Johanne Blackwood

21st September 2023 

Private and Confidential 
Mr Sean Horstead 
HM Area Coroner for Essex 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Mr Horstead, 

Mrs Johanne Blackwood (RIP)  

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford  
Essex 
SS11 7XX 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 
5,  of  the  Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of  the  Coroners 
(Investigations) Regulations 2013, dated 27th July 2023 in respect of the above, which was 
issued following the inquest into the death of Mrs Blackwood. 

I would like to begin by extending my deepest condolences to Mrs Blackwood’s family. The 
Trust sympathises with their sad loss.  

The  matters  of  concern  as  noted  within  the  Regulation  28  Report  have  been  carefully 
reviewed and noted.  I will now respond in full to these concerns in the hope that this provides 
both  yourself  and  Mrs  Blackwood’s  family  with  comprehensive  assurance  of  changes  that 
have been made at the Trust to address the concerns you have raised.  

1.  Lack of a formal handover between care coordinators 

As part of the Inquest hearing, it was recommended by yourself, as the presiding Coroner, 
that the operational management at Essex Partnership University Foundation Trust (EPUT) 
consider establishing a mechanism and process for a formal structured handover between 
care coordinators. The service manager took this recommendation on board and has been 
working with colleagues and departments to produce a purposeful template that will form part 
of the Patient Electronic Record specific to the care coordinators’ handover. This document 
has been approved, for implementation Trust wide, following a process of consultation and 
with comments gathered from all community services.  

This process is being used to capture vital information around patients, their care, risk, care 
plan and areas that are under review.  The approved template will also be used as a handover 
tool  by  any  care  coordinator  who  moves  on  from  their  role.  This  will  allow  the  team  and 
relevant managers to look at the required steps/process in order to ensure oversight while a 
new care coordinator is appointed, ensuring continuity of patient care. For example, from the 
handover, the former care coordinator might suggest that a weekly contact is maintained with 
the patient and this can be facilitated by the team leads/manager.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In addition, where notice has been given by any care coordinator (of their departure from the 
Trust) the team will promptly make an attempt to recruit another member of staff with an aim 
of ensuring an overlap of at least two weeks, to allow for effective handover and continuity of 
care, again Trust wide. 

This provides an opportunity to introduce the new care coordinator to all their patients face to 
face and also get to know the patients’ care and needs in more detail. On a positive note, the 
team has recently been able to recruit more substantive staff which will reduce the reliance 
on temporary/agency staff. 

By way of an update, the Team at Grays Hall have extra care coordinators in post to respond 
to the service demands and currently there are no vacant posts that have not been covered 
either by agency and permanent staff. 

2.  Lack of a policy or procedure requiring that a formal handover is documented in the 

medical records. 

As  highlighted  in  Care  Programme  Approach  Policy  and  Procedure,  there  is  a  clear 
expectation  of  the  need  to  ensure  that  a  tailored  review  is  undertaken  when  a  new  care 
coordinator is allocated. This is to establish rapport with the patient, meet family and carers, 
review  care  plan,  undertake  risk  assessments  and  maintain  contingency  planning  i.e.  the 
actions that are required for events  like relapse symptoms, crisis etc. by the patients or those 
involved in their care.  

As highlighted above, the introduction of a new template as part of handover will enable this 
type of vital information to be captured, updated and reviewed in a timely way which will take 
into account all the necessary information within the patient’s clinical records. The handover 
template (Care Coordinator to Care Coordinator Transfer of Care Document) will form part of 
the  patient’s  electronic  record  and  will  be  easily  accessible  to  anybody  working  with  the 
patient. 

3.  Lack of clarity over who has oversight and is responsible for the care of patients in the 
community when no care coordinator is allocated/a new care coordinator is awaited. 
This third concern was previously raised as part of the PFDR issued in the case of SM 
(RIP).  

The Community Mental Health Team (CMHT) based at Grays Hall, as well as CMHT teams 
across the Trust have access to the Team caseloads via the Trust Intranet system “Client  
Information  Website”  which  provides  a  breakdown  of  all  patients  open  to  the  team.  The 
feature provides further information on the full team case list which denotes allocated care 
coordinators and those who have not assigned a care coordinator yet. The team manager 
and team leads, are able to utilise this tool to have an oversight of team caseloads alongside 
the  Management  and  Supervision  Tool  (MaST).  This  system  allows  for  Trust  wide  access 
and scrutiny on case load requirements.    

The Grays Hall / Trust wide CMHT’s teams have a process in place where all patients under 
their caseload are RAG rated according to their level of needs. This document is used as part 
of the Multi-Disciplinary Team (MDT) discussion in order to establish any change required or 
review for the patients, when these are brought to the attention of the MDT.   Where there is 
indication that a new care coordinator is required, this patient will be ‘Red’ rag rated which 
will act as a highlight and prompt an overview to members of the MDT. The team leads and 
manager  will  determine  early  actions,  including  any  capacity  considerations,  to  facilitate 
allocation of a new care coordinator.   

 
 
 
 
 
 
 
 
 
 
 
 In the event that a new care coordinator is not available, the team ensure that those patients 
without an allocated care coordinator have direct contact from clinicians within the team. This 
is done through a clinical MDT approach; patients are prioritised according to their presenting 
need  and  contact  is  through  the  use  of  creating  from  the  Duty  Person  and  Buddy  worker 
System.  In  addition  the  staff  have  opportunities  to  work  additional  safe  hours,  by  way  of 
overtime which includes weekends and evenings so that all patients have a timely review by 
a practitioner avoiding any extended gaps in care whilst a care coordinator is appointed.   

Grays  Hall  staffing  establishment  has  significantly  improved  over  the  last  year  with  the 
recruitment of two Band 6 and one Band 7 permanent staff and the use of regular agency 
staff. There are two more permanent care coordinators starting in October 2023.  

In addition, the team are using the Care Coordinator to Care Coordinator Transfer of Care 
Document which is completed by the outgoing care coordinator and will conduct a handover 
with the team leads and managers.   This document is part of the patient electronic record so 
any subsequent care coordinators will be able to see vital information readily. 

The document itself has been created from the Thurrock locality, however has been shared 
across  all  EPUT  Community  Mental  Health  Services  which  use  both  Mobius  and  Paris 
(Electronic  Patient  Record  systems).  The  clinical  change  managers  who  support  new 
templates and reviews of documents for Mobius and Paris have both been involved in the 
development of the ‘Care Co-ordinator to Care Co-ordinator’ transfer document.   

This concern has been previously raised within the matter of SM (RIP) within the Regulation 
28 report dated 25th February 2022, it is noted that in both cases, there was a period of time 
before death when the patient did not have a care coordinator. In Mrs Blackwood’s care, this 
was a regrettable error and was due to a lack of staff and a delay in the new allocation. In 
SM’s case, there was a view that a care coordinator was not needed. However, both cases 
raised the question of what oversight should be in place to ensure someone remains stable 
and  they  are  given  safety  netting  advice  when  they  do  not  have  an  appointed  care 
coordinator.  I hope that the assurances and changes to practice set out within this response 
satisfactorily addresses this concern. 

4.  A failure to update the risk assessment, care plan and security plan 

The team manager and team leads now receive monthly performance updates with regards 
to the various care standards compliance which include care plan and risk assessment 
which are then shared with the care coordinators for action. In addition, during supervision 
sessions with care coordinators, the supervisor will conduct a highlight review from MaST             
which provide clear options for care coordinators caseload for that particular supervisee.  

MaST uses information from  patients’ clinical care records to provide a clear visual display 
of individual or team’s caseloads with an ability to filter by risk of crisis, level of complexity or 
frequency of contacts. MaST is used to identify patients that are high risk or those who are in 
need  of  enhanced  support.  MaST  is  able  to  pick  up  the  cohort  of  patients  that  are  not 
engaging  or  are  in  need  of  increased  care  requirements  and  shows  when  care  standards 
such as risk assessments or care plans need to be reviewed. 

Training in the use of MaST has been rolled out already with the Community Mental Teams 
on the Mid and South Essex locality, and will be extended across all EPUT Community Mental 
Health  Teams  as  a  phased  implementation.  There  have  been  further  bespoke  sessions 
undertaken for the use of MaST in the MDT in the Community Teams at Grays Hall. MaST 

 
 
 
 
 
 
 
 
 
 
 
 
 will also provide each clinician, team leader, Manager or Consultant the opportunity to see 
whether  any  documentation  require  updates  or  escalation.  For  example,  this  could  be  in 
relations to care plan, risk assessment or annual reviews for physical health.  

In order to improve capacity and patient contact, the team has recently increased the number 
of support workers to work with care coordinators in care provision. This is in return providing 
care coordinators with more opportunity and time to ensure that their patient documentation 
is kept up to date.   

The  support  workers  from  Grays  Hall  /  CMHT’s,  conduct  a  daily  handover  where  their 
workload is discussed. The importance of clear, structured handovers is being cascaded via 
learning and awareness sessions and newsletters.   

The allocated caseloads and any issues of concern are promptly brought to the attention of 
the  team  Leads/manager  or  allocated  care  co-ordinator  for  further  actions  including  any 
required escalation.  

During staff team meetings there are various agenda items that are discussed which include 
arising  issues,  productivity,  information  sharing  etc.  The  leads  and  managers  again, 
emphasise the need for clinicians to ensure that their care records are up to date. If they need 
protected  time  to  ensure  this  task  is  completed  this  is  facilitated  by  the  team  Leads  and 
manager. 

In summary, the Trust acknowledges that Mrs Blackwood did not have an updated community 
risk  assessment  and  care  plan.  These  documents  should  have  been  updated  following 
discharge from the inpatient ward and when there were changes to presentation, risk and the 
plan in which they were working towards. Evidence within the clinical records suggest that 
care  coordinator  had  been  making  plans  to  update  the  care  plan  and  risk  assessment, 
however this was not completed prior to Mrs Blackwood’s sad death. 

Whilst being mindful of not repeating the evidence provided to your Court during this Inquest, 
we re-iterate our regret at the fact that Mrs Blackwood’s husband was not offered a carers’ 
assessment, although this was considered at intervals in his wife’s care, more should have 
been done to support him. We sincerely apologise for the distress this would have caused. 

I  hope  that  I  have  provided  some  reassurances  around  the  steps  that  we  have  taken  to 
address the issues of concern contained within your report.  We know there is an acute need 
to embed and effect change, hence we will monitor the above provisions to ensure these are 
contributing to our overall aim of keeping patents safe and delivering therapeutic care. 

Please do let me know if you require any further information at this stage, including copies of 
any of the documents referred to above.   

We will await your direction before sharing a copy of this reply with the family and the CQC 
(the latter having requested a copy of the same). 

Yours sincerely, 

Chief Executive