Eleanor Rose Murphy-Richards

PRIVATE AND CONFIDENTIAL  

Ms Sonia Hayes 
Assistant Coroner  
Mid Kent and Medway Coroner’s Court 

Sent via email to: 
kentandmedwaycoroners@kent.gov.uk 

Trust Head Office 
CEME Centre 
West Wing 
Marsh Way 
Rainham 
RM13 8GX 

17 August 2021  

Dear Ms Hayes 

Re: Inquest Touching Upon the Death of Ellis Murphy Richards 

I  refer  to  the  Regulation  28  report  dated  11th  July  2021,  issued  in  respect  of  your 
concerns regarding the risk of future deaths.   

Concerns 

The concerns that you have detailed within Regulation 28 report include as follows: 

“(1)  Ellis’ Safety Plan did not set out: 

a. 
b. 

the responsibilities of the Child & Adolescent Mental Health Team  
did not contain a contingency plan should Ellis agree to go to Accident & 
Emergency 

(2)  On  14th  October  2020  there  was  a  deviation  from  the  agreed  Safety  Plan 

without an updated risk assessment.  

(3) 

(4) 

Not all relevant information was shared between the Child & Adult Mental Health 
Team  about  the  circumstances  disclosed  of  events  on  the  night  of  29th 
September of Ellis’ failed attempt at hanging as part of a risk assessment.  

Ellis was found to be in need of a Mental Health Act assessment. Management 
advice  was  sought  about  risk  and  what  action  should  be  taken  should  Ellis 
refuse to go to hospital, the advice was contact the police. This advice did not 
take into account that Ellis had a history of absconding and that he could not be 
prevented leaving the centre.” 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I  am  extremely  saddened  by  the  death  of  Ellis  and  wish  to  express  my  heartfelt 
condolences to the family of Ellis. I appreciate that we cannot do anything to bring Ellis 
back. However, I can reassure you that we are taking the learning from this sad incident 
very seriously and provided our detailed response to each of the concerns raised by 
you as follows.  

(1) 

Ellis’ Safety Plan did not set out: 
a. 
b. 

the responsibilities of the Child & Adolescent Mental Health Team  
did not contain a contingency plan should Ellis not agree to go to 
Accident & Emergency 

Responsibilities of CAMHS 

The purpose of a Safety Plan in Mental Health services is to document, communicate 
what  interventions  have  been  agreed  to  be  provided  by  the  health  care  teams  to 
address the clinical needs of the patient. The Safety Plan (also referred to as Crisis & 
Safety Plan or Care Plan) can be used as an aide memoire in respect of care that the 
patient  can expect  to  receive.  The  Safety  Plan also assists  the healthcare  teams  in 
ensuring the continuity of care. 

I  have  reviewed  the  paginated  medical  records  bundle  (‘the  bundle’)  which  was 
submitted to the Court and confirm that the safety plans indicate responsibilities of the 
Child & Adolescent Mental Health Services (CAMHS) (i.e. what was the agreed and 
expected input from CAMHS).  

CAMHS  Crisis  &  Safety  Plan  dated  11th  February 2020  (Page  N.379 of  the  bundle) 
provides  that  the  agreed  actions  were  for  Ellis  to  “…remain  on  Dolphin  Ward  to 
complete  NAC  treatment  and  observation  on  his  physical  health…  Crisis  team  to 
screen on Wednesday on Dolphin Ward Mum spoke of not being able to keep him safe 
at home...”  

CAMHS  Crisis  &  Safety  Plan  dated  12th  February 2020  (Page  N.381 of  the  bundle) 
provides that agreed actions for the responsible Health Care Practitioner at CAMHS 
was to liaise with CAMHS Crisis Team whilst Ellis is in under the crisis team care. It 
also  provides  that  a  joint  review  had  been  arranged  for  19th  February  2020.  It  also 
provides that CAMHS Crisis Team should consider inpatient admission if they feel that 
safety cannot be maintained in the community.  

CAMHS  Crisis  &  Safety  Plan  dated  19th  February 2020  (Page  N.383 of  the  bundle) 
provides  that  CAMHS  Crisis  Team  should  remain  involved  with  daily  visits  by  a 
qualified  member  of  the  team.  It  also  provides  that  CAMHS  should  discuss  bed 
availability with bed management team on a daily basis.  

CAMHS  Crisis  &  Safety  Plan  dated  22nd  June  2020  (Page  N.227  of  the  bundle) 
provides that ALOT or CAMHS can provide additional support if needed.   

The  most  recent  care  plan  agreed  on  23rd  June  2020  (Page  N.224  of  the  bundle) 
provides that Ellis’ risk will be assessed on a weekly basis by a Health Care Practitioner 
from CAMHS.   

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Contingency plan  

Ellis safety plan dated 22nd June 2020 (Page N.227 of the bundle) provides that, if he 
is unable to keep himself safe, even with the support of others, he is to attend A&E for 
further assessment in a place of safety.  

In  the  event  that  Ellis  did  not  agree  to  attend  A&E  and  the  health  care  team  were 
concerned about his safety in the community, they would have had an option to raise 
their  concerns  with  the  police  who  have  statutory  power  to  detain  patients  under 
Section 136. In this case, the Trust notified the police as soon as it became apparent 
that he was not willing to attend A&E.  

In the circumstances the Trust acted within their remit as prescribed by law. The Trust 
had no legal power to hold Ellis. Given this, the Trust considers that it did comply with 
its safety plan for Ellis. The Trust also consider that the contingency plan would have 
been, at the correct time, to have called the police, which did occur.   However as a 
learning organastion the Trust fully accepts that there are always elements of cases 
that can be used for learning it will continue to reflect on its practice and procedures 
for all cases going forward. 

(2)  On 14th October 2020 there was a deviation from the agreed Safety Plan 

without an updated risk assessment.                                      

Ellis  sadly  died  on  30th  September  2020;  therefore  I  believe  that  the  date  of  14th 
October 2020 within your expressed concern is an error.  

If you are referring to the risk assessment and safety plan effective on 30th September 
2020 and the alleged deviation from the agreed Safety Plan by the psychiatrist. I note 
that there was no deviation from Ellis’ safety plan and the risk assessment was carried 
out by the psychiatrist.  

The safety plan effective on 30th September 2020 is documented on page N.227 of 
the bundle  which  provides  that  if Ellis is unable  to  keep  himself  safe,  even  with  the 
support of others, he is to attend A&E for further assessment in a place of safety.  

Based on the audio recording of the evidence (morning of inquest day 3) I understand 
that  on  30th  September  2020  the  psychiatrist  made  the  decision  to  not  ask  Ellis  to 
attend to A&E. This decision was based on the dynamic risk  assessment which the 
psychiatrist conducted while speaking to Ellis on the telephone at around 10am on 30th 
September  2020.  This  decision  was  also  made  in  the  knowledge  there  was  a 
prebooked appointment with his care coordinator later that day, which Ellis attended. I 
understand that, before making the decision not to ask Ellis to attend A&E at the point 
of their assessment, the psychiatrist weighed up risks and benefits of Ellis being asked 
to attend the A&E. The decision was made on the basis of clinical judgement at the 
time of the telephone assessment, considering the information available to them and 
their  assessment  of  Ellis’  mental  state,  that  it  would  be  appropriate  for  Ellis’  to  be 
assessed face to face by his care coordinator, with whom he had a well-established 
therapeutic relationship, rather than a healthcare practitioner at an A&E who he did not 
know.  I  understand  that  the  psychiatrist  was  concerned  that  Ellis  may  not  be  as 
cooperative  and forthcoming  with  an  unfamiliar health  care  practitioner as he  would 
otherwise  be  with  his  care  coordinator.  The  face-to-face  appointment  with  his  care 
coordinator had been scheduled for 3 pm on 30th September 2020.  

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I have been advised that as part of their consideration of how to proceed at the time, 
the psychiatrist recognised that Ellis might well have a wait of several hours at A&E 
and  was  aware  that  Ellis  had  a  history  of  selective  engagement  with  healthcare 
professionals. I have also been advised that it is customary practice that young people 
are seen by the team clinicians during working hours unless there are concerns about 
immediate safety or indications that the young person cannot be kept safe by the family 
in which case they are advised to seek A&E support.  

I have been advised that the psychiatrist was aware that such an approach had been 
adopted in the past. The family had been informed of the safety plan previously and 
had taken Ellis to A&E at times of crisis. Ellis’ grandmother confirmed that she would 
accompany  him  to  the  planned  appointment  with  the  care  co-coordinator  on  30th 
September 2020, which I understand she did. 

I understand that the psychiatrist stated in their oral evidence that, had Ellis had not 
been subject to pre-scheduled face-to-face appointment, they would have asked him 
to attend A&E. As above however, Ellis did attend that face-to-face appointment. I also 
understand that at the inquest there was no evidence that Ellis showed or indicated 
suicidal ideation or self-harm between the telephone call at 10am and the face-to-face 
appointment. 

As above, the risk assessment was a dynamic one, based on an evolving situation, 
clinical judgement and experience. As per the response below, a discussion between 
the psychiatrist and the care coordinator occurred later that day. On that basis, a risk 
assessment was undertaken, albeit, not a formal one, however, we fully accept that 
there are always elements that can be used for learning and whilst the Trust considers 
it acted reasonably, it will continue to reflect on its practice and procedures. 

(3) 

Not all relevant information was shared between the Child & Adult Mental 
Health Team about the circumstances disclosed of events on the night of 
29th  September  of  Ellis’  failed  attempt  at  hanging  as  part  of  a  risk 
assessment.  

It  is  my  understanding  that  the  psychiatrist  contacted  the  care  coordinator  after  the 
telephone  assessment  of  Ellis.  The  psychiatrist  shared  the  information  that  was 
available to them at the time. The psychiatrist informed the care coordinator about the 
incident the previous night involving a ligature. The psychiatrist was not aware at that 
time of  the  second  incident  at  the  Youth  Club.  The psychiatrist also  discussed  their 
assessment of Ellis’ suicide risk. They explained to the care coordinator that Ellis did 
not want to talk to them about the incident, which impacted on the ability to risk assess 
and establish if there were ongoing suicidal thoughts, intent or plans. The psychiatrist 
shared their consideration of whether to refer Ellis to A&E as well as their reasons for 
concluding that Ellis meeting with his care coordinator would on balance allow for a 
better risk assessment and therapeutic outcome. The psychiatrist and care coordinator 
agreed  that  a  decision  could  be  taken  regarding  the  next  course  of  action  after  the 
review by the care coordinator. The psychiatrist had documented their findings in Ellis’ 
medical records, which were accessible to the care coordinator. Paragraph 54 of the 
witness  statement  of  the  psychiatrist  dated  15th  December  2020  (Page  A194  of  the 
inquest bundle) provides as follows: 

“I shared my concerns about recent ligature, and my difficulty in assessing risk as Ellis 
was  not  engaging.  A  agreed  to  assess  risk  and  to  update  ALOT,  following  A’s 
appointment with Ellis, later that afternoon.” 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 I also note that Paragraph 54 of the witness statement of the care coordinator, dated 
15th December 2020 (page A178) provides the following: 

“On 30 September 2020, I received a call at 2pm from [redacted] who advised me that 
[they] had carried out a review with Ellis over the telephone at 10am. [They] said he 
had tied a ligature round his neck the previous evening. Nan had said he was OK and 
that he would be attending the appointment at 3pm with me”. 

I understand that immediately on commencement of the  pre-scheduled appointment 
with  the  care  coordinator  at  3pm  on  30th  September  2020,  the  care  coordinator 
explored the self-harming incident with Ellis and his grandmother to establish the full 
facts surrounding the incident the previous evening and to review the current risk status 
established (paragraph 56 of the witness statement of the care coordinator dated 15th 
December  2020  (  page  A179  of  the  inquest  bundle).    It  was  at  this  point  that  Ellis 
disclosed  for  the  first  time  the  details  of  the  second  incident  at  the  Youth  Club  and 
discussed this with the care coordinator. 

If your concern relates to the second incident at the Youth Club, I understand that when 
speaking to the psychiatrist, prior to the appointment with the care coordinator, Ellis 
did  not  disclose  information  about  this  incident  to  the  psychiatrist.  Therefore,  the 
psychiatrist could not have been expected to have the knowledge of this information 
when sharing her concerns regarding the risk to the care coordinator. 

Given this, it is felt by the Trust that appropriate information was disclosed to the care-
co-ordinator  and  that  it  was  appropriate  for  the  care  co-ordinator  to  elicit  further 
information from Ellis at the face-to-face appointment. 

(4) 

Ellis  was  found  to  be  in  need  of  a  Mental  Health  Act  assessment. 
Management  advice  was  sought  about  risk  and  what  action  should  be 
taken  should  Ellis  refuse  to  go  to  hospital,  the  advice  was  contact  the 
police.  This  advice  did  not  take  into  account  that  Ellis  had  a  history  of 
absconding and that he could not be prevented leaving the centre.” 

I understand that once the care coordinator completed the assessment of Ellis’ risks 
they appropriately sought advice from the Team Manager as stated in their statement, 
paragraph 66 (page A180 of the inquest bundle): 

“My manager agreed regarding hospital admission and said that I should refer Ellis for 
this  support  from  the  Crisis  Team  and  also  said  to  ask  Nan  to  take  him  to  A&E 
immediately. I checked with my manager what I should do if Ellis did not get into the 
car with Nan and she advised to call the police.’ 

The management advice did take into account the possibility that Ellis may not agree 
to  co-operate  to  go  to  the  A&E,  as  it  included  the  instruction  to  contact  the  police, 
should he not agree to go to the A&E.   

The care-coordinator and their Manager were acutely aware that it would not be legal 
and could be alleged to be an assault on the person or unlawful imprisonment, should 
restraint or deprivation of liberty techniques have been used, by the community mental 
health nurses to restrain or detain an individual.  

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The police have powers under Section 136 of the Mental Health Act to detain a person 
who is in a public place and appears in immediate need of care or control; the police 
would thereby take them to a place of safety for assessment.   

As  soon  as  Ellis  left  the  premises  and  refused  to  attend  A&E  the  care  coordinator 
contacted the police immediately to inform them of the incident, risks and concerns of 
safety. This was the first indication that Ellis was not willing to attend A&E and so the 
first opportunity to  update  the police.  Had  the  police been  telephoned before,  when 
there was no indication that he would not attend A&E, there is no evidence they would 
have attended.  

We  wish  to  provide  clarification  of  a  statement  within  the  section  ‘Circumstances  of 
death’, on page 2 of the Regulation 28 report: 

“Ellis  was  rescued  from  an  attempt  to  hang  himself  at  home  on  the  night  of  29th 
September and had planned telephone psychiatric review the next morning with details 
of the failed attempt, that Ellis wanted to kill himself and could not keep himself safe” 

The psychiatrist has explained that Ellis did not report to them that he wanted to kill 
himself. As above, Ellis did not want to talk to the psychiatrist about the incident, which 
impacted  on  the  ability  to  risk  assess  and  establish  if  there  were  ongoing  suicidal 
thoughts, intent or plans. At the time of the psychiatrist’s review it was not evident that 
Ellis had ongoing suicidal intent or plans. In addition, he did not express that he would 
not be able to keep himself safe, as he did to the care coordinator at the appointment 
later  that  afternoon.  During  the  meeting  with  the  care  coordinator,  Ellis  explicitly 
indicated that he had not wanted others to keep him safe. 

As part of our internal review of the findings of inquest and feedback from the family of 
Ellis we have identified incidental learning (detailed in the Serious Incident report in the 
bundle)  to  ensure  continuous  improvement  of  our  services.    We  have  arranged  a 
meeting with the family for  6th September 2021 to share our incidental learning and 
provide further reassurance in respect of improvements made within the service.   

I  hope  that  my  detailed  response  to  your  concerns  raised,  cross  referenced  with 
various  documentary  evidence,  appropriately  addresses  your  concerns.  As  stated 
above the Trust fully accept that there are always elements of cases that can be used 
for learning. I am mindful of the incredible personal loss to all those that loved Ellis, we 
will continue to ensure that anything we can do to prevent future loss of lives will be 
implemented across our services. 

I  understand  that  your  Regulation  28  report  may  be  shared  with  the  Chief  Coroner 
which in turn may be published on the Judiciary website, although we note that the 
responses  to  such  reports  do  not  tend  to  be  published.    Should  the  Chief  Coroner 
decide  to  publish  your  Regulation  28  report,  the  trust  requests  (pursuant  to  the 
Regulation 29(8) of the Coroner (Investigations) Regulations 2013) that it may be in 
the public interest for our response to be published alongside your Regulation 28 report 
in an anonymised manner.  

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  If you have any further queries, please contact my office on 

. 

Yours sincerely 

Chief Executive 

www.nelft.nhs.uk