Trinder Birdi

PRIVATE & CONFIDENTIAL 
Ms Nadia Persaud 
Senior Coroner 
Waltham Forest Coroners Court 
Queens Road 
Walthamstow, London 
E17 8QP 
Sent via email: 

Your Ref:  
Our Ref:  

Dear Ms Persaud 

Chief Executive 
Trust Head Office 
West Wing 
CEME Centre 
Rainham 
Essex 
RM13 8GQ 

17 December 2020 

Re: Inquest touching upon the death of Trindi Kaur Birdi 

I refer to your letter dated 25 November 2020 and the enclosed Regulation 28 report issued in 
respect  of  your  concerns  regarding  the  risk  assessment  and  management  at  Psychiatric 
Liaison Service (PLS). 

The  Trust  has  taken  into  consideration  concerns  highlighted  in  the  Regulation  28  report  and 
would like to briefly outline the current systems of safeguarding the service users’ risks as well as 
inform you on what action will be taken to make these systems even more robust to address your 
concerns.  

Current Risk Assessment and Management arrangements 

At present the systems to safeguard the patients risk within the trust include the following: 

  Clinical Risk Assessment and Management policy; 
  Clinical Risk Assessment and Management mandatory training – standard (one off) and 

advanced modules (3-yearly) 

  Learning  from  Serious  Incidents  through  quarterly  directorate-led  Lessons  Learned 

events and monthly team business meetings 
  Monthly risk assessment compliance audits 
  Monthly  clinical  supervision  with  all  staff  whereby  2-3  clinical  cases  are  reviewed  for 

quality of assessment and care planning, including risk assessment 

Policy  

NELFT’s Clinical Risk Assessment and Management Policy outlines that NELFT staff should 
recognise  that  other  agencies  may  be  carrying  out  risk  assessments  and  have  risk 
management plans in relation to the same patients and that these should be considered.  

The  policy  goes  on  to  address  actions  that  are  to  be  taken  where  there  is  a  significant 
difference of opinion between professionals in the risk level or risk management of a patient.  

Chair:  
Chief Executive: 

www.nelft.nhs.uk 

 
           
                  
   
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 It  supports  clinicians  faced  by  complex  presentations  of  significant  levels  of  risk  to  seek 
advice and support from senior colleagues on duty.  Specifically, it outlines that, in the case 
of different opinions/ conclusions between clinicians it is important for all involved in the risk 
assessment  to  review  their  findings  and  to  discuss  the  basis  for  their  respective  views.   
Clinicians  are  instructed  that  it  is  not  acceptable  for  an  assessment  of  risk  by  one 
professional, or team, to simply be ‘over-ruled’ or ignored by another. It is vital that any such 
differences are identified, explored, understood and resolved.  

The policy goes on to instruct staff to resolve this difference in opinion of risk by  obtaining 
the  opinion  of  a  suitably  skilled  senior  clinician,  or  turning  to  a  senior  manager.  All  such 
involvement should be documented. This should be done immediately if there is possibility of 
a serious acute risk.  

Further  escalation  in  such  matters  includes  encouraging  involvement  of  the  on-call 
consultant and on-call manager, where required.  

Training  

The Trust has mandated Clinical Risk Training for clinical staff (non-medical and medical).  The 
standard  module  is  mandated  to  be  completed  once  and  the  advanced  module  is  to  be 
completed every three years. 

The training content includes outlining Best Practice guidance in risk assessment, learning from 
the Francis Report and highlights key factors to consider in risk assessment, as documented in 
the NELFT Clinical Risk Assessment and Management Policy.  Two of these factors pertain to 
this  report:    one  is  that  positive  risk  management  as  part  of  a  carefully  constructed  plan  is  a 
required competence of all mental health practitioners, the other is that the risk management plan 
should include a summary of all risks identified, formulations of the situations in which these risks 
may occur and actions to be taken by the practitioner and service user in response to crisis. 

Whilst the Clinical Risk Standard training does not go into detail regarding difference of opinion in 
the risk level rating of a service user, the Clinical Risk Advanced training covers a variety of case 
scenarios of which this may be one.   

Risk assessment quality monitoring  

The Trust has a system in place to proactively monitor the quality of the risk assessments. This is 
to ensure that any deviation from the required standard will be proactively identified in a timely 
fashion, instead of relying on a serious incident investigation, after a serious incident has taken 
place, to review the quality of the risk assessments. 

In the main, this is conducted through monthly ‘live’ RIO supervision where recent assessments, 
risk assessments and care plans are scrutinized by the clinician and their immediate supervisor in 
order to ensure practice standards are maintained.  Performance issues that are identified within 
these meetings are managed in line with the Trust’s Capability Policy.  

I  can  confirm  that  the  monthly  supervision  compliance  for  the  Psychiatric  Liaison  Service 
substantive  staff  is  100%.    Bank  staff  who  are  employed  temporarily  in  this  service,  who  have 
substantive roles in other teams, complete their monthly supervision as part of their substantive 
roles. 

Chair:  
Interim Chief Executive: 

www.nelft.nhs.uk 

            
                 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 Action to improve the service 

In order to improve the current systems briefly outlined above the trust has agreed to take further 
actions as follows: 
1.  A  requirement  will  be  introduced  for  a  referral  to  the  on-call  psychiatrist  to  be  completed 
where the presenting risk is significantly different to that of another clinician (including GP) 
who has reviewed the patient on the same day. 

2.  The  assessment  template  used  within  the  Psychiatric  Liaison  Service  will  be  amended  to  
to  concerns  raised  by 

prompt 
friends/family/healthcare staff, protective factors and risk management plan. 

the  consideration  given 

the  documentation  of 

3.  A requirement will be introduced to conduct regular monthly clinical supervisions with all bank 
staff who work on a temporary basis with the Psychiatric Liaison Service, where they are not 
already receiving this within their substantive team. 

4.  The Psychiatric Liaison Service have committed to introducing a regular monthly session for 
all staff within this service to learn from historic serious incidents and unexpected deaths.  
5.  A review of the Clinical Risk Advanced level training to include case scenarios that indicate a 

difference in clinical opinion, and to reiterate guidance how to address these scenarios. 

I hope that the above and the enclosed action plan provides reassurance to you that the Trust 
has  taken  this  sad  incident  very  seriously  and  that  it  reflects  our  commitment  to  improve  care 
quality and patient safety. If you have any further queries, please contact my office on 

. 

Yours sincerely 

Chief Executive 

Chair:  
Interim Chief Executive: 

www.nelft.nhs.uk