PFD report

Grazyna WALCZAK · Prevention of Future Deaths report

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Issued 4 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.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
7

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 raised2

  1. Failure to complete investigation reports within 72 hours of death
    Part of recurring concern: Unreliable safety investigation reports and disclosure
  2. Failure to routinely ask patients whether their families may be involved in their care
    Part of recurring concern: Failure to establish patients’ consent for family involvement in mental health 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.6

  1. Action

    Implement 72-hour reporting through the Datix patient-safety incident reporting system.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021.
  2. Action

    Prepare and deliver training for divisional staff on the Datix 72-hour reporting process.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021.
  3. Action

    Develop 72-hour reporting process maps for users to improve compliance and reporting quality.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 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

    Next-of-kin information will not be mandatory because patient confidentiality must be protected and access to the service should remain unrestricted.

    Stated by North London NHS Foundation TrustUnable 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

Failure to complete investigation reports within 72 hours of death

Wider context from the report

“2. The 72 hour investigation report that should be produced within 72 hours of death, to enable fast learning that may be of immediate benefit to other patients, was not completed until last week, some five months after Ms Walczak’s death. That is obviously not acceptable and could put others at risk by a potential failure to learn. ”

Is this part of a recurring concern?

Yes — Unreliable safety investigation reports and disclosure.

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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 routinely ask patients whether their families may be involved in their care

Wider context from the report

“1. Ms Walczak was seen by a psychological wellbeing practitioner from the Camden and Islington iCope service two or three days before her death. She was assessed as being at low to moderate risk to herself. However, she was not asked if she would agree to her family being notified of the situation and of her current mental ill health. Her son would dearly like to have been told what was happening and would have acted accordingly. I heard evidence that iCope does not routinely ask their patients if families may be involved. This seems to be a policy worthy of reconsideration. ”

Is this part of a recurring concern?

Yes — Failure to establish patients’ consent for family involvement in mental health care.

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

Implement 72-hour reporting through the Datix patient-safety incident reporting system.

Verbatim wording from the response

“The following key recommendations were made and are being implemented”

Source location

2021-0063-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 8 March 2021

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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

Prepare and deliver training for divisional staff on the Datix 72-hour reporting process.

Verbatim wording from the response

“The following key recommendations were made and are being implemented”

Source location

2021-0063-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 8 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

Develop 72-hour reporting process maps for users to improve compliance and reporting quality.

Verbatim wording from the response

“The following key recommendations were made and are being implemented”

Source location

2021-0063-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 8 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 the Trust-wide 72-hour reporting process and analyse report timeliness to identify improvements.

Verbatim wording from the response

“This Trust has undertaken a review of the timeliness of 72-hour reporting to ensure adherence to meeting the requirements of the National SI Framework and to implement improvements in light of the prevention of future deaths report. This will ensure more timely reporting and organisational learning takes place.”

Source location

2021-0063-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 8 March 2021

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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

Evaluate the new 72-hour reporting process and the effectiveness of its training, reporting progress to the Quality and Safety Programme Board.

Verbatim wording from the response

“6. To evaluate the training package with the divisions after 3 months.”

Source location

2021-0063-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 8 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 the 72-hour report submission process using quality-improvement methods, with progress monitored through existing executive and quality-safety governance arrangements.

Verbatim wording from the response

“The following key recommendations were made and are being implemented”

Source location

2021-0063-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 8 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

Next-of-kin information will not be mandatory because patient confidentiality must be protected and access to the service should remain unrestricted.

Verbatim wording from the response

“The iCope service has reviewed the policy on contact with clients’ families in light of the PFD report. Up to now the service has not routinely collected information on ‘Next of Kin’ and would contact the person’s GP if that information was needed. iCope does, however, quite often involve relatives or partners in aspects of treatment if appropriate and with the consent of the patient. The service takes the confidentiality of its patients very seriously, so would not want to make it mandatory for people to give NOK information in order to access the service.”

Source location

2021-0063-Response-from-St-Pancras-Hospital-Redacted
Page 1 · response
Published 8 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.1

  1. 1

    Routinely ask all service users whether they wish to provide emergency contact details and record them in electronic case records.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.

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

Routinely ask all service users whether they wish to provide emergency contact details and record them in electronic case records.

Verbatim wording from the response

“However, in an emergency situation, where it might be necessary to contact someone very quickly, it would be prudent for the service to have that information available without having to go via the GP (which could cause a delay). The service has therefore agreed and implemented routinely asking for emergency contact details for all the people it sees, if they choose to share this information. It will be made clear that this information (an emergency contact name and telephone number) would only be used in emergency situations. The information will be recorded on the electronic case record so would be easily accessible to staff if it was needed (for example if someone became physically unwell during a session or we were very worried about risk and unable to get hold of the patient).”

Source location

2021-0063-Response-from-St-Pancras-Hospital-Redacted
Page 2 · response
Published 8 March 2021

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