Nigel Malloy

NHS

Hampshire Hospitals
NHS Foundation Trust

Management Offices

Basingstoke and North Hampshire Hospital
Aldermaston Road

Basingstoke

Hampshire

RG24 SNA

Direct Dial: 01256 313035
Email: alex.whitfield@hhft.nhs.uk

Senior Coroner
Coroner’s Office
Castle Hill
Winchester
$023 8UL
07 September 2018

By e-mail only to: hampshirecoroners@hants.gov.uk

Dear Sir
Inquest in relation to the death of Mr Nigel Malloy

| acknowledge receipt of the Prevention of Future Deaths Report dated 19 July 2018 (the “Report”), issued to
Hampshire Hospitals NHS Foundation Trust (the “Trust”), under paragraph 7, schedule 5, of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Firstly, on behalf of the Trust, | offer my sincere condolences to the family of Mr Malloy, to whom | am very
sorry for their loss. The Trust’s alcohol liaison team remember Mr Malloy well and were saddened to hear of
his death, they too would like to offer their condolences.

| note there appears to be three concerns in the Report, which require a response from the Trust. | set out
below each concern which relates to the Trust, together with our response. It is unfortunate that the Trust was
not included in the Inquest so we did not have an opportunity to share our records and address these concerns
at the time, together with any other concerns yourself or Mr Malloy’s family may have had.

1. Mr Malloy had multiple admissions to the Emergency Department at Royal Hampshire County
Hospital (part of the Trust) but was then discharged once sober without any follow up.

Please find attached a brief chronology of Mr Malloy’s admissions to the Trust’s Emergency Department in so
far as they relate to alcohol use (Appendix 1) which we hope will provide assurance to yourself and Mr
Malloy’s family. We are of course happy to share the full records which provide more detail if this would be
helpful.

As you will see, numerous attemps were made to support Mr Malloy and to encourage him to engage with the
help available but he had capacity to make his own decisions.

The Trust alcohol inclusion service is predominantly an inpatient service (as there are external providers who
cover outpatient services) however they do run a fortnightly outpatient clinic. It is recognised that this clinic is
not frequent enough for chaotic patients and therefore Inclusion is the most appropriate service for them
however as Mr Malloy was initially not willing to enage with Inclusion, an outpatient appointment was

Hampshire Hospitals NHS Foundation Trust includes Chairman: Elizabeth Padmore
Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital Chief Executive: Alex Whitfield
and Royal Hampshire County Hospital

www.hampshirehospitals.nhs.uk

arranged so that there was some follow-up on how he was doing. Unfortunately he did not attend, however
shortly after he re-attended A+E and thereafter seemed willing to engage with Inclusion.

As well as regular liaison with Mr Malloy the Alcohol Liaison team spoke with his family to provide support and
information about the services available and the Trust provided summaries to his GP after each admission as
set out in Appendix 1.

2. On 22” September 2017, Mr Malloy referred himself to the Inclusion Service provided by South
Staffordshire and Shropshire NHS Foundation Trust (SSSFT).

The Trust’s alcohol liaison team faxed a referral for Mr Malloy to Inclusion on 21.09.17 at 15:44 and also spoke
with them on 22.09.17 to let them know the referral had been made and to arrange for Mr Malloy to attend
the following day. A copy of the referral is attached (Appendix 2) and you will see that it includes details of the
previous admissions to the Trust and the advice that Mr Malloy had been given.

Referrals to Inclusion can be made in two ways; if the Patient consents, the Trust can make a referral using the
24 hour referral service (as happened on 21.09.17) or the Patient can self-refer. Where a patient does not
consent to the Trust making a referral they will be advised to self refer and provided with a leaflet and
information about how to do so and the service that Inclusion provides.

Mr Malloy had been counselled about engaging with Inclusion during his previous admissions in August
however at that time was unwilling to do so and would not authorise for the Trust to make a referral.

On 20.09.17 the Trust’s alcohol liaison team received a phonecall from Mr Malloy’s family who were concerned
about the state he was in. During this phonecall there was discussion of the Inclusion service run by SSSFT and
the importance of Mr Malloy engaging with the same to ensure that he was seen more regularly. The alcohol
liaison team subsequently saw Mr Malloy during his admission on 21.09.17 and he was again counselled in
relation to engaging with Inclusion and on this occasion agreed for a referral to be made as outlined above.

Prior to Mr Malloy’s discharge on 22.09.17 he was informed that the referral had been made and an
appointment with Inclusion scheduled for the following day which he indicated he would attend. The alcohol
liaison team checked with Inclusion shortly afterwards that Mr Malloy had attended the appointment as
planned and they confirmed that he had; a keyworker had been assigned and Mr Malloy was engaging with
that keyworker. Usual practice is then that Inclusion provide support and follow-up for the patient.

3. There was no sharing of information between the Alcohol Liaison Service provided by the Trust and
the Inclusion Service provided by SSSFT or coordinated plan to treat his alcohol dependence.

As per our response to point 2 above, the Trust made the initial referral to Inclusion on 21.09.17 and
subsequently liaised with them to arrange Mr Malloy’s first attendance and ensure that Mr Malloy had
attended as planned.

When Mr Malloy was subsequently re-admitted to the Trust in October 2017, the Trust spoke with Mr Malloy’s
keyworker at Inclusion on a number of occasions to provide an update on how Mr Malloy was doing and the
treatment he was receiving. Inclusion were also informed on the day of discharge that Mr Malloy had been
advised to present at Inclusion. We can see that during Mr Malloy’s admission from 16" to 20" October 2017
there was liaison with Inclusion on 17°, 18" and 20" October.

During this admission Mr Mailoy was also re-counselled regarding the importance of continuing to engage with
Inclusion together with the advice to attend there on discharge. There was also liaison with Mr Malloy’s GP
from both Inclusion and the Trust.

Our next contact with Inclusion was 2 November 2017 when Mr Malloy had failed to attend an appointment
with them, we confirmed that he was not an inpatient at the Trust’s hospitals and later heard that he had sadly
died.

In addition to the above liaison, the Trust also engages with a High Intensity User Group which identifies
patient’s who are frequent attenders and involves monthly liaision between the Trust, Inclusion and Southern
Health. Mr Malloy was identified as a high intensity user and his case would have been discussed at the group
to see whether there was any further support which could be provided.

Actions
In summary the actions already in place/taken are as follows;

e A24 hour referral service and dedicated pathway with Inclusion

e Leaflets available about Inclusion Service to provide to patients

e At the time of Mr Malloy’s admissions to the Trust, Inclusion were running a weekly inreach service on
a Sunday.

e Inclusion currently provide an adhoc inreach service where they attend on arrangement or if they are
visiting one of their service users who is a current inpatient

e Regular telephone liaison between Inclusion and the Trust when one of their users is an inpatient or in
relation to referrals

e Liaison when Inclusion are onsite to find out how patients we have referred to them are getting on
Referrals made to Mental Health Provider for assessment

e Monthly High Intensity User Group involving multiple providers to discuss whether there is any further
support which can be provided to high intensity users such as Mr Malloy

e There are ongoing discussions between Public Health England Commissioners, Hampshire County
Council, Mental Health Services and Primary and Secondary Care to improve the quality and access to
services for those impacted by these types of illness.

I trust that this provides assurance that the concerns raised have been investigated and promptly addressed by
the Trust. Should there remain any further concerns, | would welcome the opportunity to address these for
you.

Yours faithfully 4
Alex Whitfield :

Chief Executive .
Hampshire Hospitals NHS Foundation Trust