Camden and Islington NHS Foundation Trust

“the team manager and service manager have updated the CDAT Operational Policy and have implemented a daily duty sheet/tracker”

“Any service user of the Crisis Team who is being considered for discharge because of non-engagement must be discussed in the Crisis Service Multi- Disciplinary Meeting with senior overview of the decision to discharge.”

“we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.”

“we have asked to be provided with copies of CANDI's finalised Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately”

“The nurse in question was an agency professional, employed by NHS Professionals. (NHSP). tn light of this case, he has been suspended from working at this level of expertise until the serious incident review has been completed.”

“We have also reinforced the importance of working with families in our updated, risk assessment training which has been rolled out over the last 12 months.”

“we have issued staff at North Camden Crisis House with clear guidance to ensure that numbers and contact details are clearly provided to families participating in a services user's care so they are able to speak directly to a senior staff member.”

“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”

“We have strengthened the direct mental health referral protocol from Whittington Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison Team Service, so that patients attending Whittington Emergency who need to see a mental health professional can be immediately and directly referred. This mental health referral protocol was in place before your inquest into Mr [name redacted] death, but has since been significantly strengthened in that the patient themselves can now trigger”

“Following the inquest into the death of Mr [name redacted] you noted the following failures by the Crisis team: to visit Mr [name redacted] twice a day despite a plan to do so; to record why twice daily visits were not attempted; to communicate within the team and with the two Crisis houses; to consider hospital admission despite the fact that Mr [name redacted] was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill”

“the Clinical Director for the Acute Division has clarified and disseminate the Trust's bed management policy to its employees emphasising that, 'any patient requiring a bed will be offered admission regardless of their Mental Health Act status'”

“The Trust has a clinical risk assessment and management policy in place. It has been reviewed and updated in September 2014 and is currently being consulted upon.”

“requests for checks should be followed up within six hours of them being made”