Andrew Aitken

Barts Health INHS|

NHS Trust

Medical Director
Barts Health NHS Trust
Trust Executive Offices
Ground floor, Pathology Block
The Royal London Hospital
London, E1 2ES

Telephone:
www. bartshealth.nhs.uk

Ms M E Hassell

Senior Coroner for Inner North London
St Pancras Coroner's Court

Camley Street

London

N1C 4PP

30 January 2015

By special delivery

Dear Ms Hassell

Inquest touching the death of Mr Andrew James Aitken

| write in response to your Regulation 28: Report to Prevent Future Deaths, dated 15
December 2014.

Your first concern was regarding a number of Mr Aitkens tablets that his ex-girlfriend

stated were left on the hospital bedside cabinet next to Mr Aitken
whilst he was in ACCU. The concern being that as Mr Aitken had attempted suicide
he could, reasonably, be expected to attempt this again.

The investigation involved looking into the patient’s medical records and interviewing
the staff involved. An entry dated 11 June 2014 states that the member of staff
involved took the tablets then ‘informed to SPR, kept it locked needs to be destroyed
or handed to pharmacist tomorrow’.

This was sent to [EE Matron of ACCU at The Royal London Hospital. She
identified the member of staff involved iE, and interviewed
her. iiiiproduced a witness statement. EE§confirms that on 11 June 2014
she and the SPR decided to hand the tablets to a Pharmacist for destruction. As she
was unable to contact the ward Pharmacist she locked the tablets in the medicine
cupboard.

Your second and third concerns are being investigated and addressed separately by
the East London NHS Foundation Trust.

Barts Health NHS Trust: Newham University Hospital, The London Chest Hospital,
The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross University Hospital.

Barts Health INHS|

NHS Trust

Your fourth and final concern was that Mr Aitken was discharged from hospital in
gown and socks, with no clothes and shoes.

The investigation involved communicating with who is the senior sister
on ward 11C. She told me that she remembered this man very well. She stated that
he was medically fit and the psychiatry team had discharged him; he was willing to
go home and so they could not keep him in hospital. He did not have any clothes
with him and he told staff that no one could bring him any in. The Trust booked and
paid for a taxi to take him home as they did not want him going home on public
transport in hospital pyjamas. The ward did receive a complaint in June whereby a
safeguarding alert was raised, although it was deemed that the ward had done
everything it could at the time and so the safeguarding was closed.

Thank you for bringing your concerns to my attention. | trust that you are assured |
have taken them seriously and investigated them appropriately.

Yours faithfully

Medical Director
Barts Health NHS Trust

|, The London Chest Hospital,
Barts Health NHS Trust: Newham University Hospital, p ‘
The Royal London Hospital, St Bartholomew’s Hospital and Whipps Cross University Hospital

East London INHS

NHS Foundation Trust

Trust Headquarters
EastOne

22 Commercial Street
London E1 6LP
Telephone: 020 7655 4177
Fax: 020 7655 4076

JECEIVE

9" February 2015

Coroner M E Hassell
Senior Coroner

Inner North London

St Pancras Coroner's Court

Camley Street 11 FEB 2015
London ;
NiGaPE POPLAR CORONER'S

CCURT _
Dear Madam

Inquest touching upon the death of Andrew Aitken (dod 10.08.14)

This is a formal response to your Regulation 28 Report dated 15" December 2014 in
which you set out your concerns relating to the care Mr Aitken received from East
London NHS Foundation Trust and Bart’s Health NHS Trust.

You have set out four areas of concern in your report. Two relating to Mr Aitken's
care under this Trust and two relating to his care under Bart's Health NHS Trust. The
areas of concern set out at point 2 and 3 relate to the actions of East London NHS
Foundation Trust and | will respond to these below. A separate response will be
provided by Bart's Health NHS Trust.

At the Inquest you heard that Mr Aitken had been seen and assessed on three
occasions during his admission to the Royal London Hospital by the Rapid
Assessment, Interface and Discharge (RAID) Service, which is based within the
Emergency Department at the Royal London Hospital. The Service provides a one-
stop shop for individuals who require mental health assessments in the Emergency
Department or who are inpatients at the Royal London Hospital, Mile End Hospital or
the London Chest Hospital. The aim of the service is to prevent unnecessary
admission to inpatient mental health care, reduce length of stay on acute general
wards and to resolve immediate issues and concerns and direct patients to primary
and secondary services that can provide ongoing care, treatment and support.

Mr Aitken had been admitted to the Royal London Hospital following a serious
overdose on 8" June. He was referred to the RAID Service on 11" June and was
seen and assessed by the Service on 12", 13" and 14'" June. During the Inquest
you heard direct oral evidence from the Duty Psychiatric Doctor who had undertaken
the third and final assessment on 14" June.

Chair: Marie Gabriel Chief Executive: Dr Robert Dolan

You heard that during assessment Mr Aitken had informed staff that he was not
registered with a GP but he had disclosed an admission to a Psychiatric Hospital in
Prestwich at the age of 16, some 14 years earlier.

Your first concern related to the decision by staff not to contact services in Prestwich
to obtain collateral information regarding Mr Aitken, as in the absence of a GP this
provided the only source of history from healthcare professionals.

lam in complete agreement with you regarding the importance of gaining collateral
information from any available sources. As you are aware the Trust undertook a
Serious Incident Review (SIR) looking at the care and treatment of Mr Aitken and the
Review considered this issue. Sources of collateral information in the absence of a
GP can be; healthcare professionals previously involved with a patient and family
and friends. Our SIR agreed that clinical staff had limited information and history
regarding Mr Aitken in light of the fact that he did not have a GP. Senior staff in the
RAID Service are clear that they would expect staff to follow up and try to obtain all
information available regarding an individual. The RAID Operational Policy is
currently being finalised and the importance of obtaining collateral information will be
included within this.

The Review found that staff had clearly explored sources of collateral! information
with Mr Aitken. However, Mr Aitken had informed staff that both his parents were
dead and that he had no contact with his siblings. Staff did ask Mr Aitken’s consent
to contact his ex-partner but he was clear that he did not want staff to do so and
there was no indication for staff to go against his wishes. It was therefore not
possible for staff to pursue these avenues in order to obtain collateral information.
The Review considered whether the decision taken by staff not to pursue services in
Prestwich for information was reasonable. In considering this it was relevant to
consider that RAID involvement with any patient is short term and the SIR concluded
that it was highly unlikely that such historical information would have been obtained
during the short time he was under their care to inform their assessment of him. It
was therefore felt that the decision not to contact services in Prestwich had been
reasonable. The Review was satisfied that staff had explored other potential sources
of collateral information.

You also heard evidence at the Inquest regarding the outcome of the assessments
by RAID staff who concluded that Mr Aitken would benefit from a referrai to primary
care talking therapies and he had been advised that he should register with a GP in
order to pursue such a referral. At the Inquest a friend of Mr Aitken stated her belief
that primary care talking therapies would not have accepted such a referral given
such a recent and serious overdose and asked why a referral to secondary mental
health services had not been undertaken. You explored this with the doctor who had
undertaken the final assessment. You were concerned having heard the evidence
that a referral to secondary mental health services had not been considered and this
was particularly of concern in light of the fact that the deceased did not have a GP.

The SIR considered this point noting that the RAID Service is able to make direct
referrals to secondary mental health services and where indicated can refer a patient
to the Home Treatment Team, Crisis Services or the Community Mental Health
Team. Community Mental Health Teams manage those patients with enduring
mental health problems and the SIR found that the assessments undertaken had
been comprehensive and that there had been no indication that this level of input
was necessary for Mr Aitken.

Po Chief Executive: Dr Robert Dolan

Whilst the appropriateness of a referral to primary care talking therapies (delivered by
APT) is not raised in your report | thought it would be helpful to address this in my
response, particularly in light of the fact that our SIR did not conclude that a referral
to the CMHT had been indicated.

Improving Access to Psychological Therapies (IAPT) is a NHS programme of talking
therapy treatments recommended by the National Institute for Health and Clinical
Excellence (NICE) which supports frontline mental health services in treating
depression and anxiety disorders. The SIR considered that the recommendation by
RAID staff that Mr Aitken would benefit from this service was an appropriate plan. A
recent serious overdose should not preclude entry into an IAPT service. Following
referral a thorough assessment would take place and this would determine the extent
of suicidal ideation, plans that may be present, access to means, protective factors
and additional risk factors such as drug and alcohol use. The outcome of this
assessment will determine whether the individual is safe to be treated using a
psychological therapy within primary care by a single practitioner.

The SIR found that psychiatric staff are unable to register a patient with a GP and it
was considered to have been good practice for a letter to be sent to Mr Aitken
following his discharge to remind him to register with a GP. Whilst it is preferable for
patients to be referred to IAPT services by their GP to ensure that appropriate
support and follow up is available this is not compulsory and it is possible for patients
to self-refer. Taking into account your concerns | believe that this information should
be provided to patients who have been assessed would benefit from the IAPT
service. Whilst it is clear, with the benefit of hindsight, that Mr Aitken is unlikely to
have self-referred | do think that it is important to ensure that our staff are aware that
patients are able to do this and senior staff in the RAID team will ensure that this is
brought to the attention of staff by way of their regular business meeting. In addition
to this consideration is currently being given on the best way to ensure that all staff
working in Tower Hamlets have access to this information.

The key issue that did arise in our SIR was in relation to a review by a Consultant
Psychiatrist. It is an expectation that all patients under the care of the RAID Service
should be reviewed by a Consultant Psychiatrist either face to face or as part of a
clinical discussion or supervision of junior doctors. The Review identified that all
patients were discussed on a daily basis (Monday to Friday) at the Service’s Clinical
Team meeting which always involves at least one Consultant Psychiatrist along with
junior Drs on duty, the nurse consultant and a nurse from the Emergency
Department, with staff from Occupational Therapy and Psychology attending once a
week. However, the SIR identified that there was no documentation of the
discussion which had taken place on this occasion and a recommendation has been
made to ensure that there is a system in place so that clinical discussions from the
daily clinical meeting are always recorded within the patient's medical records. In
addition the SIR has made a recommendation in relation to the processes in place to
ensure that junior doctors discuss patients seen during liaison duties in Consultant
Supervision.

Po Chief Executive: Dr Robert Dolan

| hope that the above information provides the necessary assurance that the Trust
has appropriate policies and procedures in place and that we will be taking action to
appropriate steps to address the shortcomings identified.

Yours sincerely

Dr Kevin Cleary
Medical Director

Chair: Marie Gabriel Chief Executive: Dr Robert Dolan