Christopher Larsen

Email: 

  Bridge Park Plaza  
   Bridge Park Road 
Thurmaston 
Leicester 
LE4 8PQ 

Tel: 

www.leicspart.nhs.uk 

Via email c/o 

13th June 2024 

Dear Miss Thistlethwaite 

Christopher Henrik Larsen 

Inquest date: 21st March 2023 & 10th May 2023 

On behalf of the Leicestershire Partnership NHS Trust (‘the Trust’), I am responding 
to  your  Report  to  Prevent  Future  Deaths  (hereafter  “your  Report”)  dated  30  April 
2024 concerning the death of Christopher Henrik Larsen. In advance of responding 
to  the  concerns  raised  in  your  Report,  I  would  like  to  express  my  deepest 
condolences to  Mr Larsen’s family and loved ones. The Trust wishes to assure  the 
Larsen  family  and  HM  Coroner  that  the  concerns  raised  about  his  care  have  been 
listened to, reflected upon and action has been taken as a result.  

I am very sorry that you were required to issue such a report before the completion 
of  the  evidence  in  this  Inquest,  but  I  hope  that  this  response  will  provide  you  with 
assurance that changes have been implemented.  

In your report, you have raised three Matters of Concern: 

1. 

Safe and Well call on the 5th January 2023 

‘The Nurse who undertook the Safe and Well Call on Mr Larsen on 5 January 2023 
did not read his medical records or his referral document before making the call. The 
Nurse accepted that she was therefore not aware of the risks relating to Mr Larsen at 
the time of making the call. She stated that if she had been aware of the risks, she 
would have explored the events prior to the referral, including the suicide attempt, 
and confirmed whether or not Mr Larsen was having suicidal thoughts and whether 

Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ 

 
 
 
 
 
 
  
 
 
 
                
 
 
  
 
 
 
 
   
 
 
 
 
 
          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 he had intent to act on any thoughts he might have been having, during the Safe and 
Well Call.’ 

Regular training, clinical supervision and reflection sessions take place routinely for 
clinical staff, however following this feedback, additional training and reflection 
sessions were undertaken with the nurse, and the line manager of the nurse to fully 
understand the context in this case. A full investigation into the nurses’ practice is 
underway internally; this will include consideration of the appropriateness of an NMC 
referral in line with Trust processes. In the meantime, the nurse is restricted from 
undertaking any nursing shifts within community services within the Trust or as a 
practicing lone qualified member of staff in an inpatient setting until the investigation 
concludes.  

2. 

Current practice around Safe and Well Calls. 

‘The same Nurse advised at the first day of the inquest, which is currently part-heard, 
that she still does not review a patient’s medical records before making a Safe and 
Well Call. Further, the Nurse confirmed that she does not have the time to read the 
whole of the referral document before making the Safe and Well Call, she only has 
enough time to read part of it.’ 

We  understand  and  recognise  that  this  has  occurred  previously  and  as  part  of  our 
ongoing learning we are reviewing all causal factors whilst reminding clinicians of the 
importance  of  reviewing  medical  records  before  taking  any  clinical  decisions. 
team  regarding  professional 
Additional 
responsibility  for  reading  a  clinical  record  before  making  calls  and  taking  clinical 
decisions.  

training  has  been  delivered 

this 

to 

Training and team meetings are important vehicles for us in reminding people of the 
importance of this, and we are also formalising this by updating the Central Access 
Point  Standard  Operating  Procedure  (SOP)  to  be  explicit  that  it  is  the  clinician’s 
responsibility  to  manage  their  own  allocated  work  for  the  shift,  look  through  the 
referrals having  considered  the  patient  record  and  prioritise  the  triage  calls  on  risk, 
urgency and patient availability. 

3. 

Access to risk documentation 

‘Further, and as in the case of Mr Larsen, sometimes patients self-refer to the 
service. On those occasions, the referral documents are populated containing only 
what a patient tells the person completing the document. There may be pertinent and 
important information contained within the medical records relating to risk that is not 
disclosed by the patient, for whatever reason, and does not form part of the referral 
document. In these cases, the failure to read a patient’s medical records can lead to 
important information being missed and possibly important issues not being explored 
by the person making the Safe and Well’. 

As a learning point from the feedback provided, we are reviewing the layout of the 
safe and well template to ensure that this is in a format which makes this as easy as 
possible for call takers to review the information and assess risk and capture 
information from the call. The new template will be co-produced with staff and will be 
signed off by the Information Management and Technology (IM&T) Clinical Safety 
and Improvement Group. 

This will be available within the full electronic patient record (EPR) which the team 
has access to.  

Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ 

 
 
 
 
 
 
 I  trust  that  the  response  outlined  above  provide  assurances  that  the  Leicestershire 
Partnership  NHS  Trust  has  controls  in  place  to  minimise  a  recurrence  of  the 
circumstances around Mr Larsen’s death. 

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 

Chief Executive  

Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ 
Chair: Crishni Waring    Chief Executive: Angela Hillery

Room 100/110 Pen Lloyd 
Building 
County Hall 
Leicester Road 
Glenfield 
Leicestershire 
LE3 8RA 

Tel: 

www.leicspart.nhs.uk  

Ref 

8 August 2024 

Dear Miss Thistlethwaite 

Christopher Henrik Larsen 

Inquest date: 21st March 2024, 10th May 2024, and 13th June 2024 

On  behalf  of  Leicestershire  Partnership  NHS  Trust  (hereafter  ‘the  Trust’),  I  am 
responding to your Report to Prevent Future Deaths (hereafter “your Report”) dated 
13th  June  2024  concerning  the  death  of  Christopher  Henrik  Larsen.  In  advance  of 
responding to the concerns raised in your report, I would like to express my deepest 
condolences to Mr Larsen’s family and loved ones. The Trust wishes to assure the 
Larsen family and HM Assistant Coroner that the concerns raised about his care have 
been listened to, reflected upon and actions have been taken as a result.  

Concern 1: Multi-disciplinary Team (MDT) Meeting 

“I am concerned about the Leicestershire Partnership NHS Trust MDT meetings and 
their  functionality.  Mr  Larsen  was  discussed  at  three  meetings,  at  two  of  the  three 
meetings none of the attendees had met Mr Larsen. It was at an MDT meeting where 
Mr Larsen was deemed to be “low risk” (having initially been deemed to be high risk 
by the Central Access Point), it is not possible to understand why Mr Larsen’s risk was 
downgraded to low risk by the MDT meeting because the MDT meeting documentation 
does not contain that information. The issue of poor documentation relating to MDT 
meetings  and  their  decision  making  is  something  which  could  have  ramifications 
across the whole Trust and also for other bodies who come together to provide care 
for patients. The MDT meeting either misread or misunderstood Mr Larsen’s medical 
records. The notes document that Mr Larsen explained that he had previously placed 

 
 
 
 
 
 
  
 
 
 
 
                
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 a bag over his head and that this remained the way he would end his life, he advised 
that he  could  not  give  assurances  that  he  would  not  try to do  this again.  The  MDT 
documentation however states that Mr Larsen “wrapped plastic bag over his face but 
self-rescued,  does  not  want  to  do  it  again.”  This  is  incorrect.  The  MDT  meeting 
therefore proceeded, and  made decisions  based  upon,  incorrect  information.  There 
were several requests made to MDT meetings for Mr Larsen to have a medic review, 
the  MDT  Regulation  28  –  After  Inquest  Document  Template  Updated  16/05/2023 
deemed this to be unnecessary but there is no documentation explaining the rationale 
of  those  decision.  The  Trust  SI  report  states  that  “it  is  unfortunate  that  he  was  not 
reviewed  by a  medic.”  At  the  second  MDT meeting on 17th  November the  working 
diagnosis in relation to Mr Larsen was an acute stress reaction. This working diagnosis 
was not revisited at the third MDT on 22nd November. The Trust’s SI report states that 
by 17th November there was evidence of a severe depressive disorder, this potential 
diagnosis was not identified or explored by the MDT meeting.” 

As  part  of  immediate  learning  and  action  taken  relating  to  the  concerns  you  have 
raised  directly  about  the  MDT  meeting  and  documentation,  we  have  reviewed  and 
made  substantial  changes  to  the  MDT  template  to  be  used  for  MDT  meetings 
[Appendix 1].  In addition, after engagement with clinical staff and extended reflection 
on the death of Christopher Larsen, we have also implemented a process to provide 
further clarity on the reason for referral into the MDT meeting via pre-MDT sections to 
be completed on the MDT template. This template will be completed by the clinician 
who  had  the  last  clinical  contact  with  the  patient  prior  to  the  MDT  meeting.    The 
information  captured  in  this  template  and  the  reason  for  the  referral  into  the  MDT 
meeting will be discussed with the patient at this clinical contact and will support the 
information captured within the patient’s notes and risk assessment.   

The  MDT  meeting  attendance  has  also  been  reviewed  to  include  a  senior  nurse 
clinician to oversee the process along with medical colleagues and other members of 
the  crisis service.   The  MDT  meeting  will  utilise  the  information  within  the  pre-MDT 
template  and  the  most  recent  Core  assessment,  Risk  assessment  and  the 
contemporaneous  clinical notes  to  inform  the  clinical  discussions.   The  discussions 
within the MDT will be captured in real-time in the MDT template and the outcomes, 
decisions and actions agreed and documented; the MDT template forms part of the 
patient notes and will be immediately available.  The template also enables specific 
actions  and  owners  to  be  captured,  this  includes  responsibility  for  contacting  the 
patient to inform them of the outcome as a follow-up to the clinical consultation which 
prompted  the  referral;  this  also  enables  a  further  opportunity  for  the  clinician  to 
understand if the clinical presentation has changed since the referral was made. 

To provide assurance to the Directorate senior clinical team, audits will be undertaken 
monthly to ensure the processes and documents are being completed fully and to the 
standards expected.  Feedback from the audits will be shared with the staff involved 
via  their  weekly meeting  to  ensure  they are aware  of  areas  requiring  improvement. 
The outcomes of the audit will be reviewed within the Directorate Quality and Safety 
Governance meeting, with evidence of learning shared; this will be monitored monthly.  
In  addition,  the  Chief  Nurse  and  Medical  Director  will  review  the  audits,  sample  of 
decisions  and  outcomes  of  the  new  process  in  six  months  to  provide  additional 
assurance and scrutiny. 

 
 
 
 
 The process was implemented on 08 July 2024 and the outcome of the first audit is 
due to go to the Directorate Quality and Safety meeting on the 22 August 2024. 

In addition to the above, there is an opportunity for key clinical discussions to be held 
in  daily  team  debriefs  based  on  clinical  need;  the  outcomes  of  which  will  be 
documented in the patient notes and discussed with the patient if required.  

The Crisis Resolution Home Treatment Team Standard Operating Procedure (SOP) 
[Appendix  2]  has  also  been  reviewed  and  amended  to  clearly  explain  all  these 
processes  for  our  staff  and  includes  specific  guidance  on  how  to  identify  when  a 
medical review should  be  considered/offered  as  this is not  required  for all  patients. 
The revised SOP was agreed on 24 July 2024 and was circulated to all staff via email 
on 25 July 2024; it was also shared in team meetings which take place weekly.  Staff 
have  been  required  to  sign  a  confirmation  that  they  have  read  and  understand  the 
SOP and the new process.  

Concern 2: Risk Assessment 

“At his initial triage (undertaken by the Central Access Point) Mr Larsen was deemed 
to be high risk. At a later MDT meeting Mr Larsen was deemed to be low risk. It is not 
possible to explore the rationale behind the downgrading of Mr Larsen’s risk to low 
because there is no documentation about the decision making. The Trust’s SI report 
identified the fact that several “red flag” risk factors which applied to Mr Larsen were 
not “robustly considered” when assessing Mr Larsen’s risk. The Trust’s SI report states 
that it was “unclear why it was felt the risks had subsided by the time of discharge on 
3.12.2022.” 

Clinical risk assessment is a dynamic process undertaken by clinicians when they are 
with  the  patient,  considering  all  information  relating  to  a  patient  with  the  view  of 
assessing  the  likelihood  of  the patient  acting  in  a manner which may  be  harmful to 
themselves and/or others. Part of a clinical risk assessment includes the consideration 
of  risk  factors.  Risk  formulation  as  part  of  the  risk  assessment  brings  together  an 
understanding  of  personality,  history,  current  mental  state,  environment,  potential 
causes and protective factors, or changes in any of these. If there are indicators which 
would indicate the presence of increased risk factors, then these will be explored on a 
case-by-case basis by the assessing clinician.  

The risk assessment undertaken by the clinician presenting a case to the MDT, forms 
part  of  the  information  considered  by  the  MDT  in  accordance  with  NICE  [NG225] 
guidelines which state that decisions about care should not be made based on risk 
assessment tools and should be based on clinical formulation. Additionally, they state 
that the forementioned 'red flag' risk factors alone do not indicate the likelihood of self-
harm  or  suicide  amongst  the  patients  under  crisis  (who  by  the  nature  of  their 
presentation, would all be deemed at a higher level of risk than those in the general 
population).    The  MDT  considers  the  clinicians  assessment  of  risk  at  the  time  of 
assessment.  When  the  outcome  of  the  MDT  is  shared  with  the  patient,  it  offers  a 
further  opportunity  for  the  clinician  to  assess  whether  the  risk  presentation  has 
changed from the previous assessment. 

 
 
 
 
 As the assessment of risk is a key component to the effectiveness of the clinicians 
working  within  the  Crisis  team,  the  Trust  is  completing  a  review of  our  competency 
framework and the audit tool to support the monitoring of robust documentation of risk 
assessment/formulation.  This  review  was  completed  on  02  August  2024.  The 
outcomes  of  the  review  will  be  presented  to  the  Urgent  Care  Quality  and  Safety 
Meeting on the 22 August 2024 to inform any required changes.  

Concern 3: Discharge 

“Mr Larsen was discharged from the care of LPT on 3 December 2022, there was no 
planned support for Mr Larsen post-discharge other than some counselling which was 
due to start three weeks later. The Trust’s SI report states that it is “unclear why it was 
felt the risks had subsided by the time of discharge on 3.12.2022” and that Mr Larsen 
had the “presence of ample markers for high risk of completed suicide” yet he was 
discharged back to the care of his GP and into a lacuna of care with no pre-arranged 
support other than counselling which would not commence for three weeks.” 

The  Crisis  Resolution  Home  Treatment  Team  is  a  short-term,  needs-based 
intervention  service  whose  primary  role  is  to  mitigate  the  requirement  for  inpatient 
admission  to  an  acute  mental  health  hospital  setting.  Patients  are  referred  into  the 
service for intensive home treatment from a variety of different settings, including both 
primary and secondary care. For a substantial number of patients who have received 
care  from  the  team,  a  referral  into  secondary  care  is  not  clinically  appropriate  or 
indicated. Many patients are subsequently discharged back to primary care following 
the  formulation  of  a  clear  crisis  and  contingency  plan  which  is  formulated  in 
collaboration with the patient (and carers where applicable).  

A  crisis  and  contingency  plan  includes  information  about  how,  where  and  when  a 
patient can seek support for their mental health should the need arise, including the 
identification of 24-hour access to mental health support via the Urgent Care Pathway 
within LPT (set up in line with the requirements set out by NHS England Five Year 
Forward View (2014), the NHS England Long Term Plan (2019) and the Crisis Care 
Concordat (2014) which state that people with mental health problems should be able 
to get help 24 hours per day before they get to crisis point.  

At the point of discharge from the Crisis Team, the decision is discussed and explained 
to the patient and a discharge letter is formulated which outlines the care a patient has 
received,  alongside  any  changes  to  their  medication  and  a  copy  of  their  crisis  and 
contingency plan. Additionally, within the discharge meeting with the patient their risk 
assessment is formally updated on their records to accurately capture any significant 
changes to their risk profile and clinical formulation both whilst under the care of the 
team and at the point of discharge. 

The Crisis Resolution Home Treatment Team’s SOP states that all patients will only 
be discharged following an MDT discussion. Should a patient request early discharge 
(earlier than planned) from the team, the case will be escalated to a CRHT consultant 
and/or the Duty Team Lead. At this point, the patient’s care and clinical presentation 
(including  risk  formulation)  will  be  considered,  and  a  decision  about  discharge  (or 
escalation of care) will be made and documented in the patient’s notes. It is important 
to note that should it be felt following a clinical review of presentation that there is an 

 
 
 
 
 
 increased  likelihood  of  a  patient  acting  in  a  manner  which  may  cause  harm  to 
themselves and/or others if they were to be discharged early from the team, then care 
would be escalated depending on urgency at this point. Examples of this may include 
the  consideration  of  a  formal  Mental  Health  Act  Assessment  or  escalation  to 
emergency services for immediate risk concerns. 

Concern 4: The Serious Investigation (SI) and Reporting Process at LPT 

“I  remain  concerned  about  inadequacies  in  the  Serious  Incident  Investigation  and 
Reporting processes at Leicestershire Partnership NHS Trust. The Serious Incident 
Investigation into Mr Larsen’s death did uncover and accepted some failings in relation 
to the care provided to Mr Larsen. However, it failed to uncover all the matters arising 
at inquest and, some of the matters that it did uncover do not have correlating items 
of  work  listed  in  the  action  plan.  There  was  no  exploration  of  the  MDT  meeting’s 
functionality or documentation as part of the SI investigation. Further, I have concerns 
about the implementation and embedding of the lessons learned which are identified 
by the SI Report. In this case the live witnesses who gave evidence during the course 
of the inquest did not demonstrate that learning had filtered down to the front-line staff. 
I am therefore concerned that the SI process at LPT does not support a robust and 
critical  analysis  and  investigation  of  the  care  provided  to  patients,  further,  I  have 
concerns about the ability of the Trust to embed changes and learning. This failure to 
properly explore matters and learn where possible inevitably leads to a delay, or failure 
altogether, to learn lessons which are vital to patient safety across the whole Trust.” 

We  take  learning  form  serious  incidents  very  seriously  and  have  taken  on  board 
feedback  provided  relating  to  the  processes  within  the  Trust.    All  serious  incident 
reports  are  reviewed  by  the  Medical  Director  and  Chief  Nurse  to  ensure  that  they 
provide a critical analysis and investigation of the care provided to patients.  We also 
recognise  that  the  transition  to  the  new  National  Patient  Safety  Incident  Response 
Framework (PSIRF) has taken time to embed.  Feedback from the new PSIRF process 
has  been  positive  from  families  and  clinicians.  In  order  to  make  the  process  more 
robust  a  rapid  improvement  programme  is  underway  to  utilise  quality  improvement 
methodology to identify any improvements which can be made to the process. 

In  addition,  the  Director  of  Nursing  and  the  Medical  Director  have  initiated  quality 
summits that have focussed on safety, leadership, and governance within the crisis 
pathway.  The  summits  have  been  a  collaborative  space  involving  leaders and  staff 
within the service to ensure accountability and learning. 

I trust that the proposed actions that we have described above do collectively provide 
assurance  that  the  Leicestershire  Partnership  NHS  Trust  is  taking  a  number  of 
immediate measures to respond to the concerns set out by HM Coroner in her Report. 

 
 
 
 
 
 
 
 
 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 

Chief Executive  

Enc  
Appendix 1 MDT template 
Appendix 2 The Crisis Resolution Home Treatment Team Standard Operating Procedure 
(SOP)