North East London NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust has agreed to take actions to address concerns raised, detailed within an attached action plan. (AI summary)
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Dear Madam
Re: Inquest touching upon the death of Evelina Vilkiene
I refer to your letter dated 6 March 2023 and the Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.
At the conclusion of the hearing into the death of Evelina Vilkiene, you expressed the following concerns in respect of the care provided by NELFT:
1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.
2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews. This was in contravention of the general requirement for amber zoned patients to be seen at least weekly.
We have carefully considered the Regulation 28 report and agreed to take actions to address concerns raised by you. We have detailed the actions which we will take, within the attached action plan, for your kind consideration.
I would like to take this opportunity to thank you for raising your concerns as part of this inquest. We find learning from inquests extremely valuable and are very grateful for your comprehensive investigation, which benefits not only the families of the deceased, but also the Trust and its service users.
I trust that the above and the attached action plan reassure you that the Trust has taken this tragic death very seriously indeed, and that it reflects our commitment to improve care quality and patient safety.
If I can further assist, please do contact my office on
Re: Inquest touching upon the death of Evelina Vilkiene
I refer to your letter dated 6 March 2023 and the Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.
At the conclusion of the hearing into the death of Evelina Vilkiene, you expressed the following concerns in respect of the care provided by NELFT:
1. When Evelina was stepped down from the Home Treatment Team to the Early Intervention Psychosis Team, there was no detailed risk assessment or jointly agreed risk management plan.
2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe.
3. Following the medical review on the 26th May 2022 there were no further care co-ordinator reviews. This was in contravention of the general requirement for amber zoned patients to be seen at least weekly.
We have carefully considered the Regulation 28 report and agreed to take actions to address concerns raised by you. We have detailed the actions which we will take, within the attached action plan, for your kind consideration.
I would like to take this opportunity to thank you for raising your concerns as part of this inquest. We find learning from inquests extremely valuable and are very grateful for your comprehensive investigation, which benefits not only the families of the deceased, but also the Trust and its service users.
I trust that the above and the attached action plan reassure you that the Trust has taken this tragic death very seriously indeed, and that it reflects our commitment to improve care quality and patient safety.
If I can further assist, please do contact my office on