Carol Guest

Chief Executive’s Office 
Woodfield House 
Tickhill Road Site, Tickhill Road, Balby 
Doncaster, DN4 8QN 

Email: 

PRIVATE AND CONFIDENTIAL 

31st October 2024 

Ms N J Mundy 
Senior Coroner 
South Yorkshire (East District) 
Coroner’s Court and Office 
Crown Court, College Road 
Doncaster, DN1 3HS 

Dear Ma’am, 

Re: Regulation 28 Report in relation to the inquest touching upon the  
death of Carol Ann Guest (D.O.B:  10.11.1948) 

Thank you for the issue of your regulation 28 report regarding Carol.  As you, and Carol’s family 
would rightly expect, this has been treated with great seriousness and priority inside the Trust.  
, and our Chief Nurse, 
The Board, in public, acknowledged receipt, and myself, 

 have led the organisational response relayed here.  The Board Quality Committee, 

now chaired by an experienced GP, will hold us to account to take the actions that I outline. 

I should be direct that we do not believe that crisis provision was a relevant factor in what 
happened to Carol.  It is apparent from the attached case summary from 
were missed opportunities to refer her to the established older peoples’ community team.  Having 
received a referral on March 15th, an appointment was expedited to take place on March 26th.  
Carol was unaware of both the referral (not issued to her, and the appointment, owing to her 
death).  It is deeply regrettable that relatives who cared for Carol may have been left, in evidence 
before you, with the impression that crisis services were a primary cause of harm.  We will be 
seeking to meet with family members to hear from them and to share our conclusions with them. 

 that there 

However, accepting the preventive intent of your order to explore crisis service provision, and the 
possibility of communication weaknesses inside the Trust, and with GP partners, we agree that 
there is room for improvement.  That is the focus of the balance of this response. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 What we will be changing? 

We have found that our arrangements for accepting crisis referrals for older people are 
inconsistent within RDaSH, and do not benefit from agreed written protocols.  This will change 
with issue of a new operating protocol to those working clinically on November 7th 2024 – 
effective immediately. 

Local service specifications from commissioning bodies do appear to create age-based 
parameters for who can access which services.  The Trust committed earlier in 2024/25 to 
remove such externally directed barriers to our services, both for children and young people, and 
older adults.  We are working to a programme to do this by spring 2025, as the changes involved 
require us to provide additional training to staff.in different presentations and techniques.  To be 
clear, services will still have specialists focusing on particular conditions, but the distinctions 
between teams will not be driven by age-parameters. 

For crisis services, it is apparent that ‘out of hours’ our teams would routinely see those in 
greatest need regardless of age.  However, during standard daytime hours, calls may be diverted 
to older people’s mental health teams. There then appears to be a further deflection back to 
general practitioners.  Our guidance protocol will make clear to teams that crisis 
presentations should be assessed by the team regardless of age or time of day.  This 
would bring services in Doncaster and Rotherham into line with practice already in our North 
Lincolnshire services. 

We will set out our revised arrangements in writing for those providing the services, but also for 
local GPs.  We will also ensure that, during November, relevant primary care leadership meetings 
are advised of the changes.  That is because we suspect that, over a period of years, pathway 
changes have been made, and practices have varied knowledge of them.  The arrangements will 
also be clarified in our triage-SPA and to NHS111.  This work will be complete before the end of 
November.  In putting this change into place, we will also clarify for local practices, the best 
routes through which themselves to seek advice, and how to make referrals including urgent 
referrals.  Importantly this will be shared with our communities, carers and patients through all our 
communication channels.  

There is some evidence that dedicated older peoples’ crisis services have merit.  Whilst we will 
keep the introduction of such services under review, we have not found a compelling case to 
create such services and, to do so, would require significant investment from the Integrated Care 
Board locally.  We consider it unlikely that this will occur over the next two years, and as such it is 
important our existing teams are better able to respond to needs among all adults.   

We ourselves are working to invest in training and skills development for teams, with a 
programme being developed for 2025 to this end, so that we have confidence that differences of 
presentation and treatment options, are better understood for older adults among those whose 
recent experience is focused on younger adults.  This training support would be a combination of 
mandated time, and voluntary extended learning.  During 2024 the Trust invested in dedicated 
Learning Half Days, compulsory for all staff, through which to better disseminate knowledge, and 
to reflect on quality improvements.   

Through 2025/26, the Trust is introducing DIALOG/DIALOG+ into our services and replacing the 
Care Programme Approach (CPA).  The intention of this change, adopted by some other mental 
health providers nationally, is to better support patients and their carers, with plans of care that 
are outcome focused.  Introducing DIALOG should help us too to have a more accessible 

 
 
 
 
 
 
 
 shared language across the primary/secondary care interface.  The change again will break 
down assumed barriers between teams, pathways, and age-cutoffs.  Training began in 
September 2024 and continues through to April 2026: the teams involved in Carol’s referral will 
be part of this rollout during 2025. 

How we will test whether this has been effective? 

We understand that simply issuing guidance alone is not sufficient.  It will be important to 
measure the changes outlined, and to test whether they are embedded and understood.  To that 
end, we will make sure that: 

• 

Induction arrangements for our local crisis teams, and wider community mental health 
teams, take account of what is described in this letter.  This month the Trust introduced new 
induction arrangements across the organisation, with a dedicated day for in-team local 
induction complimented by a much more in-depth institutional induction, taking place in our 
communities.   

•  We continue to audit waiting times for care.  In September 2023 the Trust adopted a 
strategy that seeks from April 2026, to meet an urgent wait time of 48 hours for 
response, and four weeks for routine care.  During 2024 we believe we have effectively 
created systems to monitor these commitments, and to begin to move towards them in all 
our services. 

•  We are rolling out presently new arrangements to support patient-led booking, and 

cancellation, of appointments.  From spring 2025, we routinely offer digitally enabled 
arrangements to support patients to do this – a change that of course also makes it 
easier for family members to have delegated access to information about pathways of care.  
This will also allow us to apply some standards to the pace of triaging referrals and issuing 
information about appointments.  Even where a wait time exceeds our targeted standards, 
we would want patients to know at any given time what is happening to their referral and to 
know how to seek help about that. 

• 

• 

The Trust’s Equity and Inclusion Group, which I chair, is already auditing the work to replace 
age-specific policies in our pathways.  We will work with clinical audit to consider how best, 
in our 2025/26 programme of audit, evaluation of access for crisis presentations in older 
adults.  This should help us to have a better picture of patterns of demand, through which to 
further refine services. 

The learning half days, cited above, are mandatory for employees, and from January 2025 
attendance will be monitored.  It is recognised that some services, such as wards and crisis 
teams, will struggle to attend – and specific rotational arrangements including paid extra 
hours – have been put in place mindful of that.  I have made arrangements to have a 
specific analysis done of attendance in the Rotherham CMHTs and crisis teams for the 
coming quarter, such that I can confident colleagues working in those teams have taken up 
access to the support outlined in this letter. 

 
 
 
 
 
 
 
 
 I should be grateful - should you have chance – if you might indicate whether this response is 
sufficient and what, if any, future reporting you might require from us.  We believe we will be able 
to evidence material change, over coming months, and would be more than willing to provide an 
additional report to you – based on the actions above best timed for a year from now – to 
demonstrate the impact of the changes we have described. 

Your sincerely 

Chief Executive 

For action: 

, Acting Medical Director and consultant psychiatrist (SRO) 

, Chair of quality and safety committee and Chief Nurse 

, Care Group Director  

(Doncaster adult mental health and learning disabilities care group) 

, Care Group Director,  

(Rotherham adult mental health care group 

, Care Group Director 

(North Lincolnshire adult mental health/talking therapies care groups)  

For information: 

, non-executive chair of quality committee 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex A:  Trust case clinical summary 

1. 

In considering our response and learning I have briefly summarised the case below. 

2. 

Ms Guest had been diagnosed with mixed anxiety and depression whilst under primary 

care. The first recorded diagnosis of this was in 2007. She was treated with a several 

antidepressant medications including citalopram, lofepramine, mirtazapine and fluoxetine 

which were initiated and monitored by her GP. Her primary care records indicate that she 

took the medication reliably and had a good response to it. 

3. 

In 2012 she was referred by her GP to Rotherham Talking Therapies for Cognitive 

Behavioural therapy due to her reporting anxiety and depressive symptoms. On completion 

of the therapy, she self-rated that her symptoms had significantly improved. 

4. 

From 2014 until early 2024 she was not treated with any medication for her mental health 

except for brief periods with low dose diazepam. 

5. 

On 8 January 2024 she saw 

, Primary Care Mental Health Practitioner, saying she 

had been struggling with low mood and having broken sleep 6 weeks. It was noted during 

this appointment that she had no suicidal ideation. Antidepressants and therapy were 

discussed with Ms Guest requesting time to think through her options. She was given 

information about how to refer herself to Rotherham Talking Therapies.  

6. 

She attended her GP surgery along with her partner on 1 February 2024 and saw a student 

at the practice. She was complaining of low mood and anxiety. She also reported a loss of 

confidence that had been present for some six to eight weeks. She reported sleep problems 

for 6 weeks, loss of weight despite a normal intake and a loss of energy. She described 

being anxious about leaving the house. It was identified that she had a number of stressors 

such as her mother having recently being put in a care home.  Ms Guest had previously 

been a carer for her mother so this led to a big change in routine and loss of role. She had 

also recently been told that she had macular degeneration after an eye test. Following this 

appointment she was referred to a Primary Care Mental Health Practitioner. 

 
 
 
 
 
 
 
 7. 

On 2 February 2024 she had a telephone call with a GP, 

, where the weight loss 

was discussed and it was organised for her to have some investigations for this to rule out a 

physical cause of the weight loss. During this appointment she also expressed concern 

about the diagnosis of dry age-related macular degeneration for which there is no specific 

treatment and can lead to sight loss. 

8. 

On 9 February 2024 during a telephone appointment with 

, Ms Guest was 

informed that she had an elevated tumour marker CA19-9 (Carbohydrate antigen 19-9). 

This can be raised primarily in pancreatic cancer but also other cancers and conditions. A 

follow-up CT scan of her chest, abdomen and pelvis was requested. 

9. 

This scan was performed on 14 February 2024 and did not show any evidence of 

malignancy. 

10.  She saw a Primary Care Mental Health Practitioner, 

, on 14 February 

2024 and during this appointment she denied suicidal ideation but reported ongoing 

depressive and anxiety symptoms leading to a request for a GP to prescribe antidepressant 

being made. 

11.  Citalopram was started by 

 on 15 February 2024 following the request from 

. 

12.  On 20 February there was a telephone call to the Rotherham Crisis Team from 

, 

her daughter-in-law. During the call, it was expressed that Ms Guest was feeling low and 

guilty. The outcome of the call was for 

 to make contact with her GP or Talking 

Therapies for a referral to the older people’s community mental health team to be made. 

13.  On 23 February 2024 she was seen by 

 with 

, her daughter-in-law. It 

was reported that she was not taking the citalopram regularly and that she hadn’t noticed 

any benefit from taking it. The medication was switched from citalopram to mirtazapine and 

low dose diazepam was prescribed for her to take on as required basis. During this 

appointment Miss Guest described some symptoms indicating possible delusional beliefs 

such as someone from British Gas had cancelled “everything” including her pension, and 

 
 
 
 
 
 
 NHS accounts. Follow up was arranged for 3 weeks time. 

14.  Citalopram is an SSRI (Selective serotonin reuptake inhibitors) medication and benefits are 

usually apparent only two to four weeks after commencing treatment. It would be unusual to 

expect benefits of starting antidepressant medication after only one week. SSRIs can 

however lead to an initial worsening of anxiety and agitation and so the decision to change 

to a more sedating antidepressant such as mirtazapine could have been beneficial. 

15.  NICE recommends that when antidepressants are started that follow up should occur within 

2 weeks of starting the medication. NICE also recommends that patients presenting with 

psychotic depression should be referred to a specialist mental health team. 

16.  On 8 March 2024 there was a telephone call with 

 and 

 and concerns were 

raised that Ms Guest was not taking her medication and that her delusions were getting 

worse. It was noted in this appointment that an urgent referral to the older people’s 

community mental health team was to be made. This referral was eventually sent on 15 

March 2024. 

17. 

The referral was sent as an electronic task to the Single Point of Access. The usual route of 

urgent referrals would be to contact the Older people’s community mental health team duty 

worker or to speak to the Crisis Team via telephone. Given how this referral was sent it 

would have been impossible to have responded within a week given that the referral was 

only sent some 7 days after it was decided to make an urgent referral.  In addition, the 

urgency of the referral is not immediately identified on the document. 

18. 

The referral was triaged on 20 March 2024 (in five days) and it was arranged for an 

appointment to be made with a psychiatrist. This appointment was to be booked for 26 

March 2024. The appointment was not sent out due to the team becoming aware of Ms 

Guest’s tragic passing. 

27th October 2024 

, Acting Medical Director