Freeda Glausiusz
20 Oct 2021 · Coroner Mary Hassell · Inner North London
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of seriousness in crisis line calls
“I was shocked when I listened to the recording of the call that [REDACTED] made to the crisis line the day before his daughter died.”
2. failure to assess and respond to risk
“The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation; did not listen to [REDACTED] ; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis.”
3. repeated failure to act on prior concerns
“This is not the first time that I have made a PFD report to ELFT about its crisis line.”
4. delayed provision of internal investigation documents
“I received a copy of the SI report the day before the inquest.”
5. absence of timely debrief after incident
“I never received a copy of the 48 hour hot de-brief.”
6. unreasonable delay in providing witness statements
“My officer first requested witness statements and a copy of any internal investigation on 7 June, over four months ago, and asked for the statements to be provided by 20 August.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The Crisis Line call taker read his medical notes and so knew this history, but nevertheless did not ask him if he was now feeling suicidal.”
This report
“the clinician did not elicit clear risks during the conversation; did not listen to [REDACTED] ; talked over him; did not appear empathic; and dismissed his distress about his daughter,”
Identical hazardConfidence 0.90 · high
This report
“I never received a copy of the 48 hour hot de-brief.”
Later report
“However, no notes were made of that and no entry was made on Mr [name redacted] medical record”
Responses
2023-0199-Response-from-East-London-NHS-Foundation-Trust.pdf ↗· East London NHS Foundation Trust
Stated action · May 2020
“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 action · July 2021
“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 action · 20 November 2021 - 28 November 2021
“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.”
Stated action · January 2022
“From January 2022, a larger Trust-wide Crisis Line call quality audit will take place. The audit tool has already been devised.”
Stated action · 17 December
“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.”
Stated action · 24 November 2021
“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.”