Gillian O’Keefe

GP Registrar:

Westminster Coroner's Court 11" December 2017
FAO: Susan Lord (Clerk to HM Coroner)

Inner West London

Horseferry Road

London

SW1P 2ED

Re: Gillian O’Keeffe DOB 31/05/1966 Coroners Report 1100360.
Thank you for your letter, | sincerely apologise that you have had to contact us again regarding this enquiry.

We sent out the original correspondence 2 weeks ago which unfortunately seems you have not received, |

have printed off the report again and enclosing with this letter.

If you require any further information please do not hesitate to contact me direct on 020 8685 2345.

Yours sincerely,

Practice Manager
Cricket Green Medical Practice

INVESTOR IN PEOPLE

75-79 MILES ROAD, MITCHAM, SURREY CR4 3DA Tel. 020 8648 0822/0354 Fax: 020 8640 4013
www.cricketgreen.co.uk e-mail: MERCCG.enquiriescricketgreen@nhs.net

Coroner's Report (1100360) O'Keffe

REFERENCE: ‘Matter of concern 5’ on page 2 of the report stating there appeared
to be no easy or appropriate way that family of a mental health patient could share
information and/or concerns about the patient with the care team, particularly the

patient's care-co-ordinator.

INFORMATION SOUGHT: is there a process in place whereby families can make
information of concern formally known to a patient’s care team - either a system-wide
policy or specifically relating to the patient’s GP practice (Cricket Green Medical

Practice).
GP Practice Perspective

We have discussed the case with the GP practice and can confirm that a Significant
Event Analysis (SEA) has been undertaken by the practice to identify lessons

learned.

The issues raised were in relation to a process whereby families can raise concerns
to a patient’s care team. The GP is one option for patients’ family to raise their
concern. However, in this case there wasn’t an issue with the family raising concerns
with the practice as the GP practice were already aware of the concerns and had
raised these directly at a liaison meeting with the Trust, and in addition, had re-
referred the patient back to the Trust. The issue related to the Trust picking up the

concerns and acting to address them.
CCG Perspective

Having discussed the case with the GP practice, we are satisfied that the practice
raised their concerns about the patient via the correct process i.e. by raising at their
quarterly liaison meeting with the Trust, and by re-referring the patient back to the
care of the Trust. On reflection, the lessons learned include other processes that the
practice could have utilised to raise their concerns about this lady, including the

following:

e Via GP Alert system (Amber Alert for Merton CCG) — This enables GP
practices and other healthcare professionals to raise concerns about patient

care directly to the CCG. The CCG is very responsive to alerts received and

have evidenced outcomes in relation to quality improvement as a result of

quality alerts.
° Via GP Clinical lead for the Trust, who could raise the concerns directly at the

Clinical Quality Review meetings with the Trust.
In relation to patients’ families, they could raise concerns:

° Directly with the Trust via their PALs and Complaints service; or
° Directly to the CCG stating that they have unsuccessfully raised their concerns
with the Trust.

The CCG will be reviewing the Trust's action plan for addressing the issues raised by
the Coroner, and a learning event will be undertaken to review the system-wide
issues that the case as identified in order to ensure that the system is able to allow
families easier access to health professionals should they need to raise care issues

about their relatives.

RG From Jackie Doyle-Price MP

Parliamentary Under Secretary of State for Care and Mental Health

Department
of Health een whiohat
London
SW1A 2NS
Angela Hodes 020 7210 4850
HM Assistant Coroner Inner West London
65 Horseferry Road
LONDON
SWIP 2ED
Our reference: PFD-1100360
23™ November 2017

Neos A Meola

Thank you for your Report dated 28 September to the Secretary of State for Health
about the death of Mrs Gillian O’Keeffe. I am responding as mental health sits within
my portfolio.

I was very saddened to read of the regrettable circumstances surrounding Mrs
O’Keeffe’s death. Please pass my condolences to her family and loved ones. I
appreciate this must be a very difficult time for them.

Your Report details concerns around the decision to discharge Mrs O’Keeffe from
mental health services; the lack of communication with Mrs O’Keeffe’s GP; the
difficulties faced by the family in making their concerns known to mental health
services; and the absence of policies in place at the South West London and St
George’s Mental Health NHS Trust to follow up the GP’s subsequent concerns.

The matters raised are operational and relate to the South West London & St
George’s Mental Health NHS Trust. However, it is important to make clear the
national policy expectations in relation to the issues you have raised.

The Mental Health Act 1983 Code of Practice, whilst being statutory guidance for
providers of services under the Act should be observed as best practice by all
commissioners and providers of services to people who may become subject to the
Act. We revised the Code of Practice in 2015 and set out guiding principles to
improve the care for patients. The principles include mental health providers
involving patients’ carers and families in decisions about their care. The Code of
Practice also makes it clear that we expect multi-disciplinary teams involved in care

planning and discharge to include all relevant professionals and agencies which may
be involved in a person’s care.

My officials have made enquiries and I am encouraged that the Trust is taking action
to respond to these concerns in your Report, as well as those raised by the family, in
addition to learning identified through its own investigations into Mrs O’Keeffe’s
care and treatment.

While the Trust has explained the rationale for the decision to discharge Mrs
O’Keeffe from its services, it acknowledges that more engagement should have taken
place with key stakeholders in reaching this decision.

Learning lessons where things have gone wrong is essential to ensuring the NHS
provides safe, high quality care. You will know from the response provided by the
Trust on 21 November that the Trust has identified actions to take in response to the
concerns you have raised. This includes updating the Trust’s clinical
disengagement/did not attend policy to be more prescriptive in the actions to take and
engagement with key stakeholders when taking a decision to discharge a patient.

The Trust advises that it will take action through staff learning mechanisms to
promote the importance of the involvement of GPs in pre-discharge multi-
disciplinary meetings. Further, the Trust is working to produce guidance for GPs in
how they can raise concerns and referrals and is looking to strengthen the
engagement of families and carers and liaison with primary care.

My officials also made enquiries with the Wandsworth Clinical Commissioning
Group (CCG) and I understand the CCG will review the Trust’s action plan for
addressing the concerns you have raised.

Wandsworth CCG advises that it is satisfied that the GP Practice took action to raise
concerns about Mrs O’Keeffe through the correct processes (i.e., the GP quarterly
liaison meeting with the Trust). However, when considering learning points from this
case, I am informed that the CCG and Practice have identified other processes and
routes the Practice could have used to raise concerns. These include the GP Alert
System that enables GP practices and other health professionals to raise concerns
about patient care directly to the CCG, and the GP clinical lead for the Trust, who can
raise concerns directly at clinical review meetings within the Trust.

I am advised that a learning event will be undertaken to review the system-wide
issues that the case has identified and to ensure that the system is able to allow

ae

Department
of Health

families easier access to health professionals should they need to raise care issues
about their relatives.

I hope this information provides assurance that there are processes available to
families and GPs to raise concerns about patient care in such circumstances. Such
processes are the responsibility of individual NHS trusts and you have taken the
correct course of action in addressing your concerns to the South West London & St
George’s Mental Health NHS Trust, and I hope the Trust’s response is helpful.

Thank you for bringing the circumstances of Mrs O’Keeffe’s death to our attention.
 JOUWUS

JACKIE DOYLE-PRICE

South West London and St George’s INHS|

Mental Health NHS Trust

Chief Executive’s Office

South West London and St Georges
Mental Health NHS Trust

Trust Headquarters, Building 15
Springfield University Hospital

61 Glenburnie Road

21°! November 2017

Ms Angela Hodes

HM Assistant Coroner Inner West London
65 Horseferry Road

London

SW1P 2ED

Dear Ms Hodes
Regulation 28: Report to Prevent Future Deaths

| am writing to you following receipt of the Regulation 28: Report to Prevent Future
Deaths dated 28'" September 2017 regarding the sad death of Mrs Gillian O’Keefe
as a result of an overdose of medication. You have requested South West London
and St Georges Mental Health NHS Trust respond to five matters of concern that
you have detailed in your correspondence.

In order to examine all of the concerns a meeting was convened on 31% October
2017 by Associate Director of Governance and Risk, with

Clinical Director of the Community, and Head of
Nursing and Quality for the Community Adult Services. The meeting reviewed the
details of the case and whether there were missed opportunities, as well as the
possibility of gaps in our services with regard to care and treatment that may have
prevented Mrs O’Keefe’s death.

| have responded to each of your concerns as they were raised in your
correspondence:

Chief Executive, David Bradley Chairman, Peter Molyneux

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INHS

South West London and
St George's Mental Health

1) That the decision to discharge Mrs O’Keeffe ‘for non-engagement’ from the
local Mental Health NHS Foundation Trust care in January 2017 appeared
illogical when it was likely, having regard to the facts, that she was in greatest
need of their help: she was a service user of long standing, she had an acute
deterioration in her mental state in March 2016, that there had been concerns
raised by her family in October 2016 and that no professionals had been able
to make visual contact with her since October 2016.

The decision to discharge was based on the following:

e Mrs O’Keefe had never expressed suicidal thoughts nor abused alcohol or
taken illicit drugs

e the GP confirmed that Mrs O’Keefe had picked up a prescription on 6" of
January (4 days before the decision to discharge)

e the Care Co-ordinator noted that Mrs O’Keefe appeared stable in her mental
state when last seen on 22" November and that she had reasonable self-care

e the Care Co-ordinator had not noticed any hypomanic symptoms outside of
some emails Mrs O'Keefe sent to Members of Parliament

e the risk to Mrs O’Keefe and to others was assessed as low.

It is stated in your correspondence that no professionals had been able to make
visual contact with Mrs O’Keefe since October 2016. This is incorrect as visual
contact was made with Mrs O’Keefe on 22™ November 2016 by the Care Co-
ordinator who recorded that she appeared stable in mental state.

We have provided rationale for the decision to discharge but also acknowledge that
more engagement should have taken place with key stakeholders prior to Mrs
O’Keefe’s discharge. Since this incident, our Clinical Disengagement/Did Not Attend
Policy has been updated. The updated version is more prescriptive with regards to
what actions need to be taken before a patient can be discharged and this includes
engagement with the GP and inclusion of the GP in the decision to discharge.
Adherence to this policy is audited through our clinical audit programme.

2) In view of her history and the inability of the Trust or GP surgery to make
contact with Mrs O’Keeffe it was highly unlikely that she would self-refer.

The Trust agrees with this statement. Attempts had been made to engage Mrs
O'Keeffe by telephone and through home visits. The team were of the opinion that
her risk to self and others was low (although they acknowledged she was
vulnerable). The discharge summary was sent to Mrs O’Keefe’s GP, with the request

Chief Executive, David Bradley

NHS Trust

Chairman, Peter Molyneux

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© Respectful CO Open @ Collaborative @ Compassionate Consistent

INHS

South West London and
St George's Mental Health

that they re-refer the patient if it was required. However, a crisis plan including
relapse indicators was not sent to the GP or Mrs O’Keefe on discharge, nor was
there liaison with the family at the point of discharge.

The importance of sending the Trust approved template for a crisis plan to GPs will
be re-enforced to staff through team and local governance meetings and via the
Trust's dissemination of learning mechanisms such as the monthly bulletin, etc. This
will again form part of the clinical audit cycle. The importance of family liaison and
engagement forms part of our triangle of care programme. This programme is just
about to start its round of ‘self-assessments’ and with the community services this
learning will be cascaded through this process.

3) There was no pre-discharge multidisciplinary meeting to include and inform
the GP before discharge nor attempt to ensure that there was a seamless
transition to the GP surgery.

Mrs O’Keefe did not attend the CPA (Care Programme Approach) meeting on 10" of
January 2017. The Consultant Psychiatrist and Care Co-ordinator reviewed the care
and treatment in her absence. The Care Co-ordinator had made several attempts by
telephone and home visits to contact Mrs O’Keefe. The care plan documented that
the GP should continue the prescription of Quetiapine and should follow up with Mrs
O'Keefe and re-refer her if required. A letter outlining the care plan was sent to the

GP.

There is no evidence that the GP was invited to this meeting. The Trust recognises
that the decision to discharge would have benefitted from an early discussion and
review between the RST and the GP prior to a formal discharge letter being sent out.

The Trust’s revised Clinical Disengagement/Did Not Attend Policy states that the
team should liaise with the GP and invite them to be involved in the decision to

discharge the patient.

The importance of involving the GP in the decision to discharge will be re-enforced to
staff through team and local governance meetings and via the Trust’s dissemination
of learning mechanisms such as the monthly bulletin, etc. The clinical audit cycle will
reinforce the importance of this being in place.

4) Evidence was given at the inquest that there was no procedure or policy in
place at the Trust to follow up on GP concerns or referrals particularly where
there was likely to be a degree of urgency

Chief Executive, David Bradley

rics) Respectful

NHS Trust

Chairman, Peter Molyneux

ws , Open @ Collaborative @ Compassionate Consistent

INHS

South West London and
St George's Mental Health

The GP raised a concern with the Trust Consultant after a GP Liaison meeting at the
Practice in February 2017. The GP was advised to re-refer the patient in writing. The
Trust understands that the GP drafted a referral letter but that this was not sent to
the Trust at the time.

The referral was never sent by the GP but this concern highlights the need for some
clear guidance for GPs regarding concerns they may have. The Trust is in the
process of formalising this with the lead CCG GP involvement. It will be shared with
GP colleagues once it has been signed off.

It is also worth noting that the Trust is in the process of developing a primary care
liaison team with the objective of improving communication between GPs and the

Trust.

5) There appeared no easy or appropriate way that the family were able to
share information and their concerns about Mrs O’Keeffe’s mental health with
the professional team, consequently, notwithstanding the family’s continual
and concerted attempts to notify Mrs O’Keeffe’s care coordinator, they felt that
the professionals were unaware of the parlous state of Mrs O’Keeffe’s mental
health and the family’s serious concerns.

The occasions when the team were contacted by the family and their responses are
detailed below:

24" October 2016: Concerns were raised by Mrs O’Keefe’s sister. In response to
these concerns, the Care Co-ordinator made an unannounced visit to Mrs O’Keefe
on the same day but she was not at home. The Care Co-ordinator attempted to
contact Mrs O’Keefe’s sister but was unable to speak with her so left a message.
The Care Co-ordinator also contacted the GP surgery who confirmed that Mrs
O'Keefe had collected her monthly prescription on 17" October 2016.

25" October 2016: The Care Co-ordinator made another unannounced visit but Mrs
O'Keefe was not at home. The Care Co-ordinator made telephone contact with Mrs
O’Keefe who explained she was in a café and planning to visit her mum in
Lincolnshire and that she would meet the care Co-ordinator at the team base on 28"
October 2016.

28" October 2016: Mrs O’Keefe did not attend the appointment. The Care Co-
ordinator made contact with her by telephone and Mrs O’Keefe explained she was
still in Lincolnshire. The Care Co-ordinator left a message on Mrs O’Keefe’s sister's
telephone to update her and confirm whether she saw her sister at their mum’s

home.

Chief Executive, David Bradley

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NHS Trust

Chairman, Peter Molyneux

(75 Open © Collaborative @ Compassionate Consistent

INHS

South West London and
St George's Mental Health

The Trust was disappointed to learn that the family felt that there wasn’t an easy way
to share information and their concerns about Mrs O’Keefe with the team. The
Clinical Director is currently scoping a quality improvement project in relation to Care
Programme Approach (CPA) focussing on the engagement of families/carers and
liaison with primary care. In addition to this, the Head of Nursing for the service is
organising a learning event so that each of the actions identified in the plan can be
shared with the team, with the event providing an opportunity for reflection and
learning. As referred to earlier the trust is also committed to the triangle of care
principles and is just about to undertake the next round of self-assessments.

Enclosed with this letter is a plan detailing the actions taken already or the proposed
actions to be taken along with a timetable for action.

Our deepest sympathies are extended to the family and friends of Mrs O’Keefe. The
conclusion that we have reached indicates that there is more work to be done with

our teams regarding communication with families/carers and the inclusion of key
stakeholders with regard to decisions around discharge.

Yours sincerely

Bf foashA

David Bradley
Chief Executive

Chief Executive, David Bradley

© Respectful

NHS Trust

Chairman, Peter Molyneux

Open @ Collaborative @ Compassionate Consistent