Jonathan Hamer

Chief Executive’s Office 
South West London and St George’s Mental Health NHS Trust 
Elizabeth Newton Building 

Springfield University Hospital   
15 Springfield Drive   
London SW17 0YG 
Direct Line: 020 3513 6212 

 E-Mail: 

11 June 2025 

Private & Confidential 

Lydia Brown  
Senior Coroner for West London 
25 Bagleys Lane 
Fulham 
London 
SW6 2QA 
United Kingdom 

Our internal Reference: Incident Number 

Dear Ms Brown,  

Re:  Regulation  28  Report  to  Prevent  Future  Deaths  –  Jonathan  Mark  George 
Hamer 

I am writing in response to the Regulation 28: Report to Prevent Future Deaths, dated 
10 April 2025, concerning the very sad death of Mr Jonathan Mark George Hamer. 

South West London and St George’s Mental Health NHS Trust (SWLStG) acknowledges 
the  matters  of  concern  raised  in  your  report  and  takes  them  extremely  seriously.  To 
ensure  a  comprehensive  response,  the  issues  outlined  have  been  reviewed  with  the 
clinical leadership team involved in Mr Hamer’s care and will be shared with our Trust 
Board Quality Committee and in our Public Board meeting in July 2025. 

Below is our response to each of the identified concerns: 

Communication  

The MATTERS OF CONCERN are as follows: 

1.  ‘There were communication difficulties experienced by Jonathan’s family and his 
supported  housing  with  the  community  mental  health  trust  responsible  for  his 
ongoing  healthcare  during  the  early  part  of  2024.    Telephone  calls  and  text 
messages were unanswered and there was no communication to confirm that in 

Chief Executive, 

  Chairman, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 fact the care co-ordinator had a period of annual leave followed by an unplanned 
period of sick leave.  It was unclear at inquest if service users and their support 
network had been provided with details of any service changes and current up to 
date  contact  details.    This  meant  that  important  information  was  not  being 
received by the community mental health team. 

2.  The community mental health team actively encouraged communication by text 
message and emails but had no system in place to intervene when the care co-
ordinator was not at work and had left no “out of office” message.  There was no 
system  to  return  or  redirect  incoming  calls  or  messages  so  these  remained 
unread and unanswered.  Those initiating the communication were unaware that 
the information was not being received or actioned by the Trust.’ 

We fully acknowledge and regret the communication failures identified in this case. 
The lack of appropriate cover arrangements and failure to redirect important messages 
during the care coordinator’s absence represented a serious lapse in service continuity 
and risk management. 

The Trust has procured a digital communication system, called Envoy which enhances 
communication and engagement with patients.  Envoy enables centralised, monitored 
messaging across SMS from the Trust to patients regarding appointments and 
provides some ability for patients to provide a SMS through to Envoy around 
appointments. 

While this system improves our communication with patients, there remains some 
limitations and therefore is supported with the following. 

▪  A new Standard Operating Procedure (SOP) for using Envoy, including cover 

arrangements during periods of planned and unplanned leave. 

▪  Training for all administration staff, with phased expansion to other clinical staff 

within community teams. 

▪  A revised process for case list management when unplanned leave occurs, to 

ensure continuity of care. 

In addition, we have reinforced the following protocols across all community teams: 

▪  Text messaging is now limited to routine communication, such as appointment 

reminders, and must only be used with patient consent. Staff have been 
instructed not to share clinically sensitive or identifiable information via SMS. 
▪  We have asked community teams to add specifically created email footers to 
their personal NHS emails to advise recipients that the mailbox may not be 
monitored and to provide alternative team contact details and crisis service 
links. 

Chief Executive, 

  Chairman, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 ▪  Teams have been reminded not to rely solely on individual work communication 
channels and to ensure team mailboxes and phone lines are promoted and 
accessible. 

▪  Teams have also asked to ensure they always set voice message to inform 

people who they can contact in their absence, typically either the team base or 
crisis services. 

▪  We have updated our ‘how to make contact with the trust’ and care team page 

on our website to reflect our approach. 

While we considered prohibiting SMS messaging entirely, our clinicians advised that 
text-based communication can be a helpful and preferred means of engagement for 
many service users. As such, we have sought to adopt a more risk balanced position 
to help preserving flexibility and accessibility while we continue to implement the use 
of Envoy. We have asked all care co-ordinators to ensure that they are clear that SMS 
is not for urgent communication.  We have also updated our guidance about how to 
make contact with the trust and care team on the website to reflect that SMS is not for 
urgent or important communications and to use the team contact details for such 
matters. 

The Envoy system has already been implemented in some of our clinical therapy 
teams, and we are now progressing plans to roll it out more widely across all 
community teams. We are currently working with the community team involved in Mr 
Hamer’s care to ensure they are among the first to benefit. 

The revised SOP reinforces the requirement for staff to set ‘out of office’ replies and 
voicemail messages on their mobile phones. These should include an alternative 
contact number as part of the standard message—for example: "If your call is urgent 
or important, please contact [alternative number]." Importantly, the Envoy system will 
support the administration team in notifying and engaging with patients when a staff 
member is unexpectedly unwell and absent from work. 

The Trust is investing in a new digital solution centred around the NHS App and an 
integrated central patient portal. This initiative aims to significantly enhance 
communication between patients and clinicians, thereby reducing associated safety 
risks. A key requirement of the project is the provision of secure messaging 
functionality, enabling timely, confidential communication and supporting alerting and 
escalation processes for patients who may be approaching crisis. The project is 
currently in development, with tendering underway to support NHS App integration. 
Completion is anticipated during 2026. 

Zoning 

The MATTERS OF CONCERN are as follows: 

Chief Executive, 

  Chairman, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 ‘Jonathan’s  case  was  not  “zoned”  that  is,  given  a  priority  coding  on  the  case 
management  system.   Therefore,  there  was no expected  period  for case  review or 
regularity  of  expected  contact.    The  multi-disciplinary  meetings  and  supervision 
meetings when Jonathan’s case was discussed failed to recognise and address this 
issue.  Appropriate zoning and regular reviews are a fundamental part of mental health 
care and should be embedded and prioritised as part of each patient’s care planning.’ 

We accept the concern raised and recognise that appropriate zoning and regular 
review are essential components of safe, coordinated mental health care. 

In response, the Trust has reviewed and strengthened its zoning and case 
prioritisation processes across all relevant community mental health teams.  

The following measures have now been implemented: 

▪  Unzoned Patients: Any patient not currently assigned a zone is flagged and 
updated by the Team Manager and Consultant Psychiatrist, with oversight 
maintained via daily huddle discussions to ensure appropriate zoning is agreed 
and recorded.  Senior Managers also complete regular reviews across the 
Community Service Line on teams with unzoned patients to ensure action is 
taken immediately. 

▪  Daily Huddle Reviews: All patients identified within the red or amber zones or 
who have not been zoned are now discussed daily at multidisciplinary team 
huddles. This includes a review of risks, current concerns, and plans for care 
delivery, especially during periods when the allocated healthcare professional is 
unavailable. 

•  Zoning Meetings:  Our teams are being reviewed to ensure that they are 

holding a minimum of two zoning meetings per week in line with our current 
policy.  

▪  Enhanced Oversight: The Enhanced Response Practitioner and Team 

Manager jointly review red and amber zoned patients daily. In addition, patients 
requiring enhanced support (regardless of zoning) are flagged and reviewed to 
ensure timely interventions. 

▪  Green Zone Monitoring and Escalation: Patients categorised as green are 
reviewed during regular clinical supervision. Where there are any signs of 
deterioration, concerns are raised during the daily huddle, prompting a patient 
review meeting. This meeting may result in a re-zoning decision and updated 
intervention plan based on assessed risk and support needs. 

To help embed this process consistently, we have also taken the opportunity to review 
and revise our team huddle agendas. A standardised huddle directive has been 

Chief Executive, 

  Chairman, 

 
 
 
    
 
 
 
 
 
 
 
 
 
 introduced across all community teams, with clear expectations regarding zoning 
discussion, escalation procedures, and risk review. This standardised approach took 
effect from 1 June 2025 and clear training and implementation support in place to 
ensure this becomes embedded in practice and this will be audited against in 6 
months’ time. 

These steps aim to ensure that zoning is not only applied consistently but also actively 
used to guide care planning, prioritisation, and review frequency in line with best 
practice. 

We extend our sincerest condolences to Mr Hamer’s family and support network. The 
Trust  is  committed  to  learning  from  this  tragic  event  and  ensuring  that  the  issues 
identified do not recur.  We are also grateful to all those involved in the inquest process, 
whose contributions support our continued efforts to improve patient safety and care. 

Yours faithfully 

Chief Executive  

Chief Executive, 

  Chairman,