Jonathan Meaney

Royal Free London INHS

NHS Foundation Trust

Royal Free Hospital
Pond Street
London

NW3 2QG

Tel: 020 3758 2000

Coroner ME Hassell

HM Senior Coroner

Inner North London

St Pancras Coroner’s Court
Camley Street

London N1C 4PP

22 September 2017

Dear Madam
Response to Regulation 28 Prevention of Future Deaths Report — Jonathan MEANEY

| have set out within this letter the Trust’s responses to the Matters of Concern that you have
brought to our attention in your Regulation 28 Prevention of Future Deaths Report dated 24
August 2017.

| have been assisted in compiling the Trust’s responses by:

° Senior Operations Manager, Emergency Department; and
. Consultant in Emergency Medicine.

We have carefully considered the Matters of Concern, all of which relate to care that was
delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service,
based within the Royal Free Hospital Emergency Department. The staff working within the
Mental Health Liaison service are employed by the Camden & Islington NHS Foundation
Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI
manage the Mental Health Liaison service. If a patient attending in the Trust’s Emergency
Department is considered to have a mental health problem (pertinent to the attendance) or
requires a mental health assessment, they are referred to the Mental Health Liaison service,
which will then assess the patient and take responsibility for referring onwards to either
CANDI’s inpatient facilities or another mental health trust, as appropriate.

It follows that the Matters of Concern will need to be addressed substantively by CANDI,
which we note has received your Prevention of Future Deaths Report. We understand that
CANDI are undertaking a Serious Incident investigation and we are committed to working
closely with CANDI, as necessary, to assist them in completing this investigation, developing
and implementing an action plan to prevent similar incidents in future and to otherwise assist
them in preparing their response to your Prevention of Future Deaths Report. Additionally,
we have asked to be provided with copies of CANDI’s finalised Serious Incident investigation
report and response to your Prevention of Future Deaths Report, to ensure that any
opportunities for learning within this Trust are captured and shared appropriately.

world class expertise # local care www.royalfree.nhs.uk

Dominic Dodd, chairman David Sloman, chief executive

If you require any further information please do not hesitate to contact me.

Thank you for bringing these matters to the Trust’s attention. The Trust is continuously
seeking to improve the quality and safety of the care that it provides to its patients and your
Preventing Future Deaths Report has been a helpful contribution to this ongoing and
extremely important process.

Yours sincerely

Professor Steve Powis
Group Medical Director

Copy to: . Legal Services Manager, Camden and Islington NHS Foundation
Trust

NHS

Camden and Islington
NHS Foundation Trust

Executive office

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

19 October 2017

Coroner ME Hassell

Senior Coroner

Inner North London

St Pancras Coroner’s Court
Camley Street

London N1C 4PP

Dear Madam
Prevention of future deaths report - Jonathan Meaney

1 write further to your Regulation 28 Prevention of Future Deaths report dated 24
August 2017 in which you highlighted concerns about the care provided to Mr
Meaney.

You have brought to our attention a number of concerns which | will address below.

The urgency around securing a bed for Mr Meaney

Following the decision to admit Mr Meaney to hospital in the early hours of 14 March
2017, there was no bed available. Mr Meaney spent 40 hours in the Royal Free’s
emergency department waiting for a bed at which point he expressed a wish to
leave. You are concerned that there seemed to be no urgency about the need fora
bed for such a seriously il! man.

Unfortunately, the demand for beds at the time of Mr Meaney’s presentation was
particularly high. At that time, the Trust was experiencing extreme and unusual

pressure in terms of requests for psychiatric beds. Specifically, on the 14 and 15 of
March 2017, there were 28 referrals for beds for mental health patients pending.

Chair: Leisha Fullick Your partner in CRI
Chief Executive: Angela McNab care & improvement

C&l ts an NHS Foundation Trust providing mental heatth and substance misuse services to people Hving In

@ camden BISLINGTON Camden and Isington end a substance misuse and psychological therapies service to residents In Kingston

NHS

The allocation of a bed is a centralised task, undertaken by the bed management
team, managed by Camden and Islington NHS Foundation Trust. The bed
management team received the referral from psychiatric liaison psychiatry,
requesting a psychiatric bed for Mr Meaney at 04.46am on 14 March. Patients are
prioritised according to both their clinical need, and the assessment of risk, for
example, whether the patient is in a safe place. Patients who are not in places of
safety i.e. at home or in police custody would take priority for acute beds. The
referrals list is something that can change rapidly depending on the priority of new
referrals and whether the risk of an existing referral has changed. Senior staff meet
daily to review all pending referrals and to estimate when a bed will become
available.

From the clinical information relayed to the bed management team about Mr
Meaney’s presentation, he was considered to be suicidal, and at significant risk of
harm to self. This risk was balanced against the fact that he was in a safe place; he
was given a bed in a single bay within the Clinical Decisions Unit (a small, short stay
ward, designed to accommodate patients who are awaiting outcomes to be decided);
he was asleep for 12 hours; and had a mental health nurse with him at all times.

The manager of the psychiatric liaison team has informed me that his team
telephones the bed management team to obtain updates about bed availability. They
would also provide the bed management team with any updates on the clinical
situation of each patient, and whether anything has changed in terms of clinical need
and risk. Telephone calls to the bed management team were made on 14 March at
10.05 and 20.54. A further telephone call was made on 15 March at 10.00.
Unfortunately, the position remained that there were no beds available.

We are undertaking a serious incident review of this case. Part of its scope is to
undertake an in-depth analysis to ascertain in further detail exactly what steps were
taken as a Trust to secure Mr Meaney a bed. We will forward you our serious incident
review on its completion. We are aiming to complete our review in November.

The assessment undertaken by the mental health nurse before Mr Meaney was
discharged on 15 March
Your concerns are as follows:

- When the mental health nurse assessed Mr Meaney before discharge, he did not question
Mr Meaney’s assertion that he had not intended to take an overdose two days before.
This was despite the fact that Mr Meaney had told the assessing doctor that he had been
trying to kill himself and he had written notes of intent;

KN

NHS

The mental health nurse assessed Mr Meaney as rational and having good insight despite
that fact that he raised a physical problem for which no organic cause had been found;
and

- The mental health nurse did not consult any other member of the team before clearing
Mr Meaney as fit for discharge from a mental health point of view.

We fully accept that the mental state assessment undertaken by the mental health
nurse was insufficiently comprehensive and lacked the depth that we would expect.
We agree that the nurse did not properly explore or challenge Mr Meaney’s new
assertion that his overdose was not in fact to take his life, and that it was a
misjudgment that Mr Meaney had good insight into his symptoms. As the nurse
acknowledged at the inquest, in view of the complexities of Mr Meaney’s presenting
symptoms; his suicide attempt of the previous day and notes of intent; and the
doctor’s decision that he needed to be admitted to hospital, he should have
consulted with a member of the team before allowing Mr Meaney to go home.

Asa result of this case, we have put the following measures in place:

As referred to above, we are currently undertaking a serious incident review of this
case so we can explore in further detail the sequence of events and contributory
factors that led to this incident. The learning from the review will be shared within
the relevant clinical team by the clinical director and lead investigator in our
divisional quality forum where we discuss the learning arising from individual cases.

The nurse in question was an agency professional, employed by NHS Professionals.
(NHSP). In light of this case, he has been suspended from working at this level of
expertise until the serious incident review has been completed. We have also shared
your report with the HR department of NHSP and they are currently in contact with
our liaison service manager who will keep them up to date with the findings of our
serious incident review investigation;

Any decision taken by agency or bank staff to change the original decision made by
another full time clinician whereby they are de-escalating the outcome, must be
discussed and agreed with a senior member of the team and this must be clearly
recorded in the patients notes;

All agency or bank staff who work regularly with the team will receive regular formal
clinical supervision from the team manager in line with Trust employees. This will
ensure the same level of professional accountability and clinical support that all full
time employees receive; and

Any agency professional working as settled members of the team will have the same

access to Trust training as Trust staff.

NHS

Referral letters to the GP

You raised your concern that the mental health nurse sent the GP a discharge
summary, but he did not provide an accompanying note to alert the GP that he had
referred Mr Meaney for counselling, and the GP would need to action this.

Going forwards, if there is any specific action that we need a GP to carry out, the
mental health liaison team will now write an accompanying note to alert the GP to
the specific action and what they are required to do.

To conclude, we agree fully that there are significant lessons arising fram this case. |
hope that the information in this letter assures you as to how seriously we are taking
the issues arising from this case, and our ongoing determination, drive and
commitment to ensure that our decision making process is comprehensive and
robust. As | said earlier, we will forward you our serious incident review as soon as it
is completed.

Yours Write

Angela McNab
Chief Executive