William Lound

14 February 2018
PRIVATE & CONFIDENTIAL

HM Assistant Coroner Kevin McLoughlin
HM Coroner Court

INHS'

Greater Manchester
Mental Health

RECEI ED NHS Foundation Trust

45 FEB 1h Trust Management Offices
1* Floor, The Curve

Bury New Road

Prestwich

M25 3BL

Tel: 04161 357 1326
Web: www.gmmh.ohs.uk

Paderborn House
Howell Croft North
Bolton

BL1 10Y

Dear Mr McLoughlin

Re: Inquest into Mr William Lound - deceased

| am responding to the Regulation 28 issued to the Trust on 19 January 2018 following the
death of Mr William Lound.

In your letter to the Trust you have raised a number of concerns identified for Greater
Manchester Mental Health NHS Foundation Trust. | have highlighted the concerns you have
raised for the Trust and provided the Trust’s response below.

The care and treatment provided to Mr LA (Mr Lound’s attacker) in 2015/16 whilst in
the community was fragmented, lacked continuity and an appropriate management
strategy. Instead of being treated by the same team of psychiatric clinicians in 2015,
he was admitted to four different psychiatric wards during 2014. The consultants
involved in his treatment did not confer sufficient to produce a clear management plan.

As you aware following our Medical Director's statemented evidence provided at Mr Lound’s
inquest, one element of medical oversight identified by the NHSE Independent NICHE
investigation was the high rate of consultant vacancies and use of locum cover and the impact
of this on continuity and quality of care to Mr Lound’s attacker. Since the acquisition by
Greater Manchester West Mental Health NHS Foundation Trust (now GMMH) of Greater
Manchester Mental Health Trust and the commencement of the transformational work in
Manchester there has been an active drive to recruit substantive staff in all areas with
particular emphasis on inpatient wards. Since the acquisition, we can now confirm that all
substantive consultant appointments across in-patient areas within our Manchester services
have now been filled.

There is on-going work to develop a consistent divisional model of service delivery in
Manchester. This is designed so that there is enhanced continuity of care for service users
by simplifying and rationalising the service model. We have invested in clinical and
operational leadership across Manchester to drive forward this consistent clinical model. The
operational and clinical leadership of our Manchester service follows the divisional structure
e.g. Lead Consultant for North Manchester Community Mental Health Team and Home-
based Treatment Team with a Service Manager for North Community and Urgent Care.

The Trust is committed to safeguarding children, young people and vulnerable adults and
requires all staff and volunteers to share this commitment.
Greater Manchester Mental Health NHS Foundation Trust, The Curve, Bury New Road,
Prestwich, Manchester M25 3BL (Tel: 0161 773 9121)

Improving Lives

Together they chair the North Community Senior Leadership Team. There is a similar
structure in in-patient services with a Lead Consultant and Inpatient Service Manager for Park
House. Our services are clinically led and operationally partnered. This structure provides
enhanced medical leadership, closer supervision of consultants including any locum
appointments and active recruitment into vacancies are all a priority of these !eadership posts.

As part of the new organisation (GMMH) we now have a designated Strategic Lead for Patient
Flow who has reviewed the Standard Operating Procedure for managing admissions and
discharges. This role includes the following key elements:

e To monitor the use of Adult, Older Adult and PICU inpatient beds and ensure that there
are robust bed management systems and process in place across Greater Manchester
Mental Health Inpatient services. That there are clear policies and procedures, including
bed management meetings to monitor current inpatient progress, discharge planning and
transfers of care when clinically appropriate.

e Toreduce the use of Out of Area Placements and create capacity within the Trust Inpatient
Services, to enable service users requiring Inpatient care to be admitted as close to home
as possible. Consistent with their needs, recovery focused and reduce the possibility of
service users being transferred between units and teams unless it clinically indicated or
in an emergency. We are aware that Out of Area Placements have a significant impact on
continuity of care and the reduction of Out of Area Placements is a key work stream for
the trust.

e To attend professionals meetings/case conferences for complex cases as required, to
ensure all aspects of such individuals care have been considered by all relevant
professionals and external organisations involved in their care and treatment, such as
Consultant, Care Coordinator, Forensic specialist, Learning difficulty services, GMP,
Probation, Housing etc

e Lead on a Trust Wide bed management meeting that focuses on developments, new
initiatives, monitors incidents, and promotes an environment for continuous shared
learning and good practise across all in-patient services.

The Patient Flow Team have responsibility to identify high-risk individuals where the concern
regarding continuity of care is heightened and endeavour to admit to an appropriate
consultant with previous knowledge of the patient if this is possible and clinically appropriate
It is the role of the Patient Flow team to minimise multiple team involvement and to attempt
to ensure that high-risk patients will be admitted under the same team if this is possible.

The trust is reviewing all the care-planning procedures in the light of the lessons learned from
this case to ensure that there is continuity of care and a consistent management plan with
particular emphasis on high-risk individuals. Discharge procedures have also been reviewed
and high-risk patients should not be discharged without a completed formal discharge care
plan and risk assessment with consultant oversight. The discharge care plans will include
consideration of the risk of disengagement and non-compliance and the response to these.

GMMH has ensured careful consideration is being given to the management of service users
who go AWOL and the risk assessment process to be carried out prior to a multidisciplinary
team discharging them.

A variety of incidents should have alerted the clinicians and others involved in his
management to the need for a multi-disciplinary case conference or a reassessment
by an experienced Forensic Psychiatrist. Neither of these took place and in
consequence warning signs of impending violence went unrecognised. Examples
included being found by the Police in a public place in possession of a bladed article
whilst under the influence of some substance and admitting he was hearing voices
commanding him to kill people.

Patients transferred to HBT and CMHT will be considered in daily zoning meetings so that
escalating risk can be identified at the earliest opportunity and appropriate actions taken.
Zoning is a whole team approach to care enabling a targeted clinical response that can adapt
quickly to changes in service users needs and risk. It encompasses a traffic light system
whereby service users are placed in different zones dependant on level of need and risk,
which determines the type of interventions that are offered.

Patients at risk of disengagement will be considered in zoning meetings by the enhanced
CMHT and if required can be managed by the Manchester Engagement Team working
alongside the CMHT. The integration of this team and its functions in the divisional structures
is part of the ongoing transformation work in Manchester.

There is also ongoing work to enhance the provision of substance misuse treatment to
patients with closer working with the providers of substance misuse services in the city and
further training and support for CMHT staff within GMMH.

In addition we are working with colleagues in the Trust's forensic services to develop in-reach
forensic support in the management of high-risk/ MoJ patients in the community, especially
in areas such as Central West CMHT with a higher proportion of such patients. This will
facilitate improved risk assessment and management, forensic opinion and case
conferences.

Valuable background information was not circulated to those involved in the attacker’s
treatment with the result that they were deprived of the crucially important medical
history that would have signposted the potential risks (particularly if the attacker was
no longer taking the medication which controlled his schizophrenia and had once
again resorted to using illicit drugs). An example of this concerns a 20 page Discharge
reported prepared in January 2013 by a Consultant Forensic Psychiatrist at the time
the attacker was being prepared to leave Ashworth High Security Psychiatric Hospital.
This was not seen at the material time by the Care Co-ordinator, the GP nor the
Consultant Psychiatrist who undertook treatment on two different psychiatric wards
and in the community.

Patients with a significant forensic history are now being identified on the newly developed
special notes system within AMIGOS the current Electronic Patient Record used in our
Manchester services so that individuals presenting will have care plans and discharge plans,
which are informed by these risks.

GMMH has developed a business case to introduce the PARIS electronic clinical record
system bring our Manchester services in line with the wider Trust. This has now been
approved by the GMMH Trust Board and will be introduced over the next 12-15 months. This
will further enhance accessibility of these assessments to the treating teams.

On three occasions during 2015 other clinicians who encountered the attacker
recommended that a Mental Health Act assessment be considered with a view to the
attacker being sectioned. These recommendations were not acted upon. Judgements
were made by Consultant Psychiatrists that the attacker was not detainable. These
judgements merited a second opinion at the last, preferably by a Forensic Psychiatrist.
Had the issues been evaluated with the benefit of the forensic history, the attacker’s
propensity to violent conduct may well have triggered a Mental Health Act
Assessment.

Following learning from Mr Lound’s death GMMH are currently developing proposals for
forensic in-reach to support Consultants, CMHTs and in-patient services in Manchester,
particularly around second opinions of service users. We are specifically looking at job
planning forensic sessions in areas of Manchester with increased numbers of high-risk
patients to offer timely access to support advice and expertise in managing these complex
cases.

The Trust transformational work streams have also identified the importance of the enhanced
community model. One key element of this is to complete a caseload review in terms of both
number and complexity of patients. We have also identified enhanced supervision of
caseloads and review of complexity to ensure that workers are appropriately supported. As
part of this work we have also identified the need to reduce consultant only caseloads
significantly to ensure that the consultants are fully engaged with the multi-disciplinary teams
for discussions on zoning, risk and prioritisation of high risk patients.

Gaps in record keeping hindered by the co-ordination of treatment. Examples included
a void in the medical notes to explain why the murderer had been transferred from one
acute psychiatric ward to another (with a different consultant and clinical team), a
discharge in his absence taking place on 8 October 2015 without any record of a risk
assessment having been produced or a pian as to how he was to be followed up and
who was to be notified, nor an explanation as to who had authorised the “discharge in
absence” and why this was done.

GMMH has developed a rolling programme for all healthcare professionals promoting the
importance of good record keeping. This training is currently being delivered across our
Manchester services and will incorporate the lessons learned raised following Mr Lound’s
death.

The importance of good record keeping will form an active part of the ongoing audit
supervision of all clinical staff.

Yours sincerely
Md, y

Beverley Hufmphr

Chief Executive