Jacqueline Cobain

South London and Maudsley NHS Foundation Trust 
Maudsley Hospital 
Denmark Hill 
London, SE5 8AZ 

17th May 2024 

Ms Michelle Haste 
Assistant Coroner for Inner London 
South 
London Inner South Coroner’s Court 
1 Tennis Street 
London  
SE1 1YD 

Private & Confidential 

Dear Ms Haste 

Re: Regulation 28 Report to Prevent Future Deaths  

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 25th March 2024, 
which you sent following the inquest into the death of Ms Cobain.  

In the report, you raised the following concerns:   

1.  When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by 
email on Saturday 4 September 2021, the system nevertheless generated an automatic 
questionnaire which is normally sent 24 hours prior to a scheduled assessment 
appointment. The system had not recognised that Mrs Cobain had cancelled her 
appointment. She completed the questionnaire. 

2.  Mrs Cobain’s responses to the questionnaire contained what were accepted to be 

concerning responses 

3.  Due to the cancellation the questionnaire was not reviewed by a clinician until after Mrs 

Cobain’s sad death 

4.  Changes have been made to the protocols around cancellation and language has been added 

to the assessment template 

5.  However, there is no system or protocol to alert a clinician to review concerning responses 

and to consider appropriate next steps, where (outside the usual protocol and time frame of 
submission and review within 24 hours of the assessment appointment) the patient has 
completed the questionnaire, and for whatever reason, the assessment appointment with 
the clinician is not for a period of several days/weeks as was the case in Mrs Cobain’s case.  

The trust’s response to these concerns is as follows: 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Mrs Cobain completed a number of short questionnaires. 
The questionnaire completed by Mrs Cobain which has 
caused some concern was the Patient Health Questionnaire-
9. This is a measure used to give an indication of possible symptoms of depression experienced by an 
individual over the past two weeks. It is not a diagnostic tool nor is it a risk assessment. The 
questions are intended only to help inform and structure an in-person assessment. They are also 
used to provide a quantitative baseline against which progress in later treatment can be measured. 
Clinical research indicates that these types of measures have no predictive value as an assessment of 
suicidality and, indeed, recently published NICE guidance confirms that they must not be used in this 
way.  

The question of concern asks about the frequency of “thoughts that you would be better off dead or 
harming yourself in some way”. It is important to note that a high percentage of patients self-
referring to a Talking Therapies Service with depressed mood will score similarly to Mrs Cobain on 
this question. Whilst this may be indicative of depressed mood, it is not predictive of suicidal 
ideation or behaviour. Most people scoring above 0 on this question will not report active suicidal 
plans when seen for an in-person risk assessment.  

As you have noted, following the investigation into this very sad death, our Talking Therapies 
Services have made some changes to practices around these questionnaires. Our patient record 
system, IAPTUS, sends these questionnaires out in advance of an assessment appointment 
automatically via a webform. The use of these questionnaires as part of assessment is a nationally 
mandated requirement for all Talking Therapies Services. Patients receiving this webform from our 
Talking Therapies Services now receive a message which states the following:  

This facility is provided in the knowledge that questionnaires are an aid to monitoring your progress 
prior to an appointment with a clinician. It is not intended to be used to convey direct messages to 
clinical staff or gain access to urgent support. These measures will only be viewed at the time of your 
appointment. 

TO SEEK URGENT HELP IN A MENTAL HEALTH CRISIS 
If you feel at risk of hurting yourself or someone else, you should 

·        contact your GP 
•  or go to your local A&E at St Thomas' Hospital or King's College Hospital 
•  or call the SLAM 24 hour information line on 0800 731 2864 for further advice 
• 

if you are experiencing feelings of distress or despair organisations such as The Samaritans 
tel: 116 123 can also be contacted at any time. 

This message now makes it very clear that the service does not provide urgent help in an emergency 
and gives advice as to how this type of help can be accessed. Information around how to access 
urgent or emergency help is repeatedly provided to patients including at the time of booking an 
appointment and with appointment confirmation documents.  

Mrs Cobain contacted the team by email to cancel and request to rebook her original assessment 
appointment on a Saturday giving the explanation that she had had a family emergency. Her 
message was picked up by the administrative team on the Monday morning and the appointment 
cancelled on the IAPTUS system. As the system is configured to send out webforms automatically 24 
hours prior to an appointment the questionnaire had already been sent to Mrs Cobain on the 
Sunday. Talking Therapies teams are not currently commissioned to be open at weekends in line 
with most non-emergency, primary care services.  

 
 
 
 
 
 
 
 
 In a primary care service such as Talking Therapies 
Southwark, it is important and appropriate that we respect 
the autonomy of our patients and their ability to make 
decisions about their engagement with treatment. Where someone gives a good explanation for a 
cancellation and makes a request to rebook it would be considered clinically reasonable to honour 
this without chasing the patient particularly given that patients are provided with advice as to how 
to contact urgent help if needed.  

In an average month, the Talking Therapies Southwark Service receives between 1100 and 1200 
referrals and carries out approximately 800 assessments. In line with most primary care services, 
they have a relatively high rate of patient cancellations. In an extremely busy service such as this, 
resources are structured carefully to ensure first assessment appointments are offered as quickly as 
possible. As we have noted, scores such as Mrs Cobain’s on the PHQ-9 are common in self-referring 
patients and most will not be presenting with high risk. If the service were to follow up by telephone 
every cancelled appointment, this would have an inevitable impact on the speed with which 
assessment appointments could be offered. An increase in assessment waits would, we know from 
clinical experience, be more likely to increase risk to our population. We believe, therefore, that the 
balance of risk is better served by us continuing to focus resources in the way that we do and not in 
developing a new protocol to automatically follow up cancelled appointments as suggested.  

I hope that this response addresses the concerns which you have raised and explains why the trust 
has chosen to take the steps it has. I thank you for bringing these issues to our attention.  

Best wishes 

Chief Executive 
South London and Maudsley NHS Foundation Trust