Evelina Vilkiene
PFD Report
All Responded
Ref: 2023-0082Deceased
All 1 response received
· Deadline: 30 Apr 2023
Coroner's Concerns (AI summary)
The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions and medication weaning for a patient at increased self-harm risk, and did not ensure required weekly reviews.
View full coroner's concerns
1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.
2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews. This was in contravention of the general requirement for amber zoned patients to be seen at least weekly.
2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews. This was in contravention of the general requirement for amber zoned patients to be seen at least weekly.
Responses
Action Planned
The Trust has agreed to take actions to address concerns raised, detailed within an attached action plan. (AI summary)
The Trust has agreed to take actions to address concerns raised, detailed within an attached action plan. (AI summary)
View full response
Dear Madam
Re: Inquest touching upon the death of Evelina Vilkiene
I refer to your letter dated 6 March 2023 and the Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.
At the conclusion of the hearing into the death of Evelina Vilkiene, you expressed the following concerns in respect of the care provided by NELFT:
1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.
2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews. This was in contravention of the general requirement for amber zoned patients to be seen at least weekly.
We have carefully considered the Regulation 28 report and agreed to take actions to address concerns raised by you. We have detailed the actions which we will take, within the attached action plan, for your kind consideration.
I would like to take this opportunity to thank you for raising your concerns as part of this inquest. We find learning from inquests extremely valuable and are very grateful for your comprehensive investigation, which benefits not only the families of the deceased, but also the Trust and its service users.
I trust that the above and the attached action plan reassure you that the Trust has taken this tragic death very seriously indeed, and that it reflects our commitment to improve care quality and patient safety.
If I can further assist, please do contact my office on
Re: Inquest touching upon the death of Evelina Vilkiene
I refer to your letter dated 6 March 2023 and the Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.
At the conclusion of the hearing into the death of Evelina Vilkiene, you expressed the following concerns in respect of the care provided by NELFT:
1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.
2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews. This was in contravention of the general requirement for amber zoned patients to be seen at least weekly.
We have carefully considered the Regulation 28 report and agreed to take actions to address concerns raised by you. We have detailed the actions which we will take, within the attached action plan, for your kind consideration.
I would like to take this opportunity to thank you for raising your concerns as part of this inquest. We find learning from inquests extremely valuable and are very grateful for your comprehensive investigation, which benefits not only the families of the deceased, but also the Trust and its service users.
I trust that the above and the attached action plan reassure you that the Trust has taken this tragic death very seriously indeed, and that it reflects our commitment to improve care quality and patient safety.
If I can further assist, please do contact my office on
Sent To
- North East London Foundation Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
30 Apr 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 20th June 2022 I commenced an investigation into the death of Evelina Vilkiene aged 45 years. The investigation concluded at the end of the inquest on 2nd March 2023. The conclusion of the inquest a narrative conclusion: Evelina Vilkiene took her own life whilst under the care of the mental health services. She was at increased risk of harm to herself following a decision to wean her clonazepam medication on the 26 May 2022, but there was no careful risk management plan and there were no significant assessments of her mental health following the 27 May 2022”.
Circumstances of the Death
Evelina Vilkiene suffered from a first psychotic episode in November 2021 and required care from the mental health services. She was admitted to the care of the intensive home treatment team and then transferred to the care of the early intervention in psychosis team. In April 2022 she presented in crisis again, presenting with severe depression. She was accepted again by the home treatment team and remained under their intensive support until 21 May 2022. There was no detailed risk assessment at the time of step-down, or jointly agreed risk management plan. At the time of step-down she presented as anxious in relation to her medication and showed a dependence to clonazepam. A medical plan was set to wean her off the clonazepam on the 26 May 2022, with no carefully devised risk management plan put in place. There was no care co-ordinator visit following the medical review on the 26 May 2022. On the 7 June 2022, Evelina was found hanging in the basement of her home address. A paramedic pronounced her life extinct on scene. Police deemed the circumstances as non-suspicious. A note was found which contains Evelina's stated intention to take her own life.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.