Duncan Holloway

Coroner ME Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London  
N1C 4PP 

7 March 2025 

Dear Coroner Hassell, 

Thank you for sending the Prevention of Future Deaths Report.  We would like to express our sincere 
condolences to the family and friends of Mr Holloway. 

The  Association  takes  any  concerns  raised  about  the  standards  of  practice  for  our  members 
extremely seriously.  

This letter aims to respond transparently and in good faith to the concerns you have raised.  

1.  Mr  Holloway’s  BACP  accredited  psychotherapist  did  not  make  any  notes  of  her consultations 
with him, because he had asked her not to. She gave evidence that she is not bound by law or 
ethics to keep any notes. 

All BACP members must adhere to BACP's Ethical Framework.  

Paragraph 15 makes explicit reference to the need to keep accurate records.  

Working to professional standards. 
15. We will keep accurate records that:  
-  are  adequate,  relevant  and  limited  to  what  is  necessary  for  the  type  of  service  being 
provided  
- comply with the applicable data protection requirements – see www.ico.org.uk 

The client has the right to request that session notes are not kept (GDPR), and it is up to the 
individual practitioner to determine if they are willing to work with a client who has explicitly 
requested that session notes are not recorded.  

Paragraph  31  covers  BACP’s  requirement  to  contract  and  communicate  the  agreed  terms 
clearly and transparently. 

Building an appropriate relationship. 31. We will give careful consideration to how we reach 
agreement with clients and will contract with them about the terms on which our services 
will be provided. Attention will be given to:  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a. reaching an agreement or contract that takes account of each client’s expressed needs and 
choices so far as possible.  
b. communicating terms and conditions of the agreement or contract in ways easily understood 
by the client and appropriate to their context.  

c.  stating  clearly  how  a  client’s  confidentiality  and  privacy  will  be  protected  and  any 
circumstances in which confidential or private information will be communicated to others.  

d. providing the client with a record or easy access to a record of what has been agreed.  

e. keeping a record of what has been agreed and of any changes or clarifications when they 
occur.  

f.  being watchful  for  any  potential contractual  incompatibilities  between  agreements with 
our clients and any other contractual agreements applicable to the work being undertaken 
and proactively strive to avoid these wherever possible or promptly alert the people with the 
power or responsibility to resolve these contradictions.  

Where  BACP  receives  a  complaint  that  a  member  is  not  practicing  in  line  with  the  Ethical 
Framework, BACP will conduct a thorough assessment under  its robust Professional Conduct 
Procedure.  Any member of  the  public may make a  complaint  about  a  member’s conduct  to 
BACP. 

In addition to BACP’s comprehensive Ethical Framework and Professional Conduct procedure, 
BACP also provides all its members with access to a range of Good Practice in Action (GPiA) 
resources. Our GPiA resources are based on current research and evidence and reviewed by 
member-led focus groups and experts in the field. We provide four guidance documents that 
relate to the keeping of records:  

•  Confidentiality and record keeping within the counselling professions GPiA 065 
•  What  do  we mean  by records  and record  keeping  within  the counselling  professions? 

GPiA 066 

•  Record keeping within organisational settings in the counselling professions GPiA 068                                                                                                                       
•  Practical aspects of record keeping within the counselling professions GPiA 067 

2.  Can  it  be  right  that  suicidality  is  completely  omitted  from  BCAP  accredited  psychotherapy 

training? 

BACP accredited courses, must meet all the course requirements set by BACP. These 
requirements ensure that all students on accredited courses must be trained in evidenced-
based risk assessment strategies and must be taught to negotiate an appropriate therapeutic 
contract which may include referral.  

These requirements mean that all students are taught how to refer to suitable referral 
agencies, such as mental health crisis teams, emergency services when required, and that 
students are taught how to cover the circumstances whereby they may need to take that 
action as part of the contracting phase.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 B4.7 Formal course time must be given to:  

i.  Training in assessment procedures consistent with the rationale and British 

Association for Counselling and Psychotherapy www.bacp.co.uk philosophy of the 
course. This must include the important elements of a risk assessment strategy 
informed by evidence-based practice and relevant research.  

ii.  Teaching the students to conceptualise the nature of the clients’ issues and to 
negotiate an appropriate therapeutic contract, which may include referral. 

This is also underpinned by the requirements set out in BACP’s Ethical Framework, which all 
courses must cover with students. 

B4.6 The course must ensure that students are formally introduced to the Ethical Framework 
before starting client work. The course must demonstrate that it assists its students to 
develop as ethical, accountable and reflective practitioners. 

3.  …can  it  be  right  that  contacting  the  police  in  such  a  situation  is  not  taught  as  part  of 

psychotherapy planning. 

According  to  the  BACP  Accreditation  of  Training  Courses,  all  students  enrolled  in  BACP-
accredited courses must be trained in making informed decisions about breaching confidentiality 
when necessary. This includes understanding when it is appropriate to refer clients, particularly 
in situations requiring emergency intervention.  

Furthermore, the BACP Ethical Framework for the Counselling Professions emphasises the ethical 
responsibility  of  practitioners  to  prioritise  client  safety,  including  making  referrals  and 
contacting emergency services when there is a significant risk of harm. 

Counsellors and psychotherapists on accredited courses are taught to take such decisions based 
on  their  assessment  of  what  intervention  is  needed.  Balancing  this  alongside  the  need  to 
maintain client confidentiality (unless there are justifications for breaching confidentiality). A 
course would not teach students to contact police solely based on an assessment undertaken by 
a third party, which we are given to understand was the situation in this case. 

4.  Should there be a mechanism of ensuring that a psychotherapist who is unable to deal with 

suicidality does not practise with clients who may experience this? 

An individual who does not pass the accredited course or the equivalent certificate of 
proficiency is not eligible for Registration with BACP.  

Given the robust training and assessment requirements in place, it should be expected that all 
members on the BACP Register are trained to support clients who express suicidal ideation, in 
safety planning and how to apply the balance of confidentiality against client safety. 

5.  Mr Holloway was seen and fully assessed by Northwest London clinicians when he was taken to 
hospital by police following an episode of self-harm on 30 June 2024. Police attendance had 
been prompted by Mr Holloway’s brother, calling from abroad. 

Mr Holloway’s brother was particularly disappointed that it seemed as if Mr Holloway’s care was 
not joined up between the different agencies. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 BACP acknowledges the disappointment expressed by Mr Holloway’s brother.  

As the psychotherapist contracted was a private practitioner there is currently no ability for them 
to  be  included  in  any  integrated  care  planning  that  may  have  been  available.  Mr  Holloway  was 
under  no  obligation  to  inform  his  GP  or  any  other  care  provider  that  he  was  seeking  private 
psychotherapy. Consequently, it may have been that other agencies were unaware of this. BACP 
has no knowledge as to whether Mr Holloway did share this information or not. 

I hope that this letter provides the necessary clarification but if you have any further questions, 
please do not hesitate to contact me. 

Yours sincerely 

Director of Professional Standards, Policy and Research

Trust Headquarters 

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

Email: 

. 

Private and Confidential 
Senior Coroner Mary Hassell 
Inner North London 
St Pancras Coroner’s Court 
Camley St 
London N1C 4PP 

16th April 2025 

Dear Ms Hassell 

Re Inquest touching the death of Duncan Holloway 

I am writing further to the inquest for Mr Duncan Holloway which concluded on 16th January 
2025 and following which you issued a Prevention of Future Death report to the British 
Association for Counselling and Psychotherapy (BACP) and  North London NHS Foundation 
Trust (note, not North West London NHS Trust).  The inquest found that Mr Holloway died by 
suicide after
concern raised in your report in regard to the Trust are as follows:  

 at around 5am on 18th July 2024.  The matters of 

Mr Holloway was seen and fully assessed by North West London clinicians when he was 
taken to hospital by police following an episode of self harm on 30 June 2024. Police 
attendance had been prompted by Mr Holloway’s brother, calling from abroad. Mr Holloway’s 
brother was particularly disappointed that it seemed as if Mr Holloway’s care was not joined 
up between the different agencies.  

We would like to begin by expressing our deepest sympathies to Mr Holloway’s family and 
loved ones. We are very sorry to hear that Mr Holloway’s brother has concerns with regard 
to the communication that took place between the agencies involved.  It is unfortunate that 
we only learned of this concern at the end of the inquest hearing which meant that there was 
not an opportunity to explore the nature of this concern in more detail.  

Mr Holloway was assessed by the Trust’s Mental Health Crisis and Assessment Service 
(MHCAS) on 30th June 2024 after emergency services, having been alerted by Mr 
Holloway’s brother calling from abroad, attended his property and brought him to A&E. This 
was the extent of the Trust’s involvement in his care.  As the assessing clinician explained in 
evidence, she was concerned about the circumstances leading to Mr Holloway’s attendance 
in the department and the risk he might pose to himself when under the influence of alcohol 
or substances. However, he was capacitous and very clear that he did not wish to engage 

Better Mental Health. Better Lives. Better Communities. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 with mental health or alcohol services.  He did not meet the 

criteria for compulsory detention under the Mental Health 

Act.  The clinician did her best to engage him but ultimately Mr Holloway made the choice to 
decline any ongoing involvement with services. 

The Trust entirely recognises the importance of communication between its services and 
service users’ professional and personal support networks to support joined up care and 
manage risks.  Service users are vital partners in their own care.  However, with the 
exception of key support networks (such those offered by a service user’s GP or next of kin), 
and although we enquire, the Trust relies on service users to expressly alert it to the 
involvement of any other   networks.  In accordance with our standard process when anyone 
is brought to A&E and a mental health assessment is carried out, a summary was promptly 
sent to Mr Holloway’s GP.   

The Trust was not aware that Mr Holloway had sought the support of a private therapist and 
was only made aware of this involvement during the inquest hearing. It appears that the 
therapist’s involvement postdates the Trust’s assessment of Mr Holloway at A&E. The Trust 
always seeks to involve all relevant parties in a patient’s care.  However, this only possible 
with their consent and, although we enquire, the Trust is reliant on service users making it 
aware of who the relevant parties are.  It is therefore difficult to see what the Trust could 
have done differently in this case.  Notwithstanding this, the Trust will continue to reflect on 
this incident, which it will share through its various governance forums as part of its 
commitment to learning and improvement.  

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.