PFD report

Olayemi Oluwarotimi Kodjo Kehinde · Prevention of Future Deaths report

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Issued 24 Apr 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
9

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 of staff authorised to supervise S.17 leave to identify serious incidents requiring meaningful intervention
  2. Failure of the Trust to identify matters requiring a full governance investigation
    Part of recurring concern: Inadequate safety incident investigations
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 the Patient Safety Incident Response Framework to guide compassionate incident responses, investigation decisions, learning and improvement.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 April 2024.
  2. Action

    Perform two-monthly electronic dip-sample audits against the section 17 leave guidance and review outcomes to support improvements.

    Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 April 2024.
  3. Action

    Review historic incidents through InPhase reporting, Incident Review Group discussion, directorate oversight and, where necessary, Patient Safety Incident Group consideration of a 72-hour report.

    Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 April 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 of staff authorised to supervise S.17 leave to identify serious incidents requiring meaningful intervention

Wider context from the report

“1. In July 2011, Mr Kehinde was an inpatient subject to an order under S.3 Mental Health Act 1983. On 2nd July 2011, Mr Kehinde was granted escorted S.17 leave to return home to collect belongings. Mr Kehinde left the ward in the company of a mental health nurse and they both travelled to a tattoo parlour. Mr Kehinde’s face was tattooed with a large permanent tattoo. No action was taken by the nurse to prevent this act occurring. The incident was not investigated as a serious incident by the Trust. Whereas the court does not suggest that a facial tattoo constitutes a factor that would likely cause a future death, concerns arise regarding; • The ability of staff authorised to supervise S.17 leave at identifying serious incidents that require meaningful intervention. • The ability of the Trust to identify matters that require a full governance investigation. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 of the Trust to identify matters requiring a full governance investigation

Wider context from the report

“1. In July 2011, Mr Kehinde was an inpatient subject to an order under S.3 Mental Health Act 1983. On 2nd July 2011, Mr Kehinde was granted escorted S.17 leave to return home to collect belongings. Mr Kehinde left the ward in the company of a mental health nurse and they both travelled to a tattoo parlour. Mr Kehinde’s face was tattooed with a large permanent tattoo. No action was taken by the nurse to prevent this act occurring. The incident was not investigated as a serious incident by the Trust. Whereas the court does not suggest that a facial tattoo constitutes a factor that would likely cause a future death, concerns arise regarding; • The ability of staff authorised to supervise S.17 leave at identifying serious incidents that require meaningful intervention. • The ability of the Trust to identify matters that require a full governance investigation. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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 the Patient Safety Incident Response Framework to guide compassionate incident responses, investigation decisions, learning and improvement.

Verbatim wording from the response

“3. In 2023 the reporting and management of investigations changed with the implementation of the nationally mandated Patient Safety Incident Response Framework (PSIRF). PSIRF supports the development of an effective patient safety incident response system, that prioritises compassionate engagement and involvement of those affected by patient safety incidents (including patients, families and staff), and”

Source location

Response from NELFT
Page 2 · response
Published 30 April 2024

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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

Perform two-monthly electronic dip-sample audits against the section 17 leave guidance and review outcomes to support improvements.

Verbatim wording from the response

“Electronic dip-sample audits will be performed on a two-monthly basis, against the guidance, and the outcome of the audit will be reviewed by the relevant directorates to support any required improvements in this area.”

Source location

Response from NELFT
Page 2 · response
Published 30 April 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

Review historic incidents through InPhase reporting, Incident Review Group discussion, directorate oversight and, where necessary, Patient Safety Incident Group consideration of a 72-hour report.

Verbatim wording from the response

“6. Once the Trust is made aware of an incident that is historic, it reviews the historic incident utilising the current process in place, which consists of reporting it as an incident on InPhase, discussion of the incident at the IRG meeting, and following further directorate oversight, and where deemed necessary, preparation of a 72-hour report for presentation at the PSIG forum. This provides a robust decision-making mechanism, ensuring that the investigation of an historic incident is treated with the same care and attention as all incidents.”

Source location

Response from NELFT
Page 3 · response
Published 30 April 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

Prepare detailed guidance for safely escorting patients on section 17 leave and responding to serious incidents, reckless decisions, absconding or attempted absconding.

Verbatim wording from the response

“1. To ensure that staff who escort a patient on supervised leave under section 17 of the Mental Health Act 1983 (‘s. 17 leave’), are able to do so safely and are able to identify serious incidents that require meaningful intervention, and to provide appropriate and timely intervention, new guidance for leave from inpatient wards for mental health patients has been prepared. This guidance (attached) sets out in detail the process to be undertaken before, during, and after escorting a patient on s. 17 leave, and also covers actions to be taken if the patient intends what may be an ill-advised or reckless decision, and/or absconds or attempts to do so. The first page of this guidance contains on a single page an ‘At a glance guidance for escorted leave for mental health patients’ as a flowchart, to enable effective learning for staff involved in s.”

Source location

Response from NELFT
Page 2 · response
Published 30 April 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

Launch the section 17 leave guidance across the Trust and disseminate it through electronic communications, intranet publication, management channels, supervision and relevant training.

Verbatim wording from the response

“2. This guidance will go live across the Trust in June 2024 and will be communicated to all staff via the Trust electronic newsletter and a copy of this guidance will be placed on the Trust’s intranet. It will also feature in regular Mental Health Act (MHA) introductory and refresher training, and through wider learning at Trust-wide Learning & Development events. This guidance will also be circulated to the Integrated Care Directors, Directors of Nursing, Associate Directors of Nursing, the Directors, the Associate Medical Directors, and the matrons, some of whom were involved in the preparation of the guidance and disseminated through managers’ and matrons huddles, as well as in staff supervision.”

Source location

Response from NELFT
Page 2 · response
Published 30 April 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 and operate a weekly Patient Safety Incident Group to oversee qualifying incidents and determine appropriate learning responses.

Verbatim wording from the response

“4. With the implementation of PSIRF, the Trust initiated a weekly Patient Safety Incident Group (PSIG) forum chaired by the Executive Chief Nursing Officer to oversee incidents that have met the threshold for a PSIRF learning response. There are several learning responses to incidents. Decisions about the type of investigation to undertake are decided at the weekly PSIG forum, and a learning response is decided, based on the local PSIRF plan, national PSIRF recommendations via NHS England (NHSE), and following presentations from clinical staff who share immediate learning outcomes.”

Source location

Response from NELFT
Page 3 · response
Published 30 April 2024

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.3

  1. 1

    Transition incident reporting and management from Datix to InPhase to support nationally mandated Learning From Patient Safety Events reporting.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 April 2024.
  2. 2

    Hold regular directorate incident review meetings to provide further oversight of incidents requiring additional scrutiny, including unexpected harms.

    Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.
  3. 3

    Hold a weekly Incident Review Group with directorate nursing oversight to review incidents centrally before local management.

    Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 April 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

Transition incident reporting and management from Datix to InPhase to support nationally mandated Learning From Patient Safety Events reporting.

Verbatim wording from the response

“5. In 2024, the Trust transitioned from one incident reporting and management system (Datix), to another (InPhase). This is, in part, to satisfy the NHSE requirement for LFPSE (Learning From Patient Safety Events).”

Source location

Response from NELFT
Page 3 · response
Published 30 April 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

Hold regular directorate incident review meetings to provide further oversight of incidents requiring additional scrutiny, including unexpected harms.

Verbatim wording from the response

“2. Each directorate holds a regular incident review meeting, at which incidents requiring further oversight (such as unexpected harms) are reviewed.”

Source location

Response from NELFT
Page 2 · response
Published 30 April 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

Hold a weekly Incident Review Group with directorate nursing oversight to review incidents centrally before local management.

Verbatim wording from the response

“1. The Trust holds a weekly Incident Review Group (IRG) to review incidents that have occurred across the organisation. The Associate Directors of Nursing (ADoNs) for each directorate attend that meeting to provide oversight on their own incidents. This ensures that incidents are seen centrally before being disseminated across their relevant directorates for local management processes.”

Source location

Response from NELFT
Page 2 · response
Published 30 April 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