Thomas Jayamaha

Chief Executive’s Office 
The Resource 
Duncan Macmillan House 
Porchester Road 
Nottingham 
NG3 6AA 

2 June 2023 

Private and Confidential 

Dr Didcock 
HM Assistant Coroner for Nottingham and Nottinghamshire 
Nottinghamshire Coroner’s Office 
The Council House 
Old Market Square 
Nottingham 
NG1 2DT 

Dear Dr Didcock,  

Please  find  below the  organisational  response  to the  recently  received  Preventing  Future  Deaths 
Report, following the unfortunate death of Mr Thomas Jayamaha.  

The Matters of Concern raised within the report:  

1.  Delayed  progress  of  the  Autism  Strategy  work  across  the  Trust.  I  ask  that  the 
Nottingham  and  Nottinghamshire  Integrated  Care  Board  provide  a  joint  response 
with the Trust to address this concern, as I accept progress with the Autism work 
will depend upon resources and the agreed Commissioning of specific services. 

The Trust and the ICB have worked in partnership to produce an action plan (Appendix 1) outlining 
the  implementation  of  key  components  of  the  autism  strategy  and  implementation  plan  including 
flagging and identification, reasonable adjustments, peer support, care planning and workforce. The 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 ICB and Trust will work together, with wider system partners to support improvement ambitions set 
out in the response. 

2.  Insufficient progress with Complex Case Management. 

Mr. Thomas Jayamaha was referred to the Trusts’ Local Mental Health Teams (LMHTs), on multiple 
occasions, however the complexity of his case was not appropriately identified, and the cumulative 
effect of multiple referrals did not prompt sufficient enquiry by the team. 

To safeguard against this in the future a clinician-led triage assessment is being rolled out in a staged 
manner  across  the  teams  (as  part  of  our  Transformation  Programme).  In  addition,  a  Monday  – 
Friday, Daily Triage Meeting attended by leads from multiple teams within the Directorate, is also 
being introduced across all Adult Mental Health (AMH), Local Mental Health Teams (LMHTs). 

The roll out of the LMHT transformation programme has been staged over a three-year period, with 
Triage Assessments rolled out across that time, but with Triage Meetings rolled out in Year 3. Year 
1 (21/22) focused on the Mid Notts teams, where the triage assessment process is now complete. 
Year 2 (22/23) has focused on the South County Teams, where the triage assessment process is 
now also complete. Year 3 (23/24) is the City Teams, where the process of introducing the triage 
assessment is currently ongoing, in line with the planned activity. 

Triage Assessment 

This is a different way of managing referrals from the traditional booking system. When referrals are 
received by the team the patient is telephoned within 1 working day to make a triage assessment of 
their  needs,  to  signpost  or  refer  to  alternative  services  if  appropriate  or  to  ascertain  appropriate 
priority level if a full assessment is required.   

It also affords an opportunity to explain what the service has to offer and expected waiting times. 
Once the telephone triage has taken place, if next steps are clear and agreed with the patient, this 
is actioned on the day. Alternatively, if less clear and there is a level of complexity, this will be fed 
back within the LMHT MDT either on the same day, or the next day, and a decision made about next 
steps. 

To support this process, a triage form (see Appendix 2) has been developed and was launched in 
RiO in June 2022. This form enables the conversation with the patient to be recorded directly into 
RiO  using  the  SBARD  approach  (Situation,  Background,  Assessment,  Risk/Recommendations, 
Decision). The form will then be generated into a letter template so that the outcome of the discussion 
will be shared with the patient and referrer as a care plan, rather than needing to type a separate 
letter. The form also prompts the triage worker to explore with the patient who their support networks 
are  both  personal  and  professional,  who  they  would  like  us  to  contact  and  if  the  patient  has  any 
additional support/communication needs to strengthen engagement with services.  

Following a review of the form earlier this year, several changes were made. The form now captures 
why a contact with a patient has not been able to take place, some examples of this may include: 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 patient has not answered the phone or incorrect contact details were provided by the referrer (further 
reasons  listed  in  the  triage  tool).  This  is  to  help  us  understand  what  the  main  challenges  are  to 
engaging with patients at this stage and then support further developments to reduce some of these 
barriers.  Where  an  internal  referral  has  been  made  from  another  service  within  Nottinghamshire 
Healthcare  NHS  Foundation  Trust,  a  telephone  triage  may  not  always  be  required,  however  all 
external referrals should receive a triage call. Where it has not been possible to contact the patient 
after two attempts, the team should revert back to making a decision based on the written information 
provided by the referrer and, if further information is required, should involve a discussion with the 
referrer to support decision making regarding next steps for referral. This is to ensure that decisions 
relating to referrals are made in a timely manner so that patients can receive the support they need 
in an appropriate timeframe. 

Once the triage tool has been completed by the triage worker, the tool can be downloaded into a 
care  plan  letter  that  can  then  be  sent  out  to  the  patient  and  referrer,  so  they  have  a  copy  of  the 
discussion and agreed plan. Another amendment to the form was the addition of the Mental Health 
Crisis Line number on the letter, should the patient need additional support at any time.   

The Trust acknowledges it is important to be reassured that this new process is being adhered to 
consistently within the relevant LMHTs. As the form sits within the RIO system, compliance can be 
easily established through the use of audits. Not only does the audit establish whether a form has 
been completed for each referral, but in cases where it has not, a reason code needs to have been 
recorded, which provides additional detail and data to review.  

Triage assessment progress in City LMHTs 

The planning phase of implementing the triage assessment process was due to begin from April 
2023 onwards. However,  the city teams have reflected on and responded to the positive feedback 
from the other teams and have begun to pilot triage earlier than was initially planned. Progress has 
been varied across the four city teams as follows: 

LMHT City South 

City South are conducting the full triage assessment process as described above. This has been 
the case since January 2023. 

LMHT City Central 

City Central are conducting the full triage assessment process as described above. This has been 
the case since March 2023. 

LMHT City North 

City North began the new triage process but had to put his on hold due to a number of staff 
vacancies. The team are now working with the Transformation Team to implement this, anticipating 
full roll out by the end of quarter 2, 2023. This is currently in the planning phase. 

LMHT City East 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 City East did implement the triage process in January 2023 and were finding benefit from this but 
have also currently had to put this on hold due to the impact on the team of vacancies and 
absence. The team is also working with the Transformation Team to implement by the end of 
quarter 2. This is currently in the planning phase. 

Daily Triage Meeting 

The next phase of the triage process is to establish a wider Daily Triage Meeting. The daily triage 
meeting remit will be for new referrals into service.  The aim of the meeting is to provide support to 
the triage workers around decision making on next steps where there is a level of complexity, and 
next steps are not as clear. This will ensure the patient receives care from the right professional on 
the right pathway for them, and their referral into services is managed in a seamless and efficient 
way.  The  MDT  approach  will  also  support  a  ‘no  wrong  door’  approach  to  the  patient  experience, 
reducing barriers and thresholds when accessing the best pathway for their needs.  

Key Objectives  

  The aim of the meeting is to support decision making around patient pathways following the 

triage call.  

  The triage worker will use the MDT forum to support decision making where the case 
appears more complex and/or they require more guidance regarding next steps. 

  The MDT will help identify and agree the most appropriate pathway and ensure patients are 

not being passed around services or coming up against complicated thresholds to 
accessing services. 

  The meeting will provide support to the triage workers each day. 
  This will enable a daily MDT forum without making it resource heavy for each team. 
  Each team will take it in turns to provide the MDT representation. So, for example a 

psychology representative will attend each day, but for each team the psychologist would 
only be attending once a week. This would work the same way for the other professions 
supporting the MDT make up.  

  Each specialism in the meeting will provide a representative for all patients discussed 

 

rather than just their own team. 
It will enable wider teams/services to attend such as, Step 4 Psychology, Personality 
Disorder Pathway workers, Early Intervention in Psychosis colleagues, Substance Misuse 
Colleagues (SMS). 

  Each day a rotating member of the MDT will take it in turns to chair the meeting. Their role 
will not be to make the final decision but to ensure time keeping, facilitating the MDT to 
contribute to the discussion and ensure actions are agreed and allocated for each patient 
discussed. The triage workers will not need to take the chairing role. 

  All decisions/actions made within the meeting will be documented in RiO and action sheet 

completed. 

  This removes the need for written internal referrals/meetings 
  Supports recommendations following Coroner’s Inquest 

The  process  has  been  piloted  within  our  Mid  Notts  teams  in  2022,  and  logistic  and  practical 
amendments have been made. The meeting is currently due to be fully instigated in the Mid Notts 
team by the end of quarter 2, 2023, with roll out across all LMHT’s by the end of quarter 4 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 The Terms of Reference are attached as Appendix 3 for a more in-depth description of the process. 

3.  The Serious Incident Investigation process. 

The last issue I identify as a risk for the future is the quality, and quality assurance, 
of Trust Investigations. If a review is limited in scope and does not consider previous 
Serious Incident Investigation reports, and does not produce robust learning, as in 
this case, there is a continuing risk that similar issues will occur again. 

As  an  organisation  we  understand  the  importance  of  the  investigation  of  Serious  Incidents  and 
ensuring that the investigation undertaken is both detailed and robust and provides every opportunity 
to establish learning to prevent recurrence. In this case our investigation fell below the standard we 
would have expected and for that we would unreservedly apologise for the distress and disruption 
caused as part of your coronial process. 

The learning from the outcome of this preventing future deaths report will be shared as part of on-
going training provided to staff undertaking serious incident investigations and those involved within 
the approval process of investigations. 

Incident Investigation Training: 
We  continue  to  work  with  external  partners  to  ensure  that  staff  undertaking  serious  incident 
investigations  are trained  and  knowledgeable  in  investigation  techniques.  We  will  continue  in  our 
commitment  to  providing  a  2-day  training  event  for  investigators  based  on  a  “Systems  Based 
Approach” (SBA). This approach is advocated by the Patient Safety Incident Response Framework 
(PSIRF) which will be implemented within NHS Organisations during the autumn of 2023. The role 
of SBA is to identify the systems-based problems when an incident occurs, rather than focusing on 
the individuals involved. Our aim is to train 100 investigators year on year.   

We have recognised that whilst the centralised investigation team gives us a consistent approach to 
investigations, the volume of investigations means we must utilise operational staff as part of the 
overall  investigation  process,  hence  the  provision  of  incident  investigation  training.  However,  in 
training these people we also need to ensure we continue to eliminate variation, so to assist with this 
we have put in place support and mentoring which will be provided through the dedicated centralised 
investigation team. We have established monthly drop-in meetings (via MS Teams) to enable staff 
with on-going investigations have access to both advice and supervision support to assist with their 
investigative responsibilities. 

Investigation Terms of Reference: 
For each serious incident investigation, clear and specific terms of reference are drafted and shared 
with the divisions for comment at draft level before final sign off. They assist with the scope of the 
investigation  and  carefully  balance  ensuring  that  investigators  are  clear  of  the  investigation 
requirements and expectations, and that they are directed to any specific areas to be considered,  
without being too prescriptive which could risk restricting the panel / investigator in their review. 

When completed, terms of reference are signed off as follows: 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Concise level terms of reference are signed off within the Division concerned by either Head 

of Nursing or Associate Director of Nursing 

•  Comprehensive level terms of reference are signed off at Executive Director level 

Quality Assurance of Investigation Reports: 
We also recognised that we needed to strengthen our overall review of our investigation reports and 
ensure  those  individuals  who  are  approving/authorising  the final  report  have the skills  to  critically 
appraise the report and ensure it is fit for purpose. 

Whilst historically we have facilitated a one-off session to assist managers with the quality assurance 
process,  we  have  now  looked  to  extend  our  training  offer.  Therefore,  working  with  our  training 
providers,  we  have  commissioned  a  series  of  Serious  Incident Quality  Assurance training  events 
during 2023/2024. 
The  course  will  provide  the  attendees  with  skills  to  critically  assess  the  investigation  report  and 
ensure it concentrates on Systems Based outcomes and SMART actions. Our aim is to train at least 
50  people  each  year.  The  purpose  of  this  training  is  to  provide  senior  individuals  who  have 
responsibility for approving reports with the skills to analyse the report, ensure fairness, that systems-
based  learning  has  been  applied  and  that  the  report  and  findings  reflect  the  agreed  terms  of 
reference  and  any  questions  raised  by  the  patient  or  family.  The  Trust  recognises  the  need  to 
consider  neurodiversity  when  undertaking  investigations.  Guidance  has  now  been  developed  to 
support  investigators  to  consider  individual  need,  reasonable  adjustments,  access  to  learning 
development and consultation forums   

Family Liaison Team: 
As a Trust we also recognise the valuable part that families play within the investigation process. 
With the establishment of our Family Liaison Team during mid 2022 it has enabled us to take the 
opportunity  to  significantly  improve  the  communication  and  interaction  we  have  with  families  and 
patients when an incident occurs, and more particularly a serious incident.  

The Family Liaison Team will therefore play an important part in ensuring we improve the quality and 
inclusivity  of  the  serious  incident  investigation  process  for  families.  Family  Liaison  will  also  be 
involved in the serious incident investigation and quality assurance training. 

Divisional/Directorate response: 
The Adult Mental Health Directorate of Nottinghamshire Healthcare Trust have in the past 12 months 
reviewed their clinical governance processes and employed a new Clinical Governance Team. This 
includes  a  Serious  Incident  and  Complaints  Lead.  This  band  7  clinician’s  focus  is  on  supporting 
investigators with serious incident investigations and ensuring that the quality of the report is to the 
highest  standard.  A  new  process  has  now  also  been  developed  that  ensures  all  serious  incident 
reports  within  the  directorate  are  reviewed  by  the  appropriate  Operational  Manager  that  is 
responsible for the team or individual that was involved in the care of the patient that is deceased. 
The  Operational  Manager  reviews  the  report  and  often  meets  with  the  investigator  to  ensure  all 
elements  are  the  report  are  factual  and  the  investigation  covers  all  appropriate  issues. 
Recommendations are also discussed and based on this, quality improvement plans are developed 
and implemented. 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 I hope the information above provides the assurance that we have and continue to consider your 
recommendations seriously, and that we are actively seeking to improve the services we provide by 
implementing the actions outlined. 

Yours sincerely  

Chief Executive 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA