Ben O’Hara

NHS

Camden and Islington
NHS Foundation Trust

Executive Office
4" Floor, East Wing
St Pancras Hospital

4 St Pancras Way
London NW1 OPE

www_candi.nhs.uk
24th June 2021

Private and Confidential
Senior Coroner ME Hassell
Inner North London

St Pancras Coroner’s Court
Camley Street

Nic 4PP

Dear Coroner Hassell

Re: Inquest into the death of Benjamin O’Hara — Prevention of Future Deaths report

| am writing further to the inquest for Benjamin O’Hara which was heard on 11™ March
2021. Following the inquest you issued a Prevention of Future Deaths report and
subsequently kindly granted the Trust an extension to allow for completion of our Serious
Incident (SI) investigation report prior to responding. As explained at the inquest, our
commissioners had authorised a ‘clock stop’ on this investigation due to pressures on
services in light of the Covid 19 pandemic, and at the time of the inquest the investigation
was in its early stages. Despite this, it is noted that the issues set out within the matters of
concern had already been identified within the investigation at the time of the inquest, and
evidence was given by the investigator around this. They were subsequently included within
the terms of reference and | will address them in this response in turn. A copy of the full SI
investigation report is enclosed; it provides full context around these issues and will of
course also be shared with the family of Mr O’Hara.

1. None of the healthcare professionals who assessed or treated Mr. O’Hara in the period
leading up to his death asked if he would give permission for his family to be contacted. If

Our investigation considered the issue of contact with family across the number of teams
that were involved in Mr O'Hara's care from 2018 onwards, as well as in the period
immediately leading up to his death. It found that there was a lack of consistency around

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this, complicated by the fact that at times Mr O'Hara reported a difficult relationship with
his family, with fluctuating views about whether he wanted them to be involved. It appears
that this may have led to assumptions being made around his future wishes in this regard,
helpful. It is acknowledged that this was potentially a missed opportunity, given that Mr
O’Hara’s mother was his main social contact and support outside mental health services.

It is also noted at this point that whilst in the period from September 2020 onwards there
did appear to have been an escalation in Mr O’Hara’s presentation, in the month prior to his
death and the 2 contacts with CSPA that took place during that time, a deterioration in Mr
O’Hara’s condition was not identified. At this time he described problems sleeping but
denied suicidal thoughts, and he appeared satisfied with the discussions that took place
with the clinicians on duty.

The Trust recognises the vital role that carers have in supporting their loved ones/our
service users and is committed to working in partnership with carers. In order to address
the issues around contact with next of kin in this case, the report has recommended that
the Crisis Teams review carers policy and benchmark quality standards for
carer/family/social engagement against the national Triangle of Care self-assessment. An
action plan, including a training package, will be agreed following this self-assessment. This
should be completed by August 2021.

In addition, all teams within the acute division of Trust services have been reminded at team
business meetings of the importance of family engagement.

There was an alert on Mr. O’Hara’s medical record, saying that admission to hospital was
unhelpful to him. However, this had been placed on the record 18 months before his
death and had not been reviewed since. If it had been brought up to date, it could have
affected the decision not to detain him on 3 October.

An alert on Mr. O’Hara’s Carenotes states ‘17/04/2018: Information Sharing special
requirements - If Mr. O’Hara presents to crisis services, please consult Duty worker at the
Personality Disorder Service. Hospital admission is not helpful or suitable for him’.

If clinicians accessed the risk tab on Carenotes to review the alert the following information
was available ‘Mr O’Hara is at low risk of self-harm and suicide. He will often present that he
wants to kill himself however he has not attempted this in the past. He benefits from space
to let out his frustration and talk about his current difficulties. With support and validation,
he can then reflect that he can manage this safely at home with support from the
community team. He responds well to feeling empowered with life decisions.”

The alert was raised at a time when Mr O'Hara was presenting to emergency services. The
alert was there to ensure the Personality Disorder Service (the team working with Mr
O'Hara at the time) were contacted to avoid Mr O'Hara being admitted, if there was a less
restrictive option available. The use of the phase ‘not helpful or suitable for him’ was stated

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as the author of the note identified that Mr O'Hara associated his previous hospital
admission with feeling looked after rather than an intervention aimed at improving his
mental state. At the time the alert was created it was discussed with Mr O’Hara, who agreed
with the plan.

Alerts should be reviewed regularly to ensure the information remains relevant. If the
information in the alert suggests contacting a secondary care team, the secondary care
team should review the alert accordingly on discharge to incorporate this change. In this
instance the alert was not reviewed on discharge. Alerts should also provide important
information and should refrain from being opinion orientated. On interview, numerous staff
assessing Mr. O’Hara indicated that the alert on Carenotes influenced their review.

The report has recommended that the process of using alerts on Carenotes be reviewed and
updated, ensuring it is conducted in accordance with when risk assessments are reviewed.
Protocols for using alerts, including wording, are to be agreed as part of the risk assessment
and suicide prevention strategy. A task and finish group is already in place and managing this
work which is expected to be completed by August 2021.

The review undertaken on 3 October was with a $12 approved doctor and an approved
mental health professional, but was not a formal mental health act assessment. If the
crisis team had been aware of this, they may have sought a formal mental health

This appears to have been a clerical error in the progress note entered by the clinician,
where the progress note was titled Mental Health Act Assessment, but in fact it was a
review by a section 12 approved doctor and Approved Mental Health Professional (AMHP),

By holding interviews with clinicians, the investigation found that this would have limited
impact on the decision made on the day of the assessment. If the section 12 approved
doctor or duty AMHP had further concerns and felt admission was necessary, they could
have completed a first recommendation and requested a second opinion doctor. However,
it does appear that it impacted Islington crisis team (ICRT) views on their available courses
of action. ICRT were under the impression that a formal Mental Health Act Assessment
(MHAA) had been completed, and when Mr. O’Hara disengaged from ICRT almost
immediately after being discharged, they felt they had no grounds to request another
MHAA as nothing had changed in his presentation, and therefore opted for discharge.

Despite ICRT feeling like the option of MHAA was closed to them, they did not explore this
further with the duty team who advised on these matters. The report has made a
recommendation to improve communication between the crisis teams and other teams in
the Trust, so that in future the crisis team ensure they discuss further any decisions by other
teams which are of concern to them. Progress against this action will be reviewed in August

2021. CR

4. Mr. O'Hara did not have a care coordinator or other member of the community mental
health team in overall charge of his care. This person would have been able to note his
in 2020.

After being discharged from the Personality Disorder Service in June 2019, Mr O'Hara was
only in contact with acute services. Interviews found that the Islington crisis team
recognised the increased frequency of presentation to acute services, and attempted to
liaise with the Personality Disorder Service, but did not make a formal referral.

Given Mr O’Hara’s frequent disengagement from services, which was his right to do, it is
unclear if he would have been able to engage with the Personality Disorder Service, and if
this would have provided the consistency, as previously he had found it highly challenging.
However, it would have provided a single point of access for reviewing his care which may
have made a difference in noticing the pattern of escalation earlier.

Since Mr O’Hara’s death the Trust has developed a new post for a Senior Crisis Liaison Nurse
to work between Personality Disorder and crisis services. This is intended to provide good
support for individuals with a diagnosis of Personality Disorder to receive more consistent
community acute care. This post was appointed to in June 2021 and the impact of this new
position will be kept under review. This role is in addition to the two Senior Crisis Specialist
Nurses already appointed who work at the interface between Personality Disorder

and inpatient services. The overall aim of all 3 roles is to improve communication between
teams including formal referral processes. Crisis teams have also been reminded that they
may bring complex cases to the complex case panel/risk panel for discussion and support.

| hope that my response clarifies the position and provides you with the necessary
reassurance. If you need any further information, please do not hesitate to contact me.

Yours sincerely

Chief Executive
Camden and Islington NHS Foundation Trust