Nigel Harper

Edward Jenner Court 
Pioneer Avenue 
Gloucester Business Park 
Brockworth 
Gloucester 
GL3 4AW 

25 July 2023 

Mr D.D.W Reid 
His Majesty’s Senior Coroner 
Martins Way 
Stourport on Severn 
Worcestershire 
DY13 8UN 

Dear Mr Reid 

Ref: The Late Nigel David Harper -9131813 

I  am  writing  on  behalf  of 
containing the Regulation 28 Prevention of Future Deaths Report relating to this case. 

,  Chief  Executive,  in  response  to  your  letter  of  5  June  2023 

On  conclusion  of  the  inquest,  you  established  that  there  was  a  lack  of  understanding  between 
Gloucestershire Health & Care NHS Foundation Trust and Herefordshire & Worcestershire Health & Care 
Trust  regarding  how  each  other’s  urgent  care  services  are  run;  and  that  there  was  a  lack  of  clarity 
concerning process for urgent referrals or requests. The Trust has now had opportunity to reflect on its 
practice and I am pleased that we have been able to identify improvements which will minimize the risk 
of a similar tragic event recurring in the future. 

The learning from Mr Harper’s death has focused on two key strands. 

1.  Improving  understanding  between  both  trusts  regarding  how  their  mental  health  urgent 

care services operate. 

In terms of improving understanding between the two organisations, I can confirm that senior managers 
from both trust’s urgent care mental health services have met to discuss this matter in detail and shared 
each other’s Crisis Teams Operational Policies. These documents describe the purpose and scope of the 
individual services involved and include detail concerning referral and triage.  

2.  Strengthening the Standard Operating Procedure (SOP) of our Mental Health Liaison Team 

regarding inter trust referrals and transfers of care. 

Our  Mental  Health  Liaison  Team  has  reviewed  its  SOP  and  made  the  following  additions  under  the 
Discharge section of the document.  I enclose a copy for your information and these changes can be seen 
on Page 17. 

▪  Where referrals are made by the MHLT team to any service either within the trust, or externally, 
there will be a clearly defined agreement of what this service will provide and the timeframe of 
that intervention.  

Main office: Edward Jenner Court, Pioneer Avenue, Gloucester Business Park, Brockworth, Gloucester, GL3 4AW 
Chair: Ingrid Barker Chief Executive: Douglas Blair 

 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ▪  Any  referrals  or  requested  contact  must  be  followed  up  via  a  confirmed  email  immediately 
following contact being made (including a copy of the assessment, an outcome of referral made 
and  agreed timeframe for  that  contact).  A  subsequent  entry  will  be  made  on  EPR.  (Electronic 
Patient Record) 

This  document  is  currently  in  draft  but  will  be  ratified  at  the  next  Mental  Health  &  Learning  Disability 
Inpatient & Urgent Care Governance & Performance meeting on 7 August 2023. In the interim it is being 
shared with all members of the team via team meetings, and as such, we will be able to evidence that 
staff  are  aware  of  these  important  changes.  Additionally,  in  six  months’  time,  we  will  undertake  a  dip 
sample audit of Mental Health Liaison Team referrals to test our  practice and ensure that learning has 
become embedded. 

I would be grateful if you could share a copy of this response with Mr Harper’s family and relay our deepest 
apology for the gaps in service provision that the inquest identified. We continue to reflect on the learning 
from his death and aim to improve the safety of patients through the changes made.  

If I can be of further assistance, please let me know. 

Yours sincerely 

Medical Director 

      Deputy Medical Director

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

27 July 2023 

Mr D D W Reid  
HM Senior Coroner  
Worcestershire Coroner’s Court 

Dear Mr Reid, 

Re:   The Late Nigel David Harper - 

Regulation 28 report to prevent future deaths - response  

Thank you for forwarding on your Regulation 28 report.  I have read your report carefully and attempted 
to address your concerns that you have raised as a result of the coronial inquiry regarding the death of 
Nigel Harper.  

In your report, you highlighted the following points of concern:- 

Concern 

You concluded that the events in Mr Harper’s case arose out of the lack of understanding between 
two  NHS  Trusts  concerned  (Herefordshire  and  Worcestershire  Health  and  Care  NHS  Trust 
(HWHCT) and Gloucestershire Health and Care NHS Trust (GHCT) as to how each other’s mental 
health services operate – otherwise agreements would have been made for Mr Harper’s mental 
health to be assessed urgently, as was intended.  You were concerned that staff at HWHCT and 
GHCT  do  not  understand  how  to  make  urgent  mental  health  referrals  or  requests  for  urgent 
mental health assessments to each other, and there remains a risk that other deaths may occur 
in similar circumstances in the future. 

Firstly,  I  think  it  is  important  to  address  why  this  missed  opportunity  occurred  in  the  first  place.  
Fundamentally,  it  would  appear  there  was  a  genuine  breakdown  in  communication  between  the  two 
organisations.  The clinician in the GHCT Mental Health Liaison Team made contact with HWHCT Crisis 
Resolution Team (CRT) to discuss a patient that they had assessed in their local emergency department. 
I gather that GHCT assumed this conversation constituted an urgent referral, although this was not the 
reciprocal  interpretation,  with  HWHCT  staff  believing  that  it  was  for  information  only  initially,  awaiting 
confirmation of the final discharge plan once the GHCT clinician had confirmed with the patient and his 
family.   

 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
  
  
 
 
 I  wish  to  reassure  you  that  as  a  Trust,  we  have  very  much  reflected  upon  this  missed  opportunity.  
HWHCT raised a Ulysses report regarding the care and treatment received, latterly escalating this to a 
serious incident review.  An investigating officer was identified within the Division, who was responsible 
for  undertaking  a  detailed  investigation  using  root  cause  analysis  methodology.    In  addition,  the  staff 
involved have been given the opportunity to reflect on the incident via a psychology-led debrief and will 
have been able to discuss any further issues or concerns in individual supervision.   

, Deputy Director for Urgent Care Mental Health (GHCT) and 

On receipt of the joint Regulation 28, 
, Operational Lead for Urgent Care (HWHCT) met 
, Solicitor 
with 
(HWHCT).    The  purpose  of  this  meeting  was  to  take  a  detailed  examination  of  the  circumstances 
surrounding  the  communication  between  both  organisations  and  to  work  collaboratively  on  a  suitable 
solution.  As a result, changes to local policy have been made (outlined below) and communicated to 
those staff in the affected services by email dated 18 July 2023.   

In an attempt to prevent reoccurrence, we have reviewed/amended our CRT Operational Policy to include 
a specific  section  on  inter-Trust referrals  and  transfers  of  care.   In  summary,  if  a  patient  presented in 
crisis  to  out-of-County  emergency  services/organisations  our  standard  operating  procedure  has  been 
updated to address this situation, as below:- 

Following  an  assessment,  it  may  be  that  the  patient  requires  ongoing  care  and  treatment  under 
HWHCT.  In  these  circumstances  both  providers  share  responsibility  for  ensuring  that  the  patient’s 
referral/transfer of care is seamless and that access to service provision is initiated on the basis of 
clinical  urgency.    This  process  should  start  with  a  telephone  conversation  between  the  external 
organisation and staff from HWHCT, seeking to clarify and agree the following: 

•  The exact nature/purpose of the call (i.e. referral or information only)  
•  The degree of urgency and response required (in keeping with NHSE MH Access Standards 2021);  
-  Very urgent: contact with patient within 4hrs (CRT)  
-  Urgent: contact with patient within 24hrs (CRT/Home Treatment Team (HTT)) 
-  Routine: contact with patient within 72hrs (HTT) 

Once the appropriate response has been mutually agreed, HWHCT will document the outcome of the 
discussion on Carenotes, our electronic patient record system.  In addition, the referrer will provide a 
comprehensive/documented assessment (to include formulation of risk and management plan) to the 
receiving service at their earliest convenience.   

For completeness I have included an updated version of our standard operating procedure. 

I hope this reassures you that the Trust has learnt from your concern and have ensured we have 
reviewed this missed opportunity.  We now believe there is a robust system in place to ensure that 
such a situation cannot occur in future.  

I hope that the information above adequately addresses your concerns. 

I do not have any submissions to make in respect of publication of this response.  I would be grateful if 
you could kindly send a copy of my response to those to whom you copied your Regulation 28 report. 

Yours sincerely 

Chief Executive 

Enc. 

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