James Agius

Chief Executive Officer 
Trust Head Office 
West Wing 
CEME Centre 
Rainham 
Essex 
RM13 8GQ 

        29th November 2024 

PRIVATE  & CONFIDENTIAL  

Ms S Hayes 
HM Coroner 
Essex Coroner’s Service 
Seax House 
Victoria Road South 
Chelmsford 
Essex 
CM1 1QH 

By email only to:  

Trust ref: 1512  

Dear Madam, 

Re: Inquest touching upon the death of Jamie Agius 

I refer to your Regulation 28 report, dated 7 October 2024, detailing your concerns about the risk 
of future deaths in light of the findings of this Inquest.  

I should like to extend my sincere condolences to the family of Mr James Agius.  This must have 
been an extremely difficult time for them, and I hope that my response provides them, and you, 
with  assurances  that  the  North  East  London  Foundation  Trust  (NELFT)  has  taken  action  to 
address the issues set out in your report. 

I note that your concerns relate to: 

1. 

2. 

3. 

The  medical  record  documentation  for  Mr  Agius  had  significant  omissions  that 
included an incomplete risk assessment in February 2022 for Mr Agius following 
his  transfer  following  crisis  intervention  with  the  Home  Treat  Team  to  avoid 
admission to hospital when Mr Agius attempted to take his own life.  

The evidence of assessments of Mr Agius’s mental state provided to the inquest 
indicated a difference of opinion as to whether Mr Agius was displaying hypomanic 
esymptoms on 12 and 13 February 2022.  

Evidence  was  heard  that  there  is  new  national  training  for  assessing  risk  for 
patients with mental health concerns but there was no evidence that the Trust has 
implemented this training. 

Chair: 
Chief Executive: 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust acknowledges your concerns and wishes to advise that prior to, and following, the sad 
passing of Mr James Agius, a number of changes have been put in place, and I would like to 
highlight that these include the following: 

1.  Medical Record Documentation 

The  Trust  has  completed  a  thematic  review  of  patient  safety  incidents  with  the  intention  of 
identifying themes and patterns occurring within these.  Resulting from this was the establishment 
of Trust wide workstreams aimed to address the identified gaps and then embed learning around 
these across the Trust.  Of pertinence to the concerns raised in this instance, is the Improving 
Quality of Record Keeping and Clinical Documentation workstream. 

The aim of this workstream is to establish any system weaknesses associated with poor record 
keeping, understand the behaviour associated with this and to improve recording keeping and 
create  a  healthy  record  keeping  culture.    The  Quality  Improvement  initiatives  around  this 
workstream have so far been successful in creating a Trust wide intranet page accessible to all 
staff offering direction on the importance of accurate and good record keeping.  In addition to 
this, the Trust has develoepd quick access to guidance and information on issues such as cut 
and paste and commonly used acronyms and clinical abbreviations.  Readily accessible links to 
good record keeping practice are also available and consequences of failing to comply with this 
and guidance on how to escalate concerns are also captured and available to all staff within this 
platform.  

Revised training packages have also been put in place that cover the principles of good record 
keeping  standards.    These  are  essential  training  for  all  staff  and  are  covered  as  part  of  the 
induction to NELFT.  

To support good record keeping practice in the Home Treatment Teams (HTT) in NELFT, all staff 
completing home visits to service users are expected to complete their records utilising an agreed 
template.    This  ensures  that  the  visit  and  documentation  of  what  took  place  will  cover  areas 
including  (though  not  limited  to),  mental  state  examination,  social  situation,  physical  health 
concerns, risk assessment, safeguarding and that these lead to a clear plan to be followed by 
the team.  Adherence to this is monitored within through a fortnightly progress note audit that is 
completed.  The last audit that was completed for the Barking and Dagenham HTT was on 3rd 
November 2024, with the team scoring 100% for adherence to use of the correct template.  All 
entries reviewed also included a full Mental State Examination and risk assessment.  

2.  Varying opinion on diagnosis  

Mr Agius was under the care of the Barking and Dagenham HTT (BDHTT) for a period of three 
days over the weekend of 11th - 13th February 2022. The concern highlighted was in reference to 
the difference of opinion regarding whether Mr Agius was displaying hypomanic symptoms on 
the 12th and 13th February 2022.  

According to his electronic care records, on 12th February 2022, Mr Agius reported feeling elated 
in mood, but it was the opinion of the HTT staff member that visited that there was no objective 
symptoms  observed  in  the  interaction  that  took  place  to  confirm  this.    The  staff  member,  it 
appears  made  this  conclusion  based  on  Mr  Agius’  speech  being  considered  normal  in  all 
modalities and a general perception that he appeared to be settled.  When Mr. Agius was again 
visited  on  13th  February 2022,  he reported  his mood  to be  fluctuating  and that  he  was “hyper 
manic” and suffering from BiPolar Disorder.  The opinion of the staff member on this day was that 
other than appearing slightly anxious he was again otherwise considered settled in mental state 
with reference to an absence of any speech abnormalities or psychotic symptoms.  

Chair: 
Chief Executive: 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Mr Agius’ medical records would suggest that there was consistency in the opinion of the two 
staff members that visited, in as much that they both did not see evidence of  an elated mood. 
Had Mr Agius been under the BDHTT for a period longer than the three days he was, he would 
have been reviewed by the medical team, in line with the HTT Standard Operating Procedure 
and greater clarity regarding his diagnosis would have been achieved.  

When  HTT  staff  complete their mental  state  examinations,  where there is  a potential  concern 
regarding a mood disorder, staff will make reference to a service user’s speech and observation 
of any psychotic symptoms.   This is completed as abnormalities within these domains can be 
common  features  of  a  manic  episode  (International  Statistical  Classification  of  Diseases  and 
Related Health Problems 10th Revision (ICD-10)). 

3.  Incomplete Risk Assessment 

The  final  concern  raised  related  to  the  risk  assessment  completed  and  NELFT’s  progress  in 
transitioning from the previous risk stratification model of assessing risk to that of risk formulation. 
As correctly referenced in your report, this change will reflect national recommendations on the 
most effective means of assessment of the risk suicide and self-harm (NICE NG225 Self Harm: 
assessment, management and preventing recurrence).  

The Trust does have a programme in place to roll out training in relation to this.  The Acute and 
Rehabilitation Directorate (ARD, which the HTTs are part of) was identified as the first directorate 
to engage in this risk formulation training.  This roll out began in September 2024.  All qualified 
clinical staff within the directorate will be trained in this approach by the end of December 2024. 
The roll out of this will then be extended throughout the Trust, with all areas fully trained by April 
2026.  Within the Barking and Dagenham HTT, 16 of the 19 qualified staff have been trained, 
with the remaining staff all booked to complete this training in December of this year. 

I hope this response gives assurance that the Trust continues to take learning from Inquests very 
seriously and has put actions in place following Mr Agius’s sad death. 

If I can be of any further assistance or if you would like a further update on the progress made to 
address your concerns, please do not hesitate to contact me. 

Yours sincerely  

Chief Executive

Chair: 
Chief Executive: 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Chair: 
Chief Executive: 

www.nelft.nhs.uk