Louise Crane

Trust Headquarters 

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

Private and Confidential 
HM Assistant Coroner Ian Potter 
Inner North London 
St Pancras Coroner’s Court 
Camley St 
London N1C 4PP 

30 September 2025 

Dear Sir, 

Re Inquest touching the death of Louise Crane 

I am writing further to the inquest for Louise Crane which concluded in June 2025 and 
following which you issued a Prevention of Future Deaths (PFD) report to the Trust.  
Louise Crane sadly died by suicide on the Trust’s Topaz ward in September 2024.  We 
would like to begin by expressing our deepest sympathies to  Ms Crane’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 and prevent 
similar incidents. 

The PFD report acknowledges that  at the time of the inquest hearing the Trust had 
made  progress  in  addressing  some  of  the  concerns  identified  in  its  internal  Board 
Level  Panel  Inquiry  (BLPI)  investigation  report,  however  some  additional  matters 
emerged as a result of the inquest process. The matters of concern raised in the report 
are summarised as follows.  

Record Keeping / Professional Standards  
There was evidence that staff on Topaz Ward would sometimes use the ID card of 
another  member  of  staff  to  make  notes  on  the  electronic  records  system,  without 
making it clear who the entry was made by. In this case, there were two entries that 
appeared  to  have  been  made  by  a  support  worker,  that  were  made  by  a  nurse. 
Misleading and inaccurate record keeping can create confusion and significantly risks  
the continuity of care. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Lack of Professional Curiosity / Therapeutic Engagement – Audits  
The Trust’s BLPI included actions where improvement was to be measured by carrying 
out audits.  However, the Ward Manager gave evidence that there had been issues 
with audits in the past, which remained unaddressed.  

In addition, it was evident during the inquest that staff struggled with the concept of 
‘therapeutic  engagement’,  with  some  maintaining  that  Ms  Crane  had  received  a 
sufficient level of therapeutic engagement from Ward staff, contrary to the findings of 
the Trust’s BLPI and the subsequent findings of the jury.  

Step down / discharge from PICU to acute ward  
There  was  evidence  that  the  Trust’s  systems  were  unable  to  accommodate  Ms 
Crane’s needs during her transition from an intensive to an acute care setting.  

Therapeutic Engagement / Professional Curiosity – Generally  
Ms Crane had become withdrawn from around 12 September 2024 onwards. Many of 
the Trust’s witnesses denied this, despite evidence to the contrary. There appears to 
have been a general inability among staff to exercise professional curiosity.   

Observations on Topaz Ward  
The Trust’s BLPI identified issues in relation to required observation levels. This was 
compounded by evidence at the inquest, that the support worker conducting the 11:30  
check on 19 September did not see any part of Ms Crane, and on trying to open the 
door noted there was some resistance but nevertheless  assumed she was sat with 
her  back  to  the  door.    There  were  concerns  about  staff  training  in  what  is  required 
when carrying out observations.  

Communication and Culture  
The  Trust’s  BLPI  recognises  there  were  issues  with  documentation  and  record 
keeping, which is a key tool for communication. However, the evidence heard revealed 
a more general lack of communication between staff at all levels and leadership.  
The  substantive  consultant  psychiatrist  for  Topaz  Ward  said  that  they  would  not 
change the care provided. This raised concerns that the senior clinician for the Ward 
does not accept or appreciate the issues identified by the Trust.  

Trust Action Plan  
Insofar that aspects of the BLPI action plan were outstanding and / or awaiting Board 
level  approval  at  the  time  of  the  inquest  hearing,  concern  remained  regarding  the 
extent of implementation.   

Action taken 

To provide some context, it is noted that Ms Crane’s death occurred on 19/09/2024 
whilst  Topaz  ward  and  the  Highgate  site  were  part  of  Camden  and  Islington  NHS 
Foundation Trust which was working in partnership with Barnet Enfield and Haringey 
NHS  Trust  as  the  North  London  Partnership.  On  01/11/2024,  the  Trusts  formally 
merged  to  become  a  new  organisation,  the  North  London  NHS  Foundation  Trust 

2 

 
 
 
 
  
  
  
  
  
 
 
 
 (NLFT).  Topaz  ward  is  on  the  Highgate  site  and  sits 

within the Hospital Division of the organisation. 

In response to significant operational and clinical concerns, including the sad death of 
Ms  Crane,  the  Hospital  Division  of  the  NLFT  was  formally  placed  under  Enhanced 
Mandated  Support  (EMS)  on  13/12/2024.  EMS  was  initiated  to  address  immediate 
safety risks, improve service delivery, and embed sustainable quality improvements. 
EMS  is an  internal  executive  led  support structure  with  weekly reporting  to  support 
immediate and rapid improvement. 

The EMS programme was designed to be a structured, tiered intervention aimed at 
stabilising services, improving patient safety, and fostering a culture of accountability 
and continuous improvement. EMS was structured around a three-tiered model: 

•  Tier 1: Immediate safety actions (6-week plan) 

•  Tier 2: Medium-term improvements (4 weeks–3 months) 

•  Tier 3: Long-term sustainability (3+ months) 

Tier 1 focused on immediate safety actions, including staffing enhancements, physical 
health  monitoring,  and  ward  observations.  Tier  2  addressed  medium-term 
improvements  such  as  leadership  development,  environmental  upgrades,  and 
workforce  training.  Tier  3  aimed  at  long-term  sustainability  through  cultural 
transformation,  integration  of  closed  culture  review  findings,  and  systemic  change. 
Each  tier  was  governed  by  a  clear  set  of  objectives,  timelines,  and  accountability 
mechanisms, with regular oversight from executive leadership. The transition from Tier 
1  to  Tier  3  was  guided  by  performance  metrics,  executive  feedback  and  risk 
assessments.  The EMS programme was completed in July 2025 and has now been 
stepped down to ongoing Mandated Support. 

Key Achievements 

Several  significant  milestones  were  achieved  during  the  EMS  period  including  the 
below: 

Milestone 
6-Week Safety Plan 

Confidence to Care Plan (C2CP) 

Closed Culture Review 

Description 
Successfully  implemented,  addressing 
critical  safety  concerns;  enhanced 
staffing, 
upgrades, 
environmental 
strengthened physical health monitoring 

Launched, introducing SMILE framework 
to  empower  staff  with  confidence  to 
search, make it safe, intervene, lead, and 
escalate 

Review 
externally 
commissioned investigator in April 2025 

completed 

by 

3 

 
 
 
 
 
 
  
 
 
 Training Initiatives 

Environmental Improvements 

Service User Feedback 

Staffing Improvements 

Ward Environment 

Datix and Observation Model 

and  subsequently  approved,  identifying 
areas  for  improvement  and  informing 
Tier 3 planning 

PMVA, ILS, and BLS expanded; peer-led 
learning and reflective practice sessions 
introduced 

CCTV  upgrades,  Wi-Fi  enhancements 
initiated  to  support  safer  and  more 
efficient care delivery 

Positive  feedback  on  ward  activities, 
safety, and responsiveness 

Addressed  shortages, 
coordination, 
reviews 

improved  shift 
launched  safer  staffing 

Improvements  with temperature  control, 
ward aesthetics, ISS responsiveness 

introduced 
Improved  Datix  usage, 
Enhanced 
Day  model, 
Perfect 
observation  model  review  and  policy 
changes. 

Below, we explain the actions taken and ongoing to address each matter of concern, 
ensuring  that  all  measures  directly  contribute  to  improving  patient  safety  and  care.  
Please note that whilst this response has retained the structure of the concerns as set 
out in the PFD report, the issues are interlinked and there will be information under 
some headings which is also relevant to others and not necessarily repeated.   

Record Keeping / Professional Standards  
The  Trust  recognises the  vital importance  of  accurate  record  keeping  in  supporting 
safe patient care.  It is acknowledged that access to Smart Cards to support the use 
of Rio (the Trust’s Electronic Patient Record system) has been an issue, particularly 
for staff working via our bank staff provider NHS Professionals (NHSP).  As part of the 
EMS  program,  this  was  investigated  and  processes  streamlined  so  that  all  existing 
and  new  staff  are  now  able  to  apply  for  a  Smart  Card  and  complete  RIO  training.  
Going forward, in order to be booked onto a bank shift, NHSP staff must have a Smart 
Card. As a result, all staff (substantive and NHSP) can now make their own records 
on the RIO System thereby reducing any reliance on using other colleagues’ accounts. 
Ward managers are expected to complete a daily review of staff attending their wards 
to check access and ability to record accurately.  

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 In addition, staff have been reminded of their GDPR obligations which are covered in 
the Trust’s Information Governance mandatory training and that Smart Cards allowing 
access to Trust information systems should not be shared.  Where exceptionally this 
cannot be avoided, the entry must clearly state who the entry is actually being made 
by in order to avoid any confusion. 

Lack of Professional Curiosity / Therapeutic Engagement – Audits  

Following the inquest, the staff team on Topaz ward have been supported to further 
reflect on the care provided to Ms Crane, in particular in regard to the findings around 
lack of professional curiosity and therapeutic engagement.  We are satisfied that there 
is understanding amongst staff about what this is, but it is recognised that there have 
been barriers to implementing it effectively.  Factors involved include staffing levels 
and  skill  mix,  lack  of  time  due  to  number  of  tasks  staff  are  responsible  for  and 
standards  of  clinical  documentation.    One  of  the  overarching  aims  of  the  ongoing 
improvements is to support staff so that they have time to ensure that every individual’s 
clinical  needs  are  met.    As  part  of  the  on-going  mandated  support  program,  the 
Division has initiated several actions to address this: 

Staffing 

1)  A Safe Staffing skill mix review was completed by the Nursing Directorate and 
approved  by  the  Executive  Management  Committee  to  upgrade  the  staffing 
model of all acute inpatient wards within the Hospital Division. This means that 
an additional 24 Registered Nurses will be recruited by October 2025 to initiate 
the new staffing ratio of 3 Nurses and 2 Health care support workers on day 
shift (previously 2 nurses and 3 Health care support workers). The increased 
number  of  qualified  clinical  staff  will  support  with  dedicated  quality  time  to 
engage in therapeutic engagement time on the wards. We have also reviewed 
the  input  from  other  allied  health  professionals  (Occupational  Therapists, 
Activity  Coordinators  and  ward  Psychologists)  to  improve  engagement  via  a 
range  of  professionals  on  the  inpatient  wards.    In  addition,  a  discharge 
facilitation team has been introduced which works with all our inpatient wards 
to support with some of the practical and administrative tasks around discharge 
planning  which  were  previously  being  undertaken  by  nursing  staff,  with 
subsequent impact on time available to provide care.  Current feedback is that 
this team is having a significant positive impact on capacity. 

2)  The new discharge facilitation team comprises of: 

a.  8 full time ’network navigators’ – band 4 workers embedded in the ward 
MDTs (one on each acute ward), supporting with early identification of 
barriers to discharge and ensuring resolution of issues raised and links 
to community teams 

b.  2 full time discharge coordinators – band 6, one for male wards one for 

female, full time, working on flow and creating capacity 

c.  1 full time band 7 team manager 
3)  Realigning matrons to quality and safety work: 

5 

 
 
 
 
 
 
 
 
 
 a.  Matron  line  management  has  been  moved  from 
operational  service  managers  to  the  Associate 
Director  of  Nursing  to  re-establish  their  role  as  one  of  quality  and 
standards. 

b.  Operational work (flow, bed creation, discharges) has been taken away 

from the matrons in order to prioritise the quality and safety work. 

The significant staffing changes and realignments outlined  above are specifically 
designed to release time to care for our clinical staff. By creating the discharge 
facilitation team, realigning matrons and increasing the qualified ratio of staff on 
the ward, we increase the capacity to deliver the care we employed our staff to do 
and  that  they  were  trained  for.  It  takes  away  significant  amounts  of  non-clinical 
activity which was keeping them behind a computer screen or off the ward.  

Standardising ward timetables 

4)  It is also acknowledged that some of the therapeutic engagement with patients/ 
actions which would evidence professional curiosity were not being captured 
within our clinical  documentation.  To support improvement, the Division has 
rolled out the ‘Perfect Day’ model which essentially standardises the inpatient 
ward  day  timetable  across  all  our  wards.  The  Perfect  Day  model  provides  a 
timetable  for  the  day  which  is  predictable  and  understandable  by  all  staff, 
patients  and  visitors.  It  also  provides  a  standardised  digital  template  for 
handovers that is completed daily and uploaded to the electronic patient record 
(EPR) system every day before 11am evidencing key information such as risk, 
barriers to discharge etc.  This has been implemented via Quality Improvement 
methodology  with  ideas  for  improvement  including  use  of  a  standardised 
template to record MDT discussions, RiO notes being open and visible to all 
attendees and documentation of how MDT decisions around observation levels 
are made having positively yielded results. These are now part of business as 
usual for all wards in the Hospital division. 

Audit is considered a vital tool in monitoring and providing assurance that the 
Perfect Day model improvements around documentation are being 
implemented consistently.   The role out of the model was initially supported 
by a band 8c Director of Operations working in the division and auditing the 
results. This has now been handed over to the newly formed discharge 
facilitation team to continue with the audits. 

5)  The audits include a 10-point checklist of the handover documentation fidelity 
to  model  with  max  score  400  points. As  of  end August  2025  average  audit 
weekly score across the division was c.300. 

6)  Monitoring of the impact of the model is via adherence to a number of factors: 

a.  Ward discharges being facilitated before 1 pm so that bed availability is 
identified early and admissions happen in working hours which is safer 
and increases therapeutic opportunity 

b.  Formulation  meetings  happening  within  72  hours  of  admission  and  
attendance of, for example care coordinators, relatives, trusted others. 

6 

 
 
 
 
 
 
 
 Step down / discharge from PICU to acute ward  

Bed  capacity  remains  challenging  with  there  being  a  very  high  level  of  demand  for 
beds  across  the  area  the  Trust  serves.    This  means  that  there  are  frequently  long 
waits, both for people to be initially admitted to a bed (for example, from A&E) and for 
step down from PICU to the acute wards.  Realistically, this is not likely to change in 
the near future and it means that we are not able to plan step down in the way that we 
might ideally wish to.  However, all the other areas of work set out in this response 
that  are  ongoing  to  release  time  to  care  and  make  patients  safer  are  expected  to 
impact positively on this process and improve the experience for patients.  There will 
be increased time to spend with patients when they are first admitted; to ensure that 
every individual’s needs are incorporated into their care plan so they can be effectively 
supported through this period of transition.  Additionally, we are in the early stages of 
a  further  conversation  about  this  with  a  workshop  recently  commenced  on  the 
women’s PICU ward.   In November the Trust is moving to a new structure with the 
current divisions to be replaced by care groups, bringing all inpatient wards for adults 
of working age across the organisation under the same management structure.  This 
will support us to make best use of all our available beds across the entire Trust. 

Therapeutic Engagement / Professional Curiosity – Generally  
This concern is addressed earlier in this response where it is explained what is being 
done to ensure that staff have time to care and engage therapeutically with patients 
by  addressing  staffing  issues  and  reducing  non-clinical  responsibilities.  This  is 
supported by the other aspects of the programme which focus on improving clinical 
documentation, communication within the team and the culture of care. 

Observations on Topaz Ward  
We recognise that observations  are an area that have presented challenges for the 
organisation  but  we  are  committed  to  getting  this  right;  observations  are  central  to 
ensuring patient safety on our wards. There is also a need for consideration of patients’ 
privacy  and  dignity  and  to  ensure  that  they  are  conducted  in  a  way  which  is  not 
unnecessarily intrusive.  Following a review of observations as part of the  EMS and 
learning  from  the  BLPI,  a  new  template  has  been  piloted  on  three  wards.  This 
specifically prompts staff undertaking observations to check for and record Signs of 
Life.    Staff  are  expected  to  enter  the  patient’s  room  and  check  their  level  of 
alertness/breathing where this is not immediately apparent, for example, by looking 
for chest movement when a patient is sleeping. This template has now been rolled out 
to  all  inpatient  wards  in  the  Hospital  Division  and  is  included  in  the  new  NLFT 
Supportive Observation and Engagement policy.   

Use of bank staff presents a challenge as they may not receive the same training as 
substantive staff.  We are addressing this through the recruitment referred to earlier 
which will reduce our reliance on bank staff, and where we do use bank staff, wherever 
possible these will be from a regular pool of staff who are trained on Trust policies and 
procedures.  We are also ensuring all staff working a bank shift receive an induction 
to the ward which includes how to carry out observations. 

Following  implementation  of  the  new  template,  we  have  observed  increased 
accountability on the part of staff undertaking observations and clearer documentation.  

7 

 
 
 
 
 
 
 
 
 Observation  sheets  are  now  monitored  daily  by  the 
Nurse in Charge, Ward Manager, Matron, and out of hours 

via the Senior Site Coordinators.  In addition, the Division has initiated a weekly CCTV 
and  documentation  review  and  reconciling  these.  This  is  undertaken  by  the  Ward 
Managers and Matrons to ensure that documentation is accurate and up to date. We 
have  also  increased  visibility  of  Nurse  Leaders  (Ward  Managers,  Matrons  and 
members of the Senior Leadership Team) to support this work.  As of August, the role 
of  the  Matrons  has  changed  so  that  they  are  now  focussed  on  clinical,  rather  than 
operational duties, with an emphasis on improving nursing standards and the quality 
of care. 

Communication and Culture  

Between November 2024 and January 2025 the Trust delivered 15 full away days for 
the wards on the Highgate campus. These away days used the new NHS ‘Culture of 
Care’1 standards as their focus and included all the ward multidisciplinary teams and 
senior management. Discussions around the importance of therapeutic engagement 
and  professional  curiosity  were  central  to  these  sessions,  focusing  on  identifying 
barriers  and  implementing  strategies  for  improvement.  They  were  facilitated  by 
Organisational Development  colleagues  who  compiled  reports on  the  learning  from 
the  away  days  about  the  different  cultures  on  our  wards  and  reported  back  to  the 
senior  leadership  group  to  support  each  individual  ward  with  developing  their 
approach to patient care.  A set of overarching recommendations was also made and 
these are currently being progressed as part of the ongoing programme of work. In 
addition,  Topaz  ward  specifically  engaged  in  an  additional  Quality  Improvement 
programme of working on ‘Improving Therapeutic Engagement on the ward’. Although 
this is still in its initial stages, it will be progressed with the wider programme of work 
being undertaken by the division. 

Trust Action Plan  

The  actions  allocated  to  the  Division,  and  those  that  form  part  of  the  Trust’s 
improvement plans, are underway and/or completed.  A copy of the action plan with 
progress updates is enclosed with this response. 

We sincerely hope that the information provided above about this whole scale review 
of safety and culture of care across the Highgate Campus demonstrates how seriously 
we take the issues that have been raised by the PFD report. 

We  will  continue  to  monitor  the  impact  of  all  the  changes  noted  above  through  the 
following mechanisms: 

1)  Monitoring of incidents reported within the organisation, to ensure a continued 
reduction in the number of patient safety incidents occurring on our wards 
2)  Monitoring and acting on patient and carer feedback received via all relevant 

processes including 

1 NHS England » Culture of care standards for mental health inpatient services 

8 

 
 
 
 
 
 
 
 
 
 a.  Text  messages  feedback  system  -  all  discharged 
patients  receive  a  text  message  with  a  link  to  a 
survey to complete feedback on their inpatient stay 

b.  Community meetings, Patient and Family complaints and compliments. 

3)  Pulse staff surveys. 
4)  Ongoing  review  of  all  actions  at  the  Mandated  Support  meetings  that  are 
chaired  by  executives  and  report  to  the  Executive  Management  Committee 
(EMC) 

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

Yours sincerely, 

Chief Medical Officer 

9