Gary Etherington

Oxleas 
NHS  Foundation Trust 

Oxfeas NHS  Foundation Trust 

Pinewood House 
Pinewood Place
Dartford 
Kent 
DA27WG 

Tel: 01322 625700 
Fax: 01322 625727 

24July 2020 

Dr Andrew Harris 
Senior Coroner 
London Inner South 
Southwark Coroners court 
1 Tennis Street 
London  SE11YO 

Dear Dr Harris, 

Re: Regulation 28 response to Prevent Future Deaths (PFD) Report following the inquest into the 
death of Mr. Gary Etherington 

Thank you for your correspondence of 30 June 2020 containing a regulation 28 report to Prevent Future 
Deaths (PFD) following the conclusion of the Inquest into the death of Mr. Gary Etherington on 24 June 
2020. I note that the medical cause of death was: lo. Cardiac Arrythmia, lb Amitriptyl/ne and 
Nortriptyline overdose. II Coronary Artery Disease and the "conclusion as to the death was Suicide". 

This response is made on behalf of Oxleas NHS Foundation Trust with regard to the concerns you set out 
in the PFD report. These concerns are: 

•  The Mental health Act Assessment on April 5 2018 did not involve 
•  Mr Etherington was discharged from Oxleas' care at the end of July 2018 without consultation 

 and 

with 
g"n<1ral practitioner who referred him back to Oxleas at the beginning of July 2018. 

 and a detailed communication was not provided to Mr. Etherlngton's 

Furthermore, you have asked that I consider whether any further Investigation af the failings Is required 
and whether there is a need to review the conduct of our Root Cause Analysis investigations as, in your 
opinion, this did not recognise or investigate these failings. 

My response provides further context regarding the assessments, conduct of Root Cause Analysis 
investigations in the Trust and changes we have made and will make as a consequence of the PFD 
report. 

I would like to begin by stating that following a review of the Root cause analysis investigation report 
and Mr Etherlngton's cllnlcal records It Is clear that the matters of concern you have raised were not 
addressed in sufficient detail in the report. That said, the report identified key learning and 
recommendations as: 

•  Communication and liaison with wider support network in assessment and treatment 
•  Cllnlcal supervision of cases 

/MINDFUL 
VEMPLOVER 

mm disability
l'.!'lr:sil confident 
COMMITTED-

 The first sought to address the absence of involvement of
treatment of Mr Etherington and the second recommendation was as a result of the absence of direct 
supervision of the student who discharged Mr Etherington on 30 July, some four days after a discussion 
with the team manager during which the discharge plan was agreed. 

 in the assessment and 

The involvement of families and carers is a Trust quality priority and the Trust has developed a Support 
Network Engagement Tool (SNET) to help clinicians identify key support networks and engage them in 
assessment and treatment. in addition, care plans are audited every month to check for evidence of 
involvement of each patient's support network especially families and carers and whilst the results of 
these audits show Improvement over the last few years but we recognise there is more to be done. 

Regarding your specific concern about the Mental Health Act Assessment, it is important to outline what 
the Mental Health Act states and the context of the assessment here. The records show that the 
assessment was conducted close 'Iii midnight at Plumstead Police Station on 5 April 2018. The  medical 
assessments were carried out by a senior trainee in psychiatry who was on-call that night and a section 
12 approved independent doctor (not an employee of Oxlen NHS Foundation Trust). 

There is no requirement under the Mental Health Act for an assessing doctor to obtain any collateral 
Information as part of their assessment. Section 12 of the Act requires·that a doctor making a 
recommendation may only do so  if they havepersonally examined the patient. There is no legal duty 
placed on the doctors to consult each other, or anyone else. The European Courts have held that the 
medical assessment must be based  on the actual state of mental health of the person concerned and 
not solely on past events (Varbanov v Bulgaria (2000) MHLR 263 para 47). 

There is a requirement for the Approved Mental Health Practitioner (AMHP)a notify the Nearest 
Relative (where practicable) before making an application under section 2. However, In this case Ill the 
two doctors did not make recommendations, the AMHP was unable to make an application and 
therefore there was no requirement to,notify the nearest relative. 

However, the criteria for detention under the Mental Health Act states that a person may be detained 
with 'a view to the protection ofother persons' and so I take the view that in completing an assessment 
it may be beneficial (even if it is not required) to obtain collateral information where possible and this 
may be more relevant where neither doctor has previous acquaintance. This is certainly in  line with the 
Trust goal of engaging families and carers in assessment and treatment and is also supported by the 
Mental Health Act code of practice which states as follows in in paragraph 14.71: 

A medical examination must Involve: 

•  direct personal exam/notion ofthe patient and their mental state, ond 
• 

consideration ofa/I available relevant clinical Information, including that in  the possession of 
others, profess/anal or non-professional. 

The  Root Cause Analysis investigation concluded that the strained relationship between Mr and 

 and the restraining order against Mr Etherington contributed to the failure to engage with 
. To ensure learning from this incident, I will share the PFD report and this response 

with all doc:tors, especially trainees in psychiatry, and have asked that this is a topic of discussion at our 
Oxleas Section 12 and Approved Clinician refresher course for doctors. 

Turning to your second concern that Mr Etherington was discharged without adequate consideration of 
his symptoms and communication to his general practitioner, I have ensured that all our primary care 
teams (PCP), who are the gateway to our secondary mental health services, write comprehensive letters 
to general practitioners addressing the specific issues raised by the general practitioner including 
outlining the outcome of assessments and treatment advice. 

2 

 
 Finally, you have asked me to consider whether there is a need to review the conduct of our Root Cause 
Analysis Investigations In the Trust. 

The Trust's process of managing Incidents Is underpinned by the NHS England Serious Incident 
Framework (2015), which advocates Root Cause Analysis as ta method for investigating Serious 
Incidents. The Trust conducts "Level 2 comprehensive investigations" as defined in the Framework: 
"suited ta complex issues which should be managed by a multidisciplinary team Involving experts ond/or 
specialist investigators". 

The use of the "Structured Judgement Review" was later recommended but has since been abandoned 
by non-Acute Trusts as the complexity of serious Incidents makes it difficult to apply. 

In July 2018 the Trust commissioned KPMG to undertake a review of the whole process of managing and 
Investigating Serious Incidents and the final report published in October 2018. One of the 
recommendations from the review was that a central Serious Incidents Team should be created to deal 
specifically with oversight of the Investigation and monitoring of all Serious Incidents. Prior to this, 
Serious Incidents were Investigated within the Directorates as was the death of Mr Etherington which 
was investigated 111111'11  3 month period (December 2018 to February 2019). 

The central Serious Incidents Team which was established in April 2019 conducts investigations thus 
offering consistency, robustness and appropriate follow up to ensure actions are completed and 
learning Is shared across the Trust. A systematic approach, adopting Root Cause Analysis, is applied to 
each Investigation. The investigation is carried out with the view to identifying weaknesses in systems 
and/or processes and to understand what went wrong and why and how any Identified problems can  be 
rectified. The Team  Lead  undertakes the following to sustain this: 

I.  Maintains a status report on all serious Incidents; 
ii. 

Ensures investigations into serlOJII incidents are conducted and completed within 60 working 
days; 

ill. 

iv. 

Completes an analysis of incident data to identify and monitor trends/problems and  for taking 
appropriate action. 
Shares serious investigation reports and action plans with commissioners a  provide relevant 
supporting information as required; 

v. 

Co-ordinates and oversees the management and investigation of serious Incidents; 

In addition, the Incident Management Polley and Procedures was updated In Aprll 2019 (subsequently 
updated April 2020) to reflect the changes within the Serious incident Team and stipulates that the 
Terms of Reference for the investigating panel must Include: 

•  The circumstances surrounding the incident; 

•  The appropriateness and adequacy of care and treatment; 

•  Additional issues arising; 

•  Consideration to the involvement of family and/or carers; 

•  Health and Safety Concerns where the matter involves staff; 

• 

Issues of equality and diversity. 

3 

 Since the Implementation of these changes to the management of Serious Incidents In April 2019, the 
Trust Is confident that Investigations are thorough, reliable and Identify problems In care, with 
appropriate action documented to address these. 

To conclude, I am grateful for your report which has ensured that additional measures are Instituted so 
lessons are learned from the death of Mr Etherington. I hope that I have addressed all your concerns 
and from the forgoing, I have reassured you that no further Investigation is  required and that Root 
Cause Analysis Investigations In the Trust are thorough and comprehensive to ensure problems and 
failings in care are identified, necessary Improvements are made and lessons learned as a result. 

Yours sincerely 

Dr lfy Okocha 
Medical Director and Deputy Chief Executive 

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