Gary Richards

South London and Maudsley INHS|

NHS Foundation Trust
Chief Executive’s Office

1* Floor, Administration Building
The Maudsley Hospital
Denmark Hill

London

SE5 8AZ

Fax:
Private and Confidential

Dr Andrew Harris

HM Senior Coroner
London Inner South
Southwark Coroner's Court
1 Tennis Street

Southwark SE1 1YD

4" July 2014
Dear Dr Harris,

Re: Mr Gary Richards, aged 39, died 16 October 2012,
Case ref: 2515-12

| am writing in response to the Regulation 28 Report to Prevent Future Deaths
dated 9 May 2014, which you sent following the Inquest into the tragic death
of Mr Richards.

In the report you raised three main matters of concern. | have set these out
again below, each followed by my response and details of actions taken by
the Trust, where appropriate.

1) Psychiatric staff did not properly assess his risk of self-harm, nor
communicate his vulnerability to others. At discharge on 10 May 2012
his risk of self-harm was not fully measured. On being seen on
14 June 2012 his risk assessment was not recorded and the risk plan not
sent to his GP. The consultant explained that the risk was not
mitigatable as no mental illness was found. Evidence was heard that his
forensic history indicated that he belonged to a group of patients with 80
times the risk of suicide compared with the general population, yet he
was considered at low risk. The value of performing a proper risk
assessment to demonstrate the risks and vulnerabilities of the patient to
other agencies, such as housing and social services, does not seem to
have been considered, although it was reluctantly conceded by the
consultant to be of value especially as homelessness presented as the
primary problem.

2)

It is correct that there is no formal documentation of risk in the correct
location on the PJS (our electronic patient record system) either at the
point of his presentation under Section 136 or whilst on the Triage Ward.
This was noted by the Trust’s investigators in their report. However, there
is clear evidence in the clinical records that risk was assessed and is
documented in the detailed entries made by the ward medical staff during
his admission. It was acknowledged that there was a risk of suicide but
this was not linked to mental illness but rather the difficult social
circumstances he found himself in, in particular, his homelessness. | am
not aware specifically of any research evidence that suggests that those
with a forensic background have a suicide risk 80 times higher than the
general population but | do acknowledge that the risk is greater in those
who have a mental illness and a forensic background. | do not feel that
this is relevant in Mr Richard’s case as he did not have a mental illness.

| believe that the clinicians involved in Mr Richards’ care were aware of the
impact of his homelessness on his risk of suicide and that their focus on
ensuring that he received the help that he required, by referring him to the
Single Homeless Intervention and Prevention agency (SHIP) was the
correct course of action to follow. This was, in reality, all that they could
do to mitigate the suicide risk.

The Trust's policy on risk assessment is clear in its documentation and
staff have been reminded to ensure that when risk is assessed, that this is
documented in the correct fashion in the relevant section of the electronic
patient record to ensure that this is easily accessible by all clinical staff.

After discharge in May, he was not followed up, as there was no
address and his mobile phone number was not recorded. After
attendance in June, again there was not a mobile phone number
recorded. After attendance in June, again there was a failure to
contact him for follow-up, reported to be due to a phone failure. The
failure to ensure reliable communication pathways for follow up is a
potential risk for vulnerable patients.

On the day of his discharge in May, Mr Richards was very angry and on
being informed of his discharge, he left the ward without waiting to have
any follow-up arrangements confirmed.

A further review of Mr Richards’ records indicates that when he was seen
in the outpatient clinic in June, the service was aware of his mobile phone
number. In fact, he had been called the day before by a social worker at
the community team and asked to attend the outpatient appointment on
14 June as his GP had been concerned that he had again reported
suicidal ideation.

In September, following his presentation at A&E, the team leader at the
community team attempted to ring him to offer a community appointment.

2

3

—

She tried, using the number on file, but it was unobtainable. There was no
other way of making contact with Mr Richards, so she left a message at
the A&E department asking him to make contact with her should he
re-present as he had booked an appointment to see her on 2 October.

The contact details for all patients are confirmed at the point of discharge
and are re-checked periodically. This appears to have happened in

Mr Richards’s case but as he remained homeless, the mobile which he
had given was the only way he could be contacted. He had not taken up
any of the accommodation offers made by SHIP.

| am very sorry that the investigation report which was forwarded to you
had not made this clear.

The Serious Untoward Incident Report (Acute Mental Health
Comprehensive Level Two Report, 10 October 2012) found seven
areas of concern and service delivery problems, including
weaknesses in risk assessment and recognition of suicide plan, lack
of clarity of responsibility for risk assessment, inadequate 7 day
follow up and communications with GP and problems in support as
ho mental illness. A plan was adapted which required review of
clinical pathway focusing on risk assessment, staff induction and a
review of homeless services and interagency working. Despite the
intervening eighteen months, progress on these was not evident and
it was clear that these actions had not been completed.

It is concerning that the investigation revealed that there was a lack of
clarity with regard to who is responsible for completing risk assessments.
The care pathway for the triage ward is very clear that a risk assessment
is conducted on admission. As mentioned above, this did occur but was
not recorded correctly. | am satisfied that these assessments were indeed
carried out, but the issue is that they were not recorded in the correct
location and therefore, not immediately obvious to others viewing the
records. All staff have been reminded that the risk assessment should be
recorded in the correct place.

Conducting 7 day follow up of homeless people can be difficult but | am
satisfied that staff made attempts to contact Mr Richards using the
telephone number he had provided and through leaving messages for him
to contact his community team, should he re-present at the A&E
Department.

All new staff to the Trust are inducted through a central induction
programme. This is supplemented by individual induction programmes in
each ward or team ensuring that staff are fully familiar with the specific
ways of working at a local level. This includes how to assess and
document risk for all patients.

Although Mr Richards did not have a mental illness, staff did acknowledge
his suicidal intent and were aware that this was directly related to his
homelessness. It is clear from his records that there was recurrent
mention of committing suicide by jumping in front of a train. Although this
may not have been noted specifically by the clinical team, his recurrent
mention of suicide was. | do not feel that the method by which he said he
would commit suicide is significant in this particular case. The way of
addressing this was through assisting him in finding accommodation
through SHIP. In order to obtain help through SHIP, he needed to be
officially homeless and could not be considered as such, as long as his
name was on the tenancy of the property he had shared with his wife. He
was advised of how to go about obtaining legal advice to rectify this in
order that he could obtain support from SHIP.

Homelessness features highly amongst the patients that the Trust cares
for. However, | am pleased to inform you that we have been successful in
obtaining funding in the sum of £500,000 from the Guys and St Thomas’
Hospital Charity to pilot a mental health specific homeless project working
with those who present to our services. This will be linked to an existing
scheme which is in place across King’s and St Thomas’ Hospitals for
those who enter our services who are homeless, and where our staff will
have direct access to the expertise in an already established homeless
scheme. | am sure that this will lead to an improvement in the service we
can provide to patients who are in this unfortunate situation.

I note that although Mr Richards’ GP was notified of his discharge from
hospital in May, there is no record of a discharge summary having been
sent. This is clearly unacceptable and this has been taken up with the
ward consultant. There is a clear expectation that a discharge summary
will be sent to GPs for all discharges.

| hope that this letter addresses the issues that you have raised and | would
like to thank you for bringing your concerns to my attention.

Yours sincerely,

Dr Matthew Patrick
Chief Executive