Billy Jenkins

11 April 2020 

Private & Confidential 

Ms Jacqueline Devonish 
Assistant Coroner 
South London Coroner’s Office 

Dear Madam, 

Oxleas NHS Foundation Trust 

Pinewood House 
Pinewood Place 
Dartford 
Kent 
DA2 7WG 

Tel: 01322 625700 
Fax: 01322 625727 

Regulation 28 response to Prevent Future Deaths Report following the inquest touching the 
death of Mr Billy Jenkins  

Thank you for your correspondence of 21 February 2020 containing a regulation 28 Report to 
Prevent Future Deaths (PFD), following the inquest into the death of Mr Billy Jenkins which 
concluded on the 20 February 2020. This response is made on behalf of Oxleas NHS Foundation 
Trust in regard to the issues of concern outlined below; 

1.  The findings of the internal investigation by Oxleas NHS were that the 

assessment undertaken by the Community Mental Health Nurse did not elicit 
sufficient information to enable the multidisciplinary (MDT) team to properly 
review Mr Jenkins mental health. Despite this the MDT proceeded with a review 
and decided that he did not have a mental health condition without seeking 
further assessment. 

2.  The Community Mental Health Nurse did not document her formulation or 
impression. The plan moving forward was not robust and did not explore 
protective factors or minimise harm and there was an over reliance on alcohol 
and drug use as the cause of is suicidal ideation. There appeared to be no 
proforma of questions to ask. 

3.  As a direct consequence of the limited information gathering Mr Jenkins was not 

properly assessed and it was not known whether he had a mental health 
diagnosis which required treatment. 

4.  It was not known whether as a result of this death there had been any lessons 
learned by the teams involved in care and treatment of him, or whether there 
had been any training or support requirements identified for the community 
mental health nurse. 

My response provides further context regarding the expectations of the Trust regarding the 
assessment process. As outlined in the Trust Root Cause Analysis (RCA) investigation the 
assessments conducted did not meet the expected standards of the organisation.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The nurse referred to in your concerns, who conducted the assessment, is an agency member 
of staff who has worked with various teams within the Bexley community mental health service 
for over two years. Whilst we endeavour to recruit permanent members of the Team we 
invariably utilise agency staff as vacancies arise and due to the individual’s knowledge of the 
service she has been utilised in different teams during those two years as vacancies arose.  

Due to her on-going work she has been treated as a permanent member of the Team receiving 
supervision and training regarding the expectations of the role as well as clinical cases reviews 
and discussions. Her work had always been deemed to be of a high standard by differing Team 
managers she had come into contact with. Despite this however, the quality of the assessment 
process did not meet the Trusts expectations and standards in the case of Mr Jenkins. This has 
been followed up in detail with the nurse in question who has been very distressed by the 
death of Mr Jenkins and noted gaps in her practice. A plan has been put in place to carefully 
monitor and evaluate her work to ensure that she has understood the expectations of the role 
and demonstrates an improvement in her practice whilst she remains working in the Trust. The 
operational manager of the community mental health service is responsible for ensuring this is 
achieved. 

Following this incident we have taken further measures to ensure the assessment of patients 
within the community mental health team are robustly managed in order to ensure that the 
MDT has sufficient information to review an assessment and to ensure that where there is any 
disparity in diagnosis that a further face to face assessment is conducted. The operational team 
manager is monitoring this practice through discussions in Team meetings, supervisions and 
MDT case discussions. 

I will set out in more detail below the changes we have made in relation to all four issues you 
have outlined. 

As a result of the incident the community mental team core induction tool was sent to all CMHT 
managers to go through with all the new starters and other established colleagues to reinforce 
the expectations of their roles and the assessment process. This was shared with all staff in 
supervision and an email has also been sent to all members of staff. Reflective practice sessions 
have also been conducted focusing on documentation and record keeping, particularly 
assessment (needs and risk) and formulation. The impact of this is being monitored in Team 
meetings and in reflective practice meetings. This will be reviewed again after the current 
unusual working practices in relation to Covid 19. 

In addition to the above, the quality of the assessments being carried out is monitored within 
team meetings and in 1:1 supervision. Monthly care plan audits is an additional system to 
monitor quality and standards of practice, it also dictates that we are reviewing the quality of 
assessments conducted. The operational team manager is responsible for reviewing and 
actioning areas of improvement arising from this. 

In order to further support staff we have instigated a Trust wide rolling programme of training 
for mental health community teams. This consists of STORM, a two day suicide prevention 
programme which offers skills based training in risk assessment and safety planning. Also we 
have rolled out DICES an evidence based approach to assess and manage risks. The checklist 
provided during this training support the formulation of risk in the risk assessment utilised by 
the Team. The training supports staff to notice and assess any risks present, manage the risk 

2 

 
 
 
 
 
 
 
 take action to minimise the possibility of the risk happening and demonstrate that you have 
assessed and managed the risk as well as it is possible to do so  and thus supporting timely and 
effective treatment. The operational manager of the community mental health team is 
monitoring to ensure all new and existing staff have attended the training and sessions will be 
on-going following the current Covid 19 situation. We are also exploring online versions of 
training in the meantime.  Other individual training needs are being picked up in Supervisions to 
ensure practice meets the required standards. Although the community mental health nurse is 
an agency worker as she has worked across a number of the teams that form the community 
mental health service she will also access the training and supervision outlined. 

Since the death of Mr Jenkins the RCA report has been shared with the team and across the 
Trust so that similar Teams can reflect on the lessons learnt. The actions arising from the 
investigation have also been implemented including areas addressed above. Additional learning 
reflects the need to ensure that all service users who are receiving care and treatment from 
Oxleas mental health services and also use drugs and or alcohol have equal access to all strands 
of treatment available to those who are not using substances. Only if there is clear evidence 
that the use of substances will impact on the ability to clinically benefit from any treatment 
would a decision be made to withhold treatment and in these instances this would be reviewed 
regularly with the service user and the team. 

I hope my response has adequately addressed your concerns. 

Yours sincerely  

Dr Ify Okocha 
Acting Chief Executive 

cc 

 Service Director 
 Clinical Director 
 Associate Director 

3