Debrata Sircar

| Oxleas NHS

MOF OVIKG lives NHS Foundation Trust
18 November 2016
2a Ne iV nie Pinewood House

Mr John Thompson : Pinewood Place
Clerk to Senior Coroner Dartford
Southward Coroner’s Court Kent
1 Tennis Street DA2 7WG
Southwark Tel: 01322 G25XXX
London SSE1 1YD Fax: 01322 G25XXK

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Website: www.oxleas.nhs.uk

Dear Mr Thompson
Re: Regulation 28: Preventing Future Death Report

lam writing to you in response to the PFD (Preventing Future Deaths) report dated 11 October
2016 and received on 13 October 2016. This was issued in relation to the death of Debrata Sircar
(case file no: 00519-16(JB).

The report highlighted the following matters of concern:

He was at risk from falls, associated with his alcohol abuse and had frequently presented in A&E |
department with symptoms and injuries associated with intoxication. He was unfit to be treated
in the community. There appeared to be no sense of urgency in securing a bed. He was booked
fora Mental Health Act (MHA)Assessment 11 days after it was advices he needed hospitalisation,
by which time he had died. The court was informed the delay related to the unavailability of a
local authority MHA practitioner. In the intervening 11 day period there was an absence of an
interim care plan, identified in the SUI investigation. Although there were plans for increased
contacts in future for interim care for those pending MHA assessment, it was unclear who would
take the lad and how a patient would be psychiatrically monitored in that period. The Trust
acknowledges the long period of time it took to arrange a Mental Health Act assessment however
this was not, despite what the court heard, due to the unavailability of an Approved Mental
Health Act Practitioner (AMHP).

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On 12 February 2016 a referral was received by the Central AMHP team for a Mental Health Act
assessment. This referral followed concerns from Mr Sircar’s ex-wife and children regarding his
mental and physical health and the fact that he was not caring for himself.

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At this point no referral had been made to the Home Treatment Team (HTT). The duty AMHP
provided the referrer with consultation, suggesting the following actions: the referring
Community Psychiatric Nurse (CPN) to contact the HTT to present DS’s case, as per protocol (HTT
had recently been involved in his care and treatment, post discharge from inpatient services in
January 2016). Contact was established that day with Mr Sircar and he was agreeable to contact
from the HTT. The Responsible.Clinician (RC) and the CPN who visited him that day identified that
the assessed risks could be managed through HTT. HTT however did not feel that was the case.
This disagreement meant that the case was referred back to the AMHP service.

On 15 February 2016, as per protocol, the police risk assessment was sent to the allocated care
co-ordinator (CCO) for completion and an update on Mr Sircar’s situation was requested. The
completed police risk assessment was received from CCO the following day on 16 February 2016.
This was then forwarded to the police on 17 February 2016. Communication took place with both
the community team and family the following day. On 19 February 2016 the police returned the
police risk assessment with the message that they would not be attending the assessment. The
AMHP team then began coordinating the assessment without police involvement. On 22 February

2016 the AMHP team made further attempts to secure the necessary Section 12 medical input
into the assessment and were informed that Mr Sircar had passed away.

As acknowledged already and outlined above, there were certainly delays in the organisation of
the MHA assessment. These were multifactorial but were not due to the unavailability of an
AMHP. Any issues relating to cross-agency working with the police are escalated to the regular

Metropolitan Police Service/ London Ambulance Service/ Oxleas interface meetings. Given that
delays can occur in the organisation of assessments, it is crucial that risks are managed in the
meantime. The lack of an interim risk management plan was identified as part of our Serious
Incident investigation and was the reason for our investigation identifying the following action:

e® The request for a MHA Assessment should trigger review of zoning and risk management
plan, which would include increased contact with the allocated worker. HTT should have
an agreed role in delivering the risk management plan while an individual is awaiting a
MHAA.

Following our review, we have instigated the following change in practice:

e When a client is referred for an MHA.assessment they should be rezoned into Red until
the MHA has been completed. Any referral to HTT during this period should highlight what
role is expected from HTT with regard to risk Management.

e Zoning meetings to review those individuals considered high risk (i.e. those in the red

zone} take place three times per week and agreed actions to mitigate risks are minuted. In
addition, regular weekly interface meetings between community and home treatment
tears now take place to ensure that the clinical pathway between services is working

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| hope that my response has addressed your concerns.

Yours sincerely

Ben Travis
Chief Executive

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