North London NHS Foundation Trust
PFD Addressee
Reports: 27
Earliest: Oct 2013
Latest: 23 Jun 2025
100% 2-year response rate (above 83% average). 52% of classified responses show concrete action taken.
PFD Reports
16 resultsLouise Crane
All Responded
2025-0317
23 Jun 2025
Inner North London
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.
Action Taken
(AI summary)
The Trust has implemented measures including mandatory training on record keeping, increased audit frequency and revised content, a new supervision policy, a 'ward buddy' system, and Quality Improvement programmes, with ongoing monitoring of changes.
Duncan Holloway
All Responded
2025-0102
20 Feb 2025
Inner North London
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.
Noted
(AI summary)
The BACP acknowledges the concerns and explains its ethical framework regarding record-keeping, confidentiality, and training requirements for members, noting the limitations of integrated care planning with private practitioners. The Trust expresses condolences and explains that the patient declined further engagement with services, and that it relies on patients to inform them of involvement with other networks such as private therapists. It states it will reflect on the incident and share learnings through governance forums.
Hayley Beavington
All Responded
2025-0097
20 Feb 2025
Inner North London
Mental Health related deaths
Suicide
Concerns summary (AI summary)
A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior doctor on challenging this decision, leading to premature discharge and the patient's death.
Action Taken
(AI summary)
The Trust has implemented changes including a new Risk Escalation Standard Operating Procedure, a Crisis Hub Health Professional Line, and updates to the Admission Avoidance Standard Operating Procedure, with improved risk documentation and escalation pathways.
Claire Homer
All Responded
2023-0448
10 Nov 2023
Inner North London
Other related deaths
Concerns summary (AI summary)
The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts are absent, led to a critical email going unanswered, resulting in delayed care.
Action Taken
(AI summary)
Barnet, Enfield and Haringey Mental Health Trust discussed out-of-office responses and escalation procedures with staff, issued a template for out-of-office replies, ensured voicemail messages follow the same practice, updated online information with duty mobile numbers, reiterated the need for clear doctor cover arrangements, and emphasised the importance of balancing service needs with leave requests and clear patient handovers.
Odichukwumma Igweani
All Responded
2023-0296
16 Aug 2023
Milton Keynes
Mental Health related deaths
Concerns summary (AI summary)
A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment and care, despite their obvious deteriorating condition.
Noted
(AI summary)
The ICB will work with primary care practices to ensure patients declined registration receive details on how to find and register with a GP and ensure practices are aware of the mental health single point of access. They will also work with CNWL to ensure mental health crisis information is available in surgery waiting areas and continue to work with 111 providers on the dedicated process for mental health due in Spring 2024. Red House Surgery states it was unable to register the patient due to their address being outside the practice catchment area, and this is practice policy. They assert they provided the mother with the number for the crisis centre, which is practice policy for anyone raising a mental health concern who cannot access a GP. CNWL will discuss the case in a Care Quality Improvement Forum meeting, cascade a learning leaflet to local GPs via the Primary Care Network (PCN) alliance, and supply posters to GP surgeries with information on how to access mental health services via the ED at MKUH. Nationally, NHS England are working with NHS 111 to create a dedicated process to access MH services due in April 2024.
Demet Akcicek
All Responded
2022-0277
5 Sep 2022
Inner North London
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary (AI summary)
A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team discussion, and made inadequate notes, with no clear trust-level actions to prevent future recurrences.
Action Taken
(AI summary)
The CDAT team has updated its Operational Policy and implemented a daily duty sheet/tracker to ensure appropriate follow-up for all issues logged, which is checked daily by the senior on duty. The team has also been reminded of record-keeping obligations.
Agnes Lambert
All Responded
2018-0410
17 Dec 2018
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
Action Planned
(AI summary)
The Trust is rolling out 'vital conversations' training for managers and reviewing its disciplinary policy to include clearer criteria for investigations. A specially-trained staff member will review cases to challenge whether a formal hearing is required, and the refreshed policy is expected to be complete in March 2019.
Jonathan Meaney
All Responded
2017-0244
24 Aug 2017
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the patient's premature release without proper consultation or confirmed follow-up care.
Noted
(AI summary)
The Royal Free London NHS Foundation Trust notes that the concerns relate to Camden & Islington NHS Foundation Trust (CANDI)'s Mental Health Liaison service, and that CANDI is undertaking a Serious Incident investigation. They have asked to be provided with copies of CANDI's Serious Incident investigation report and response to the Prevention of Future Deaths Report. Camden and Islington NHS Foundation Trust outlines several actions taken and planned: Clinicians involved have been prevented from working at this level of expertise until the SIR review is complete. Any decision to change the original decision made by another full time clinician whereby they are de-escalating the outcome, must be discussed and agreed with a senior member of the team and this must be clearly recorded in the patients notes; All agency or bank staff who work regularly with the team will receive regular formal clinical supervision from the team manager in line with Trust employees and agency staff will receive the same access to Trust training as Trust staff. Referral letters to GPs will include an accompanying note to alert the GP to any specific action they need to carry out.
Emily Voukelatou
All Responded
2017-0004
11 Jan 2017
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also indicated poor communication and information handling within the service.
Action Taken
(AI summary)
The Trust stresses the importance of family input and states it is routinely assessed, with patient consent, throughout the care pathway. The trust issued guidance to staff at North Camden Crisis House to ensure that numbers and contact details are clearly provided to families.
Matthew Groom
All Responded
2015-0503
12 Nov 2015
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, did not involve hospital security, and inadequately communicated the patient's detention need to police.
Action Taken
(AI summary)
The Trusts strengthened the mental health referral protocol from Whittington ED triage and added a new black phone in Whittington Health ED specifically for the police to pre-alert them to patients who are being brought to WH ED under Section 136 of the Mental Health Act, also creating a new Standard Operating Procedure. The Trusts strengthened the mental health referral protocol from Whittington ED triage and added a new black phone in Whittington Health ED specifically for the police to pre-alert them to patients who are being brought to WH ED under Section 136 of the Mental Health Act, also creating a new Standard Operating Procedure.
Mark Daniels
All Responded
2015-0208
1 Jun 2015
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
Action Taken
(AI summary)
Camden and Islington NHS Foundation Trust have put in place a comprehensive action plan to address the concerns raised regarding failures by the Crisis team, with measures implemented across all Crisis Teams and Crisis Houses and a plan to monitor their implementation.
Keith Gallimore
All Responded
2015-0184
11 May 2015
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.
Action Planned
(AI summary)
IAPTUS training will be provided to a small number of front-line staff in the Acute Division to enable routine checks on all new patients against the IAPTUS system, expected to take place at the end of September.
Tamara Holboll
All Responded
2015-0171
27 Apr 2015
London North (Inner)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between clinicians and bed managers.
Action Taken
(AI summary)
Camden and Islington NHS Trust has amended the action plan template and revised guidance for writing recommendations, adding an action row to prompt authors to write an action for each recommendation. They are also reviewing and improving their Serious Incidents processes.
Noleen McPharlane
All Responded
2014-0370
7 Aug 2014
London North (Inner)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of input from other professionals despite poor patient rapport.
Action Planned
(AI summary)
The Trust updated its clinical risk assessment and management policy in September 2014. All clinical staff will be instructed to discuss methods of self-harm with service users and care plans will be set to prevent self-harming practices by November 2014.
Stephen Ward
All Responded
2014-0248
29 May 2014
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.
Noted
(AI summary)
Response is blank.
Abdullahi Sharif Abokar
All Responded
2013-0323
3 Dec 2013
Inner North London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff abandoning the patient.
Action Taken
(AI summary)
The Trust implemented a "Rapid Improvement Plan" for Coral ward, including mandatory training in suicide risk assessment and in-hospital life support, simulation exercises every 6 months, revised resuscitation scene management, and specialist training in oxygen use. The nurse involved is being managed under the Trust's capability policy.