East London NHS Foundation Trust

“The Trust has thoroughly investigated the incident and is following established disciplinary procedures for each staff member who failed to comply with the required observation standards in relation to Mr. [name redacted] care. Where evidence of non-compliance with the Trust's policies or failure to meet expected clinical standards has been identified, appropriate action is being taken in line with our disciplinary framework.”

“the Trust has reviewed and updated its mobile phone policy to establish clear guidelines on the acceptable use of personal phones within clinical settings, with the effect that staff are completely prohibited from using personal mobile phones during shifts.”

“the frequency of visits by a lead Nurse or a Matron on night shifts has been increased to twice a month from once a month for three months. These visits are focused on maintaining high standards of care and ensuring that all clinical practices, including the monitoring of physical health observations, are being consistently followed.”

“The Tower Hamlets Crisis Services acknowledge that on 23 November 2021 the calls made by Ms [name redacted] mother to the Home Treatment Team (HTT) were not recorded in the RiO medical records or passed on. 6. Steps are now in place to ensure calls are not missed: the administrators' office will now be covered with admin staff during the team handover from 14:00 to 16:00 to ensure calls are not missed. 7. In addition, HTT staff will be offering carers and significant others a check-in/follow up call for”

“The Trust has considered your Notice extremely carefully. As well as setting out the steps that the Trust has already taken in this area (for the benefit of those who did not attend the inquest but have an interest in this matter), this response will also set out the further steps that the Trust has taken since 2023 and are looking to enact.”

“The Trust intends to incorporate scenarios involving patients going AWOL on escorted leave into its induction training for new staff in the relevant services. In addition there will be a 2-yearly refresher for Section 17 and Escort training. The scenario training will incorporate such situations and include reference to the information that needs to be considered by the escorting staff and fed back to staff on the wards to help in making a decision around risk and level of escalation needed. The”

“The clinical decision made, that [name redacted] should not leave Gardner Ward unescorted was not followed and 2) this decision was not communicated to all members of staff”

“A full review of the Trust's VTE policy”

“A VTE Screening and Assessment Clinical Alert was disseminated across the Trust”

“Changes were made to the new doctors' induction and junior doctors handbook to include information on VTE assessments”

“Anti-psychotic medication has been added as a consideration on the Trust's VTE assessment tool”

“The Trust's monthly two day physical health training programme now includes a session on VTE risk”

“A yellow card warning was raised with the manufacturers of the anti-psychotic, Zaponex through the Medicines Health Regulations Authority (MHRA) to alert to two patients who have both passed away from pulmonary embolism whilst on Zaponex”

“In May 2020, immediately, after Ms [name redacted] death, the Deputy Borough Director listened to calls by each staff member to assess the quality of the care being provided.”

“In July 2021, the Deputy Borough Director listened to recorded calls from each staff member working on the Crisis Line. The standard was overall good. However, the outcome was that the contract of an Agency Nurse was terminated and another nurse was commenced on a performance management process.”

“Between 20 November 2021 - 28 November 2021, the CCG conducted a 'mystery shopping' audit of the Crisis line to measure responsiveness to calls. 70% of calls were answered in one minute or less, with 20% less than two minutes.”

“From January 2022, a larger Trust-wide Crisis Line call quality audit will take place. The audit tool has already been devised.”

“The City and Hackney Crisis Line Operational Policy has been updated to include a section on how call handlers should deal with concerned relatives and family members. This will be ratified on 17th December at the ELFT London Crisis Strategy Group and the updated content will be discussed with staff members at their team business meeting on 6 January 2022.”

“medical records training for all senior nurses was provided on 24 November 2021 to all senior nurses and managers at the Trust. The focus of the training was good record keeping, observations and retrospective record keeping.”

“additional risk assessment training had been put into place and would continue to be delivered on an ongoing basis”

“Firstly, the Named Professional for Safeguarding Children will ensure that Safeguarding Children Training, which is mandatory for all staff, will include information about the Leaving Care Team and their involvement with a young person up to the age of 25.”

“a memo has been distributed to all clinical Staff in City and Hackney highlighting the issue”