John Kirby

A mernber of:

Association of UK University Hospitals Sussex Partn ership

NHS Foundation Trust

Swandean

Arundel Road

Ms Hamilton-Deeley Weer ens
The Coroner's Office BN13 3EP

Woodvale, Lewes Road
Brighton
BN2 3QB

eo ea oe tee emt er er ane

Your Ref: VHD/TS/Kirby Bort donenitnenatnennnmta

26 February 2019

Dear Ms Hamilton-Deeley

Thank you for your letter dated 7 December 2018 enclosing your Report to Prevent Future
Deaths under Regulation 28 Coroners (Investigations) Regulations 2013. | write to
formally respond and to provide you with details of the actions taken by the Trust as a
result of the matters identified during the Inquest.

| will address each of the eight Matters of Concern contained within your Report, in turn:
Delay in dealing with Mr Kirby between August 2017 and March 2018.

Mr Kirby was referred by his GP on 4 August 2017 and was offered an initial appointment
for 15 August 2017. When he did not attend he should have been contacted to reschedule
the appointment. Instead, almost a month passed and then Mr Kirby's wife made contact
to seek support. Whilst an appointment was then made for 20 September 2017, in light of
the information provided by Mrs Kirby, Mr Kirby should have been followed up more
quickly and assertively. Additionally, Mr Kirby should not have then experienced
unacceptably long gaps between his first Medical review on 31 October 2017 and his
second and final review on 20 March 2018. The Trust’s Serious Incident investigation
identified these lack of assertive follow-ups and unacceptably long gaps as failings in Mr
Kirby's care. The recommended measures to address those failings involved establishing
that Mr Kirby's Lead Practitioner's caseload was such that he had sufficient capacity to
ensure an appropriate level of care was delivered and that there be greater oversight and
management of his caseload. | confirm that those measures were and continue to be
taken. Specifically, there has been a significant reduction in his caseload coupled with
robust and ongoing review of that caseload and supervision to secure that he is fully
supported to deliver the level of care that is expected.

Chair: Peter Molyneux Chief Executive: Samantha Allen
Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP

www. sussexpartnership.nhs.uk

A teaching trust of Brighton and Sussex Medical School

Decision to ask Mr Kirby to complete ADHD questionnaires and apparently suggest
that he should be prescribed Concerta.

| understand that Mr Kirby was provided with the ADHD questionnaires by his Lead
Practitioner following his initial assessment with Mr Kirby on 20 September 2017. At that
assessment, Mr Kirby was questioning his diagnosis. His Lead Practitioner considered
there to be a number of ADHD indicators in Mr Kirby's presentation so explored it as a
possibility and as part of the picture of Mr Kirby’s mental health difficulties. Subsequently,
at the first medical review on 31 October 2017 MMexplained to Mr Kirby that he
wouid discuss the findings of his assessment with his Neurobehavioral colleagues, with a
prescription of Concerta being a possible outcome.

As your concern centres on clinical decision-making | asked the Trust's Chief Medical
Office to set up a group of senior medical colleagues to review

medical practice in relation to ADHD. The terms of reference of that medical decision-
making group (DMG) included consideration of the use of ADHD questionnaires for
diagnosis as well as consideration of the assessment and diagnosis of ADHD and
recommended prescribing.

An immediate action that was taken was to ensure that «| ADHD patients
were co-managed with the Neurobehavioural Team. Additionally, a clinical review of all
ADHD prescribing within the relevant team was completed which, | am pleased to say, did
not identify any concerns. :

An outcome of the DMG review was to seek assistance from Professo

ini ychiatry, University of Sussex) who has agreed to review Mr Kirby's case wit
ie 25 March 2019 and recommend any training needs, focussing on using
NICE guidance and loca! shared care protocol for ADHD cases.

Although made a diagnosis he did not follow the NICE Guidance, inform
the GP, start prescribing, consider alternatives to prescribing, have a formal note
made of the consultation with Mr Kirby when the impact of the diagnosis was
discussed with him or discuss the diagnosis with his next of kin.

As indicated above, the Trust has taken the action of seeking the assistance of Professor
Critchley, as an ADHD expert, to ensure that | practice in relation to ADHD
accords with good practice. Additionally, further assurance is provided by the co-
management of ADHD patients with the Neurobehavioural Team.

Prior to this case, Professo orked with our Neurobehavioral Service to ensure
their understanding of NICE guidance. A further action from the DMG review of this case
is that Professo/{aa has been asked to repeat that piece of work he did last year to
re-inforce working with the NICE guidance.

Upon receipt of the GP’s letter dated 16 April, i did not further review Mr
Kirby before he was prescribed Concerta which is outwith the NICE Guidance.

As referred to above, the action taken by the Trust to evaluate clinical
decision-making and understanding of the NICE guidance is through the assistance of
Professor Critchley.

Why was Mr Kirby prescribed Concerta without any (further) review?

The DMG review found tha practice style favoured consultation via telephone
rather than face-to-face discussion, in part, this was considered to be a result of his large
caseload but also due to the relationships he has established with GPs. Those
relationships were considered to be good and his availability to GP’s for their consultation
was considered as positive. However, it was recognised that NBII did not work in
line with the local shared care protocol. The DMG have discussed this with [to
enable him to reflect on his practice and establish good practices in the future when
sharing care with GPs.

Why was he not properly monitored as he should have been had the NICE Guidance
been adhered too?

erm wholly accepts that he should have arranged for Mr Kirby to be reviewed by
im inic_so that he could be monitored. It is highly regrettable that this did not happen
a assures me that he has reflected on his practice. The aforementioned
actions taken by the Trust, particularly co-management by the Neurobehavioural Team,
ensures that ongoing monitoring occurs for our ADHD patients.

The A&E admission on 4'°-5" April should have alerted the Trust to the information
Mr Kirby had given that he was suicidal and ‘wanted to die’.

informs me that he reviewed the details of Mr Kirby’s A&E admission upon
receipt of the letter from the GP seeking the prescribing advice. His clinical opinion at that
time was that Mr Kirby’s presentation at A&E was not new; that is to say that he had
previously presented similarly when under the influence of alcohol AE so took
into account that Mr Kirby was assessed by the Mental Health Liaison Team who didn't
consider re-referring him. Therefore] concern for Mr Kirby was not heightened
by this attendance at A&E.

Why did those interviewing Mr Kirby in A&E not take more details of the suicide
attempt when the rope broke?

| am informed that the evidence at the Inquest showed that Mr Kirby provided the
Pavillions A&E liaison nurse with this suicide attempt information but that our Mental
Health Liaison nurse was not aware of it. As this has identified a gap in the working
between the two services the manager responsible for our Mental Health Liaison Team
has worked with her Pavillions counter-part to create an_ information sharing protocol

which sets out the steps that the teams now take to establish robust communication
between them.

In addition to the above, the DMG took a number of further steps to establish wider
learning. Firstly, the ADHD NICE guidance was shared with all doctors via Mediconnect
which is our doctors’ intranet forum for highlighting items of importance/interest/learning
etc. Additionally, the issues arising from this case are to be presented for learning and
discussion at the Trust's forthcoming Effective Care & Treatment Conference next month.
Furthermore, we are to publish a story, based on this case and to specifically include the
issues surrounding co-morbid substance misuse, in our Patient Safety Matters: this is an
internal learning publication that we use to improve patient safety.

Finally, | would like to assure you tha shared your concerns and the actions we
have taken with Practitioner Performance Advice (formerly NCAS) to ensure that there
was no further action that they felt ought to be taken and | confirm that they were satisfied
with our actions.

| trust that the content of this response addresses your concerns and provides you with
complete reassurance. However, if any further clarification is required or | can assist
further in any way then please do not hesitate to contact me.

With kind regards.

Wee,

Samantha Allen
Chief Executive