Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0507, written 1 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Sep 2025 |
|---|---|
| Reference | 2025-0507 |
| Deceased | [REDACTED] |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| Category | Mental Health related deaths |
| Organisation named | East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Prevention of Future Deaths Report REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Officer East London NHS Foundation Trust Robert Dolan House 9 Alie Street London E1 8DE 1 CORONER I am Ian Potter, assistant coroner for the coroner area of Inner North London. 2 CORONER’S LEGAL POWERS 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 3 INVESTIGATION and INQUEST On 9 June 2022, an investigation was commenced into the death of , aged 23 years at the time of her death. The investigation concluded at the end of an inquest heard by me (and a jury) between 28 July 2025 and 15 August 2025. 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 4 CIRCUMSTANCES OF DEATH The following is a summary of the jury’s findings: 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 being confiscated on the evening of 6 June 2022, increased. On the morning of 7 June 2022, efforts to secure the return of her mobile telephone, to no avail. mobile telephone agitation made numerous At 10:38 on 7 June 2022, (room 7). At 10:40 on 7 June 2022, entered she was found unresponsive by staff in room 7 at 11:14. 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 death: - The automatic door locking or ‘fob’ system was not working; - was not permitted access to items that could be used as a ligature, and the fact that the ‘fob’ system was not working - 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. 5 CORONER’S CONCERNS 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) final admission under the I am aware that, prior to 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 death and the jury This was not working at the time of 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 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. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. 7 YOUR RESPONSE 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and the following: • 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. 9 Ian Potter HM Assistant Coroner, Inner North London 1 September 2025
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Office of the Chief Medical Officer Trust Headquarters Robert Dolan House 5th Floor 9 Alie Street London E1 8DE Private & Confidential HMC Ian Potter 27 October 2025 Dear Sir RE: REGULATION 28 REPORT I am writing to provide a formal response to the concerns set out in the Regulation 28 report that you issued on 1 September 2025 following the inquest touching the death of The Trust gratefully notes your observations that it has already made progress in some areas, and that you commend its work in doing so. You noted various continuing concerns as follows: Concern 1 – Patient Observations Concern 2 – 1:1 or ‘eyesight’ Observations Concern 3 – Auditing of Record-Keeping Concern 4 – Door-locking/’fob’ System Concern 5 – Risk Assessment of Patients Concern 6 – Understanding of Risk Concern 7 – Attitudinal Concerns Concern 8 – Effective Clinical Oversight at Tower Hamlets Centre for Mental Health I have addressed these in turn below. Please note that in respect of Concerns 2, 4, 5, 6, 7 and 8 the Trust entirely acknowledges the reasons for your concerns and has considered them extremely seriously. The Trust has done a considerable amount of work since very sad death in June 2022 and as such is reassured that no further action is required. Patient Observations You heard evidence about the significant amount of work that the Trust has done in relation to this issue over the past years and as such I do not intend to duplicate it here. Readers of this response who did not attend the inquest can find further details in the Trust’s response to the Regulation 28 report issued in relation to . I would like to draw your attention to an article published in the International Journal for Quality in Healthcare shortly after inquest took place, where the results of some of the Trust’s interventions to improve observation practices have been quantified. Observation completion and therapeutic engagement were shown to have improved following the introduction of zonal observations, a board relay, and life skills activities led by recovery workers. Sustained improvements were seen in all 10 measures used in this work, as evidenced by shifts in statistical process control charts. General observation completion increased by 1.2% (to 99.57%), and intermittent observation completion rose by 1.9% (to 98.25%). Incidents of physical violence were reduced by 23%, verbal aggression by 38% and racial aggression by 60%. Restrictive practice use also reduced, with restraint reduced by 16%, prone restraint by 35%, seclusion by 38%, and rapid tranquillisation by 26%. Staff sickness also decreased by 16%. was nursed on intermittent observations and you have noted that they were often not being used as a tool to aid therapeutic engagement. The Trust shares your concern about whether these observations are realistically providing opportunities for therapeutic engagement, and has been exploring how the use of intermittent observations can be reduced while strengthening safer, more compassionate forms of care. Instead of relying so much on scheduled checks, the focus will be on creating ward environments where relational, therapeutic engagement is the default. It is important to note that other ‘types’ of observation such as hourly observations and 1:1 observation will still take place as clinically indicated. The Trust’s work on this project is comprised of two phases: Phase 1 (April – October 2025): Ten inpatient wards will test new approaches to reducing intermittent observations with hands-on support from local Improvement Advisors, QI coaches, and sponsors. Real-time data will be gathered to guide decision-making and monitor impact. Phase 2 (November 2025 onwards): The most effective ideas will be refined and tested in new conditions to build confidence in their effectiveness. Once a strong degree of belief is established, these changes will be spread across all ELFT inpatient wards using a structured approach to scale. 1:1 or ‘eyesight’ Observations The member of staff in question has had their knowledge refreshed about the expectations of the Trust’s observations policy and the Trust’s mobile phone policy. The latter was updated in 2024 to include material on staff use of mobile phones, making it clear that they are not allowed in clinical areas unless there is an exceptional reason agreed with a local manager. There has been shared learning with all staff across the unit on the use of mobile phones whilst on duty, in 2024. Auditing of Record-Keeping The Trust is moving towards using CCTV to objectively audit whether observations have been made as recorded. This is anticipated to commence in January 2026 to allow for staff training to download and access CCTV footage. Door-locking/’fob’ System The ward environment – including the locking systems / fobs – has been added as an agenda item onto Ward Safety Huddles. A representative of the Trust Estates team normally attends these huddles and any issues with the system can be escalated directly to them. In the event of failure, staff are briefed to proactively close doors themselves and to encourage patients to close their own doors. I understand that there has been an occasion since death when a malfunction has been successfully rectified in the space of a single day, indicating that the revised system is working effectively. Risk Assessment of Patients There is a rolling programme of monthly Dialog+, my safety plan and risk assessment training for staff, with each member of staff completing this as a one-off. In terms of the Trust’s expectations regarding whether staff should commence the My Safety Plan and Dialog+ documents in the absence of patient engagement, staff are expected to complete the Dialog+ and My Safety Plan within 72hours of admission; where patients are not able to engage in this process staff will revisit and obtain their input. Staff are also encouraged to obtain collateral information from family, friends and carers. There are weekly case note audits to look at the quality of dialog+ including patients’ views, which provides opportunities for clarity of processes and expectations related to this documentation to be reinforced. Understanding of Risk Although you have – very properly – not specified which staff you are referring to, the Trust believes it knows who you mean. I do, very respectfully, want to emphasise that human error can always occur in a high-pressure situation, and an isolated occurrence of human error does not in and of itself mean someone is unsuited to a caring role. The Trust has carefully considered this and reviewed matters with staff as necessary. Attitudinal Concerns All qualified nursing staff are undergoing brief initial training around the role of the nurse in charge which includes allocation of outstanding tasks (assessments, care plans etc) and monitoring the completion of these. A longer electronic training package is being developed. This has already been completed in Tower Hamlets. A standardised handover template has been introduced which facilitates the identification of outstanding nursing and medical tasks to be allocated. The lead nurse and matrons are attending nursing handovers to monitor and embed this practice. The daily unit huddle meeting in the Tower Hamlets Center for Mental Health requires ward managers to feedback on each new admission and the completion of their initial assessments and care planning. This is monitored until it is reported that all tasks have been completed. There is a record kept of this. Effective Clinical Oversight of Medical Staff at Tower Hamlets Centre for Mental Health Concerns about the conduct or capability of medical staff are managed following the East London NHS Foundation Trust ‘Maintaining High Professional Standards in the Modern NHS’ (MHPS) policy, in line with the nationally agreed MHPS framework. It ensures all concerns are addressed fairly, transparently, and with patient safety as the priority. Misconduct matters are handled locally through the Trust’s Disciplinary Policy, with additional procedures for doctors under MHPS. The course of action depends on whether concerns are deemed serious or non-serious: non-serious concerns may be managed informally or through local resolution, while serious concerns trigger formal procedures as outlined in the MHPS and relevant disciplinary policies. These processes are implemented when necessary after considered review by medical managers and colleagues from Human Resources. External advice is routinely sought from Practitioner Performance Advice within NHS Resolution. Both before and subsequent to this incident occurring, there have been occasions when formal measures have been put in place regarding the performance of medical staff in the Trust, demonstrating the seriousness with which the Trust take this issue. Conclusion I hope this response provides sufficient reassurances to you and to the family of about the learning that has taken place at the Trust since her sad death. I would like to offer my sincere and heart-felt condolences to her family at this difficult time. Yours sincerely Chief Medical Officer
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