Hayley Beavington

Trust Headquarters 

4th Floor, East Wing 
St Pancras Hospital 
 4 St Pancras Way  
London NW1 0PE  

Email: 

Private and Confidential 
Senior Coroner Mary Hassell 
Inner North London 
St Pancras Coroner’s Court 
Camley St 
London N1C 4PP 

17th April 2025 

Dear Ms Hassell 

Re Inquest touching the death of Hayley Beavington 

I am writing following the inquest for Hayley Beavington which concluded on 10th February 
2025 and following which you issued a Prevention of Future Death report to the Trust.  The 
inquest found that Ms Beavington died by suicide shortly after her discharge from the Royal 
Free Hospital where she had been under the care of the North London NHS Foundation 
Trust (NLFT) psychiatric liaison team.  The matters of concern raised in your report were as 
follows: 

When planning for Ms Beavington’s discharge from hospital, it was agreed that the best 
place for her to go was a local crisis house. Upon application, the foundation year 1 doctor 
(FY1) was told by the crisis house team that this was not possible because: - Ms Beavington 
had secure accommodation; and - she was no longer actively suicidal. This was despite the 
fact that: - there was a strong suspicion that Ms Beavington was the victim of cuckooing in 
her own home; and - the team view was that she was definitely at risk of suicide. The 
consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any 
instruction as to how to challenge the decision that the consultant believed was wrong. 
Instead, the consultant instructed the FY1 to leave it for three days and then just try again in 
the same way. By this time, Ms Beavington decided that she had waited too long and did not 
want another attempt to be made. Ms Beavington was discharged home and killed herself at 
1am the next morning. 

We would like to begin by expressing our deepest sympathies to Ms Beavington’s family and 
loved ones. We recognise the profound impact of her death, and our focus in this response 
is to outline the actions we are taking to strengthen our systems, prevent similar incidents, 
and ensure that those in crisis receive the right support at the right time. 

Better Mental Health. Better Lives. Better Communities. 

Chair: 
Chief Executive: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This response has been prepared collaboratively between the community and hospital 
divisions of the Trust, ensuring that all relevant processes are reviewed and improved to 
reduce future risks. To ensure that these changes are embedded, we will continue reviewing 
declined referrals through governance meetings, identifying patterns and making further 
improvements as needed. 

Key Areas Identified in the PFD Report & Actions Taken 
The PFD report identified several key areas where improvements were needed to prevent 
similar situations in the future. Below, we outline each concern and the actions taken to 
address it, ensuring that all measures directly contribute to improving patient safety and 
care. 

By way of context, crisis houses at the Trust exist as an informal alternative to inpatient 
admission. We have 7 crisis houses available across the Trust and since we merged as a 
single organisation on 1st November 2024, we are working hard to standardise referral 
processes and practices across the 7 houses and 5 boroughs. This is being led by a newly 
appointed band 7 crisis house lead dedicated to this work. 

Crisis houses are informal settings and can manage a lower risk of presentation than an 
acute inpatient ward and do not accept people who are detained under the Mental Health 
Act; they are community based low support settings. Because of the setting each house has 
a level of autonomy about the patients they accept. As a consequence of this, crisis teams 
have the authority to ‘refuse’ a referral in a way that does not happen with a referral into 
inpatient services. When a referral is declined, the clinical team making the referral is 
informed and alternative plans need to be made to either escalate to an inpatient admission 
or de-escalate to the patient’s home - with or without crisis team involvement. 

1. Escalation process for declined crisis house referrals 
Previously, when a Crisis House referral was declined, there was no clear pathway for 
escalation. This meant that decisions could be final without further review, leaving some 
cases without immediate intervention. 

What We Are Doing: 

•  All declined referrals must now be escalated for senior clinical review before a final 

decision is made; this will ensure that no referral is left without further review and will 
seek to reduce the risk of missed opportunities for intervention. 

•  The Crisis Hub Health Professional Line now provides 24/7 access for clinicians 
needing urgent escalation or referral guidance. This guarantees that immediate 
support is available, reducing the risk of delays. 

•  A structured, step-by-step escalation process has been introduced to ensure that all 

decisions are transparent and accountable. 

•  A designated senior clinician or service lead has been appointed to oversee the 
escalation process to ensure that all declined referrals are formally reviewed, an 
alternative plan put in place and the final decision clearly documented.  

The updated Joint Working Protocol (March 2025) formalises this approach by ensuring that 
liaison, crisis, and community teams engage in joint reviews within two hours of a referral at 
A&E, preventing delayed escalation. 

Better Mental Health. Better Lives. Better Communities. 

Chair: 
Chief Executive: 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 2. Out-of-Hours (OOH) Escalation Gaps 
Previously, clinicians were uncertain about who to escalate urgent cases to during evenings, 
weekends, and bank holidays, leading to potential delays in care. 

What We Are Doing: 

•  The pathway has been reviewed to make it clear that in the event of a referral being 

declined it is the responsibility of the referring team to review and agree an 
alternative plan. 

•  The Crisis Hub Line now provides immediate access to senior clinicians 24/7, to 

ensure that every decision is reviewed in real time thereby preventing overnight gaps 
in risk management. 

•  Where Crisis Houses are closed, the Tactical On-Call team will now ensure that an 
alternative risk management plan is in place until a reassessment can take place 
during operating hours. This may include temporary support from the Home 
Treatment Team (HTT) or inpatient admission if needed to ensure immediate safety. 

The NLFT Standard Practice for Community Teams and Wards on Hospital Admissions 
(2025) strengthens Out of Hours (OOH) escalation by requiring that hospital admissions be 
communicated to the relevant community teams the same day to ensure that hospital and 
community services work together seamlessly.  

3. Documentation & Risk-Based Decision-Making 
There was insufficient documentation of risk-based decisions, making it harder to track why 
referrals were declined and whether risks were properly reassessed. 

What We Are Doing: 

•  All declined referrals must now be clearly recorded on RiO to ensure that decisions 

are transparent, and risks are reassessed at every stage. 

•  Senior clinicians are now required to review risk assessments at key points to reduce 

the chance of missed warning signs. 

•  The Crisis Hub Line now logs all escalation calls to provide a record of decisions 

• 

made in crisis situations and to ensure learning and accountability. 
In addition to this, senior clinicians must now schedule a follow-up review within an 
agreed timeframe to ensure risks are monitored over time. 

•  Where a service user declines admission, their capacitous decision must now be 

clearly documented, alongside any conditions for reconsideration should they change 
their mind. 

The Joint Working Protocol (2025) mandates that all referral outcomes from A&E must be 
clearly documented in RiO to ensure that risk-based decisions are fully traceable and 
reviewed.  

4. Governance & Oversight 
There was no structured way to review declined referrals and learn from cases where 
service users were unable to access crisis support. 

What We Are Doing: 

•  All declined referrals are now reviewed in routine governance meetings to ensure 
that trends and patterns are identified early and actions taken to prevent repeated 
incidents. 

Better Mental Health. Better Lives. Better Communities. 

Chair:
Chief Executive: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Managers now track referral decisions to ensure 
lessons are being learned. This will be reviewed quarterly as 
part of the governance framework to assess the impact of changes and ensure 
continuous improvement. 

•  Governance leads will now be responsible for identifying systemic issues from 

declined referrals and reporting trends to the senior leadership team for targeted 
improvements. 

•  Oversight processes have been strengthened to prevent cases falling through gaps 

to ensure a continuous review of referral patterns and the escalation trends. 

The NLFT Standard Practice for Community Teams (2025) ensures that hospital admissions 
are tracked across community teams, requiring email and phone communication between 
teams, reducing the risk of governance gaps.  

How these changes Prevent Future Deaths 

These updates directly address the concerns raised in the PFD Report by ensuring that: 

•  No referral is declined without a formal escalation and risk review process. 
•  Decision-making structures are clear, with defined accountability at all levels. 
•  Out-of-hours pathways are explicit thereby reducing gaps in governance and 

response times. 

•  Risk documentation is standardised and linked to escalation pathways thereby 

ensuring oversight. 

•  The Crisis Hub Health Professional Line strengthens real-time clinical decision-

making thereby ensuring urgent cases receive immediate senior input. 

•  Training and system updates reinforce staff confidence in risk-based decision-

making. 

•  These improvements are monitored through routine governance reviews, thereby 
ensuring that lessons are continuously learned and embedded into practice. 

To ensure staff awareness of these changes they will be shared and discussed at team 
meetings and governance meetings across our services, as well as at senior leadership and 
shared learning forums, with the expectation that the improvements and learning are 
supported at senior level and cascaded effectively.  For new staff, we have agreed to include 
these updates as part of their induction to help maintain momentum and continue building a 
culture of openness and shared responsibility around risk, escalation, and documentation. 

We remain fully committed to learning from this case and ensuring that improvements are 
embedded in practice, so that individuals in crisis receive the support they need at the right 
time. 

I hope that this response provides the necessary assurance.  Please contact me if you have 
any queries. 

Yours sincerely 

Chief Medical Officer 

Better Mental Health. Better Lives. Better Communities. 

Chair: 
Chief Executive: