PFD report

Mark Patrick DANIELS · Prevention of Future Deaths report

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Issued 1 Jun 2015•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
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised7

  1. Lack of clinical direction in crisis care
    Part of recurring concern: Failure to provide effective on-duty clinical leadershipPart of recurring concern: Unreliable crisis team care provision
  2. Lack of cohesion in crisis care
    Part of recurring concern: Unreliable coordination of mental health crisis responsesPart of recurring concern: Unreliable crisis team care provision
  3. Failure of communication within the crisis team and with crisis houses
    Part of recurring concern: Unreliable coordination of mental health crisis responsesPart of recurring concern: Unreliable crisis team care provisionPart of recurring concern: Unreliable crisis-team access and communication
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

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

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 June 2015.

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

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

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

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

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 June 2015.

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
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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