East London NHS Foundation Trust

PFD Addressee
Reports: 38 Earliest: Jul 2014 Latest: 5 Mar 2026

89% 2-year response rate (above 83% average). 62% of classified responses show concrete action taken.

Response Status (last 2 years, 9 reports)
Responded 8 No Response 1
AI Classification
Action Taken 62%
Action Planned 24%
Noted 14%
Disputed 0%
Based on 42 classified responses
PFD Reports Received by Quarter
PFD Reports
38 results
Janet Williams
Historic (No Identified Response)
2017-0218 11 Sep 2017 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.
Fallon Abby
All Responded
2017-0288 8 Aug 2017 London Inner (North)
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Suicide
Concerns summary (AI summary) Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and sharing crucial information, depriving the patient of support upon discharge.
Action Planned (AI summary) The Trust's safeguarding children training will include information about the Leaving Care Team, and bespoke training will be provided to ward managers and matrons for cascading to staff. The ward's operational policy will be reviewed to include contacting the Leaving Care Team upon admission of a young person previously in care, and staff will work with the young person to negotiate the involvement of their social worker.
Songul Bozdag
All Responded
2017-0219 26 Jul 2017 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The care co-ordinator failed to conduct mandatory patient reviews, maintain accurate records, and update medication dosages, leading to under-medication, with no systemic safety net.
Action Taken (AI summary) The Trust has implemented an inbox-based system to communicate discharge care plans to CMHT staff, and monthly supervision for care coordinators is now working in line with Trust procedures. Regular audits are being undertaken to maintain a robust oversight on the process.
Andrew Codling
All Responded
2017-0339 23 Jun 2017 Bedfordshire and Luton
Community health care and emergency services related deaths Suicide
Concerns summary (AI summary) A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.
Action Taken (AI summary) East London NHS Trust has developed and implemented a new protocol within CMHTs regarding the use of mobile phones in communication with service users, including an explanatory letter with contact information and guidance for responding to messages.
Jamie Elliott
All Responded
2017-0135 25 Apr 2017 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for patients with worsening conditions, despite identified concerns.
Action Taken (AI summary) The Trust distributed a memo to clinical staff in City and Hackney regarding contact with external providers. A policy has been updated to include referrals to the Home Treatment team where patients haven't been seen within 48 hours of referral, needing prioritization and potential consultant review.
Luke Moulding
All Responded
2017-0121 13 Apr 2017 Bedfordshire and Luton
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical "opt-in" follow-up letter was not sent after a psychiatric consultation, and the current system of typing letters rather than using pre-printed materials caused significant delays.
Action Taken (AI summary) The Trust has updated its Operational Policy for CMHT, now requiring opt-in letters to be sent within 5 working days, subject to local audit. This followed a serious incident review that identified delays in sending such letters.
Christiana Pelle
Historic (No Identified Response)
2017-0118 10 Apr 2017 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report identifies a lack of clear guidance for nurses on when to involve a patient’s GP, the absence of a system for sharing information between the Community District Nursing Team and other agencies, and a lack of a system for communicating concerns with the care provider agency.
Mariana Pinto
All Responded
2017-0093 14 Mar 2017 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not escalate an urgent situation or prompt emergency services involvement.
Action Planned (AI summary) Following a serious incident review, the Trust updated its Operational Policy for CMHT, mandating that opt-in letters be sent within 5 working days, and will conduct local audits to ensure compliance. East London NHS Foundation Trust is developing a written discharge care plan to clarify the limitations of the Home Treatment Team, and will increase flexibility to bring forward visits for service users experiencing deterioration in their mental health between scheduled visits from October 2017. From October 2017, the service will be reconfigured to provide the availability for 24 hour face to face contact if required and an enhanced urgent response service.
Jack Susianta
Historic (No Identified Response)
2016-0176 6 May 2016 London Inner North
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
Brenda Morris
All Responded
2016-0065 19 Feb 2016 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths Suicide
Concerns summary (AI summary) Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned leave and substandard documentation.
Action Planned (AI summary) The Trust has developed an 'In-patient leave agreement' and an 'In-patient leave checklist' to be completed before a patient goes on leave, with a pilot on older persons wards aiming for full introduction by the end of the month and quarterly audits starting in July 2016.
Chentoori  Chanthirakumar
Historic (No Identified Response)
2016-0037 5 Feb 2016 London Inner (North)
Suicide
Concerns summary (AI summary) Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting confidentiality, prevented effective support for a distressed student.
Andrew Aitken
All Responded
2014-0561 15 Dec 2014 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without a GP.
Action Planned (AI summary) The Trust investigated the concerns, interviewing staff and reviewing medical records, finding that tablets left at the bedside were intended to be destroyed by a pharmacist and were locked in a medicine cupboard. The Trust booked and paid for a taxi to take the deceased home after discharge, as he had no clothes. The Trust will ensure staff are aware that patients can self-refer to the RAID service and is considering how to best communicate this information to all staff working in Tower Hamlets. The Trust will also ensure clinical discussions from daily clinical meetings are recorded in patient medical records and that junior doctors discuss patients seen during liaison duties in consultant supervision.
Graham Darby
Historic (No Identified Response)
2014-0367 24 Jul 2014 London North
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.