John Moore

Parliamentary Under Secretary of State  
Department of Health and Social Care 

39 Victoria Street 
London 
SW1H 0EU 

November 09 2022 

Sean Horstead 
Coroners Office 
Seax House 
Victoria Road South 
Chelmsford, Essex 
CM1 1QH 

Dear Mr Horstead,  

Thank you for your letter of 8 February 2022 to the then Secretary of State for Health and 
Social Care, about the death of John Moore. I am replying as Minister with responsibility 
for Mental Health, and thank you for the additional time allowed.     

Firstly, I would like to say how deeply sorry I was to read the circumstances of Mr Moore’s 
death and I offer my most heartfelt condolences to his family.  We must do all we can to 
ensure such failings in care do not occur again. The circumstances your report describes 
are very concerning and I am grateful to you for bringing these matters to my attention.  

In preparing this response, Departmental officials have made enquiries with NHS England, 
as well as the relevant regulator in this instance, the Care Quality Commission. 

You may find it useful to know that the NHS Long Term Plan1 sets out our ambitious 
investment in community mental health services for adults with severe mental illness. As a 
result, since April 2021, all areas are receiving significant additional, ring-fenced funding to 
develop fully integrated primary and community mental health services built around 
Primary Care Networks. This investment includes an improved access to psychological 
therapies, improved physical health care, employment support, personalised and trauma 
informed care, medicines management and support for self-harm and coexisting 
substance use. By 2023/24, this investment will amount to almost £1billion extra per year 
for adults and older adults with severe mental illness. 

Twelve early implementer sites have been in receipt of ongoing transformation funding 
since 2020 to test these new integrated models of primary and community mental health 
care in line with Long Term Plan and the Community Mental Health Framework for Adults 

1 https://www.longtermplan.nhs.uk/publication/nhs-mental-health-implementation-plan-2019-20-2023-24/  

 
 
 
 
 
 
 
 
 
 
 
 
 
 From Maria Caulfield MP 
Parliamentary Under Secretary of State  
Department of Health and Social Care 

39 Victoria Street 
London 
SW1H 0EU 

and Older Adults2.  

All integrated care systems have started work to transform their community mental health 
pathways from 2021/22 in line with published guidance, and ensure the transformed 
models exist in all primary care networks by 2023/24. These models will enable people 
with severe mental illness to have greater choice and control over their care and support 
them to live well in their communities. 

With regard to mental health and homelessness more generally, in 2019 NHS England 
announced that, as part of the NHS Long Term Plan, £30 million would be used to 
establish new specialist mental health provision for people sleeping rough in those parts of 
England most affected by rough sleeping. The ambition was for new specialist mental 
health provision for people who sleep rough to be established in 20 high-need areas by 
2023/24. The NHS has already met and exceeded this ambition, having now established 
23 sites, one of which has opened in Southend, Essex during 2021/22. 

These services are part of co-ordinated efforts to ensure that people who sleep rough 
have better access to NHS mental health support – joining up care with existing outreach, 
accommodation, drug and alcohol and physical healthcare services. They bring together 
doctors, nurses and other clinicians to co-ordinate treatment and support with other local 
organisations including councils. In each area, outreach teams – comprising NHS and 
local authority staff – identify rough sleepers in need of help, support them to access a GP 
and then on to the new expert psychiatric help. 

Furthermore, during 2021 and 2022 we have provided £16million to develop, implement 
and learn from the adoption of new ‘out of hospital care’ models for people experiencing 
homelessness. This funding provides wrap-around care for people at risk of homelessness 
on discharge from hospital in 17 areas.  

I would also like to assure you that we are committed to working with the suicide 
prevention sector, and more broadly, over the coming year to review our 2012 Suicide 
Prevention Strategy for England. We have worked closely with the Zero Suicide Alliance 
and Royal Colleges to publish a refreshed consensus statement and accompanying 
guidance, that will support frontline staff in sharing information if someone is at risk of 
suicide.   

We are investing an additional £57million in suicide prevention by 2023/24 through the 
NHS Long Term Plan. This will see investment in all areas of the country to support local 
suicide prevention plans and the development of suicide bereavement services. In addition 

2 https://www.england.nhs.uk/publication/the-community-mental-health-framework-for-adults-and-older-
adults/  

 
 
 
 
 
 
 
 
 
 
 From Maria Caulfield MP 
Parliamentary Under Secretary of State  
Department of Health and Social Care 

39 Victoria Street 
London 
SW1H 0EU 

to this, we also provided an extra £5 million in 2021/22, to be made available specifically to 
support suicide prevention voluntary and community sector organisations. 

In December 2021, we launched our £4 million Suicide Prevention Grant Fund for 
voluntary and community sector organisations, to support them to continue to deliver vital 
suicide prevention services. And in February 2022, we announced an additional £1.5 
million to top-up the existing grant fund. This additional funding will further help support the 
suicide prevention voluntary and community sector to meet the needs of people at risk of 
suicide, or in crisis.   

Finally, I would add that, the Essex Mental Health Independent Inquiry has recently been 
set up to investigate matters surrounding the deaths of mental health inpatients in NHS 
Trusts across Essex, including the Essex Partnership University NHS Foundation Trust, 
between 2000 and 2020.  

The Inquiry is currently gathering evidence which will then inform its recommendations to 
Government on what changes may be needed to improve mental health inpatient care, 
both in Essex and wider systems. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.  

Kind regards,

1st April 2022 

Private and Confidential 
Mr Sean Horstead 
Area Coroner 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Mr Horstead, 

Trust Offices 
The Lodge 
Lodge Approach 
Wickford 
Essex 
SS11 7XX 

I am writing to set out the Trust’s formal response to the report made under paragraph 7, 
Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013, dated 8 February 2022, which was issued following the 
inquest touching the death of Mr John Moore. 

I would like to begin by extending my sincere condolences to the family and friends of Mr 
Moore. This has been an extremely difficult time for them and I hope that my response provides 
assurance that the Trust takes their loss seriously and has taken action to address the issue of 
concern raised in your report. 

In response to the matters of concern: 

1.  EPUT Care Coordinators receive inadequate training for the role. Care Coordinators carry 
significant responsibilities to coordinate the care provided to an often extremely vulnerable 
cohort of patients. This responsibility was significantly heightened in the context of the 
Covid-19 pandemic, and the accompanying periods of 'lockdown', when vulnerable and 
often isolated sufferers of mental health illness and disorders, including those with 
substance misuse issues, became increasingly isolated and thus increasingly vulnerable. 
Notwithstanding the imposition of this additional responsibility, the evidence in this and 
similar coronial investigations has established that Care Coordinators receive no formal 
training for the role and, at best, are introduced to it via the 'shadowing' of colleagues 'on 
the job'. At inquest evidence was provided by an experienced (Band Ba) EPUT Clinical 
Manager that the lack of formal training for the pivotal role of Care Coordinator within 
EPUT is one that reflects the same practice in NHS Trusts across the country. 

The Care Programme Approach (CPA) was introduced by the Department of Health in 1991 and 
updated in 2008. It was intended to provide greater shape and coherence to local approaches 
supporting people with severe mental illnesses in the community. This was based on care 
coordination, care planning and case management and had a central role in the planning and 
delivery of secondary care mental health services since its implementation. 

In January 2019, the NHS published its Long Term Plan which committed to transforming 
community mental health services by funding and implementing new and integrated models of 
primary and community mental health service for people with severe mental health problems 
across England. The Community Mental Health Framework (2019) proposed the replacement of 
CPA for community mental health services while retaining the principles based on good care 

 
 
 
 
 
 
 
 
 
 
 
 
 
 coordination and high quality care planning. In recent years, there have been a number of 
concerns raised by stakeholders that the way in which CPA is used represents a major barrier 
to providing the higher quality, more flexible and personalised care that the Community Mental 
Health Framework envisages and that patients need. 

In July 2021, NHS England published a position statement with regard to the planned future of 
CPA. This document states: 

The Community Framework makes clear that one of its purposes is to enable services to shift 
away from an inequitable, rigid and arbitrary CPA classification and bring up the standard of 
care towards a minimum universal standard of high-quality care for everyone in need of 
community mental healthcare. A flexible, responsive and personalised approach following a 
high-quality and comprehensive assessment means that the level of planning and co- 
ordination of care can be tailored and amended, depending on: 

the complexity of an individual’s needs and circumstances at any given time 

• 
•  what matters to them and the choices they make 
• 
•  professional judgment. 

the views of carers and family members 

The new approach is based on the following five broad principles, some of which are further 
outlined below: 

•  A shift from generic care co-ordination to meaningful intervention-based care and 

delivery of high-quality, safe and meaningful care which helps people to recover and 
stay well, with documentation and processes that are proportionate and enable the 
delivery of high-quality care. 

•  A named key worker for all service users with a clearer multidisciplinary team (MDT) 
approach to both assess and meet the needs of service users, to reduce the reliance 
on care co-ordinators and to increase resilience in systems of care, allowing all staff to 
make the best use of their skills and qualifications, and drawing on new roles including 
lived experience roles. 

•  High-quality co-produced, holistic, personalised care and support planning for people 
with severe mental health problems living in the community: a live and dynamic 
process facilitated by the use of digital shared care records and integration with other 
relevant care planning processes (eg section 117 Mental Health Act); with service 
users actively co-producing brief and relevant care plans with staff, and with active 
input from non-NHS partners where appropriate including social care (to ensure Care 
Act compliance), housing, public health and the voluntary, community and social 
enterprise (VCSE) sector. 

•  Better support for and involvement of carers as a means to provide safer and more 
effective care. This includes improved communication, services proactively seeking 
carers’ and family members’ contributions to care and support planning, and 
organisational and system commitments to supporting carers in line with national best 
practice. 

•  A much more accessible, responsive and flexible system in which approaches are 
tailored to the health, care and life needs, and circumstances of an individual, their 
carer(s) and family members, services’ abilities and approaches to engaging an 
individual, and the complexity and severity of the individual’s condition(s), which may 
fluctuate over time. 

With regard to the shift from generic care coordination to meaningful interventions, the position 
statement states: 

2 

 
 
 
 
 
 
 
 Care co-ordination is important work and has often been under-appreciated as a function 
which should provide high quality care to service users, often within an outmoded and 
historically resource-constrained system. While many service users find care co-ordination 
valuable – and while care co-ordination may form a significant part of the overall support that 
someone with a severe and complex mental health problem receives – care co-ordination is 
not a meaningful intervention in and of itself. 

In order to achieve the transformation of community mental health services that we want to 
see across England, providers and their partners should therefore move away from care co- 
ordination as an intervention in itself and focus delivering compassionate, meaningful, 
intervention-based care which has been planned between the service user and their care 
team (eg timely commencement of a course of psychological therapy). At the same time, the 
Framework’s emphasis on ensuring that flexible, longer-term systems of care are in place for 
people with severe mental health problems should be maintained. This will allow the easy 
‘stepping up’ or ‘stepping down’ of care as needed, and will remove the harmful prospect of 
people in need of long-term care being ‘discharged’ and left with no support, or having to 
battle to re-enter services. 

Current systems relating to CPA will remain in place until implementation of the new framework 
is  agreed.  In  light  of  this,  the  Trust  are  delivering  an  enhanced  care  coordination  training 
package as we recognise from recent incidents that whilst a person’s professional training and 
preceptorship equips them with the skills for care coordination, there is clearly a need for further 
support for staff in this area. 

The  training  has  been  developed  and  has  a  planned  roll  out  this  month.  All  staff  within 
community  mental  health  services  will  be  required  to  undertake  the enhanced  training and  I 
would  be  happy  to  share  the  training  slides  with  you  should  you  like a  copy  for  your  records. 
This  training  will  remain  in  place  until  the  new  Community  Framework,  setting  out  the  new 
universal standards, is agreed. 

2.  The evidence in this case, and in other recent inquests heard by me and fellow coroners in 
this jurisdiction, establishes the following common themes in respect to the inadequate 
performance of several EPUT Care Coordinators. In my settled view, these themes are (at 
least to a significant degree) a consequence of inadequate training for the role: 

(i) 

(ii) 

failure to maintain basic record keeping generally and, particularly, with respect 
to the recording of contacts or, potentially importantly, failed contacts with the 
deceased in the weeks and months prior to a self- inflicted death; 
a failure to formally up-date Care Plans and Risk Assessments in a thorough 
and/or timely fashion, or at all; 

The Trust accepts that it needs to improve record keeping and there are a number of methods 
in place to monitor and review the completion of timely and accurate documentation, which 
include: 

•  95% target for recording within 24-48 hours of contact. 
•  Caseload review in line management supervision. 
•  Monthly performance reports which identify activity by clinical staff and what, if any, 
documentation is incomplete. Where this is the case, individual conversations taking 
place with clinical staff to address in a timely way to ensure that appropriate action is 
taken to address the issue. 

The Trust is in the process of gathering data in order to implement the Management and 
Supervision Tool (MaST) caseload management tool, which will help the care coordinator to 

3 

 
 
 
 
 
 
 
 
 
 electronically manage their caseload more effectively. This is a nationally developed 
framework which links in with current electronic systems to provide algorithms and indicators 
for increasing risk as well as disengagement; factors that would be discussed within a Multi- 
Disciplinary Team (MDT) meeting. In addition, the tool would automatically RAG a patient 
based on the inputted data, and this would support clinical decision making around which 
patients are to be presented to the MDT meeting. Evidence from the research nationally is 
that staff using this tool become more effective at recognising patients at risk and improving 
record keeping. Pilot sites have been agreed and they will implement MaST initially. 

(iii) 

inadequate communication with other primary and secondary care providers; 

The Trust has identified mental health clinicians working within the Primary Care Networks 
across Essex which will increase the efficacy of communication between primary and 
secondary care providers. In addition to this, we have ensured that the importance of 
communication with other services and organisations forms a key part of the enhanced care 
coordinator training. 

(iv) 

consistently, insufficient attention to the potential clinical significance of 
'disengagement' with services by patients; 

I can confirm that the Trust’s Disengagement Guideline is currently under review and the 
updated version will include the use of “Purple” RAG rating which will be used by community 
mental health teams to identify disengaging patients and ensure that they are discussed 
regularly in MDTs. 

(v) 

failure to recognise the need to raise issues relating to a patient with the Multi- 
Disciplinary Team Meetings or in supervision with experienced supervisors. 

It is within a professional’s role to determine whether a patient’s care would need to be 
presented to the MDT meeting and this is based on clinical judgement. A care coordinator is a 
registered professional who would work within their code of conduct, which provides a clear 
framework for accountability and responsibility, and the Trust values. Care coordinators would 
have undertaken Trust induction and training in order to support their role and would be 
deemed to be equipped to independently make clinical decisions around presentation to MDT. 
Their decision would be based upon dynamic risk assessment of the patient, the therapeutic 
relationship they have with the patient and their family, and their identified needs. Not all 
patients on caseloads would require discussion at the weekly MDT meeting as there are other 
means of formulating discussions to meet the needs of the patient. 

3.  The evidence received in the course of Mr Moore's inquest disclosed that the record 

keeping of supervision sessions, where a Care Coordinator might seek or be provided with 
further advice and support from a senior colleague, was incomplete and inadequate. 

The requirement for undertaking and recording supervision is clearly outlined in the Trust’s 1:1 
Support and Appraisal Policy and Procedure and I will ensure that all care coordinators 
receive additional guidance on this subject. 

4.  A lack of formal (or even informal) records of the nature, extent or duration of ad hoc 'on 

the job/shadowing' training, apparently provided to new Care Coordinators. 

As mentioned in point 1 above, the Trust is implementing enhanced care coordination in April 
2022. 

4 

 
 
 
 
 
 
 
 
 
 
 
 I hope that I have provided you with robust assurance that the Trust has taken steps to address 
the issues of concern in your report, that we are continuing to take action to strengthen the care 
provided to our patients, and that patient safety is the Trust’s top priority. 

Yours sincerely, 

Chief Executive 

5

Sean Horstead 
Area Coroner, 
Essex and Thurrock Coroner’s Service,  
Essex County Council,  
County Hall,  
Chelmsford  
CM1 1QH 

National Medical Director and Interim 
Chief Executive of NHS Improvement 
NHS England & NHS Improvement  
Skipton House 
80 London Road 
London 
SE1 6LH 

18 May 2022 

 Dear Mr Horstead 

Re: Regulation 28 Report to Prevent Future Deaths – John David Moore who 
died on 10 June 2021  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 
February 2022 concerning the death of John David Moore on 10 June 2021. I would 
like to express my deep condolences to John Moore’s family.  

I would like to apologise for the length of time this response has taken.  

I note the inquest concluded that Mr Moore’s death was as a result of suicide, with a 
medical cause of death of: 

1a Fatal pressure on the neck  

Following the inquest, you raised concerns in your Report that you have heard 
evidence at a number of recent inquests held in your jurisdiction concerning the 
deaths of individuals with a history of involvement with EPUT Mental Health 
Services.  In particular that Care Co-Ordinators receive inadequate training for their 
roles, which involve carrying significant responsibilities to coordinate the care 
provided to an often extremely vulnerable cohort of patients. I note that your 
concerns include common themes in respect to the inadequate performance of 
several EPUT care coordinators, namely inadequate record keeping, updating care 
plans and risk assessments, inadequate communication with other primary and 
secondary providers, insufficient attention to the potential clinical significance of 
‘disengagement’ with services by patients and the failure to raise relevant issues at 
Multi-Disciplinary Team meetings or in supervision with supervisors.  

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The EPUT response has been shared with NHS England and Improvement and I am 
assured that the actions will deliver on your concerns about the training of the 
current Care Coordinators.    

The NHS Long Term Plan sets out ambitious investment in community mental health 
services for adults with severe mental illness. From April 2021 all areas are receiving 
significant additional, ring-fenced funding to develop fully integrated primary and 
community mental health services built around Primary Care Networks (PCNs) which 
includes improved access to psychological therapies, improved physical health care, 
employment support, personalised and trauma informed care, medicines 
management and support for self-harm and coexisting substance use. By 2023/24, 
this investment will amount to almost £1billion extra per year for adults and older 
adults with severe mental illness. 

12 early implementer sites have been in receipt of ongoing transformation funding 
since 2019/20 to test new integrated models of primary and community mental 
health care in line with LTP and the Community Mental Health Framework for Adults 
and Older Adults.  

All Integrated Care Systems (ICSs) have started work to transform their community 
mental health pathways from 2021/22 in line with published guidance, and ensure 
the transformed models exist in all PCNs by 2023/24. These models will enable 
people with severe mental illness to have greater choice and control over their care 
and support them to live well in their communities. 

Thank you for bringing these important patient safety issues to my attention and 
please do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director and  
Interim Chief Executive of NHS Improvement