Tom Sweeting

Lydia Brown  
Acting Senior Coroner for West London  
West London Coroner Service  
25 Bagleys Lane  
Fulham  
London  
SW6 2QA 

Trust Headquarters 
1 Armstrong Way 
Southall  
Middlesex  
UB2 4SD 

06 March 2024 

Dear Madam  

RE: Regulation 28 Report to Prevent Future Deaths- Mr Thomas Sweeting  

I write on behalf of West London NHS Trust in relation to the Prevention of Future Deaths Report 
sent via email on 9th January 2024.  The Trust has now had an opportunity to review the Matters 
of Concern raised.  

I would like to begin by offering my sincere condolences to the family of Mr Sweeting for their 
very  sad  loss.  As  a  Trust  we  have  taken  your  concerns  very  seriously  and  have  sought  to 
address  these  issues  as  quickly  as  possible  to  ensure  lessons  are  learned  to  benefit  other 
patients in the future.  

I, therefore, below respond to each of the matters as they were raised in your correspondence: 

Matters of Concern 

Concern 1 

Mr.  Sweeting  was  assessed  in  relation  to  his  mental  ill  health  presentation  by  the 
Consultant liaison psychiatrist, but the Trust template was not completed, which was not 
in  compliance  with  the  Trust  policy  and  criticised  in  the  Trust  serious  incident  report.  
There is a concerning mismatch of what more junior colleagues are expected to do and 
be trained in, compared with Senior practitioners demonstrated work practises.   

Although  the  Trust’s  review  identified  that  a  risk  assessment  had  taken  place,  this  was  not 
recorded  in  line  with  the  Trust  policy.  We  acknowledge  that  this  was  likely  due  to  service 
pressures in the team on the day and feedback has been provided to the Team involved, and to 
the sister services in our other two boroughs, to improve performance in this area. 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 There  was  a  holistic  assessment  of  Mr  Sweeting’s  needs  and  a  management  plan  which 
considered biological, psychological  and  social interventions  based  on  the  assessment  of  his 
needs at the time.  

The Trust shares your concern about the perceived mismatch between senior practitioners’ work 
practices and expectations  of junior colleagues, and since this incident has confirmed that all 
members of staff received the same training and are expected to adhere to the same policies. 
Whilst it is normal practice in most healthcare settings for certain aspects of documentation and 
assessment to be delegated across the multidisciplinary team, including to trainee doctors, the 
supervising consultant retains responsibility for ensuring adequate supervision. Learning from 
this event has been incorporated into the teaching plan for future trainees rotating through LPS 
settings,  and  will  be  reflected  upon  by  the  senior  practitioners  involved  in  their  monthly 
management meetings and annual appraisal.  

Concern 2 

No  letter  of  discharge  was  sent  at  the  time  Mr.  Sweeting  was  seen  by  the  liaison 
psychiatry  team,  and  a  letter  was  only  generated  in  response  to  investigations  taking 
place after the death.  The team acknowledged that there were “problems” with sending 
out letters at the time, and no evidence was brought before the court that this issue has 
now  been  resolved.    Letters  should  be  dispatched  within  24  hours  of  attendance.  
Communication between the various community teams and setting out the treatment plan 
to the patient are important factors that were not effective during Mr. Sweeting ’s care and 
remain a concerning omission where there may be a simple and effective remedy. 

Following  an  attendance  in  an  Emergency  Department,  where  a  referral  to  the  Psychiatric 
Liaison service is made, two items of correspondence are generated to ensure communication 
with  the patient’s  primary  care  team. The first  is generated  by  and  is the  responsibility  of  the 
acute trust (the Emergency Department), through their electronic records system (Cerner). This 
includes a summary prepared by Emergency Department staff of their assessment and advice. 
All Liaison Psychiatry practitioners have access to this system and ensure a contemporaneous 
note  is  recorded  on  Cerner  which  Emergency  Department  staff  may  incorporate  into  their 
discharge note. The second letter is manually generated by the Liaison Psychiatry team itself, 
and is a specific letter to the General Practitioner (GP) providing a more detailed summary of 
the specific mental health interventions and plan. 

The Trust acknowledges that at the time of this incident in the Hounslow Liaison Psychiatry Team 
there were issues with ensuring that the second (mental health specific) letter was sent to the 
patient’s GP within 24 hours of attendance to Emergency Departments, due to capacity issues 
within the team which resulted in an administrative backlog.  

At the time, the interim solution for this issue was to contact the patient’s general practice by 
telephone to hand over any time-sensitive clinical information, including prescribed medications.  

It was evident during the hearing that there were different accounts of the telephone exchange 
between the junior doctor and the GP. It is documented that the junior doctor spoke with the GP 
to ensure that the information related to Mr Sweeting’s management plan was shared. 

In light of the learning from this incident, the team undertook a formal quality improvement 
project between September 2021 and July 2022 that led to a sustained improvement in the 
quality and efficiency of GP correspondence.  

 
 
 
 
 
 
 
 
 
 
 An automated letter template has been developed, which auto-populates with information 
pulled from the electronic record, to simplify clinicians’ work when completing these letters. A 
more robust GP communication process was implemented to send letters to GP practices via 
secure emails, to eliminate postal delays, with other copies sent by post.  

This project significantly improved the problem of timely GP correspondence, however the risk 
of recurrence is not entirely eliminated. Therefore, in light of this Coroner inquest the service is 
initiating a 3-borough response to fully address on-going systemic obstacles to timely 
communication with primary care. GP correspondence is now monitored by the senior 
management team on a daily basis, is a standing item in the team governance meeting and 
monitored in the service-wide governance meeting. This will constitute the basis of a new 
service-wide tri-borough protocol for GP letters, which the LPS service and Clinical Lead are 
jointly developing as part of our response to this inquest. Since the implementation of the 
protocol, HLPS has achieved 97.1% of letters sent within one working day between 20/02/2024 
and 05/03/2024. This is an improvement from 72.4% compared to the same period last year.  

Concern 3 

It was acknowledged that obtaining collateral information from the family is vital, but in 
this case was delegated to a very junior member of the team who was in the early stages 
of her training.  It should be considered if this task is appropriate to delegate, and if so 
what  information  should  be  sought  from  families/carers  and  how  that  should  be 
effectively used to support patient care. 

The Trust has reviewed this practice, and whilst the collating of collateral information will remain 
an important training task for junior members of staff, that there was a shortfall in supervision in 
this  instance  and  improvements  were  required  in  the  expectation  of  how  the  task  should  be 
undertaken.  To  aid  with  this,  a  secondary  induction  programme  into  the  service  has  been 
introduced for new staff, which sets out how this task will be demonstrated, and observed before 
carried  out  independently  with  supervision.  The  service  has  commissioned  a  piece  of  co-
development  work  with  our  Experts  by  Experience  as  Carers  representatives  to  improve  the 
practices further.   

Concern 4 

The Trust showed good intentions of reviewing the training programme, but were unable 
to evidence that planned 6 monthly audits had actually taken place, and so there was no 
evidence before the court that the new training that had arisen from the serious incident 
findings was effective.  Introducing new training, templates and supervision performance 
appraisals  all  seem  to  be  positive  interventions,  but  in  the  absence  of  any  process  to 
audit their effectiveness, it is concerning that the Trust have no way in which to judge 
their impact. 

The Trust recognises that the purpose of an audit is to learn and understand whether there is a 
gap  in  practice.  However, the Trust  also adopted  developmental programme  and  supervision 
structures to ensure the learning from incidents is embedded.  

 
 
 
 
 
 
 
 
 
 
 
 
 The Trust undertook three audit cycles since April 2023 on assessments following individuals 
presenting to Acute Hospitals with self-harm. This demonstrated that the service is consistently 
meeting the standards put forward by NICE (National Institute for Heath and Care Excellence). 
Since this incident, the service has also completed an external accreditation process led by the 
Royal College of Psychiatrists College Centre for Quality Improvement, known as the Psychiatric 
Liaison  Accreditation  Network  (PLAN).  This  required  validated  assessment  against  multiple 
domains of practice, feedback from staff, referrers, patients and carers, and external peer review 
on the services provided.  

The service governance structures in place to share learning through a Service Line Quality and 
Performance  meeting  into  the  borough  team  based  Clinical  Improvement  Groups  which  are 
documented.  A  quarterly  Mortality  and  Morbidity  meeting  has  been  introduced  for  liaison 
psychiatry teams to reflect on and learn from incidents.  In addition, learning from our incidents 
is now fed  into  an  annual team  development  programme,  in  the form of  a  thematic  review  of 
serious incidents, teaching and a complex case discussion forum. All clinicians receive regular 
clinical supervision which monitors the quality of work individual clinicians conduct. 

I hope that the above information provides you assurance that we have acknowledged and taken 
action  to  address  the concerns  that  you have  raised,  to  reduce  the  risk  of future preventable 
harm  to  our patients. As  a Trust  we  are  committed  continuously  to  improving  our services  to 
address  areas  of  underperformance  related  to  patient  safety,  experience  and  the  delivery  of 
high-quality care.  

Please do not hesitate to contact me should you have any questions or queries. 

Interim Chief Executive Officer