Louise Crane (1)
23 Jun 2025 · Coroner Ian Potter · Inner North London
The coroner's concerns
1. inaccurate record keeping
“There was evidence that staff on Topaz Ward would sometimes use the ID card of another member of staff to makes notes on the records system, without making it clear who the entry was actually made by”
2. lack of therapeutic engagement
“numerous members of staff from Topaz Ward gave evidence during the inquest and it appeared that many of them struggled with the concept of 'therapeutic engagement'”
3. unsafe step down discharge
“There was evidence that the Trust's systems were unable to accommodate the needs of Ms [name redacted] in ensuring that her transition from an intensive care to an acute setting was as safe as possible for her”
4. non‑compliant observations
“The Trust's own internal investigation highlighted issues regarding the review of required observation levels”
5. inadequate observation checks
“the support worker conducting this check did not see any part of Ms [name redacted], and on trying to open the door noted there was some resistance”
6. communication breakdown
“matters, a lack of good communication more generally raises significant patient care risks and”
Responses
2025-0317-Response-from-North-London-NHS-Foundation-Trust.pdf ↗· North London NHS Foundation Trust
Stated action · 01/11/2024
“To provide some context, it is noted that Ms [name redacted] 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)”