Christopher Allum

BramleyH~aj!g 

The Langford Centre, 55-65 De La Warr Road, Bexhill-on-Sea, East Sussex, TN40 2JE 

2nd January 2024 

Mrs Laura Bradford 
Assistant Coroner for East Sussex 
Unit 56, Innovation Centre, 
Highfield Drive, St Leonards 
Hastings 
TN38 9UH 

Dear Mrs Bradford, 

Inquest into the death of Mr Christopher Allum: Regulation 28 Report 

I write further to your Regulation 28 Report dated 10th November 2023, addressed to both The 
Langford  Centre  and  NHS  England.  My  response  is  on  behalf of The  Langford  Centre  as 
Director of Clinical Services and Compliance. 

I anticipate that you will share a copy of this response with Mr Allum's family, and I would like 
to once again express my condolences for their tragic loss. 

You have expressed concerns regarding The Langford Centre, in respect of the following two 
issues: 

a)  Gaps at the initial referral and admission  stage in obtaining and recording information 

regarding a patient's previous methods of self-harm and suicide, and; 

b)  The seeking  and  recording  of relevant  information from  an individual's family  at the 

point of admission. 

I note that in relation to your further concern relating to difficulties in accessing a patient's NHS 
notes, you made reference during your conclusions to the unprecedented steps The Langford 

 
 
 Centre  have  taken.  These  steps  include  an  agreement  with  the  Sussex  Partnership  NHS 
Foundation Trust (SPFT), which allows Langford's qualified medical staff full read only access 
to a referred  patient's medical records. 

Whilst we  fully accept the concerns raised within your report,  it is the Langford's view that all 
parties involved in the admission process of mental health referrals ought to  have been  made 
Interested Persons at the Inquest. This would  have allowed for greater collaboration between 
the  different  organisations  in  implementing  the  series  of  corrective  measures  we  have 
introduced to address your concerns. 

In  order  to  address  concerns  relevant  to  The  Langford  Centre,  we  have  been  liaising  with 
SPFT  and  the  following  corrective  measures  have  been  agreed  with  our  partners  to  be 
implemented from  1st January 2024; 

a)  Our  initial  referral  form  has  been  amended  to  include  an  additional  field,  entitled 
'Previous  Suicide  Methods,'  which  must  be  completed  by  the  referrer.  This  field 
includes a supporting sub-section headed 'Previous Suicide Methods Used,' which  is 
intended to record details of the self-harm methods. 

Completion of this  information on  behalf of a referring Trust or Body is mandatory and 
the initial referral will  not be accepted at the triaging  stage at Langford,  unless there is 
a narrative explaining why it has been left incomplete. This will of course include those 
patients who do not have a history of suicide or self-harm. 

In  order to further explore possible past suicide attempts and to ensure full  capture of 
a patient's self-harm history at the admission stage, both the initial medical assessment 
and formation of risk assessment, completed by the triaging doctor at Langford, include 
the same subsections. 

You will of course appreciate that this updated process is in the context of our renewed 
referral  process which includes the receipt of 28 days of medical records,  relevant risk 
assessments from  the  referring  Trust  and  full  read  only  access  to  a patient's  entire 
medical records. 

b) 

ln respect of seeking information from  an  informal patient's family,  this  step is entirely 
dependent upon the individual's consent. 

-our  initial  medical  assessment  and  risk  assessment forms  have  been  amended  to 
include a detailed section regarding obtaining consent to speak with  a patient's family 

 and  next of kin.  Written  consent must _be  recorded,  together with details of the  next of 
kin to contact. 

If agreed,  a qualified member of·staff is subsequently tasked  with reaching  out to the 
family  and  recording vital information.  The document includes a section ta,  record the 
information  provided  by  a  family  or  relative.  Obtaining  contact  information  and 
speaking with the  next of kin  are  now a mandatory task at Langford. 

Please be  assured that,  notwithstanding consent being  obtained,  family members are 
still  invited  to  attend  the  Multidisciplinary  Meetings  conducted  by  our  Consultant 
Psychiatrists at the 48 to 72 hour stage.  This additional measure will  however, seek to 
reassure  families  and  open  a  line  of  communication  very  early  in  the  process  of 
admission. 

Finally,  as there have been  amendments to o_ur initial processes,  training updates have been 
rolled  out  company  wide.  This  includes  training  to  staff  who  triage  our  initial  referral 
documents,  medical  doctors  who  conduct  the  initial  assessments  and  consultants  who 
oversee  our  ward  rounds  and  MOT's.  All  staff  have  been  fully  informed  of  the  additional 
processes  and  the  sensitivities  surrounding  the  nature  and  detail  of the  information  being 
requested. 

We continue to collaborate with  our working partners in continuing to  improve and  strengthen 
our admission  processes.  The  Langford  Centre  is  committed  to  working  with  its  partners  in 
continuing to develop the  referral form to  ensure that the  referring  individual is  admitted  with 
as comprehensive and  robust an account of the patient's risks  and circumstances. 

We  believe  that  the  improvements  identified  above  will  enhance  our  current  referral  and 
admission procedures. 

I trust that this response provides you with an assurance that action has been taken to address 
the two specific concerns raised. 

Yours sincerely, 

Director of Clinical Services & Compliance. 

The Langford Centre.

Laura Bradford 
East Sussex Coroner’s Office 
Unit 56 Innovation Centre 
Highfield Drive 
St Leonards on Sea 
East Sussex 
TN38 9UH 

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

8 January 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Christopher Richard 
Allum who died on 15 May 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  10 
November 2023 concerning the death of Christopher Richard Allum on 15 May 2022. 
In advance of responding to the specific concerns raised in your Report, I would like 
to  express  my  deep  condolences  to  Christopher’s  family  and  loved  ones.  NHS 
England are keen to assure the family and the coroner that the concerns raised about 
Christopher’s care have been listened to and reflected upon.  

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Christopher’s family or friends. I realise 
that responses to Coroner Reports can form part of the important process of family 
and  friends  coming  to  terms  with  what  has  happened  to  their  loved  ones  and 
appreciate this will have been an incredibly difficult time for them. 

In preparing this response, your Report was reviewed by specialist colleagues from 
the  national  Mental  Health  Team  at  NHS  England,  the  Getting  It  Right  First  Time 
Programme  for  crisis  and  acute  mental  health  and  Specialised  Commissioning  for 
Mental Health, all of whom have provided input.  

Your Report raised concerns over gaps in obtaining information about and recording 
previous methods of self-harm and suicide at initial referral and admission stage and 
in seeking and recording relevant information from an individual’s family.  

The  Langford  Centre  is  operated  by  Bramley  Healthcare,  an  independent  Mental 
Health Care Provider providing services within the South of England. I note that you 
have also addressed your Report to the Centre, and they would be the appropriate 
organisation to respond to the above concerns. NHS England will carefully review and 
consider their response to you.  

Christopher was sadly at high risk of suicide and self-harm at the time of his admission 
to the Langdale Centre, and I note that this was included in the referral notes received 
by the Centre. While the referral paperwork unfortunately did not refer to the previous 
ligature attempt made by Christopher, Clinical Leads at NHS England have advised 
that it should still have been part of any risk management plan given Christopher’s risk 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 of suicide. It is also not clear to NHS England from your Report why Christopher’s care 
notes were not accessed by staff at the Centre until after his death.  

While  we  await  further  correspondence,  NHS  England  does  understand  from  the 
Langford  Centre  that they have  taken actions to  address  the  gaps  identified  by the 
coroner which has included amendment to their Acute Referral Form. The new referral 
form includes boxes to record details of previous suicide and self-harm attempts and 
methods used. It also includes a box for relative/care views and information as well as 
a  requirement  to  provide  a  reason  if  they  have  not  been  contacted  to  discuss  the 
referral.  

Christopher’s  case does highlight the  importance of  effective  information  sharing  to 
support  providing  the  best  care  possible  where  individuals  are  transferred  between 
different care settings. That is why joined up partnership working is one of the four key 
principles  underpinning  NHS  England’s  guidance  on  Acute  inpatient  mental  health 
care  for  adults  and  older  adults  that  was  published  in  July  2023.  This  document 
provides specific advice on good practice on information sharing as well as guidance 
on the holistic assessment that should take place when someone enters a new facility, 
including identifying any safeguarding or risk issues, including risk to self and others. 
This includes guidance on the key actions that should take place within 72 hours of 
admission which include:  

• 

• 

• 

• 

• 

• 

Person’s  electronic  patient  record  (EPR)  reviewed  (including  identifying  any 
recorded advance choices and reasonable adjustments required), checking back 
key information from the person’s EPR with them and their chosen carer/s and 
noting any changes/updates.  

Holistic assessment completed and uploaded to the person’s EPR.  

Purpose  of  admission  statement  and  estimated  discharge  date  (EDD)  agreed 
with the person and their chosen carer/s and uploaded to the person’s EPR.  

Interventions  and 
commenced/maintained, and a physical health check completed.  

for  physical  and  mental  health  conditions 

treatment 

Formulation review completed and care planning begun.  

Discharge planning begun – identifying what needs to happen for discharge to 
occur. 

Where an independent provider is not able to access an EPR for any reason, rapid 
access to the information through other avenues should be part of local protocols.  

While I note that this guidance was published after Christopher’s death, I hope that it 
provides some assurance to the coroner and Christopher’s family around the current 
guidance  and  processes  in  place  to  support  providers  in  preventing  the  issues  in 
Christopher’s care from occurring in the future.  

In  2022,  NHS  England  also  established  its  Mental  Health,  Learning  Disability  and 
Autism  Inpatient  Transformation  Programme  to  support  cultural  change  and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 implement a new model of care for the future across all NHS funded mental health, 
learning disability and autism inpatient settings. As part of the Programme, all mental 
health inpatient independent sector providers will receive support to move away the 
use  of  risk  assessment  tools  to  co-produced  safety  planning  in  line  with  guidelines 
from the National Institute for Health & Care Excellence (NICE), and the Government’s 
Suicide  Prevention  Strategy,  from  2024  onwards.  The  Programme  also  includes  a 
focus on increasing the role of family voice.  

Your Report also raised concerns around the difficulties faced by the private sector in 
accessing NHS patient notes.  

NHS  England  is  working  to  enhance  the  sharing  of  patient  information  to  and  from 
Voluntary,  Charity  and  Social  Enterprise  (VCSE)  and  other  independent  sector 
providers who are commissioned by NHS organisations. 

VCSE  and  other  independent  sector  providers,  commissioned  by  the  NHS  are 
increasingly being connected to Local Shared Care Records (SCR). Integrated Care 
Boards  (ICBs)  are  responsible  for  determining  which  organisations  should  be 
connected  to  their  local  SCRs,  and  to  support  them  to  connect.  Over  the  next  two 
years,  there  is a requirement  for ICBs to  connect  all  Local Authorities with  a social 
care  responsibility  and  a  ‘priority’  list  of  community  care  providers,  which  includes 
numerous independent sector providers commissioned by NHS organisations, to their 
local SCRs. 

I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director