Jonathan Zucker

4 x
ws From Jackie Doyle-Price MP

Parliamentary Under Secretary of State for Care and Mental Health

Department
of Health Richmond House
79 Whitehalf
. Lond
Our reference: PFD-1094055 ema
Mr Andrew Walker Esq.

HM Senior Coroner Northern District of Greater London
North London Coroners Court

29 Wood Street

Barnet

ENS 4BE

27 September 2017

Teau Wr Webi

Thank you for your letter of 26 June, received by the Department of Health on 8
August about the death of Mr Jonathan Daniel Zucker. I have been asked to respond.

I was very saddened to read of the circumstances surrounding Mr Zucker’s death.
Please pass my condolences to his family and loved ones. I appreciate this must be a
very difficult time for them.

In your Report you raise concerns that there was no requirement or system in place
for a lead clinician from either the private or NHS mental health services to oversee
and co-ordinate Mr Zucker’s care.

You issued your Report to the Royal College of Psychiatrists, as well as the
Department, and officials have liaised with the Royal College on this matter of
concern.

While it is difficult to comment without further detail on the individual circumstances
that have given rise to this area of concern, I can set out the expectations and
guidance in place around care planning and continuity of care for patients receiving
mental health care.

To ensure a smooth transfer when patients transition through care pathways and
settings, including between private and NHS services, we expect clinicians and their
teams to follow best practice on communication, accountability and effective co-
ordination of care.

Department
of Health

where appropriate. The Royal College of Psychiatrists points to the General Medical
Council (GMC) guidance on Continuity and coordination of care published in 2013,
and the consensus statement on information sharing and suicide prevention published
in 2014.

Finally, I am aware that the Royal College of Psychiatrists intends to ask its
Professional Practice and Ethics Committee to consider the concerns you have raised,
and to determine if more can be done in the areas of consultant accountability,
ownership during transitions and care where more than one team is involved.

I hope this information is helpful. Thank you for bringing the circumstances of Mr

Zucker’s death to our attention.

JAC DOYLE- PRICE

Senior Coroner Andrew Walker Esq. 
North London Coroner’s Court 
29 Wood Street 
Barnet 
EN5 4BE 

14th September 2017 

Dear Mr Walker, 

Re:  Mr Jonathan Daniel Zucker (Regulation 28 Report - Action prevent 
Future Deaths). 

Thank you for sending me the report pertaining to the above dated June 26, 
2017. 

The Royal College of Psychiatrists (RCPsych) is the professional medical body 
responsible for supporting psychiatrists. The College sets standards and 
promotes excellence in psychiatry; leads, represents and supports psychiatrists; 
improves the scientific understanding of mental illness; works with and 
advocates for patients, carers and their organisations. The College does not work 
on the care of individuals and I am not able to comment on the specific 
circumstances surrounding the case of the death of Jonathan Daniel Zucker. We 
were given very little detail in this case, and when we asked for more were told 
our only option was to pay for an audio recording of the coroner’s inquest. This 
was not something we were able to do. However, I have considered your 
findings of fact in this case, and have the following comments to make in 
relation to the important issues that they raise.  

The difficulties surrounding transition occur at many junctures, not just transfer 
between private and NHS patients.  For example: when patients move house; 
transition from CAMHS to adult services; transfer between teams; more 
politically relevant now - discharge from out-of-area admissions. These 
difficulties are best overcome by holding to good practice on communication, 
accountability and effective co-ordination of care. These key topics are discussed 
below. 

Care co-ordination 

The co-ordination of care should be undertaken by the care co-ordinator with the 
policy of the Care Programme Approach (CPA) guiding this work. The College is 
aware that CPA policy can be interpreted and applied differently across the 
country. Ideally a care co-ordinator will be able to negotiate patient discharges 
and their integration into the care of a new team. However, there are 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 circumstances in which this is not straight-forward, e.g. if a section is ending or 
a person is being discharged from hospital. 

Communication with colleagues 

The GMC recommends all doctors ‘share all relevant information with colleagues 
involved in your patients’ care within and outside the team, including when you 
hand over care as you go off duty, and when you delegate care or refer patients 
to other health or social care providers’.i This information sharing with 
colleagues is a key part of good practice that will help ensure that patients are 
kept safe. 

Communication with family and carers 

Communication with families is also key to patient safety, as laid out in the 
consensus statement on information sharing and suicide prevention: ‘Obtaining 
information from and listening to the concerns of families are key factors in 
determining risk. We recognise however that some people do not wish to share 
information about themselves or their care. Practitioners should therefore 
discuss with people how they wish information to be shared, and with whom. 
Wherever possible, this should include what should happen if there is serious 
concern over suicide risk’.ii 

Accountability and continuity of care 

Good practice, which should apply in transfers from private sector to NHS, is to 
have a clear care plan stating when one team takes over the care, and when the 
psychiatric responsibility is handed over, which is not necessarily the same 
time.  The GMC are clear that ‘doctors should establish clearly with their 
employing or contracting body both the scope and the responsibilities of their 
role. This includes clarifying: lines of accountability for the care provided to 
individual patients; any leadership roles and/or line management responsibilities 
that they hold for colleagues or staff; and responsibilities for the quality and 
standards of care provided by the teams of which they are a member. This is 
particularly important in circumstances in which responsibility for providing care 
is spread between a number of practitioners and/or different agencies’.iii  

There is also guidance on best practice for psychiatrists provided in RCPsych’s 
‘Good Psychiatric Practice:  

‘A psychiatrist must refer patients to other services or colleagues as indicated by 
clinical need and local protocols:  
(a) the psychiatrist should facilitate the smooth transfer of care between  
services, and provide a comprehensive summary of the clinical case to the 
receiving doctor/professional to enable them to take over the safe management 
and treatment of the patient 
(b) when discharging from care, the psychiatrist should inform the patient, the 
referrer and the primary care team about the possible indications for future 
treatment and how to access help in future  
(c) if there are disagreements or difficulties about transfer arrangements, the 
psychiatrist must ensure that the safety of the patient and others remains the 
first concern and must facilitate the swift resolution of any difficulties.’iv 

 
 
 
 
 
 
 
 
 
 Actions that will be taken by RCPsych 

Patients should only have one psychiatrist, and particularly only one responsible 
clinician. This is the best way to ensure good accountability, continuity of care 
and communication. Unfortunately, the College has limited power in this area, 
but will do what it can to address the problems outlined above. I have discussed 
, and we are both of the opinion that our 
this issue with our Dean, 
Professional Practice and Ethics Committee are in the best position to take 
forward the College’s actions on these issues. The next meeting of the 
committee is on 2nd November 2017 and the specific issues of: consultant 
accountability; ownership during transitions; and care where more than one 
team is involved will be on the agenda and the college’s next steps will be 
decided. 

Yours sincerely, 

Registrar 
Royal College of Psychiatrists 

i General medical Council (2013) Continuity and coordination of care  
ii Mental Health, Equality and Disability Division (2014)  Information sharing and suicide prevention Consensus 
statement  
iii General medical Council (2013) Good Medical Practice: Accountability in mental health teams 
http://www.gmc-uk.org/guidance/ethical_guidance/accountability_in_multi_teams.asp 
iv Royal College of Psychiatrists (2009) Good Psychiatric Practice CR154