Prevention of Future Deaths reports · 2020

John Ashley

Regulation 28 report to prevent future deaths, reference 2020-0071, written 16 Mar 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report16 Mar 2020
Reference2020-0071
DeceasedJohn Ashley
CoronerPenelope Schofield
Coroner areaWest Sussex
CategoryMental Health related deaths · Suicide (from 2015) · Community health care
Organisation namedSussex Partnership NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Ms Schofield 
Senior Coroner West Sussex  
Sent by email: penelope.schofield@westsussex.gov.uk 

Dear Ms Schofield 

Response to Regulation 28 Report dated 16 March 2020 

Swandean 
Arundel Road 
Worthing 
West Sussex 
BN13 3EP 

Tel: 0300 304 0673 

11 May 2020 

Email: 
chiefexecutive@suss
expartnership.nhs.uk  

I  write  formally  to  respond  to  your  report  to  prevent  future  deaths,  under  Regulation  28 
Coroners (investigation) Regulations 2013. 

Your report raises the following concerns: 

1.  Mr Ashley's care and treatment plan was not updated when his mental health 

deteriorated; 

2.  Staff were not recording interactions with Mr Ashley in the Carenotes system, and 
often emails were not copied into these notes.  Therefore there was a lack of 
compilation of key information relating to Mr Ashley; 

3.  There was no system in place for Lead Practitioners to be notified of an important 

entry in a patient's Carenotes where action was required; 

4.  Mr Ashely had not been seen by a Psychiatrist for over a year and there was no 
evidence that the deterioration of his mental health (and his non-compliance with 
his medication) had been reviewed by the professionals' weekly meetings; 

5.  There was a discrepancy in the Trust's own policies as to when a risk assessment 

should be reviewed; 

6.  Save for the duty scheme, there appears to be no procedure in place for another 
practitioner to cover a Lead Practitioner's case load or any formal handover when 
they are on leave.  Therefore there was no single person who has update 
knowledge of a patient who may be in need or whose mental health was 
deteriorating; 

7.  The MHLT did not make use of the patient's Care & Support Plans or Central Risk 

Assessment; 

8.  There was no clear procedure for GPs to be updated by Care Coordinators with 

details of a patient's current treatment plan if it had changed.  This was particularly 
important where there was no regular assessments by a Psychiatrist who would in 
normal course of events, be providing such updates. 

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 

 
 
 
 
 
 
 
 
 
 
 
     
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I address your concerns as follows: 

1.  Updating of care and treatment plans when a patient deteriorates 

In the case of Mr Ashley, it is acknowledged that his care plan contained out of date 
information and did not accurately reflect his changing circumstances. There were also 
missed opportunities to update his risk assessment using the risk event functionality within 
our Carenotes system. These concerns were identified in the Trust's Serious Incident 
Review and 
had responded to those concerns through caseload reviews, clinical records audits and 
supervision.  

 Team Leader, gave evidence at the inquest of how the service 

The Trust monitors performance in each of these areas and there are individual 
performance dashboards for each team within the Carenotes system that allow clinicians 
to monitor their own performance when they log onto the system. Team Leaders and other 
managers also have access to team/service based reports through our "Report Manager" 
performance system and these provide an audit function and allow managers to have an 
overview of team performance.   

I am informed that at the inquest, 
receive regular clinical and managerial supervision and this allows managers and clinical 
supervisors to monitor the quality of someone's work and record keeping as well as 
address any concerns about individual practice. This process remains in place with 
compliance monitored at a team and Trust level. 

 was also able to confirm that clinicians 

The Trust is continuing to monitor compliance with care plans, risk assessments and 
supervision and since autumn last year, we have revised our care plan and risk 
assessment formats/processes, updated our policies and training programme to improve 
standards of care. 

In my letter to you dated 20 December 2019, I detailed some of these steps and I would 
like to confirm that the Trust has successfully implemented these changes with a view to 
preventing future deaths.  Specifically, we have introduced a new universal risk 
assessment and this captures risk events in chronological order and improves record 
keeping.  Although the format of the risk assessment has changed, the principles of robust 
risk assessment, remains the same, and our Trust continues to use the '5 P's' risk 
formulation model to provide a narrative and summary of the past risks.  

We have invested in the recruitment of a Lead Clinician, and they are responsible for 
delivering face-to- face risk assessment training, and to date has provided training to over 
950 clinical staff.  The training utilises national and local learning from serious incidents 
pertinent to the clinician's work environment and has been consistently well evaluated.  

Page 2 of 6 

 
 
 
 
 
 
 
 
 
 I regret that the risk assessment was not updated in the records as it should have been in 
Mr Ashley's case, however his risks were continually assessed and I understand that this 
was accepted by the Coroner's expert, 

2.  Staff were not recording interactions with Mr Ashley in Carenotes and often e-

mails were not copied into these notes.  Therefore there was a lack of 
compilation of key information relating to Mr Ashley 

It is standard practice for all interactions with patients to be recorded on the Carenotes 
system and these records are available and accessible to clinicians in all parts of our 
service to review.  In the case of Mr Ashley, it was evident that our acute and community 
services used his health records to share information, make clinical decisions and review 
his care.  However, I understand that you had specific concerns that email 
correspondence from Mr Ashley's sister, was not uploaded to his record.   I would advise 
that it is not customary practice to upload all email correspondence. However, the Trust 
 contact to be recorded on the system.   
would expect a record and detail of 

At the inquest, staff explained that they use an out of office assistant (automatic reply) to 
advise patients, carers or other health professionals of their absence and how to seek help 
if required.  I understand that the Lead Practitioner used this system whilst he was on 
annual leave and 
was under the impression that the Trust had a system for monitoring emails of the Lead 
Practitioner who was on leave when she sent her emails which isn’t the case but we will 
ensure out of office automatic replies are clear in how someone will seek help when the 
practitioner is on leave.  

 was directed to contact a duty worker.  However, 

The Trust recognises the importance and value of carer involvement, and this is 
acknowledged in the Serious Incident Report, specifically the role 
caring for her brother. We continue to emphasise the need to actively seek consent from 
patients to allow carers and family to participate in their treatment and care.  As a result of 
this recommendation and learning from other similar incidents, the Trust now provides a 
Carer's Pack specifically designed to involve families and carers.   The pack provides 
information about a carer's entitlement to a carer’s assessment and the relevant local 
services they can access for support. I am enclosing a copy of the pack with this letter for 
your information.  We also have bespoke Carers Training provided by paid Carer Leads, 
and local teams have updated their "Triangle of Care self-assessment tools" and 
developed action plans to improve carer engagement. 

 played in 

3.  There was no system in place for Lead Practitioners to be notified of an 
important entry in a patient's Carenotes where action was required 
I acknowledge that our Carenotes system does not have an automatic function to alert 
Lead Practitioners and/or the clinical care team when another clinician has accessed a 
patient's records or recorded clinical activity.  However, I would like to reassure you we 
have processes and procedures in place to allow clinicians to share information when 

Page 3 of 6 

 
 
  
 
 
 
 
 required.  In the case of Mr Ashley, it is evident that there was sharing of information 
between the teams which were involved in his care e.g. the Worthing Recovery & 
Wellbeing Team, and Mental Health Liaison Team, shared information when Mr Ashley 
used out of hours services and the Lead Practitioner or Duty Worker responded to 
concerns and reviewed his treatment and care.  

I  acknowledge  that  in  this  case,  it  was  a  specific  concern  that  a  Lead  Practitioner  when 
returning from leave should be aware of important developments regarding his/her patient.  
It  is  the  responsibility  of  a  Lead  Practitioner  and  other  members  of  staff  returning  from 
leave,  to  review  their  caseload  and  establish  if  there  were  any  concerns  during  their 
absence  and  I  understand  that  Mr  Ashley's  Lead  Practitioner  did  make  himself  aware  of 
events  when  he  returned  from  leave  (he  addressed  this  in  his  addendum  report  at  the 
Inquest).  Nevertheless,  I  wish  to  reassure  you,  that  I  agree  that  it  is  important  that  there 
should  be  a  handover  following  a  leave  of  absence,  particularly  in  the  case  of  the  most 
vulnerable patients  and  staff  are  actively  encouraged  to  ensure  that  this takes  place and 
this will become part and parcel of staff risk assessment training. 

4.   Mr Ashely had not been seen by a Psychiatrist for over a year and there was 

no evidence that the deterioration of his mental health (and his non 
compliance with his medication) had been reviewed at the professionals' 
weekly meetings 

Mr Ashley had a medical review on 1 August 2017 with a Psychiatrist and should have had 
a 12 month follow up review thereafter.   

Mr  Ashley  did  have  a  medical  review/telephone  consultation  with  a  Consultant  Locum 
Consultant Psychiatrist on 30 October 2018 when there was a concern about his health.  
I regret that Mr Ashely was not seen by a Psychiatrist as regularly as he should have been 
i.e  annually,  however  I  can  report  that  the  Trust  has  successfully  appointed  two 
substantive  Consultant  Psychiatrists  for  Worthing  this  year,  and  they  joined  the  team  in 
March.    They  are  supported  by  an  Associate  Specialist.    This  will  enable  us  to  facilitate 
medical  reviews  in  a  timely  manner  and  negate  the  need  for  a  waiting  list.  The  medical 
caseload  is  currently  being  reviewed  with  a  view  to  ensuring  that  every  patient  has  an 
annual medical review as required. 
In  respect  of  your  concern  that  Mr  Ashley's  condition  was  not  discussed  in  the 
multidisciplinary  (MDT)  meetings,  I  would  like  to  reassure  you  that  MDT  meetings  occur 
weekly  and  Lead  Practitioners  and  other  colleagues  are  invited  to  present  cases  where 
they require advice and support, or cases which require a multidisciplinary approach. The 
decision  as  to  whether  a  case  should  be  discussed  at  a  MDT  meeting,  is  a  matter  of 
clinical judgment, and in Mr Ashley's case, his Lead Practitioner and others involved in his 
care,  did  not  consider  this  support    was  necessary  and  his  care  was  reviewed  by  the 
experienced staff who were directly involved in his care.  
My understanding is that it is not common practice for every patient to be discussed at a 
MDT meeting. 

Page 4 of 6 

 
 
 
 
 5.  There was a discrepancy in the Trust's own policies as to when a risk 

assessment should be reviewed 

The Trust accepts that the current Clinical Risk Assessment and Safety Planning/ Risk 
Management Policy and Procedure policy is unclear as it has two potential review dates 
when the risk assessment should be updated.  The current policy is under review and this 
has been addressed as part of that.  The new policy is in the final stages of ratification and 
will be available for staff very shortly.   

6.  Save for the duty scheme there appears to be no procedure in place for 

another practitioner to cover a Lead Practitioner's case load or any formal 
handover when they are on leave.  Therefore there was no single person who 
had up to date knowledge of a patient who may be in need or whose mental 
health was deteriorating 

This concern was addressed in my letter of 20 December 2019 wherein I sought to convey 
that Mr Ashley was treated as part of a team, and that a plan was in place (as part of his 
overall care plan), to ensure that there was adequate support when his Lead Practitioner 
was not available.  Prior to going on leave, I understand that Mr Ashley's Lead Practitioner 
visited to discuss cover arrangements and his crisis/contingency plan.  It is apparent that 
Mr Ashley understood the arrangements as he attended his planned appointments at the 
Wellbeing Café and Clozaril Clinic, and he accessed the duty system and the Mental 
Health Liaison Team for further support.   

I  appreciate  that  there  may  be  some  merit  in  delegating  care  to  an  individual  colleague 
when  the  Lead  Practitioner  is  on  leave,  however  such  a  system  is  not  without  risk  as  a 
patient  may  find  himself  without  a  contact  in  the  event  that  the  delegated  colleague  is 
himself  absent  for  any  particular  reason.    The  duty  system  will  always  ensure  that  there 
are  experienced  mental  health  practitioners  available  to  respond  to  an  urgent  enquiry  or 
crisis,  who  will  have  access  to  up  to  date  knowledge  of  the  team  systems,  and  how  to 
access  urgent  Multi-disciplinary  Team  care  and  intervention.  Rather  than  delegating 
responsibility to just one individual, the system which is in place, ensures that the team as 
a whole will take responsibility to ensure that care is provided, when the Lead Practitioner 
is  absent.    I  would  also  add  that  the  Carer's  pack  and  the  Trust's  Carer's  handbook, 
contains guidance on what to do in the event there is concern for the person being cared 
for. 

7.  The MHLT did not make use of the patient's Care & Support Plans or Central 

Risk Assessment 

 was critical of the assessment undertaken by the 

I understand that 
MHLT and considered that they should have considered the care plans.  I would like to 
explain that the MHLT has its own assessment format and this includes a risk assessment 
and action plan section and is designed in this way for ease of sharing information with 
primary care. At the Inquest, I am informed that the MHLT Team Leader gave evidence as 

Page 5 of 6 

 
 
 
 
 to how he and his colleagues reviewed Mr Ashley's health records and contacted Worthing 
Recovery and Wellbeing to agree a treatment plan for him, in the knowledge that his Lead 
Practitioner was on annual leave and Mr Ashley required support from a duty worker. 

8.  There  was  no  clear  procedure  for  GPs  to  be  updated  by  Care  Coordinators 
with details of a patient's current treatment plan if it had changed.   This was 
particularly  important  where  there  was  no  regular  assessments  by  a 
Psychiatrist  who  would  in  normal  course  of  events,  be  providing  such 
updates 

Mr Ashley should have had a medical review on an annual basis and I wish to assure you 
that it is our practice to send a clinical letter to the GP as well as a copy to the patient.  It is 
also  Trust  practice  to  send  a  copy  of  the  care  plan  and  information  about  changes  to 
medication or physical health assessments undertaken by our service.  I am informed that 
the GP practice received copies of Trust letters from the last medical review and copies of 
the  assessments  undertaken  by  the  Mental  Health  Liaison  Team  and  these  contained 
details of the perceived risk and action plan agreed with the patient.  

I  do  hope  that  you  will  be  reassured  that  in  light  of  the  recruitment  of  two  Psychiatrists, 
going  forward,  reviews  will  take  place  without  any  undue  waiting  time  and  GPs  will 
continue to be kept informed of all reviews which take place.  

I trust this response addresses your concerns and provides you with reassurance that the 
Trust takes its responsible to reduce the risk of future deaths seriously.  However if any 
further clarification is required, please do not hesitate to contact me. 

If following receipt of this response you would like to meet with the clinical team to see and 
discuss  how  the  various  changes  have  been  implemented  I  would  be  only  too  happy  to 
facilitate this. 

Yours sincerely  

Samantha Allen 
Chief Executive 

ENC: Carer's Pack (N.B: to follow hardcopy by post) 

Page 6 of 6
Also filed under 2020-0071: John-Ashley-2020-0071-Redacted.pdf
REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

Ms Samantha Allen 
Chief Executive 
Sussex Partnership NHS Foundation Trust 
Swandean 
Arundel Road 
Worthing 
West Sussex 
BN13 3EP 

1 

CORONER 

I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of WEST SUSSEX 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On 6th November 2018  I commenced an investigation into the death of John Ashley, 
aged 57. The investigation concluded at the end of the inquest on 6th December 2019. 
The conclusion of the inquest was a Narrative Conclusion namely “John Ashley took his 
own life whilst suffering a deterioration of his mental illness. His deterioration was not 
fully appreciated by those treating him within the Sussex Partnership Trust and they 
failed to provide him with the additional level of care that he required. His death was 
contributed to by neglect. “ 

Following the Inquest I indicated that I was minded to make a Regulation 28 report but 
would like to hear submissions from the Interested Persons. An extention for receipt of 
these submissions was granted to 17th January 2020. 

I have fully considered the submissions that I have received in preparing this report. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 

CIRCUMSTANCES OF THE DEATH 

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths will occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

1.  Mr Ashley’s Care and Treatment Plan was not updated when his mental health 

deteriorated. 

2.  Staff were not recording interactions with Mr Ashley in the CareNotes system 

and often emails were not copied into these notes. Therefore there was a lack of  
compilation of key information relating to Mr Ashley. 

3.  There was no system in place for Lead Practioners to be notified of an important 

entry in a patient’s CareNotes where action was required.  

4.  Mr Ashley had not been seen by a Psychiatrist for over a year and there was no 
evidence that the deterioration of his mental health (and his non compliance with 
his medication) had been reviewed by the professionals weekly team meetings. 

5.  The Inquest identified that there was a discrepanciy in the Trust’s own Policies 

as to when a Risk Assesment should be reviewed. 

6.  Save for the duty scheme there appears to be no procedure in place for another  
practictioner to cover a Lead Practictioner’s  case load or any formal handover 
when they are on leave.  Therefore there was no single person who has 
uptodate knowledge of a patient who may be in need or whose mental health 
was deteriorating. 

7.  The Inquest heard evidence that the Liasion Mental Health Team at the Hosptial 

did not make use of patient’s Care and Support Plans or Central Risk 
Assessment. 

8.  The was no clear procedure for GPs to be updated by Care Coordinators with 
details of a patient’s current treatment  plan if it had been changed.  This was 
particulary important where there was no regular assessments by a Psychiatrist 
who would in the normal course of events be providing such updates.  

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe your 
organisation] have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 11th May 2020. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons:- 

 Sister of the deceased 

Leigh Day, Solicitors for the family 

I am also under a duty to send the Chief Coroner a copy of your response.  

2 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

 Date   16th March 2020 

Penelope Schofield, Senior Coroner 

3

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