Luke Whitelaw

1 February 2024 

Private & Confiden�al   
Ian Poter  
Assistant Coroner 
Coroner area of Inner North London 
Poplar Coroner’s Court 
127 Poplar High Street 
London 
E14 0AE 

Dear Mr Poter, 

Pinewood House  
Pinewood Place  
Dar�ord  
Kent  
DA2 7WG  

Re: Response to Prevent Future Deaths Report touching the death of Mr Luke Mervyn Whitelaw      
(Date of Death: 17 March 2023)  

This response is made on behalf of Oxleas NHS Founda�on Trust in response to the Regula�on 28 
Report  to  Prevent  Future  Deaths  following  the  inquest  touching  the  death  in  custody  of  Mr  Luke 
Whitelaw who died on 17 March 2023, with the mater of concern outlined below;   

•  Mr Whitelaw’s re-admission to hospital was indicated as early as 2 February 2023; 

however, he was not re-admitted to hospital, informally or otherwise. 

•  A verbal referral was made for Mr Whitelaw to be urgently reviewed by a psychiatrist 

following the appointment on 2 February 2023, but not acted on. 

•  The Oxleas NHS Foundation Trust’s Serious Incident Investigation Report, dated 8 

September 2023, identified numerous matters and learning points, including, but not 
limited to the following: 

•  There had been a lack of “professional curiosity” in the assessment and planning of 

Mr Whitelaw’s care and treatment 

•  Discussions and assessments of risk should be clearly documented 
•  Risk formulations should consider both current and historic/contextual risks and 

incorporate ratings of mood to ensure that these are not used in isolation and are 
linked with appropriate interventions  

•  There were “missed opportunities identified in relation to LW’s self-reported 

deterioration following his discharge from hospital which do not appear to have 
been fully explored.” 

Having reviewed the concerns below is a summary of actions we have taken to improve practice in 
the areas highlighted.  

Oxleas Acute Mental Health Patient Flow and Bed Management policy (updated in December 2023) 
provides guidance on the purpose of an inpatient admission; and actions to be taken when Crisis 
Resolution and Home Treatment Team (CRHTT) identify that someone’s clinical needs indicate that 

 
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 an inpatient bed is required. The CRHTT policy and training for staff includes guidance on assessing 
and managing risk, and changes to the risks and clinical presentation. 

We have discussed with the team members of CRHTT the need to precisely document discussions 
about medication or medical  review in future (i.e. to outline date and time of discussion, who was 
involved in the discussion, and the outcome that was agreed). Since this time, significant discussion 
and training has taken place with all clinicians in this team to document key discussions and 
decisions – including when the clinical needs changes to the point that inpatient care is indicated. 
Training and discussion has also taken placed during 2023 and into 2024 with the consultant 
psychiatrists, managers and clinical staff about meaningful discussion and documentation of same, 
and consideration of written notes. 

In 2023 an improvement plan was put in pace for this clinical team to address gaps which were 
identified during the investigation and gaps which were identified as a result of day-to-day 
oversight. This plan is monitored by the service director and the clinical director for the Acute & 
Crisis Directorate and will continue until such time that we are satisfied that the care provided is to 
the standard needed, and for at least until July 2024. 

The improvement plan is broad and incorporates the following: 

•  assurance on the quality of clinical care by the embedding of clinical  standards 
• 

risk assessment and documentation. Embedding a culture of risk assessment and 
management that is based on holistic assessment, clinical formulation, and full descriptions 
of the risks considering historical and dynamic factors.  In 2023 we have directed clinicians 
not to rely on ratings such as “low, medium high” in the context of risk  

•  Embedding a meaningful reflective practice culture  
•  The head of nursing, Head of psychology,  Clinical Director and operational managers have 
worked closely with the clinical leads and managers to create an ongoing support structure 
to continue improve on the Clinical Standards of care and Treatment. 

As part of the reflective discussion with senior clinical leads on 9th November 2023, specific 
attention was given to making sure that the team understand their responsibilities around 
maintaining robust clinical standards and risk assessment.  This discussion included, for example: 

•  Changes in clinical presentation and risk; and consideration of the clinical threshold for 

moving from treatment at home to inpatient admission 

•  Professional curiosity on exploring the individual’s clinical presentation and the relationship 

to their support network and social circumstances.  

•  Application of the DICES training in day-to-day practice.  The DICES training provides 

clinicians with the skills, confidence, and competence to engage in an open dialogue with 
individuals and their social network. 

•  Reinforcement of the standards around articulating and narrating risk narrative risk 

formulation based on the 4 key factors: static factors, dynamic factors, future factors and 
strengths and protective factors. 

Training & development of staff 

 
 
 
 The Greenwich CRHTT has received DICES training, delivered by Association of Psychological 
Therapies.  DICES Risk Assessment and Management System helps a practitioner assess risk using a 
system of checklist whereby all the risks that a client in crisis may be susceptible to are asked and 
explored by the practitioner. 

The outcome of this checklist will help to formulate a risk management plan using the DICES 
acronym, Describe the risk, identity options to keep the client safe. Choose the preferred option, 
explain the chosen option and share the risk management plan with members of the MDT. One of 
the key benefits of DICES is to help the team move away from the stratification of risk of high, 
medium, low which does not provide a narrative of what actions will be taken to keep the patient 
safe. 

•  Over 50 staff from all CRHTT’s have attended the 2-day course. To date 11 of the 
Greenwich Home Treatment Team been trained and accredited since the training 
was introduced in March 2023 

•  More training is planned in early 2024 for further staff.  
•  The Greenwich Home treatment managers are also trained in DICES to provide 

• 

leadership oversight of its implementation in the team. 
In addition, the Practice Development Nurse and Quality Improvement lead have 
been supporting the Greenwich HTT to apply the learning into day-to-day practice 
•  The “Heads Together” CRHTT skills and development programme to improve skills 
competencies is ongoing with the Greenwich Home Treatment with a focus on 
assessments, risk assessments and robust formulations. 

•  Similar to the approach we used in similar clinical teams, the practice development 
nurses will now begin a process to demonstrate clinical competency of individual 
clinicians- identifying general gaps in skills and training. 

Assurance that improvements are occurring: 

•  The practice development nurses, and the Head of Psychology have been supporting the 
teams with risk assessment and formulation of complex case discussions on clients on the 
case load who present with significant concerning risks.  

•  The team managers, with the support of the Practice Development nurses, audit the quality 
of risk assessments and to ensure that practitioners are not stratifying risks as low, medium 
or high. 

We have already judged that the team are improving in confidence in the use of DICES risk 
assessments and formulation to support a sophisticated appraisal and communication of clinical 
risk.  

The most recent audit carried by the Crisis services Manager on 16th January 2024 demonstrated 
that out of 34 cases reviewed, 28 of the risks assessment were of expected standards.   1 of the 34 
cases had risks ratification documented but there was  good parallel documentation on the risk 
narrative for that case. 

 
 
 
 
 Clinical Leadership 

The Clinical Lead and the local managers attend the daily MDT to provide senior clinical leadership 
and guidance on clinical discussions. In addition, the team have access to the Head of psychology 
also provides direct clinical input and consultation to the team from August 2023. The team have 
regular reflective practice to have a protective space to share any learning and best practice to 
continue to foster an environment for continuous leaning and improvement for clinical practice. 

We have also had intensive engagement with clinicians and the transformation team to co- design a 
single crisis assessment form that allows to capture a person journey /story in one single document 
on the patient recording system. This would prompt clinicians to add to assessment that was carried 
out previously which reduce the risks of clinicians not considering the full documentation on what 
has been happening in that person care. The form has recently gone live on the Patient clinical 
record as of 22 January 2024 and is on testing phase for which we are collecting feedback. 

In terms of process and documentation, the standards have been reinforced with the managers 
and clinicians, including for example: 

•  ALL MDT discussions to be documented and content of the discussions to be recorded 

clearly in the clinical notes, including the plan and rationale. 

•  Protected time ringfenced for the team to prioritise discussion of complex cases.  
•  A weekly session facilitated (in the interim until there is a team psychologist in post) by the 
Head of Psychology to support the multi-disciplinary team to carry out clinical formulation 
and risk assessment.  

•  On a trust wide basis, work is underway to review the Trust Risk assessment template on the 
electronic patient record.  This will support the embedding of the fresh approach to risk 
assessment, formulation, communication and recording. 

Yours sincerely 

Chief Execu�ve