PFD report

Dean Martin Ford · Prevention of Future Deaths report

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Issued 4 Dec 2024•East 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
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 raised2

  1. Failure to audit risk assessments for referred patients not accepted by the team
    Part of recurring concern: Failure of care and safety auditing to identify deficiencies
  2. Failure to carry out holistic formulations of risk to self
    Part of recurring concern: Inadequate mental health risk assessmentPart of recurring concern: Unreliable assessment of suicide and self-harm risk
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.1

  1. Action

    Deliver and expand face-to-face risk-formulation training across acute, rehabilitation and borough-based staff, including new starters.

    Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 December 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

Failure to audit risk assessments for referred patients not accepted by the team

Wider context from the report

“(3) The Trust carries out risk assessment audits for clients who are accepted into the mental health and wellbeing team. There are no audits into risk assessments for those persons who are referred to the team, but not accepted by the team. As these patients who are safety net of ongoing mental healthcare, it is of concern that the quality of risk assessments for these patients is not audited. ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies.

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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 carry out holistic formulations of risk to self

Wider context from the report

“(1) Despite clear guidance from NICE in September 2022 relating to the need for a holistic formulation of risk to self, two NELFT teams involved in Mr Ford’s crisis care failed to carry out a holistic formulation of the risk he posed to himself. (2) A clinical lead for the mental health and wellbeing team within NELFT, gave evidence at the inquest in December 2024 that Mr Ford’s risk was deemed to be low because “the main factor around risk is that he denied any risk to self and denied any suicidal thoughts”. This simplistic assessment of risk is not compliant with the NICE guidelines. It is of concern that a senior member - clinical lead - within the mental health and wellbeing team is not applying the correct risk formulation. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment; Unreliable assessment of suicide and self-harm risk.

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

Deliver and expand face-to-face risk-formulation training across acute, rehabilitation and borough-based staff, including new starters.

Verbatim wording from the response

“We have undertaken a very thorough review of all policies, procedures and associated training and worked closely with our experts by experience. We launched our Risk Formulation training in September 2024 and have been delivering a day-long face-to-face training. The training utilises videos we made of experts by experience and carers talking about their experience of risk and suicide. We have now trained some 80% of our acute and rehabilitation colleagues, and moved to Borough based training in January 2025 and have started training colleagues in Barking and Dagenham.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 9 December 2024

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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.5

  1. 1

    Review risk-related policies, procedures and associated training with experts by experience.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
  2. 2

    Introduce additional staffing in the Mental Health Direct service to increase responsiveness and capacity to monitor and respond to calls.

    Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 December 2024.
  3. 3

    Ensure consultant presence in daily morning and evening multidisciplinary decision-making meetings for Mental Health and Wellbeing Team referrals and assessments.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
  4. 4

    Roll out the nationally recognised Mental Health Triage Tool and support its embedding through outcome monitoring and stakeholder, carer and service-user feedback.

    Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 December 2024.
  5. 5

    Establish a formal steering group to oversee implementation of NICE risk-formulation guidance.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 December 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

Review risk-related policies, procedures and associated training with experts by experience.

Verbatim wording from the response

“We have undertaken a very thorough review of all policies, procedures and associated training and worked closely with our experts by experience. We launched our Risk Formulation training in September 2024 and have been delivering a day-long face-to-face training. The training utilises videos we made of experts by experience and carers talking about their experience of risk and suicide. We have now trained some 80% of our acute and rehabilitation colleagues, and moved to Borough based training in January 2025 and have started training colleagues in Barking and Dagenham.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 9 December 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

Introduce additional staffing in the Mental Health Direct service to increase responsiveness and capacity to monitor and respond to calls.

Verbatim wording from the response

“From January 2025, the service will also have additional staffing in place to enable the service to be more responsive to calls, thereby improving the capacity of the service to monitor and respond to call activity.”

Source location

Response from North East London Foundation Trust
Page 3 · response
Published 9 December 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

Ensure consultant presence in daily morning and evening multidisciplinary decision-making meetings for Mental Health and Wellbeing Team referrals and assessments.

Verbatim wording from the response

“Within the Mental Health and Wellbeing Teams (MHWTs) there are multi-disciplinary team processes that support effective working. All new referrals are discussed in a daily morning MDT meeting in the Mental Health and Wellbeing Teams (MHWTs), and the consultant is now present in the decision-making process. If the decision is made to gather more information, staff allocated to the duty team on the day will phone the patient, arrange a face-to-face appointment or conduct a home visit, and these are all dependent on the discussion that takes place in the morning meeting. There is another daily meeting in the evening to discuss the outcomes of all the assessments that take place during the day and again the consultant is present in the meeting.”

Source location

Response from North East London Foundation Trust
Page 3 · response
Published 9 December 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

Roll out the nationally recognised Mental Health Triage Tool and support its embedding through outcome monitoring and stakeholder, carer and service-user feedback.

Verbatim wording from the response

“Within this service specifically, we have also changed the triage tool that is in use and are currently rolling out the nationally recognized Mental Health Triage Tool which supports the appropriate prioritization and responses for all mental health crisis calls. We will continue to support the embedding of the tool, by monthly monitoring of call outcomes, meeting monthly with local services and stakeholders for feedback, as well as engaging carers and service users for feedback, which is monitored centrally by the patient experience team in NELFT.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 9 December 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

Establish a formal steering group to oversee implementation of NICE risk-formulation guidance.

Verbatim wording from the response

“To implement the significant developments in practice outlined in NICE guidance, we established a formal steering group in August 2023 after a period of national scoping and a review of the available literature. We made contact with Oxford NHS Trust and Kent and Medway NHS and Social Care Partnership Trust (KMPT), who we understand were some of the very few NHS trusts to have begun full implementation of this guidance at this point in time.”

Source location

Response from North East London Foundation Trust
Page 2 · response
Published 9 December 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