East London NHS Foundation Trust
NHS / Health Body
Action Taken
East London NHS Foundation Trust has already made progress improving patient observations, observation practices, record keeping, risk assessments, understanding of risk, and clinical oversight, with interventions like new observation policy, therapeutic engagement improvements, enhanced auditing, and strengthened handover procedures. (AI summary)
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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
Private & Confidential
HMC Ian Potter
27 October 2025 Office of the Chief Medical Officer Trust Headquarters Robert Dolan House 5th Floor 9 Alie Street London E1 8DE
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.
Private & Confidential
HMC Ian Potter
27 October 2025 Office of the Chief Medical Officer Trust Headquarters Robert Dolan House 5th Floor 9 Alie Street London E1 8DE
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.