Lisa Thompson

Ms S Hayes 
Assistant Coroner for Oxfordshire 
Oxfordshire Coroner's Office 
The Oxford Register Office 
Second Floor 
1 Tidmarsh Lane 
Oxford 
OX1 1NS 

Chief Executive’s Office 

Trust Headquarters    

Littlemore Mental Health Centre 
Sandford Road 
Littlemore 
Oxford 
OX4 4XN 

6 April 2021 

Dear Ms Hayes 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS  
INQUEST INTO THE DEATH OF MRS LISA THOMPSON 

I write in response to your report dated 10 February 2021.    Firstly, thank you for your report. 
The Trust has considered your concerns very carefully and I hope that my reply will provide 
you with assurance that the Trust is taking appropriate action. 

Following the conclusion of the inquest into Mrs Thompson’s death your office provided the 
Trust  with  an  audio  recording  of  your  summary  of  the  evidence,  findings  of  fact  and 
conclusion.  A  copy  of  the  audio  recording  was  shared  with  the  Trust’s  Head  of  Quality  
Governance, Clinical Director for Oxfordshire Mental Health (Dr Rob Bale, who gave evidence 
at the inquest) and the author of the completed Root Cause Analysis Report.  Separately, the 
Trust received a complaint from Mrs Thompson’s husband on 1st October raising 10 concerns 
and the Complaint Investigating Officer, who is a Service Manager at the Trust, has listened 
to the recording.  

As such, the Trust has been on notice of your concerns and had the opportunity to include 
your concerns as part of the investigation into Mr Thompson’s complaint.  

The concerns you raised with us were: 

(1) There was no clear care plan in place following an emergency review of Mrs Thompson 

on 13th March 2020 

(2) The care plans and risk assessments at the mental health Trust were not updated: 

(a)  with  material  information  on  the  facts  and  circumstances  of  Mrs  Thompson’s 

overdoses of her medication; 

(b) the two most recent overdoses were not recorded; 

 
 
 
 
  
 
 
 
 (c)  with further information disclosed by the doctor who treated her most recent 
overdose that Mrs Thompson had lied about the severity of her overdose that it 
was probably double that which she initially disclosed also that this was her 4th 
overdose and another could not be ruled out;  

(d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist on 
13th  March  2020  when  there  was  a  telephone  conversation  between  Mrs 
Thompson and her care co-ordinator. 

In Mrs Thompson’s case, there are several points at which updated information is added to 
Mrs Thompson’s records, but the Trust agrees with you that  the updates were not added 
under the Care Plan and Risk Assessment sections of the records. That is not in line with our 
policy. 

In relation to the review on 13th March 2020, there is a plan written down in the main body 
of  the  notes  on  13th  March  2020.    However,  the  care  plan  and  risk  assessment  were  not 
updated. As you heard, the care co-ordinator then spoke to Mrs Thompson. On reflection 
since the inquest 
 recognises that it was not clear to the family what the plan was, 
even when the care  co-ordinator made her  call. The family did not go home with a clear 
message. 

We have considered our approach in terms of ensuring patients and their families go home 
following a consultation with a clear plan. This will be picked up in the quality improvement 
work that I describe below. We recognise that often patients and their family members may 
be  in  a  state  of  distress  in  such  consultations  and  our  clinicians  need  to  ensure  that  our 
patients understand clearly the plan made at the end of a consultation.  

The  Trust’s  complaint  investigation  has  been  completed  and  the  Trust  wrote  to  Mr 
Thompson on 12th March 2021 to report on the findings of the investigation. I can report to 
you that the Complaint Investigation Officer identified the following issues to be addressed 
by the Trust:  

1.  To ensure patients on the Care Programme Approach have a current and up to date risk 
assessment  and  care  plan  which  is  shared  with  the  patient  (and  their  family  as 
appropriate).   

2.  Review  how  risk  formulations  and  assessments  are  recorded  and  reviewed  in  the 
electronic care record, ensuring consideration of family’s views and ensuring best practice 
is adopted in relation to involving families in our patient’s safety plans.  

3.  Embed Multi-disciplinary Team care plan reviews for patients at risk of suicide. 

4.  Review  the  current  Clinical  Risk  Assessment  and  Management  mandatory  training  to 
include safety planning which takes into account family involvement using the triangle of 
care approach1.  In common with many mental health trusts, OHFT uses the Triangle of 

1 https://www.oxfordhealth.nhs.uk/carers/triangle/ 

2 

 
 
 
 Care, which is a therapeutic alliance between carers, service users and professionals. This 
is a national accrediated scheme which seeks to ensure at all times the involvement of 
carers  and  families  in  care  and  treatment.  For  further  information  I  attach  a  leaflet 
produced for professionals (“A”) and a leaflet for service users (B”), which I hope is helpful. 

The Complaint Investigation has recommended actions to be taken and those are in place. 
Some issues have been worked on previously and there is ongoing work for the Trust to 
continue to carry out in order to keep the quality of our services under constant review. One 
of the actions we are taking is being completed by our Chief Nurse, who is working with 
senior  colleagues  to  review  themes  that  have  arisen  from  complaints,  serious  incident 
investigations and inquests. This is to ensure that we can particularly identify themes, such 
as ensuring family involvement in care and treatment and improving how risk formulation is 
documented, in order to improve outcomes for patients. Based upon the thematic findings 
from  the  investigations  of  complaints  and  serious  incidents  we  think  that  a  Quality 
Improvement  approach  should  be  taken  to  explore  risk  assessment,  formulation  and 
documentation processes within our mental health services in order to improve practice in 
these areas. 

To that end, the Trust has a Quality Improvement team2 who are dedicated to working with 
our local teams to continually improve the quality of our services. Our Chief Nurse has asked 
the Quality Improvement team to ensure areas of improvement relating to this tragic serious 
incident  are  considered  alongside  other  themes  identified  from  the  thematic  review,  in 
particular: 

-  Ensuring family members are included in care and treatment in a systematic way using 

the triangle of care.  

-  Ensuring risk formulation and suicide risk assessment are enhanced and embedded 
in the safety planning for patients, including their families and ensuring cumulative 
deliberate self-harm events are noted and acted upon. 

Please be assured that this work is a high priority for the Trust.  Trust audits in the coming 
year will include looking at the the quality of risk assessments and care plans.  We have also 
included safety planning questions into our CPA and Essential Standards audits. I also hope 
it will help to inform  you about work being  carried out if I attach  the Trust’s Action Plan 
record (“C”).  

2 The Oxford Healthcare Improvement (OHI) centre supports the trust in providing safe, better quality care to patients and improve the 
working lives of staff. OHI’s aim is to improve patient safety and the quality of care for people in hospital, communities and homes through 
a programme of quality improvement, research, training and collaboration. OHI team members come from a range of backgrounds to 
ensure  that  practice-based  problems  are  viewed  through  different  lenses  and  improvement  projects  are  approached  in  a  systematic 
manner with clear evaluation. The team includes clinicians, non-clinicians, researchers and analysts. 

3 

 
 
 
 
 Once again, thank you for your report and please do not hesitate to contact me if you would 
like any further information at this stage.  I am happy to write to you again if you would like 
to receive an update on the work being carried out by our Quality Improvement team.  

Yours sincerely 

Chief Executive  

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