David Chatburn

From the Rt Hon Jeremy Hunt MP
Secretary of State for Health

Department
of Health Richmond House
79 Whitehall
London
POCI_851047 aS SIA 2NS
we Tel: 020 7210 3000
Mrs L Hashmi . Mb-sofs@dh.gsi.gov.uk
Assistant Coroner “
HM Coroner’s Court
The Phoenix Centre
Church Street
Heywood OL10 ILR 4? MAY 2Ois
Ber her. Jules,

Thank you for your letter following the inquest into the death of David Chatburn. I
was sorry to read of the events that led to Mr Chatburn’s death and wish to extend
my sincere sympathies to his family.

I understand that Mr Chatburn had a long history of mental health problems,
including depression and drinking alcohol to excess and had probably been
suffering from bi-polar disorder for some time. It was not until December 2012 that
he agreed to consider medical treatment for this condition and his General
Practitioner then prescribed the drug Lamotrigine which he believed was favoured.
by the local community psychiatrists.

Mr Chatburn was not seen or assessed by a Consultant Psychiatrist and his GP
continued solely to treat and manage his therapy, although it appeared that follow-
up appointments were generally informal and opportunistic rather than pro-active.

Mr Chatburn’s mental health continued to fluctuate and, on 18th October 2013, a
dog-walker discovered him hanged from a tree.

You raise the following concerns:

© there was no referral made by the GP to the Psychiatric services for an
expert diagnosis/opinion/management and treatment plan. The GP
considered that there was no need, as he felt clinically competent to
manage the deceased's care and in any event, had a special interest in
mental health, although he conceded that he was not formally recognised
as a GP with a Special Interest (‘GPwSpi’) and whilst confident in his
ability to manage the deceased's care, his area of special interest was in
fact the management of addictions.
Irrespective, he felt that he was best placed to assess, diagnose and treat

the deceased on the basis that had he referred Mr Chatburn to the single
point of entry system, the person ‘triaging”’ would not have been

medically qualified and would not have known the deceased as well as he
felt he did.

the GP did not consider the appropriateness of the medication prescribed,
particularly in light of the patient’s past mental health history - preferring
to rely upon the presumed, anecdotal preferences of the community
psychiatrists.

the GP was unable to refer the deceased, as a new patient, directly to the
in-house community based psychiatrist, thus effectively defeating the
object.

the GP felt it was sufficient for him to simply discuss the deceased's care
with the practice-based community psychiatrist and thus, no need for a
referral to the single point of entry process. Such discussions were not
necessarily case specific in any event but rather, general in nature.

the GP’s recollection of events was not supported by contemporaneous
record keeping, thus calling into question accuracy.

the GP did not use a recognised assessment tool, as an adjunct or
otherwise, in his clinical evaluation of the deceased. He felt that they were
ineffective and of little, if any, value.

the processes GPs are expected to use in order to access mental health
services for their patients are unnecessarily bureaucratic and deterrent.
GPs can no longer simply contact a Consultant Psychiatrist directly for
advice. Everything must pass through the single point of entry.

the ‘triage’ process used by the single point of entry system is not always
managed by a medically qualified practitioner — this being a vital stage
in determining diversion/allocation.

GPs cannot refer patients outside their Clinical Commissioning Group
area without special permission/approval by the same. In order to do so, a
‘special case’ must be argued. This potentially limits patient (and
practitioner) accessibility and treatment.

The Department of Health is supporting local organisations in taking effective
action to improve mental health. The Department’s mental health strategy and
implementation framework, and suicide prevention strategy (Preventing Suicide in
England), focus on specific actions which local organisations can take to improve

Department
of Health

mental health across the life course in their areas. In addition, “Closing the Gap:
priorities for essential change in mental health” (launched in January 2014) sets out
the Department’s priorities for action and progress over the next couple of years.

Mental health and well-being is a priority for this Government and we are investing
over £400m to give thousands of people, in all areas of the country, access to
improved psychological therapies. Public Health England is also making mental
health one of its five health impact priorities as part of work to improve the public’s
health. Their priorities for 2013/14 include a commitment to develop a national
programme on mental health in public health that supports, “No Health Without
Mental Health” (a cross-government outcomes strategy). This means prioritising the
promotion of mental wellbeing, the prevention of mental health problems and
suicide, and improving the wellbeing of those living with and recovering from
mental illness.

Many of the issues you raise concern the decisions and actions taken by the GP who
diagnosed and treated Mr Chatburn. I note that you have sent your report to the
Pennine Care NHS Trust and the York House Surgery and J would expect them to
properly address these concerns.

My officials have consulted NHS England, as the main commissioner of primary
care services, about your report. NHS England has advised that the GP’s clinical
behaviour will be discussed at their next Performers Screening Group (PSG). The
PSG will then determine if any specific actions need to be taken.

In addition, the General Medical Council (GMC), which is independent of
government, is the body responsible for setting good medical standards for doctors.
If there is concern about the GP’s fitness to practise, this should be raised directly
with the GMC.

Your remaining concerns relate to the current system for accessing mental health
services in primary care. I am aware that a number of other inquests in the past have
similarly focussed on the issue of a lack of clearly defined pathways for referral by
GPs into mental health environments. The way in which these services are accessed
is decided locally by the relevant NHS Trust. Thus your concerns surrounding the
single point of entry, triage system and the evident bureaucracy are also more
appropriately dealt with by the Clinical Commissioning Group (CCG) and Pennine
Care Foundation Trust (FT). lam aware that the CCG is preparing its response in
conjunction with eee Director for the Greater

Manchester Area Team) and Pennine Care.

You raise a concern that GPs were unable to refer patients outside their Clinical
Commissioning Group area without special permission/approval by the CCG and
that this potentially limits patient (and practitioner) accessibility and treatment. I
can advise that this is no longer the case. From 1 April 2014 patients with a mental
health condition have had the same legal rights as physical health patients at first
outpatient appointment to choose the provider that will deliver their care. The GP,
or other referring healthcare professional, remains responsible for determining the
clinically appropriate treatment to meet patients’ needs.

Where the service or treatment is routinely commissioned by the patient’s CCG,
patients may choose any clinically appropriate provider in England, as long as the
provider has a contract with any NHS commissioner in England for that service.
When the service is not routinely commissioned by the CCG, patients may apply to
their CCG’s Independent Funding Review Panel for a preferred referral to be
considered for approval. Patients should discuss their options with their GP.

However, a number of exemptions to the legal right to choice of provider, at first
outpatient appointment, remain. These will be set out in guidance that NHS England
is about to consult on, entitled “Interim Guidance: Implementing patients’ right to
choose any clinically appropriate provider of mental health services.” This
guidance will help commissioners, GPs and providers implement the new legal right
to choice.

T hope that this response is helpful and I am grateful to you for bringing the
circumstances of Mr Chatburn’s death to my attention.

JEREMY HUNT