John Ioannou

AOS From Norman Lamb MP
Minister of State for Care and Support

Department
of Health
Richmond House
79 Whitehall
London
SWIA 2NS
Mr Andrew Walker, Tel: 020 7210 4850
North London Coroner’s Court
29 Wood Street
Barnet
ENS 4BE
27 FEB 201%

- Prde> (eer,

Thank you for your letter regarding matters of concern arising from the inquest into
the death of Mr John Ioannou.

I understand that Mr Ioannou committed suicide at his home while under the care of
Barnet, Enfield, and Haringey Mental Health Trust for Bipolar Affective Disorder.
Mr Ioannou’s medication for Bipolar Affective Disorder was prescribed by his GP
and the last prescription was written in August 2013, approximately eight months
prior to Mr Ioannou’s death.

You raised a concern that there is no guidance in place for GPs to use when a patient
does not collect medication prescribed to treat a mental health condition. I note you
have previously raised concerns about the difficulty of ensuring patients are taking
prescribed medications for mental health conditions in relation to the deaths of
Duncan Lockhart and Dean Elie. The same legislation applies in this case. That is;
under the Mental Health Act 1983 a person in England or Wales with a ‘mental
disorder’ can be admitted to hospital, detained, and treated without consent either for
the safety of the individual or for the protection of other people.

The decision to detain a person to hospital or put a person under supervised
community treatment is taken by clinicians and other health professionals following
specific procedures. There is also provision for a court or judge to make an order to
admit a person to hospital.

The Mental Health Act 1983 aims to protect people who cannot make decisions for
themselves. People are assumed to have capacity to make their own decisions, unless
a lack of such capacity can be established. Capacity is based on a person’s ability to

understand relevant information, retain relevant information, use or weigh relevant
information, and communicate decisions. It is important to note that where a person
has capacity to make their own decisions the person may do so, even if their
decisions are considered unwise. People with and without mental health conditions
might make decisions considered to be unwise or not in their own best interest. It
was not established that Mr Ioannou lacked capacity; therefore he was free to make
his own decisions.

Health and care services have a duty to ensure that patients receive adequate support.
This means that all patients must receive relevant information about treatments,
including any potential consequences of not following a course of treatment.

The National Institute for Health and Clinical Excellence (NICE) has published
guidelines which set out best practice for the treatment of Bipolar Disorder. This
includes guidance that where a patient is being treated solely in a primary care
setting (e.g. by a GP) the patient should be re-referred to secondary care if treatment
adherence is poor. The guidelines also state that in managing crisis, risk and
challenging behaviour in adults with Bipolar Disorder secondary care providers
should develop a risk management plan and share it with the patient’s GP.

We expect all GPs to follow best practice guidance when caring for patients with
Bipolar Disorder, and therefore to re-refer a patient back to a secondary care
provider when that patient is not consistently taking medication prescribed for the
treatment of Bipolar Disorder.

However, there is a larger question of how a GP would become aware that a patient
had stopped taking medication, particularly if medication is prescribed on a repeat
prescription which allows patients to order re-fills without seeing their GPs. Over
one billion prescription items are issued by general practices each year and it would
therefore be a large and complex task to monitor individual patients. Aside from the
practicalities, there would be issues of appropriate data sharing, patient consent, and
the right to refuse treatment. NHS England advises that it has sought the advice of its
Primary Care Patient Safety Expert Group and Mental Health Patient Safety Expert
Group on what action might feasibly be taken in this area. NHS England will be able
to provide an update on these discussions by the end of April 2015.

It is also worth noting that, although not the case with Mr Ioannou, patients might
collect prescriptions (or have them collected on their behalf by a friend or family
member) but not actually take the medication. It is therefore very difficult to be sure
that any patient with capacity is actually taking prescribed medication.

Department
of Health

Thank you for bringing this matter to my attention. I trust this reply has addressed

your concerns.

c —a dnnce eA, ‘

NORMAN LAMB