Jada Monoja

Parliamentary Under Secretary of State for  
Mental Health and Women’s Health Strategy 

39 Victoria Street 
London 
SW1H 0EU 

28 June 2024 

Our Ref: PFD – 24-05-17 - Monoja 

Mr Xavier Mooyaart 
Assistant Coroner, Inner South London  
Southwark Coroner’s Court 
1 Tennis Street, London 
SE1 1YD 

Dear Mr Mooyart, 

Thank you for your Regulation 28 report to prevent future deaths dated 17 May 2024 
about the death of Mr Jada Monoja. I am replying as the Minister with responsibility 
for mental health and patient safety.      

Firstly, I would like to say how saddened I was to read of the circumstances of 
Jada’s death and I offer my sincere condolences to his family and loved ones. The 
circumstances your report describes are concerning and I am grateful to you for 
bringing these matters to my attention.  

Your report raises concerns over how the risk assessment tool on the Trust’s 
Electronic Patient Journey System (EPJS) is used. 

The specific details of your concerns should be addressed in the responses from the 
Oxleas NHS Foundation Trust and NHS England. However, we recognise the issues 
associated with the use of risk assessment tools in the care of people who may be at 
risk of suicide.  The ability of clinicians to identify and manage an individual’s risk of 
suicide is critical to enabling treatment and longer-term support that can help to 
reduce suicidal risk. However, risk assessment tools and scales, used in isolation, 
cannot accurately predict risk of self-harm or suicide and any use of such tools must 
only be as part of a wider, person-centred conversation to best understand and 
assess an individual’s suicidal risk.  

In September 2022 the National Institute for Health and Care Excellence (NICE) 
published updated guidance on Self-harm: assessment, management and 
preventing recurrence (NG225). This states that risk-assessment tools and scales 
should not be used to predict future suicide or repetition of self-harm and should not 
be used to determine who should and should not be offered treatment.  Furthermore, 
NICE’s guidance is clear that the focus of assessments should be on the needs of 
the individual and how to support their immediate and long-term psychological and 
physical safety. 

1 

 
 
 
 
  
 
 
 
 
 
 
 
 
 In September 2023, the 5-year Suicide Prevention Strategy for England was 
published, which included over 130 actions aimed at reducing the suicide rate within 
two and a half years. As part of this, a number of groups were identified for 
consideration for tailored or targeted action at a national level, including people in 
contact with mental health services.  

It is important that culture and practice across mental health services reflects an 
individualised, person-centred approach to safety-planning and risk management, 
and that access to appropriate support is not closed off as a result of assessments of 
risk. One of the key actions set out in the strategy is that NHS England would identify 
opportunities to improve the quality and culture of risk management and safety 
planning within mental health services. The position regarding risk assessments was 
included in wider guidance to improve care standards for mental health inpatients 
published in April 2024 and available at: Culture of care standards for mental health 
inpatient services. The strategy also stated that NHS England would scope and start 
delivery of training and quality improvement programmes.   

I hope this response is helpful. Thank you for bringing these concerns to my 
attention.  

Yours sincerely,

Mr Xavier Mooyaart 
HM Assistant Coroner 
Inner South London Coroner Area  
Southwark Coroner’s Court 
1 Tennis Street 
London  
SE1 1YD 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

25 July 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Mr Jada Monoja who died 
on 17 November 2020  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 May 
2024  concerning  the  death  of  Jada  Monoja  on  17  November  2020.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Jada’s family and loved ones. NHS England are keen to assure 
the  family  and  the  Coroner  that  the  concerns  raised  about  Jada’s  care  have  been 
listened to and reflected upon.   

Your Report raised concerns over the Risk Assessment Tool used in Jada’s case and 
that it was not used in line with Oxleas NHS Foundation Trust (Oxleas) policy.   

One  of  the  key  actions  set  out  in  the  Government’s  Suicide  Prevention  Strategy 
(published on 11 September 2023) was that NHS England would identify opportunities 
to  improve  the  quality  and  culture  of  risk  management  and  safety  planning  within 
mental health services. The position regarding risk assessments was included in the 
NHS  England  guidance  to  improve  the  culture  of  care  for  mental  health  inpatient 
services in April 2024: Culture of care standards for mental health inpatient services.  

The Suicide Prevention Strategy also stated that NHS England would scope and start 
delivery of training and quality improvement programmes. It is important that culture 
and practice across mental health services reflects an individualised, person-centred 
approach  to  safety-planning  and  risk  management,  and  that  access  to  appropriate 
support is not closed off as a result of assessments of risk.  

Following engagement from my London regional colleagues, Oxleas have advised the 
South  East  London  Integrated  Care  Board  that  that  they  designed  a  clinical  risk 
training workshop, for clinicians who work with people with mental health illness, on 
risk assessment and formulation. The training supports teams to apply a personalised 
approach 
formulation  based  on  data  and 
recommendations  from  The  National  Confidential  Inquiry  into  Suicide  and  Safety  in 
Mental Health (NCISH). The training addresses the emerging concerns about over-
reliance  on  risk  assessment  tools  and  risk  rating  in  predicting  suicide  risk,  offering 
important clinical messages for daily practice. Oxleas are also an active participant in 

risk  assessment  and 

risk 

to 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 the Royal College of Psychiatrists’ Culture of Care Programme, which is a programme 
aimed at improving the culture of inpatient mental health, learning disability and autism 
wards so that they are safe, therapeutic and equitable places in which to be cared for. 
I note that you have also addressed your Report to Oxleas, who may be able to provide 
you with further information around your concerns.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Jada, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

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

Switchboard: 

E-mail: 

26th July 2024 

His Majesty’s Coroner 
1 Tennis Street 
London 
SE1 1YD 

For the attention of Assistant Coroner Mooyaart 

By email 

Private & Confidential 

Dear Assistant Coroner Mooyaart 

Re: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS  

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 
Friday 17th May 2024, which you sent following the inquest into the death of Mr J 
Monoja. 

In the report, you raised the following concerns:   

Risk Assessment Tool on the online system (EPJS) is not used in line with Trust 
policy. The detailed indicators informing the risk assessment were not updated.  A 
longer narrative assessment of the patient was instead placed in the patient 
chronology. 

(1) If the risk indicators set out in the tool are not systematically reviewed or 
reconsidered, then the assessment of risk that follows will then be based on 
incomplete and/or out of date, and therefore misleading, information.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (2) Absent the above, and dating of revisions within a compound document, it is not 
clear on what indicators any risk assessment is in fact based. 
(3) To the extent the risk assessment is used as a benchmarking tool, the impression 
given to the most recent viewer is then likely to be incomplete and misleading.  
(4) The potential benefit of using the tool to establish a point of benchmarking/ 
comparison is in any event lost where the compound narrative assessments are not 
clearly dated and signposted (as was the case in this inquest).   
(5) If the detailed patient assessment is instead placed as a new entry in the general 
chronological notes, the usefulness of the risk assessment tool as a clear, well 
signposted, dated assessment and documentation of the patients of risk(s), is lost, 
requiring a reviewer to instead review the general chronological log of entries on the 
EPJS where it is not required to be articulated in the same terms, and may be more 
difficult to identify in a longstanding patient.   

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

As you have noted, following the investigation into this very sad death, the Trust is 
committed to improving our approach to risk assessment, formulation and safety 
planning. To this effect, leads have been appointed to start this work and last month 
the Trust was successful in a bid to be one of the second wave pilot sites to work 
with the National Culture of Care team to adapt our risk assessment and formulation 
tool. The purpose of this is to train staff in current best practice with regards to risk, 
and to embed sustained change in practice across the Trust. This is a major piece of 
work over the next 18 months, with significant service user involvement and using 
quality improvement methodology. Progress will be tracked by regular meetings and 
review of data with the culture of care team. 

It is recognised that at times risk assessment documents are partially updated and 
the communication with regards to risk is of the utmost importance to ensure we 
provide safe and clinically effective care.  

As a result, we will be issuing a blue light bulletin to all clinical staff by Friday 9th 
August 2024 reminding them of the need to ensure risk assessment documents are 
updated at appropriate intervals including at the time of assessment in line with the 
Trust risk assessment policy.  

Teams will ensure this is being completed through regular audits of risk assessments 
on the Trust Audit Systems ‘Tendable’. From June 2024, the Trust has made 
changes to the auditing system of Risk assessments for inpatients, crisis and 
community services to ensure that this is a now stand-alone audit tool to ensure the 
quality and accuracy of risk assessments for patient within our care.  

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.  

Yours sincerely, 

 
 
 
 
 
 
 
 
 Chief Executive 
South London and Maudsley NHS Foundation Trust 

Cc