Matthew Williamson

Mr Christopher Murray 
Assistant Coroner West London 
25 Bagley’s Lane 
London 
SW6 2QA 

Dear Mr Murray 

1 Armstrong Way 
Southall 
UB2 4SD 

T: 0208 354 8354 

13th January 2020 

Reference – Regulation 28 Report to Prevent Future Deaths 

Further to your Regulation 28 Report sent on 15th October 2019 to the Trust, 
1. 
in relation to the inquest into the death of Matthew George Williamson, who died on 
24th October 2018, please find our response set out below. 

2. 

The matter of concern which you raised was as follows: 

“There appears to be a lack of opportunity for carers and family members to 
provide  more  pertinent  information  to  clinical  mental  health  teams  and  the 
interplay  between  mental  health  providers  isn’t  clear.  This  makes  it  very 
difficult  to  navigate  as  there  is  no  patient  road  map  which  would  assist  with 
access to and type of treatment”. 

Mr  Williamson  had  been  under  the  care  of  West  London  NHS  Trust, 
3. 
specifically  the  Ealing  Primary  Care  Mental  Health  (EPCMH)  Team,  when  he  was 
found  dead,  hanging  in  the  family  home  on  24th  October  2018.  He  had  been 
discharged  from  the  EPCMH  service  twenty  days  prior  to  his  death.  The  Trust 
conducted  a  Level  2  Investigation  into  the  incident,  and  published  a  report  of  the 
findings. We understand that you have already seen this; however, this is attached 
for your convenience. 

4. 
In relation to the concern you raised in your Regulation 28 Report, and noted 
above, the Trust investigation included a specific Term of Reference for the panel to 
review: 

“To establish whether there was effective and appropriate communication and 
liaison between the patient’s family and all agencies involved in the patient’s 
care to meet his needs”. 

5. 
The  Trust  investigation  concluded  that  the  “communication  between  the 
patient’s  family  and  all  agencies  involved  in  the  patient’s  care  was  inadequate”.  It 
was  also  noted  in  the  investigation  report  that  the  family  of  Mr  Williamson  also 
highlighted what, in their view, were “multiple issues with regards to communication 
between services”.  

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 The investigation noted that the family also made it clear that they were keen 
6. 
to  ensure  that  those  family  members  and  carers  close  to  and  supporting  a  patient 
with  mental  health  problems,  would  be  more  involved  in  the  clinical  assessment 
processes  in  future.  These  are  concerns  that  we  are  absolutely  committed  to 
addressing. 

The  key  issues  identified  in  the  Trust  investigation,  which  are  related  to  the 

7. 
above Regulation 28 Report included:  

  Disjointed  commissioning  and  national  reporting  requirements  has  led  to  3 
different  clinical  record  systems  being  used  by  teams,  which  are  not 
interoperable with each other. 

  Trust operational policy makes no provision for family involvement during the 

assessment and/or treatment phase.  

  There  is  a  lack  of  local  guidance  for  managing  instances  where  consent  to 

involve the family is denied by the patient. 

  Further staff training in Carer Awareness is necessary. 

 

‘Triangle of Care’ principles were inconsistently implemented within the teams. 

8.   We are pleased to report that we are making good progress to address all the 
issues identified above and that are within our control.  

9. 
Specifically,  as  it  is  often  GPs  who  will  see  patients  with  a  range  of  mental 
health difficulties and who will then refer patients needing mental health services, we 
have  established  the  Trust  Single  Point  of  Access  (SPA)  to  support  both  GP 
referrals, and to help signpost people in need who have chosen not to see a GP, or 
who are unable to see a GP.  

10. 
The SPA is also known as the 24/7 Helpline, and is a telephone based service 
which  manages  all  adult  mental  health  referrals  as  well  as  providing  telephone 
support to patients and carers. The SPA helps to provide the right out-of-hours care 
for people in crisis 24 hours a day, 7 days a week, 365 days a year. When someone 
feels  unsafe,  at  risk  or  unable  to  cope  without  professional  advice,  trained  mental 
health advisors and clinicians will work with people to enable them to manage their 
difficulties without having to access other services. In an emergency, the SPA aims 
to respond within four hours, and within 24 hours in urgent cases, any time of day or 
night – these are the same response times for acute NHS services. 

11. 
The  SPA  ensures that  all  referrals from  GPs,  carers and  other statutory  and 
third  sector  referrals  are  processed  and  responded  to  in  a  timely  way,  following  a 
robust clinical triage process.  

12. 
The service manages all adult referrals, except those for cognitive impairment 
or dementia services. The SPA also provides the out of hours service for child and 
adolescent mental health services. 

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 13.  GPs  can  also  refer  patients  who  they  consider  to  have  mild  or  moderate 
mental  health  difficulties  directly  to  the  Trust  Primary  Care  Mental  Health  teams.   
These  teams  offer  a  specialist  mental  health  service  for  those  people  who  do  not 
need an intensive multi-disciplinary package of care, but would benefit from medical, 
psychological, occupational or nursing support to help them maintain their wellbeing 
or recover from a period of mental health difficulties.  

For  those  people  needing  more  intensive  care,  West  London  Secondary 
14. 
Community  Mental  Health  Care  is  provided  by  specialist  mental  health  teams  and 
involves a case management approach, with the possibility of more intensive input. 

15.  While  successive  national  mental  health  policies  and  strategies  have  left 
Community  Mental  Health  Teams  (CMHTs)  unchanged,  the  new  community 
framework  calls  for  “transformation  and  modernisation”.  Existing  CMHTs  in  most 
areas  of  the  country  are  based  entirely  in  secondary  (specialist)  care  and  they 
operate  with  thresholds  that  require  someone  to  have  a  level  of  severity  of  mental 
health  need  to  qualify  for  support.  The  national  framework  anticipates  that  this 
should  be  replaced  by  a  new  “core”  community  mental  health  service,  which  will 
incorporate  existing  CMHTs  with  primary  care  mental  health  services,  in  a  place 
based offer aligned to the Primary Care Networks. 

Importantly,  the  framework  refers  to  a  ‘no  wrong  door’  policy  to  make 
16. 
meaningful  support  far  more  accessible,  whilst  addressing  the  current  assessment 
system by outlining a bigger role for local government and the voluntary sector. The 
use of ‘alliance contracting’ is promoted to bring a wider range of providers together 
to meet people’s needs 

17.  As a result of this new framework, West London NHS Trust services are in the 
process  of  transforming  to  a  series  of  integrated  primary  and  secondary  mental 
health  teams,  wrapped  around  the  Primary  Care  Networks.  Our  new  service  will 
offset  the  need  for  criteria  to  be  met  to  access  a  more  intensive  input  at  times  of 
increased mental health need, and will ensure that boundaries between services are 
removed.  

18. 
This  means  that  once  a  person  is  referred,  the  ‘system’  will  respond  to  the 
needs of the patient – rather than to an increased clinical acuity, leading to a referral 
and  gateway  assessment.  This  will  enable  a  time-limited  period  of  specialist 
intervention  and  intensive  input  to  be  delivered.  These  changes  are  already 
underway and will be fully implemented during 2020 / 2021. 

19.  We  are  addressing  the  involvement  of  carers  and  families  through  the 
‘Triangle  of  Care’.  The  Triangle  of  Care  was  launched  in  July  2010  by  the  Carers 
Trust  and  the  National  Mental  Health  Development  Unit,  emphasising  the  need  for 
better local and strategic involvement of carers and families in the care planning and 
treatment of people with mental ill-health.  

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 The  ‘Triangle  of  Care’  sets  out  how  carers,  service  users  and  professionals 
20. 
should  work  together  to  support  recovery  and  to  sustain  patient  wellbeing  by 
including and supporting carers.  

The Trust is a formal member of the ‘Triangle of Care’ membership scheme, 
21. 
and  we  have  committed  to  implementing  the  standards  set  out  in  the  ‘Triangle  of 
Care’.  Part of  this includes  submitting  regular  progress  reports to  the  Carers Trust. 
Progress reports for each stage of implementing the ‘Triangle of Care’ (Stage 1 and 
Stage 2) are expected. At West London NHS Trust, ‘Stage 1’ is the roll out of self-
assessments throughout our inpatient services and crisis teams, and ‘Stage 2’ is the 
roll  out  of  self-assessments  throughout  community  services.  We  are  currently 
considering  whether  a  further  stage  is  required  for  our  community  physical  health 
services.  

22. 
To  support  implementation  of  the  ‘Triangle  of  Care’  across  the  Trust,  an 
overarching  project  delivery  plan  and  risk  log  has  been  developed.  This  has  been 
presented  to  the  Trust  Board.  Regular  project  delivery  updates  are  reported  to  the 
Trust  Service  User  and  Carer  Experience  meeting,  and  from  there,  to  the  Trust 
Board. 

23. 
In  August  2019,  the  Trust  was  given  its  first  Carers  Trust  Triangle  of  Care 
star. The first star is for completing Stage One (self-assessing all inpatient and crisis 
teams)  and  then  committing  to  improve.  We  are  committed  to  achieving  further 
progress, and this star an encouraging start, and is the first of three required before 
we are given full recognition by the Carers Trust. 

In order to continue towards Stage 2 and beyond, the Trust has identified the 

24. 
following areas for development: 

• 

• 

• 

• 

To  continue 
in 
implementing the Triangle of Care whilst embedding it into day-to-day practice 

to  strengthen  managerial,  clinical,  and  carer  support 

To focus on the expectation that all staff attend Carer Awareness Training  

To take steps to establish a Carers Council 

To strengthen how we measure the impact of the work we do 

Further  details  about  the  work  we  are  doing  is  available  on  our  ‘Triangle  of 

25. 
Care’ webpage, which can be found by following the link:  

https://www.westlondon.nhs.uk/patients-and-carers/caring-for-
someone/triangle-of-care/ 

Finally, although much of the work underway across West London NHS Trust 
26. 
is part of a wider regional and national strategy to address the issues outlined in the 
Regulation  28  Report,  our  Trust  investigation  report  clearly  identified  some  local 
actions  that  the  Trust  must  take  to  address  the  issues  highlighted  above.  These 
included: 

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   Amendment of operational policies to include sections on strengthening family 
involvement; managing cases where consent is not given; and the adoption of 
the Triangle of Care. 

  Ealing  PCMHS  staff  must  attend  Carer  Awareness  and  Triangle  of  Care 

training sessions. 

27.  We are pleased to report that the above two actions have been completed. 

28. 
The  challenges  involved  in  improving  opportunities  for  carers  and  family 
members  to  provide  more  pertinent  information  to  clinical  mental  health  teams,  as 
well  as  improving  and  elucidating  the  interplay  between  mental  health  providers 
need to be addressed both locally, and strategically. We believe we are making good 
progress in both areas, as outlined in the narrative above. We also acknowledge that 
further work is required, but believe that we have a clear strategy and aim identified 
to address this during the coming year. 

29.  We  are  more  than  happy  to  provide  you  with  further  information  should  the 
above  not  suffice.  Please  do  not  hesitate  to  contact  either  myself  or 

, Head of Patient Safety and Clinical Effectiveness, should this be the case. 

Yours sincerely, 

Carolyn Regan 
Chief Executive  
West London NHS Trust 

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