Mark Patrick DANIELS · Prevention of Future Deaths report

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Issued 1 Jun 2015•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.

View original report

Concerns: 7
Recipients: 1
Responses found: 1
Stated actions: 2

Recipients and published responses

North London NHS Foundation Trust

Addressed to Camden and Islington NHS Foundation Trust, now represented here by North London NHS Foundation Trust.Response found

Full report text

This is the full text from the original published report.

Open published report

Explains the investigation, the inquest, the evidence considered and the coroner’s conclusion.

Describes the events and care leading up to the death.

Sets out risks the coroner believes could cause future deaths unless action is taken.

Investigation and inquest

On 3 December 2014, I commenced an investigation into the death of Mark Daniels, aged 56 years. The investigation concluded at the end of the inquest earlier today. I made a narrative determination, which I attach.

Circumstances of the death

Mr Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. There was an agreement that he be admitted to Rivers Crisis House, but this never took place.

Coroner’s concerns

You will see from the determination attached, that I found there was a failure by the crisis team:

- to visit Mr Daniels twice a day, despite a plan so to do;
- to record why twice daily visits were not attempted;
- to communicate within the team and with the two crisis houses;
- to progress the referral to a crisis house promptly;
- to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house.

I gained the impression of a lack of cohesion and clinical direction.

Concerns and recipient responses

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

Report evidence summary

Concerns raised7

Lack of clinical direction in crisis care
Part of recurring concern: Failure to provide effective on-duty clinical leadership Part of recurring concern: Unreliable crisis team care provision
Lack of cohesion in crisis care
Part of recurring concern: Unreliable coordination of mental health crisis responses Part of recurring concern: Unreliable crisis team care provision
Failure of communication within the crisis team and with crisis houses
Part of recurring concern: Unreliable coordination of mental health crisis responses Part of recurring concern: Unreliable crisis team care provision Part of recurring concern: Unreliable crisis-team access and communication

Failure to consider hospital admission for a patient presenting significant suicide risk
Part of recurring concern: Failure to provide clinically indicated psychiatric admission Part of recurring concern: Unsafe individualised treatment planning for acute mental health risk
Delays in progressing referrals to a crisis house
Part of recurring concern: Unreliable crisis team care provision Part of recurring concern: Unreliable mental health referral pathways
Failure to record reasons when twice-daily crisis team visits are not attempted
Failure to conduct twice-daily crisis team visits in accordance with the care plan
Part of recurring concern: Failure to provide required daily mental-health team visits Part of recurring concern: Unreliable crisis team care provision

Stated actions 2

North London NHS Foundation Trust
Monitor implementation of the measures across the Crisis Teams and Crisis Houses.
North London NHS Foundation Trust
Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.

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 clinical direction in crisis care

Wider context from the report

“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”

Is this part of a recurring concern?

Yes — Failure to provide effective on-duty clinical leadership; Unreliable crisis team care provision.

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 cohesion in crisis care

Wider context from the report

“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”

Is this part of a recurring concern?

Yes — Unreliable coordination of mental health crisis responses; Unreliable crisis team care provision.

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 of communication within the crisis team and with crisis houses

Wider context from the report

“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”

Is this part of a recurring concern?

Yes — Unreliable coordination of mental health crisis responses; Unreliable crisis team care provision; Unreliable crisis-team access and communication.

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 consider hospital admission for a patient presenting significant suicide risk

Wider context from the report

“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”

Is this part of a recurring concern?

Yes — Failure to provide clinically indicated psychiatric admission; Unsafe individualised treatment planning for acute mental health risk.

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

Delays in progressing referrals to a crisis house

Wider context from the report

“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”

Is this part of a recurring concern?

Yes — Unreliable crisis team care provision; Unreliable mental health referral pathways.

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 record reasons when twice-daily crisis team visits are not attempted

Wider context from the report

“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”

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 conduct twice-daily crisis team visits in accordance with the care plan

Wider context from the report

“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”

Is this part of a recurring concern?

Yes — Failure to provide required daily mental-health team visits; Unreliable crisis team care provision.

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

Monitor implementation of the measures across the Crisis Teams and Crisis Houses.

Verbatim wording from the response

“measures have been put in place across all the Crisis Teams and the Crisis Houses in the Trust to address the concerns you have raised and there is a plan to monitor the implementation of these measures.”

Source location

2015-0208-Response-by-Camden-and-Islington-NHS-Trust
Page 2 · response
Published 1 June 2015

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

Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.

Verbatim wording from the response

“████████ Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them – the action plan is appended at the end of this letter. As you can see from the action plan updates, several”

Source location

2015-0208-Response-by-Camden-and-Islington-NHS-Trust
Page 1 · response
Published 1 June 2015

Open published response

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located: 1/1

Data last updated 7 September 2026

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised7

Lack of clinical direction in crisis care

Lack of cohesion in crisis care

Failure of communication within the crisis team and with crisis houses

Failure to consider hospital admission for a patient presenting significant suicide risk

Delays in progressing referrals to a crisis house

Failure to record reasons when twice-daily crisis team visits are not attempted

Failure to conduct twice-daily crisis team visits in accordance with the care plan

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

Stated actions 2