Alan MacDonald

aX

addcounsel

28 Grosvenor Street
Mayfair
London
W1K 4QR
29" March 2018

Dear Madam

Re. Regulation 28 Report to Prevent Future Deaths following the inquest touching the
death of Alan Macdonald (date of death 29.08.17)

| write in response to your Regulation 28 (PFD) Report dated 21 February 2018. This has
been carefully reviewed and | now set out my response below.

1. Addcounsel's clinical director, a non-medically qualified counsellor, continued to visit Mr
MacDonald while Mr MacDonald was being treated as an inpatient at the Nightingale by
a consultant psychiatrist...The daily Addcounsel visits inevitably entailed further cost to
Mr MacDonald, as well as the additional cost of going through Addcounsel to the
Nightingale in the first place, without giving treatment in return.

As set out in your Report, this issue has been addressed and the actions set out in the
Client Death Review undertaken following Mr MacDonald's death have now been put in
place. Our system has changed in the following ways:

e If actlient is not going to be treated by Addcounsel they are discharged entirely to the
care of the service that is deemed more suitable at the time (in Mr MacDonald's case
this would have been the Nightingale Hospital) and this is recorded clearly in the
client’s notes. At Addcounsel we now only case manage clients to whom we are
delivering services.

e If Addcounsel services are later requested, for example following discharge from a
psychiatric hospital, then a new referral will need to be made.

e When aclient is discharged to the care of another service they are clearly recorded
in our record as ‘discharged’. The record will need to be reopened if they return to
Addcounsel services at a later date.

e Where Addcounsel are not providing any immediate care, the financing of any
onward referral and treatment is now handed over entirely to the new provider who
will deal with this directly.

¢ | have written to the Medical Director at the Nightingale Hospital and requested to
meet with him in order to discuss the changes to our processes; and to ensure that
there is a clear communication channel between us and that everyone has a clear
understanding of how our referral process will work.

¢ [will also be writing to the other organisations to which we refer patients to ensure
our process is clearly set out and understood; and that everyone has a common
understanding of how we will work going forwards.

2. One of Mr Macdonald’s worries, expressed at consultation with his psychiatrist when
Addcounsef's clinical director was present, did centre on his financial situation. He was
very anxious that his money was running out and he was not earning while he was in
hospital (After discharge from hospital, he told a friend that he had paid Addcounsel
£20,000, and was not going to pursue follow up treatment)...Despite the fact that the
Addcounsei clinical director knew of Mr MacDonald's money worries, he neither brought
this to the attention of Addcounsel’s relationship director, the person responsible for
charging Mr MacDonald, to enable consideration to be given to reducing the charges;
nor did he highlight to Mr MacDonald the potential to access care via the NHS.

| would like to take this opportunity to highlight that our understanding of the evidence
was that Addcounsel's clini j Michael Ishmail, was present on one occasion
when Mr MacDonald lie financial concern was sometimes a trigger for
his depression/anxiety; this was during the initial assessment on the day of admission to
the Nightingale Hospital. The reference in the PFD report to Mr MacDonald stating that
‘he was very anxious that his money was running out and he was not earning while he
was in hospital is presumably a reference to a comment made later on during his period

inpatient, to an employee of Nightingale Hospital and, | would say, not in a

presence. Further, it is important to highlight that the reference to £20,000

includes the cost of Mr MacDonald's Stay and treatment at Nightingale Hospital and is
not representative of the cost of Addcounsel’s services alone.

When Addcounsel was set up we made a conscious decision to keep the discussion of
finances separate from the therapeutic process, to avoid the latter being compromised.
We still maintain that it is not the role of the clinician/therapists to discuss the cost of
treatment with a client and this is why we employ a dedicated relationship manager to do
this. However, we do recognise and appreciate that in a situation such as Mr
MacDonald's, there needs to be a system in place to make sure that Clinicians/therapists
are able to bring relevant financial concerns to the attention of the relationship manager.

We are therefore in the process of writing a new policy to cover such situations. This
policy will create a ‘red-flag’ in relation to a client making any reference to concerns
about finances; the cost of treatment etc. The policy will state the following:

¢ Any time a reference is made to finances this is and (with the

consent of the client) communicated in writin or Addcounsel’s
clinical operations —

. discuss this with our relationship director,
ill then be able to have a discussion with whoever is
counsel's services (either the client themselves or sometimes a

third-party) in order to look at possibilities in terms of reducing costs and/or

finding an alternative treatment provider which might, in some situations, be the
NHS. This system would ensure that the client’s financial concerns are
addressed and an opportunity is given for them to reduce the services provided
by Addcounsel and/or seek treatment by an alternative provider.

© This policy will need to be agreed by our Independent Governance Committee
and we hope to have it in place by the end of May 2018. It will then be distributed
to each member of our multi-disciplinary team (MDT) by Michael Ishmail with a
clear reminder of the process to follow in relevant situations.

Pending ratification of the policy we have already put in place interim measures to ensure
our MDT is aware of this change in practice. Discussions have taken place and|

will write to every member of our MDT to advise them about the new policy which
will be coming into place at the end of May 2018 and to give them instructions as to how
to approach relevant situations in the meantime. Members of the MDT will be told to bring
any concerns t ‘© be dealt with appropriately (and in a way which
reflects the new system coming into place).

We are also exploring ways in which we can put in place increased investigation into a
client's ability to pay for Addcounsel services when they first approach us. We are in the
process of re-writing our ‘Terms and Conditions’, which are provided to all clients when
they first register with Addcounsel; and consideration is being given to including
information within this document about the bespoke nature of the treatment provided by
Addcounsel and the resulting financial implication of this. We always aim to ensure that
all clients are fully aware of the type of service they are signing up to and the likely costs
involved, so that they can withdraw if they feel it is not suitable for them.

| hope you are reassured by my response to the concerns you have raised in relation to
Mr MacDonald's sad death, the circumstances of which have been discussed at length
and the implications for Addcounsel acknowledged.

Yours faithfully,

X

Mr Paul Flynn
CEO and CQC Nominated Individual