Rebecca Pykett

Ms Emma Serrano, Area Coroner  
Stoke-on-Trent & North Staffordshire Coroner 
Stoke on Trent and North Staffordshire  
Stoke Town Hall,  
Kingsway,  
Stoke-on-Trent,  
ST4 1HH 

National Medical Director & Interim 
Chief Executive, NHSI 
Skipton House 
80 London Road 
London 
SE1 6LH 

13th December 2021 

Dear Ms Serrano, 

Re: Regulation 28 Report to Prevent Future Deaths – Rebecca Claire Pykett (25 
February 2019)  

Thank you for your Regulation 28 Report dated 17 July 2021 concerning the death of 
Rebecca Claire Pykett on  25 February 2019. Firstly, I would like to express my deep 
condolences to Rebecca’s family.  

I note the recent inquest concluded Rebecca Pykett’s death was a result of 

Following the inquest, you raised concerns in your Regulation 28 Report to NHS 
England regarding the allocation of a care coordinator to support Rebecca with her 
care.  

1. During the course of the inquest evidence was heard in regard to the fact that

each patient who is under the care of the CMHT should be allocated a Care Co-
Ordinator.  This Care Co-Ordinator will be responsible for co-ordinating the care
that each CMHT patient will receive.

2. The allocation of the Care Co-Ordinator was of concern as there was no system
to ensure that a Care Co-Ordinator was actually being allocated into this role.
What was taking place was that a clinician was being chosen, in Rebecca Pyketts
case, her Consultant Psychiatrist who was no, in fact carrying out the role, and
tasks expected as a care co-ordinator.

3. An example would be that the allocated Care Co-Ordinator should be allocated

within 5 days, see their patient within 5 days, and complete a care plan.  This did
not happen in Rebecca Pyketts’ case.

NHS England and NHS Improvement 

 
 
 
  
 4. 

It appears that there was routine allocation of the allocated Consultant 
Psychiatrists as care co-ordinator.  The reason behind this routine allocation was 
that Lorenzo (the patient record keeping system employed by the north 
Staffordshire Combined Healthcare NHS Foundation Trust), required this box to 
be filled in.  Therefore the allocation of the care Co-Ordinator was being dealt 
with as a “box ticking” exercise, to satisfy the record keeping system.    

5.  Once allocated, in this way, it was clear from the evidence that was produced at 

inquest that no such role was carried out by the Care Co-Ordinator.   

Care coordination is an important function needed to support people with complex 
mental health needs and the Community Mental Health Framework sets out a clear 
ambition for services to ensure all people requiring support, care and treatment in 
the community have a co-produced, personalised care plan in place which takes into 
account all of their needs. The level of planning and coordination of care will vary, 
depending on the complexity of their needs and for people with more complex 
problems, who may require interventions from multiple professionals, one person 
should have responsibility for coordinating care and treatment and this coordination 
role can be provided by workers from different professional backgrounds. 

This is also described in the recently published Care Programme Approach – 
Position Statement which sets out how community mental health services should be 
working towards a minimum standard of high quality care for everyone in need of 
community mental health support, including ensuring everyone has a named key 
worker with a multi-disciplinary team approach to both assess and meet the needs of 
patients.  

I note that the Trust was also sent a copy of the Regulation 28 Report and they have 
responded to the specific concerns about their Electronic Patient Record system and 
care coordinator allocation processes. 

We are working with NHSX to support improvements in the use of digital systems, 
including Electronic Patient Records in mental health services. In 2020/21 £30million 
was invested to support the digitisation of mental health providers. A significant 
portion of this funding was to improve digital infrastructure and provide hardware for 
services to improve their digital and remote care offer.  In 2021/22 a further 
£50million is being allocated to improve digital capability mental health providers 
including improving Electronic Patient Records.   

NHS England and NHS Improvement (NHSEI) recognise the considerable 
improvements needed to advance community mental health services to ensure 
everyone who needs high quality care and support can access it in a timely way.  

The work described above is underpinned by commitments set out in the  Long 
Term Plan to improve community mental health, so people receive the support that 
they need to help them stay well.  

All local areas have received funding to develop and begin delivering new models of 
care that integrate primary care and community mental health services for adults 
with severe mental health problems. By the end of 2023/24, all areas will have one of 

  
 
 
 
 
 
 
 
 these models in place, with care provided to at least 370,000 adults per year 
nationally. 

These models of care will give people greater choice and control over their care. 
They will also improve access to a range of interventions and support, including 
psychological therapies, physical health care, employment support, medicines 
management and support for self-harm and coexisting substance use, with care 
increasingly personalised and trauma-informed. The new models should also ensure 
appropriate links are made with other mental health services, for example inpatient 
and crisis services, to ensure patients have a seamless experience of care and that 
their needs can be met in the most appropriate setting.  

We acknowledge the historic treatment gaps for people with severe mental health 
problems and are committed to addressing this through the work set out above, as 
well as through the Clinical Review of Access Standards. Accessing care in a timely 
way is an important factor in improving outcomes for patients and NHSEI is 
developing a 4 week waiting time standard for community mental health. A 
consultation on this standard has just closed and pending a review of the responses, 
NHSEI will provide a formal response and next steps.  

While there is still work to be done to address the issues set out above, we hope the 
information provided offers some reassurance that we at NHSEI are committed to 
improving community mental health services.  

Thank you for bringing this important patient safety issue to my attention. 

Yours sincerely, 

National Medical Director & Interim Chief Executive, NHSI

Dr 

Consultant Psychiatrist/Medical Director 
Trust Headquarters 
Lawton House 
Bellringer Road 
Trentham 
ST4 8HH 

Date: 1st October 2021 

Emma Serrano, Area Coroner  
Stoke-on-Trent & North Staffordshire Coroner 
Stoke on Trent and North Staffordshire  
Stoke Town Hall,  
Kingsway,  
Stoke-on-Trent,  
ST4 1HH  

Dear Mrs Serrano 

Regulation 28 Report – Prevent Future Deaths 
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion 
there  is  a  risk  that  future  deaths  will  occur  unless  action  is  taken.  In  the  circumstances  it  is  my 
statutory duty to report to you. 

The MATTERS OF CONCERN are as follows: 

(1) During the course of the inquest evidence was hear in regard to the fact that each patient who
is under the care of the CMHT should be allocated a Care Co-Ordinator.  This Care Co-Ordinator
will be responsible for co-ordinating the care that each CMHT patient will receive.

(2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that
a Care Co-Ordinator was actually being allocated into this role.  What was taking place was that
a clinician was being chosen, in Rebecca Pykett’s case, her Consultant Psychiatrist who was
no, in fact carrying out the role, and tasks expected as a care co-ordinator.

(3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days,
see  their  patient  within  5  days,  and  complete  a  care  plan.    This  did  not  happen  in  Rebecca
Pykett’s case.

(4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-
ordinator.  The reason behind this routine allocation was that Lorenzo (the patient record keeping
system  employed  by  the  north  Staffordshire  Combined  Healthcare  NHS  Foundation  Trust),
required this  box  to  be filled  in.   Therefore  the  allocation  of the  care Co-Ordinator  was being
dealt with as a “box ticking” exercise, to satisfy the record keeping system.

(5) Once allocated, in this way, it was clear from the evidence that was produced at inquest that no

such role was carried out by the Care Co-Ordinator.

www.combined.nhs.uk 
Follow us on Twitter: @CombinedNHS 
Follow us on Facebook: www.facebook.com/NorthStaffsCombined 

 
 
 
 
 
 Trust responses to Matters of Concern Above 

(1)  The revised Trust Care Management Policy provides details on the role of the Care Co-ordinator 
being  responsible  for  co-ordinating  patient  care.  On  receipt  of  this  notice,  we  reviewed  our 
practice  to  provide  assurance  that  there  were  no  gaps  in  Care  Co-ordinator  provision.  I  can 
confirm that procedures have been implemented since the incident to ensure that the Trust policy 
is  adhered  to.  This  is  monitored  and  reviewed  on  a  monthly  basis  at  internal  performance 
meetings. 

(2)  Since  this  incident,  we  have  reviewed  our  processes  and  procedures  and  have  clarified  the 
expectations associated with the role of Care Co-ordinator through additional training. Weekly 
reports are reviewed by the Team Leaders to monitor the performance of all staff allocated as 
Care Co-ordinators. Individual staff members are provided with the information pertaining to their 
individual  case  load  with  the  expectation  that  they  will  address  any  outstanding  issues,  the 
following week’s report  provide assurance that this has been done. 

(3)  The  revised  Trust  Care  Management  Policy  provides  expectation  in  terms  of  the  timeframes 
required for allocation, assessment, care planning and review (see appendix 1). Training for all 
Care  Co-ordinators  has taken  place to  ensure  that staff are  aware  of  the full  requirements  of 
their  role.  Assurance  that  this  process  is  followed  is  monitored  through  the  weekly  review  of 
compliance  reports,  overseen  by  Team  Leaders.  This  data  is  further  reviewed  at  Service 
Manager  and  Associate  Director  Level  with  accountability  being  provided  through  Monthly 
Performance Review sessions with the Executive team. 

(4)  Care Co-ordinators are allocated according to the patients assessed clinical needs. For many 
patients,  it  is  appropriate  that  a  consultant  psychiatrist  fulfils  the  role  of  a  Care  Co-ordinator 
should the patient remain on standard care.  This is recorded in the Electronic Patient Record 
(EPR) using the Care Programme Approach (CPA) determination tool or the individual’s core 
assessment. The allocated Care Co-ordinator may change should the individual needs of the 
patient  change.  Therefore,  the  Trust  can  confirm  that  this  is  not  treated  as  a  “box  ticking” 
exercise.  This process is aligned to the Trust Policy.     

(5)  The Trust recognises from this inquest process that the role of the Care Co-ordinator did not 
meet  the  standards  expected.  Since  this  was  highlighted  we  have  addressed  these  gaps,  as 
previously stated the weekly reports provide feedback on key aspects of the care coordinators 
role. 

While there is still work to be done as set out in the action plan below (see appendix 2), I hope that 
the  information  provided  above  provides  assurance  that  we  at  North  Staffordshire  Combined 
Healthcare  NHS  Trust  are  committed  to  improving  practice  and  implementation  of  the  Care 
Management Policy.  

Please do not hesitate to contact me should you need any further information. 

Yours sincerely 

Dr 
Consultant Psychiatrist 
Executive Medical Director  

 
 
 
 
 
 
  
 
 
 
 
 Trust systems and processes that provide assurance: 

Appendix 1 

Standard Operating Procedure (SOP) - Crisis Response SOP between Crisis Care Centre and 
CMHT’s 
  New referrals:- Routine referrals to CMHT’s will be assessed within 28 days if clinical judgement 
indicates  that  28  days  is  not  sufficient  to  manage  their  presenting  needs  their  care  will  be 
managed by the Crisis Care Centre and interventions put in place until handover of care to the 
CMHT. 

  Service users in crisis and needing contact within 72 hours will be managed by the Crisis Care 

Centre 

  Where patients  are  receiving  only  outpatient  appointments  any  crisis  will  be  managed  by  the 

Crisis Care Centre 

There have been a number of changes and revisions to our triage processes which are not covered 
by the above SOP, neither is the process for Care Coordinator allocation. 

Performance monitoring 
  Weekly performance reports are distributed to CMHT team leads. The reports show an overview 
of caseload alongside key performance indicators with highlighted cells to indicate where criteria 
has not been met. In respect of the matters of concern raised the following data is included for 
each patient on the caseload: 

o  CPA status 
o  Name of Care coordinator 
o  Date of last review 
o  Whether the review is in date (according to specified standards) 
o  Type of care plan (CPA or Non CPA) 
o  Date of last plan 
o  Whether the care plan is in date 
o  Whether the care plan is offered to the client 
o  Date of next planned appointment 
o  Whether risk assessment has been completed. 
o  Date of risk assessment 

The above are all key elements of the care coordinator role. Team leaders have a role in monitoring 
the performance of their team and taking actions to address any identified deficit. Patients allocated 
to Consultant Psychiatrists are included in the report and there is no difference in the expectations 
of this group of staff in terms of meeting the standards expected of the care coordination role. 

The current Care Management Policy  
NHS  England  and  NHS  Improvement  position  statement  indicates  a  need  for  a  shift  away  from 
generic care coordination to meaningful interventions with documentation and processes that are 
proportionate and enable the delivery of high quality care. A named key worker for all service users 
with a clearer MDT approach to both assess and meet the needs of service users. 

As the transformation process progresses there is a need to review our current policy in light of the 
above  requirements  whilst  maintaining  the  standards  that  are  embedded  within  the  current  CPA 
framework. 

 
 
 
 
 
 
 
 
 Action Plan                                                                                              Appendix 2 

Identified Action 
A  process  mapping  exercise  will  be 
undertaken  to  ensure  that  there  is 
consistency in practice and no gaps 
in  the  process.  This  will  capture  the 
developments  in  practice  that  have 
been  implemented  but for  which  we 
currently  have  no  documented 
procedure. 
Standing  Operating  procedures  will 
be  developed  which  will  encompass 
the 
care 
coordinator  allocation  processes  as 
identified 
the  process 
mapping exercise. 
Team  leaders  will  continue  to  utilise 
the  weekly  reports  to  monitor  the 
performance of individuals within the 
team  in  meeting  the  required  Care 
coordination standards. 

triage  and 

referral, 

through 

No 
1 

2 

3 

the  course  of 

Area of Concern 
During 
the 
inquest evidence was heard in 
regard  to  the  fact  that  each 
patient who is under the care of 
the CMHT should be allocated 
a  Care  Co-Ordinator.    This 
Care  Co-Ordinator  will  be 
responsible  for  co-ordinating 
the  care 
that  each  CMHT 
patient will receive.   

The  allocation  of the  Care Co-
Ordinator  was  of  concern  as 
there was no system to ensure 
that  a  Care  Co-Ordinator  was 
actually  being  allocated  into 
this  role.    What  was  taking 
place  was  that  a  clinician  was 
being  chosen, 
in  Rebecca 
Pykett’s  case,  her  Consultant 
Psychiatrist who was not, in fact 
carrying out the role, and tasks 
expected  as  a  care  co-
ordinator. 

Lead 

Completion date 
October 4th 2021 

Assurance 
NA 

October 31st 2021  SOP  will  be 

ratified  at 
directorate  and  trust  level. 
The  reports  referred  to  in 
provide 
3  will 
action 
assurance 
that  standards 
are being met. 
Overview  of  performance  is 
maintained  at  Directorate 
level 

Team Leaders  Ongoing 

www.combined.nhs.uk 
Follow us on Twitter: @CombinedNHS 
Follow us on Facebook: www.facebook.com/NorthStaffsCombined 

             
 
 
 
 
 
 
 
 
 
 
 
 
 4 

An  example  would  be  that  the 
allocated  Care  Co-Ordinator 
should  be  allocated  within  5 
days, see their patient within 5 
days, and complete a care plan.  
This did not happen in Rebecca 
Pykett’s case. 

5 

6 

of 

that 
allocation 

there  was 
It  appears 
the 
routine 
Consultant 
allocated 
Psychiatrists  as 
co-
care 
ordinator.    The  reason  behind 
this  routine  allocation  was  that 
Lorenzo  (the  patient  record 
keeping  system  employed  by 
Staffordshire 
the 
Combined  Healthcare  NHS 
Trust),  required  this  box  to  be 
filled 
the 
the  care  Co-
allocation  of 
Ordinator  was being  dealt  with 
as  a  “box  ticking”  exercise,  to 
satisfy 
record  keeping 
system.    

  Therefore 

North 

the 

in. 

The  example  provided  is  not  as 
stated  in  the  current  Trust  Care 
Management Policy, however it is felt 
that  the  current  document  does  not 
present  the  required  standards  in  a 
concise and accessible manner and it 
would  therefore  be  appropriate  to 
review  the  policy.  A  review  of  this 
policy will also be required in order to 
implement  the  Community  Mental 
is  a 
Health  Framework.  This 
significant  piece  of  work  and  will  be 
ongoing  as  the  transformation  work 
progresses. 
Care  coordinators  are  allocated 
according to clinical need. 
The agreed SOP will outline how this 
need is assessed and how individuals 
are  informed  that  they  have  been 
allocated to a patient.  
In conjunction  with the  policy  review 
a training package will be developed 
roles  and 
which  outlines 
responsibilities  of  staff.  This  to  be 
rolled 
the 
to 
implementation of the revised policy. 

support 

out 

the 

Trust Head of 
Nursing 

June 2022 

The  Community  Safety 
Matrix  provides  ongoing 
audit  of  Care  management 
standards. 
annual 
Community  Mental  Health 
survey  audits 
the  patient 
experience. 

The 

Team Leads 

Ongoing 

Monitored 
performance reports 

through 

Trust Head of 
Nursing  

July 2022 

Monitored 
performance reports.   

through 

www.combined.nhs.uk 
Follow us on Twitter: @CombinedNHS 
Follow us on Facebook: www.facebook.com/NorthStaffsCombined 

             
 
 
 
 
 
 
 
 
 
 
 
 Once  allocated,  in  this  way,  it 
was  clear  from  the  evidence 
that  was  produced  at  inquest 
that  no  such  role  was  carried 
out by the Care Co-Ordinator.   

See action no 3 above. 

www.combined.nhs.uk 
Follow us on Twitter: @CombinedNHS 
Follow us on Facebook: www.facebook.com/NorthStaffsCombined