Maria Kelly

Our EMIS reference: 

Date: 09-Oct-2024 

Dear Colleague,  

Re: Ms Maria Kelly, DoB: 26-Nov-1969, 

HQ: 77 Gray’s Inn Road, London 
WC1X 8TS 

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🌎 graysinnmedical.co.uk 

Many thanks for your communication dated 27th September 2024.  

We completely agree with your correspondence. As you have correctly noted, we had made countless attempt 
at contact including telephone calls, SMS messaging, and even written letters. I am unsure if you had seen the 
correspondence with the Duty worker with South Camden Recovery and Rehabilitation team in January 2024 
who had written saying they had visited her at home already, and just asked us if we had heard anything from 
her or seen her. We did respond to that letter. My apologies as it may have been my understanding that, this 
correspondence and the knowledge of their home visit and data gathering did appear to be a welfare check as 
mentioned. 

However, we will of course endeavour to clarify if things have been sorted in future, and if not, possibly call 
Adult Social Care (we have recently been told by police about other cases that they do not do welfare checks 
anymore). We have discussed this with practice management here and the clinical lead - myself. 

Yours sincerely, 

MBBS MRCGP 
General Practitioner 

This practice adheres to the prescribing and treatment policy drawn up by North Central London. 
Therefore not all medication and treatments can be prescribed on the NHS. If you require further details please consult 
the following resources: 
Prescribing – http://www.camden.nhs.uk/gps/prescribing-guidelines 
Treatments – http://www.camden.nhs.uk/gps/IFR 

GRAY’S INN MEDICAL PRACTICE  77 Gray’s Inn Road  London WC1X 8TS 

www.graysinnmedical.co.uk

Trust Headquarters 

4th Floor, East Wing 
St Pancras Hospital 
 4 St Pancras Way  
London NW1 0PE  

Email: 

Private and Confidential 
Ms Melanie Lee 
Assistant Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley St 
London N1C 4PP 

21st November 2024 

Dear Coroner Lee 

Re Inquest touching the death of Maria Kelly 

I am writing following the inquest for Maria Kelly which concluded on 12th September 2024 
and following which you issued a Prevention of Future Deaths report to the Trust.  The 
matters of concern raised were as follows: 

Ms Kelly’s medical records show that she suffered from a large number of medical 
conditions including steatosis of the liver, hydronephrosis, left anterior fascicular block, 
chronic kidney disease, iron deficiency anaemia, gastrooesophageal reflux, hyperlipidaemia, 
simple schizophrenia, borderline personality disorder, recurrent depressive disorder and 
anorexia nervosa (possibly in remission). She had been also diagnosed with Non-Hodgkins 
Lymphoma in the past. She was prescribed repeat medications of Atorvastatin and 
Lansoprazole for her physical health problems, and Flupentixol (as directed by her 
consultant) and Mirtazapine for her mental health. A prescription appears to have been last 
issued by her GP on 1 August 2024. From 23 August 2023 until the practice was notified of 
her death, her GP summary showed 31 failed encounters for mental health reviews, as well 
as failed encounters for blood tests and bowel screening. Her last medical (mental health) 
review with South Camden Rehabilitation of Recovery Team (SCRRT) was on 7 March 
2023. Ms Kelly’s care coordinator went on leave in September 2021. Ms Kelly was placed 
onto the waiting list for allocation of a new care coordinator on 29 December 2023 after a 
review of the team’s patient list found that there had been no contact with her since 11 
August 2023. It was recorded that there were “many attempts” (not quantified) to contact her. 
After a review on 29 December 2023 there were then 12 unsuccessful home visits and 6 
failed telephone attempts. Despite this, no welfare check was undertaken, nor any request 
for a welfare check made to her housing officer or police, until neighbours raised concerns 
on 14 May 2024. 

Better Mental Health. Better Lives. Better Communities. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust acknowledges the serious concerns raised by the Coroner following the inquest 
into the death of Ms Kelly. The Trust is committed to addressing these concerns through a 
series of actions aimed at preventing future incidents and ensuring the safety of all service 
users. A summary of the actions we have already taken and the further steps we plan to 
implement to mitigate risk and improve service delivery is provided below:  

1. Re-allocation and Handover Process 
We have reviewed and strengthened our re-allocation and handover processes to ensure 
continuity of care during staff transitions. A new handover template is now in use, 
standardising the transfer of key information when a staff member leaves. This ensures that 
service users and carers are promptly informed of any changes and are provided with clear 
contact details for their new care coordinator. 

For service users who are still unallocated, we have implemented a welfare call system. 
These patients are regularly contacted to check in on their well-being. New guidance has 
also been put in place to ensure effective management of these patients, including clear 
instructions on when to escalate concerns. This initiative forms part of an ongoing Quality 
Improvement (QI) project aimed at improving care continuity and safety. 

2. Staffing Challenges and Recruitment 
Between May and September 2023, there were a number of vacancies within the team 
(South Camden Rehabilitation and Recovery Team). This resulted in cases being added to 
the waiting list, impacting service continuity. The Trust has been actively recruiting to 
address this shortfall, including organising targeted recruitment events.  

All substantive social work posts have now been recruited to. We have successfully recruited 
into three nursing vacancies and put long term experienced agency staff in place to address 
current shortfall. Additionally, we have introduced new roles, such as a Band 7 position to 
supervise Band 4 Assistant Practitioners, reducing the reliance on harder-to-recruit Band 6 
nurse posts. Recruitment to these posts will continue. 

Our new locality teams, set to be mobilised from February 2025, will work in collaboration 
with Integrated Community Teams to offer more flexible staffing options. This will enable us 
to manage resources more effectively during periods of reduced staffing, ensuring continued 
care for service users. We have also replaced two locum social workers with permanent 
social workers, ensuring greater stability in the team. A nursing Team Manager has been put 
in place to ensure effective nursing management and support.  

3. MaST (Management and Supervision Tool) Implementation 

The MaST tool will play a key role in improving caseload management and prioritisation. 
Staff training is currently underway, with sessions delivered throughout October to enable 
the implementation of MaST. A MaST Champion has been appointed to guide the team 
through the implementation process. Training will be completed by November 2024, after 
which MaST will enable real-time tracking and prioritisation of high-risk service users. This 
will ensure close monitoring of service users on the waiting list, and timely follow-up. 

4. Case Tracking and RAG System 

We have reinforced our case tracking procedures using the RAG-rating system which 
identifies levels of risk (Red, Amber, Green). Weekly allocation meetings are held to ensure 
that high-risk cases are prioritised for follow-up. While we await MaST full implementation,  

Better Mental Health. Better Lives. Better Communities. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 manual audits are conducted to ensure all cases are responded to effectively. The newly 
launched Integrated Community Teams will support service users through shared Multi-
Disciplinary Team (MDT) meetings, improving communication between GPs, housing 
officers, and social workers. 

5. DNA (Did Not Attend) Policy 
The DNA policy is currently under review to formalise new working processes in the 
management of DNA. The policy outlines clear steps for escalating cases after two 
consecutive missed appointments, ensuring disengaged service users are followed up 
promptly. The revised policy will be implemented through staff training to ensure consistent 
implementation. The impact of this policy will be monitored through a Quality Improvement 
(QI) project. 

6. Right Care Right Person (RCRP) Guidance 
We have provided guidance to staff on the use of the Right Care Right Person (RCRP) 
protocols to ensure effective escalation to external agencies (specifically the Police) to 
support the management of welfare checks and missing persons.  This includes escalating 
within the Police system when requests for support with welfare checks are declined by 
Police.  

To note, a police welfare check for Ms Kelly was requested by the team on 3 April 2024 but 
this was declined by the Police. Police advised the duty worker to call an ambulance. 

7. Escalation of Declined AMHP Referrals 
We are strengthening our procedures for managing situations where AMHP (Approved 
Mental Health Professional) service requests, such as Section 135(1) warrant applications, 
are declined. When a request is refused, staff are required to escalate the matter to senior 
management for further review. These cases are also discussed during Multi-Disciplinary 
Team (MDT) meetings to explore alternative actions and ensure the safety and wellbeing of  
the service user are prioritised. Social workers in the team are being trained as AMHPs to 
improve interface working. 

8. Communication with GPs and LCR (London Care Record) 
Improving communication with GPs is a priority to ensure coordinated care for service users. 
We are organising additional training on the use of the London Care Record (LCR) to 
enhance information sharing between our teams and primary care providers. This will ensure 
that GPs are promptly notified if concerns arise or if service users disengage from care. The 
integration of our teams into the new Integrated Community Teams will strengthen 
collaboration with GPs and other community services, enabling a more coordinated, 
collaborative and effective approach to care. 

9. Staff Wellbeing  
We are prioritising staff wellbeing through regular check-ins and support initiatives. These 
include reminding staff about Trust-wide initiatives such as weekly mindfulness sessions and 
access to mental health support services. We are also focused on workload management, 
ensuring staff have the necessary resources and support to prevent burnout and maintain a 
healthy work-life balance.  

Better Mental Health. Better Lives. Better Communities. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 10. Clinical Governance 
We are enhancing and standardising governance meetings across the division to ensure 
staff are kept informed and have opportunities to discuss cases requiring urgent attention. 
These governance meetings will prioritise attendance and focus on sharing key learning 
from incidents, promoting a culture of continuous improvement.  

11.  Client Contact Information Accuracy 
To address ongoing challenges with service users being unreachable due to outdated 
contact details, we have instructed team administration to lead an initiative to ensure all 
client contact details are accurate and up to date in RiO (the Trust’s electronic patient 
records system). Care Coordinators are being allocated time slots to review and update their 
client contact details. This proactive step is expected to improve contact and engagement, 
reducing risk associated with missed appointments or service disengagement. 

It is noted that the Trust was not invited to give evidence at Ms. Kelly’s inquest. We would 
have welcomed the opportunity to address the Court directly on this matter and provide 
assurance to the Coroner and family around the learning that has taken place following Ms. 
Kelly’s sad death. We would be grateful if this could be considered in future cases where any 
issues of concern may arise.  

I hope that this response provides the necessary assurance.  Please contact me if you have 
any queries. 

Yours sincerely 

Chief Medical Officer 

Better Mental Health. Better Lives. Better Communities.