Carl Ellson

Kirkham House 
John Comyn Drive 
WORCESTER 
WR3 7NS 

Chief Executives Office 
2 Kings Court 
Charles Hastings Way 
Worcester 
WR5 1JR 

13th February 2023 

Mrs Louise Hunt 
HM Senior Coroner for Birmingham and Solihull 
50 Newton Street 
BIRMNGHAM 
B4 6NE 

Dear Mrs Hunt 

We are writing to respond to the Regulation 28 Report to Prevent Future Deaths which was 
addressed to Herefordshire and Worcestershire Health and Care NHS Trust and NHS 
Herefordshire and Worcestershire Integrated Care Board.  Whilst we recognise our different roles, 
we are working collaboratively (along with other partners) in identifying the needs of our population 
for mental health services and ensuring that our services are designed to meet those needs.   

Thank you for raising your concerns.  We would like to address them each in turn: 

Concern 1 – The system for GPs to contact Mental Health Teams for urgent review is not 
clear nor safe. 

The Trust’s current process for enabling urgent access to mental health services is longstanding 
and we thought well recognised.  GPs can contact the Single Point of Access (SPA) who pass the 
referral on to the relevant/local Home Treatment Team (HTT) who then triage the referral and 
either allocate themselves or the Crisis Team dependant on risk and clinical presentation.  If a call 
comes through out of hours, it goes straight to the Crisis team which is a 24/7 service. 

If on the rare occasion no staff are available to take the call (due to being on other calls) there is 
an answer phone facility or there is an option for the SPA to transfer the call to an alternative HTT 
to screen the referral. 

We recognise that this is a different model to that of Birmingham with which you may be more 
familiar.  Our model is different as our geography is much bigger.  In Birmingham, GPs call SPA 
who then call one number which takes them to a joint Home Treatment Team and Crisis Team. 

During our investigation and roundtable discussions the Trust was assured that GPs have been 
part of the transformation of our services and been provided with all the relevant numbers for their 
Neighbourhood Mental Health Teams and SPA for referral purposes.  These numbers have not 
changed for several years.  Relevant numbers have been confirmed with local GPs and are the 

 
 
 
 
 
 
           
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 same numbers available to the public.  Both email address and contact telephone number are 
prominent on the GP Referral Form.  Whilst we believe GPs are aware of the correct numbers, 
going forward, we will continue to issue reminders to all GP surgeries of the contact numbers 
through Teamnet, which is the service used for all referral and service information.  Between our 
two organisations we are refreshing all of the information on Teamnet, to ensure that the 
information is both relevant and prominent. 

In addition, the Trust acted to remind GP colleagues of the process to contact SPA in 
communications sent on the 31st December 2022.  The following information was reiterated and 
confirmed: 

‘Routine referrals should be sent electronically.  All routine referrals will be received via email to 
the Single Point of Access (SPA) on the following email address:  
WHCNHS.amhreferrals@nhs.net.  Urgent/same day referrals should be telephoned through to the 
Single Point of Access on 01905 681477.  If you need a copy of the referral form, you can contact 
the administration team on the Single Point of Access telephone number and request a copy.  The 
Crisis Resolution Teams also provides advice on mental health services and presentations to 
health care professionals via a dedicated professionals line.  This can be accessed by contacting 
the 24/7 Helpline on 0808 1969127.’ 

As part of striving for continuous improvement our Medical Leadership Forum (which includes the 
ICB, Trust and General Practice) will also take this issue forward, to reiterate the process and 
ensure any concerns are addressed. 

Concern 2 – The system in place is for the patient to call the Mental Health Practitioner.  
The patient is likely to be in crisis and therefore the burden should not be put on them to 
make the call.  

We would like to reassure you that a process is in place which does not burden the patient with the 
responsibility of making a call to initiate engagement with services when in a crisis.  In this 
instance, the patient in this case was not asked by the Home Treatment Team or the Crisis Team 
to call them at any point.  Further, it is never the usual process for a patient to contact Home 
Treatment following a referral from a GP.  The call takers from both the Home Treatment Team 
and the Crisis Team, who took the call from the SPA on the day in question both state they did not 
ask the GP to tell the patient to call either team.  This is supported by the contemporaneous 
recording following the conversations.  

The process is once the referral is triaged and accepted by Home Treatment (or the Crisis Team) 
from a GP, the Home Treatment Team contact the patient to initiate the engagement.  On this 
occasion, the Crisis Team had clinical contact through the patient’s GP, prior to the Home 
Treatment Team.  As soon as the Crisis Team referred back to the Home Treatment Team, a 
telephone call was received into the Home Treatment Team directly from the patient.  The HTT call 
taker has expressed their ‘surprise’ at receiving an incoming call from the patient as this is not part 
of our process.  The patient had not been directed to initiate contact by either the Crisis Team or 
the Home Treatment Team and therefore we cannot explain why the patient picked up the phone 
and called the Home Treatment Team directly. 

However, in this instance it is believed the patient was also aware of our Healthy Minds Service 
through his professional role.  This service is delivered adopting the national model of Increasing 
Access to Psychological Therapies (IAPT) programme.  This service relies on the patient being 
self-motivated and engaging for their treatment to be beneficial.  Referrals to Healthy Minds 
include self-referrals, so clinical staff wondered if this was why the patient called the team direct.   

We hope the above assures you that patients in crisis would never be expected to contact either 
the Crisis or Home Treatment Team, with those teams contacting patients. 

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 Concern 3 - GPs should be fully aware how to request an urgent psychiatric review for a 
patient.  

The Trust follows a national model which allows GPs to refer for an urgent psychiatric assessment 
in terms of a psycho-social assessment by a Home Treatment or Crisis Clinician, and within that 
they can provide an opinion that they believe a medical review from a psychiatrist is required. 
However, the gatekeeping for this, as well as the responsibility to arrange it, falls on the Home 
Treatment and/or Crisis Clinician completing the subsequent assessment.  GPs can also refer to 
the Neighbourhood Mental Health Team for a review from a psychiatrist although this route is not 
intended for urgent referrals.  

The Trust’s investigation did identify that the GP in this case would have liked to refer directly to a 
psychiatrist.  We understood that they were reassured that the Trust follows the national model.  
Within our process the patient can see a consultant psychiatrist if they were taken on by the Home 
Treatment Team, as medical reviews are an integral part of how that team operates.  The action 
from the investigation was therefore to ensure that local GPs were supported and provided with 
this information going forward.  Again, this was achieved by sending all GPs direct 
communications with a reminder of this information on 31st December 2022.  In addition, we have 
ensured that the relevant information is on Teamnet and also regularly discussed in the local 
primary care network meetings between GPs and their local mental health teams.  As part of our 
engagement with primary care, each practice has a named contact in their local mental health 
team, to raise any concerns if they arise. 

The main area of confusion appeared to be that the GP wanted an urgent review by a consultant 
psychiatrist and the Home Treatment Team only provide this for patients who are being brought 
onto their team for visits.  The patient did not want Home Treatment Team input but agreed to 
medication changes which he suggested himself.  It was identified that the GP wanted a specialist 
psychiatric review due to her concerns that the patient was “leading his own treatment plan”.  

As the patient declined the input of the HTT other than a one-off assessment, he was not seen by 
the team, which would have involved medical review. 

Both the Trust and ICB are working closely with primary care to ensure that our services are fit for 
purpose and have mechanisms in place to discuss any concerns that arise.  The issues that have 
been raised will be discussed through these local fora on an anonymised basis, to capture any 
additional actions.  As part of our operational delivery of mental health services, work has been 
commissioned from a third party to better understand the patient experience, one of our priority 
areas will be to review the crisis pathway to identify any further improvements. 

Whilst we appreciate your concerns our clinical view is that the current system, which follows the 
national model, is appropriate.  If following an urgent assessment/review by one of our 
gatekeeping teams (Crisis Resolution or Home Treatment) there is an identified need for urgent 
medical input, we have access to psychiatrists in hours or on-call psychiatrists out of hours.  
However, in this case, our view was that a review by a consultant psychiatrist was not clinically 
indicated and following the internal investigation we were satisfied that the outcome of the 
assessment was appropriate.  

As you will be aware, the Trust reviewed the care provided in this instance and would ordinarily 
then provide that review to the ICB for approval.  Given Dr Ellson’s professional role at the ICB, 
arrangements were made for the Trust report to be subject to review by an independent third party. 
This has now concluded and the outcome will be shared with Dr Ellson’s family.   

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 From the Trust’s perspective it is recognised that some of the evidence provided here was not 
given at Court, even though a number of clinical staff had provided statements for preparation of 
the Inquest, they were not required to adduce oral evidence.  It is accepted that proportionality is 
important in determining who will adduce oral evidence at a hearing, our learning is that had one of 
these witnesses attended Court they may have been able to address your concerns in evidence. 

Neither the Trust or ICB has any representations to make in respect of publication of this 
response. 

We hope that the above adequately responds to your concern, however, if you consider it is helpful 
to discuss further do not hesitate to contact either the Trust or ICB. 

Yours sincerely 

Chief Executive 
Herefordshire & Worcestershire 
Health and Care NHS Trust 

Chief Executive 
NHS Herefordshire and Worcestershire ICB 

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