Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Judith Maike Obholzer who died on 12 July 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12 July 2024 concerning the death of Judith Maike Obholzer on 12 July 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Judith’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Judith’s care have been listened to and reflected upon.

Your Report raised concerns over the pathways and ability to share information and undertake referrals between private and NHS mental health services, as well as the ability for private medical practitioners to access GP details. You raised this within the context of the significant pressures currently being placed on NHS mental health services and the impact of this likely increasing the number of patients turning to private mental health services. As part of its Long Term Plan commitments to improve mental health care, NHS England has increased investment in adult and older adult community mental health services by £1 billion per year since 2019/20. Commitments in the plan have also included a significant expansion of urgent and emergency mental health care and access to crisis services. Your Report highlights the importance of effective information sharing, to support providing the best care possible, where individuals are transferred between different care settings. The National Care Records Service (NCRS) is the successor to the Summary Care Record application (SCRa) and by design removes a large amount of the reported barriers to adoption within many care settings including the private sector. The NCRS provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes. It is free to use and includes additional features and services beyond the legacy SCRa product. It provides access to a number of centrally provisioned national digital services that support the direct care of patients, including Summary Care Records (SCR), the National Record Locator (NRL) service and the Personal Demographics Service (PDS).

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

04/09/2024

The SCR is a national database that holds electronic records of important patient information such as current medication, allergies, and details of any previous bad reactions to medicines. It is created from GP medical records - whenever a GP record is updated, the changes are synchronised to SCR. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient's direct care, but do not need access to the patient's full record. As such, the SCR is intended to provide a summary of the patient’s GP record, including key information most likely to be of benefit to patients during an unscheduled care encounter. The SCR Team at NHS England have undertaken significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services trialling the use of SCRs within settings where they have previously been unavailable, and this work continues. The Team will work with an Expert Advisory Committee to seek full rollout approval within the independent/private sector and consider the scope of this approval and any specific exclusions, constraints, or caveats. Responsibility for delivering shared care records sits with local Integrated Care Boards (ICBs). Each ICB’s shared care records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England. Further information on Integrated Care Boards and Systems can be found here: NHS England » What are integrated care systems? NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and it provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. Our vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust, to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history. The NRL removes the need for organisations to create duplicate copies of information across systems and organisations, by facilitating access to up-to-date information directly from the source. It will also provide users with an indication of the organisations with which a patient currently has a care relationship, to enable a user to contact the service responsible for a plan to support the patient in the event of a crisis. Mental Health Crisis plans are one of the pointer types supported by the NRL service. The NRL does not store any of the Mental Health data but points users to where they can find it. NRL information can be consumed from source through the National Care Records Service (NCRS). In instances where multiple pointers are returned, users have the ability to sort results by creation date.

Work is also in progress to review the interface between the NHS and non-NHS funded independent health providers. This work is in its infancy, but NHS England can provide an update to the Coroner in due course if this would assist. We understand that the Care Quality Commission (CQC) are also undertaking work regarding standards for online care and are exploring opportunities for better sharing of information both into private sector providers and receiving information back to the patient’s registered GP practice from private providers. Access to the GP record is available to private clinicians through some IT systems suppliers and is being gradually rolled out further.

NHS England has also engaged with South West London and St George’s Mental Health NHS Trust. They have advised us that at the time Judith required NHS crisis support, their website provided clear signposting for private providers needing to make an emergency mental health referral. Since receiving your Report, we also note that they have made this more visually prominent on the website. I will refer you to the Trust for further information, who I understand are issuing their own response to you.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Judith, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

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.

Dear Madam

Re: Regulation 28 Report to Prevent Future Deaths – Judith Obholzer

I am writing to you following receipt of the Regulation 28: Report to Prevent Future Deaths (PFDR) dated 12th July 2024, regarding the sad death of Mrs Judith Obholzer.

The PFDR was addressed to NHS England (NHSE), the Department of Health (DH) and South West London and St George’s Mental Health NHS Trust (the Trust) being the third listed recipient. This letter provides the Trust’s response to the matters of concern that you have detailed in your correspondence.

The PFDR was shared with the clinical leadership teams in the Community and Acute and Urgent Care Service Lines and the Trust’s Communications Department to ensure the Trust responds fully to the points of concern raised by HM Assistant Coroner.

I therefore respond to each of your concerns and direction as stated within your PFDR correspondence:

(1) In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are

Chief Executive, Chairman, providing treatment as well as the NHS, ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure.

The Trust shares your observation that there could be an increase in patients seeking to access private support during these times of high demand for services nationally and, in particular, within the London region.

The Department of Health and Social Care produced guidance for NHS patients who wish to consider additional private care, and we have provided a link to this belowi. In line with this guidance, NHS organisations, including the Trust, cannot withdraw NHS care where a patient chooses to fund additional private care, additionally that patients will also have their place for treatment on an NHS mental health waiting protected. Naturally, we expect the DH response to you in regard to this PFDR will cover this aspect in more detail.

However, in addition to the DH guidance, the Trust has a ‘Private Providers Shared Care Policy’ (Appendix 1) which was ratified in January 2024. This clearly sets out the respective roles and responsibilities of the Trust and private providers. This policy was drafted with input from Consultant Psychiatrists from a private provider and supplements the DH guidance to add specific clarity for the Trust.

The Trust accepts that this policy was not referenced and it appears there was a lack of appreciation that the policy existed during the Inquest. In response to the concern raised in the PFDR, the Trust will ensure this policy is made accessible on the Trust's website (in the GPs/Professionals section of our website) and its existence will be further communicated internally and also through our local GP networks.

Unfortunately, there is currently no national or local system which enables the Trust to have the contact details of every private provider operating in its catchment area and, therefore, it is not feasible to provide information about the referral process to all these providers and those we are not aware exists. Furthermore, In Mrs Obholzer’s case, the private provider that gave evidence at the Inquest and who assessed Mrs Obholzer shortly before her death, was not based in the catchment for our Trust.

If a private provider considers a patient is at high risk of harm to self or others, it would be expected that they would either seek to make contact with the patient’s local mental health services or contact NHS services via 111 or A&E. With this in mind, the Trust has ensured that information for private providers is more clearly visible on the Trust’s website (please see below more detail).

(2) During the evidence the private consultant psychiatrist gave evidence that he was unable to refer patients directly to NHS provided crisis teams as a direct alternative to

Chief Executive, Chairman, informal treatment in a private hospital. The evidence from South West London and St George’s Mental health Trust was that direct referrals can be made although the evidence on the exact mechanism was unclear. In Mrs Obholzer’s care, the (apparent) lack of ability of the private consultant psychiatrist to directly refer to the crisis team meant that she did not receive the community crisis support alternative to hospital admission that she required. Consideration should be given to ensuring that the pathway for urgent/crisis referrals from private practitioners to the NHS are clear to all (both for this area and throughout the country) and, if it is not already the case, to ensuring a process that allows private practitioners to arrange crisis support through the NHS directly.

The Trust notes the Coroner’s desire that this aspect of the PFDR is reviewed from a national perspective and considers that the DH and NHSE will be able to address this within their response.

However, the Trust would like to assure the Coroner that private providers can refer their patients to the Trust’s crisis services when required. Private providers can telephone or make a referral about someone they are concerned for to our crisis services via the Trust’s Mental Health Crisis Line in the same way as a GP or other non-Trust health professional. If a private provider contacts the Mental Health Crisis Line, advice will be provided, and their patient will be directed into the correct care pathway dependent upon the patient’s presentation and risk factors. In an emergency scenario, private providers can also call 999 or 111 and patients are able to attend A&E to access the pathway for crisis services.

At the time Mrs Obholzer accessed Trust services, there was clear information available on the Trust’s website regarding how to access Trust crisis services via the Mental Health Crisis Line and what to do in a mental health emergency. This could be accessed from a prominent orange link (button) on the homepage marked ‘I need help now’. It is unclear if the private psychiatrist who gave evidence at the Inquest attempted to access the Trust’s website.

In response to the PFDR, the Trust has reviewed and further improved the information available for all healthcare professionals on the Trust website to ensure it is more easily accessible. The link (button) on the front page of the website is now red to make it even more prominent and marked ‘Urgent Help’ (Home - Website (swlstg.nhs.uk).

To aid, I have provided some screenshots of our website, with the below first showing the new red ‘Urgent Help’ button.

Chief Executive,

Chairman,

There is also a second button marked ‘urgent help’ on the front page which states ‘healthcare professionals making referrals can call our 24/7 crisis line on 0800 028 8000’. People can access further information by clicking this button – see screenshot below.

When either of these two buttons are clicked, they go to information about services that can be accessed in an emergency (https://swlstg.nhs.uk/urgent-help). This includes the specific information in bold type that says ‘Any healthcare professional can also contact the mental health crisis line if making a referral for someone experiencing a mental health crisis’.

Chief Executive, Vanessa Ford Chairman, Ann Beasley

In addition, you will see below, the Trust has included an amber header on the GPs/Professionals page with the telephone number of the Mental Health Crisis Line so it is clear how a ‘GP, partner agency or private provider’ can make a referral in a crisis. (Referring to our services - Website (swlstg.nhs.uk)

Additionally, we have again shared our crisis information externally, which we do at regular intervals. This includes on social media and in extra places on our website including news articles and in information about our campaigns.

(3) In the course of the evidence it was confirmed that the private consultant psychiatrist was unable to send the urgent letter to Mrs Obholzer’s GP in part because their details

Chief Executive, Chairman, had not been provided. Consideration should be given to ensuring that all medical practitioners (private and NHS) can access GP registration details for patients and GP contact details to avoid delays where there is an urgent need to contact a person’s GP.

The Trust does not feel able to provide a response to this aspect of the PFDR as access to GP registration details is a national issue. We understand that the response to this concern will come from the DH or NHSE response.

(4) In the course of the evidence it was confirmed that there is no sharing of medical notes between private practitioners and NHS providers. This (along with other factors) led to delays in a treatment plan being set by Wandsworth SPA as they had to obtain further details regarding Mrs Obholzer’s CBT from Mrs Obholzer rather than being able to access the notes through a shared system. Consideration should be given to ensuring a system is in place to allow sharing of medical information between practitioners across Trusts and also between NHS and private providers.

Systems and processes for information sharing between NHS and private providers is principally a consideration for NHSE and the DH who are best placed to provide guidance around the GDPR and confidentiality considerations.

However, locally the Trust is reviewing its approach to how information can be shared in line with consent and the confidentiality policy. Naturally, the Trust is not able to share clinical information with a private practitioner (and vice versa) without the explicit consent of the patient, except in rare cases where risk considerations mean information sharing is essential.

The Trust is exploring ways to obtain advanced consent to share information can be captured in the clinical record when patients are also accessing private services, as part of the assessment and on-going care planning process and this will be recorded in their clinical records. The Trust is currently reviewing the best way to collect this information and operationalise the process.

The Trust will remind all staff of the ‘Urgent Care Pathway’ in a Monthly Learning Bulletin article (to be published by October 2024). Staff will also be reminded to regularly check if service users are receiving private treatment and discuss consent to share information. Staff will also be signposted to the Trust’s ‘Private Providers Shared Care Policy’, so they are aware of the process if they are contacted by a private provider regarding a patient in crisis. This policy will also be shared through our local GP networks.

The Trust remains committed to continuous learning and improvement and we are very grateful for all those involved in the Inquest. This PFDR and the response will be reviewed and monitored at the Trust’s Mortality and Suicide Prevention Committee, which is attended by senior representatives from all the Trust’s service lines.

Chief Executive, Chairman, Finally, the Trust is ready to respond to future guidance issued by NHSE or the DH regarding information sharing between NHS organisations and private practitioners.

Dear Ms Oakley

Thank you for your Regulation 28 report to prevent future deaths dated 12 July about the death of Judith Maike Obholzer. I am replying as the Minister with responsibility for Patient Safety, Women’s Health and Mental Health.

Firstly, I would like to say how saddened I was to read of the circumstances of Judith’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these matters to my attention.

Thank you for highlighting your important concerns about the pressures on NHS mental health services, the interface between private practitioners and NHS providers and the sharing of medical information between the two. I know that you have also addressed these matters of concern to NHS England and South West London and St George’s Mental Health NHS Trust and I look forward to working with both organisations, where appropriate, to avoid a repetition of the tragic events of this case.

It is clear that many people, like Judith, with mental health issues are not getting the support or care they need, which is why this Givernment is taking action to fix the broken system to ensure we give mental health the same attention and focus as physical health and that people can be confident of accessing high quality mental health support when they need it.

As part of our mission to build an NHS that is fit for the future, we will recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment which will also help ease pressure on busy mental health services. To help reduce the lives lost to suicide, these new workers will be specially trained to support people at risk. More broadly, we will modernize legislation of the Mental Health Act to give greater choice, autonomy, enhanced rights and support, and ensure everyone is treated with dignity and respect throughout treatment.

I know that NHS England has outlined to you the work they are taking forward to improve sharing of information and records overall. I understand that work is also in progress at NHS England to review the interface between NHS and non-NHS funded independent health providers, and that NHS England has offered to update you on this important work as it progresses. I assure you, I have written to NHSE colleagues to ensure this is driven forward and these points are addressed.

I hope this response is helpful and thank you again for bringing these concerns to my attention.