Sean Fegan

Email: 

22 April 2021 

Mr Gordon Clow 
HM Assistant Coroner for Nottingham and Nottinghamshire 
Nottinghamshire Coroner’s Office 
The Council House 
Old Market Square 
Nottingham 
NG1 2DT 

Chief Executive Office 
Duncan Macmillan House 
Direct Line: Porchester Road 
Nottingham 
NG3 6AA 

Tel: 

Dear Mr Clow 

Please find the organisational response to the recently received Preventing Future Deaths Report following the  
death  of  Sean  Fegan,  the  inquest  of  which  was  concluded  on  25th  March  2021.  We  once  again  take  this 
opportunity to offer our sincere condolences to Mr Fegan’s family. 

For ease, we will respond to each of the concerns you raised in turn. 

1. 

  Decision making surrounding the need for secondary mental health care 

A decision was taken in December 2019 that Mr Fegan did not require mental health treatment at all 
in the absence of adequate information or assessment and for reasons which appeared incorrect. 

The  Trust  has  reviewed  this  case  in  terms  of  the  decisions  made  at  the  initial  referral,  from  the 
perspective of whether too narrow a view was taken at the time.  

At the time the decision was made, it was made in joint approach with the commissioned service for drug 
and alcohol support, Change, Grow, Live (CGL), who were present at the time, and with the benefit of  
his  substance  misuse  notes.  The  prescriber  and  the  consultant  were  also  there  and  considered  the 
referral carefully. Whilst the patient wanted clonazepam and melatonin to be considered it is felt unlikely 
that these particular drugs would have been prescribed given his risks, particularly given the addictive 
potential  of  clonazepam.  Melatonin  is  not  licensed  for  use  in  adults,  it  is  a  grey  drug  on  the  Area 
Prescribing Committee, as the evidence for benefit is too limited.   

Nevertheless we acknowledge that at this point in time he had had a previous admission of some length 
and more information could have been obtained from his GP about his current mental health, and more 
consideration could have been given to the details pertaining to his previous admission into B2. The team 
have reflected over this, and consider that undertaking an assessment at this point would have enabled 
a clearer formulation to be developed with him, with a rounded consideration of the interplay between  
Mr Fegan’s ASD, substance misuse and any underlying mental illness, to inform a plan for him. The Clinical 
Director  will explore opportunities for shared learning with other clinicians and teams from Mr Fegan’s 
story. This will also be explored in discussion with his family. 

The  NHS  long  term  plan  identifies  some  key  objectives  for  change  in  relation  to  the  management  of 
mental  health  care  across  primary  and  secondary  services.  This  includes  the  employment  of  mental 
health practitioners in primary care settings, who will be actively engaged in the management of referrals 

 
 
 
 
 
 
 
 
 
 
 
 
 
 with the Local Mental Health Teams. This will ensure much better oversight, closer working relationships 
and  better  communication.  As  part  of  the  Trust’s  Transformation  Project,  we  are  now  working  more 
closely with primary care. There  is a pilot  scheme  due  to start  in May 2021, involving band 6 mental 
health nurses, triaging referrals by contacting both the referrer and the patient. There will be access to a 
senior MDT panel for discussion in complex cases. 

A Neurodevelopmental Specialist Service (NeSS) is now established, from 1st April 2021, to offer diagnosis 
and  post-diagnostic  support  for  autistic  people.    NeSS  will  provide  training  and  development  of 
competence in mental health services to support assessment, care planning, advice, and crisis support 
for autistic people with mental health conditions in the community.  Advice can be sought in relation to 
complex referral decision making involving individuals with autism as a diagnosis.  

The Trust is also strengthening the support provided to people with autism in crisis by recruiting a speech 
and language therapist dedicated to work with autistic people in crisis in the community, by making use 
of the  additional funding that  will be made  available from NHS  England.  There  is an ongoing mental 
health division wide steering group for autism that brings together clinical and non-clinical colleagues to 
clarify treatment pathways for autistic people and share good practice within the mental health division. 

2. 

  Access to mental health treatment 

Mr  Fegan  had  complex  mental  health  conditions  and  experienced  very  high  levels  of  distress  and 
anxiety as a consequence. He was declined mental health treatment on two occasions by the Trust. Mr 
Fegan took an overdose due to his frustration at not being able to access mental health services which 
he needed. Whilst this was not the cause of Mr Fegan’s death, it created a dangerous state of affairs. 

The Trust is clear that substance misuse is often part of a wider MH presentation and we work routinely 
and without hesitancy with patients with co-morbid drug use. It must be understood that when drug use 
is very significant, it can act as a barrier to specific psychological therapies, and in some circumstances, 
this needs to be addressed as a first priority. We aim to address the immediate needs  in the context of 
the  whole  patient,  including  treatment  of  substance  misuse.  Mr  Fegan  had  engaged  well  with  the 
commissioned service for substance misuse, CGL. 

We accept that,  the rationale behind decisions such as those made in this case could be shared with the 
patient and family at an earlier stage and in a clearer fashion, which would have been of clear benefit to 
patients such as Mr Fegan who might otherwise feel like they are being denied treatment. Additionally, 
this would provide  patients with direction and reassurance that there is an overall plan for their care, 
and this was a missed opportunity to engage with Mr Fegan in a positive way. There is currently work in 
the Trust on involving the patient in the triage process which  is being piloted and this is detailed later. .  

As a trust we regret that Mr Fegan was discharged from CRHT without being made aware that he had 
been accepted for assessment by the LMHT and without an appointment date.  Upon discharge from the 
CRHT  Mr  Fegan  was  made  aware  that  he  could  contact  the  CRHT  for  support at  any  time.  The  Local 
Mental Health Team have reviewed their process to ensure that the referrer and patient is contacted as 
soon  as  a  decision  is  made  after  considering  the  referral  letter.  As  identified  above  the  service 
transformation will ensure joint working and delivery of care across primary  and secondary care, with 
improved continuity. 

3. 

  Dual diagnosis  

it was acknowledged that there was a ‘gap’ within the services in relation to dual diagnosis patients. 
There was evidence of a resistance to agreeing to provide a service to patients with significant drugs 
misuse problems. 

 
 
 
 
 
 
 
 
 
 
 There is no resistance to, or policy within the Trust against treating dual diagnosis patients. The Trust is 
commissioned to work with CGL (Change, Grow, Live), who provide this service. We regret that the family 
and the inquest were left with the  impression that the  Trust is  reluctant   to  engage  with  this patient 
group and reassert that this is not the case; people with co morbid substance misuse are supported by 
our services. 

As part of the Trust’s Transformation Project and as part of a pilot there will be three substance misuse 
workers embedded within the LMHTs, who will facilitate closer working with CGL, and recruitment is now 
underway to fill these posts . The substance misuse workers will also provide training and best practice 
procedures to staff, whilst also assisting with the more complex presentations. 

The Trust’s strategy for promoting integrated care for people with comorbid mental health and substance 
misuse  comprises  of  a  number  of  components.      This  includes  training  on  dual  diagnosis  which  is 
enhanced by the appointment of the substance misuse staff. There is  a bi-monthly collaborative clinical 
reference group for dual diagnosis now established, which includes a range of clinical staff from different 
services  across  Nottinghamshire,  enabling  case  discussion  and  identification  of  pathways  for  mental 
health and substance misuse. There is also good engagement with public health in relation to the wider 
strategy in developing this area. The trust is currently exploring employment of peer support workers 
including  number  of  posts  and  their  deployment,  supervision  and  training  requirements,  any  specific 
roles to be undertaken by peer support workers and how to evaluate their impact.  

4. 

  Liaison with family members  

There was  no  evidence  of  proactive  attempts  to  engage with  family  members,  even  when services 
withdrew. When a family member sought to share concerns, these were rebuffed. 

Continuity in a person’s care and liaison with family is really important to us. The Crisis Resolution Home 
Treatment (CRHT) Team operate to respond to, manage and contain risk, and therefore liaison with the 
family is very helpful and essential to support holistic assessment and treatment where they are engaged.  
The Trust has now implemented a carer peer support worker post in the Mid-Notts CRHT team which can 
specifically  assist with this liaison.   

We recognise and sincerely regret that the family’s experience of contact with the crisis team led to a 
feeling of being rebuffed, and we have reviewed a recording of the telephone call.  A sense of a time 
pressure    is  evident  in  the  call.    We  note  that the  crisis  worker  did  listen  to  the  concerns  raised  and 
managed to relay that there was a plan in place for contact with Mr Fegan the following day. The CRHT 
Team has since been expanded to relieve some of these pressures on staff.  This includes an additional 
5/6 band 6 nurses and 3 health care support workers. There is also an additional prescribing clinic run at 
the weekend by the team’s non-medical prescriber.  

CRHT training on handling of telephone calls was rolled out at the start of the pandemic and is about to 
resumed. This includes triage of call (including family member calls), how to handle calls, and subsequent 
actions.  

The Trust operates under the Triangle of Care. The Triangle of Care (ToC) membership scheme promotes 
shared working between carers, professionals and people using services. Each service within the Trust 
has  to  self-assess  what  this  will  look  like.  Within  the  CRHT,  considering  the  terms  of  the  ToC,  the 
communication of the care plan will be more carefully considered. Upon discharge from the service, a 
checkpoint will be added to the checklist for the discharging team evaluate and discharge their obligation 
to liaise with the family at that point.  

 
 
 
 
 
 
 
 
 
 
 
 The Trust has written to  Mr Fegan’s family who have confirmed their willingness to be engage with us 
and share their experience. There is a meeting planned with the Clinical director and governance team 
to discuss their experience in more detail with the aim of improving our practice.  

5. 

  Implementation of care plans  

A care plan was devised by the liaison nurse and psychiatrist, only to be overruled by persons who had 
not themselves assessed Mr Fegan, on an incorrect basis, and without a review of the risk assessment 
justifying that decision. Mr Fegan was called and invited to agree to the withdrawal of services. Such a 
practice runs the significant risk that patients who are less assertive or who have poor insight into their 
mental health needs will be said to have ‘agreed’ that a service is no longer required. 

The  CHRT  Teams  provide services  for those  with  immediate  needs  and  aim  to  prevent  admissions to 
hospital. If there are no immediate risks, the patient can be discharged from the CRHT caseload, with the 
option to self-refer if risks were to increase.   

The Trust will always aim to work with patients to decide the most appropriate level of care. This process 
is a dynamic one, and we will always seek to include the patient in the decision making.   The decision 
making to discharge from CRHT at that point was based on immediate needs and in the knowledge that 
We  acknowledge  that  Mr.  Fegan  did  have  psychiatric  diagnoses  and  he  had  an  open  referral  for 
assessment with the LMHT and could re refer to CRHT if his situation changed.  It will be emphasised to 
staff  that  if  a  care  plan  is  changed,  there  needs  to  be  clear,  accurate  documentation  relating  to  the 
discussion and rationale for this change, including review of risk. This will be captured in feedback to the 
team, including reflections on the decision making to discharge at that point and the evidence behind it. 
We are reviewing guidance to staff in the Standard Operating Procedure for the crisis teams to ensure 
accurate decision making when stepping down from crisis team care, and an audit will be developed to 
provide ongoing assurance. Findings will be shared through our internal lessons learned bulletin, and the 
Trust’s regular Quality & Risk Meetings.  

The Crisis team has since been enhanced and expanded to allow for the increasing number of patients 
on its caseload,  and there will be more training available specifically relating to ASD presentations as 
outlined in paragraph  one and six. 

6. 

  Autism awareness 

I  was  concerned  that  Mr  Fegan’s  presentation  acted  as  a  barrier  to  a  proper  understanding  of  his 
mental health needs. In line with his autism diagnosis, he did not present in a socially typical way of 
expressing his feelings and emotions in a demonstrative manner, but rather ‘jumped’ to his view about 
what treatment he required, namely prescriptions. This was misunderstood by professionals on more 
than one occasion. 

mandatory training in learning disability and autism is being piloted from April 2021 
The 
for all health and social care staff.  This training will be delivered in three tiers; Tier 1: autism awareness, 
Tier 2: for  all clinicians and  Tier 3, for  advanced specialists.  There  is an ongoing national pilot on the 
delivery of this training. The Trust’s Learning and Development teams are involved in planning delivery 
of this training within the Trust in line with national recommendations. As mentioned earlier the Trust 
has the Neurodevelopment Steering group established with a working group in place, including AMH and 
NeSS,  with  the  aim  of  developing  and  enhancing  the  clinical  care  pathways.  Also  established  is  the 
Neurodevelopmental Case Discussion Forum, facilitated by an experienced clinician in the NeSS service, 
where clinicians can bring complex cases to present and discuss, and obtain advice.  

 
 
 
 
 
 
 
 
 
 
 
 The service has also undertaken work around learning from deaths of individuals with autism, part of 
which is the Learning from Autism Deaths Thematic Review. The learning from this will be included in 
training and future service developments. 

These actions will be monitored within the Trust through a specific Quality Improvement Plan with the General 
Manager as the nominated lead.  

I hope the information above provides the assurance that we have considered your recommendations seriously 
and are actively seeking to improve the services we provide by implementing the actions outlined.  

Yours sincerely  

Chief Executive