Mark Kinzley

THE EVERGREEN SURGERY 
26 High Street, Wanstead, London, E11 2AQ 
   Email:  

Tel: 

17 May 2024 

Mr G Irvine 
HM Senior Coroner 
East London 
Walthamstow Coroner’s Court 
Queens Road 
Walthamstow 
E17 8QP 

Dear Mr Irvine, 

Response to Regula-on 28 Report following inquest into the death of Mark Wolfe Kinzley 

We  write  to  acknowledge  receipt  of  the  Regula:on  28  report  ('the  Report’)  dated  26  March  2024 
concerning the tragic death of Mr Mark Wolfe Kinzley. Firstly, we extend our deepest condolences to 
the family of Mr Kinzley.  As a Surgery, we were shocked and saddened to learn of Mr Kinzley's death. 
His death has deeply affected us, and we are commiPed to learning to prevent such tragedies in the 
future.  

Regarding the concerns outlined in the Report, we would like to provide the following clarifica:ons and 
addi:onal ac:ons taken by the Surgery: 

1. 

Appropriateness of the Nursing Home: 

We acknowledge the concerns regarding the suitability of the nursing home for Mr Kinzley's needs. We 
understand that his care needs were assessed by the appropriate agencies and Mr Kinzley consented 
to  the  placement  in  Cambridge  Nursing  Home.  We  wish  to  clarify  that  the  Surgery  does  not  have 
authority over the placement decisions of individuals in nursing homes. Likewise, the Surgery would 
not be involved in the assessment of placement suitability. 

On the 26 October 2023, one of our clinicians, 
any  support  from 
consulta:on, 
Kinzley’s placement needed to be reviewed by the appropriate agencies. 

,  reviewed Mr Kinzley. Mr Kinzley declined 
  at  this  :me  regarding  his  physical  or  mental  health.  AZer  this 
 discussed with the care home nursing staff about considering whether Mr 

 
      
 
 
 
 
 
 
 
 
 
 We  would  like  to  take  this  opportunity  to  assure  you  that  all  our  clinicians  have  appropriate 
safeguarding training and that the Surgery staff would raise safeguarding alerts if there were concerns 
about the care being provided by a care home. 

2. 

Capacity Assessments:  

We  understand  that  this  concern  relates  to  Mr  Kinzley  not  having  a  formal  capacity  assessment 
undertaken and documented and not having the appointment of an advocate.  

Our clinical staff conducted mul:ple assessments of Mr Kinzley's capacity during his interac:ons with 
our  Surgery.  Capacity  assessments  are  ques:on  and  :me  specific.    At  the  :me  of  Mr  Kinzley’s 
assessments by our clinicians, he was deemed to have capacity. There are various decisions that Mr 
Kinzley made regarding his physical and mental health detailed in the medical record. We detail these 
below:  

On 12 Jan 2023 consent was obtained from Mr Kinzley to refer him to the neurology service regarding 
his cerebellar ataxia.  On 27 April 2023, Mr Kinzley consented to a referral to the ‘first fit’ (seizure) clinic. 
On 7 September 2023, the surgery received a request to complete a best interest decision to give Mr 
Kinzley the COVID-19 vaccina:on. This request was received as part of a request for authorisa:on for 
mul:ple residents of the home. One of our clinicians has commented in the medical record at the :me 
that Mr Kinzley had previously refused this vaccina:on and that our clinician felt he had capacity to 
make decisions about this. Our clinician reviewed this with Mr Kinzley on 12 September 2023 and he 
then consented to receiving the COVID-19 and influenza vaccina:on. 

Regarding his mental health, on the 16 March 2023, Mr Kinzley was assessed with regard to anxiety 
and agita:on. He was offered medica:on and he declined this. Similarly, on the 1 August 2023, Mr 
Kinzley was assessed by 
 regarding erra:c behaviour. It was felt that this behaviour could be 
related to anxiety. Mr Kinzley declined any medica:on for this. On the 26 October, he was calm but had 
shown  erra:c  behaviour  in  the  preceding  days.  Mr  Kinzley  declined  any  form  of  support  from  the 
Surgery. At the :me of these consulta:ons, there was no evidence that Mr Kinzley did not have capacity 
to make the decisions he did about his care.  

We have noted that there is no documenta:on that a referral to mental health services was offered. 
We  have  reflected  as  a  Surgery  that  it  is  important  to  document  in  the  medical  record  all  of  the 
management op:ons discussed with a pa:ent. 

At the Surgery’s last consulta:on with Mr Kinzley, 
 was informed by the nursing staff (who 
are also capable of capacity assessments) that Mr Kinzley had capacity. During this consulta:on and 
assessment of Mr Kinzley, there was no indica:on that Mr Kinzley lacked capacity or needed further 
formal assessment of his capacity. 

  2 

 
 
 
 
 
 
 
 
 
 Independent of the Surgery assessments, Mr Kinzley had a Depriva:on of Liberty safeguarding (DOLS) 
assessment (circa July 2023) aZer he was prescribed an emergency medica:on to be used if Mr Kinzley 
had a prolonged seizure. If he did have a seizure, by defini:on, he would not have capacity to make 
decisions  about  his  care  and  this  medica:on  would  be  indicated  in  his  best  interest.  It  is  our 
understanding that the DOLS assessment should include an assessment of capacity to make decisions. 
We remain unaware of this assessment outcome.  

We do consider Mr Kinzley’s past medical history to be significant and in future, we will endeavour to 
encourage pa:ents to follow the medical advice whilst respec:ng their autonomy to make their own 
decisions. We recognise that Mr Kinzley was socially isolated despite living in a nursing home. We agree 
that support from a next of kin or advocate can oZen help pa:ents make decisions about their own 
care. We have taken steps as a prac:ce to iden:fy and help pa:ents who we iden:fy as not having such 
support, which we explain in more detail later. 

This  case  has  been  formally  discussed    with  the  whole  clinical  team  at  a  surgery  wide  clinical 
governance mee:ng on the 23 April 2024. We have a weekly prac:ce mee:ng as a forum to discuss 
cases and pa:ent care. At the governance mee:ng we agreed that clinicians would bring any similar 
cases to the weekly mee:ng to discuss them with the wider team to support gefng a collec:ve opinion 
on the case. Individual cases could also be discussed at the monthly care home mul:disciplinary team 
(MDT) mee:ng that the Surgery is a member of. The care home MDT is a mee:ng between local health 
agencies (GP, Geriatricians, Mental Health Services) and local care homes focusing on learning specific 
to care home pa:ents care and also an opportunity to discuss individual cases.  

We  have  also  agreed  that  in  any  similar  cases  in  future,  we  would  formally  document  the  capacity 
assessment. At our next prac:ce Governance mee:ng (23 July 2024), we are providing an educa:onal 
session to the whole clinical team on capacity assessments, with a par:cular focus on more complex 
capacity assessments. 

3. 

Referral to Mental Health Services: 

Whilst we recognise the importance of mental health assessments and referrals for individuals with a 
history  of  mental  health  issues,  we  emphasise  that  any  referral  to  mental  health  services  in  this 
situa:on would have required Mr. Kinzley's consent. He was deemed to have capacity at the :mes he 
was assessed, and therefore any referral would have been con:ngent upon his willingness to consent 
to such services.  

Following the inquest, our named clinician, Dr Barker, for the care home has made the care staff aware 
that  the  local  mental  health  teams,  also  accept  referrals  from  pa:ents,  carers,  and  other  medical 
professionals, in addi:on to referrals from a GP. This may be appropriate for any future cases as it would 
allow the care home to make a referral without wai:ng for a GP assessment, such as pa:ents with 
fluctua:ng capacity or emergency situa:ons.  

  3 

 
 
 
 
 
 
 
 
 In our wider Surgery prac:ce, we regularly share mental health crisis support details with a pa:ent's 
next of kin or rela:ve, provided we have the pa:ent's consent. Since the inquest, we have updated our 
Surgery text message that we send to pa:ents and their next of kin. Previously, it included informa:on 
about talking therapy services and crisis support. Now, it offers more comprehensive details about the 
various mental health services available in Redbridge and how pa:ents can access them. This updated 
message also serves as a readily accessible reference resource for clinicians when needed. 

We  would  also  like  to  take  this  opportunity  to  highlight  the  following  further  ac:ons  taken  by  our 
Surgery since the inquest: 

• 
Any  new  registered  pa:ent  that  resides  in  a  care  home  already  has  an  ini:al  formal 
comprehensive assessment by our clinician within a week of registra:on. We use the Comprehensive 
Geriatric  Assessment  (CGA)  as  a  template  for  this.  This  is  a  holis:c  assessment  of  the  health  and 
wellbeing of an individual, with formula:on of a care plan addressing any needs iden:fied. We have 
agreed at the Surgery Governance mee:ng that all care home pa:ents at this assessment would also 
be specifically assessed for social isola:on. We have agreed that this would include iden:fying if they 
have a next of kin, rela:ve or someone else they would like to be involved in their care. This will then 
be documented in their care plan. If there is concern around social isola:on, more support could then 
be provided. The support can be tailored to the needs of the individual and this could include referral 
to befriending services (a support program that connects volunteers with individuals who are lonely or 
socially isolated) or more formal advocacy service.  

• 
We have agreed that our Surgery’s social prescriber could be more involved with our care home 
pa:ents. We recognise that this may help to support pa:ents in the future who are iden:fied as being 
socially isolated. Our social prescriber has access to various support services including the befriending 
services men:oned above. 

We  have  contacted  and  arranged  for  VoiceAbility,  who  provide  formal  and  more  general 
• 
advocacy services in Redbridge, to come and speak to the Surgery team about the services they offer 
and how they can help us with the care of our pa:ents.  VoiceAbility are running this training session 
for the Surgery on the 10 June 2024. 

Wider determinants of health – the wider determinants of health are a diverse range of social, 
• 
economic, and environmental factors which influence people’s mental and physical health. The surgery 
has recently started asking newly registered pa:ents for informa:on about this to support the care we 
provide them. We are looking to expand this to all our currently registered pa:ents in the near future. 

• 
We have asked that nursing staff at the nursing home provide the ABC behaviour chart to the 
clinician on the care home round if they have concerns about a pa:ent's behaviour. The ABC behaviour 
chart is an observa:on tool that helps to detail and understand the causes of certain behaviours.  It 
records what happened before, during and aZer episodes of par:cular behaviours. This will allow our 

  4 

 
 
 
 
 
 
 
 
 clinicians  to  have  more  detailed  informa:on  about  any  behaviour  allowing  prompt  assessment  and 
appropriate interven:on. 

• 
We will be sharing this case and our learning with our Primary Care Network (the collec:on of 
11 prac:ces in Wanstead and Woodford) and care home mul:disciplinary mee:ng (MDT) to support 
wider learning and discussion among healthcare professionals. The date of this is not yet confirmed 
but discussions are taking place with the appropriate individuals to facilitate this in the near future. 

In conclusion, we would like to assure you that we take the concerns raised in the report seriously and 
are commiPed to pa:ent safety and providing the best medical care to our pa:ents.  

Please do not hesitate to contact us if you require any further informa:on or clarifica:on about our 
response. 

Yours sincerely, 

, On behalf of the Partners 

The Evergreen Surgery 

  5

Concern raised by
the coroner

Background information and
supportive evidence

Action

By   When

Completed

All adult
placements
are based on
an
assessment
of the
individual’s
needs prior to
placement.

1.

I have doubts
that the
location of Mr
Kinzley’s care
was
appropriate.
Mr Kinzley
was a socially
isolated adult
suffering from
a profound
neurological
disorder and
mental illness.

The Nursing Placement was arranged
and facilitated via the Discharge to
Assess hospital pathway and the
provider identified as suitable to meet
his care and support needs.

Once placed a further review was
undertaken and in Feb 2023, a referral
was completed for an Independent
Mental Capacity Advocate (IMCA) a
Mental Capacity Assessment
completed, and a referral was made to
Occupational Therapy Services.

From our records there are no
concerns raised by the OT, SW or
IMCA relating to the suitability or
otherwise of the placement.

The Local Authority records confirm
that the outcome of the IMCA
involvement (as requested by
Cranbrook and Loxford Locality
HASS) was that it was in Mr Kinzley’s
best interest to remain long-term in his
current placement where he remained
up until his tragic death.

The care home advised that they were
able to continue to meet his needs. Mr
Kinzley stated (as part of his review),
that although he did not want to
remain in his current placement, he
did not want to move anywhere else
and that he is being cared for in his
current place.

Mr Kinzley was scheduled for an
annual Adult Social Care Review in
February 2024 (unless notified by the
care home of any significant changes
in his presentation or care and
treatment needs).

R28 C Merchant 08/05/2024

 Mr Kinzley was formally assessed by
both duly qualified and authorised BIA
and S12 doctor (05/07/2023) following
an application by the Care Home for a
DoLS authorisation given the level of
restrictions placed upon him with his
care and treatment in the
accommodation. Both agreed he
lacked capacity regarding matters
relating to his accommodation, care
and treatment at the care home. A
recommendation was made for the
maximum permissible duration of an
authorisation of 12 months.

As part of the DoLS procedure Mr
Kinzley had access to an advocate
(Independent Mental Capacity
Advocate (IMCA) and the IMCA was
consulted with by the Best Interest
Assessor given Mr Kinzley’s lack of
capacity. The IMCA hereby acting as
his voice regarding considerations of
his best interests regarding
accommodation, care and treatment.

From the enquiries we understand the
Cambridge Nursing home staff
identified that MK was at risk of self-
harm and referred to his GP in
October 2023 following the usual
process.

The Local Authority were not notified
of any changes to Mr Mark Kinzley’s
mental health during his stay at
Cambridge Nursing Home.

2. No formal

assessment of
Mr Kinzley’s
capacity was
undertaken
whilst a
resident at the
nursing home.
Such an
assessment
may have
resulted in an
advocate
acting as his
voice in his
best interests.

3.
During the same
period, Mr Kinzley
was not referred for
a mental health
assessment despite:

a. His history of
mental illness.

b. His history of
deliberate self-harm.

c. His history of
accidental self-harm
when agitated.

d. His deteriorating
mental state during
the month prior to
his death.

R28 C Merchant 08/05/2024

BIA/S12
doctor and
IMCA

Completed

6 months
from date of
submission

The Local
Authority will
deliver
targeted
training to
care providers
regarding
safeguarding,
escalation
processes/an
d risk
identification.

It will be
emphasised
to all
providers that
if there is any
indication
there is
evidence of a
risk of self-

 .

harm or other
harm to
health, that
the Local
Authority is
informed at
the same time
as the health
professionals
and an
appropriate
safeguarding
notification
made to the
First Contact
Team.

R28 C Merchant 08/05/2024