Reece Nelson

IN THE MATTER OF THE INQUEST IN TO THE DEATH OF REECE WILLIAM NELSON 

RESPONSE OF NAVIGO TO THE PDF REPORT DATED 5.12.23  

FROM MARIANNE JOHNSON, HM ASSISTANT CORONER FOR NORTH 

LINCOLNSHIRE AND GRIMSBY 

Introduction 

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This is the response of Navigo to the Regulation 28: Report to Prevent Future Deaths 

(the Report) raised by Marianne Johnson, HM Assistant Coroner for North Lincolnshire 

and  Grimsby,  dated  5  December  2023,  following  the  conclusion  of  an  inquest  on  5 

December  2023  into  the  death  of  Reece  William  Nelson,  who  died  on  28  February 

2022 when he was found hanging from his wardrobe door at his home address. 

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Navigo  Health  and  Social  Care  CIC  (Community  Interest  Company)  provides  NHS 

commissioned  adult,  child  and  adolescent  mental  health  services  in  North  East 

Lincolnshire. 

Issue raised by the Coroner 

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The concern as set out in the Report is: 

On  the  morning  of  Reece  Nelson's  death  his  family  attempted  to  contact  his  Care 

Coordinator due to concerns regarding his mental state. The Care Coordinator was on 

sick leave, however this information was not reported to the family and therefore no 

return  call  was  made  to  them.  Had  the  family  been  made  aware  that  the  Care 

Coordinator was on sick leave they would have tried alternative routes to contact the 

mental health services to seek assistance. 

Response to the Concern 

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The response is as follows: 

4.1 

Navigo would like to convey its sincere condolences concerning the death of Reece 

William Nelson.   

4.2 

Navigo  became  aware  that 

  (Reece  William  Nelson’s  Grandmother) 

dialled  the  mobile  phone  of 

  (Reece  Wilson  Nelson’s  Care-

Coordinator) on the morning of his death, following a conversation on 20 October 2022 

between 

, 

  (Reece  William  Nelson’s  Grandfather)  and 

 (Navigo’s Head of Operational Governance and Quality).  

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 4.2 

Navigo  informed 

  and 

 that  it  would  review  staff  cover 

arrangements  in  its  Community  Mental  Health  and  Wellbeing  Services  Operational 

Policy (‘the Policy’). 

4.3 

Upon reviewing the Policy, the paragraphs below were drafted for inclusion: 

In the event a Care Coordinator rings in sick or any other sickness absence 

period, the Team Leader will go through staff diaries and task admin to phone 

each patient to let them know their worker is off sick, the Team Leader will also 

determine whether alternate support is required in the absence of their Care 

Coordinator. In the event other support is required the Team Leader is to liaise 

with  the  duty  person  to  arrange  this.  The  team  are  to  be  made  aware  and 

relevant  duties  allocated  in  the  morning  huddle  by  the  Team  Leader.  All 

patients will be made aware that they can contact our duty worker for support 

at any time during office hours Monday to Friday 9am to 5pm. The duty worker 

is  able  to  conduct  a  home  visit  where  needed.  Duty  person  to  explain  the 

crisis/out of hour’s process and reiterate to the patient that all relevant crisis 

contact details are found on the patient’s care plan. If the Care Coordinator is 

a nurse and off sick, priority allocation of depots to be covered by other qualified 

nurses. If a patient has a planned home visit, Team Leader to ensure this is 

completed by duty person, Support Worker and or another Care Coordinator.  

For  prolonged  periods  of  sickness  absence,  Team  Leader  will  allocate 

caseload to other Care Coordinators.   

4.4 

The amendments to the Policy as contained in 4.3 above were approved at the Policy 

Group  meeting  on  18  January  2023  and  the  amended  version  of  the  Policy  was 

uploaded to Navigo’s rainmeter on 27 January 2023. 

4.5 

The  Policy  has  since  been  re-written  following  the  Community  Mental  Health 

transformation and alignment with Primary Care Teams and is now entitled Primary 

Care Networks and Community Mental Health Teams Operational Policy (‘the Revised 

Policy’) and the paragraphs read as follows: 

In  the  event  a  Community  Mental  Health  Team member  of  staff telephoning 

sick or any other sickness absence period, the Team Leader will go through 

staff diaries and task admin to phone each patient to let them know their worker 

is off sick.  The Team Leader will also determine whether alternate support is 

required  in  the  absence  of  their  identified  Key  Worker.    In  the  event  other 

support is required the Team Leader is to liaise with the Duty Worker to arrange 

this.    The  team  are  to  be  made  aware  and  relevant  duties  allocated  in  the 

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 morning huddle by the Team Leader.  All patients will be made aware that they 

can contact our Duty Worker for support at any time during office hours Monday 

to Friday 9am to 5pm.  The Duty Worker is able to conduct a home visit where 

needed.  Duty Worker to explain the crisis/out of hours process and reiterate to 

the patient that all relevant crisis contact details are found on the patients care 

plan.    If  the  Care  Co-ordinator  is  a  Nurse  and  off  sick,  priority  allocation  of 

depots  to  be  covered  by  other  qualified  Nurses.    If  a  patient  has  a  planned 

home visit, Team Leader to ensure this is completed by Duty Worker, Support 

Worker  and/or  another  worker.    For  prolonged  periods  of  sickness  absence 

Team Leader will allocate caseload to other workers.    

For  periods  of  annual  leave,  workers  are  responsible  for  ensuring  robust 

planning  takes  place  to  ensure  service  users  and  their  families  receive  the 

correct level of support as per the agreed care plan. 

4.6 

The Revised Policy was approved by the Clinical Governance Committee on 22 March 

2023 and uploaded to Navigo’s rainmeter on 20 June 2023. 

4.7 

The Coroner’s Office sought confirmation, in its e-mail of 18 October 2023, that the 

policy change (concerning cover arrangements) identified in Navigo’s Serious Incident 

Report had been implemented and this was duly provided by Navigo in an e-mail of 

the same date.   

Action proposed by Navigo in response to the concern 

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Navigo will continue to operate in accordance with the Revised Policy and will ensure 

processes to inform both new and existing staff members of the cover arrangements 

remain in place and are audited.   

Voicemail  messages  on  Navigo  work  phones  will  include  contact  details  for  urgent 

assistance.  A communications plan will be developed for its implementation and an 

assurance plan to monitor compliance.  

If the family have any further questions Navigo would be happy to receive them from 

the family and will respond directly to the family. Any further questions can be raised 

by contacting: 

Patient Advice and Liaison Service 

Navigo House 

3-7 Brighowgate 

Grimsby 

North East Lincolnshire 

DN32 0QE 

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 Email: 

Phone:

 (Office hours 9am-5pm Monday to Friday or voicemail) 

Signed 

Position Chief Executive 

Dated 30th January 2024 

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