Matthew Groom

Camden and Islington

NHS Foundation Trust

Executive office

4" Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 OPE
Tel: 020 3317 7016
www.candi.nhs.uk

11 January 2016

HM Senior Coroner for Inner North London ME Hassell
St Pancras Coroner’s Court

Camley Street

London N1C 4PP

Dear Senior Coroner Hassell,
Re: Matthew Groom (deceased) Regulation 28 Prevention of Future Deaths report

We are writing to respond to your Regulation 28 Prevention of Future Deaths report of 12"
November 2015 regarding the late Mr Matthew Mark Groom. We are writing jointly on
behalf of our two NHS Trusts.

We have worked jointly to make improvements to address the matters of concern that you
raised. This work has been led by the Clinical Director for the Acute division lan Griffiths on
behalf of this Trust and Executive Medical Director Dr Richard Jennings on behalf of the
Whittington.

Where appropriate in this letter we make it clear which improvements are to be led by
which Trust.

1. Matter of concern - Matt Groom waited four hours in the emergency unit before he saw
a mental healthcare professional for the first time. | heard that, at the time in these
circumstances, it was not possible for a triage nurse to arrange for immediate mental
health assessment.

Improvements in response to concern
We recognise that it is important for us to improve our joint service so that avoidable delays
in mental health assessment are minimised as much as possible.

Chair: Leisha Fullick Your partner in
Chief Executive: Wendy Wallace care & improvement
2a C&l is an NHS Foundation Trust providing treatment and social care for mental ill-health
2 Camden @ ISLINGTON and substance misuse in adults in partnership with Camden and Islington councils.

NHS

The improvements that we have made to address this issue are:

a) We have strengthened the direct mental health referral protocol from Whittington
Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison
Team Service, so that patients attending Whittington Emergency who need to see a
mental health professional can be immediately and directly referred. This mental health
referral protocol was in place before your inquest into Mr Groom’s death, but has since
been significantly strengthened in that the patient themselves can now trigger a prompt
and direct referral to the Mental Health Liaison Team simply by requesting this.

b) The mental health referral protocol has also been strengthened by creating a new
referral flow-chart for frontline staff, which has been disseminated and embedded. The
protocol is attached to this letter.

2. Matter of concern - Diazepam was prescribed but never administered.

Improvements in response to concern
We recognise that it is essential to minimise the chance that prescribed medication is

inadvertently omitted.

The improvements that we have made to address this issue are:

a) We have refreshed and embedded a Whittington ED departmental protocol that clearly
defines the responsibility of prescribers to inform the assigned nurse once a prescription
has been issued. It also directs the nurses to regularly check patient’s drug charts to
check for any medications prescribed. In circumstances such as Mr Grooms, where the
patient is not in a defined cubicle with an assigned nurse, prescribers should highlight
the prescription to the nurse-in-charge of the area.

b) This protocol will be monitored through regular audit, which has been adapted to
incorporate checking for medication administration.

c) We have strengthened handover of patient information between Whittington ED and
Camden and Islington Mental Health Liaison Team so that this now involves explicit
checking between the teams as to whether:

e medications have been prescribed and administered

e medications have been prescribed and refused

e there are any outstanding medications that have been prescribed but have yet to be
administered

NHS)

thoroughly and making specific notes of any prescribed medications written by the ED

The staff were also reminded of the importance of checking the written records

colleagues before or during their assessment of the patient, and to record their findings
clearly in the patient’s record.

d) We are making arrangements to reduce the risk of psychiatric or anxiolytic medication
being inadvertently omitted, we are making arrangements to ensure that Camden and
Islington Mental Health Liaison Team prescribers can prescribe in Whittington ED. The
Camden and Islington liaison psychiatry consultant is providing the details of Mental
Health Liaison Team prescribers who will then be issued with honorary Whittington
contracts in order that they can then prescribe medication in Whittington ED.

3. Matter of concern

The mental health nurse who then saw him did not consider what action to take if he should
suddenly decide to leave, most particularly given that she felt unable to conclude the
assessment without waiting for a doctor to come in from home to assist.

Improvement in response to Concern

The question of what action may be appropriate in the event of someone leaving the ED
before an assessment or during an assessment is complex both from a clinical and legal
perspective.

Individuals who have attended the ED voluntarily are informal patients and are not subject
to any form of legal detention such as the Mental Health Act. For informal patients staff may
try and persuade patients not too leave, but cannot in any manner prevent them leaving.

A general duty of care can be applied in circumstances where someone is actively violent or
is actively trying to hurt themselves or others, and then a physical intervention can be
applied by NHS staff. This was not the case for Mr Groom.

The Mental Health Act enables appropriately trained staff to deprive someone of their
liberty and enforce treatment; rightly this assessment requires a high threshold to be met.
Alongside this the assessors have to consider the persons capacity to make this decision.
Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display
behaviour that was sufficiently concerning that it required Mr Groom to be immediately
detained under the Mental Health Act or any other Act.

Both Trusts have committed to improving staff awareness of their legal duties, what the
options are associated with the various circumstances and clinical contingency planning in
line with legal options. These are detailed under point 4.

In Mr Groom’s case, following the mental health nurse’s initial assessment, she did not reach
the conclusion that Mr Groom was acutely suicidal and in urgent need of restraining should

3

INHS

he leave the assessment setting. At the point at which the nurse stopped her assessment to
speak with the on call SpR doctor for advice, she did not consider it appropriate to document
a contingency plan about what action to take were Mr Groom to leave. This was based on
the fact that Mr Groom was not considered to pose an immediate risk of absconding or a risk
to himself or others. In this respect Mr Groom did not qualify for detention under the
Mental Health Act (or the Mental Capacity Act) and therefore there would have been no
legal powers to prevent him from leaving. (Although the assessment was incomplete, this in
itself would not have been grounds for preventing him from leaving either.) The Trust did
not establish that there were any significant clinical competency concerns in relation to the
mental health nurse’s clinical judgment.

4. Matter of concern - When Matt did leave the department, the assessing doctor asked the
nurse to call the Police, but neither doctor nor nurse considered seeking urgent assistance
from hospital security, given that they were by now both of the view that he would probably
now have to be detained under section of the Mental Health Act.

Improvement in response to Concern
To improve the reliability of assessments made by the Whittington and Camden and

Islington frontline staff to consider and plan what action to take should a patient suddenly
decide to leave, both organisations are jointly preparing a joint framework and reference
document that will be used in the ED to outline and further reinforce clear steps with regard
to:

1. Early Assessment/determination of risk.

2. Determining capacity and whether restraint under the MCA is a proportionate
response.

3. Proactive instructions to security staff if potential restraint is considered justified.
Reinforcing existing practice in terms of formal observations by an assigned nurse in
the clinical area.

5. Clear documentation of the risk management steps taken (or of no specific plan if risk
considered low.)

6. Communication between to the two services.

7.

This will be completed by March 2016. This will assist staff working in the ED but also
security staff to determine when it is appropriate to lawfully detain someone against their
will.

Following the inquest we have reviewed the case and we are satisfied that our clinicians did
everything within their power to prevent him from leaving the Whittington ED on the night
in question.

NHS

5. Matter of concern - The nurse who then contacted the Police did not then convey this to
them, but requested a welfare check that would be satisfied by knowing he was with a family
member.

Improvement in response to concern

For the reasons described above (in response to concern 3) Camden and Islington NHS
Foundation Trust is satisfied that Mr Groom did not display behaviour that indicated that he
was at immediate risk of harm to himself or others to require that the police perform an
active search for him. Had this been the case then the Trusts practice is to convey this
information to the police. Camden & Islington NHS FT already has joint protocols with the
Police, concerning people who leave Trust premises and / or go missing.

As | understand it the police were alerted that if they were to see Mr Groom, they should
consider bringing him back to hospital if the family members he left with were concerned.
As we understand it, this would also normally entail the police’s consideration of the use of
section 136 legislation if thought appropriate. The police were provided with his last known
address.

We recognise that it is important to continuously improve joint working between clinicians
and the Police.

The improvements we have made to facilitate this are:

a) We have a new black phone in Whittington Health ED specifically for the police to pre-
alert us to patients who are being brought to WH ED under Section 136 of the Mental
Health Act, and to communicate any other urgent information.

b) We have a new Standard Operating Procedure for patients brought to the Whittington ED
under Section 136 of the Mental Health Act.

c) The Trusts regular meetings with the police have been supplemented by an additional
monthly meeting between Whittington, Camden and Islington and a named inspector
from Islington Police to agree further actions to improve joint working.

We hope that this response to your Prevention of Future Deaths report reassures you that
our two trusts have jointly made significant improvements to reduce the likelihood of any
further tragedy like that of Mr Groom’s death occurring again. Please do not hesitate to
contact us if you would like to discuss anything that we have written here or if there is any
other information that we can usefully provide.

NHS

Yours sincerely

\

Wendy Wallace
Chief Executive

Copied to: Dr Richard Jennings - Executive Medical Director on behalf of The Whittington
Hospital NHS Trust

Camden and Islington

NHS Foundation Trust

Executive office

4" Floor, East Wing
St Pancras Hospital
4 St Pancras Way
London NW1 OPE
Tel: 020 3317 7016
www.candi.nhs.uk

11 January 2016

HM Senior Coroner for Inner North London ME Hassell
St Pancras Coroner’s Court

Camley Street

London N1C 4PP

Dear Senior Coroner Hassell,
Re: Matthew Groom (deceased) Regulation 28 Prevention of Future Deaths report

We are writing to respond to your Regulation 28 Prevention of Future Deaths report of 12"
November 2015 regarding the late Mr Matthew Mark Groom. We are writing jointly on
behalf of our two NHS Trusts.

We have worked jointly to make improvements to address the matters of concern that you
raised. This work has been led by the Clinical Director for the Acute division lan Griffiths on
behalf of this Trust and Executive Medical Director Dr Richard Jennings on behalf of the
Whittington.

Where appropriate in this letter we make it clear which improvements are to be led by
which Trust.

1. Matter of concern - Matt Groom waited four hours in the emergency unit before he saw
a mental healthcare professional for the first time. | heard that, at the time in these
circumstances, it was not possible for a triage nurse to arrange for immediate mental
health assessment.

Improvements in response to concern
We recognise that it is important for us to improve our joint service so that avoidable delays
in mental health assessment are minimised as much as possible.

Chair: Leisha Fullick Your partner in
Chief Executive: Wendy Wallace care & improvement
2a C&l is an NHS Foundation Trust providing treatment and social care for mental ill-health
2 Camden @ ISLINGTON and substance misuse in adults in partnership with Camden and Islington councils.

NHS

The improvements that we have made to address this issue are:

a) We have strengthened the direct mental health referral protocol from Whittington
Emergency Department (ED) triage to the Camden and Islington Mental Health Liaison
Team Service, so that patients attending Whittington Emergency who need to see a
mental health professional can be immediately and directly referred. This mental health
referral protocol was in place before your inquest into Mr Groom’s death, but has since
been significantly strengthened in that the patient themselves can now trigger a prompt
and direct referral to the Mental Health Liaison Team simply by requesting this.

b) The mental health referral protocol has also been strengthened by creating a new
referral flow-chart for frontline staff, which has been disseminated and embedded. The
protocol is attached to this letter.

2. Matter of concern - Diazepam was prescribed but never administered.

Improvements in response to concern
We recognise that it is essential to minimise the chance that prescribed medication is

inadvertently omitted.

The improvements that we have made to address this issue are:

a) We have refreshed and embedded a Whittington ED departmental protocol that clearly
defines the responsibility of prescribers to inform the assigned nurse once a prescription
has been issued. It also directs the nurses to regularly check patient’s drug charts to
check for any medications prescribed. In circumstances such as Mr Grooms, where the
patient is not in a defined cubicle with an assigned nurse, prescribers should highlight
the prescription to the nurse-in-charge of the area.

b) This protocol will be monitored through regular audit, which has been adapted to
incorporate checking for medication administration.

c) We have strengthened handover of patient information between Whittington ED and
Camden and Islington Mental Health Liaison Team so that this now involves explicit
checking between the teams as to whether:

e medications have been prescribed and administered

e medications have been prescribed and refused

e there are any outstanding medications that have been prescribed but have yet to be
administered

NHS)

thoroughly and making specific notes of any prescribed medications written by the ED

The staff were also reminded of the importance of checking the written records

colleagues before or during their assessment of the patient, and to record their findings
clearly in the patient’s record.

d) We are making arrangements to reduce the risk of psychiatric or anxiolytic medication
being inadvertently omitted, we are making arrangements to ensure that Camden and
Islington Mental Health Liaison Team prescribers can prescribe in Whittington ED. The
Camden and Islington liaison psychiatry consultant is providing the details of Mental
Health Liaison Team prescribers who will then be issued with honorary Whittington
contracts in order that they can then prescribe medication in Whittington ED.

3. Matter of concern

The mental health nurse who then saw him did not consider what action to take if he should
suddenly decide to leave, most particularly given that she felt unable to conclude the
assessment without waiting for a doctor to come in from home to assist.

Improvement in response to Concern

The question of what action may be appropriate in the event of someone leaving the ED
before an assessment or during an assessment is complex both from a clinical and legal
perspective.

Individuals who have attended the ED voluntarily are informal patients and are not subject
to any form of legal detention such as the Mental Health Act. For informal patients staff may
try and persuade patients not too leave, but cannot in any manner prevent them leaving.

A general duty of care can be applied in circumstances where someone is actively violent or
is actively trying to hurt themselves or others, and then a physical intervention can be
applied by NHS staff. This was not the case for Mr Groom.

The Mental Health Act enables appropriately trained staff to deprive someone of their
liberty and enforce treatment; rightly this assessment requires a high threshold to be met.
Alongside this the assessors have to consider the persons capacity to make this decision.
Camden and Islington NHS Foundation Trust is satisfied that Mr Groom did not display
behaviour that was sufficiently concerning that it required Mr Groom to be immediately
detained under the Mental Health Act or any other Act.

Both Trusts have committed to improving staff awareness of their legal duties, what the
options are associated with the various circumstances and clinical contingency planning in
line with legal options. These are detailed under point 4.

In Mr Groom’s case, following the mental health nurse’s initial assessment, she did not reach
the conclusion that Mr Groom was acutely suicidal and in urgent need of restraining should

3

INHS

he leave the assessment setting. At the point at which the nurse stopped her assessment to
speak with the on call SpR doctor for advice, she did not consider it appropriate to document
a contingency plan about what action to take were Mr Groom to leave. This was based on
the fact that Mr Groom was not considered to pose an immediate risk of absconding or a risk
to himself or others. In this respect Mr Groom did not qualify for detention under the
Mental Health Act (or the Mental Capacity Act) and therefore there would have been no
legal powers to prevent him from leaving. (Although the assessment was incomplete, this in
itself would not have been grounds for preventing him from leaving either.) The Trust did
not establish that there were any significant clinical competency concerns in relation to the
mental health nurse’s clinical judgment.

4. Matter of concern - When Matt did leave the department, the assessing doctor asked the
nurse to call the Police, but neither doctor nor nurse considered seeking urgent assistance
from hospital security, given that they were by now both of the view that he would probably
now have to be detained under section of the Mental Health Act.

Improvement in response to Concern
To improve the reliability of assessments made by the Whittington and Camden and

Islington frontline staff to consider and plan what action to take should a patient suddenly
decide to leave, both organisations are jointly preparing a joint framework and reference
document that will be used in the ED to outline and further reinforce clear steps with regard
to:

1. Early Assessment/determination of risk.

2. Determining capacity and whether restraint under the MCA is a proportionate
response.

3. Proactive instructions to security staff if potential restraint is considered justified.
Reinforcing existing practice in terms of formal observations by an assigned nurse in
the clinical area.

5. Clear documentation of the risk management steps taken (or of no specific plan if risk
considered low.)

6. Communication between to the two services.

7.

This will be completed by March 2016. This will assist staff working in the ED but also
security staff to determine when it is appropriate to lawfully detain someone against their
will.

Following the inquest we have reviewed the case and we are satisfied that our clinicians did
everything within their power to prevent him from leaving the Whittington ED on the night
in question.

NHS

5. Matter of concern - The nurse who then contacted the Police did not then convey this to
them, but requested a welfare check that would be satisfied by knowing he was with a family
member.

Improvement in response to concern

For the reasons described above (in response to concern 3) Camden and Islington NHS
Foundation Trust is satisfied that Mr Groom did not display behaviour that indicated that he
was at immediate risk of harm to himself or others to require that the police perform an
active search for him. Had this been the case then the Trusts practice is to convey this
information to the police. Camden & Islington NHS FT already has joint protocols with the
Police, concerning people who leave Trust premises and / or go missing.

As | understand it the police were alerted that if they were to see Mr Groom, they should
consider bringing him back to hospital if the family members he left with were concerned.
As we understand it, this would also normally entail the police’s consideration of the use of
section 136 legislation if thought appropriate. The police were provided with his last known
address.

We recognise that it is important to continuously improve joint working between clinicians
and the Police.

The improvements we have made to facilitate this are:

a) We have a new black phone in Whittington Health ED specifically for the police to pre-
alert us to patients who are being brought to WH ED under Section 136 of the Mental
Health Act, and to communicate any other urgent information.

b) We have a new Standard Operating Procedure for patients brought to the Whittington ED
under Section 136 of the Mental Health Act.

c) The Trusts regular meetings with the police have been supplemented by an additional
monthly meeting between Whittington, Camden and Islington and a named inspector
from Islington Police to agree further actions to improve joint working.

We hope that this response to your Prevention of Future Deaths report reassures you that
our two trusts have jointly made significant improvements to reduce the likelihood of any
further tragedy like that of Mr Groom’s death occurring again. Please do not hesitate to
contact us if you would like to discuss anything that we have written here or if there is any
other information that we can usefully provide.

NHS

Yours sincerely

\

Wendy Wallace
Chief Executive

Copied to: Dr Richard Jennings - Executive Medical Director on behalf of The Whittington
Hospital NHS Trust