Lack of suicide risk assessment after discharge

“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.”

“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.”

“Between 20 November 2021 - 28 November 2021, the CCG conducted a 'mystery shopping' audit of the Crisis line to measure responsiveness to calls. 70% of calls were answered in one minute or less, with 20% less than two minutes.”

“From January 2022, a larger Trust-wide Crisis Line call quality audit will take place. The audit tool has already been devised.”

“The City and Hackney Crisis Line Operational Policy has been updated to include a section on how call handlers should deal with concerned relatives and family members. This will be ratified on 17th December at the ELFT London Crisis Strategy Group and the updated content will be discussed with staff members at their team business meeting on 6 January 2022.”

“medical records training for all senior nurses was provided on 24 November 2021 to all senior nurses and managers at the Trust. The focus of the training was good record keeping, observations and retrospective record keeping.”