Abbigail Smith

22nd July 2026 

Private and Confidential 
Ms Sonia Hayes  
HM Area Coroner for Essex 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford   CM1 1QH  

Dear Ms Hayes 

Abbigail Louise Smith (RIP) 

Trust Headquarters 
The Lodge 
Lodge Approach 
Wickford 
Essex 
SS11 7XX  

I write 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 27th May 2026. 

This notice was received by the Trust on the above date, following the inquest into the sad 
death of Abbi. 

I would like to begin by extending my deepest condolences to Abbi’s family. The Trust 
expresses its sincere sympathies and acknowledges the profound nature of their loss. 

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed 
and noted.  I will now respond in full to the concerns raised in the hope that this provides both 
yourself and Abbi’s family with comprehensive assurances of the changes that have been made 
at the Trust to address the concerns you have raised.  

Concern 1: Abbi spent most of her adult life in detention and Abbi was transferred to a 
specialist Tier 4 mental health hospital by EPUT for investigation and assessment of her 
diagnosis who confirmed she did not have personality disorder. Abbi was seen by very junior 
clinicians even though she was an extremely complex patient.  

Response:  

The Trust accepts that Abbi's history, complexity and recent specialist diagnostic review should 
have informed a higher level of senior clinical oversight. In retrospect, the level of consultant 
involvement did not adequately reflect the complexity of her presentation. 

At this time Consultant caseloads within the community team at The Gables were elevated.  The 
process for outpatient appointment allocation was on the basis of clinician availability rather 
than patient complexity or clinical seniority.  

In response, the Trust has taken the following actions: 

  The Gables community team has revised its allocation processes. Senior nursing 

colleagues now triage patients prior to allocation, with the Consultant holding oversight 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 of all clinic bookings. Allocation decisions are explicitly informed by the complexity of 
the patient's presentation, the experience and expertise of the proposed clinician, 
together with appropriate supervision support.  

  To ensure consistency across wider Trust services, the requirement for Consultant 
oversight of psychiatry outpatient clinic allocations is being embedded across all 
community services.   

  Senior clinical supervision and consultant support is now available to all clinicians 

managing complex patients. 

Concern 2) The diagnosis of personality disorder was later reapplied to Abbi by a junior in 
the  community  with  no  rationale  recorded  and  this  was  not  noted  or  queried  by  the  local 
community team or Consultant Psychiatrist.  

Response:  

EPUT acknowledges that following Abbi's discharge from the Tier 4 hospital, the diagnosis of 
personality disorder was reapplied by a junior clinician within the community team without 
any recorded clinical rationale.  

The Trust further acknowledges that this was not identified or queried by the community 
team or the responsible Consultant Psychiatrist at the time. Whilst personality disorder and 
other psychiatric diagnoses may coexist, the Trust accepts that the rationale for reintroducing 
the diagnosis was not clearly documented and should have been subject to senior clinical 
review. 

The  Trust  has  strengthened  requirements  for  documented  clinical  rationale  when  any 
diagnosis is amended or reapplied. Consultant oversight of diagnostic decisions for complex 
patients is an expectation within the community teams. The Community First team will further 
embed  these  expected  standards  structurally,  by  reducing  Consultant  caseloads  and 
ensuring that oversight is achievable in practice. 

Concern 3) In October 2021 Abbi suffered a deterioration in her mental health with reported 
non-compliance  of  Clozapine  medication.  The  Consultant  Psychiatrist  emergency  plan  was 
not followed: 

a.  Short-term  prescription  of  Diazepam  to  assist  with  an  exacerbation  of  distressing 
symptoms  to  permit  Abbi’s  Clozapine  to  be  re-titrated  was  incorrectly  continued  as  a 
permanent  prescription  in  the  absence  of  a  medical  review  and  this  was  not  compliant 
with the NICE Guidelines. 

b.  Urgent follow-up  required for  a predicted  and inevitable deterioration in the  event  of 
continued non-compliance did not take place.   

c.  Abbi’s  medical  records  were  not  updated  as  required;  there  were  omissions  in  the 
significant information about Abbi’s clinical condition and Abbi was not escalated back to 
the  Consultant  Psychiatrist.    These  matters  were  then  not  understood  by  the  mental 
health professionals as Abbi continued to deteriorate and increase of Abbi Diazepam was 
prescribed. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Response:  

EPUT accepts that although contact with Abbi continued the Consultant's emergency plan 
was only partially followed during this period.  

The Consultant acted appropriately in October 2021 prescribing a carefully considered short-
term bridging plan whilst awaiting Clozapine recommencement and arranging a medical 
review for December 2021.  

However, the Trust acknowledges that Diazepam was converted from PRN to twice daily 
without clear documented medical authorisation and Abbi's decision to decline.  Abbi had 
capacity at this point to make decisions in regards to her care and treatment.  Clozapine 
recommencement, was not escalated back to the Consultant. 

Following notification that Abbi had ceased taking her prescribed Clozapine, the Care 
Coordinator acted promptly by contacting her to assess her mental state and subsequently 
undertaking further reviews, including a home visit to discuss her wellbeing, treatment plan 
and medication adherence. Throughout these contacts, Abbi engaged appropriately.  

The Care Coordinator sought urgent medical advice regarding recommencement of 
Clozapine through re-titration and alternative treatment options if this was declined, resulting 
in an urgent Consultant review. Following assessment, the Care Coordinator and Clozaril 
Nurse met with Abbi to discuss restarting Clozapine; however Abbi decided not to do so, 
reporting that the newly prescribed Quetiapine and Promethazine were working well. This 
view was also reflected by staff within her supported accommodation and acknowledged by 
the Trust. 

In response the Trust has taken the following actions: 

  A Trust wide audit of benzodiazepine prescribing in the community has been 

commissioned to provide assurance that all prescribing adheres to NICE Guidelines 
and BNF guidance regarding indication, dosage, duration, and review, with findings 
informing quality improvement actions where required. 

  Consultant Psychiatrists are required to adhere to Trust policy and NICE guidance on 

benzodiazepine prescribing, with particular emphasis on short term use, clear 
documentation of clinical rationale, and explicit review dates. Adherence continues to 
be monitored via direct supervision reviews.  

  Non-attendance by a patient prescribed time-limited medication (such as 

benzodiazepines) will trigger an urgent review of treatment plan, raised jointly by the 
Care Coordinator and the prescribing medic, to ensure the ongoing appropriateness 
of the prescription is actively assessed. 

  The Care Coordinator who was involved in Abbi’s care now ensures that all email 

documentation is saved on the patient’s records.  In addition, Trust wide training has 
been delivered on the importance of ensuring full records are stored / saved in a 
timely manner into patient records.   

These standards are being re-enforced across community services through the Trust’s 
Community First transformation programme, which aims to deliver a structural reduction in 
Consultant caseloads to ensure that clinical oversight and escalation are consistently 
achieved in practice. 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 Concern 4) Abbi remained on a treatment regime during her last admission and discharge at 
the mental health Trust that was known and recorded as had not been previously successful. 
Abbi  had  positively  responded  to  Clozapine  in  the  past  such  that  Abbi  was  discharged  to 
supported  living  from  the  Tier  4  specialist  unit.  Abbi’s  deterioration  with  continued  non-
compliance with Clozapine was recorded by the local community Consultant Psychiatrist as 
predicted and inevitable. No plans were put in place to mitigate this. 

Response:  

The Trust accepts that whilst the risk of deterioration was recognised, the subsequent 
change in Abbi's treatment engagement was not escalated in a way that allowed the original 
risk mitigation plan to be reviewed and amended. 

Whilst concern 3 indicates that the emergency plan was not followed, whereas concern 4 
suggests that a treatment regime was in place, it is the Trust’s respectful submission that the 
Consultant acted appropriately in October 2021, documenting the clinical risk clearly, 
introducing an interim bridging regime, and arranging a medical review for December 2021.  

Critically, at the October 2021 review Abbi agreed to restart Clozapine, and the Consultant's 
plan was therefore clinically sound and made on the basis of that agreement.  

Following the October review Abbi subsequently told her Care Coordinator that she would 
not restart Clozapine. Clozapine is a treatment that requires consistent patient engagement. 
Variable or intermittent compliance is not clinically viable and recommencement requires re-
titration under controlled conditions.  

The Trust however acknowledges that this change in Abbi's position was not escalated back 
to the Consultant. The Trust acknowledges that the Care Coordinator was regularly seeing 
Abbi and there was no observed clinical deterioration apparent at those contacts. 

In response the Trust has taken the following actions: 

  Upon staff becoming aware that a patient is not taking their medication as prescribed, 
immediate escalation is made to the responsible Consultant Psychiatrist, the case is 
discussed at the multidisciplinary team (MDT) meeting, risk is formally assessed and 
RAG-rated within the zoning meeting, and an agreed action plan is documented; a 
copy of the MDT minutes is uploaded to the patient’s electronic record (PARIS) and 
circulated to all relevant professionals. 

  Supported living providers working with complex patients are now included in safety 
and escalation planning at the point of discharge and at Care Programme Approach 
reviews. 

These standards are being reinforced across community services through the Trust’s 
Community First transformation programme, which will deliver a structural reduction in 
Consultant caseloads to ensure that the oversight and risk mitigation planning required for 
complex patients is consistently achieved in practice. 

Concern  5)  Abbi  deteriorated  significantly  at  the  end  of  January  2022  and  February  2022 
requiring  police  to  take  Abbi  to  a  place  of  safety  due  to  her  presentation  and  level  of  self-
harm  and  suicidality  that  required  a  Mental  Health  Act  assessment.  Professional  concerns 
were  raised  about  inaccurate  clinical  information  contained  in  the  documentation  from  the 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Approved  Mental  Health  Act  Professional  (AMHP)  that  were  about  another  patient.  Abbi 
made a video about the contents of this letter that reinforced her view that professionals did 
not  care  about  her.  Abbi  received  an  apology  about  the  inaccuracies  in  this  AMHP 
assessment shortly before her death.  

Response:   

Please note that the AMHP service is not provided by EPUT, this is provided by Essex 
County Council (ECC) who would be best placed to respond to this concern.    

Concern 6) There were issues in communication and sharing of information. Evidence was 
that some EPUT staff did not appreciate Abbi’s history and did not read the medical records 
or query inconsistencies. Not all clinical contacts were appropriately recorded. 

Response:   

The  Trust  accepts  that  there  were  occasions  where  relevant  historical  information  was  not 
fully considered and where clinical contacts were not recorded consistently. 

A task and finish group was established as part of the Trust PSII Review Action Plan in 
respect of the vital importance of records review. In response to this concern, staff have been 
reminded again to review relevant patient history and gather information from family (where 
there is consent to do so). As per the evidence presented in court such reminders form part 
of structured supervision meetings as well as service governance meetings.   

Staff  continue  to  ensure  the  family  are  given  a  voice  in  relation  to  key  information  and 
relevant history, this is facilitated by inviting families to MDT meetings (if the patient agrees) 
and direct access to medical and nursing teams.   

Trust  services  also  use  the  MaST  tool  to  monitor  and  audit  caseloads.  MaST  employs  an 
algorithm  which  takes  into  account  a  number  of  different  factors  that  might  influence  a 
patient's  needs  –  like  housing,  medications,  disabilities  and  other  health  conditions  –  and 
highlights  where  a  patient  may  need  additional  support.  The  dashboard  highlights  patients 
who may be at increased risk of crisis. It also flags when patients have not been contacted 
recently,  or  need  a  follow-up  appointment.  While  MaST  is  not  designed  to  replace  clinical 
expertise  and  judgement  in  managing  their  caseloads,  it  brings  a  range  of  relevant 
information into one place, enabling informed, evidence-based decisions. 

Concern  7)  Staff  supporting  Abbi  were  not  trained  in  Autism  or  how  to  communicate  with 
Abbi  as  a  neurodivergent  person  with  a  learning  disability.  Expert  evidence  was  that  there 
was  insufficient  exploration  of  how  this  impacted  specifically  on  Abbi  and  how  best  to 
communicate  with  her  and  how  information  should  have  been  presented  to  her  about  her 
diagnosis,  care  and  treatment.  The  evidence  of  some  later  training  was  not  considered 
sufficient. 

Response:   

The  Trust  accepts  that  greater  consideration  could  have  been  given  to  how  Abbi's  autism 
and learning disability influenced her communication needs, understanding of diagnosis and 
engagement with services. 

All staff are now required to take part in the national mandatory Oliver McGowan training 
which was legislated on 1st July 2022, and rolled out at EPUT in 2023. 

5 

 
 
 
 
   
 
 
 
 
 
   
 
 
 
 A number of steps have been taken to address Neurodiversity support within the Inpatient 
setting. There is a section on page 41/42 in the EPUT Therapeutic Acute Inpatient Operating 
Model for Adults and Older Adults’ (2024) with the heading ‘Adults with a learning disability 
and autistic adults’ which includes ‘reasonable adjustments’ and NHSE Guidance references, 
which includes key actions which need to take place for adults with a learning disability and 
autistic adults. 

A range of different initiates are available on different wards, within the Linden Centre there 
are now Sensory Rooms within three of the wards (including Galleywood). The sensory 
rooms have dimmed lights, sensory equipment such as sensory chairs, rocking chairs, black 
out blinds, projectors, a water bed, and weighted blankets. These rooms have been 
developed with the help of Occupational Therapists, Psychology and the patients themselves 
and are available to use 24/7. 

In additional sensory boxes are available for the patients’ individual rooms within the Linden 
and Crystal Centres. These include risk assessed items such as fidget toys, bands, ice  
packs. Should the individual have their own individual sensory items these can be included to 
enable a patient centred approach.  

Patients with an identified Neurodiversity need / diagnosis will have a specified care plan 
suited to their needs working alongside the MDT. Staff are also clear to seek the support of 
Psychology when a need is identified as well as the Trust- Autism Specialist, Dr Dakin.  

In respect of our Community care, guidance in relation to the managing of persons with a 
learning disability or autism are set out in the Transforming Care Programme which is a UK 
health and social care initiative established in 2012 following the Winterbourne case.  This 
guidance aims to reduce reliance on inpatient care and enhance community-based support. 
It's driven by the "Building the Right Support" strategy and involves various initiatives across 
health and social care sectors 

The key goal of the program aims to improve the quality of care and quality of life for people 
with learning disabilities and/or autism, and to reduce inappropriate hospital admissions and 
lengths of stay by enhancing community based support.   

All clinicians are trained in their core training to make reasonable adjustments. This is 
covered in mandatory training. 

Mid and South Essex Integrated Care Board (MSE ICB) commissioned Essex County 
Council (ECC) to provide these services which is in the form of the ‘Transforming Care 
Team’. ECC manages the Dynamic Support Register (DSR) which is a register of people 
with learning disability and/or autism who are at increased risk of hospital admissions. 
Community Teams and other parties are able to make referrals into the DSR panel where 
they are discussed and if appropriate added to the register.  

Where it is noted that risks are increasing in the community, a Community Care Treatment 
Review (CCTR) is held to review what appropriate support should be provided to mitigate a 
hospital admission. These reviews are also held prior to discharge from an inpatient setting, 
and is known as a Care Treatment Review (CTR). ‘Case Handlers’ from the Transforming 
Care Team work across inpatient settings with the inpatient services and Community Mental 
Health Teams looking at appropriate discharge planning. This was not in place at the time of 
Abbi’s passing and is still developing. 

6 

 
 
 
 
 
 
 
 
 
 
 The Gables Specialist Mental Health Team (SMHT) have recruited a new post, a Community 
and Inpatient Liaison Practitioner Community Psychiatric Nurse (CPN). This role is intended 
to work directly with inpatient services.  

This member of staff will meet with the patients on the ward, attend ward reviews and work 
closely with the inpatient team to ensure a safe discharge, improve communication and 
provide a more seamless service. It is anticipated that having a CPN involved from 
admission will allow earlier identification and communication with other providers involved in 
the person’s care.  

From a psychology perspective, a number of staff within the Trust have undertaken the 
National Autism Training Programme which has a specific focus on inpatient settings.  The 
in-patient Psychology team have used this framework to develop a one day training around 
working with Autistic individuals for inpatient staff.  This has been in operation for 
approximately 2 years at the Trust.  

In-patient Psychologists support around PBS (Positive Behaviour Support Plans) and CTRs 
(Care and Treatment Reviews). In terms of community teams, we have psychologists based 
in community teams who work to support colleagues around reasonable adjustments for 
working with Autistic individuals.  

Concern 8) There were no professionals’ meetings to consider how best to respond to Abbi 
when in crisis and how crisis could be mitigated to avoid hospital admission. Abbi was a 
complex young woman who suffered an obvious and predicted deterioration.  

Response:   

The Trust has considered this concern is detail.  The Trust acknowledges that the MDT 
meetings should manage the risks involved with the individuals and their families.   
The Trust acknowledges that, given the complexity of Abbi’s presentation and the recognised 
risk of deterioration, there should have been greater multidisciplinary oversight and more 
structured crisis planning to reduce the risk of hospital admission. 

In response, the Trust has strengthened arrangements to ensure that patients presenting 
with deterioration, increased risk, or medication non-compliance are promptly escalated to 
the responsible Consultant Psychiatrist, discussed within MDT and zoning meetings, and 
managed through documented risk assessments and action plans. Supported living 
providers are now routinely included in safety planning and CPA reviews to improve 
coordinated responses during periods of crisis. Where relevant other professional are 
involved and professional meeting are coordinated accordingly. 

As stated above, the Trust has also implemented the MaST tool to identify patients at 
increased risk of crisis in order to facilitate earlier review. The Trust rolled out this tool from 
April 2024, which is now in place across all community teams. In addition, patients with 
autism and/or learning disabilities can now be referred through the Dynamic Support 
Register and Community Care and Treatment Review processes to bring agencies together 
to consider enhanced community support and alternatives to hospital admission. 

These improvements are being further embedded through the Community First 
transformation programme, which is strengthening MDT oversight, consultant involvement, 
and risk management arrangements for patients with complex needs. 

The Trust recognises the importance of coordinated multi-agency working in supporting 
individuals with autism and/or learning disabilities who may be at risk of crisis or hospital 

7 

 
 
 
 
 
 
 
 
 
 
 
 admission. Patients identified as being at increased risk can be referred to the Dynamic 
Support Register (DSR), which is managed through the Transforming Care programme. 

Whilst the DSR does not provide direct clinical intervention, it brings relevant agencies and 
services together to ensure that concerns are identified, information is shared, and 
appropriate support arrangements are considered. Where concerns arise regarding a patient 
on, or potentially requiring inclusion on, the DSR, this can trigger review through the relevant 
Transforming Care processes, including consideration by the Dynamic Support Register and, 
where appropriate, a Community Care and Treatment Review (CCTR). 

These processes enable health, social care and other partner agencies to work 
collaboratively to identify needs, review existing support arrangements, and consider 
additional interventions that may help reduce the risk of deterioration or hospital admission. 
This is supplemented by existing community mental health support, multidisciplinary review, 
crisis services, and joint working with learning disability and autism services where 
appropriate. 

The DSR tracks vulnerable individuals at risk of admission, while the CCTR is a formal 
review meeting to improve care plans and speed up community discharges.   

Concern 9) Abbi's diazepam was continued and increased during her crisis and 
deterioration.  Abbi was prescribed a treatment medication regime that had been 
unsuccessful in the past and had not mitigated attempts to end her life by ligature whilst she 
was detained in her last admission under the Mental Health Act. 

Response:   

The Trust accepts that continued prescribing of Diazepam should have been supported by 
clearer review arrangements and consultant oversight.  Please see responses to concerns 3 
and 4 

In  line  with  the  evidence  presented  to  the  Court,  Diazepam  or  any  Benzodiazepine 
medication  can  be  continued  or  increased  in  a  crisis.    As  with  most  antipsychotic 
medications, these do not always take effect immediately. During a crisis it would be against 
standard clinical practice to discontinue a long-term medication unnecessarily. Each person’s 
medication needs are considered individually and in light of their presentation.   

There is now an Electronic Patient Medication System in place where clinicians are able to 
see  the  patient’s  previous  medical  history  in  respect  of  previous  hospital  attendances  and 
past medication reviews. There is now greater pharmacy input in place for Inpatient Services, 
with pharmacists now sitting in on MDT’s and supporting medication history reviews.  

The Court is asked to also note the assurance set out above at concern 3 

Concern  10)  There  were  no  up-to-date  care  plans  and  risk  assessments  in  place  for  Abbi 
during her detention and when she was discharged to the community on 14 February 2022 to 
mitigate  a  known  significant  risk.  Abbi  had  tied  multiple  tight  ligatures  during  her  11-day 
admission under detention of the Mental Health Act and had her usual clothing removed on 4 
February due to her risks, the precise date her clothing was returned, and the rationale was 
not recorded. 

8 

 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 Response:   

The Trust accepts that components of the care planning and risk assessment documentation 
were not updated to the standard expected and that the rationale for certain restrictive 
interventions was not always sufficiently recorded. 

In the interests of safety and based on risk assessment, it is noted that Abbi was issued with 
anti-ligature clothing during her admission (with her clothes being returned after discharge); 
during this time her attempts at ligatures were reduced.  

The provision of anti-ligature clothing is discussed and agreed by MDT. These decisions are 
regularly reviewed and documented. Such clothing is not used as standard.   

To ensure that risk assessments are up to standard, a record keeping audit is undertaken at 
every shift at the Linden Centre to monitor details, accuracy and that information is up to date 
particularly with recent incidents. This is undertaken by the allocated qualified staff member 
and any identified actions are cascaded at the end of every shift. Should any staff have an 
identified training need this will be addressed in supervision to ensure performance 
management.  

Management Teams and staff also have access to an electronic Trust dashboard which is 
specific to each ward and provides a full oversight of relevant ward information about the 
current patients (including records, risk assessments and care plans), this supported the 
identification of any record gaps that can then be promptly addressed. These are printed on 
a daily basis for staff. 

Concern 11) On 9 February 2022 community mental health staff required 3 conditions to be 
met before they would support Abbi’s discharge, none of which were met on 14 February 
2022.  Abbi was a very complex patient and her care co-ordinator wanted to attend Abbi’s 
ward review on 14 February and emailed the consultant psychiatrist that she had not 
received a link. The ward review went ahead in absence of the care co-ordinator and 
concerns that the care co-ordinator had about Abbi’s risks of her harming herself and ending 
her life on the discharge were escalated. The plan did not change.  

Response:   

Discharge Planning meetings occur throughout the patient’s admission, this ensures 
constant focus on how to support someone through to discharge and provides enhanced 
opportunities for MDT in-put.  

A weekly discharge planning meeting is held on each ward with all key care workers and 
community leads present to highlight any complex discharges. This is documented within the 
action plan.  Meetings may still proceed without a member of the community team being 
present.  All members of the team have access to the records / MDT notes relating to 
planned discharges.  All MDT’s and ward reviews have a member of staff from the Home 
First Home Team in attendance.  

Abbi was reviewed by the Care Coordinator on the day following discharge. The 
contemporaneous clinical records indicate that the Care Coordinator assessed Abbi’s 
presentation and concluded that ongoing follow-up by the Community Mental Health Team 
was appropriate and that Home Treatment Team involvement was not warranted at that 
stage. The risks identified at the time were recognised by both inpatient and community 
teams as longstanding and chronic in nature.  

9 

 
 
 
 
 
 
 
   
 
 
 
 
 The discharge decision was based on the multidisciplinary assessment of risk, the patient's 
clinical presentation, and the judgement that ongoing management within community mental 
health services represented the most appropriate and proportionate care plan at that time. 

It is further noted that Abbi would have also had a Care Treatment Review at point of 
discharge.  

Concern 12) Abbi had anti-ligature bedding, and her room stripped of her possessions, and 
this remained in place at the time of her discharge. The responsible clinician was informed by 
a  preceptorship  nurse  that  the  Home  Treatment  Team  had  refused  to  accept  Abbi  as  she 
had a care co-ordinator. This information was known by the treating team to be incorrect, the 
Home Treatment team had agreed to see Abbi on 25 January 2022, and other patients had 
been assessed and discharged from the Ward with these arrangements previously. This was 
not  checked  or  challenged,  and  Abbi  was  discharged  without  further  discussion  with 
professionals about an appropriate care plan 

Response:   

When a patient is presenting a significant risk towards themselves anti ligature clothing and 
bedding  can  be  considered  and  then  agreed  within  the  MDT  and  within  the  patients  ward 
review.    This  is  regularly  reviewed  through  MDTs  and Ward reviews  and  is  included  in  the 
patients  care  plan.   Ward  staff  will  consider  an  increase  of  observations  as  well  to  prevent 
further restrictions in place.  

The Home First Team in-reach staff will attend all inpatient MDT meetings and also patients 
ward  reviews,  referrals  are  discussed  where  possible  in  advance  to  have  a  clear 
understanding  of  the  intervention  needed  for  the  patient  care  and  the  plans  following 
discharge.  

Concern 13) Although Abbi had some dialogue about the future on 15 February 2022, she 
informed  the  community  mental  health  team  that  she  ‘did  not  want  to  go  on  anymore,  and 
had lived her life’. She was unable to give any assurances for her safety and was declining 
help.  Advice  from  the  Home  Treatment  Team  was  not  sought  and  the  community  team 
wanted  to  step  up  care,  but  this  had  not  been  put  in  place  and  was  not  the  process  to  be 
followed for a crisis. 

Response: 

In line with the evidence provided at the Inquest, Abbi was keen to only work with those she 
was familiar with and had built a good rapport with which included her Care Co-coordinator 
who visited Abbi at home. The community team worked hard to build this rapport with Abbi 
and with the community team as a whole and arrange visits to support Abbi in an attempt to 
build rapport.  

In line with the records held on the PARIS system for the 15th February 2022 prepared by the 
Care coordinator, Abbi was seen at home for a face to face follow up review 48 hours post 
discharge. At this time whilst Abbi expressed suicidal ideation, which is noted to be ongoing 
and  long  term,  no  firm  plan  was  expressed  although  it  was  acknowledged  that  Abbi  had 
stated  that  she  could  not  ensure  her  own  safety.  Abbi  also  spoke  of  future  planning  of 
attending a brain scan and wanting to live independently with a dog in the near future.  

Although  the  management  plan  was  not  discussed  with  the  Home  Treatment  Team,  it  was 
discussed  with  the  team  lead  (MDT) and  Duty  team.  A  decision  was  made  to  provide 
stepped up  care from the  SMHT  itself to maintain the  provision  of stability  and consistency 

10 

 
 
 
   
 
 
 
   
 
 
 
 bearing  in  mind  the  team  had  built  a  rapport  with  Abbi,  and  their  knowledge  of  her  ASD 
condition and her need for familiarity with the professional she worked with.  

Furthermore, the Gables SMHT is on the very same ground as to where Abbi resided which 
allowed for prompt access to Abbi and vice versa.  

The  care  coordinator  had  planned  to  further  discuss  the  situation  at  the  upcoming  Team’s 
weekly MDT on the 17th February 2022 which was attended by psychiatrist, psychologist, OT, 
Social  worker,  nursing  staff  and  other  professional.  The  step  up  care  was  put  in  place 
immediately on the 15th February 2022 in person and a further visit with Abbi was scheduled 
for the 16th February at 10:00hrs.  

It  is  important  to  note  that  the  Home  Treatment  Team  have  24hrs  to  complete  their 
gatekeeping assessment, whereas the Gables SMHT saw her in less than 24hrs. In addition, 
the Gables attended to Abbi via a face to face review and made a call to Abbi on the morning 
of 15th February 2022 to inform her of the discussion and plan to further support her via an 
MDT discussion.   

The Gables duly updated the team at the Pavilion where Abbi resided. It is important to note 
that Abbi would need to agree to the referral to the Home Treatment Team (HTT) before this 
could be arranged for her.   

This process followed by the Gables as a community team is in line with the current pathway 
when managing a crisis in the community i.e. the Community are required to attempt to put in 
additional measures before a referral to the HTT is made.  

Concern 14) There was a lack of understanding within the EPUT mental health teams of 
Care, Education and Treatment Reviews and that has continued. This could have prompted 
a professionals meeting for Abbi.  

Response:   

Please see response given for concern 7 above. 

I  hope  that  I  have  provided  some  reassurances  around  the  steps  that  we  have  taken  to 
address the issues of concern contained within your report.  We know there is an acute need 
to embed and effect change, hence we will monitor the above provisions to ensure these are 
contributing to our overall aim of keeping patents safe and delivering therapeutic care. 

Please do let me know if you require any further information at this stage, including copies of 
any of the documents referred to above.   

We understand that a copy of this reply will be shared with the family.   

Yours sincerely 

Interim Deputy CEO and Executive Chief People Officer 

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