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recurance

Missing hot debrief documentation after incident

Identical hazardConfidence 0.90 · high2 reports · 2021–2023 One-page brief (print or PDF)

East London NHS Foundation Trust received 2 coroners' reports about this hazard between 20 Oct 2021 and 25 Jan 2023.

They came from 1 coroner. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 6 specific actions.

2
reports
1
coroner
2021–2023
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Freeda Glausiusz↗

    20 Oct 2021 · Mary Hassell · Inner North London

    “I never received a copy of the 48 hour hot de-brief.”
    Original on judiciary.uk ↗

    East London NHS Foundation Trust responded, stating 6 specific actions.Response (PDF) ↗

    “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.”

    Stated timescale: May 2020

    “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.”

    Stated timescale: July 2021

    4 more stated actions in the Promises tab.

  2. 1 year 3 months later

    Raised again · 1st time

    Andrew Largin↗

    25 Jan 2023 · Mary Hassell · Inner North London

    Identical hazardConfidence 0.90 · high
    “However, no notes were made of that and no entry was made on Mr [name redacted] medical record”
    Original on judiciary.uk ↗

    East London NHS Foundation Trust responded.Response (PDF) ↗

  3. All reports to East London NHS Foundation Trust

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error