Nonie Atshiki

HMSC ME Hassell 

Inner North London 
St Pancras Coroner’s Court 

Camley Street 

London N1C 4PP 

Sent via email:  

Date: 03/02/2025 

ST  MUNGO’S  HOUSING  ASSOCIATION’S  RESPONSE  TO  REGULATION  28  REPORT  TO 

PREVENT FUTURE DEATHS: INQUEST INTO THE DEATH OF NONI ATISHKI  

Introduction: 

1.  I refer to your Report to Prevent Future Deaths dated 12 December 2024 (the “PFD Report”), 

concerning the death of Noni Atishki, who sadly died on 13 July 2024.  

2.  I am replying as the CEO of St Mungo’s Community Housing Association (“St Mungo’s”). 

3.  At the outset of this response, I would like to express my sincere condolences to the family of 

Noni Atishki.  

4.  This  inquest  and  the  PFD  Report  has  led  to  significant  reflection  within  St  Mungo’s,  with 

extensive discussions held within our Client Services, Quality, Health and Safety, Learning and 

Development, Governance and Compliance departments around learnings and improvements 

that we can implement internally.   

5.  At the heart of our services is our commitment to doing everything we can to keep our clients 

safe, to empower them in their individual recovery journeys and to prevent homelessness in the 

future.  When  a  death  occurs  within  our  services,  we  are  dedicated  to  understanding  what 

happened and to taking actionable steps to implement meaningful changes and improvements 

where necessary.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 6.  In  this  response,  I  outline  the  nature  of  St  Mungo’s  services,  the  charity’s  duties,  and  the 

policies, procedures and practices we have in place to ensure the safety and well-being of our 

clients.  I  then  address  the  specific  concerns  raised  in  the  PFD  Report  surrounding  the 
circumstances of Noni Atishki’s death and detail the actions we have taken or plan to take to 

improve our practice where relevant. 

7.  Please  note  that  I  have  not  enclosed  the  policies  and  procedures  that  I  have  referenced 

throughout this response. However, these can be provided to you if you wish to see these.   

The nature of St Mungo’s services: 

8.  St  Mungo’s  is  a  charity  that  provides  support  and  accommodation  to  those  affected  by 

homelessness. The organisation delivers a number of services across London and the South-

East and South-West of England, and is largely contracted to operate said services by individual 

Local Authorities.   

9.  St. Mungo’s delivers a range of services; from preventative services that support people whose 

tenancies are at risk, to outreach teams working with individuals who are experiencing a period 

of rough sleeping, through to accommodation services and support  for people to move on to 

more settled housing.  We work with individuals who all have different stories and backgrounds, 

but predominantly people with high support needs, be they related to physical or mental health, 

drug or alcohol addiction, a history of offending, domestic abuse or immigration support needs. 

As an organisation, we therefore prioritise working in partnership with, or signposting people to, 

a wide range of specialist services to deliver the support that our clients need.  

The Endell Street service:  

10. Noni  Atishki  was  a  client  of  St  Mungo’s  Endell  Street  service  at  the  time  of  her  death.  This 
service is what we would describe as a ‘first-stage’ hostel, in that the service accepts referrals 

from  the  Camden  outreach  team  for  people  who  are  sleeping  rough,  and  from  the  Camden 

Homeless Persons Service for people who have presented to the Local Authority as homeless 

and have been assessed as requiring accommodation with support. Clients of the service may 

 
 
 
 
 
 then move into their own independent accommodation directly from Endell Street or may move 

to other forms of supported housing dependent on their needs and the individual support plan 

formed with the client.  

11. As a service, Endell Street provides accommodation and support for 53 homeless single men 

and women as part of the Camden Hostels Pathway. The staff at the service work with people 

at various stages of their journey from homelessness, supporting residents to move through the 

Pathway stages towards greater independence. 

12. The  service  works  in  partnership  with  a  range  of  external  agencies  in  Camden  that  offer 

specialist support around mental health and substance use.  

13. Each client has a named keyworker who is responsible for supporting the working shift pattern 

of the hostel, whilst supporting a case load of multiple disadvantaged clients. There are seven 

keyworkers  on  the  team,  each  of  whom  work  with  eight  clients  at  any  one  time.  They  are 

supported by two Deputy Managers and a Service Manager.  

14. The  Endell  Street  team  values  a  relationship-based  approach  to  working  with  people 

experiencing  homelessness.  Every  individual  client  has  their  own  personalised  support  plan 

and safety plan in which their support needs and risks around them are recorded and agreed, 
alongside actions aiming to promote the person’s recovery.  

15. In general terms, clients at Endell Street are typically receiving support in two or more of the 

following  areas:  -  mental  health,  physical  health,  substance  use,  offending  and  managing 

relationships, and staff support them to work towards managing an independent tenancy of their 

own in future.  

16. The service is staffed 24 hours a day with a minimum staffing cover of two staff on duty at all 

times with additional staff available Monday to Friday during office hours (9:00-17:00). We have 

a separate night team of four waking night staff (two of whom are on duty at any one time), a 

cleaning and maintenance team, an apprentice and a duty worker supporting the day to day 

activities of the service. 

 
 
 
 
 
 
 Duties placed upon St Mungo’s and the policies and procedures we have in place:  

17. I note that you will be familiar with the statutory duties owed by Local Authorities generally and 

by providers of clinical services on behalf of Local Authorities and the NHS. It is important to 
point out that St Mungo’s position is different from other such parties in two key respects. First, 

the  charity  does  not  adopt  the  duties  owed  by  Local  Authorities,  for  example  under  the 

Homelessness  Reduction  Act  2017  -  we  simply  provide  certain  specified  services  to  Local 

Authorities. 

18. As touched upon above, the Endell Street service is commissioned as a ‘first stage’ hostel for 

individuals exiting a period rough sleeping, who require a medium to high level of support from 
staff on site. The service is commissioned by the Local Authority of Camden’s Commissioning 
team, as part of their ‘Adult Pathway’.  

19. Second, save for two of our CQC registered care homes, no other services within St Mungo’s 

provides any regulated care or clinical services under The Health and Social Care Act 2008 

(Regulated Activities) Regulations 2014. It is also relevant to note that clients are not detained 

under any of the Mental Health Act provisions at any point during the time a client is a resident 
with St Mungo’s. 

20. Nevertheless, St Mungo’s does have a duty to carry out its services safely and to ensure that 

those affected by its undertaking are not exposed to risks to their health and safety, so far as it 

reasonably practicable, pursuant to the Health & Safety at Work etc Act 1974.  

21. In respect of the duty to carry out its services safely, St Mungo’s fulfils these duties by working 

with clients to identify their needs. This is achieved though systematic Client Needs Assessment 

and Action Planning and we have policies and procedures to  outline this process.  Noni had 

identified  needs  in  a  number  of  areas  of  her  life  but  did  not  wish  to  be  referred  to  external 

services for tailored support.  Her Keyworker regularly reviewed with her whether she would be 

interested  in  support  from  the  Camden  drugs  and  alcohol  services,  provided  by  CGL  in  the 

borough  of  Camden,  but  she  declined to  be  referred.    She  was  supported  to  register  with  a 

community  GP  at  The  Museum  Practice  and  was  working  with  her  GP  around  her  physical 

health concerns at the time of her death.  

 
 
 
 
 22. While the Charity’s work shows that it is changing outcomes for its services users, the extent of 

its  legal  duties  is  limited  in  accordance  with  the  nature  and  specification  of  the  services  it 
provides. However, in respect of the risks arising from substance abuse, St Mungo’s policies 

and procedures are fully cognisant of the fact that where multiple persons with substance or 

alcohol  abuse  issues  will  be  living  near  each  other,  this  is  a  risk  that  does  arise  from  its 

undertaking and that it must therefore take reasonable steps to mitigate this risk. 

23. To further mitigate this risk, particularly in relation to the risk of drug use and overdose – a key 

concern touched upon in your PFD Report -   we have the following policies, procedures and 

practices in place: 

24.  First aid - 

i.  St Mungo’s has a First Aid Policy and Procedure. 

ii.  Where new staff do not already hold a relevant First Aid qualification, St Mungo’s aims for 

all client-facing staff to obtain a First Aid at Work Certificate or Emergency First Aid at Work 

Certificate within 6 months of starting employment. 

iii.  A Service Manager is responsible for ensuring that staff at their service attend training as 

soon as possible after starting work, in circumstances where they do not hold a relevant 
First Aid Qualification. St Mungo’s has a Learning and Development Team who manage the 

availability of training. 

iv.  The  Learning  and  Development  team  reviews  the  training  provision  and  attendance 

numbers  every  week  to  ensure  that  as  courses  fill  up,  additional  training  sessions  are 

scheduled. They monitor attendance by booking an initial series of dates, tracking uptake, 

and adding new dates as needed to ensure people can book sessions within their first six 

months. Their goal is to have courses available within a rolling three-month window. 

 
 
 
 
 
 
 
 
 
 v.  St Mungo’s Head of Safety and Quality Assurance reviews compliance with First Aid training 

quarterly  and  reports  the  findings  to  our  Client  Services  Committee.  Compliance  is  also 

discussed with the Learning and Development Team to ensure strategies are effective in 

improving compliance with training. For example, it was agreed to add First Aid training to 

our  Solid  Foundations  process  (refer  to  point  27  below)  to  provide  clarity  around  the 

requirements and the ability to monitor compliance, and additional training dates have been 

booked to meet upcoming requests. 

vi.  Under the First Aid Policy and Procedure, St Mungo’s definition of a First Aider is a person 

who  has  completed  a  3-day  First  Aid  at  Work  course  within  the  last  3  years  and  been 

certified as competent by the training provider. An Emergency First Aider at work is defined 

to be a person who has completed a 1-day Emergency First Aid at Work course within the 

last three years and been assessed as competent by the training provider. Therefore, we 

will accept if someone has completed such courses externally within the last three years, 

provided they were delivered by an appropriate provider, and all relevant criteria have been 

met.  

25.  Administering Naloxone - 

i.  St Mungo’s has a Drugs Policy and Procedure in place. As well as setting out St Mungo’s 

approach to ensuring the prevention of drug use within its services, the Drugs Procedure 
sets out St Mungo’s policy in relation to responding to an overdose and the administration 

of Naloxone.  The Procedure requires that in the event of a client overdosing, staff should 

immediately call 999 and never delay calling an ambulance or administering First Aid. 

ii.  St Mungo’s also have an Overdose and Naloxone Information Booklet, referenced in our 

Drugs  Procedure,  in  which  the  step-by-step  process  to  follow  is  set  out.  The  process 

includes calling an ambulance, performing basic life support (such as chest compressions) 

and administering  Naloxone.  It  also advises staff  to seek  assistance  from  the  operator  if 

unsure about how to administer Naloxone. Instructions on CPR are also included. 

 
 
 
 
 iii.  Staff can  also contact  the local  prescribing team for  information  on  Naloxone training  for 

staff and clients. 

iv.  We  have  "How  to  obtain  Naloxone  for  your  service"  guidance,  along  with  additional 

resources and guidelines for staff, including rules about drug use and the law. 

v.  We have a Complex Needs Team within St Mungo’s who provide significant resources on 

drug and alcohol  use  on  our  intranet,  including  info-sheets  on  various drugs,  handbooks 

and other materials. 

vi.  The Complex Needs Team also provide sessions for teams and clients covering overdose 

and Naloxone (on request).  

vii. The Safety and Quality Assurance team is responsible for updating the Drugs  Policy and 

collaborates  with  the  Complex  Needs  Team  in  this  process.  The  Safety  and  Quality 

Assurance team also collaborates annually on the review of deaths by overdose and agrees 

on  a  plan  to  try  to  reduce  these.  Last  year,  this  included  encouraging  all  staff  to  utilise 

existing tools, such as the Housing Opiate Overdose Risk Assessment tool, and engage 

clients in discussions about risk reduction strategies. The Complex Needs Team is always 

available to assist staff in devising more effective Safety and Wellbeing Plans focused on 

risk mitigation. 

viii. We  also  created  a  2024-25  forward  plan,  where  we  agreed  on  actions  including:  the 

Complex Needs Team will continue to provide support for incidents logged as overdoses; 

we will finalise and publish the Alcohol Management guidance; and we will publish Learning 

from Deaths Reviews to disseminate learnings within the organisation. 

26. Other training –  

i.  All  client-facing  staff  and  managers  are  required  to  complete  "Responding  to 
emergencies"  e-learning  within  the  first  three  months  of  joining  St  Mungo’s.  Amongst 

other modules, this training includes the following: 

 
 
 
 
 •  A  module  called  "medical  emergencies  and  overdose."  This  module  outlines  the 

actions to be taken in the case of an overdose, including calling emergency services 

and that "The 999 switchboard may ask for certain things to be done. You should also 

consider  a  number  of  actions  after  you  are  assured  an  ambulance  is  on  its  way." 

These  actions  may  include  rescue  breaths.  Regarding  overdose,  the  module  says, 

"You should follow the steps detailed above and contact 999 to call an ambulance. In 

addition, you can use Naloxone if available at your service." It is also clear from the 
module that the law states that “anyone can administer Naloxone for the purposes of 

saving a life. If Naloxone is available at your service, then, in the event of a suspected 

opiate overdose, as long as you understand and are comfortable doing so, you could 

administer  Naloxone.  If  you  have  received  training,  then  you  should  administer 

Naloxone". Information about further training is also included. 

ii.  Additional optional training available to staff includes: 

•  Motivational interviewing 
•  Strengths-based practice toolkit 
•  Strengths-based approach to client work – an introduction 
•  Coaching with clients 
•  Person-centred support 
•  Emotional first aid 
•  Trauma-informed care 
•  Drug and Alcohol awareness (both face-to-face and e-learning) 
•  Overdose prevention and Naloxone (both face-to-face and e-learning) 
•  Supporting clients with Opioid substitute prescriptions (e-learning) 
•  Alcohol impact session (face-to-face) 
•  Drugs and the Law (webinar) 
•  Working with opiate users (face-to-face) 
•  Unpicking dual diagnosis (webinar) 
•  Women and substance use (face-to-face) 

 
 
 Compliance Monitoring: 

27. Within  St  Mungo’s  we  have  an  ongoing  compliance  monitoring  process  called  ‘Solid 
Foundations’.  Solid  Foundations  includes  certain  indicators  which  are  considered  ‘non-
negotiable’ to ensure clients and staff are safe and supported; provides assurance to regulators, 

commissioners and funders; and ensures we are efficient and that we achieve our aims and 
objectives. We have re-launched this project from January 2025, with the ‘non-negotiables’ to 

include staff induction and all mandatory training, including first aid training. 

28.  Managers  can  check  their  team’s  compliance  with  the  non-negotiables,  which  includes 

mandatory  training  via  live  Solid  Foundation  reports,  and  can  address  any  areas  of  non-

compliance  in  support  and  supervision  meetings  with  their  staff  members  (which  take  place 
every 4–8 weeks). 

29. Service  Heads  receive  weekly  automatic  reports  on  their  region’s  Solid  Foundations 

compliance.  These reports  help them  address  gaps,  such  as  discussing  issues  with  Service 

Managers or raising them in supervision sessions. 

30. From  February  2025  our  Senior  Leadership  Team  will  review  the  Solid  Foundations  report 

monthly and develop an ongoing action plan to address any gaps.  

31. We use an Induction Checklist for new staff that must be completed within the first six months 

of  employment.  This  checklist  includes  mandatory  training  requirements,  details  on  how  to 

access training, and information on key policies and procedures, ensuring staff know where to 

find resources when needed. Additional training opportunities are also highlighted. 

32. The Learning  and  Development  Team reviews training  provision  and  attendance weekly.  As 

courses fill up, they schedule additional training sessions. They monitor attendance by booking 

initial dates, tracking uptake, and adding new sessions to ensure staff can book training within 

their first six months. Their aim is to maintain a rolling three-month availability of courses. 

 
 
 
 
 
 
 
 Matters of concern in the PFD Report  

33. I have carefully reviewed the PFD Report and have noted in particular that during the course of 

the inquest, the evidence revealed matters giving rise to your concern that, unless addressed 

by further action, you believe there is a risk that future deaths will occur. These concerns have 
been taken seriously and discussed extensively among relevant teams within St Mungo’s. On 

behalf of St Mungo’s, please find my response to your concerns below: 

34. Concern 1: “I heard evidence at the inquest that the night concierge who found Ms Atshiki had 
not had any first aid training from St Mungo’s. He said that he had undergone first aid training 

elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not.” 

Response:  

i. 

Immediate Action:   Where a defibrillator is available at a service, we will instruct Service 

Managers to direct staff to the relevant guidance. This information will also be added to 

our First Aid Policy and Procedure. 

ii.  Short to Medium-term Action: The Learning and Development team and the Safety and 

Quality  Assurance  team  will  continue  reviewing  compliance  with  first  aid  training  on  a 

quarterly  basis.  They  will  ensure  interventions  to  improve  compliance  are  regularly 

assessed and will agree on actions if compliance needs improving. 

We are updating our First Aid Procedure to include clear guidance on First Aid at Work 

and Emergency First Aid at Work qualification criteria, and to stipulate that only where a 

staff  member  is  confident  in  delivering  First  Aid  (including  the  use  of  defibrillators  and 

delivery  of  CPR)  in  line  with  such  criteria,  will  a  previously  obtained  certificate  prior  to 
employment at St Mungo’s be considered and accepted. 

We will conduct a review on our  “Responding to Emergencies” mandatory e-learning to 

ensure that it clearly sets out our approach and what we expect from staff in an emergency 

situation. This review will be completed by June 2025.  

 
 
 
 
 
 
 
 Whilst it is my understanding that there is no legal requirement for housing associations to 

provide defibrillators, we will review the potential for expanding our access to defibrillators 

in key locations,  particularly in 24-hour  hostels where the risk  of  health emergencies is 

higher. This review will include where defibrillators are already located in our services, the 

criteria for a service obtaining a defibrillator, taking up offers of free defibrillators from Local 

Authorities where available, and considering whether to purchase them, where not.  This 

review will be completed by May 2025.  

35. Concern 2: “Whilst not relevant in this case, I was told that the hostel does stock Naloxone 

(used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not 
trained in its use.” 

Response: 

i. 

Immediate  action:  We  understand  that  the  night  concierge  may  have  not  received 

training in using Naloxone, which we accept may affect how a person responds in the 

case of an overdose. The Service Manager at Endell Street is arranging for the staff team 

to refresh their Naloxone training. Training is available as an on-line video recommended 
by  the  St  Mungo’s  Complex  Needs  Team  that  staff  can  watch.  However,  whilst  we 

strongly encourage staff to use Naloxone in overdose situations, we do not make this 

mandatory. We accept that not all our staff (who are non-clinical and recruited to provide 

housing-related  support)  would  feel  comfortable  or  confident  in  administering  an 

injection.  

In addition to the abovementioned training and guidance that we already have in place 

regarding the administration of Naloxone, our Complex Needs Team will develop a short 

guidance document for services to keep accessible within services. This document will 

provide straightforward guidance on what to do in the event of an overdose, including 

administering  Naloxone.  Service  Managers  will  ensure  that  all  staff  know  where  this 

document is located.  

ii.  Short to Medium-term action: The Service Manager will ensure that regular Naloxone 

training is provided to all new staff, as well as refresher training either by the local drug 

 
 
 
 team  or  by  attending 

the 

training  provided  by  our  Complex  Needs  Team. 

Organisationally,  we  will  provide  targeted  communication  over  the  next  6  months  to 

encourage all managers to ensure that staff in first-stage hostels, including night staff, 

are trained on how to administer Naloxone and have regular refresher training in place. 

As  noted  above,  key  policies  are  highlighted  for  client  services  within  our  Induction 
Checklist.  We  are  adding  the  St  Mungo’s  Drugs  Policy  and  Procedure  and  Drug 

Awareness  training  to  the  list  of  key  policies  and  training  to  be  completed  by  client 

services staff as part of the Induction Checklist.  

We will conduct a review to determine whether it would be appropriate to add Overdose 

Prevention and Naloxone Training to our mandatory training list for first-stage hostels, 

where  there  is  a  higher  prevalence  of  clients  using  substances.    This  review  will  be 
completed by October 2025.  

36. Concern 3: “The evidence at inquest was that there are only ever two members of staff working 
at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night 

concierge stayed with her as she lay across the stairs, while the other member of staff stayed 

by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted 

to perform cardiopulmonary resuscitation on Ms Atshiki. 

There is no evidence that if CPR had been performed it would have changed the outcome for 

Ms  Atshiki.  However,  in  another  situation  it  might.  And  in  another  situation,  it  might  be  the 

second  member  of  staff  who  falls  ill.  That  would  only  leave  the  night  concierge  to  attempt 
resuscitation.” 

Response:  
In  terms  of  staffing  levels,  it  should  be  noted  that  we,  St  Mungo’s,  develop  and  review  our 

staffing models within each of our service contracts at the start and before any extension of a 

contract.  In  many  of  our  high  support  services,  we  have  a  minimum  of  two  staff  members 

working at night, who undertake waking night shifts (on site and awake at all times), and who 

 
 
 
 
 
 
 support the safe running of the service. We always ensure that our proposed staffing model will 

allow the service to be run safely, before bidding, accepting or delivering any service contract. 

However,  it  also  important  to  note  that  due  to  the  nature  of  the  financial  environment  within 

which we are commissioned, and the significant financial pressures that Local Authorities who 

often  commission  us  face,  there  are  significant  and  growing  pressures  to  meet  financial 

envelopes  dictated  by  those  commissioning  our  services.  This  sometimes  means  that  in 

services where it might be preferable, but not necessarily essential, to have a third staff member 

on shift in the rota, we are unable to do so due to the financial constraints of the contract. 

We  use  tried  and  tested  service  models  to  meet  the  needs of the  client  group  and  the 

requirements of the  service  and  building(s).  These  models  are  reviewed  throughout  the  life 

cycle of the contract and at the point of contract renewal or negotiation to ensure they are still 

meeting  the  requirements of the  service.  Our  staffing  models  are  co-designed  by  multiple 

departments  across  St  Mungo’s, 

including  Client  Services,  Finance,  HR,  Business 

Development and Property Services, before being signed off by our Executive Directors. 

In terms of concerns around the use of CPR: 

i.  Immediate  action:    We  understand  that  the  outcome  in  this  case  would  not  have  been 

changed by CPR, but in other cases timely CPR could impact the outcome.  

In addition to the immediate actions related to First Aid Training (noted under Concern 1), as 

detailed above, we have relaunched our Solid Foundations process as of January 2025. First 

Aid training will be tracked in Solid Foundations to increase visibility and improve reporting. 

Responding to Emergencies e-learning has also been added to Solid Foundations for better 

compliance tracking and reporting. As noted above, First Aid Training and the Responding to 

Emergencies e-learning covers the provision of CPR. 

ii.  Short to medium-term action:  In addition to the actions related to First Aid Training (noted 

under  Concern  1),  the  Service  Manager  at  Endell  Street  will  complete  a  review  of  training 

completion for all staff, including night staff, and will ensure that all staff have completed the 

Responding  to  Emergencies  e-learning.  The  Service  Manager  will  also  ensure  that  staff 

 
 
 
 
 
 complete the annual refresher, so that staff are confident in their ability to perform CPR in any 

situation. 

We are also updating our First Aid Policy and Procedure to further reflect and reiterate the 

requirement for First Aiders and Emergency First Aiders to provide CPR when necessary. 

Conclusion: 

40. On behalf of St Mungo’s, I am grateful for your recommendations that will enable us to be as 

well-equipped as possible to respond to similar incidents in the future.   

41. I  hope  that this response assists  you  in understanding  St Mungo’s role as a  charity  and the 

action it has and will continue to take in relation to the safety and wellbeing of its clients.  

42. Should you require any further information, please do not hesitate to contact me. 

Yours sincerely 

CEO, St Mungo’s