Central and North West London NHS Foundation Trust

PFD Addressee
Reports: 29 Earliest: Feb 2014 Latest: 24 Mar 2026

75% 2-year response rate (below 83% average). 59% of classified responses show concrete action taken.

Response Status (last 2 years, 4 reports)
Responded 3 No Response 1
AI Classification
Action Taken 59%
Action Planned 32%
Noted 5%
Disputed 3%
Based on 37 classified responses
PFD Reports Received by Quarter
PFD Reports
29 results
Ronald Meikle
No Identified Response
2026-0168 24 Mar 2026 Milton Keynes
State Custody related deaths
Concerns summary (AI summary) Key concerns include widespread availability of illicit drugs, inconsistent response to intoxication, fragmented information sharing, blocked observation panels, and inadequate support for vulnerable prisoners.
Brian Ringrose
All Responded
2025-0399 1 Aug 2025 Milton Keynes
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) Police officers failed to follow critical restraint training, including prolonged prone positioning and inadequate welfare monitoring. Officers also did not apply the National Decision Model or challenge inappropriate techniques, contributing to the death.
Action Taken (AI summary) The hospital has updated its Police Custody SOP, incorporated Emergency Department-specific guidelines, is reviewing training on restraint and restrictive practices, and has reiterated Toxbase guidelines to clinicians. Breakaway and conflict resolution training remains mandated. The trust has implemented a joint entry protocol for documentation, mandating verbal handovers post-assessment and reinforcing the principle that discharge from ED should not proceed with unresolved safety concerns. Refresher and Human Factors training are also taking place. Thames Valley Police has reviewed training material on handcuffing, implemented additional Personal Safety Training, provided training to officers on medical issues that can arise with prolonged restraint, rolled out the College of Policing's 'Upstander' E-Learning, and included communication and handover protocols in training scenarios.
Edward Cassin
All Responded
2025-0315 18 Jun 2025 Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was a lack of understanding of Speech and Language Therapy and Dietetic policies among hospital staff, compounded by siloed working between healthcare Trusts, hindering patient care.
Action Taken (AI summary) The Trust is transferring the Speech and Language Therapy service to Milton Keynes University Hospital on 22 October, enhancing training to include practical elements, and working with the hospital on a quality improvement initiative focused on dysphagia care. A new electronic referral process has been implemented to ensure referrals are standardized and can be triaged effectively. The hospital is running a Quality Improvement Programme focused on dysphagia management, delivering a Fundamentals of Care training programme for all clinical staff, and working to improve access to patient records across different systems. The SALT service will transition in-house at MKUH.
Florence Stewart
All Responded
2024-0539 10 Oct 2024 Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation efforts.
Action Taken (AI summary) The Trust has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement, including meetings with staff, strengthened induction for temporary and new staff, and realigned the Nurse in Charge role. The Trust Resuscitation Group has also developed a visual aid for oxygen cylinders and distributed written communication to staff.
David Siirak
All Responded
2024-0174 7 Mar 2024 West London
Other related deaths
Concerns summary (AI summary) Ward staff demonstrated a chaotic and panicked response to an emergency, lacking experience from real or simulated incidents, and critical simulation training is still absent.
Action Taken (AI summary) The Trust has taken action to improve staff training in emergency response, including additional in-situ simulation sessions and building a simulation room. Learning from simulations is shared via team meetings and presented to the Resuscitation and Deteriorating Patient Committee.
Adrian James
All Responded
2024-0128 7 Mar 2024 Inner West London
Mental Health related deaths Suicide
Concerns summary (AI summary) The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
Noted (AI summary) NHS England expresses condolences and outlines its commitment to improving community mental health services nationally, but states that responding to the specific concerns raised by the coroner is the remit of the named NHS Trust. They confirm the concerns have been shared with their national Mental Health Team and Regulation 28 Working Group. The Trust outlines actions taken and planned, including issuing additional guidance on managing suicide risk, sharing learning with the team, updating policies, and reminding staff of the need for communication amongst professionals involved in treatment.
Roberto Bottello
All Responded
2024-0087 16 Feb 2024 Inner West London
Mental Health related deaths
Concerns summary (AI summary) Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, despite clear signs of acute psychosis.
Action Planned (AI summary) NHS England colleagues will be asked to share the learnings from the case within their health and care systems, and will consider whether any further action needs to be taken regarding the concerns. CNWL has implemented measures including establishing dedicated s136 hubs, improving communication, and maintaining safer staffing levels, and SPA no longer manages calls from the Police or supports locating Health Based Place of Safety (HBPOS) suites. All HBPOS suites across London update the SMART Tool in real time. The Metropolitan Police Service reminds recruit police officers about airwave etiquette including the phonetic alphabet and expects them to demonstrate competence through role play activities; the training material is being amended to emphasise the requirement to use the phonetic alphabet to conduct name checks.
Jacqueline Smith
Partially Responded
2023-0304 21 Aug 2023 West London
Alcohol, drug and medication related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support process focused on enforcement, left a vulnerable tenant without effective assistance.
Action Taken (AI summary) The London Borough of Hillingdon has implemented a Hoarding Panel with representatives from various teams, provides training to officers to recognize and support residents that hoard, and refers complex cases to MARAC while avoiding enforcement action.
Nicola Norman
Historic (No Identified Response)
2023-0097Deceased 14 Mar 2023 Inner West London
Suicide
Concerns summary (AI summary) The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, follow up on distressed callers, or routinely escalate critical concerns to clinicians or the GP.
Robert Kelly
All Responded
2022-0364 15 Nov 2022 Milton Keynes
Suicide
Concerns summary (AI summary) An elderly, post-operative patient was discharged from hospital without a care package or follow-up, and subsequent GP referrals for home support were mishandled, highlighting a systemic lack of patient aftercare.
Disputed (AI summary) The hospital disputes the coroner's concerns, stating that Mr. Kelly's discharge was appropriately handled, he had mental capacity, and a care package was not deemed necessary. They state that hospital procedures functioned well and could not have reasonably foreseen subsequent events. The Trust reviewed its referral process for the District Nursing Single Point of Access service following the incident. The Standard Operating Procedure will be amended to ensure tighter follow-up when additional referral information is requested.
Daniel O’Sullivan
Partially Responded
2022-0330 21 Oct 2022 Inner South London
Alcohol, drug and medication related deaths Suicide
Concerns summary (AI summary) The decision to rescind Mental Health Act detention was flawed due to a failure to update the suicide/self-harm risk assessment and an absence of a comprehensive care and treatment plan for core needs.
Action Planned (AI summary) Central and North West London NHS Foundation Trust has implemented changes including safety planning for all patients, strengthening processes for recording patient leave, improved training, strengthened scrutiny of serious incident reports and is transitioning to the new national framework, PSIRF. The Department of Health and Social Care notes that the draft Mental Health Bill proposes a statutory duty on clinicians to create a care and treatment plan for relevant patients detained under the Mental Health Act.
Clifford Rose
All Responded
2022-0329 20 Oct 2022 Milton Keynes
Care Home Health related deaths
Concerns summary (AI summary) Remote telephone assessments for vulnerable, elderly patients yield inaccurate information, as individuals may misrepresent their abilities. All assessments should be conducted face-to-face, ideally involving family members, for accurate needs identification.
Action Planned (AI summary) Milton Keynes City Council has agreed to a reciprocal arrangement with CNWL to access healthcare (System One) and social care (Liquid Logic) systems, with technical issues to be addressed in early 2023. Central and North West London NHS Foundation Trust is updating assessment templates to include mandatory questions about family involvement and other service providers, and sharing lessons learned with staff.
Bathsheba Shepherd
Historic (No Identified Response)
2021-0099 28 Mar 2021 London (West)
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person to register with a GP due to a lack of documentation pose ongoing risks.
Prince Fosu
All Responded
2020-0148 6 Jul 2020 West London
State Custody related deaths
Concerns summary (AI summary) Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported to healthcare managers, hindering joint working and risking critical issues being missed.
Action Planned (AI summary) The IMB will deliver training to all immigration detention IMB members by the end of 2020, and require it for all future members with refresher training every three years. The training will focus on monitoring those in separation, raising concerns, and responding to allegations of abuse. The Trust is developing robust educational pathways within Offender Care and will develop a “train the trainer” programme to enable local sites to provide mental health awareness training routinely. The Offender Care directorate is drafting guidance on when a patient should be referred to the mental health team, including conditions and symptoms and will be circulating it as a standalone document to all CNWL staff and to all partner agencies by the end of November 2020.
Andrew Goldstraw
Partially Responded
2020-0041 21 Feb 2020 Hampshire (Central)
Alcohol, drug and medication related deaths State Custody related deaths Suicide
Concerns summary (AI summary) The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword search.
Action Taken (AI summary) Central and North West London NHS Foundation Trust has made changes to healthcare services at HMP Winchester, including internal training on SystmOne, Mental Health risk assessments and a joint learning bulletin stressing the importance of sharing information.
Iain Macinnes
Historic (No Identified Response)
2020-0118 24 Sep 2019 Milton Keynes
Community health care and emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) The trust failed to inform the patient's family about his deteriorating condition and transfer to the Home Treatment Team, despite his expressed wish for their involvement in his care.
Amir Siman-Tov
Historic (No Identified Response)
2019-0302 28 Aug 2019 London (West)
State Custody related deaths
Concerns summary (AI summary) Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.
Michael Folley
Partially Responded
2019-0230 21 Jun 2019 Hampshire (Central)
State Custody related deaths
Concerns summary (AI summary) The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.
Action Planned (AI summary) Hampshire Constabulary will mandate electronic self-learning packages on Prisoner Escort Records for Custody Officers and Detention Officers, review the content annually, and raise the issues in the Regulation 28 Notice at the next HM Courts and Tribunal Service working group meeting. CNWL NHS Trust details existing ACCT and SASH training, reception screening processes with standardized training being rolled out, twice-yearly care records audits, and staff supervision policies including discussion of care plans and risk assessments.
Georgia Nelson
All Responded
2019-0140 29 Apr 2019 London Inner (West)
Mental Health related deaths Railway related deaths
Concerns summary (AI summary) There is a lack of suitable housing specifically for young patients with severe and enduring mental health issues.
Action Planned (AI summary) RBKC and partner agencies are working together to identify ongoing needs and service developments arising from the closure of rehabilitation inpatient beds at Horton, including a potential local 'wrap around community rehab offer' with support and rehabilitation services in supported accommodation within 18 months. CNWL acknowledges the concerns raised and states that as discharge planning starts at admission, they will follow new NICE guidance on considering rehabilitation as appropriate. They offer a range of person-centred interventions and have a well-developed vocational service, offering Employment Support using the Individual Placement and Support Model, a User Employment Programme and a strong programme of Peer Support.
Peter Garvin
Partially Responded
2019-0069 27 Feb 2019 London Inner (West)
Mental Health related deaths Suicide
Concerns summary (AI summary) Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking private care negatively impacted patient care. A carer's assessment was also not offered.
Action Taken (AI summary) CNWL NHS Trust has drawn up a protocol for staff working with patients who seek advice or treatment from a private clinician, setting out how to work with private sector colleagues and how to explain the process to patients, drawing on national guidance.
John Pearce
All Responded
2019-0068 25 Feb 2019 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The District Nursing Team failed to urgently refer a patient with a severely worsening knee wound, visible over two months of regular visits, leading to significant delays in hospital admission.
Action Taken (AI summary) The Trust acknowledged failures in care and has re-trained staff in wound management, including the use of the NEWS2 tool for deteriorating patients. They will also conduct a 3-month action plan to ensure improvements are embedded, including improved communication and escalation procedures with specialist services and GPs.
Maximilien Kohler
Partially Responded
2018-0316 24 Oct 2018 London Inner (West)
Child Death Mental Health related deaths
Concerns summary (AI summary) Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of services for chronic, complex conditions.
Noted (AI summary) The Trust provides an account of their involvement with the patient's case, including the referral and assessment process for a possible co-morbid eating disorder, and explains why a full ASD assessment was not carried out by their service. The Department of Health and Social Care acknowledges concerns about outcomes for young people on the autistic spectrum and is launching a comprehensive review of the autism strategy, expected to report in November 2019, which will include a national call for evidence.
Caroline Scott
Historic (No Identified Response)
2018-0155 21 May 2018 Milton Keynes
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Out-of-hours emergency mental health services are inadequate, and medical staff do not fully understand the emergency referral policy.
Sarah Reed
Partially Responded
2017-0238 28 Jul 2017 London (City)
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths State Custody related deaths
Concerns summary (AI summary) Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment unit, resulting in her self-inflicted death.
Action Planned (AI summary) CNWL NHS Trust has clarified report request procedures with HMPPS, ensured report requests are communicated to consultants promptly, updated care plan templates to include release planning, audited CPA meetings to improve attendance, and launched an Offender Care Transformation Board to reduce self-harm and avoid unexpected deaths. HMPPS is reviewing procedures for fitness to plead reports, developing a framework to support families with prison visits (due in 2018), implementing recommendations from the Farmer Report on family ties, and implementing a new model of offender management in custody by March 2019 to ensure external agencies are notified of a prisoner's release.
Jack Portland
Partially Responded
2017-0049 21 Feb 2017 Buckinghamshire
Hospital Death (Clinical Procedures and medical management) related deaths State Custody related deaths
Concerns summary (AI summary) No specific concerns regarding future deaths were detailed in the provided text, only contact information.
Action Taken (AI summary) Extensive suicide and self-harm prevention training has been delivered to staff since 2015, new procedures have been introduced to improve ACCT management, prisoners will be able to register with a GP practice before leaving prison from July 2017, and future disclosure to the Coroner's Court will be done through GLD. The Section 17 leave form has been amended, and a new SOP for managing leave includes discussions with family. The Trust also reports on weekly monitoring processes and has introduced the appointment of a Named Professional to offer support and guidance to families.