2025-0507: Prevention of future deaths report

Chief Executive Officer 
East London NHS Foundation Trust Robert Dolan House 
9 Alie Street 
London 
E1 8DE 

I am Ian Potter, assistant coroner for the coroner area of Inner North London.

I make this report under paragraph 7, Schedule 5, of the Coroners and  Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

https://www.legislation.gov.uk/ukpga/2009/25/schedule/5
https://www.legislation.gov.uk/uksi/2013/1629/part/7/made

The inquest concluded with a short-form conclusion of misadventure.
The medical cause of death was: 
1a hypoxic-ischaemic brain injury
1b cardiac arrest 
1c suspension by ligature 

The following is a summary of the jury’s findings:
[REDACTED] was detained under section 2 of the Mental Health Act 1983 and was admitted to Brick Lane Ward at the Tower Hamlets Centre for Mental Health (THCMH) on 2 June 2022. Following an escalation in her presentation she was transferred to Rosebank Ward (a psychiatric intensive care unit) at  THCMH on 5 June 2022. 
 
Following an incident that culminated in [REDACTED] mobile telephone being confiscated on the evening of 6 June 2022, [REDACTED] agitation increased. On the morning of 7 June 2022, [REDACTED] made numerous efforts to secure the return of her mobile telephone, to no avail. 
 
At 10:38 on 7 June 2022, [REDACTED] entered [REDACTED] (room 7). At 10:40 on 7 June 2022, [REDACTED] she was found unresponsive by staff in room 7 at 11:14. [REDACTED] did not intend to take her own life. 
 
She was subsequently conveyed to the Royal London Hospital, where her death was verified at 17:06 on 7 June 2022. 

The jury found that numerous factors probably contributed to  [REDACTED] death: 
The automatic door locking or ‘fob’ system was not working; [REDACTED]   was not permitted access to items that could be used as a ligature, and the fact that the ‘fob’ system was not working [REDACTED]  
Staff were aware of the increased risks of the ‘fob’ system not working, but there was ‘not a widespread practice of closing doors to prevent or  reduce the risk’;  The standard of observations being carried out at the time showed that observations were often not meeting the expectations of the Trust’s  own policy. 

They found a number of additional matters possibly contributed to the death.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless  action is taken. In the circumstances, it is my statutory duty to report to you. 

I acknowledge that the East London NHS Foundation Trust (the Trust) has  made some progress in addressing some areas of concern identified prior to  the inquest, and that is to be commended. However, there remain some  matters of concern that do not appear to have been addressed adequately, or at all, and the evidence also revealed other matters that have not been  identified in the Trust’s improvement plan. 

The MATTERS OF CONCERN are as follows:
1)  Patient Observations (generally)
I am aware that, prior to  [REDACTED] final admission under the care of the Trust in 2022, other concerns had been raised by a coroner regarding patient observations within the Trust. Those concerns were  first raised in 2021 (following a patient death in 2018). Concerns  included the quality of observations and the falsification of  observations. Despite assurances from the Trust in numerous action  plans since, the evidence in this inquest revealed widespread concerns across two wards at THCMH (Brick Lane Ward and  Rosebank Ward) about observations that were carried out. Such  concerns included: the level of detail in observation records not  meeting the expectations of the Trust’s own policy; the accuracy of  timing’s in some observations was questionable; observations were  often not used as a tool to aid therapeutic engagement with patients;  and some observations were inaccurate or possibly falsified.  

The evidence received and heard during the inquest did not reassure me that this matter has been adequately addressed. Given the  importance of observations in keeping patients safe, I remain  concerned that significant risks remain. 

2)  1:1 or ‘within eyesight’ Observations 
The CCTV footage played at inquest showed a member of staff who was allocated to ‘within eyesight’ observations of another patient sat on the back of a chair (with their back facing the patient’s bedroom  door) and engaged on their mobile telephone. That member of staff  initially told the court that they were conducting the ‘within eyesight’  observations correctly and could see the patient in question. This  raises significant concern, not only about the quality of 1:1 observation but also about staff attitudes and approach to observations that are  integral to keeping patients safe (see below at para 7)). 

3)  Auditing of record keeping 
The Trust’s evidence regarding auditing nursing / clinical records 
provided little, if any, reassurance that the system in place is bringing about a truly measurable or meaningful change.  

4)  The door-locking / ‘fob’ system 
This was not working at the time of [REDACTED] death and the jury found this to have been a contributory factor in her death, in that it  allowed her access to other patient’s bedrooms. There was evidence  to suggest that the system is now working as intended, which is  positive. However, the cause for concern is whether there is a sufficient system in place to guide and assist staff in what to do if the  door locking system were to fail again. The evidence was that, at the  material time, staff were aware that this was an issue that put patients  at increased risk; however, there was evidence that staff did not fully appreciate the nature and extent of the increased risk or deploy measures to sufficiently reduce the risk. 

5)  Risk assessment of patients 
The Trust accepted that there were issues in the risk assessment of [REDACTED] in that: what documentation there was stated there  were risks but did not fully assess the risks; there was no ‘My Safety Plan’ in place; and ‘Dialog+’ had not completed. At the time, staff said  that they had been trained regarding risk assessment and its  importance. However, when giving evidence at the inquest, numerous members of staff were vague in their understanding of risk  assessment. For example, a senior member of staff said that it was  possible to complete the ‘My Safety Plan’ documentation even if a  patient did not want to engage with the process, whereas other  members of staff were insistent that if a patient doesn’t engage then  the document should not be completed. 

6)  Understanding of risk 
Some Trust witnesses who gave evidence appeared to lack an 
appreciable understanding of what could constitute serious risks to  patients. In some instances, this seemed to go beyond possible 
training issues and raised potential questions about suitability for being in a caring role. 

7)  Attitudinal concerns 
There was a recurrent theme in the evidence provided by nursing and 
support staff that certain clinical tasks (including, but not limited to, the  completion of risk assessment documentation) could simply be left for  the next shift to complete. The net result of this was that such tasks  were not completed, allowing the risks associated with non-completion to be perpetuated.  

The court was told that all shifts (on Rosebank Ward in particular)  were busy and staff often did not have time to complete the tasks  allocated to them. However, CCTV footage showed, for example, a  member of staff (allocated to complete observations and not on a  designated break at the material times) checking their mobile  telephone and sitting in the lounge reading the newspaper instead of undertaking their clinical role.  

8)  Effective clinical oversight at THCMH 
There was clear evidence at the inquest that, following an extended 
bank holiday weekend period, there was a lack of consultant cover on Rosebank Ward and the male PICU ward, which led to one consultant attempting to cover both wards. This, in itself, is not the concern for  the purposes of this report, but it puts the matter into some context. 
The consultant that was providing the cover to both wards gave evidence at the inquest, as did other senior nursing staff. The  consultant’s own evidence raised questions about their own professional judgment in providing that cover to the wards and  assessing the risks. The evidence of a senior nurse was that specific  concerns had previously been raised about the consultant in question,  including that consultant not being a “very responsive consultant” and  there having been “a pattern” with this consultant not reviewing  patients in a timely manner. The court was told that those concerns  had previously been raised with the Trust’s Clinical Director and  Associate Clinical Director and, despite this, no discernible change had been noted. The Trust’s response to this during the inquest was to say that the consultant in question no longer works for the Trust and  therefore the risk has been addressed.  In my opinion, this is a  misunderstanding of the risk. I consider that the risk is that senior  nursing staff raised a serious issue with very senior (director level)  clinicians about a pattern of issues creating risk to patients (some  relating to other patient deaths and / or other serious untoward  incidents) and little, if any, evidence was provided about how the Trust  dealt with this serious issue from a clinical governance and oversight  point of view. As such, the concern remains. 

In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. 

You are under a duty to respond to this report within 56 days of the date of 
the report, namely by 27 October 2025. I, the coroner, may extend the period.

Your response must contain details of actions taken or proposed to be taken, setting out the timescale for action. Otherwise, you must explain why no  action is proposed. 

I have sent a copy of my report to the Chief Coroner and the following:
[REDACTED] family; and 
The Care Quality Commission, for information.

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted  summary form. She may send a copy of this report to any person who she  believes may find it useful or of interest. You make representations to me, the coroner, at the time of your response, about the release or the publication of  your response by the Chief Coroner.