Nathan Lowe

Hertfordshire Partnership INHS|

University NHS Foundation Trust

Chief Executive's Office

The Colonnades
Beaconsfield Road

Hatfield

Herts AL10 8YE

Tel: 01707 253851

Email: tom.cahill@hpft.nhs.uk
Website: www.hpft.nhs.uk

Her Majesty's Coroner

City of London Coroner’s Court
78-83 Upper Thames Street
London

EC4R 3TD

13 October 2016

Dear Dr Palmer

| am writing in response to your letter, and the Regulation 28 report dated 23 August 2016,
which was received in my office on 25 August 2016.

It may first be helpful to explain that this is the first such report that the Trust has received
for many years. It has therefore been taken very seriously and has been highlighted to our
Commissioners and reported on at Executive Team Committee and our Board of
Directors.

The sad death of Nathan Lowe was reported by the Trust as a serious incident to our
Commissioners in May 2016 in accordance with the NHS England Serious Incident
Framework, March 2015. It has been subject to a robust internal investigation undertaken
by a Clinical Director who works as a consultant psychiatrist in our Adult Acute services.
The purpose of the review was to establish facts and consider any potential areas of
learning for the community team and the wider Trust. It was unfortunate that although the
serious incident investigation itself had been completed, the report had not been finalised
when the Inquest was heard on 19 August 2016.

| have enclosed a copy of the Trust's serious incident report for your records. As part of
the Trust’s commitment to the NHS Duty of Candour, a copy of the report has been sent to
Mr Lowe’s mother, who helpfully contributed to the review process. An offer has also been
made by the report author to meet with Mrs Lowe to go through the findings.

You will see from the enclosed report that the investigation did identify a number of areas
where practice could have been improved and where there were missed opportunities for
more assertive action to have been taken in the follow up of Mr Lowe post discharge. The
specific areas of learning identified were as follows:

«+ The importance of multi-disciplinary working

“+ The need for clarity about who will take responsibilities for actions arising from
multi-disciplinary team discussions and meetings

“* Awareness around suicide risk factors

“+ Potential risks relating to disengagement

“» Gathering of information from all available sources to inform the risk management
plan

Our Galues

Welcoming Kind Positive Respectful Professional

“* Consideration of risk relating to medication non-compliance
“ The importance of medicines reconciliation between primary and secondary care
services

An action plan has been put in place to address these areas of learning which has been
shared with our local Clinical Commissioning Group. The action plan will continue to be
monitored by the Service Line Lead and the Managing Director until the actions taken to
address the recommendations are fully implemented into clinical practice. The learning
has also been shared more widely across other Trust teams by use of a learning
summary.

| am aware that immediately following completion of the serious incident report the Service
Line Lead responsible for this Quadrant met with the North West Adult community team
members to discuss the learning and take the opportunity to personally review existing
processes to look at ways in which the multi-disciplinary ways of working could be
strengthened. The following actions have been taken since that time:

1. Improved communication between professionals in the MDT meetings

2. Improved leadership in the team which has created a greater level of oversight
around follow up and multi-disciplinary team decision making for service users on
the case load who have complex needs

3. Clear actions and timeframes by when these actions will be completed and by
whom, are now more clearly recorded in the notes of each MDT meeting. These
actions and associated timeframes and leads are also recorded in the service
user's electronic record.

4. Areflective practice process has been undertaken with the care coordinator by the
community clinical nurse lead.

5. A review of the care coordinators case load is being undertaken to identify if there
are any further areas where actions may need to be taken

6. Acclinical zoning tool is being piloted in two community teams including the North
West. Through training this will assist in identifying those service users in each of
the community teams who have high risk factors that require increased monitoring
and interventions by the multi-disciplinary members of the clinical team.

7. As part of a quality improvement initiative a specific clinical risk training package
around increasing awareness of suicide risk factors to support risk management
decision making has been developed and delivered to the community teams in the
North West and East and South East Quadrants.

8. A Lead Pharmacist/Medicines Safety Officer has commenced in post; part of this
key role will be to identify and implement learning in relation to medication
incidents which will include ways in which medicines reconciliation and joint
working between GP’s and the Trust can be improved.

As part of the Trust's commitment to a zero suicide ambition, on 9 November 2016, the
Trust is participating in a Public Health led Hertfordshire Suicide Prevention stakeholder
event. The aim of the event is to bring together representatives of the many diverse
organisations who together can achieve the vision of making Hertfordshire a county where
no one ever gets to a point where they feel suicide is their only option and to develop a
Hertfordshire wide suicide prevention strategy. Speakers on the day will include a train
driver, a service user with lived experience of surviving a suicide attempt and a family
bereaved by suicide.

This builds on work by the Hertfordshire Spot the Signs, Save a Life suicide prevention
campaign which was launched in collaboration with Hertfordshire Mind Network, local GP
surgeries and the East and North Herts Clinical Commissioning Group building on work
undertaken in Detroit on suicide prevention by Dr Ed Coffey. This is one of four ‘Zero

Suicide’ Programme sites developed across the East of England region. The overarching
goals of the project have been to educate the general public on depression and suicide;
educate GP’s, GP receptionists, district nurses, and community nurses about screening,
identifying and managing suicidality effectively in primary care.

Clinical risk training is a mandatory training requirement for staff in clinical roles to attend
every three years. The Trust is at present reviewing this training programme to include
more serious incident case studies to encourage discussion amongst attendees and
inform clinical practice. A Project Lead has been identified.

| do hope you feel that this response provides you with sufficient detail and assurance
about actions taken by the Trust in response to the Prevention of Future Death report in
respect of the death of Mr Lowe. If you require any further information or clarity about any
aspect of this response please do not hesitate to contact my office on the number listed at
the top of this letter.

Yours sincerely

(\CL

Tom Cahill
Chief Executive Officer

Enc.