Oleg Khala

Professor Fiona J Wilcox 
HM Senior Coroner   
The Coroner's Court 
65, Horse ferry Road 
London 
SW1P 2ED 

Trust Headquarters 
1 Armstrong Way 
Southall  
Middlesex  
UB2 4SD 

29th August 2023 

Dear Professor Wilcox 

RE: Regulation 28 Report - Oleg Khala 

I write on behalf of West London NHS Trust in relation to the Prevention of Future Deaths Notice 
sent via email on 6th July 2023. The Trust has now had an opportunity to review the Matters of 
Concern raised.  

I would like to begin by offering my sincere condolences to the family of Mr Khala for their very 
sad loss. As a Trust we have taken your concerns very seriously and have aimed to address 
these issues as quickly as possible to ensure lessons are learned to benefit other patients in the 
future. I will respond to each issue in turn. 

Matters of Concern 

The generic, tick-box style of history recording by the crisis team (“CATT”) which does 
not paint a full and proper picture of the mental health of the patient, especially compared 
to the assessments of psychiatric liaison, are such that risk may be unrecorded and 
under appreciated by CATT and patients thus be put at risk. 

In line with the Practice Guidelines for Crisis Line Response and Crisis Resolution and Home 
Treatment Teams (Royal College of Psychiatrists Quality Network), our local protocols indicate 
that CATT assessments should be whenever possible carried out as joint assessment with the 
referrer. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Trust policy and mandatory training for staff encourages risks to be assessed using a 
formulation based approach in line with the NICE guidance (NG225) issued in September 2022. 
This emphasises that risk assessment tools should not be used to predict suicide or determine 
who or who not should be offered treatment or who should be discharged. 

However, it is considered positive practice to consider using validated triage tools such as the 
UK Mental Health Triage Scale to assess the urgency of response which might be offered to 
patients presenting in mental health crisis. During 2022 we have adapted our protocols within 
WLT, informed by the UK Mental Health Triage Scale to guide clinicians triaging assessments 
regarding which or our services is best placed to meet the needs of the patient in a timely way. 
The implementation of this is under ongoing review. 

It is the responsibility of the CATT staff to ensure that accurate, up-to-date information is 
collected at the assessment including collateral history from patients’ carer/family member 
wherever this is possible. The person(s) completing the assessment will communicate and 
agree the outcome of the assessment with the referrer and discuss the assessment findings in 
the multi-disciplinary team (MDT) handover. When out of hours’ assessments are completed 
and the decision is to admit the service user the decision to admit is discussed with the on–call 
specialist registrar and on-call consultant psychiatrist to agree an appropriate safety and 
admission plan. 

That the role of CATT to look for alternatives to admission may risk CATT discharging 
patients who would benefit from admission and risk the repeat of making treatment plans 
that had recently failed such as in this case. Rather than looking for admission 
alternatives being a core function, should CATT rather better be focussed on the best 
treatment plan for the individual patient and thus admission being viewed as a clear 
option where appropriate rather a last resort, as it often appears to be presented in such 
cases before the coroner. 

The  Trust  expects  all  assessments,  including  for  CATT,  to  take  into  account  individual 
circumstances  and  clinical  need,  recognising  that  CATT  may  not  be  suitable  for  some  service 
users and there are a range of other crisis pathways and interventions available to all patients, 
including acute inpatient admission under the Mental Health Act 1983, or as a voluntary patient. 
The service user’s choice of obtaining treatment at hospital or at home should be also taken into 
account which is a key part of adhering to the least restrictive option for service users.  

Home treatment by definition is an appropriate alternative to hospital admission for working age 
and  older  adults  with  severe  mental  illness  (e.g.  schizophrenia,  manic  depressive  disorders, 
severe  depressive  disorder)  with  an  acute  psychiatric  crisis  of  such  severity  that,  without  the 
involvement of a CATT, hospitalisation would be necessary. Such  patients should be willing to 
receive  home  treatment  which  can  be  safely  provided  in  their  home  environment.  Treatment 

 
 
 
 
 
 
 
 interventions, procedures  and protocols will  be  evidence-based  and  compliant  with  the  Quality 
Network  for  Crisis  Resolution  and  Home  Treatment  Teams  (QN-CRHTT)  standards  and  NICE 
(National Institute of Clinical Excellence) guidelines 

1 Guidance | Service user experience in adult mental health: improving the experience of care for 
people using adult NHS mental health services | Guidance | NICE  

We  are  confident  that  these  principles  are  consistent  with  best  practice,  for  example  the  core 
principles  identified  within  The  Independent  Review  of  the  Mental  Health  Act  1983  chaired  by 
Professor Sir Simon Wessely “Modernising the Mental Health Act”, published in December 2018 
–  which  emphasised  “Choice  and  Autonomy”,  a  principle  of  “Least  Restriction…  and  that  less 
restrictive  alternatives  must  always  be  considered”,  a  “Therapeutic  Benefit”  principle,  and  a 
principle of treating “the Person as an Individual”. 

That the provision of care co-ordinators be increased and improved so that patients who 
require them have ready access at the time of need and are not placed on a waiting list. 

The  Trust  received  significant  investment  in  2020-21  to  implement  a  more  flexible  model  of 
community-based mental healthcare for adults and older adults with a wide range of mental health 
needs based upon the NHS England Community Mental Health Framework for Adults and Older 
Adults and the NHS England Long Term Plan. In recent years, concerns about the use of the Care 
Programme Approach (CPA) in community mental health services have been raised and a new 
approach is developing. NHS England and NHS Improvement have published a formal statement 
which states that community mental health services should move away from CPA while meeting 
core principles of care. 

Within the MINT model of care, we aim to support individuals who require long term mental health 
support with coordinated care by a named clinician, and that this clinician is appropriately skilled 
to provide the interventions recommended in the coproduced care plan. We also recognise (in 
line with the national specification for community mental health services, upon which MINT teams 
have been designed) that some individuals will receive ‘care coordination’ for only a time limited 
period in line with their needs.  

As  part  of  the  implementation  of  this  we  have  developed  and  are  deploying  standardized 
protocols, enhanced documentation practices, and regular training sessions to promote effective 
coordinated care by any named clinician involved in patient care. These measures aim to mitigate 
potential risks and ensure that patients receive the highest quality of care in a coordinated manner. 

 
 
 
 
 
 
 
 
 We acknowledge that the implementation of the MINT model in West London NHS Trust has faced 
a  number  of  challenges,  not  entirely  within  the  direct  control  of  the  Service,  and  this  was 
recognised in a CQC inspection in 2022. In response to this, the Trust has a robust action plan in 
train which is addressing the areas of concern highlighted and progress against this is monitored 
at Board level.  

MINT, in line with the community mental health framework, has brought about expanding the roles 
that support service users in the community with their mental health. This includes occupational 
therapists, link workers, peer support workers, vocational rehabilitation services, social workers, 
mental health practitioners and community mental health nurses. This framework provides holistic 
biopsychosocial model of care and treatment to mental health service users. 

We head up ongoing staffing recruitment drives to recruit local and international staff. We have 
put  significant  resource  into  growing  our  own  workforce  through  apprenticeship  posts  in  allied 
health professions, nursing and social work apprenticeships. West London have also met staffing 
needs  through  international  recruitment  of  appropriate  mental  health  workers. We  are  working 
closely with staff and team managers to ensure we are retaining staff through our wellbeing and 
development opportunities. 

That patients to be discharged by CATT, as well as patients to be admitted are discussed 
with  the  on-call  psychiatrist  so  that  plans  may  be  reviewed,  and  thus  the  risk  of  not 
admitting patients who would benefit from and/ or require admission such as Mr Khala, are 
less likely to be discharged inappropriately. 

As above, and in line with the Royal College of Psychiatrists Guidance, wherever feasible, every 
effort should be made to undertake a joint assessment with the referrer.  

CATT team members (and other non-medical and trainee medical staff undertaking assessments 
of  patients  in  crisis)  have  been  reminded  that  they  can  request  senior  discussion  with  On-call 
Consultants irrespective of decision to admit, to offer an admission to a home-based care pathway 
or to discharge. 

It is the practice within CATT for daily multidisciplinary meetings (MDT) to be held, which play a 
vital part in overseeing a safe and effective service. The ethos of the MDT is for an inclusive and 
constructive discussion around the service user where the views of all professionals, regardless 
of  their  banding  or  role  are  valued  and  facilitated.  Routine  MDT  meetings  always  include  a 
consultant psychiatrist.  

 
 
 
 
 
 
 
 
 Service users, including those who are being admitted to a home based treatment pathway, or 
who are being discharged from CATT, are routinely discussed. Cases of concern (red on the local 
traffic light system) and new referrals are discussed on a daily basis. All cases must be discussed 
in MDT at least twice weekly.  

The  focus  of  MDT  discussions  is  around  the  formulation  of  the  case,  any  changes  to  risk,  the 
progress of the individual, the response to treatment, the indication for and the engagement with 
allied  health  professionals,  barriers  to  discharge  and  likely  timing  of  transfer of  care  to  routine 
pathways for ongoing support. 

The  MDT  will  also  actively  monitor  the  operational  aspects  of  adequate  record  keeping  (e.g. 
clinical coding, contemporary risk assessment, up-to-date care plan and physical health checks). 

Formal documentation  of  handover  is  entered  into  the  clinical  records  contemporaneously  and 
captures the above, as well as all immediate care actions (e.g. frequency of visits, outstanding 
actions). 

When  using  the  traffic  light  system;  Red,  Amber,  Green,  (RAG)  all  new  cases  and  cases  of 
concern are placed on the “Red” caseload until sufficient contact has been made to allow for a 
reduction to “Amber”. This would not usually be on first contact with the service user.  

In  cases  where  the  risk  has  increased  this  should  be  captured  with  an  escalation  in  the  RAG 
rating. Changes in RAG should be made through MDT discussion.  

Planning for the withdrawal of home treatment begins early, the expectation is that the service 
user will have progressed through the traffic light process (and achieved “green” status) and the 
identified outcomes will have been met. The decision to discharge the service user from the CATT 
should  be  made  after  consultation  between  CATT  staff,  the  community  team,  the  care  co-
ordinator, medical staff, carers and the patient themselves. 

RAG rating:  

RED:  

•  Patient assessed and accepted by CATT and agreeing to work with us 

•  Anyone within the first three days of being under the team 

•  Anyone considered to be requiring review of decision to offer home treatment in favour of 

arranging admission 

•  Patients awaiting Mental Health Act assessment 

 
 
 
 •  Patients still in early aspect of their recovery and experiencing predominant symptoms of 

a mental disorder or crisis which is yet to respond to intervention 

AMBER:  

  Everyone else 

GREEN: 

•  Aims of the CATT have been met 

•  Referrals have been completed to other agencies 

•  Understanding reached as to why the crisis occurred and strategies in place to mitigate 

future episodes 

•  Patient ready for transfer or care back to primary care or MINT (or other longer term 

support services) 

•  Uncomplicated Clozapine titrations or community based ECT 

That where psychiatric teams differ in their assessments such as CATT and  Psychiatric 
Liaison, as occurred here, patients are not discharged until opinion is sort from the on-call 
consultant and re-discussion taken place between those with differing views. 

The  Clinical  Directors,  Service  Managers,  Clinical  Leads  and  Team  Managers  responsible  for 
CATT  and  Psychiatric  Liaison  are  in  regular  discussion  about  interface  matters  between  their 
services and cases of concern are reviewed regularly. All are in agreement that it is best practice 
for assessments to take place and decisions to be made jointly wherever possible, and  work is 
ongoing to embed a culture of ‘trusted assessment’ between the teams in respect of decisions to 
admit to beds or home-based treatment pathways under CATT. 

Where a joint assessment and decision is not possible, the person(s) completing the assessment 
will communicate and discuss and agree the findings with the referrer, service user and within the 
multi-disciplinary team (MDT) handover, which involves consultants. The availability of in-hours 
and  on-call  psychiatric  registrar  (approved  under  section  12  of  the  Mental  Health  Act)  and 
consultant)  to  provide  guidance  or  supplementary  assessment  in  the  event  of  clinical 
disagreement  has  been  re-communicated  to  teams,  and  will  be  incorporated  into  work we  are 
doing with partners across North West London to implement clinical escalation protocols. 

 
 
 
 
 
 
 
 That expertise covering neurodevelopmental disorders such as ASD and ADHD is available 
as part of MINT. 

In  July  2022,  the  Health  and  Care  Act  2022  introduced  the  requirement  that  CQC  regulated 
service  providers  ensure  their  staff  receive  training  on  learning  disability  and  autism  which  is 
appropriate to the person’s role. The Part 1/tier 1 Oliver Mc Gowan training on Learning Disability 
and Autism has been made mandatory for all clinical staff in West London NHS Trust.  

The content has been developed with reference to tier 1 and tier 2 capabilities contained within 
the Core Capabilities Framework for Supporting Autistic People and Core Capabilities Framework 
for Supporting People with a Learning Disability.  

Both frameworks are nationally recognised and have been developed to provide a focus on the 
skills, knowledge and behaviours expected for staff offering services to autistic people or people 
with  a  learning  disability.  All  staff  that  require  a  general  awareness  of  this  support  for  autistic 
people  or  people  with  a  learning  disability  are  advised  they  need  to  cover  all  of  the  tier  1 
capabilities in the framework. Part 2 of the training is being developed within West London NHS 
Trust and will be launched in 2024.  

In terms of specialised ASD support in West London NHS Trust, Acute Mental Health Services 
benefits  from  an  Autism  Liaison  Service  which  can  be  contacted  for  consultative  input  for  any 
service  users  with  a  diagnosis  of  Autism.  Plans  are  in  place  to  further  expand  this  service  for 
service users within Ealing MINT with a diagnosis of autism or suspected autism, with a view of 
this being rolled out to other boroughs, if successful. This will also involve consultative input to 16-
25 teams. 

ADHD assessment and treatment is not commissioned or provided as part of the West London 
Trust.  

Service users of the boroughs of Ealing, Hammersmith and Fulham and Hounslow are referred to 
other services commissioned by North West London Integrated Care Board. They offer diagnosis 
and treatment for adults with ADHD. Once treatment is stabilised, prescribing and monitoring will 
be  transferred  back  to  the  GP.  They  currently  do  not  offer  psychological  interventions  for  the 
treatment of ADHD in our clinic. The wait time for assessment is currently 18-24 months. GP’s are 
responsible for making ADHD referrals directly to the other providers if they believe the service 
user meets the threshold for assessment and on completion of a screening assessment.  

WLT SPA (single point of access) provides additional support in forwarding all ADHD assessment 
requests to the other providers directly.  

 
 
 
 WLT is in discussion with North West London ICB to develop a local commissioned pathway for 
ADHD assessment and intervention. 

I hope that we have been able to provide you with assurance that we have reviewed and sought 
to address the concerns that you have raised. We are committed to continuously improving our 
services to ensure patient safety, experience and the delivery of high-quality care in line with best 
practice.  

Please do not hesitate to contact me should you have any questions or queries. 

Yours sincerely,  

Deputy Chief Executive Officer