Dear Madam

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.

Chair: Chief

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

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

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

January to March Waltham Forest

April to June Havering

May to July Redbridge

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

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.