George Fraser
23 May 2025 · Coroner Nadia Persaud · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of documented care plan
“There was no clear and documented care plan in place whilst Mr [name redacted] was under the care of the Mental Health and Wellness Team”
2. lack of robust risk assessment
“There was no robust risk assessment carried out by the Mental Health and Wellness team”
3. lack of response to missing person concern
“The Mental Health and Wellness Team had been unable to reach Mr [name redacted] from the 16 July 2024. On the 18 July 2024 a friend contacted the mental health team to raise concern about his lack of contact with Mr [name redacted]. No action was taken at this time to review the risk of harm to Mr [name redacted] or to determine whether the Trust's missing person procedure should be activated. There was no meaningful contact with the family to report the concerning lack of contact with Mr [name redacted], until the 29 July 2024”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“significant omissions that included an incomplete risk assessment in February 2022 for Mr [name redacted] following his transfer following crisis intervention with the Home Treat Team”
This report
“There was no robust risk assessment carried out by the Mental Health and Wellness team.”
Responses
2025-0247-Response-from-North-East-London-Foundation-Trust.pdf ↗· North East London Foundation Trust
Stated action · 2025
“and carers. The Mental Health and Wellness team are now using the DIALOG tool in working with patients who are presenting to services. This is a quality of life and outcome measure that is completed by service users, allowing them to focus care planning work on the most important areas of their life to them across a number of domains, including mental and physical health, relationships, and accommodation. Staff use the DIALOG questionnaire to understand what matters most to the service user and this”