PFD report

Benjamin Rajinder O’HARA · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 17 Mar 2021•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
5

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

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.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to review medical-record alerts
    Part of recurring concern: Unreliable clinical safety-alert systems
  2. Lack of a care co-ordinator or community mental health team member in overall charge of care
    Part of recurring concern: Unreliable care-coordinator provision and cover for mental health service users
  3. Failure to undertake a formal mental health 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.4

  1. Action

    Review carers policy, benchmark family-engagement standards, and agree an action plan with training.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 March 2021.
  2. Action

    Improve communication between crisis and other Trust teams by requiring further discussion of concerning decisions.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 March 2021.
  3. Action

    Remind acute-division teams through business meetings about the importance of family engagement.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 March 2021.

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

  1. Position

    The Trust states that the clerical error would have had limited impact on the decision made during the assessment.

    Stated by North 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

Failure to review medical-record alerts

Wider context from the report

“2. There was an alert on Mr O’Hara’s medical record, saying that admission to hospital was unhelpful to him. However, this had been placed on the record 18 months before his death and had not been reviewed since. If it had been brought up to date, it could have affected the decision not to detain him on 3 October. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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 a care co-ordinator or community mental health team member in overall charge of care

Wider context from the report

“4. Mr O’Hara did not have a care co-ordinator or other member of the community mental health team in overall charge of his care. This person would have been in a position to note his deterioration and the increasing frequency of his contacts with the mental health services in 2020. ”

Is this part of a recurring concern?

Yes — Unreliable care-coordinator provision and cover for mental health service users.

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 undertake a formal mental health assessment

Wider context from the report

“3. The review undertaken on 3 October was with a s12 approved doctor and an approved mental health professional, but was not a formal mental health assessment. If the crisis team had been aware of this, they might have sought a formal mental health assessment when Mr O’Hara disengaged from their care on 4 October. ”

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 to ask patients for permission to contact family members

Wider context from the report

“1. None of the healthcare professionals who assessed or treated Mr O’Hara in the period leading up to his death asked if he would give permission for his family to be contacted. If she had been told of his deterioration, his mother would have returned from abroad and stayed with him. ”

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 to communicate that a review was not a formal mental health assessment

Wider context from the report

“3. The review undertaken on 3 October was with a s12 approved doctor and an approved mental health professional, but was not a formal mental health assessment. If the crisis team had been aware of this, they might have sought a formal mental health assessment when Mr O’Hara disengaged from their care on 4 October. ”

Is this part of a recurring concern?

Yes — Unreliable crisis-team access and communication.

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 carers policy, benchmark family-engagement standards, and agree an action plan with training.

Verbatim wording from the response

“The Trust recognises the vital role that carers have in supporting their loved ones/our service users and is committed to working in partnership with carers. In order to address these issues around contact with next of kin in this case, the report has recommended that the Crisis Teams review carers policy and benchmark quality standards for carer/family/sibling engagement against the national Triangle of Care self-assessment. An action plan, including a training package, will be agreed following this self-assessment. This should be completed by August 2021.”

Source location

2021-0077-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 24 March 2021

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

Improve communication between crisis and other Trust teams by requiring further discussion of concerning decisions.

Verbatim wording from the response

“Despite ICRT feeling like the option of MHAA was closed to them, they did not explore this further with the duty team who advised on these matters. The report has made a recommendation to improve communication between the crisis teams and other teams in the Trust, so that in future the crisis team ensure they discuss further any decisions by other teams which are of concern to them. Progress against this action will be reviewed in August 2021.”

Source location

2021-0077-Response-from-St-Pancras-Hospital-Redacted
Page 3 · response
Published 24 March 2021

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

Remind acute-division teams through business meetings about the importance of family engagement.

Verbatim wording from the response

“In addition, all teams within the acute division of Trust services have been reminded at team business meetings of the importance of family engagement.”

Source location

2021-0077-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 24 March 2021

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 and update the Carenotes alert process, including agreed wording protocols linked to risk-assessment and suicide-prevention processes.

Verbatim wording from the response

“Alerts should be reviewed regularly to ensure the information remains relevant. If the information in the alert suggests contacting a secondary care team, the secondary care team should review the alert accordingly on discharge to incorporate this change. In this instance the alert was not reviewed on discharge. Alerts should also provide important information and should refrain from being opinion orientated. On interview, numerous staff assessing Mr. O’Hara indicated that the alert on Carenotes influenced their review.”

Source location

2021-0077-Response-from-St-Pancras-Hospital-Redacted
Page 3 · response
Published 24 March 2021

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 Trust states that the clerical error would have had limited impact on the decision made during the assessment.

Verbatim wording from the response

“By holding interviews with clinicians, the investigation found that this would have limited impact on the decision made on the day of the assessment. If the section 12 approved doctor or duty AMHP had further concerns and felt admission was necessary, they could have completed a first recommendation and requested a second opinion doctor. However, it does appear that it impacted Islington crisis team (ICRT) views on their available courses of action. ICRT were under the impression that a formal Mental Health Act Assessment (MHAA) had been completed, and when Mr. O’Hara disengaged from ICRT almost immediately after being discharged, they felt they had no grounds to request another MHAA as nothing had changed in his presentation, and therefore opted for discharge.”

Source location

2021-0077-Response-from-St-Pancras-Hospital-Redacted
Page 3 · response
Published 24 March 2021

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.2

  1. 1

    Appoint two Senior Crisis Specialist Nurses to work at the interface between Personality Disorder and inpatient services.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 March 2021.
  2. 2

    Appoint a Senior Crisis Liaison Nurse to work between Personality Disorder and crisis services.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 March 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Trust states that deterioration was not identified during the two crisis-service contacts in the month before death.

    Stated by North London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Appoint two Senior Crisis Specialist Nurses to work at the interface between Personality Disorder and inpatient services.

Verbatim wording from the response

“Since Mr O’Hara’s death the Trust has developed a new post for a Senior Crisis Liaison Nurse to work between Personality Disorder and crisis services. This is intended to provide good support for individuals with a diagnosis of Personality Disorder to receive more consistent community acute care. This post was appointed to in June 2021 and the impact of this new position will be kept under review. This role is in addition to the two Senior Crisis Specialist Nurses already appointed who work at the interface between Personality Disorder and inpatient services. The overall aim of all 3 roles is to improve communication between teams including formal referral process. Crisis teams have also been recommended that they may bring complex cases to the complex case panel/risk panel for discussion and support.”

Source location

2021-0077-Response-from-St-Pancras-Hospital-Redacted
Page 4 · response
Published 24 March 2021

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

Appoint a Senior Crisis Liaison Nurse to work between Personality Disorder and crisis services.

Verbatim wording from the response

“Since Mr O’Hara’s death the Trust has developed a new post for a Senior Crisis Liaison Nurse to work between Personality Disorder and crisis services. This is intended to provide good support for individuals with a diagnosis of Personality Disorder to receive more consistent community acute care. This post was appointed to in June 2021 and the impact of this new position will be kept under review. This role is in addition to the two Senior Crisis Specialist Nurses already appointed who work at the interface between Personality Disorder and inpatient services. The overall aim of all 3 roles is to improve communication between teams including formal referral process. Crisis teams have also been recommended that they may bring complex cases to the complex case panel/risk panel for discussion and support.”

Source location

2021-0077-Response-from-St-Pancras-Hospital-Redacted
Page 4 · response
Published 24 March 2021

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 Trust states that deterioration was not identified during the two crisis-service contacts in the month before death.

Verbatim wording from the response

“It is also noted at this point that whilst in the period from September 2020 onwards there did appear to have been an escalation in Mr O’Hara’s presentation, in the month prior to his death and the 2 contacts with CSPA that took place during that time, a deterioration in Mr O’Hara’s condition was not identified. At this time he described problems sleeping but denied suicidal thoughts, and he appeared satisfied with the discussions that took place with the clinicians on duty.”

Source location

2021-0077-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 24 March 2021

Open published response
Back to top

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