Edward Rhodes

IN THE CORONER'S COURT FOR THE AREA OF DORSET 

BEFORE ASSISTANT CORONER MIDDLETON 

THE INQUEST TOUCHING THE DEATH OF EDWARD ENGLAND RHODES 

RESPONSE TO REGULATION 28 - BEAUFORT ROAD SURGERY 

1.  H.M. Assistant Coroner Middleton for the Coroner Area of Dorset has made a Regulation 28  Report -

Action to prevent deaths dated 1 August 2023  ("the Regulation 28 Report") concerning the death of 

Edward  England  Rhodes  ("the  Deceased").  This  arises  from  the  Inquest  of 27  July  2023  ("the 

Inquest"). 

2.  The  Regulation  28  Report  is  addressed  to  the  Practice  Manager  at  the  Beaufort  Road  Surgery,  21 

Beaufort Road,  Southboume,  Bournemouth,  Dorset,  BH6  SAJ  ("the  Practice"),  which  is  a  general 

medical  practice.  This  is  the  response  of the Partners  in the Practice to  the Regulation 28  Report  in 

accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013  ("the Response"). 

BACKGROUND 

3. 

, is a GP Partner in the Practice. 

4.  H.M.  Coroner  for  Dorset's  office  requested,  in  a  letter  addressed  to  the  Practice  dated  7  February 

2023,  "a  signed statement into  the  medical history  of the  deceased  and advise  of any  treatment  or 

medication  you  prescribed  within  the  six  months  preceding  his  death." 

  provided  H.M. 

Coroner with a statement addressing the matters in accordance with this request, dated 7 March 2023. 

5.  Neither the Practice nor 

, were afforded Interested Person ("IP") status for the Inquest. The 

Practice and 

  were not therefore  legally  represented  at  the Inquest  and were not provided 

with disclosure of the Inquest Bundle. 

0 

6. 

 gave evidence (virtually)  at  the Inquest on 27  July 2023.  He was  the first  witness  to  give 

evidence and was discharged once his evidence had concluded. He did not hear any of the subsequent 

evidence  and  played  no  further  part  in  the  Inquest.  There  were  no  other  attendees  from/for  the 

Practice. 

 PRACTICE RESPONSE TO REGULATION 28 REPORT 

7.  The  numbering  in  the  Regulation  28  Report  is  adopted.  H.M.  Assistant  Coroner  Middleton's 

comments/concerns are set out in italics, with the Practice's Response below: 

"The MATTERS OF CONCERN are as follows 

1.  During the inquest evidence was heard that: 

i. 

Mr Rhodes  wanted to  address  the  underlying causes for  his  addiction.  He  wished to  be 

referred  to  the  Mental  Health  Team  for  an  assessment.  He  was  told  by  medical 

professionals that he needed to  be 90 days sober. 

In respect of the first  sentence the Deceased had a long-standing history of addiction.  He 

had  been  a  patient  at  the  Practice  from  6  February  2020,  until  his  death.  He  first 

expressed a desire to his hepatologist (liver specialist), Dr Clare Harris,  for referral to the 

Community  Mental  Health  Team  ("CMHT")  on  16  August  2022  (having  never 

previously expressed such a wish to the Practice). 

For the  sake  of clarity,  the  GPs  at  the Practice were  not  the medical  professionals  who 

first told the Deceased the information contained in the second sentence. This came from 

(an)other medical professional(s). 

Of note,  the  Deceased  saw  his  hepatologist  (liver  specialist), 

,  on  16  August 

2022.  Following  which  the  Practice  received  a  letter  from 

  dated  18  August 

2022 and which states (our emphasis): 

"[the Deceased]  is  concerned that he may have an underlying mental health disorder that 

contributes to his relapses and is  very keen to be seen by CMHT.  However, he is  aware 

that  he  needs  to  be  completely  abstinent  of alcohol  and  recreational  drugs  for  a 

period of 90 days before this referral can be made." 

'  letter is also marked as copied to the Deceased. 

ii. 

Mr Rhodes  saw his  GP and  it was  confirmed during evidence  that a  referral would  be 

made by the GP after a period of90 days abstinence. 

 left after giving his  evidence and neither he nor the Practice were represented 

at  the  Inquest  to  hear what  others  may have  said  in their evidence. 

  does  not 

recall  giving  evidence  to  the  effect  that  "a referral  would  be  made  by  the  GP  after  a 

period of 90  days abstinence" and nor does his Statement state this. 

Following  his  consultation  with  his  hepatologist  on  16  August  2022,  the  relevant 

chronology is: 

2 

 •  The  Deceased  next  contacted  the  Practice  online  on  22  August  2022,  by  e-

Consult requesting  an  extended  sick note  until  31  October 2022.  The  Deceased 

stated (our emphasis): 

" .. . I'll be 90 days clean come 02/09/22 and I'll arrange an appointment at that 

time to get a CMHT referral." 

•  Thee-Consult was triaged and a new eMED3  (sick note) issued by 

 on 

23  August 2022. 

•  The  Deceased  attended  a  face  to  face  consultation  with 

  on  14 

September  2022  with  an  unrelated  complaint.  That  was  an  urgent,  same  day 

appointment  for  tonsillitis. 

  confirmed  in  his  evidence  that  the 

Deceased  did  not  mention  nor request  anything  about  his  mental  health  at  this 

consultation, he did not discuss the CMHT referral or "requirement" for  90  days 

abstinence  during  this  consultation. 

  gave  evidence that  the  Deceased 

was  acutely  unwell  from  tonsilitis.  The  attendance  was  entirely  unrelated  and 

addressed only the Deceased's acute presentation with tonsillitis. 

•  The Deceased's next and final  contact with the Practice was on 28  October 2022, 

again by e-Consult,  seeking a  sick note  extension until  24  December 2022.  The 

e-Consult  was  triaged  and  a  new  eMED3  (sick  note)  issued  by 

  the 

same day. 

The Practice were aware from 

'  letter and the Deceased's e-Consult message of 

22  August  2022  that  he  was  trying  to  achieve  90  days'  abstinence.  As  his  eConsult 

message of that date (set out  above)  clearly states,  the Deceased also knew he needed to 

initiate  the  contact  with  the  Practice  for  a  consultation  for  a  mental  health  review,  in 

order to receive a CMHT referral if appropriate, and he planned to do this. 

iii. 

Mr Rhodes'  GP  explained that  in  order  to  make  a  referral Mr Rhodes  had  to  make  a 

specific appointment to  discuss  the Mental Health  referral.  The  GP said that Mr Rhodes 

was aware ofthis. 

This is correct. The response at ii above is reiterated. 

iv. 

Mr Rhodes saw his GP on  14/10/22 (at that time he had been sober in  excess of90 days) 

for  a  medical  condition.  On  that  occasion  there  was  no  discussion  about  the  Mental 

Health referral. 

This is  correct.  As  explained in the Response at ii  above,  the appointment was  in respect 

of  an  unrelated,  urgent  presentation  with  tonsilitis.  There  was  no  discussion  of  his 

sobriety or CMHT referral. 

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 v. 

Mr Rhodes 'family (who  were close  to  him and had discussions with  him) gave evidence 

to  say  that  his  understanding  was  that following  the  90  day  period  of sobriety  there 

would be an automatic referral by his GP to  the Mental Health Services. 

This  reflects  the  family's  evidence  of  their  understanding  of the  Deceased's  belief. 

Response ii above is reiterated. 

vi. 

The  report from  the  addiction  support agency details  entries whereby during discussion 

with  his  Recovery  Worker  Mr Rhodes provides  a  detailed  chronology  of his period of 

abstinence  and the fact he  was  waiting to  hear from  the  Mental Health  Services for an 

assessment appointment. 

This reflects the evidence heard. 

vii. 

Mr  Rhodes' partner  gave  evidence  that  at  the  time  he  started  to  relapse  he  was  still 

waiting  for  a  date  from  the  Mental  Health  Services  and  that  he  was  expressing 

disillusionment with  the Mental Health Services. 

This reflects the evidence heard. 

2. 

I have concerns with regard to  the following: 

i. 

There  appears  to  be  an  apparent  breakdown  in  communication  or a  misunderstanding 

between  GP and patient as  to  what steps needed to  be  taken  and by  whom  in  order for 

there to a Mental Health referral. 

The  Practice  do  not  accept  that  there  was  either  a  breakdown  in  communication  nor 

miscommunication between the Practice/GPs and the Deceased. 

The  discussion  concerning  the  CMHT  referral  was  between  the  Deceased  and  his 

hepatologist,  not  the  GPs.  The  hepatologist's  letter  to  the  Practice  (18  August  2022)  is 

marked  as  copied  to 

the  Deceased  so  he  would/should  have  had  the  written 

communication, see response to  1.  ii above for details. 

It is  evident from the Deceased's e-Consult email to the Practice on 22 August 2022, that 

the  Deceased  was  aware  that  he  himself  needed  to  make  an  appointment  with  the 

Practice to  discuss  his  mental  health in order to  get  a  CMHT referral.  As  the Deceased 

clearly stated: 

"I'll be 90  days  clean come 02/09/22  and I'll arrange an appointment at that time to  get 

a CMHT referral."  (our emphasis). 

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 ii. 

Reliance appears  to  have  been placed on  verbal discussions  during consultation  and in 

circumstances where the patient is an addict. 

The "discussion" was between the Deceased and his  liver specialist and was followed up 

in  writing,  by  letter  dated  18  August  2022  marked  as  copied  to  the  Deceased.  See 

Response at 2.  i.  above which is reiterated. 

The Deceased had capacity. 

At  this  time  the  Practice  were  already  using  AccuRx  to  provide  written  safety  netting 

information  to  patients.  However,  in  this  instance,  the  conversation  was  between  the 

hepatology consultant and the patient,  with the Practice/GP never involved in the mental 

health/CMHT discussion. 

The Practice will continue to use AccuRx to provide written safety netting information to 

patients. 

The  Practice  Partners  have  discussed  collectively their position is  not  to  routinely  send 

letters to remind patients to request a referral. 

iii. 

There does not appear to  be  a system where there would be an automatic referral by the 

GP to  the Mental Health  team after a 90 day period ofsobriety unless the patient  "opted 

out" or where following an automatic referral it is  left to  the Mental Health  team to  seek 

the co operation ofthe patient. 

A system of referring patients with addiction automatically to mental health services after 

a  specified period of abstinence without  GP  review/discussion/assessment  would not be 

appropriate or workable.  There is  always  a risk of relapse at  any point during the 90 day 

period  making  review  in  advance  of referral  necessary.  Further,  a  period  of abstinence 

may  also  have  changed  the  patient's  mental  health  condition,  meaning  a  referral  is  no 

longer necessary/appropriate. 

If the Deceased had been referred to  CMHT at that time (following a GP  review)  and as 

he  was  not  psychotic/higher  risk,  then  any  such  referral  would  have  been  made  on  a 

routine  (not urgent)  basis.  However,  it  is  also  the Practice's  experience that many such 

patients are signposted back to drug and alcohol services for counselling. 

The Deceased was already under "We Are With You" and had access to counselling. 

In  the  event  an automatic  system  were  to  be implemented  (which the  Practice consider 

inappropriate),  mental health services would be inundated by referrals,  where capacity is 

already  limited and  lots  of drugs  and  alcohol  referrals  are  already being rejected  in the 

Practice's experience. 

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 iv. 

There  does  not  appear  to  be  a  letter  sent  by  the  surgery  confirming  the  respective 

responsibilities ofthe doctor and patient. " 

The  plan  for  CMHT  review  was  discussed  between the  Deceased  and  his  hepatologist 

and (as  marked on the letter) the Deceased would have received a copy of the letter sent 

to the GP practice, following that consultation confirming the plan. 

The Practice reiterates its responses to  1.  i.  and ii.  and concerns 2. i.  and ii.  above. 

STEPS TAKEN BY THE PRACTICE 

8.  On notification of the Deceased' s death and as  part of their "death audit" ( concerning an unexpected 

death),  the Practice  conducted a "death analysis"/SEA on 25  January 2023.  This  was  prior to  being 

notified of the cause of death by the Coroner. This was led by Dr Rasool. 

9.  Following  the  Inquest,  and  receipt  of the  Regulation  28  Report,  the  Practice  has  also  undertaken 

further extensive steps: 

9.1.  The Partners  have discussed the circumstances of the death,  H.M.  Assistant  Coroner's concerns 

and considered whether there needs to be  any change to  practise, at Partners'  meetings  on 7 and 

21  August 2023. 

9.2.  The  Practice  have  sought  and  obtained  copies  of  the  CMHT  referral  pathways  from  the 

Integrated  Service Manager for  Bournemouth East  CMHT,  the  "Pan Dorset  Guidance/Process" 

and  "Integrated  Community  Mental  Health  Team  Procedures"  copies  of which  are  attached. 

These had not previously been provided to the Practice. These were requested on 9 August 2023 

and  obtained  on  10  August  2023.  The CMHT's  referral  criteria does  not  specify a requirement 

for 90 days'  abstinence. 

9.3.  Under the Pan Dorset Guidance/Process the Deceased fell  into "Quadrant A": 

• 

Individuals  within  this  quadrant  would  be  experiencing  significant  mental  health problems 

and high drug and/or alcohol use (of any drug and/or alcohol). 

• 

Individuals should be typically receiving care from both statutory mental health services and 

substance misuse services,  where treatment such as  opiate  substitute prescribing,  or alcohol 

detox would be in place. 

• 

Joint  responsibility  for  coordination  would be required  for  this  group  with  commitment to 

joint assessment, care planning and treatment 

• 

If the individual only engages with either the substance misuse service OR the mental health 

service  then  either  service  should  request  advice,  guidance  and  support  from  the  other  as 

necessary. 

9.4.  Liaised with the Care Quality Commission (CQC)  in response to  initial  contact from them.  The 

CQC representative planned to raise with the Integrated Care Board ("ICB") Quality Lead. 

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 9.5.  Raised  the  wider  system  approach  with  the  ICB  directly,  namely  the  ICB  Quality  Lead  and 

Patient Safety Specialist for Dorset, having obtained details from contact with the CQC.  Emailed 

for guidance on addressing the wider system and attempted to  clarify whether there is  a "90 day 

abstinence rule" for CMHT referrals. 

9.6.  Following  discussion  with  the  ICB  communications  lead  on  3  August  2023,  obtained  a  copy 

mental health Z  card  on  17  August  2023,  as  attached  (which the Practice do  already have  and 

use but did not have opportunity to  give to the Deceased in this case due to lack of mental health 

contact) 

9.7.  Contacted and met  with ICB  Patient  Safety  Services on 30  August  2023.  Established there is  a 

review underway of the service provision for patients with alcohol dependency but that is  still at 

the  fact  finding  stage  and  the  timeframe  for  completion  is  realistically  not  until  the  middle  of 

2024. 

9.8.  By way of follow up meeting on 25  September 2023 

 (Practice Manager) and 

  attended  a  meeting  with 

  (Patient  Safety  at  Dorchester 

Hospital  and  University  Hospitals  Dorset) 

  (ICB  Transformation  Lead), 

  (Secondary  Care  Mental  Health  Service  Lead), 

  (ICB  Patient  Safety 

Lead) to  discuss matters arising and referral criteria to CMHT. The pertinent discussion points of 

relevance were: 

9.8.1  Mental Health Integrated Community Services (MHIC) long term plan was released pre-

COVID.  It lays out unmet needs for patients with mental health, addiction and wellbeing 

concerns.  A  big  part  of the  current  plan  is  around  regular  multi-disciplinary  ("MDT") 

meetings  between  these  services  coordinated  by  new  'wellbeing  coordinators'  (to  be 

employed at PCN/Neighbourhood level).  GPs will be invited to  attend these meetings to 

improve  communication/patients  bouncing  around  services  with  no-one 

taking 

ownership.  It is  specifically designed so  patients  can contact the wellbeing coordinators 

themselves  for  help  as  and  when  needed,  rather  than  GPs  needing  to  refer  each time. 

Poole and Weymouth are currently running pilots for this model,  but this is  not likely to 

be up and running locally until May 2024 at the earliest. 

9.8.2  GP  Practices  do  now  have the addition of a CMHT link worker which everyone agreed 

was a very valuable communication asset. 

9.8.3  The  90  days'  sobriety  has  never  been  a  'rule'/  referral  criteria.  It's  likely  a  historic/ 

misunderstood  'old wives  tale'.  Discussed  the  length of the  referral  criteria  document, 

which  it  was  agreed  was  unhelpful  for  clinicians.  CMHT  stated  this  was  their  policy 

rather than one  aimed  for  referring  clinicians  to  use.  All  agreed  it  would be helpful  to 

have  a  shorter/punchier  summary  for  clinicians  to  use  going  forwards.  This  will  be  a 

matter for CMHT to prepare a revised version. 

7 

 
 
 9.8.4 

In  the  case  of the  Deceased,  he  was  under  'We Are  With  You'.  It  was  confirmed that 

they  could  refer  into  CMHT  if they thought  it  necessary.  No  data  is  available  on  how 

many referrals  'We Are With You'  make,  but anecdotally,  not many as  they have their 

own Psychiatric nurses. 

9.8.5 

Plan to prepare a shared learning summary jointly with ICB.  ICB  are already providing 

mental  health Z  cards to  acute  services/ A&E departments.  CMHT  are  in the process of 

constructing  an  SBAR 

(situation,  background, 

assessment, 

recommendation) 

communication tool for acute services detailing criteria for referral to CMHT. 

8