William Abel

Leicestershire Partnership INHS|

NHS Trust

Direct dial: 0116 2950821/07786 111055
En i 7 _ _ A University Teaching Trust
Our ref: BMT/REG28/1215 Bridge Park Plaza

Thurmaston
7 December 2015 Leicestershire

LE4 8QP

By email to Leicester.coroner@leicester.gov.uk Tel: 0116 295 1350
Mrs L Brown Fax: 0116 225 5233
Assistant Coroner www. leicspart.nhs.uk
Leicester City and South Leicestershire
The Town Hall

Town Hall Square
Leicester LE1 9BG

Dear Mrs Brown
Re: William Abel

Further to your report dated 20 October 2015, in accordance with paragraph 7,
Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013, | offer the following response.

We have investigated the matters of concern that have arisen during the course of
the inquest of Mr William Abel. Please be assured that Leicestershire Partnership
NHS Trust has taken these matters very seriously and undertaken a review of the
circumstances of the case in response to concerns raised. | trust that you will be
satisfied that we have taken the appropriate measures to reduce the risk of a similar
incident occurring.

The Serious Incident investigation was conducted in the immediate period after
William’s death. It was signed off by our commissioners in June 2015 and we met
with Williams’ father on the 24 June 2015 to share with him the results of our
investigation.

In the intervening period leading up to the Coroner’s inquest, the Triage Car service
manager and team manager reviewed the appropriateness of the decisions made on
the night in question in terms of completing a Mental Health Act assessment, the
clarity defining the responsibility of the police in deciding whether to detain William,
the quality of the documentation detailing these decisions and the level of
involvement of William’s father in the decision making process and his role in
William's care.

We offer specific detail as to the recommended protocol change in the responses to
the Coroner’s concerns below.

Chair: Cathy Ellis Chief Executive: Dr Peter Miller

The matters of concern raised are as follows. —

1. Mr Abel had a diagnosis of paranoid schizophrenia and he was still under the
care of the Mental Health services at the time he was found in the vicinity of
the railway lines, expressing suicidal intention. He had missed appointments

_ and there was a history of non-compliance with medication. Staff were
available to have conducted a Mental Health Act assessment, on the night he
was Safely escorted from the railway lines, but this was not done.

The Mental Health nurse considered William's clinical history, his presenting
symptoms and situation. This included William contacting his father himself whilst at
the Police Station to ask for help and support. The nurse decided that, based on her
clinical experience and the information she had about William that a Mental Health
Act assessment would not be supported by the Social Care team and so it was not
completed. We agree with the inquest findings that this was not the correct decision.

Actions:

The nurse concerned is undergoing a detailed programme of reflective practice led
by the service’s Senior Matron. This will be fully completed by December 2015.

The protocol for Mental Health Practitioners working with the Triage Car is being
revised so that where there are clear indicators which prompt a discussion with a
patient about the possibility of an admission to an Acute Hospital and a patient
refuses to consider an informal admission, a Mental Health Act Assessment will be
considered. If the assessment is not undertaken, the reasons for this decision taken
within the context of the patient's presentation and the circumstances of the contact
with the services, will be clearly documented. The changes to the protocol have been
communicated via email to the Triage Car and Crisis Team via the service and team
managers and the final revised protocol will be discussed in both team meetings.
The communication exercise was completed during November 2015.

We will undertake an audit to monitor compliance of the revised protocol in
December 2015 and report the audit and further actions to be taken in January 2016.

2. Mr Abel was discharged into the care of his father, and inadequate
communications were made with the family, as the father was not made
aware of the professional concerns regarding a relapse in his mental health, —
that hospitalisation had been considered and the family was expected to be
responsible for his safe keeping. No attempt was made to obtain any family
information that could have impacted on the decision to take no further action
that night.

We agree with the inquest findings that William's father was not fully aware of our
concerns for William's health and documentation detailing this discussion was
unsatisfactory. It is vital that if further relevant information is available from patient's
families, that this is sought, documented and made part of each individual's
assessment and care planning.

Chair: Cathy Ellis Chief Executive: Dr Peter Miller

Actions:

Family members’ presence during an assessment will be documented and we will
ensure they are offered the opportunity to give their views, observations and
understanding in relation to the crisis and the support required of them by the
individual. This information will be documented on the assessment form by the
assessing professional and form part of the outcome of assessment.

The Triage Car and Crisis Team have both been reminded of this protocol via their
team manager and their team meetings during November 2015.

3. NICE guidelines (Clinical guidance 136) state that health care professionals
should discuss whether the patient would like the family to be involved in their
care, and to provide them with information to understand the mental health
problem and its treatments. This guideline does not appear to have been met
in this case.

William telephoned his father himself from the Police Station and asked him to come
and support him. However, we note the importance of patient choice in the
involvement of their family and have communicated a reminder to our Crisis and
Triage Car teams via email and team meetings during November 2015.

Actions:

The service is introducing an outcome of assessment and plan record form to
support the routine work of the Triage Car and Crisis Teams, ensuring that all
patients come into contact with the Triage Car Mental Health Practitioner team are
given key written information clarifying the immediate advice given, and where and
how to access help should they need it. This will also be given to a carer, friend or
family member if they are present at the assessment and the patient has consented
to their involvement. We will implement this change for the Triage Car team by the
end of December 2015 and the wider Crisis Team by the end of January 2015.

All the actions described will be monitored through the service's clinical governance
arrangements.

We hope this reassures you that we have taken appropriate action in response to
the Coroner's findings in respect of individual staff concerned and the systems and
processes supporting the Triage Car and Crisis services to provide safe and
effective care in order to reduce the risk to our future patients.

Wine

Dr Peter Miller
Chief Executive

Chair: Cathy Ellis Chief Executive: Dr Peter Miller