Michael Hindes

Chief Executive’s Office 
South West London and St George’s Mental Health NHS Trust 
Trinity Building 

Springfield University Hospital   
15 Springfield Drive   
London SW17 0YF 

19 December 2023 

Private & Confidential 

ME Hassell 
Senior Coroner for Inner West London 
West London Coroner Service 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

Dear Madam 

Our Reference: 

Re: Regulation 28 Report to Prevent Future Deaths – Mr Michael Joseph HINDES 

I  am  writing  to  you  following  receipt  of  the  Regulation  28:  Report  to  Prevent  Future 
Deaths (PFD) dated 20 October 2023, which was issued to the Trust on 13 December 
2023, regarding the sad death of Mr Michael Hindes, who died on 15 May 2023. 

You have requested that South West London and St George’s Mental Health NHS Trust 
(SWLStG)  respond  to  the  matters  of  concern  that  you  have  detailed  in  your 
correspondence.  

I have included your Matters of Concern below and our subsequent response.  

The MATTERS OF CONCERN are as follows:  

‘When Michael was taken to St George’s Hospital, he explained that he had been back 
and forth from the railway station, each time for the purpose of jumping in front of a train.  
He  was  discharged  with  a  plan  for  follow  up  by  the  community  mental  health  team 
(CMHT). I was told that the local CMHT meets at the beginning of every week, and then 
there is sometimes a delay before an appointment is made, so it was likely that Michael 
would have to wait an absolute minimum of a week to be seen.  

In the meantime, it was not thought necessary to refer him to the crisis team.  

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Michael’s  family  knew  nothing  of  his  mental  ill  health.  He  declined  an  invitation  by  the 
nurse  assessing  him  to  contact  them.  He  did  not  want  to  worry  them.  Despite  her 
awareness of the multiple therapeutic benefits of the input of a patient’s loved ones, the 
assessing nurse did not in any way try to persuade Michael to allow her to do this. 

The first that Michael’s family heard of Michael’s mental ill health was when they heard of 
his death. I am sure that, had they been made aware of it while he was still alive, they 
would have done everything in their power to support him and to engage with the mental 
health services. 

Families very often complain to me at inquest that mental health services have not done 
enough  to  try  to  bring  them  in  to  a  patient’s  care.  In  spite  of  the  frequency  of  this 
occurrence, the lesson does not seem to be being learnt. 

When you respond to this letter, I should be grateful to know not just what you have done 
to  address  the  issue  in  your  own  trust,  but  also  what  you  have  done  to  raise  national 
awareness.’ 

As you are aware through the Inquest, the clinical risk assessment undertaken at the 
time by the assessing nurse in the Psychiatric Liaison Team deemed the patient to be 
of low risk of self-harm and that he was suitable to be discharged home. In addition, with 
a  routine  referral  to  the  Community  Mental  Health  Team  (CMHT)  for  ongoing 
diagnosis/further assessment, as crisis services were not required at that time.  

The  clinical  assessment  clearly  concluded  that  the  patient  had  capacity  to  make 
decisions and the assessing nurse was of the firm view that he was clear that he did not 
consent  to  information  being  shared  with  his  family  around  his  mental  health  and 
struggles.     

In these circumstances it would therefore have been unlawful not to respect the patient’s 
decision  and  there  is  a  delicate  balance  around  applying  persuasion  and  respecting 
someone’s  rights  and  decisions.    However,  we  recognise  we  should  have  sought  to 
explore his decision further and to  relay the typical benefits of support that can come 
from  positive  family  engagement  and  awareness,  or  explored  other  support  options, 
such  as  reaching  out  to  a  close  friend.      We  also  absolutely  recognise  that  our 
documentation around this area was not sufficient.  

We  agree  with  your  general  view  that  challenges  remain  and  there  is  a  need  for 
improvements  around  how  to  best  ensure  positive  engagement  and  sharing  of 
information  between  the  healthcare  provider,  patients,  and  their  families  and  carers.     
We are committed to the national ‘Triangle of Care’ initiative that champions the bringing 
together  of  carers  and  relatives,  service  users  and  professionals.  It  aims  to 
promote safety,  aid recovery,  and  sustain  the  wellbeing  of people  with  mental  health 
issues and their carers and families.  This remains a key area of focus for the Trust.  The 
Psychiatric  Liaison  Team  continue  to  reflect  on  this  and  will  be  changing  their  local 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 protocols to strengthen the prompts to help remind clinicians how best to approach this 
subject with patients.  

As  per  your  request  with  the  PFD  to  raise  awareness  of  this  area,  we  will  take  the 
opportunity to raise awareness within the Trust via a specific newsletter article issued to 
Trust staff (known as our Monthly Learning Bulletin) to remind and promote how and 
when to best ensure there are meaningful conversations with patients around sharing 
information with families.  This will focus on the Triangle of Care approach and provide 
clarity around the delicate balance between encouraging patients whilst respecting their 
wishes and ensuring this is clearly documented.  This will be developed and issued by 
March 2024.  

We will share this and our response to the PFD with the CQC and our Commissioners 
(Integrated  Care  System)  as  per  your  wish  to  help  contribute  to  improving  greater 
awareness of this area.  

We thank you for your consideration and commitment to prevention of future deaths and 
helping us and the wider NHS to learn.   

I would like to express our deep sympathy to the family and friends of Mr Michael Hindes 
for  their  loss.  While  we  seek  to  learn  from  this  incident,  I  recognise  that  this  cannot 
diminish their pain and anguish.  

The Trust remains committed to continuous learning and improvement and we are 
very grateful for all those involved in this Inquest.   

Yours faithfully 

Director of Nursing and Quality, on behalf of 

, Chief Executive 

CC – 

, Medical Director, SWLStG