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
Matthew Russell
Partially Responded
2016-0430 27 Nov 2016 Surrey
State Custody related deaths Suicide
Concerns summary (AI summary) Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.
Action Planned (AI summary) The Trust has introduced Complex Case Review Meetings at HMP Highdown, to commence in February 2017, to include GPs, Primary Care, Mental Health, Substance Misuse; Social Care, Safer Custody and Pharmacy to ensure regular communication with all healthcare providers. They will review governance structures and processes and mental health pathway to ensure continuous learning that enable us to positively contribute to reducing the Iikelihood that anyone under our care dies in custody.
Tommy Faisali
Historic (No Identified Response)
6 Jul 2015 London Inner (West)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.
Rosemary Oladejo
All Responded
2014-0203 22 Apr 2014 London (West)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.
Action Planned (AI summary) Hillingdon CCG will review current processes for recording and communicating medication information by August 2014. They will discuss the possibility of developing one standard letter/form for use across all sectors in July 2014 and ensure practice pharmacists review and improve medicines reconciliation processes starting in July 2014. Central North West London NHS Trust will circulate a Clinical Risk Alert referencing this case in an anonymised form in the next few weeks to remind staff of the importance of communication. They will also take this to the Mental Health Partnership Board to highlight the communication lessons.
Simon McAndrew
Historic (No Identified Response)
2014-0067 19 Feb 2014 London (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details being missed, inappropriate referrals, and a lack of effective care coordination.