Robin McEwan

Email: 
Direct Tel: 01423 799318 
Reference: HaRD.008-19 

SENT VIA EMAIL 

Coronersadmin@northyorks.gov.uk 

Harrogate and Rural District  
Clinical Commissioning Group 
1 Grimbald Crag Court 
St James Business Park  
Knaresborough 
HG5 8QB 

Tel: 01423 799300 
Fax: 01423 799301 
Email: hardccg.enquiries@nhs.net 
Web: www.harrogateandruraldistrictccg.nhs.uk 

 25 January 2019 

Dear Mr Bainbridge 

Re:  

Inquest Touching the Death of Robin Andrew James McEwan.  

Thank  you  for  your  Regulation  28  Report,  dated  10  October  2018,  requesting  further  information  from 
NHS Harrogate and Rural District Clinical Commissioning Group (hereafter ‘the CCG’), and for granting 
an extension of time for providing the response until 25 January 2018. I was extremely sorry to learn of 
the death of Mr McEwan and my thoughts are with his family. 

I note the concerns raised with the CCG and have responded to each in turn below. 

Mr  McEwan  had  been  using  private  counselling  services  for  CBT.  No  reports  from  the 

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service providing that service to the patient were supplied to the GP. 

If  there  had  been  statutory  mental  health  care  instead,  one  might  expect  some  connection, 
particularly  if  medication  was  to  be  prescribed.  One  would  expect  sharing  of  information  both 
ways in the interests of the patient and his ongoing treatment(s). 

What policies/procedures/advice/standing instructions/guidance etc. do you have for GPs, aware 
of such treatments, or referring the patient for them, to require and have a two way dialogue? 

Put  another  way,  how  do  you  currently  address  the  way  to  remove  any  disconnect  in 
communication as occurred in Mr McEwan’s case. 

If you have no such means, then what do you intend to do about that to prevent future deaths? 

The CCG will review the current process in Primary Care to ensure that when GPs refer an individual for 
private  counselling,  they  request,  with  patient  consent,  a  timely  update  on  the  patient’s  progress  to 
enable a proactive person-centred dialogue to occur regarding the best way to meet the patient’s needs 
through  their  episode  of  care.   The  CCG  needs  to  ensure  that  a  consistent  approach  is  taken  across 
North Yorkshire to address the issue that private counselling services do not routinely share information 
back into Primary Care.  This is a safeguarding issue which affects a vulnerable group of patients which 

Accountable Officer – Amanda Bloor 
Clinical Chair – Dr Alistair Ingram 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the CCG fully acknowledges and is committed to addressing as detailed within the attached action plan 
(appendix one; point 3). 

As a response to NHSE’s Guidance on Co-Locating  Mental Health Therapists in Primary Care, August 
2018,  the  CCG,  on  behalf  of  the  North  Yorkshire  CCGs,  is  commissioning  trained,  first  contact  mental 
health  workers  based  within  GP  Practices  who  will  be  Improving  Access  to  Psychological  Therapies 
(IAPT) compatible.  It will be rolled out this year once training has been completed, and will help support 
a  clinically  consistent  and  responsive  approach  for  initial  access  to  mental  health  within  primary  care 
across North Yorkshire. 

 Have  you  a  view  about  “Zero  Suicide  Alliance”?  Are  your  Group  subscribed,  or 
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subscribing, to its approach as others do, according to the evidence heard at the hearing? If not, 
why not? If not, then is/are there any other primary care approach (es) your Group refers to GPs 
as good practice? (other than those contained in NICE Guidelines). 

‘Zero Suicide Alliance’ is currently being considered by the North Yorkshire Suicide Strategic Partnership 
Group, of which the CCG is a member. The ethos of the approach promoted by ‘Zero Suicide Alliance’ is 
captured within the North Yorkshire Multi-Agency Suicide Prevention Plan.  The plan is being adopted by 
our local Sustainability and Transformation Partnership Boards (STPs), and Tees Esk and Wear Valley 
NHS  Foundation  Trust  (TEWV)  from  whom  the  CCG  commissions  Secondary  Care.  The  CCG,  Public 
Health  England  and  TEWV  work  in  partnership  through  the  Suicide  Prevention  Task  Group  and  can 
access small funding streams to support initiatives to help to prevent suicide.  The available STP funding 
focuses  on  the  development  of  a  range  of  targeted  support  to:  address  the  reduction  of  stigma  and 
discrimination,  develop  mentally  healthy  communities  and  workplaces,  reduce  loneliness,  social  and 
emotional isolation and reduce suicide. Through strengthening our partnership working and collaboration, 
and  developing  the  GP  Suicide  Prevention  Lead  role  for  North  Yorkshire,  we  can  map  all  sources  of 
funding identified, which can be used to support developing stronger support within Primary Care. 

Through the Mental Health & Learning Disability Strategic Partnership Board and our development of a 
GP Best Practice Lead for North Yorkshire on Suicide Prevention, the CCG will encourage providers to 
have  the  training  offered  through  the  North  Yorkshire  Suicide  Strategic  Partnership  Group.    The  CCG 
fully supports the Secretary of State’s position that "Every suicide is a preventable death and there’s so 
much more we can do to reduce the number of people lost to it. The Zero Suicide Alliance’s new training 
and awareness tools will help health and care staff recognise the signs and step in before it’s too late, as 
well as ensuring openness and transparency when suicides do occur" 

What  diagnosis  and  self-help  tools  are  commended  to  GPs  for  the  care  of  patients  with 

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mental health problems in primary care? (other than NICE Guidelines). 

If  none  are  commended  and  GPs  are  left  to  select  for  themselves,  which  are  stated  to  be  ones 
that should be avoided, and why? 

What  policies/procedures/advice/standing  instructions/guidance  etc.  do  you  have  in  selecting 
self-help tools, if any? 

What financial support is offered when such tools are not free of charge to the patient? 

How can a GP help prevent future deaths in this way? 

Primary Care use a range of tools to care for and support patients with mental health problems which are 
recommended by the CCG.  The PHQ9 (Patient Health Questionnaire) and GAD 7 (Generalised Anxiety 
Disorder) questionnaire offers clinicians self-administrating screening and diagnostic tools for a range of 

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 mental health disorders; both are routinely used  in Primary Care and as part of the referral process  for 
the North Yorkshire IAPT Service by GPs.  Silver Cloud is a free resource for patients to use through its 
site once they have been accepted into the IAPT Service.  IAPT has an open referral process whereby 
an  individual  can  contact  the  service  directly,  either  through  the  TEWV  website,  linked  via  the  CCG 
webpage, or contacting the Service by phone.  A person does not require the need to be referred by their 
GP.  If a patient is assessed by a GP as experiencing a severe and debilitating mental health condition 
then the patient would be referred to Secondary Care. 

The CCG, as part of the Mental Health and Learning Disability Strategic Partnership, will be considering 
how  the  CCG’s  website  can  be  further  developed  to  include  a  portal  to  promote  initiatives  such  as  the 
Living  Well  in  North  Yorkshire  scheme  run  by  North  Yorkshire  County  Council  aimed  at  tackling  social 
isolation.  The CCG, as detailed in the attached action plan (appendix one; point 5) will review its website 
to  include  shared  best  practice  and  innovation,  developed  both  locally  and  elsewhere,  to  include 
initiatives such as Time to Talk and Community Living Well for both patients and GPs. 

4.   
What  policies/procedures/advice/standing  instructions/guidance  etc.  do  you  have  (other 
than  NICE  Guidelines)  for  GPs  (assuming  a  patient  consents)  to  bring  in  support  of  family  (as 
NICE  Guidelines  set  out)  for  mental  health  support/care  “scaffolding”?  How  could  that  be 
arranged? 

Would the Group accept that while a patient may have to wait a long time for statutory services 
(unless  in  obvious  crisis),  questioning  about  and  planning  for  the  security  and  safety  of  the 
patient must be a priority in the interim. What other safety planning steps might be commended? 

In the contexts of preventing future deaths and the increasing concern for managing the mental 
health  of  the  Group’s  population,  what  training  would  you  expect  your  GPs  to  have  re  mental 
health  in  Primary  Care?  What  CPD  courses  can  you  identify,  for  example,  upcoming  that  are 
relevant which might be available to your GPs? 

The  GPs  in  North  Yorkshire,  with  the  consent  of  the  patient,  liaise  directly  with  carers,  families,  and 
mental  health  services  at  an  initial  stage.  In  January  2019,  North  Yorkshire  Public  Health  England 
launched  a  self-harm  e-pathway  for  Children  and  Young  People  living  in  North  Yorkshire,  aimed  at 
professionals  who  support  them.  The  plan  is  to  develop  a  similar  pathway  for  adults,  following  the 
evaluation  of  this  initiative.    Some  GP  practices  have  specific  service  information  available  within  their 
practices  and/or  on  their  website  for  staff,  patients,  family  members  and  carers,  detailing  specialist 
support, but this is a variable picture across North Yorkshire. The development of a web based resource 
for everyone to access consistently has been identified by Primary Care as a need.  The North Yorkshire 
Mental Health Helpline is a countywide out of hour’s service offering mental health support and advice to 
people who may be concerned about their health or someone they care for.  This service is jointly funded 
by  Health  and  Social  Care  and  is  provided  through  Nottingham  Community  Housing  Association  who 
have specially trained staff.  

Public Health England has approached the CCG to help promote the awareness of MIRT (Major Incident 
Response Team) in North Yorkshire for GPs.  MIRT is a confidential support service for people who are 
caught  up  in  a  distressing  sudden  event  ‘outside’  normal  life,  and  who  provide  support  to  families 
bereaved by suicide.  Supporters are trained in Mental Health and Psychological First Aid, Safe Talk and 
Assist  Skills.    A  jointly  funded  website  with  NHSE,  Staying  Safe,  developed  by  4  Mental  Health,  is 
another  potentially  life-saving  resource  that  our  communities  have  access  to,  including  input  from 
survivors of suicidal thought, bereaved families and friends.  It provides information, guidance tools and a 
vital ‘safety plan’. All information is in an assessable format.   

There are a variety of training packages available such as We Need to Talk About Suicide, developed by 
Public Health and Health Education England.  These support all public sector professionals to feel more 

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 confident  talking  about  self-harm  to  someone.    GP  Continued  Professional  Development  is  voluntary, 
and unlike safeguarding, there is no mandated mental health training despite the latter often overlapping 
with the same vulnerable patient groups.  

The  CCG  accepts  there  is  further  work  that  needs  to  be  done  to  share  best  practice  regarding  suicide 
prevention and to promote the training available for GPs within Primary Care.  In addition, the CCG will 
look at providing additional training opportunities to GPs through their Protected Learning Time sessions 
and review how current safeguarding training could potentially incorporate suicide awareness.  

Actions for the CCG to take forward: 

1.  To  develop  stronger  links  between  the  CCG  GP  Lead  for  the  Prevention  of  Suicide  and  North 
Yorkshire Public Health. 

2. To review awareness of, and access to, GP training in suicide prevention across North Yorkshire. 

3. To review the referral process in Primary Care when referring patients to private counselling services 
with  the  aim  of  ensuring  GPs  are  informed  regarding  progress  of  patients  who  have  engaged  in 
counselling services so that they can offer appropriate support if needed. 

4.  To  look  at  the  development  of  Mental  Health  &  Psychological  First  Aid  within  Primary  Care  and  the 
CCGs. 

5. To review and further develop the CCG website to promote mental health and suicide prevention for 
both the public and professionals.  This will include ensuring the availability of self-help tools and support 
tools for carers/relatives/friends of patients suffering from mental health issues. 

6. Finally, the CCG would like to offer the family of Mr McEwan, with their permission, the opportunity to 
undertake a Serious Incident Review into the specific concerns that his death has raised, to enable us to 
learn any lessons from his tragic death to prevent future suicides from occurring. 

A  full  action  plan  is  attached  as  an  appendix  giving  each  action  a  timescale  for  completion  within  six 
months.  This work will start with  immediate effect and  will  be reported through  the CCG’s Quality  and 
Governance Committee as part of our governance and assurance framework. 

The CCG is committed to ensuring that the services commissioned for adults with mental health illnesses 
are both responsive and of high quality.  The CCG is keen to reflect on the services commissioned with a 
view  to  making  improvements  and  avoiding  future  patient  harm.  Thank  you  for  raising  these  concerns 
with  the  CCG.  I  hope  you  feel  that  the  information  provided,  together  with  the  actions  outlined  above, 
fully addresses the concerns raised. 

Yours sincerely 

Accountable Officer  - North Yorkshire Clinical Commissioning Groups  
NHS Hambleton and Richmondshire Clinical Commissioning Group  
NHS Harrogate and Rural District Clinical Commissioning Group  
NHS Scarborough Ryedale Clinical Commissioning Group  

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