Fallon Alphonsine ABBY · Prevention of Future Deaths report

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Issued 8 Aug 2017•Inner North London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
5

Described in responses

Recipients and published responses

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 contact social workers and obtain collateral history
    Part of recurring concern: Failure to obtain relevant collateral information from family and social supports
  2. Failure to invite the social worker to ward rounds
    Part of recurring concern: Unsafe operation of multidisciplinary clinical meetings

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. East London NHS Foundation Trust

    Work with admitted young people to negotiate their social worker’s involvement after informing the Leaving Care Team.

  2. East London NHS Foundation Trust

    Discuss the case and highlighted issues at regular Consultant meetings and cascade learning to junior staff.

  3. East London NHS Foundation Trust

    Review the ward Operational Policy to include contacting the Leaving Care Team when a previously looked-after young person is admitted.

  4. East London NHS Foundation Trust

    Add Leaving Care Team involvement through age 25 to mandatory Safeguarding Children Training.

  5. East London NHS Foundation Trust

    Provide bespoke Leaving Care Team training to Ward managers and Matrons for cascading to ward staff.

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

  1. East London NHS Foundation Trust

    Planned training and policy changes are considered to have adequately addressed concerns about involving Leaving Care Team social workers.

    No action considered necessaryThe respondent said that no further action was needed.

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 contact social workers and obtain collateral history

Wider context from the report

“I heard at inquest that no member of the team on Roman Ward contacted Fallon’s social worker. There was no protocol for this. If they had sought a collateral history from the social worker, they would have discovered that Fallon’s mum was not dead as Fallon had told them, but was alive and living in a hostel. The social worker had been rung by a nurse at the Royal London Hospital, but she was waiting to be invited to a ward round at Mile End Hospital and such invitation was never made. It seems unlikely that proper discussion with the social worker would have changed the outcome for Fallon, but it would have meant that valuable information would have been shared, and it would have meant that Fallon would have had the benefit of her social worker on hand upon discharge. This might be very important for another patient. ”

Is this part of a recurring concern?

Yes — Failure to obtain relevant collateral information from family and social supports.

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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 invite the social worker to ward rounds

Wider context from the report

“I heard at inquest that no member of the team on Roman Ward contacted Fallon’s social worker. There was no protocol for this. If they had sought a collateral history from the social worker, they would have discovered that Fallon’s mum was not dead as Fallon had told them, but was alive and living in a hostel. The social worker had been rung by a nurse at the Royal London Hospital, but she was waiting to be invited to a ward round at Mile End Hospital and such invitation was never made. It seems unlikely that proper discussion with the social worker would have changed the outcome for Fallon, but it would have meant that valuable information would have been shared, and it would have meant that Fallon would have had the benefit of her social worker on hand upon discharge. This might be very important for another patient. ”

Is this part of a recurring concern?

Yes — Unsafe operation of multidisciplinary clinical meetings.

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

Work with admitted young people to negotiate their social worker’s involvement after informing the Leaving Care Team.

Verbatim wording from the response

“In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.”

Source location

2017-0288-Response-by-East-London-NHS-Trust
Page 2 · response
Published 6 December 2017

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

Discuss the case and highlighted issues at regular Consultant meetings and cascade learning to junior staff.

Verbatim wording from the response

“This case and the issues highlighted will also be discussed at the regular Consultant’s meeting and again cascaded to junior staff.”

Source location

2017-0288-Response-by-East-London-NHS-Trust
Page 2 · response
Published 6 December 2017

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 ward Operational Policy to include contacting the Leaving Care Team when a previously looked-after young person is admitted.

Verbatim wording from the response

“In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.”

Source location

2017-0288-Response-by-East-London-NHS-Trust
Page 2 · response
Published 6 December 2017

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

Add Leaving Care Team involvement through age 25 to mandatory Safeguarding Children Training.

Verbatim wording from the response

“Firstly, the Named Professional for Safeguarding Children will ensure that Safeguarding Children Training, which is mandatory for all staff, will include information about the Leaving Care Team and their involvement with a young person up to the age of 25.”

Source location

2017-0288-Response-by-East-London-NHS-Trust
Page 1 · response
Published 6 December 2017

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

Provide bespoke Leaving Care Team training to Ward managers and Matrons for cascading to ward staff.

Verbatim wording from the response

“The Named Professional for Safeguarding Children will also undertake some bespoke training with Ward managers and Matrons in relation to this specific issue for cascading to all ward staff.”

Source location

2017-0288-Response-by-East-London-NHS-Trust
Page 2 · response
Published 6 December 2017

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

Planned training and policy changes are considered to have adequately addressed concerns about involving Leaving Care Team social workers.

Verbatim wording from the response

“In addition the Operational Policy for the ward will be reviewed to include the requirement to contact the Leaving Care Team in the event of an admission of a young person who has previously been in care. Once the Leaving Care Team has been informed of an admission staff will work with the young person to negotiate the involvement of their social worker.”

Source location

2017-0288-Response-by-East-London-NHS-Trust
Page 2 · response
Published 6 December 2017

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