Dear Ms Haste

Re: Regulation 28 Report to Prevent Future Deaths

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 25th March 2024, which you sent following the inquest into the death of Ms Cobain.

In the report, you raised the following concerns:

1. When Mrs Cobain cancelled her appointment scheduled for Monday 6 September 2021 by email on Saturday 4 September 2021, the system nevertheless generated an automatic questionnaire which is normally sent 24 hours prior to a scheduled assessment appointment. The system had not recognised that Mrs Cobain had cancelled her appointment. She completed the questionnaire.
2. Mrs Cobain’s responses to the questionnaire contained what were accepted to be concerning responses
3. Due to the cancellation the questionnaire was not reviewed by a clinician until after Mrs Cobain’s sad death
4. Changes have been made to the protocols around cancellation and language has been added to the assessment template
5. However, there is no system or protocol to alert a clinician to review concerning responses and to consider appropriate next steps, where (outside the usual protocol and time frame of submission and review within 24 hours of the assessment appointment) the patient has completed the questionnaire, and for whatever reason, the assessment appointment with the clinician is not for a period of several days/weeks as was the case in Mrs Cobain’s case.

The trust’s response to these concerns is as follows:

Ms Michelle Haste Assistant Coroner for Inner London South London Inner South Coroner’s Court 1 Tennis Street London SE1 1YD

Private & Confidential

Mrs Cobain completed a number of short questionnaires. The questionnaire completed by Mrs Cobain which has caused some concern was the Patient Health Questionnaire-
9. This is a measure used to give an indication of possible symptoms of depression experienced by an individual over the past two weeks. It is not a diagnostic tool nor is it a risk assessment. The questions are intended only to help inform and structure an in-person assessment. They are also used to provide a quantitative baseline against which progress in later treatment can be measured. Clinical research indicates that these types of measures have no predictive value as an assessment of suicidality and, indeed, recently published NICE guidance confirms that they must not be used in this way.

The question of concern asks about the frequency of “thoughts that you would be better off dead or harming yourself in some way”. It is important to note that a high percentage of patients self- referring to a Talking Therapies Service with depressed mood will score similarly to Mrs Cobain on this question. Whilst this may be indicative of depressed mood, it is not predictive of suicidal ideation or behaviour. Most people scoring above 0 on this question will not report active suicidal plans when seen for an in-person risk assessment.

As you have noted, following the investigation into this very sad death, our Talking Therapies Services have made some changes to practices around these questionnaires. Our patient record system, IAPTUS, sends these questionnaires out in advance of an assessment appointment automatically via a webform. The use of these questionnaires as part of assessment is a nationally mandated requirement for all Talking Therapies Services. Patients receiving this webform from our Talking Therapies Services now receive a message which states the following:

This facility is provided in the knowledge that questionnaires are an aid to monitoring your progress prior to an appointment with a clinician. It is not intended to be used to convey direct messages to clinical staff or gain access to urgent support. These measures will only be viewed at the time of your appointment.

TO SEEK URGENT HELP IN A MENTAL HEALTH CRISIS If you feel at risk of hurting yourself or someone else, you should · contact your GP
• or go to your local A&E at St Thomas' Hospital or King's College Hospital
• or call the SLAM 24 hour information line on 0800 731 2864 for further advice
• if you are experiencing feelings of distress or despair organisations such as The Samaritans tel: 116 123 can also be contacted at any time.

This message now makes it very clear that the service does not provide urgent help in an emergency and gives advice as to how this type of help can be accessed. Information around how to access urgent or emergency help is repeatedly provided to patients including at the time of booking an appointment and with appointment confirmation documents.

Mrs Cobain contacted the team by email to cancel and request to rebook her original assessment appointment on a Saturday giving the explanation that she had had a family emergency. Her message was picked up by the administrative team on the Monday morning and the appointment cancelled on the IAPTUS system. As the system is configured to send out webforms automatically 24 hours prior to an appointment the questionnaire had already been sent to Mrs Cobain on the Sunday. Talking Therapies teams are not currently commissioned to be open at weekends in line with most non-emergency, primary care services.

In a primary care service such as Talking Therapies Southwark, it is important and appropriate that we respect the autonomy of our patients and their ability to make decisions about their engagement with treatment. Where someone gives a good explanation for a cancellation and makes a request to rebook it would be considered clinically reasonable to honour this without chasing the patient particularly given that patients are provided with advice as to how to contact urgent help if needed.

In an average month, the Talking Therapies Southwark Service receives between 1100 and 1200 referrals and carries out approximately 800 assessments. In line with most primary care services, they have a relatively high rate of patient cancellations. In an extremely busy service such as this, resources are structured carefully to ensure first assessment appointments are offered as quickly as possible. As we have noted, scores such as Mrs Cobain’s on the PHQ-9 are common in self-referring patients and most will not be presenting with high risk. If the service were to follow up by telephone every cancelled appointment, this would have an inevitable impact on the speed with which assessment appointments could be offered. An increase in assessment waits would, we know from clinical experience, be more likely to increase risk to our population. We believe, therefore, that the balance of risk is better served by us continuing to focus resources in the way that we do and not in developing a new protocol to automatically follow up cancelled appointments as suggested.

I hope that this response addresses the concerns which you have raised and explains why the trust has chosen to take the steps it has. I thank you for bringing these issues to our attention.

Best wishes

Chief Executive South London and Maudsley NHS Foundation Trust