Julia MacPherson

ae Oxleas AYE
mor OvIng {ves NHS Foundation Trust

Oxleas NHS Foundation Trust

26 March 2018

Pinewood House
Private and Canfidential Pinewood Place

Dartford

Ms Sonia Hayes Kent
Assistant Coroner DA2 7WG
c/o Ms Tracey Bishop
Clerk to The Coroner's Court Tel: 01322 625034
Coroner for South London Area Fax: 01322 625727
Floor 2, Davis House Website: www.oxleas.nhs.uk
Robert Street
Croydon, CRO 1QQ
Dear Ms Hayes

RE: Preventing Future Death Report touch the death of Julia Jane MacPherson, age 54

Thank you for your letter of 14" of February 2018, which we received on the 16" of February 2018,
requiring a response by the 6" of April. The Assistant Coroner, S Hayes identified concerns and requested
details of actions that were being taken to address these.

Each matter of concern is addressed in turn:

(1) Ms MacPherson‘s mother requested a medical review for her daughter as she had concerns about
her presentation following the introduction of Clozapine which had been prescribed off license. A
note was left with nursing staff for her Responsible Clinician. The review did not take place os her
Responsible clinician did not see the note. Ms MacPherson was not reviewed on the 16” of May. A
review of her capacity to consent to treatment did not take place either even though her mother
had expressed concerns on the 15" of May and staff found her to be confused on the 17" of May.

The Trust has developed a Multidisciplinary Team (MDT) meeting template following a quality
improvement project to enable every member of the MDT to contribute to the review. There is a section
for families, carers and significant people in a service user’s life in which any concerns raised are
documented to ensure these are discussed in the meeting and agreed actions to address issues outlined.

Capacity assessments for treatment and other decisions are also reviewed at the MDT meeting and
documented to ensure that patients continue to retain or otherwise capacity to consent to treatment.

A recent audit of the use of the MDT template and capacity assessments have shown that it is being used
and that the views and concerns of families are being addressed. These audits will be carried out ona
regular basis to give assurance to the trust.

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(2) Evidence at the inquest was that hospital staff did nat regularly read clinical and nursing entries in
patient records.

The MDT template that has been developed ensures each Multidisciplinary team member /profession
provides information that should be taken account of in the meeting. This is reviewed in the meeting and
plans are formulated based on the information and discussion.

{n addition, our Medical Director, Dr Okocha will write to all consultants in the Trust reiterating the
expectations that they check and read notes which are written by their trainees and other staff.

(3) Medical records concerning discussions about her capacity to consent to the prescription of off
license medication for her mental health were missing or incomplete despite the concerns being
raised about confusion and sedation. NICE guidelines for the prescription of off licence medicines
were not followed.

Although NICE does not issue specific guidance for the use of off licence medications, the General Medical
Council and various Royal Colleges including the Royal College of Psychiatrists have issued advice for
doctors when prescribing outside of license. A letter with the respective guidance will be sent to all
doctors reminding them that they must follow these in practice. In addition, an educational meeting will
take place before the end of summer to reminder doctors of the guidance and ensure that it is being
followed in practice. Trust doctors (consultant and non-consultant grade) are expected to include this in
their appraisals and reflect on how this has changed their practice.

(4) Patients detained under the Mental Health Act have statutory forms that lists all psychiatric
medication that can be administered either on T2 (patient consents) or on T3(patient does not
consent), this requires the approval of a Second Opinion Appointed Doctor{SOAD). There is no
statutory process for recording consent to medication for informal patients.

The Trust will make clear its expectations of all doctors to regularly assess and document capacity and
consent to treatment for informal patients. This should be done as part of the weekly MDT review process
and where there are concerns about a patient’s capacity to understand treatment then the patient's
informal status must be reviewed and detention sought. This will ensure that such patients come under
the statutory process described above. For patients prescribed off-license medication, the ward
pharmacist will review the medications and ensure that all processes: discussion with patient and relatives,
on-going capacity assessments and efficacy of treatment and risk/ benefits have been checked and are
documented. If there are any concerns these will be shared with the consultant prescribing the
medication and their Clinical Director.

| hope that my response has addressed your concerns.

Yours sincerely

Heft

Helen Smith
Acting Chief Executive
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Care Quality London Region

Commission Care Quality Commission
Citygate

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Ms'Sonia Hayes *
Assistant Coroner Tal
Coroner for South London Area

Floor 2, Davis House

Robert Street

Croydon CRO 1QQ

Fax: 03000 616172
www.cqc.org.uk

26 March 2018

Care Quality Commission
Our Reference: MRR1-5003472374

Dear Sonia Hayes

Regulation 28: report to prevent future deaths following the inquest of Julia
Jane MacPherson

Following the inquest into the death of Julia Jane MacPherson, the Care Quality
Commission (the ‘CQC’) received a copy of the Regulation 28 report from the
coroner with a letter dated the 14 February 2018.

We note our legal responsibility to submit a written response to you, however some
of the matters of concern relate to the very specific circumstances of Julia
MacPherson’s individual care and treatment, so we are unable as a regulator to
comment on this.

Since Julia Jane MacPherson’s death in May 2016, we have inspected Oxleas NHS
Foundation Trust once. This was a follow up inspection of the acute wards in the
Trust, including Norman Ward, in February 2017 to see if some specific
improvements had taken place since the comprehensive inspection in April 2016.
We also carried out regular visits by our Mental Health Act reviewers, and the last
one took place on Norman Ward in March 2017.

Matters of concern:

Telephone: 03000 616161

Timeliness of medical reviews and assessment of capacity:

At our inspection of the acute wards, including Norman Ward in April 2016, we found

that there were adequate numbers of medic staff and we do not specifically
|. mention any difficulties with the timeliness @iimedical reviews. We noted that
patients had access to a multi-disciplinary = @

2005. However, at the Mental Health Act review visit in March 2017, it was found
that two patients had been prescribed high dose anti-psychotics. For one of the two
patients, the use of high dose antipsychotics was discussed but no capacity
assessment was found.

Staff not regularly reading clinical entries in patient records:

Our report following the inspection in April 2016 does not specifically mention staff
regularly reading clinical entries in patient records. It does, however, note the regular
handover meetings for core staff to share information about the patients.

Patient records not including a record of discussions when medication is used
outside of its licenced indication:

Our report following the inspection in April 2016 said that 70 patient records were
inspected. The report does not specifically mention the absence of recorded
discussions or decisions in individual patient records for the use of medicines
outside of its licenced indication.

Prescribing not in line with NICE guidance:

The inspection in April 2016 looked at 105 medicine administration records and
concluded that NICE guidance was being followed when prescribing medicines. We
did record that three patients were being prescribed medicines outside of the usual
levels, but do not raise any concerns about how that was being managed.

Recording consent to medication for informal patients:

Our report following the inspection in April 2016 does not specifically mention how
consent to treatment was recorded for informal patients. It does however say that
informal patients were given a leaflet explaining their rights.

We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We
intend to follow through some of the areas of concern in more detail. This will be to
ensure the trust has learnt from this and made the necessary improvements.

If you require any further information please do contact the Inspection Manager
Judith Edwards who can be reached through our main switchboard number 03000
616161 or by email at judith.

Yours sincerely

|
Head of Hospital Inspections (Mental Health)

ae From Jackie Doyle-Price MP

Parliamentary Under Secretary of State for Mental Health and Inequalities

Department Department of Health and Soca Care
39 Victori
of Health ictoria Street
SWIH OEU
Our reference: PFD 1120331
Ms Sonia Hayes
HM Assistant Coroner South London 08 MAY 2018

Coroner’s Service
Floor 2, Davis House
Robert Street
Croydon

CRO 1QQ

Deo An Hees ,

Thank you for your letter of 14 February to the Secretary of State about the death of
Ms Julia Jane MacPherson. I am responding as Minister with responsibility for |
Mental Health and I am grateful for the extra time in which to do so.

Your report raises several areas of concen, most of which are operational matters for
the Oxleas NHS Foundation Trust.

I wish to provide comment in relation to the area of concern that there is no statutory

process for recording consent to medication for voluntary (or informal) patients |
receiving mental health treatment, as there is for patients who are detained under the

Mental Health Act.

As you will be aware, voluntary patients should have the capacity to understand and

provide consent to their treatment. Voluntary patients should be given sufficient

information by their responsible clinician about proposed treatment to make an

informed choice. The capacity of voluntary patients to give consent to treatment

should be regularly assessed and considered by the multidisciplinary team supporting

the patient. Where there are concems about the patient’s capacity, the patient’s |
voluntary status should be reviewed and detention sought where clinically

appropriate. Chapter 14 of the Mental Health’s Act’s Code of Practice’ discusses

how this should take place.

It is sadly regrettable that on this occasion a medication review and a review of Ms
MacPherson’s capacity to consent to treatment did not take place.

Learning lessons where things have gone wrong is essential to ensuring the NHS
provides safe, high quality care. I am aware that the Trust has responded to you on
these matters separately advising the Steps it is taking to address the areas of concern
highlighted. This includes additional safeguards for patient’s prescribed off licence
medication whereby the ward pharmacist will review the medications and ensure that
all processes, including capacity assessments and efficacy of treatment, are being
checked and documented, bringing any concems to the attention of the responsible
clinician and clinical director.

I understand that the Care Quality Commission (CQC) has responded to you to advise
that its comprehensive inspection of the Trust conducted in 2016 did not highlight
any significant issues around the areas of concern highlighted through the Inquest
into the death of Ms MacPherson. CQC will be returning to the Trust later this year
and will ensure the Trust has made the necessary improvements. I hope this provides
further assurance.

Thank you for bringing the circumstances of Ms MacPherson’s death to our attention.

JACKIE DOYLE-PRICE