Daniel Lee

22nd February 2023 

Mr Eccleston 
HM Assistant Coroner, South Yorkshire (West) 
Medico-Legal Centre 
Watery Street 
Sheffield  
S3 7ES 

Dear Sir, 

Regulation 28 Response – Daniel Lee  

Trust Headquarters 
Fieldhead Hospital 
Ouchthorpe Lane 
Wakefield 
WF1 3SP 

We write in response to the Regulation 28 report following the inquest touching the death of Mr Daniel 
Lee. We would like to start with offering  the family of Mr Daniel Lee our sincere condolences for their sad 
loss. 

We hope the information supplied in this response provides assurance that the concerns raised are taken 
seriously by the Trust. We will respond to each of your concerns in turn below and adopt the same 
summary headings detailed in the Regulation 28 report. 

As you will be aware, the Trust submitted an Intensive Home-based Treatment Team (IHBTT) overview 
statement and Serious Incident Investigation report into the inquest proceedings to assist with your 
inquiry. This response will therefore build upon information previously available to you as part of the 
inquest proceedings. 

Superficiality of risk assessments 

At the outset of this response, we considered it would be helpful to provide you with information in 
respect of how community mental health services, specifically IHBTT services, operate. The model of 
IHBTT is a national approach, to which the Trust adheres.  

The role of the IHBTT can be summarised as follows: 

•  To provide an alternative to hospital admission 
•  To offer the patient the Least Restrictive option (working on the Principle of Least restrictive 
option and maximising independence as set out in the Mental Health Act Code of Practice 
[2015]). 

•  To  gatekeep  all  admissions  to ensure  that  individuals  are  not  unduly  detained under  the 

Mental Health Act or admitted to hospital inappropriately. 

 
 
 
 
 
 
 
 
 
 The IHBTT provides rapid and intensive interventions for people with acute mental health 
problems in the least restrictive environment as close to their home as clinically possible. The 
IHBTT has flexibility to respond to differing service user needs as it operates on a 24 hour, 7 day 
a week basis. Service users in receipt of IHBTT intervention and support are often identified as 
being in an acute period with their mental health and once the service user’s acute period has 
resolved, they will be referred or sign-posted to appropriate follow up services, which may include 
referral into longer-term secondary mental health support services (e.g. Core or Enhanced 
community mental health teams), discharge to their GP or sign-posted to other appropriate 
support services (e.g. Andy’s Man Club or similar). Care and interventions by the IHBTT are often 
provided in the short term, by nature of the service users being in an acute phase of their mental 
health. 

The IHBTT is a multi-disciplinary team (MDT), consisting of Psychiatrists, Registered Mental 
Health Nurses, Social Workers and other allied health professionals, not dissimilar to a ward 
MDT. Therefore, the approach to an individual’s care is multi-disciplinary from the initial referral to 
the discharge. For example, assessment for acceptance onto the IHBTT caseload is completed 
by an IHBTT practitioner and an IHBTT psychiatrist (or two practitioners if a psychiatrist is 
unavailable) and all service users on the IHBTT caseload are discussed at the daily and weekly 
MDT meeting, with the attendance of the various professionals, as a means to ensure appropriate 
and on-going oversight of risk assessment, risk management and care planning. 

Those professionals employed in the IHBTT, in the most part, work 12 hour shifts three times per 
week (not including optional overtime hours). Given that the IHBTT is a 24 hour and 7 day a week 
service, maintaining continuity of care and contacts is a key consideration of all care provided. 
Continuity of visiting practitioners was always attempted with Mr Lee, to ensure consistency of 
risk assessment, risk management and care planning (as evidenced below). An additional 
complexity in the allocation of staff for visits for Mr Lee was that he reported a preference to have 
face-to-face contacts with male practitioners, and so all efforts were made to accommodate this 
request where possible.  

Having reviewed the IHBTT contacts, we noted that Mr Lee received 40 contacts (home visits, 
telephone contacts and psychiatric reviews) whilst receiving care by the IHBTT. 

•  of these 40 contacts, 26 were planned face-to-face home visits with IHBTT practitioners.  
•  of these 26 home visits, 14 were undertaken by three different practitioners (six, five, and 

three contacts per practitioner) 
four home visits were undertaken by two different practitioners (two contacts per 
practitioner) 
the remaining 8 were one-off contacts where the practitioner only visited once.  

• 

• 

 
 
 
 
 This demonstrates that 18 of the 26 IHBTT face-to-face home visits with Mr Lee were made by 5 
practitioners, with each practitioner seeing him on two or more occasions. 

As indicated above, the IHBTT operates an MDT approach to risk assessment, risk management 
and care planning. Mr Lee was discussed during daily MDT meetings to ensure a consistent 
approach between both new and recurring visiting staff, and to ensure that all staff were aware of 
the on-going care arrangements and risks. Mr Lee was also discussed on a weekly basis at the 
IHBTT Case Management Review, which included an appraisal of risk and assignment of risk 
rating. The Case Management Review is again an MDT meeting that involved the various 
professionals from the service with knowledge of Mr Lee. The MDT and Case Management 
Review meetings are undertaken to further ensure consistency of risk assessment, risk 
management and care planning. 

We can confirm that Mr Lee was allocated a ‘Key Worker’ within the IHBTT on 21st July 2021, and 
this information was recorded on page 21 of the Serious Incident Investigation. The allocation of a 
Key Worker was undertaken during the IHBTT Multi-Disciplinary Team Meeting on 21st July 2021 
at 13:30hours and was allocated based on the caseload numbers of practitioners at the time.  

The Key Worker’s responsibilities include: 

•  The  ongoing  assessment  and  management  of  risk,  inclusive  of  updating  the  FIRM 
(formulation informed risk management) risk assessment when a change in risk is identified; 

•  The continual assessment of individual patient need;  
•  Monitoring the efficacy of prescribed medication, observing for any notable side effects or 

adverse reaction;  

•  Care planning and ensuring a collaborative care planning process; 
• 
Initiating and maintaining carer and family contact and involvement; 
•  Providing accurate and timely feedback to inform the weekly case management review and 
where possible participate in the Case Management Review (weekly discussion to appraise 
risk); and 

•  Ensuring that all entries made in relation to a home visit follow the progress note template. 

The  key  worker  provided  the  oversight  role  as  per  the  responsibilities  detailed  above  and  was 
involved in the discharge pathway for Mr Lee. However, they did not have direct face-to-face contact 
with  Mr  Lee  because  of  personal  circumstances  that  changed  their  shift  availability  (during  this 
period the practitioner predominantly worked nights).  

As a result of the learning from Mr Lee’s death, how the team allocates a Key Worker has changed 
to include the following: 

•  All service users will be allocated three Key Workers, with shared responsibilities; 

 
 
 
 
 •  Allocation of Key Workers is undertaken by the Clinical Lead for IHBTT, taking into account 

the following: 

o  Presenting clinical risks: does the patient require a male or female practitioner. 
o 
Immediate staff availability- taking into account planned shift patterns, annual 
leave, absence and training. 

At the time of Mr Lee’s care with IHBTT, the allocation of visits was undertaken based on availability 
of staff. Current practice is that in the first instance the service will now make every effort to allocate 
one of the three Key Workers to undertake the visit. This is a further introduced means of ensuring 
consistency  of  risk  assessment,  risk  management  and  care  planning.  The  IHBTT  Clinical  Lead 
undertakes  a  regular  caseload  audit  to  ensure  that  Key  Workers  have  been  allocated  to  every 
service user’s care.  

We note your concern that the “risk assessment on 16.07.21 was flawed”. This assessment was 
completed by an experienced Psychiatrist and Mental Health Nurse, both of which agreed with the 
assessment of self-harm and suicide risk following the assessment. A risk assessment considers a 
wide  and  diverse  range  of  information,  as  evidenced  by  the  clinical  entries  for  this  contact,  the 
IHBTT inquest statement and the Serious Incident Investigation report. There was a recent history 
of  attempted  ligature,  the  circumstances  around  that  were  explored,  factors  including  Mr  Lee’s 
engagement, insight into his problems, future planning and presentation post self-harming event 
were all considered as part of the global assessment of risk. These factors when combined informed 
the  grading  of  the  risk.  The  assessment  and  level  of  risk  in  a  person  is  a  combination  of  static 
(historic) and dynamic (current) factors. In Mr Lee’s case, there were no further attempts of self-
harm or suicide after 16th July 2021 (static) until his death on 16th September 2021, and he remained 
engaged with services throughout. 

We hope the above information assists your understanding of the Trust’s IHBTT service and the 
changes made as a result of the learning from Mr Lee’s death. The Trust wishes to assure you 
that all efforts will continue to be made to ensure appropriate allocation of Key Workers, 
consistency of contacts with practitioners whilst an individual remains on the IHBTT caseload, 
and risk assessment, risk management and care planning will continually be reviewed as part of 
the MDT approach to care within the IHBTT. 

Lack of key worker approach 

Please see response above regarding the allocation of a Key Worker and MDT approach to care 
for service users on the IHBTT caseload. 

Lack of communication with the armed forces 

 
 
 
 
 
 At the outset of an individual’s care, and as part of the initial IHBTT assessment, practitioners are 
required to identify and record any other agencies involved in the service user’s care. The IHBTT 
Clinical Lead undertakes a weekly caseload audit to ensure practitioners are appropriately 
identifying agencies involved in the care, and any deficits identified as part of the audit are 
addressed through the supervision of the practitioners involved. 

In December 2022, the IHBTT introduced a practitioner role with a specific focus on ensuring 
liaison with the armed forces or veteran services where the person has been identified as being 
involved with these agencies. 

The practitioner currently working in this role is a veteran themselves, and the service offer for 
any person who is either engaged in the armed forces or who is a veteran, will be offered a visit 
by this practitioner. This practitioner is also able to act as a Key Worker to these service users as 
necessary. 

Superficiality of communication with the family 

The Trust considers that families and carers provide a significant and important role in the care of 
a service user. This is reflected in the Trust’s values - “We know that families and carers matter”. 

The Trust identified through the Serious Incident investigation report that Mr. Lee’s family did not 
feel, nor was it evidenced fully, that they were substantially engaged with in respect of his care. 
As a result, the recommendation was made at Page 35 of the Serious Incident Investigation 
report “For the service to provide assurance that the involvement of service users, their families 
and Supporters, is being actively sought both at the initial assessment stage and also as care 
plans are reviewed and changed, in line with Trust policy”. 

Assurance is currently gained in respect of communication with, and involvement of, families and 
carers as follows: 

•  The IHBTT use a progress note template for every home visit. Included within this 

template is a heading titled “Family Feedback”. This acts as a prompt for staff to liaise with 
families or carers on every visit. 

•  The IHBTT Clinical Lead’s regular caseload audit identifies whether staff have sought 

recent and regular feedback from service users, their family and any carers.  

•  The IHBTT Clinical Lead’s regular caseload audit identifies whether a carer has been 

offered a carer’s assessment, as required at the outset of a services user’s acceptance 
onto the IHBTT caseload, and monitored through the weekly Case Management Review 
meetings; and 

•  Allocation of three Key Workers to ensure continuity of contacts with the service user, their 

families and carers  

 
 
 
 
 Anxiety about appropriate risk sharing 

We understand this concern relates to the contact with Mr Lee’s partner on 15th September 2021. 
We would like to take this opportunity to clarify the contact as per the information detailed in the 
IHBTT statement and Serious Incident investigation report. 

Mr Lee’s partner contacted the IHBTT service on 15th September 2021 to report her on-going 
concerns regarding Mr Lee. The clinical entry records that Mr Lee’s partner had not informed or 
agreed with Mr Lee that she would be contacting the service, nor did she wish for him to be made 
aware of the contact. Family contacts of this nature are helpful to practitioners when considering 
the practitioners assessment of risk and the person’s presentation. However, and as you will 
appreciate, it places practitioners in the situation where they may not be able to refer to the family 
concerns directly with the service user because of the possible consequences of doing so (e.g. 
break-down of relationships, anger or agitation etc). This is the ‘difficulty’ referred to by the 
practitioner in their clinical entry on this occasion. 

As indicated in your Regulation 28 report, Mr Lee had a pre-arranged appointment with an IHBTT 
practitioner following this telephone contact from his partner.  As per the IHBTT statement and 
Serious Incident investigation report records, the visiting IHBTT practitioner discussed the contact 
from Mr Lee’s partner with the practitioner that took the telephone call. The contact from Mr Lee’s 
Partner was therefore appropriately considered as part of the visiting practitioner’s assessment, 
without any barriers as to understanding around information sharing. 

I do hope the above information is of assistance and answers the concerns raised within your Regulation 
28 report following the sad death of Mr Daniel Lee. 

Yours faithfully, 

Chief Medical Officer