Trust, training Acute and Rehabilitation Directorate clinical staff first and achieving full Trust coverage by April 2026.

    Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 October 2024.
  3. Action

    Require Home Treatment Team mental-state examinations to record speech abnormalities and psychotic symptoms where mood-disorder concerns arise.

    Stated by North East London NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 October 2024.

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

  1. Position

    The medical records indicate consistent staff opinions and do not support a difference of opinion about hypomanic symptoms.

    Stated by North East London NHS Foundation 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

Significant omissions in medical record documentation

Wider context from the report

“1. The medical record documentation for Mr Agius had significant omissions that included an incomplete risk assessment in February 2022 for Mr Agius following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr Agius attempted to take his own life. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Differences of opinion in mental state assessments

Wider context from the report

“2. The evidence of assessments of Mr Agius’s mental state provided to the inquest indicated a difference of opinion as to whether Mr Agius was displaying hypomanic symptoms on 12 and 13 February 2022. ”

Is this part of a recurring concern?

Yes — Unreliable assessment of patients’ mental state.

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 implement national training for assessing risk in patients with mental health concerns

Wider context from the report

“3. Evidence was heard that there is new national training for assessing risk for patients with mental health concerns but there was no evidence that the Trust has implemented this training. ”

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

Incomplete risk assessments for patients with mental health concerns

Wider context from the report

“1. The medical record documentation for Mr Agius had significant omissions that included an incomplete risk assessment in February 2022 for Mr Agius following his transfer following crisis intervention with the Home Treat Team to avoid an admission to hospital when Mr Agius attempted to take his own life. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment.

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 Home Treatment Team staff to use an agreed home-visit documentation template covering mental state, physical health, safeguarding, risk assessment, and follow-up planning, with fortnightly audits.

Verbatim wording from the response

“To support good record keeping practice in the Home Treatment Teams (HTT) in NELFT, all staff completing home visits to service users are expected to complete their records utilising an agreed template. This ensures that the visit and documentation of what took place will cover areas including (though not limited to), mental state examination, social situation, physical health concerns, risk assessment, safeguarding and that these lead to a clear plan to be followed by the team. Adherence to this is monitored within through a fortnightly progress note audit that is completed. The last audit that was completed for the Barking and Dagenham HTT was on 3rd November 2024, with the team scoring 100% for adherence to use of the correct template. All entries reviewed also included a full Mental State Examination and risk assessment.”

Source location

Response from NELFT
Page 2 · response
Published 8 October 2024

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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

Roll out risk-formulation training across the Trust, training Acute and Rehabilitation Directorate clinical staff first and achieving full Trust coverage by April 2026.

Verbatim wording from the response

“The final concern raised related to the risk assessment completed and NELFT’s progress in transitioning from the previous risk stratification model of assessing risk to that of risk formulation. As correctly referenced in your report, this change will reflect national recommendations on the most effective means of assessment of the risk suicide and self-harm (NICE NG225 Self Harm: assessment, management and preventing recurrence).”

Source location

Response from NELFT
Page 3 · response
Published 8 October 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

Require Home Treatment Team mental-state examinations to record speech abnormalities and psychotic symptoms where mood-disorder concerns arise.

Verbatim wording from the response

“When HTT staff complete their mental state examinations, where there is a potential concern regarding a mood disorder, staff will make reference to a service user’s speech and observation of any psychotic symptoms. This is completed as abnormalities within these domains can be common features of a manic episode (International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)).”

Source location

Response from NELFT
Page 3 · response
Published 8 October 2024

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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

Put revised good-record-keeping training packages into induction for all staff.

Verbatim wording from the response

“Revised training packages have also been put in place that cover the principles of good record keeping standards. These are essential training for all staff and are covered as part of the induction to NELFT.”

Source location

Response from NELFT
Page 2 · response
Published 8 October 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

Complete a thematic review of patient-safety incidents and establish Trust-wide workstreams to address identified record-keeping gaps and embed learning.

Verbatim wording from the response

“The Trust has completed a thematic review of patient safety incidents with the intention of identifying themes and patterns occurring within these. Resulting from this was the establishment of Trust wide workstreams aimed to address the identified gaps and then embed learning around these across the Trust. Of pertinence to the concerns raised in this instance, is the Improving Quality of Record Keeping and Clinical Documentation workstream.”

Source location

Response from NELFT
Page 2 · response
Published 8 October 2024

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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

Provide all staff with an intranet resource containing record-keeping guidance, escalation information, and quick access to related documentation standards.

Verbatim wording from the response

“The aim of this workstream is to establish any system weaknesses associated with poor record keeping, understand the behaviour associated with this and to improve recording keeping and create a healthy record keeping culture. The Quality Improvement initiatives around this workstream have so far been successful in creating a Trust wide intranet page accessible to all staff offering direction on the importance of accurate and good record keeping. In addition to this, the Trust has developed quick access to guidance and information on issues such as cut and paste and commonly used acronyms and clinical abbreviations. Readily accessible links to good record keeping practice are also available and consequences of failing to comply with this and guidance on how to escalate concerns are also captured and available to all staff within this platform.”

Source location

Response from NELFT
Page 2 · response
Published 8 October 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

The medical records indicate consistent staff opinions and do not support a difference of opinion about hypomanic symptoms.

Verbatim wording from the response

“Mr Agius’ medical records would suggest that there was consistency in the opinion of the two staff members that visited, in as much that they both did not see evidence of an elated mood. Had Mr Agius been under the BDHTT for a period longer than the three days he was, he would have been reviewed by the medical team, in line with the HTT Standard Operating Procedure and greater clarity regarding his diagnosis would have been achieved.”

Source location

Response from NELFT
Page 3 · response
Published 8 October 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