Philip Dean

South West London and St George's INHS|

Mental Health NHS Trust

Medical Director

South West London and St Georges
Mental Health NHS Trust
Springfield University Hospital

61 Glenburnie Road

London SW17 7DJ

Direct =
11™ June 2014
Private and Confidential 4

Dr Fiona Wilcox .
HM Senior Coroner a \e yo i) 4
Inner West London t ; fi J ”
Westminster Coroner’s Court Va P
65 Horseferry Road y f
London

SW1P 2ED

Dear Dr Wilcox,

| am writing in response to the Regulation 28 Report to Prevent Future Deaths
and the concerns you raised following the inquest into the death of Mr Philip
Anthony Dean. | Head of Nursing for Community Services,
Consultant Psychiatrist and Wandsworth Clinical Director, Ii
ssociate Director for Psychology and Psychotherapies and Clinical
Lead for Wandsworth Psychological Therapies and Wellbeing Service (IAPT) and

, Serious Incident Lead Investigator have contributed to the
response to the six matters of concern in the order raised for ease of reference as
follows:

1. That the Home Treatment Team (HTT) is not sufficiently funded to
allow continuity of care and named designated workers.

The Trust is committed to ensuring continuity of care for service users and
although it is not within the Trust's current Operational Policy for HTT’s to
work with designated workers the policy does state that service users
accepted for home treatment, who have been newly referred or re-referred
to Mental Health Services and so do not have an existing Care
Coordinator, will be temporarily care coordinated within the team, in the
context of a whole team approach.

Trust Headquarters, Springfield University Hospital, 61 Glenburnie Road, London SW17 7DJ
Tel: 020 3513 5000 www.swistg-tr.nhs.uk

Ih partnership with,

Integrated health and social care for local people with mental health problems —
in Kingston, Merton, Richmond, Sutton and Wandsworth ‘
and more specialist mental health services for people throughout the UK

“St Georges

University of London:

The Mental Health Implementation Guide suggests that HTT’s should
provide a designated named worker, responsible for coordinating service
users care, providing continuity of care, ensuring effective communication
within the team and acting as a contact point for both service users and
Carers. Although there are a number of practical issues that currently
impact on the HTT’s ability to operate a system of designated workers a
pilot will be commenced, taking the learning from other HTT’s nationally,
and reviewed in six months.

The average length of stay for a service user in HTT is 2 to 3 weeks and a
maximum stay of 6 weeks. Staff working in HTT’s work shift patterns. The
designated worker and service users ability to have contact would be
dependent on the worker being allocated to a shift and day on which the
service user is due to be visited. This would mean constantly making
changes to the roster to facilitate contact, changing the service users visit
time and or days (which are often down to preference), setting minimum
number of designated worker visits a week or a mixture of all three options.

However, the Wandsworth HTT has implemented robust processes to aid
continuity of care for service users. There are twice daily handovers for
staff coming on duty. During the morning handover all service users who
are due a visit in the morning, any patients that are on alternate morning
visits who are not due to be seen that day and any issues which have
arisen since handover from the previous days afternoon shift or night are
discussed in detail. During afternoon handover those service users due a
visit in the afternoon and service users on alternate day afternoon visits
that are not due to be visited that afternoon shift are discussed. The
morning shift then handover their visits and make any changes to that
afternoon's visit list. This allows each shift access to pertinent information
about the service user and reduces the likelihood of information being
missed. A zoning system also operates which gives an overall indication of
the service users risk and need.

In terms of funding the HTT has been identified as being under resourced
based on the expected number of contacts for the teams caseload and the
number of crisis episodes which are expected to be completed per month.
A Trust wide Acute Care Pathway Project, undertaken in March 2014
identified that Wandsworth HTT was under established by 3 Whole Time
Equivalent (WTE) of nursing staff. Furthermore, the project identified that
Wandsworth HTT took over the management of the Trust’s Crisis line in
approximately 2009 without additional resource being provided equating to
2 additional WTE of nursing staff required. Medical staffing in HTT was not
identified as a concern. Nurse understaffing has led to a slight dependence
on agency staff in order to cover increases in workload which may have
caused some problems with continuity of care and the ability to provide
designated workers however HTT has now been allocated £214,000
investment as a result of the Acute Care Pathway Project which will be
used to fund the posts required and will increase the nursing establishment
to the appropriate level. This will assist considerably in the pilot to
introduce designated workers. Recruitment has already begun to the new

South West London and St. George’s Mental Health NHS Trust

3. That liaison psychiatry does not record pertinent information such as
GP recommends section, this denying those coming after the benefit
of the GP’s professional opinion

It is expected that the Liaison Psychiatry team do record pertinent
information in the electronic patient record and that all documentation from
referrers is uploaded and available on this system. It is expected that staff
read all relevant documentation when making an assessment. It is with
regret that the information from the GP was not passed on appropriately,
however risk is a factor that shifts and changes and each assessment will
include a new and up to date risk evaluation, based upon the person’s
current situation. As a result of the assessment made, an appropriate
decision was taken to admit Mr Dean. As risk can change very rapidly, it is
possible that the mental health assessor may come to a different
conclusion to that recommended by the GP.

4. That such an extremely psychiatrically unwell patient does not have
the benefit of assessment from a health care professional qualified to
make recommendations for section at first instance, despite explicit
referral for the same from the doctor who knows him best

It has not been possible to identify any Accident and Emergency
Department which runs a psychiatry service that has 24 hour 7 day a week
presence of Section 12 approved doctors, and none where the Section 12
doctor would always do the assessment at first instance, unless the patient
were being assessed in a police cell. Therefore it appears that Mr Dean
received the most appropriate assessment available and this is
comparable to other psychiatric services available elsewhere. The staff in
Liaison Psychiatry are very experienced in carrying out mental health
assessments and receive extensive training and ongoing supervision.

5. That secondary care services, both the HTT and Liaison Psychiatry,
appear to be under-resourced especially in terms of medically
qualified personnel and that this apparent under resource impacts on
the ability of these services to make accurate assessments of
patients

The Liaison Psychiatry service is under-resourced compared to national
guidance on staffing levels. In this regard, so are the majority of Liaison
Psychiatry departments, and the under-resourcing is a matter primarily for
the Trust's commissioners, rather than a problem of resource allocation
within the Trust. The Trust do have fewer Consultants than most London
teaching hospital Liaison Psychiatry departments however the implication
that only medically qualified staff can make accurate assessments is not
accepted. An experienced and competent Band 7 nurse will do a much
more robust assessment than a doctor who has been training in psychiatry
for a few years and their assessments will be on a par with a senior
doctor’s. An example of this was demonstrated last year when a Trust
Consultant Psychiatrist provided a Coroner with data which showed a low

South West London and St. George’s Mental Health NHS Trust

rate of suicide in patients who were assessed and discharged home by St
George’s Liaison Psychiatry team, based on Trust data collection.

6. That the SI report missed all matters in issue in this case

As part of the Serious Incident Reporting process, the Trust identifies the
level of investigation that is required for each individual serious incident. A
concise investigation is led by one of the Patient Experience Leads from
the Quality Governance Department, supported by the Serious Incident
Lead Investigator or another experienced clinician. The concise
investigation reviews the medical records, makes contact with the
family/relatives, liaises with the service or teams involved, reviews policy
and identifies learning.

An internal comprehensive investigation comprises a small panel of
clinicians led by the Serious Incident Lead Investigator. This is a more
detailed and comprehensive investigation covering all of the aspects of the
concise approach plus specific terms of reference for the incident,
meetings with family/relatives, interviews with teams and_ individual
practitioners (including GPs), benchmarking and access to expert opinion
in a particular field as required. A comprehensive investigation with an
External Chair is initiated following an inpatient death; abscond of a patient
from a secure ward; a homicide involving a patient in receipt of services;
any Never Event.

Having reviewed this investigation and the points raised at Inquest, the
Trust has identified that this incident would have benefited from a
comprehensive rather than a concise investigation. The GP would have
been invited to contribute to the Trust investigation and provide an external
context and further key lines of inquiry. This would have provided
information about the GP concerns and these would have been explored in
detail.

As a Trust we have learnt from this and as a result of a review of our serious
incident procedures, initial findings from concise investigations are reviewed after
ten working days so that the level of complexity can be considered and the case
escalated to the level of a comprehensive investigation if necessary. All
comprehensive investigations are led by an experienced clinician, quality assured
by the Serious Incident Lead Investigator, signed off by a Board member and
agreed with the Clinical Commissioning Groups. The Trust has commissioned
externally led training workshops to develop knowledge, skills and quality
assurance processes for investigations and report writing.

Root Cause Analysis investigations may identify issues that are concerning but
are deemed not to have a direct bearing on the outcome and are not identified as
a contributory factor to the incident itself. The concerns identified and highlighted
from this Inquest will contribute directly to Trust learning and development with
regards to contributions from family and relatives, external agencies and the
quality of investigations, report writing and action plans.

South West London and St. George’s Mental Health NHS Trust

In closing, | hope this letter has addressed the concerns you raised. If you would

like to discuss any aspect of this letter by telephone, then please do not hesitate
to contact me, a

Yours sincerely,

|

Medical Director

South West London and St. George’s Mental Health NHS Trust