North London NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust has implemented measures including mandatory training on record keeping, increased audit frequency and revised content, a new supervision policy, a 'ward buddy' system, and Quality Improvement programmes, with ongoing monitoring of changes. (AI summary)
View full response
Dear Sir,
Re Inquest touching the death of Louise Crane
I am writing further to the inquest for Louise Crane which concluded in June 2025 and following which you issued a Prevention of Future Deaths (PFD) report to the Trust. Louise Crane sadly died by suicide on the Trust’s Topaz ward in September 2024. We would like to begin by expressing our deepest sympathies to Ms Crane’s family and loved ones. We recognise the profound impact of her death, and our focus in this response is to outline the actions we are taking to strengthen our systems and prevent similar incidents.
The PFD report acknowledges that at the time of the inquest hearing the Trust had made progress in addressing some of the concerns identified in its internal Board Level Panel Inquiry (BLPI) investigation report, however some additional matters emerged as a result of the inquest process. The matters of concern raised in the report are summarised as follows.
Record Keeping / Professional Standards There was evidence that staff on Topaz Ward would sometimes use the ID card of another member of staff to make notes on the electronic records system, without making it clear who the entry was made by. In this case, there were two entries that appeared to have been made by a support worker, that were made by a nurse. Misleading and inaccurate record keeping can create confusion and significantly risks the continuity of care.
2
Lack of Professional Curiosity / Therapeutic Engagement – Audits The Trust’s BLPI included actions where improvement was to be measured by carrying out audits. However, the Ward Manager gave evidence that there had been issues with audits in the past, which remained unaddressed.
In addition, it was evident during the inquest that staff struggled with the concept of ‘therapeutic engagement’, with some maintaining that Ms Crane had received a sufficient level of therapeutic engagement from Ward staff, contrary to the findings of the Trust’s BLPI and the subsequent findings of the jury.
Step down / discharge from PICU to acute ward There was evidence that the Trust’s systems were unable to accommodate Ms Crane’s needs during her transition from an intensive to an acute care setting.
Therapeutic Engagement / Professional Curiosity – Generally Ms Crane had become withdrawn from around 12 September 2024 onwards. Many of the Trust’s witnesses denied this, despite evidence to the contrary. There appears to have been a general inability among staff to exercise professional curiosity.
Observations on Topaz Ward The Trust’s BLPI identified issues in relation to required observation levels. This was compounded by evidence at the inquest, that the support worker conducting the 11:30 check on 19 September did not see any part of Ms Crane, and on trying to open the door noted there was some resistance but nevertheless assumed she was sat with her back to the door. There were concerns about staff training in what is required when carrying out observations.
Communication and Culture The Trust’s BLPI recognises there were issues with documentation and record keeping, which is a key tool for communication. However, the evidence heard revealed a more general lack of communication between staff at all levels and leadership. The substantive consultant psychiatrist for Topaz Ward said that they would not change the care provided. This raised concerns that the senior clinician for the Ward does not accept or appreciate the issues identified by the Trust.
Trust Action Plan Insofar that aspects of the BLPI action plan were outstanding and / or awaiting Board level approval at the time of the inquest hearing, concern remained regarding the extent of implementation.
Action taken
To provide some context, it is noted that Ms Crane’s 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
3
(NLFT). Topaz ward is on the Highgate site and sits within the Hospital Division of the organisation.
In response to significant operational and clinical concerns, including the sad death of Ms Crane, the Hospital Division of the NLFT was formally placed under Enhanced Mandated Support (EMS) on 13/12/2024. EMS was initiated to address immediate safety risks, improve service delivery, and embed sustainable quality improvements. EMS is an internal executive led support structure with weekly reporting to support immediate and rapid improvement.
The EMS programme was designed to be a structured, tiered intervention aimed at stabilising services, improving patient safety, and fostering a culture of accountability and continuous improvement. EMS was structured around a three-tiered model:
• Tier 1: Immediate safety actions (6-week plan)
• Tier 2: Medium-term improvements (4 weeks–3 months)
• Tier 3: Long-term sustainability (3+ months)
Tier 1 focused on immediate safety actions, including staffing enhancements, physical health monitoring, and ward observations. Tier 2 addressed medium-term improvements such as leadership development, environmental upgrades, and workforce training. Tier 3 aimed at long-term sustainability through cultural transformation, integration of closed culture review findings, and systemic change. Each tier was governed by a clear set of objectives, timelines, and accountability mechanisms, with regular oversight from executive leadership. The transition from Tier 1 to Tier 3 was guided by performance metrics, executive feedback and risk assessments. The EMS programme was completed in July 2025 and has now been stepped down to ongoing Mandated Support.
Key Achievements Several significant milestones were achieved during the EMS period including the below:
Milestone Description 6-Week Safety Plan Successfully implemented, addressing critical safety concerns; enhanced staffing, environmental upgrades, strengthened physical health monitoring
Confidence to Care Plan (C2CP) Launched, introducing SMILE framework to empower staff with confidence to search, make it safe, intervene, lead, and escalate
Closed Culture Review Review completed by externally commissioned investigator in April 2025
4
and subsequently approved, identifying areas for improvement and informing Tier 3 planning
Training Initiatives PMVA, ILS, and BLS expanded; peer-led learning and reflective practice sessions introduced
Environmental Improvements CCTV upgrades, Wi-Fi enhancements initiated to support safer and more efficient care delivery
Service User Feedback Positive feedback on ward activities, safety, and responsiveness
Staffing Improvements Addressed shortages, improved shift coordination, launched safer staffing reviews
Ward Environment Improvements with temperature control, ward aesthetics, ISS responsiveness
Datix and Observation Model Improved Datix usage, introduced Perfect Day model, Enhanced observation model review and policy changes.
Below, we explain the actions taken and ongoing to address each matter of concern, ensuring that all measures directly contribute to improving patient safety and care. Please note that whilst this response has retained the structure of the concerns as set out in the PFD report, the issues are interlinked and there will be information under some headings which is also relevant to others and not necessarily repeated.
Record Keeping / Professional Standards The Trust recognises the vital importance of accurate record keeping in supporting safe patient care. It is acknowledged that access to Smart Cards to support the use of Rio (the Trust’s Electronic Patient Record system) has been an issue, particularly for staff working via our bank staff provider NHS Professionals (NHSP). As part of the EMS program, this was investigated and processes streamlined so that all existing and new staff are now able to apply for a Smart Card and complete RIO training. Going forward, in order to be booked onto a bank shift, NHSP staff must have a Smart Card. As a result, all staff (substantive and NHSP) can now make their own records on the RIO System thereby reducing any reliance on using other colleagues’ accounts. Ward managers are expected to complete a daily review of staff attending their wards to check access and ability to record accurately.
5
In addition, staff have been reminded of their GDPR obligations which are covered in the Trust’s Information Governance mandatory training and that Smart Cards allowing access to Trust information systems should not be shared. Where exceptionally this cannot be avoided, the entry must clearly state who the entry is actually being made by in order to avoid any confusion.
Lack of Professional Curiosity / Therapeutic Engagement – Audits
Following the inquest, the staff team on Topaz ward have been supported to further reflect on the care provided to Ms Crane, in particular in regard to the findings around lack of professional curiosity and therapeutic engagement. We are satisfied that there is understanding amongst staff about what this is, but it is recognised that there have been barriers to implementing it effectively. Factors involved include staffing levels and skill mix, lack of time due to number of tasks staff are responsible for and standards of clinical documentation. One of the overarching aims of the ongoing improvements is to support staff so that they have time to ensure that every individual’s clinical needs are met. As part of the on-going mandated support program, the Division has initiated several actions to address this:
Staffing
1) A Safe Staffing skill mix review was completed by the Nursing Directorate and approved by the Executive Management Committee to upgrade the staffing model of all acute inpatient wards within the Hospital Division. This means that an additional 24 Registered Nurses will be recruited by October 2025 to initiate the new staffing ratio of 3 Nurses and 2 Health care support workers on day shift (previously 2 nurses and 3 Health care support workers). The increased number of qualified clinical staff will support with dedicated quality time to engage in therapeutic engagement time on the wards. We have also reviewed the input from other allied health professionals (Occupational Therapists, Activity Coordinators and ward Psychologists) to improve engagement via a range of professionals on the inpatient wards. In addition, a discharge facilitation team has been introduced which works with all our inpatient wards to support with some of the practical and administrative tasks around discharge planning which were previously being undertaken by nursing staff, with subsequent impact on time available to provide care. Current feedback is that this team is having a significant positive impact on capacity.
2) The new discharge facilitation team comprises of:
a. 8 full time ’network navigators’ – band 4 workers embedded in the ward MDTs (one on each acute ward), supporting with early identification of barriers to discharge and ensuring resolution of issues raised and links to community teams
b. 2 full time discharge coordinators – band 6, one for male wards one for female, full time, working on flow and creating capacity
c. 1 full time band 7 team manager
3) Realigning matrons to quality and safety work:
6
a. Matron line management has been moved from operational service managers to the Associate Director of Nursing to re-establish their role as one of quality and standards.
b. Operational work (flow, bed creation, discharges) has been taken away from the matrons in order to prioritise the quality and safety work.
The significant staffing changes and realignments outlined above are specifically designed to release time to care for our clinical staff. By creating the discharge facilitation team, realigning matrons and increasing the qualified ratio of staff on the ward, we increase the capacity to deliver the care we employed our staff to do and that they were trained for. It takes away significant amounts of non-clinical activity which was keeping them behind a computer screen or off the ward.
Standardising ward timetables
4) It is also acknowledged that some of the therapeutic engagement with patients/ actions which would evidence professional curiosity were not being captured within our clinical documentation. To support improvement, the Division has rolled out the ‘Perfect Day’ model which essentially standardises the inpatient ward day timetable across all our wards. The Perfect Day model provides a timetable for the day which is predictable and understandable by all staff, patients and visitors. It also provides a standardised digital template for handovers that is completed daily and uploaded to the electronic patient record (EPR) system every day before 11am evidencing key information such as risk, barriers to discharge etc. This has been implemented via Quality Improvement methodology with ideas for improvement including use of a standardised template to record MDT discussions, RiO notes being open and visible to all attendees and documentation of how MDT decisions around observation levels are made having positively yielded results. These are now part of business as usual for all wards in the Hospital division.
Audit is considered a vital tool in monitoring and providing assurance that the Perfect Day model improvements around documentation are being implemented consistently. The role out of the model was initially supported by a band 8c Director of Operations working in the division and auditing the results. This has now been handed over to the newly formed discharge facilitation team to continue with the audits.
5) The audits include a 10-point checklist of the handover documentation fidelity to model with max score 400 points. As of end August 2025 average audit weekly score across the division was c.300.
6) Monitoring of the impact of the model is via adherence to a number of factors:
a. Ward discharges being facilitated before 1 pm so that bed availability is identified early and admissions happen in working hours which is safer and increases therapeutic opportunity
b. Formulation meetings happening within 72 hours of admission and attendance of, for example care coordinators, relatives, trusted others.
7
Step down / discharge from PICU to acute ward Bed capacity remains challenging with there being a very high level of demand for beds across the area the Trust serves. This means that there are frequently long waits, both for people to be initially admitted to a bed (for example, from A&E) and for step down from PICU to the acute wards. Realistically, this is not likely to change in the near future and it means that we are not able to plan step down in the way that we might ideally wish to. However, all the other areas of work set out in this response that are ongoing to release time to care and make patients safer are expected to impact positively on this process and improve the experience for patients. There will be increased time to spend with patients when they are first admitted; to ensure that every individual’s needs are incorporated into their care plan so they can be effectively supported through this period of transition. Additionally, we are in the early stages of a further conversation about this with a workshop recently commenced on the women’s PICU ward. In November the Trust is moving to a new structure with the current divisions to be replaced by care groups, bringing all inpatient wards for adults of working age across the organisation under the same management structure. This will support us to make best use of all our available beds across the entire Trust.
Therapeutic Engagement / Professional Curiosity – Generally This concern is addressed earlier in this response where it is explained what is being done to ensure that staff have time to care and engage therapeutically with patients by addressing staffing issues and reducing non-clinical responsibilities. This is supported by the other aspects of the programme which focus on improving clinical documentation, communication within the team and the culture of care.
Observations on Topaz Ward We recognise that observations are an area that have presented challenges for the organisation but we are committed to getting this right; observations are central to ensuring patient safety on our wards. There is also a need for consideration of patients’ privacy and dignity and to ensure that they are conducted in a way which is not unnecessarily intrusive. Following a review of observations as part of the EMS and learning from the BLPI, a new template has been piloted on three wards. This specifically prompts staff undertaking observations to check for and record Signs of Life. Staff are expected to enter the patient’s room and check their level of alertness/breathing where this is not immediately apparent, for example, by looking for chest movement when a patient is sleeping. This template has now been rolled out to all inpatient wards in the Hospital Division and is included in the new NLFT Supportive Observation and Engagement policy.
Use of bank staff presents a challenge as they may not receive the same training as substantive staff. We are addressing this through the recruitment referred to earlier which will reduce our reliance on bank staff, and where we do use bank staff, wherever possible these will be from a regular pool of staff who are trained on Trust policies and procedures. We are also ensuring all staff working a bank shift receive an induction to the ward which includes how to carry out observations.
Following implementation of the new template, we have observed increased accountability on the part of staff undertaking observations and clearer documentation.
8
Observation sheets are now monitored daily by the Nurse in Charge, Ward Manager, Matron, and out of hours via the Senior Site Coordinators. In addition, the Division has initiated a weekly CCTV and documentation review and reconciling these. This is undertaken by the Ward Managers and Matrons to ensure that documentation is accurate and up to date. We have also increased visibility of Nurse Leaders (Ward Managers, Matrons and members of the Senior Leadership Team) to support this work. As of August, the role of the Matrons has changed so that they are now focussed on clinical, rather than operational duties, with an emphasis on improving nursing standards and the quality of care.
Communication and Culture
Between November 2024 and January 2025 the Trust delivered 15 full away days for the wards on the Highgate campus. These away days used the new NHS ‘Culture of Care’1 standards as their focus and included all the ward multidisciplinary teams and senior management. Discussions around the importance of therapeutic engagement and professional curiosity were central to these sessions, focusing on identifying barriers and implementing strategies for improvement. They were facilitated by Organisational Development colleagues who compiled reports on the learning from the away days about the different cultures on our wards and reported back to the senior leadership group to support each individual ward with developing their approach to patient care. A set of overarching recommendations was also made and these are currently being progressed as part of the ongoing programme of work. In addition, Topaz ward specifically engaged in an additional Quality Improvement programme of working on ‘Improving Therapeutic Engagement on the ward’. Although this is still in its initial stages, it will be progressed with the wider programme of work being undertaken by the division. Trust Action Plan
The actions allocated to the Division, and those that form part of the Trust’s improvement plans, are underway and/or completed. A copy of the action plan with progress updates is enclosed with this response.
We sincerely hope that the information provided above about this whole scale review of safety and culture of care across the Highgate Campus demonstrates how seriously we take the issues that have been raised by the PFD report.
We will continue to monitor the impact of all the changes noted above through the following mechanisms:
1) Monitoring of incidents reported within the organisation, to ensure a continued reduction in the number of patient safety incidents occurring on our wards
2) Monitoring and acting on patient and carer feedback received via all relevant processes including
1 NHS England » Culture of care standards for mental health inpatient services
9
a. Text messages feedback system - all discharged patients receive a text message with a link to a survey to complete feedback on their inpatient stay
b. Community meetings, Patient and Family complaints and compliments.
3) Pulse staff surveys.
4) Ongoing review of all actions at the Mandated Support meetings that are chaired by executives and report to the Executive Management Committee (EMC)
If you require any further information, please do not hesitate to contact me.
Re Inquest touching the death of Louise Crane
I am writing further to the inquest for Louise Crane which concluded in June 2025 and following which you issued a Prevention of Future Deaths (PFD) report to the Trust. Louise Crane sadly died by suicide on the Trust’s Topaz ward in September 2024. We would like to begin by expressing our deepest sympathies to Ms Crane’s family and loved ones. We recognise the profound impact of her death, and our focus in this response is to outline the actions we are taking to strengthen our systems and prevent similar incidents.
The PFD report acknowledges that at the time of the inquest hearing the Trust had made progress in addressing some of the concerns identified in its internal Board Level Panel Inquiry (BLPI) investigation report, however some additional matters emerged as a result of the inquest process. The matters of concern raised in the report are summarised as follows.
Record Keeping / Professional Standards There was evidence that staff on Topaz Ward would sometimes use the ID card of another member of staff to make notes on the electronic records system, without making it clear who the entry was made by. In this case, there were two entries that appeared to have been made by a support worker, that were made by a nurse. Misleading and inaccurate record keeping can create confusion and significantly risks the continuity of care.
2
Lack of Professional Curiosity / Therapeutic Engagement – Audits The Trust’s BLPI included actions where improvement was to be measured by carrying out audits. However, the Ward Manager gave evidence that there had been issues with audits in the past, which remained unaddressed.
In addition, it was evident during the inquest that staff struggled with the concept of ‘therapeutic engagement’, with some maintaining that Ms Crane had received a sufficient level of therapeutic engagement from Ward staff, contrary to the findings of the Trust’s BLPI and the subsequent findings of the jury.
Step down / discharge from PICU to acute ward There was evidence that the Trust’s systems were unable to accommodate Ms Crane’s needs during her transition from an intensive to an acute care setting.
Therapeutic Engagement / Professional Curiosity – Generally Ms Crane had become withdrawn from around 12 September 2024 onwards. Many of the Trust’s witnesses denied this, despite evidence to the contrary. There appears to have been a general inability among staff to exercise professional curiosity.
Observations on Topaz Ward The Trust’s BLPI identified issues in relation to required observation levels. This was compounded by evidence at the inquest, that the support worker conducting the 11:30 check on 19 September did not see any part of Ms Crane, and on trying to open the door noted there was some resistance but nevertheless assumed she was sat with her back to the door. There were concerns about staff training in what is required when carrying out observations.
Communication and Culture The Trust’s BLPI recognises there were issues with documentation and record keeping, which is a key tool for communication. However, the evidence heard revealed a more general lack of communication between staff at all levels and leadership. The substantive consultant psychiatrist for Topaz Ward said that they would not change the care provided. This raised concerns that the senior clinician for the Ward does not accept or appreciate the issues identified by the Trust.
Trust Action Plan Insofar that aspects of the BLPI action plan were outstanding and / or awaiting Board level approval at the time of the inquest hearing, concern remained regarding the extent of implementation.
Action taken
To provide some context, it is noted that Ms Crane’s 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
3
(NLFT). Topaz ward is on the Highgate site and sits within the Hospital Division of the organisation.
In response to significant operational and clinical concerns, including the sad death of Ms Crane, the Hospital Division of the NLFT was formally placed under Enhanced Mandated Support (EMS) on 13/12/2024. EMS was initiated to address immediate safety risks, improve service delivery, and embed sustainable quality improvements. EMS is an internal executive led support structure with weekly reporting to support immediate and rapid improvement.
The EMS programme was designed to be a structured, tiered intervention aimed at stabilising services, improving patient safety, and fostering a culture of accountability and continuous improvement. EMS was structured around a three-tiered model:
• Tier 1: Immediate safety actions (6-week plan)
• Tier 2: Medium-term improvements (4 weeks–3 months)
• Tier 3: Long-term sustainability (3+ months)
Tier 1 focused on immediate safety actions, including staffing enhancements, physical health monitoring, and ward observations. Tier 2 addressed medium-term improvements such as leadership development, environmental upgrades, and workforce training. Tier 3 aimed at long-term sustainability through cultural transformation, integration of closed culture review findings, and systemic change. Each tier was governed by a clear set of objectives, timelines, and accountability mechanisms, with regular oversight from executive leadership. The transition from Tier 1 to Tier 3 was guided by performance metrics, executive feedback and risk assessments. The EMS programme was completed in July 2025 and has now been stepped down to ongoing Mandated Support.
Key Achievements Several significant milestones were achieved during the EMS period including the below:
Milestone Description 6-Week Safety Plan Successfully implemented, addressing critical safety concerns; enhanced staffing, environmental upgrades, strengthened physical health monitoring
Confidence to Care Plan (C2CP) Launched, introducing SMILE framework to empower staff with confidence to search, make it safe, intervene, lead, and escalate
Closed Culture Review Review completed by externally commissioned investigator in April 2025
4
and subsequently approved, identifying areas for improvement and informing Tier 3 planning
Training Initiatives PMVA, ILS, and BLS expanded; peer-led learning and reflective practice sessions introduced
Environmental Improvements CCTV upgrades, Wi-Fi enhancements initiated to support safer and more efficient care delivery
Service User Feedback Positive feedback on ward activities, safety, and responsiveness
Staffing Improvements Addressed shortages, improved shift coordination, launched safer staffing reviews
Ward Environment Improvements with temperature control, ward aesthetics, ISS responsiveness
Datix and Observation Model Improved Datix usage, introduced Perfect Day model, Enhanced observation model review and policy changes.
Below, we explain the actions taken and ongoing to address each matter of concern, ensuring that all measures directly contribute to improving patient safety and care. Please note that whilst this response has retained the structure of the concerns as set out in the PFD report, the issues are interlinked and there will be information under some headings which is also relevant to others and not necessarily repeated.
Record Keeping / Professional Standards The Trust recognises the vital importance of accurate record keeping in supporting safe patient care. It is acknowledged that access to Smart Cards to support the use of Rio (the Trust’s Electronic Patient Record system) has been an issue, particularly for staff working via our bank staff provider NHS Professionals (NHSP). As part of the EMS program, this was investigated and processes streamlined so that all existing and new staff are now able to apply for a Smart Card and complete RIO training. Going forward, in order to be booked onto a bank shift, NHSP staff must have a Smart Card. As a result, all staff (substantive and NHSP) can now make their own records on the RIO System thereby reducing any reliance on using other colleagues’ accounts. Ward managers are expected to complete a daily review of staff attending their wards to check access and ability to record accurately.
5
In addition, staff have been reminded of their GDPR obligations which are covered in the Trust’s Information Governance mandatory training and that Smart Cards allowing access to Trust information systems should not be shared. Where exceptionally this cannot be avoided, the entry must clearly state who the entry is actually being made by in order to avoid any confusion.
Lack of Professional Curiosity / Therapeutic Engagement – Audits
Following the inquest, the staff team on Topaz ward have been supported to further reflect on the care provided to Ms Crane, in particular in regard to the findings around lack of professional curiosity and therapeutic engagement. We are satisfied that there is understanding amongst staff about what this is, but it is recognised that there have been barriers to implementing it effectively. Factors involved include staffing levels and skill mix, lack of time due to number of tasks staff are responsible for and standards of clinical documentation. One of the overarching aims of the ongoing improvements is to support staff so that they have time to ensure that every individual’s clinical needs are met. As part of the on-going mandated support program, the Division has initiated several actions to address this:
Staffing
1) A Safe Staffing skill mix review was completed by the Nursing Directorate and approved by the Executive Management Committee to upgrade the staffing model of all acute inpatient wards within the Hospital Division. This means that an additional 24 Registered Nurses will be recruited by October 2025 to initiate the new staffing ratio of 3 Nurses and 2 Health care support workers on day shift (previously 2 nurses and 3 Health care support workers). The increased number of qualified clinical staff will support with dedicated quality time to engage in therapeutic engagement time on the wards. We have also reviewed the input from other allied health professionals (Occupational Therapists, Activity Coordinators and ward Psychologists) to improve engagement via a range of professionals on the inpatient wards. In addition, a discharge facilitation team has been introduced which works with all our inpatient wards to support with some of the practical and administrative tasks around discharge planning which were previously being undertaken by nursing staff, with subsequent impact on time available to provide care. Current feedback is that this team is having a significant positive impact on capacity.
2) The new discharge facilitation team comprises of:
a. 8 full time ’network navigators’ – band 4 workers embedded in the ward MDTs (one on each acute ward), supporting with early identification of barriers to discharge and ensuring resolution of issues raised and links to community teams
b. 2 full time discharge coordinators – band 6, one for male wards one for female, full time, working on flow and creating capacity
c. 1 full time band 7 team manager
3) Realigning matrons to quality and safety work:
6
a. Matron line management has been moved from operational service managers to the Associate Director of Nursing to re-establish their role as one of quality and standards.
b. Operational work (flow, bed creation, discharges) has been taken away from the matrons in order to prioritise the quality and safety work.
The significant staffing changes and realignments outlined above are specifically designed to release time to care for our clinical staff. By creating the discharge facilitation team, realigning matrons and increasing the qualified ratio of staff on the ward, we increase the capacity to deliver the care we employed our staff to do and that they were trained for. It takes away significant amounts of non-clinical activity which was keeping them behind a computer screen or off the ward.
Standardising ward timetables
4) It is also acknowledged that some of the therapeutic engagement with patients/ actions which would evidence professional curiosity were not being captured within our clinical documentation. To support improvement, the Division has rolled out the ‘Perfect Day’ model which essentially standardises the inpatient ward day timetable across all our wards. The Perfect Day model provides a timetable for the day which is predictable and understandable by all staff, patients and visitors. It also provides a standardised digital template for handovers that is completed daily and uploaded to the electronic patient record (EPR) system every day before 11am evidencing key information such as risk, barriers to discharge etc. This has been implemented via Quality Improvement methodology with ideas for improvement including use of a standardised template to record MDT discussions, RiO notes being open and visible to all attendees and documentation of how MDT decisions around observation levels are made having positively yielded results. These are now part of business as usual for all wards in the Hospital division.
Audit is considered a vital tool in monitoring and providing assurance that the Perfect Day model improvements around documentation are being implemented consistently. The role out of the model was initially supported by a band 8c Director of Operations working in the division and auditing the results. This has now been handed over to the newly formed discharge facilitation team to continue with the audits.
5) The audits include a 10-point checklist of the handover documentation fidelity to model with max score 400 points. As of end August 2025 average audit weekly score across the division was c.300.
6) Monitoring of the impact of the model is via adherence to a number of factors:
a. Ward discharges being facilitated before 1 pm so that bed availability is identified early and admissions happen in working hours which is safer and increases therapeutic opportunity
b. Formulation meetings happening within 72 hours of admission and attendance of, for example care coordinators, relatives, trusted others.
7
Step down / discharge from PICU to acute ward Bed capacity remains challenging with there being a very high level of demand for beds across the area the Trust serves. This means that there are frequently long waits, both for people to be initially admitted to a bed (for example, from A&E) and for step down from PICU to the acute wards. Realistically, this is not likely to change in the near future and it means that we are not able to plan step down in the way that we might ideally wish to. However, all the other areas of work set out in this response that are ongoing to release time to care and make patients safer are expected to impact positively on this process and improve the experience for patients. There will be increased time to spend with patients when they are first admitted; to ensure that every individual’s needs are incorporated into their care plan so they can be effectively supported through this period of transition. Additionally, we are in the early stages of a further conversation about this with a workshop recently commenced on the women’s PICU ward. In November the Trust is moving to a new structure with the current divisions to be replaced by care groups, bringing all inpatient wards for adults of working age across the organisation under the same management structure. This will support us to make best use of all our available beds across the entire Trust.
Therapeutic Engagement / Professional Curiosity – Generally This concern is addressed earlier in this response where it is explained what is being done to ensure that staff have time to care and engage therapeutically with patients by addressing staffing issues and reducing non-clinical responsibilities. This is supported by the other aspects of the programme which focus on improving clinical documentation, communication within the team and the culture of care.
Observations on Topaz Ward We recognise that observations are an area that have presented challenges for the organisation but we are committed to getting this right; observations are central to ensuring patient safety on our wards. There is also a need for consideration of patients’ privacy and dignity and to ensure that they are conducted in a way which is not unnecessarily intrusive. Following a review of observations as part of the EMS and learning from the BLPI, a new template has been piloted on three wards. This specifically prompts staff undertaking observations to check for and record Signs of Life. Staff are expected to enter the patient’s room and check their level of alertness/breathing where this is not immediately apparent, for example, by looking for chest movement when a patient is sleeping. This template has now been rolled out to all inpatient wards in the Hospital Division and is included in the new NLFT Supportive Observation and Engagement policy.
Use of bank staff presents a challenge as they may not receive the same training as substantive staff. We are addressing this through the recruitment referred to earlier which will reduce our reliance on bank staff, and where we do use bank staff, wherever possible these will be from a regular pool of staff who are trained on Trust policies and procedures. We are also ensuring all staff working a bank shift receive an induction to the ward which includes how to carry out observations.
Following implementation of the new template, we have observed increased accountability on the part of staff undertaking observations and clearer documentation.
8
Observation sheets are now monitored daily by the Nurse in Charge, Ward Manager, Matron, and out of hours via the Senior Site Coordinators. In addition, the Division has initiated a weekly CCTV and documentation review and reconciling these. This is undertaken by the Ward Managers and Matrons to ensure that documentation is accurate and up to date. We have also increased visibility of Nurse Leaders (Ward Managers, Matrons and members of the Senior Leadership Team) to support this work. As of August, the role of the Matrons has changed so that they are now focussed on clinical, rather than operational duties, with an emphasis on improving nursing standards and the quality of care.
Communication and Culture
Between November 2024 and January 2025 the Trust delivered 15 full away days for the wards on the Highgate campus. These away days used the new NHS ‘Culture of Care’1 standards as their focus and included all the ward multidisciplinary teams and senior management. Discussions around the importance of therapeutic engagement and professional curiosity were central to these sessions, focusing on identifying barriers and implementing strategies for improvement. They were facilitated by Organisational Development colleagues who compiled reports on the learning from the away days about the different cultures on our wards and reported back to the senior leadership group to support each individual ward with developing their approach to patient care. A set of overarching recommendations was also made and these are currently being progressed as part of the ongoing programme of work. In addition, Topaz ward specifically engaged in an additional Quality Improvement programme of working on ‘Improving Therapeutic Engagement on the ward’. Although this is still in its initial stages, it will be progressed with the wider programme of work being undertaken by the division. Trust Action Plan
The actions allocated to the Division, and those that form part of the Trust’s improvement plans, are underway and/or completed. A copy of the action plan with progress updates is enclosed with this response.
We sincerely hope that the information provided above about this whole scale review of safety and culture of care across the Highgate Campus demonstrates how seriously we take the issues that have been raised by the PFD report.
We will continue to monitor the impact of all the changes noted above through the following mechanisms:
1) Monitoring of incidents reported within the organisation, to ensure a continued reduction in the number of patient safety incidents occurring on our wards
2) Monitoring and acting on patient and carer feedback received via all relevant processes including
1 NHS England » Culture of care standards for mental health inpatient services
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a. Text messages feedback system - all discharged patients receive a text message with a link to a survey to complete feedback on their inpatient stay
b. Community meetings, Patient and Family complaints and compliments.
3) Pulse staff surveys.
4) Ongoing review of all actions at the Mandated Support meetings that are chaired by executives and report to the Executive Management Committee (EMC)
If you require any further information, please do not hesitate to contact me.