Amarnih Lewis-Daniel

Nadia Persaud 
East London Coroner’s Court 
Queens Road 
Walthamstow 
E17 8QP 

Coroners@walthamforest.gov.uk 

Dear Coroner, 

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

england.coronersr28@nhs.net  
7th February 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Amarnih Louis Lewis-
Daniel who died on 17 March 2021.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  11 
December  2023  concerning  the  death  of  Amarnih  Louis  Lewis-Daniel  on  17  March 
2021. In advance of responding to the specific concerns raised in your Report, I would 
like  to  express  my  deep  condolences  to  Amarnih’s  family  and  loved  ones.  NHS 
England are keen to assure the family and the coroner that the concerns raised about 
Amarnih’s care have been listened to and reflected upon.  

I apologise for the delay to responding to your Report, and for any anguish this delay 
may have caused to Amarnih’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. 

You  will  be  aware  that  NHS  England  has  previously  provided  a  report  on  the 
commissioning  of  specialised  gender  dysphoria  services  to  you,  to  assist  with  your 
investigation. For completeness, aspects of that report are repeated in the following 
response.  Given  that  Amarnih  was  aged  24  at  the  time  of  her  death,  our  response 
focuses  on  issues  relating  to  the  NHS  pathway  of  care  for  adults  with  gender 
dysphoria, and to national policy on mental health services for young people up to 25 
years of age.  

In your Report you raised five matters of concern. Some of these matters of concern 
are better addressed by the Gender Dysphoria Clinic at the Tavistock and Portman 
NHS  Foundation  Trust,  the  healthcare  professionals  directly  involved  in  Amarnih’s 
care at North East London NHS Foundation Trust and the Care Quality Commission 
(CQC). We note that you have also addressed your Report to these organisations.  

Background to NHS England’s role as Commissioner 

NHS England is the direct commissioner of specialised services for individuals with a 
diagnosis  of  gender  dysphoria.  Prior  to  2019/20,  seven  specialist  centres  were 
commissioned 
in  or  near  Newcastle,  Leeds,  Sheffield, 
Northampton, Nottingham, London and Exeter. Each of the Gender Dysphoria Clinics 
(GDCs) is operated by a Mental Health NHS Trust and is staffed by a multidisciplinary 
team  to  include  the  wide  range  of  clinical  professionals  needed  to  deliver  highly 

in  England,  based 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 individualised care and meet the presenting needs of the whole person (typically and 
variously:  clinical  psychologists;  specialist  physicians;  consultant  psychiatrists; 
consultant  endocrinologists;  clinical  nurse  specialists;  voice  and  communication 
therapists; counselling therapists).  

The consultant-led services provided by the GDCs when adult patients are referred to 
them  are  amongst  those  intended  to  commence  within  18  weeks  of  referral.  NHS 
England has been unable to commission sufficient capacity to meet that expectation 
because of the lack of specialist clinical staff (recruitment and retention) – against a 
backdrop  of  significant  increasing  demand.  Unfortunately,  waiting  times  for  a  first 
appointment  at  a  GDC  remain  very  high.  Of  patients  who  received  their  first 
appointment  in  November  2023  they  had  on  average  been  referred  382  weeks 
previously.  

You have raised the following matters of concern: 

1.  Very long waiting lists for Gender Dysphoria Clinics 

NHS England has sought to address the serious imbalance between the demand for 
gender dysphoria services and the shortage in trained clinicians who are available to 
train  and  work  in  this  field,  which  has  led  to  long  waiting  times.  In  2019/2020,  NHS 
England  re-procured  the  provision  of  gender  dysphoria  services  for  adults.  The 
expectation was that that re-procurement would bring forward new entrants and enable 
NHS  England  to  increase  the  number  of  GDCs,  and  funding  was  identified  by  NHS 
England  for  that  purpose.  That  expectation  was  not  met.  In  fact,  no  new  providers 
came  forward  from  either  the  NHS  or  independent  sector.  All  of  the  seven  existing 
GDCs submitted bids and award of renewal of contract was confirmed for all of them.  

In the circumstances, NHS England sought to grow capacity in an alternative way. Five 
pilot services were developed. The proposal was to build a new clinical workforce using 
professionals who had tended not to specialise in gender identity healthcare previously, 
based in primary care and local sexual health services, which presented the opportunity 
to develop and expand clinical capacity to an extent not possible under the historical 
delivery  model.  There  were  various  eligibility  criteria  for  accessing  the  different  pilot 
services  (for  example,  being  registered  with  a  GP  in  the  relevant  geographical 
catchment area) but all the pilot services only took patients from the waiting lists of the 
established GDCs, in chronological order of waiting. Between April 2020 and August 
2023 around 2,500 individuals were removed from a GDC waiting list to be seen by one 
of the pilot services. They were located as follows:  

a.  The Trans Plus service, delivered in a sexual health setting at Chelsea and 
Westminster Hospital NHS Foundation Trust in London (from April 2020) 
b.  The  Indigo  Service  in  Greater  Manchester,  based  in  primary  care  and 

delivered by GTD Healthcare (from December 2020) 

c.  CMAGIC,  a  primary  care  service  in  Cheshire  and  Merseyside  hosted  by 

Mersey Care NHS Foundation Trust (from March 2021) 

d.  The  East  of  England  Gender  Service,  managed  by  the  Nottinghamshire 
Healthcare  NHS  Foundation  Trust  in  partnership  with  Cambridgeshire  and 
Peterborough NHS Foundation Trust (from June 2021) 

e.  A  primary  care  service  in  Sussex  hosted  by  Sussex  Partnership  NHS 

Foundation Trust (from October 2023) 

 
 
 
 
 NHS  England directly  funded the pilot services on top  of the funding provided to the 
seven established GDCs.  

In 2023 the pilot services at Chelsea and Westminster Hospital NHS Foundation Trust 
(London) and GTD Healthcare (Greater Manchester) were moved to substantive seven-
year  contracts  with  NHS  England  following  positive  evaluations.  The  GTD  service  is 
now  open  to  new  referrals  of  patients  who  are  registered  with  a  GP  in  Greater 
Manchester, and the London service is now taking increased numbers of patients from 
the waiting list of its nearest GDC – the Tavistock and Portman NHS Foundation Trust. 
NHS England is currently out to tender to award a substantive contract for the service 
in Cheshire and Merseyside following positive evaluation of this service, and there is an 
expectation that  a similar  process will  be followed for the other two pilots  when their 
evaluations are complete in 2024 (East England) and 2026 (Sussex).  

As  mentioned  above,  to  support  the  growth  of  clinical  capacity  NHS  England  also 
established and funded the UK’s first accredited training programme in gender identity 
healthcare  which  was  launched  in  2020  and  delivered  through  the  Royal  College  of 
Physicians.  The  purpose  of  this  investment  is  to  encourage  growth  in  the  specialist 
clinical workforce available to contribute to the assessment and care of those presenting 
with gender incongruence and to treatment following a diagnosis of gender dysphoria. 

NHS England also continues to support the expansion of services in the established 
GDCs where this is possible. In 2021/22 NHS England invited all seven GDCs to put 
forward a business case for funding for the expansion of clinical capacity or direct patient 
support  as  part  of  a  discretionary  investment  process.  An  additional  investment  of 
£2.2m was set aside for this purpose. Although all this funding was deployed into the 
GDCs by NHS England, some of the funding was directed by the providers to non-
clinical forms of support for patients on the waiting list due to the difficulties in attracting 
clinical staff to work in the service itself. There is clinical opinion that telephone and 
online  support  are  a  useful  service  for  patients  on  the  waiting  list.  We  have  also 
commissioned support resources at Gender Dysphoria Clinics, to include:  

•  Screening at referral so that dedicated Named Professionals can work with 
patients  and  GPs  to  address  complex  needs,  and  for  signposting  to  local 
services and local support groups in less complex cases. 

•  Gender Outreach Workers and Peer Support Workers who meet with patients 

in local community settings. 

•  Advice and support lines delivered by third-sector support organisations. 
•  Pre-Assessment workshops with people on a waiting list, providing them with 
information  on  assessment,  intervention  pathways  and  community-based 
support.  

The Gender Outreach Worker role (referred to above) is being formally evaluated 
by a host Gender Dysphoria Clinic (Leeds and York Partnership NHS Foundation 
Trust) so that learning can be shared across other NHS Gender Dysphoria Clinics 
in 2024/25. The role has a number of potential positive benefits:  

•  Patients  are  signposted  to  local  services  for  support  in  housing  and 
employment, as well as mental and physical health needs – helping to ensure 
that such needs do not go un-met. 

 
 
 
 
 •  Providing  support  at  an  earlier  stage  may  mean  reduced  need  for  primary 
and secondary care services further along the pathway including A&E and 
crisis services. 

•  Patients are better informed and prepared for the process of assessment and 

diagnosis once they are seen by the Gender Dysphoria Clinic 

•  Demands  upon  administrative  and  clinical  staff  are  reduced,  including  the 
need to manage distress, which frees up time for patients in the service. 
•  More tailored support can be offered to patients while on a waiting list, such 
as those who are particularly vulnerable or who may have particular needs 
(age; disability; ethnicity; health needs). 

NHS England’s overall planned spend on all gender dysphoria services (adults and 
children)  in  2023/24  is  £78.17m  –  up  from  £33.4m  in  2018/19,  representing  an 
overall  increase  in  funding  of  134%  in  five  years.  In  2024/25  NHS  England  will 
refresh  the  service  specifications  for  adult  gender  dysphoria  services,  which  will 
include consideration of how to identify and address inefficiencies that may reside 
in  the  way  in  which  GDCs  manage  and  deliver  their  services  and  which  may 
contribute to long waiting times – and how to expand clinical capacity further taking 
the  learning  from  the  pilot  services.  It  is  too  early  in  the  current  year  to  provide 
precise figures for the planned budget for gender dysphoria services in 2024/25 but 
the  figure  given  represents  recurrent  funding  commitments  and  so  should  be 
regarded as the opening baseline figure for planning assumptions. 

2.  Little local support for patients who are waiting for assessment at a GDC 

Our response to concern number one above describes the support that GDCs may 
provide to individuals on the waiting list alongside support from local health systems.  

Commissioning  responsibility  for  local  services  rests  with  Integrated  Care  Boards 
(ICBs) rather than NHS England.  The make-up of local services, and their approach 
to  service  delivery,  training  and  education,  can  differ  according  to  each  ICB’s 
commissioning strategy.  

Generally, NHS England expects local mental health services to have the necessary 
skills, experience and competence to meet the needs of individuals who are on the 
waiting  list  for  gender  dysphoria  services  and  who  have  co-existing  mental  health 
issues and / or personal, family or social complexities in their lives. Local services do 
not need to be expert in the diagnosis of, and response to, gender dysphoria to meet 
these needs, though the need to improve knowledge of the issues facing patients with 
gender  dysphoria  amongst  healthcare  professionals  in  all  healthcare  settings  is 
recognised,  and  to  that  end  there  are  various  training  and  educational  resources 
available to local services and health professionals including: 

•  Training  materials  and  courses  delivered  by  NHS  organisations;  see  for 
example the courses available from the Nottingham Centre for Transgender 
Health  (Nottinghamshire  Healthcare  NHS  Foundation  Trust)  which  include 
courses  on  “understanding  trans  youth”  and  “working  with  trans  people  at  a 
time of crisis”: https://ncth.nhs.uk/training 

 
 
 
 
 •  General  Medical  Council  advice  for  medical  professionals  on  “Trans 
Healthcare”  including  “the  importance  of  providing  good  general  medical 
services to transgender and gender diverse people including supporting their 
https://www.gmc-uk.org/professional-standards/ethical-
mental 
hub/trans-healthcare 

health”: 

•  Professional guidelines such as the British Psychological Society’s guidelines 
for applied psychologists working with gender diverse individuals with mental 
distress,  but  which  may  also  be  applied  by  health  professionals  working  in 
other  disciplines  including  counselling,  nursing,  psychotherapy  and  social 
work: https://explore.bps.org.uk/content/report-guideline/bpsrep.2019.rep129 
•  Various  online  courses  for  GPs  through  the  Royal  College  of  General 
Practitioners  including  “Gender  Variance”  and  “Mental  Health  and  Suicide 
Prevention” 

•  More  specific  to  pathways  of  care  for  gender  dysphoria,  NHS  England 
commissioned the Royal College of Physicians to design and deliver the UK’s 
first accredited post-graduate training course in gender identity healthcare; the 
course began in 2020. Although aimed primarily at health professionals who 
wish  to  specialise  in  gender  identity  healthcare,  individual  modules  are  also 
suitable for other healthcare professionals who work in local settings and who 
wish to improve the experience of individuals with gender dysphoria in using 
generalist services intended for the whole population including mental health 
services  or  primary  care  services:  https://www.rcplondon.ac.uk/education-
practice/courses/gender-identity-healthcare-credentials-gih 
In September 2023 NHS England published online training materials for health 
and education professionals in how to support young people up to 18 years 
with gender distress: https://www.minded.org.uk/catalogue/TileView 

• 

Local Mental Health Provision 

From  a  policy  perspective,  the  NHS  Long  Term  Plan  (LTP)  contains  a  number  of 
commitments  to  expand  access  to  community  mental  health  support  for  those  who 
require it. This includes commitments for 345,000 more young people up to 25 years 
to access to NHS funded support each year by 2023/24. This includes through brand 
new Mental Health Support Teams in schools and colleges. We have seen significant 
increases in the number of young people being supported. Over 732,000 children and 
young people aged up to 18 years accessed NHS support in the year to October 2023. 
This is an increase of 218,000 from the start of the LTP. However, the prevalence of 
mental health need has also increased in recent years, with 20.3% of 8 to 16-year-
olds  having  a  probable  mental  disorder  in  2023,  compared  to  12.5%  in  2017. 
Increasing access remains a challenge despite the increases in young people being 
supported. 

The LTP also committed to delivering a comprehensive offer for 0 to 25 year olds that 
reaches across mental health services for children and young people as well as adult 
services.  Integral to this is improving the care and support given to young adults aged 
18-25,  ending  the  use  of  rigid  age-based  thresholds  which  see  young  people 
automatically  discharged  from  children  and  young  people’s  mental  health  services 
when they reach 18 years of age.  Equally as important is improving the support given 
to young adults within adult mental health services and NHS England is investing an 
additional  £1bn  per  year  in  transforming  community  mental  health  services  so  that 

 
 
 more people with severe mental health problems – including young adults – are able 
to access support within their communities.  The NHS has committed to ensuring that 
by 2023/24 370,000 people (including young adults) will have access support through 
these new models of care. 

3.  Lack of clarity on who is responsible for the wellbeing of the patient during 

the waiting period 

It  is  clear  that  no  individual  healthcare  professional  can  be  deemed  to  hold  clinical 
responsibility  for  a  patient  that  they  have  never  seen  for  the  purpose  of  a  clinical 
consultation. Consequently, the individual healthcare professional that holds clinical 
responsibility for a patient while they remain on the waiting list for a GDC will be the 
patient’s GP, if the patient presents to the GP, or other local healthcare professional 
who  is  involved  in  the  provision  of  care  to  the  individual.  Our  response  above  has 
described some of the various training and support materials that are available to the 
relevant health professionals.  

We  have  also  referenced  the  support  that  GDCs  may  provide  to  individuals  on  the 
waiting list alongside support from local health systems, and, the expected role of local 
services. 

4.  Local mental health services have very little specialist knowledge to support 

a person with gender dysphoria 

Our response above describes that local mental health services should be expected 
to have the skills, experience and competence to meet the needs of individuals who 
are on the waiting list for gender dysphoria services and who have co-existing mental 
health issues and / or personal, family or social complexities in their lives. We have 
also detailed some of the various training and support materials that are available to 
local health professionals; and we have described the expansion of local mental health 
provision through the NHS LTP.   

5.  Guidance on bridging prescriptions 

Your  investigation  found  that  Amarnih  had  sourced  hormone  medication  from  the 
internet.  Although  I  understand  distress  may  manifest  as  a  response  to  the  long 
waiting times for a GDC, and although I have no direct knowledge of the circumstances 
around Amarnih’s own care, the NHS strongly discourages the sourcing of unregulated 
medications.  The  independent  regulator  of  medical  professionals  in  the  United 
Kingdom, the General Medical Council (GMC) has provided guidance to GPs about 
patients  who  are  awaiting  to  be  seen  by  a  GDC  and  who  are  self-medicating: 
https://www.gmc-uk.org/professional-standards/ethical-hub/trans-
healthcare#Prescribing 

In  your  accompanying  letter  to  me  you  asked  that  I  consider  page  3  of  the  GMC 
guidance  that  deals  with  prescribing,  monitoring  and  follow-up  after  gender 
reassignment  treatment.  This  section  of  the  guidance  also  provides  advice  to  GPs 
(and to other relevant medical professionals such as consultant endocrinologists) on 
bridging prescriptions. The GMC explains that the information “is aimed at reassuring 
doctors who wish to prescribe for their transgender and gender diverse patients that it 

 
 
 
 
 
 
 
 wouldn’t be against our guidance to do so, but it does not require doctors who do not 
feel that prescribing would be of overall benefit to a patient to go down a particular 
treatment route”.  It goes on to advise that doctors: 

“.. must work within their limits of their competence; should identify the likely cause of 
the patient’s condition and which treatments are likely to meet their needs; should 
reach agreement with the patient on the proposed treatment, explaining the likely 
benefits, risks and impact, including serious and common side effects; what to do 
in the event of a side effect or recurrence of the condition; how and when to take 
the medicine and how to adjust the dose if necessary; how to use a medical device; 
the  likely  duration  of  treatment;  and  any  relevant  arrangements  for  monitoring, 
follow-up  and  review,  including  further  consultation,  blood  tests  or  other 
investigations, processes for adjusting the type or dose of medicine, and for issuing 
repeat prescriptions”. 

Your investigation found that this guidance was not widely known. It may be helpful to 
know that it is referenced in various professional and regulatory guidelines, including 
the Royal College of General Practitioners’ guidance on “Transgender Care” (2019) 
and also in the Care Quality Commission’s guidance “Adult Trans Care Pathway: what 
CQC Expects from GP Practices” (2022). We note that you have copied your report to 
the  CQC.  GPs  and  other  health  professionals  are  also  signposted  to  the  GMC 
guidance  through  the  various  webpages  hosted  by  the  GDCs,  such  as  that  of  the 
Tavistock and Portman NHS Foundation Trust, which also offers GPs advice through 
a telephone “GP Hormone Advice Line”.  

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

52 Walnut Tree Walk 
London 
SE11 6DN  

T 020 7780 7300 
F 020 7780 7301 

contact-us@together-uk.org 
www.together-uk.org 

Nadia Persaud 
His Majesty's Area Coroner for East London 124 
Queens Road 
Walthamstow London  
E17 8QP 

2nd January 2024 

Dear Ms Persaud,  

Re: Inquest touching upon the death of  Amarnih Louis Lewis-Daniel 

Please  see  below  responses  to  the  questions  that  you  asked  via  letter  on  the  5th  December 
2023. 

1.  Detail of any information sharing protocols that Together has, with associated mental 

health trusts 

Together have separate ISAs in place with NELFT and also ELFT  - attached.  In addition, we have 
the Standard Operating Procedure for Liaison and Diversion (all providers) – attached.  

2.  Any  training  or  guidance  provided  to  Together  staff  in  relation  to  the  need  to  share 

risk information with a patient's NHS treating team. 

The practitioner was an agency member of staff with us through Liquid Personnel.  It states on the 
contract we held with Liquid that 

 is a qualified Social Worker with HCPC registration.   

When  we  recruit  staff  via  agency  for  short  term  assignments  (
  was  initially  for  a  2  month 
period,  and  he  worked  with  us  5  months in total  Dec  20  –  May  21),  we  ensure  staff  come  with  an 
appropriate  qualifications  (such  as  Social  Work  or  Psychology)  which  means  they  will  have  been 
subject  to  risk  management,  information  sharing  and  safeguarding  training  as  part  of  their 
professional training.   

It is Together’s practice that all staff, including agency staff are subject to an induction period led by 
their line manager in which all organisational policies in relation to risk management and information 
sharing, as well as any local protocols are discussed with them to confirm their understanding. We 
seek  to  work  on  a  consent  basis  but  staff  are  all  inducted  to  the  principles  of  defensible  decision 
making, and that they can and must share information with care providers if there is a risk that needs 
to be shared to keep our service user or others safe.   

Staff  will  also  shadow  experienced  Practitioners  during  this  time.    Learning  also  takes  the  form  of 
regular feedback on work undertaken, highlighting best practice and learning, with Service Managers 
reviewing assessments and reports produced by the staff member regularly.   

Due  to  the  short  duration  of  agency  assignments,  Together’s  training  package  relevant  to  the 
question  posed  here  is  not  mandatory,  however  if  a  learning  need  is  identified,  we  can  offer  staff 
online training in Data Protection and Security, Safeguarding Adults (Level 3), Safeguarding Children 
(Level  3),  Recording  Skills  as  well  as  classroom  training  on  Formulation  &  Report  Writing,  Risk 
Management training and Trauma Informed Approach.   

Chief Executive: 
Registered office: 52 Walnut Tree Walk, London, SE11 6DN 
Registered charity no. 211091. Registered in England. 
A company limited by guarantee. Registration no. 463505. 

 
 
 
 
 
 
 
 
 Permanent Together L&D Practitioners also have mandatory Professional Practice Meetings (clinical 
supervision  from  a  qualified  Forensic  Psychologist),  reflective  practice  and  line  management 
supervision  to  which  they  can  take  case  discussions  and  discuss  information  sharing  protocols.  
Depending  on  the Duration  of  their  assignment,  agency  staff  may  be included  to  the PPM  and RP 
sessions but will always have line management supervision in which cases are discussed.  We also 
have an on call Manager available within the CJ team for any on the day queries staff may have in 
relation to cases.   

3.  Is  Together  part  of  the  East  London  Care  Records?  This  is  a  joint  record  platform 
hosted  by  Barts  Health  to  improve  the  continuity  of  care  across  East  London.  If  not 
part of the ELCR, is this something that could be considered? 

We do not have access to the ELCR, we have direct access to SystemOne which allows us to see 
the person’s GP summary care records but not their full medical history.  We have been informed by 
ELFT that access to ELCR is part of the “One London Project”. We would be happy to raise this with 
ELFT and our L&D commissioner to see if it would be appropriate for Together staff to have direct 
access to ELCR and when we can piloted onto the ONE LONDON PROJECT.  

4.  If  a  Together  practitioner  wishes  to  seek  collateral  mental  health  history  about  a 
patient who is known to NELFT, how would they go about doing this? Are there any 
difficulties in accessing medical history from NELFT? 

The way Together L&D staff currently access information from the NELFT CMS (RiO) when we need 
to is via a named Team Administrator who is generally responsive to our requests for information on 
the  same  day.  It  is  unknown  whether 
  was  in  possession  of  information  that  the  Client  had 
previously  been  known  to  NELFT  in  2019,  if  this  information  was  available  to  him,  we  would  have 
expected him to liaise with NELFT in relation to current risk and need.  

With the case in question, the Practitioner ended their assignment with us in May 2021 and their line 
manager  no  longer  works  for  Together.    Based  on  the  entry  to  the  case  management  system  we 
 was compliant with the expectations of the role in the following 
were using at the time (ECase), 
ways: 

• 

• 

• 

• 

• 

  did  attempt  to  offer  an  L&D  service  to  ALL-D  both  when  referred  by  SERCO  staff,  and 

again after the Magistrate expressed their concern. 

 subsequently recorded that ALL-D had declined an L&D assessment on both occasions. 

  attempted  to  contact the  AMHP  service  for  advice  on whether  a  MHAA  needed  to  take 

place.  

  did  not  request  for  the  court  to  use  Paragraph  5.    It  is  not  within  the  remit  for  an  L&D 

Practitioner to do so, The case note indicated that the judiciary made this decision.  

 shared information with the Probation Officer both by phone and email.  

Due to the time passed and that we do not have direct contact with 

 at this time, it is not possible 

 
 
 
 
 
 
 
 to verify if all of the below took place, however the following would be expected practice within the 
L&D role given the circumstances of this case: 

L&D  Practitioner  to  escalate  to  a  Together  manager  and  the  Practitioner  or  Together  Manager  to 
escalate  to  the  AMHP  Manager  if  they  could  not  get  through  to  the  AMHP  service  to  coordinate  a 
MHAA on the day. 

L&D Practitioner to attempt to seek collateral information about this service user.  As we were not on 
SystmOne at the time, the practice would have been for the Practitioner to contact the Clients GP if 
details  were  known,  and to make  enquires  with the  relevant  NHS  trust  to see if  she was  known to 
any  mental  health  teams.    We  know  that  at  times  defendants  are  seen  in  the  court  room  before 
Practitioners  have  received  responses  to  their  enquiries  as  this  is  out  of  our  control.    Practitioners 
are expected to flag with the court (list caller and Judiciary) if they are awaiting/missing information 
relevant to risk and need at the time someone is called to court.  

The Practitioner would have been expected to liaise with the “B+D Mental Health Autistic Service” to 
see what was known about risk and need given the concerns about the Clients presentation at court, 
and  if  concerns  were  sufficient  to  breach  confidentiality,  to  inform  them  of  her  upcoming  court 
appearance at Romford CC in order that she could be offered appropriate support with the process.  
L&D  Practitioner  would  be  expected  to  record  evidence  of  information  sharing  with  the  receiving 
prison about concerns relating to the Clients presentation, and the fact that a MHAA could not take 
place on the first day.   

If you have any further questions please do not hesitate to contact us for further information. 

Yours sincerely, 

Head of Quality Improvement