Danny Anderson

19 September 2024 

Private and Confidential - By Email Only   

Miss Nadia Persaud 
HM Area Coroner for East London  
Coroner’s Court   
124 Queens Road  
Walthamstow   
E17 8QP 

Dear Miss Persaud, 

Danny Jay Anderson (RIP) 

Chief Executive Office
The Lodge 
Lodge Approach 
Wickford 
SS11 7XX 
           Tel: 0300 123 0808 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of 
the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013, dated 25th July 2024 in respect of the above, which was issued following the 
inquest into the death of Danny Jay Anderson (RIP). 

I would like to begin by extending my deepest condolences to Danny’s family on behalf of the Trust. 

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed.  I 
will now respond in full to these concerns in the hope that this provides both yourself and Danny’s 
family with comprehensive assurance of changes that have been made at the Trust to address the 
concerns you have raised. For ease of reference, I have added numbering to the concerns raised: 

Concern a)  

There was no evidence of any adequate formulation of risk prior to Danny’s discharge from hospital 
on the 14 December 2022 and no evidence of any adequate risk formulation prior to Danny’s 
discharge from the community mental health team in January 2023.  

Response: 

The Trust have made improvements, at pace in respect of the processes for formulation of risk on 
discharge with the implementation of discharge steps developed by the Trust Patient Flow Team.  
There has also been a change in practice to ensure we hold a discharge planning meeting with the 
Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and 
matrons join discharge meetings to ensure a collaborative approach.  

Improvements have also been made to the joint partnership working with community teams for all 
patients, part of this change encouraging transparent conversations, including with friends/family, to 
ensure risks are identified and mitigated 

The Trust recognises that there was confusion around responsibilities of the named nurse, which 
includes risk assessment and formulating risks including plan at point of discharge.  The Trust 
Quality Matron for Fundamentals of Care is leading on an improvement project looking at processes 
for the named nurse which aims to ensure there is consistent understanding of the named nurse role 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
      
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
    
     
            
       
 
 
 
 
 
 
 
 
 
 
 
 
 and responsibility across all inpatient wards and will include the review of the Trust named nurse 
guidelines.   

The organisations recognises that the quality of the narrative used in risk assessment is essential for 
staff to understand risk.  This will always be dependent on the staff member completing this.  The 
Trust has clinical risk assessment training in place and a clinical risk policy to guide staff.  For 
ongoing support the Trust has implemented review of risk assessments and documentation 
completed as part of staff members’ clinical supervision, this enables discussion and immediate 
learning support for each staff member. 

The Trust is on an ongoing journey for improved documentation, which has included training 
sessions and a specific focus on this within supervision reviews.  Work has been undertaken to 
update the discharge letter template to include discharge planning prompts and the incorporation of 
carer involvement in the Care Programme Approach review documentation. Discharge letters have 
been reviewed by the Service User Network Group to review content and tone of correspondence.   

Additional training has been undertaken Trust wide in Community Mental Health Teams to support 
enhanced transition care planning. 

Concern b)  

The statement “Danny does not present with any suicidal ideation or self-harming behaviour“ was 
copied and pasted multiple times throughout the risk assessment template on the 14 December 
2022. There was no analysis or formulation of risk for Danny. 

Response: 

The Trust recognises that copying and pasting and the quality of documentation continues to be an 
area for improvement.  A number of improvement initiatives have been completed including copying 
and pasting safety alert being issued, enhanced documentation training and having a robust 
process in place which ensures records auditing (including checking for copying and pasting), where 
this is found the staff member is contacted and asked to complete a reflective piece.  

Our next steps on this improvement journey is the roll out of the new inpatient operating model 
which will include quality focus on key learning areas including copying and pasting and focus on the 
expectations of roles and responsibilities. 

A professional standard of record keeping is part of qualified staff professional registration.  The 
Trust expects that this standard of record keeping is met by all staff; again this is reviewed and 
discussed as part of supervision review meetings directly with staff. 

We are taking action to further strengthen response when staff are found to have copied and pasted 
in patient records and are exploring options with Human Resources. 

Concern c)  

From review of the records throughout the admission, I am concerned that there was an over-
reliance upon Danny’s answer to questions posed about suicidal ideation and intent. At the point of 
discharge, there was no evidence of information gathering around Danny’s mental state, behaviour, 
psychiatric history, history of abuse, social situation – and evidence that this information was used to 
form a judgment about the likelihood or probability of an adverse or harmful outcome (in accordance 
with the Trust’s risk policy).  

Response: 

The Trust has established a new oversight system to enable managers to identify any gaps in risk 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 formulation and crisis summary.  This is part of a clinical dashboard which shows if these key parts 
are missing.  This dashboard is available to staff and is reviewed by the nurse in charge and ward 
manager to ensure any gaps can be addressed. 

As part of all staff one to ones, supervisors work with inpatient named nurses/ community care 
coordinators reviewing their care plans and risk assessment to check quality of the clinical entries. 

There is medical oversight at point of discharge from inpatient services and this feeds into discharge 
summaries 

In addition the Trust has clinical audit processes which include a record keeping audit and a 
‘matron’s records audit’ which includes review of risk formulation and crisis summary.  Audit results 
are taken back to staff and highlighted through discussed in team meetings. The audit process has 
been reviewed and the Trust now has a person centred audit undertaken were possible with the 
names nurse to review an individual’s care and documentation thereafter.  

Within Trust community teams, key information is included in the discharge Care Programme 
Approach (CPA) review. 

The Trust has two main electronic records systems for mental health services (Mobius/Paris) means 
that information can be recorded in two difference places.  To enable staff in information gathering 
across the two systems the trust has implemented the Health Information Exchange (HIE) to provide 
one place for staff to review key information. 

There are further plans to move to one central electronic records system as part of the Trust digital 
strategy which will further enhance the records systems.  

The Trust is seeking further improvements in this area through the new operating model which 
reinforces safe discharge. The operating model launch date commences on the 26th September 
2024 and will be underpinned by a series of standard operating procedures co designed with staff. 

Concern d)  

There was no evidence of any consideration of Danny’s historical factors and experiences, more 
recent problems and existing strengths and resources (in accordance with the NICE guidelines 
2022).  

Response: 

The Trust has implemented a new processes of 1:1 engagement forms that are completed daily with 
each patient.  

Trust care plans have been improved to ensure they are personalised and historic factors, 
experiences and risks are pulled through into care planning. 

The Trust is transforming its approach to providing trauma informed care which aims to create a 
fundamental paradigm shift to considering what has happened to a person rather than what is wrong 
with a person. 

Strong and consistent family and carer engagement is essential for the Trust, as this supports 
understanding of historical risks.  This is being encouraged through the new operating model with 
engagement throughout admission and at discharge.   

The Trust has recently launched a programme for quality of care; focusing on the key element of 
safety, effectiveness and experience. This programme has important Trust wide quality priorities, 
one of which is suicide prevention, one of the current year’s focus areas is enhancing the training 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and development of our staff with the new Skills Training on Risk Management (STORM) training. 
This is an evidence-based training methodology given to frontline team members who have the 
opportunity to practice, reflect, and give and receive feedback on skills in a safe and supportive 
learning environment. It uses the highest standard level of skills development, which includes filmed 
skills practice for the more advanced courses. The focus is on the person, collaboration, 
assessment, and safety planning, and they are joined by new skill sets including Suicide and self-
harm – exploring the similarities and differences for assessment.  We aim to have 60% of all 
registered practitioners across all urgent care pathways trained by end of 2024.  Achievement of this 
training roll out is over seen by the Trust’s suicide prevention quality priority group. In addition, the 
Trust’s transformation programme ‘Time To Care’ has recognised the importance of enhancing 
clinical education within the clinical environment and has therefore invested in the introduction of six 
Professional Nurse Educators; this role has been developed for our in inpatient mental health wards 
following a national pilot of the role  

The ‘Time to Care’ programme involves a complete transformation of the way in which we operate 
our mental health inpatient wards, with the overriding aim to free up more clinical time to spend on 
direct patient care. The Time to Care Programme has redesigned how we deliver inpatient mental 
health services, based upon learning from the past, the latest national and international expert 
guidance for best practice, and most importantly input from our patients, their families and carers. 

Working alongside patients, staff and partners we have created a model of care that will offer every 
patient personalised care to support their long term recovery. We will also ensure our care takes into 
consideration how traumatic events affect a person’s behaviour and health, so that we can best 
support them in their recovery. 

At all ward MDTs there is a review to look back at the person’s history.  This also ensures that there 
has been a review of both systems / HIE. 

Concern e) 

Witnesses from consultant level to care co-ordinator level, were unable to describe a robust risk 
assessment process. I am concerned that staff do not fully understand how to assess and manage 
risk.  

Response: 

Please see previous responses re programme of workforce training and records monitoring. 

In addition we have re-shared the clinical risk policy with staff supported with poster for wards on 
safety discharge steps  

Work has been undertaken by the Director NE Essex Community Services, Trust Wide Perinatal, 
Children`s Learning Disability and Allied Health Professionals Operations to review the role and 
responsibilities of care coordinators and ongoing quality improvement for risk assessment is part of 
the Trust Disengagement Safety Improvement Programme 

Concern f) 

There was no safety plan on discharge from hospital, or prior to discharge from the community 
team, to address the clear risks that Danny posed.  

Response: 

Action is already underway as part of the Safety Action Plan to ensure there are clear documented 
actions agreed at discharge meetings and that the MDT outcome form is completed for each person 
clearly stating any actions and an overview of relapse signatures and recorded in the patient record.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 This is being monitored through Matron auditing of patient records.  Staff having been provided with 
a quick reference guide for Discharge and Transfer.   

I hope that I have provided reassurances around the steps that we have taken to address the issues 
of concern contained within your report. We are focused and committed to ensure that our quality 
improvements and transformation are consistent and sustained, and that we will continue to embed 
a culture of learning to support this. We will monitor the impact and delivery of the above provisions 
to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic 
care. 

Please do let me know if you require any further information at this stage, including copies of any of 
the documents referred to above. 

We Trust that your Court will share, as standard, a copy of this reply with Danny’s family 

Yours sincerely, 

Chief Executive