George Fraser

PRIVATE  & CONFIDENTIAL  

Ms Nadia Persaud 
HM Coroner 
East London Coroner’s Service 
124 Queens Road 
Walthamstow 
London 
E17 8QP 

By email only to:  

coroners@walthamforest.gov.uk 

Your ref:  28676512 
Trust ref: 1576 

Dear Madam 

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

23rd July 2025 

Re: Inquest touching upon the death of George Fraser 

I am writing in response to your Prevention of Future Deaths report, dated 23 May 2025, detailing 

your concerns about the risk of future deaths following the findings of the Inquest.  

Firstly, I should like to extend my sincere condolences to the family of George Fraser.  This must 

have been a challenging time for them, and I hope that my response provides you and them with 

assurance that the North East London Foundation Trust (NELFT) is taking action to address the 

issues set out in your report. 

The concerns raised were that: 

1.  There was no clear and documented care plan in place whilst Mr Fraser was under the 

care of the Mental Health and Wellness Team (MW&HT). There was a lack of structure 

to the care provided to Mr Fraser by the Mental Health and Wellness Team. 

www.nelft.nhs.uk 

 
 
 
           
 
 
 
 
 
 
 
                                    
 
 
 
 
 
 
 
 
 
 2.  There  was  no  robust  risk  assessment  carried  out  by  the  Mental  Health  and  Wellness 

team. 

3.  The Mental Health and Wellness Team had been unable to reach Mr Fraser from the 16 

July 2024. On 18 July 2024, a friend contacted the mental health team to raise concerns 

about his lack of contact with Mr Fraser. No action was taken at this time to review the 

risk of harm to Mr Fraser or to determine whether the Trust’s missing person procedure 

should  be  activated.  There  was  no  meaningful  contact  with  the  family  to  report  the 

concerning lack. 

I was sorry to hear these concerns.  As a Trust we continue to implement changes in a number 

of areas that aim to improve our service in these areas, and these are set out below. 

Care Plans 

Since 2024, we have been undertaking significant improvement work in relation to care planning.  

This has been driven by identified quality improvements, including those raised by patients and 

carers.  In doing so, we have worked in close collaboration with patients and carers. 

The Mental Health and Wellness team are now using the DIALOG tool in working with patients 

who are presenting to services.  This is a quality of life and outcome measure that is completed 

by service users, allowing them to focus care planning work on the most important areas of their 

life to them across a number of domains, including mental and physical health, relationships, and 

accommodation.  Staff use the DIALOG questionnaire to understand what matters most to the 

service user and this information helps staff and service users collaboratively develop a care plan 

tailored to the user's priorities.  The questionnaire facilitates a comprehensive assessment of the 

user's needs and can be reviewed during care plan evaluations to track progress and establish 

future goals.  Community team staff have been trained in using DIALOG for over a year, with 

refresher  training  available  as  needed.    We  are  monitoring  the  use  of  this  approach,  and  the 

number  of  plans  being  developed  in  this  way  is  increasing  as  implementation  progresses.  

Additionally,  care  planning  workshops  have  been  held  throughout  2025  and  are  scheduled  to 

continue.  These workshops aim to support staff to use their skills to co-create individualised care 

plans with service users and their support networks.  The workshops emphasise the importance 

of involving service users in the care planning process, focusing on their preferences and goals.  

Chair: 
Chief 

www.nelft.nhs.uk 

 
 
 
                               
 
 
 
 
 
 By  including  service  users  and  carers  alongside  clinical  staff,  the  workshops  foster  a  deeper 

understanding of the value of well-structured, recovery-focused care plans. 

Mental Health and Wellness Teams in Havering have also started using an electronic system, 

the  Management  and  Supervision  Tool  (MaST).    This  enables  clinicians  and  managers  to 

manage caseloads and to monitor the quality of documentation, levels of engagement, and how 

documentation reflects risk and the complexity of a patient’s needs.  This also enables monitoring 

of  DIALOG  and  care  planning,  allowing  staff  to clearly  identify,  where  review  of  the  patient  is 

required. 

The  patient  safety  investigation  report  into  Mr  Fraser’s  sad  death  also  highlighted  learning 

outcomes  in  relation  to  team  risk  management.    When  Mr  Fraser  was  not  engaging  with  the 

Mental  Health  and  Wellness  Team,  outcomes  from  the  multidisciplinary  zoning  meeting  were 

relatively passive, meaning that there was not an assertive response to support Mr Fraser.  To 

support improvements in relation to this, we have established a Quality Improvement project to 

review zoning practices across the four boroughs.  One outcome of this will be a revised template 

for teams to use to review cases, that maintains a focus on when the last face to face contact 

with  a  client  took  place.    The  implementation  of  the  MaST  tool  also  assists  practitioners  and 

supervisors in ensuring that face to face contact with clients is taking place appropriately.  

The patient safety incident investigation report also highlighted that although a transfer of care 

from the Home Treatment Team to the Mental Health and Wellness Team was completed, there 

was a  lack of  follow  up from the Mental  Health and  Wellness  Team  to  support Mr  Fraser.   In 

response to this, we have strengthened both the induction process for new care co-ordinators to 

focus on thorough handover of client information to try and maintain continuity of care, and the 7 

day follow up process for clients at the point of transfer between teams.  This change is intended 

to prevent the lack of follow up that took place in Mr Fraser’s case from occurring in future. 

Risk Assessments 

Since  the  publication  of  NICE  Guidance  NG225  on  self-harm  was  published,  focusing  on 

assessment, management, and preventing recurrence, we have been working to change Trust 

practice  in relation to  the assessment  and management  of risk.   In  November  2023,  NELFT's 

senior clinical leadership established a working group to plan for the full implementation of this 

Chair: 
Chief 

www.nelft.nhs.uk 

 
 
 
                                
 
 
 
 
 
 approach.  The working group comprises staff from all professional groups, as well as service 

users and carers.  To support implementation of this, new training has been developed, electronic 

recording  systems  reviewed  and  updated,  trainers  recruited,  and  team  support  designed  to 

ensure that staff are equipped to embed this new way of working.  This work programme  has 

been co-produced with service users and carers, including involvement in training delivery, with 

every training day supported by a service user or carer to ensure their voice was heard throughout 

the process.  This undertaking required considerable preparation before the rollout of the training 

began  in  2024.    The  training  programme  has  been  delivered  locality  by  locality,  with  three 

localities completed to date (July 2025).  Havering staff are due to complete their training at the 

end of this month, 2025 and the overall Trust training timelines are outlined in the table below. 

Directorate 

Training Dates 2024 

Training Dates 2025 

Acute and Rehab Directorate 

Sept – Dec 

Barking & Dagenham 

Waltham Forest 

Havering 

Redbridge 

January to March 

April to June 

May to July 

July to September 

Compliance is monitored in teams through individual supervision, utilising the MaST tool, as well 

as team meetings and clinically focused groups, such as the team zoning meeting.  

Feedback to date is that risk formulation does enable service users and staff to design care plans 

that are more responsive and person-centred to immediate needs and mitigate risk as far as is 

reasonably practicable and the outcome of this work will continue to be monitored by teams and 

across  the  trust.    This  ongoing  monitoring  (and  future  development  of  this  approach)  is  co-

ordinated  through  the  Trust’s  Risk  Formulation  Steering  Group  and  the  work  of  this  group 

includes  supporting  directorate  and  place-based  leaders  to  measure  patient  and  staff 

experiences,  as  well  as  ensuring  the  quality  of  risk  formulation.    The  aim  of  this  is  to  embed 

cultural change and integrate formulation-based approaches into all clinical risk discussions. 

Missed Appointments Procedure 

The NELFT Missed Appointments Policy is currently under review and the updated version is 

expected to be finalised in the Autumn of 2025.  The updated policy now includes more robust 

Chair: 
Chief 

www.nelft.nhs.uk 

 
 
 
                                
 
 
 
 
 
 
 
 
 
 
 guidance on how to work with patients in more person-centered way when they disengage or 

miss  appointments,  or  where  attempts  to  contact  the  users  of  the  service  have  been 

unsuccessful. 

The policy outlines that staff should contact the family and individuals in the service user's social 

network, the  GP,  and  any  other  services which  are involved.   The  policy also provides that  a 

contact with the Police may be indicated.  

The  policy  also  indicates  that  concerns  raised  by  family  or  friends  should  always  be  taken 

seriously,  and  these  should  be  escalated  through  management  lines  if  the  staff  member  is 

unclear  of  further  action.    Where  concerned,  staff  members  should  liaise  with  the  next  of  kin 

about  joint  visits  to  the  service  user's  place  of  residence  or  other  establishments  they  may 

frequent. 

The use of the MaST tool within teams also enables clinicians and clinical managers to easily 

see  when service users last  engaged with  the  service,  providing  information  to  clinicians  and 

team leaders on where service users are not engaging, or where clinicians are not seeing people 

regularly. This information can be addressed in individual supervision and clinical meetings. 

I  hope  that  the  above  reassures  the  family  of  Mr.  Fraser  and  the  Court  that  the  Trust  takes 

learning from Inquests very seriously and that it has taken relevant actions to improve its service.  

If I can be of any further assistance or if you would like a further update on the progress made to 

address your concerns, I would be happy to assist. 

Yours faithfully 

Chief Executive Officer 

Chair: 
Chief 

www.nelft.nhs.uk 

 
 
 
                                
 
 
 
 
 
 
 
 
 Chair: Eileen Taylor 
Chief Executive: Paul Calaminus 

www.nelft.nhs.uk