Dear Coroner Hassell,

Thank you for sending the Prevention of Future Deaths Report. We would like to express our sincere condolences to the family and friends of Mr Holloway.

The Association takes any concerns raised about the standards of practice for our members extremely seriously.

This letter aims to respond transparently and in good faith to the concerns you have raised.
1. Mr Holloway’s BACP accredited psychotherapist did not make any notes of her consultations with him, because he had asked her not to. She gave evidence that she is not bound by law or ethics to keep any notes.

All BACP members must adhere to BACP's Ethical Framework.

Paragraph 15 makes explicit reference to the need to keep accurate records.

Working to professional standards.
15. We will keep accurate records that:
- are adequate, relevant and limited to what is necessary for the type of service being provided
- comply with the applicable data protection requirements – see www.ico.org.uk

The client has the right to request that session notes are not kept (GDPR), and it is up to the individual practitioner to determine if they are willing to work with a client who has explicitly requested that session notes are not recorded.

Paragraph 31 covers BACP’s requirement to contract and communicate the agreed terms clearly and transparently.

Building an appropriate relationship. 31. We will give careful consideration to how we reach agreement with clients and will contract with them about the terms on which our services will be provided. Attention will be given to:

a. reaching an agreement or contract that takes account of each client’s expressed needs and choices so far as possible.
b. communicating terms and conditions of the agreement or contract in ways easily understood by the client and appropriate to their context.

c. stating clearly how a client’s confidentiality and privacy will be protected and any circumstances in which confidential or private information will be communicated to others.

d. providing the client with a record or easy access to a record of what has been agreed.

e. keeping a record of what has been agreed and of any changes or clarifications when they occur.

f. being watchful for any potential contractual incompatibilities between agreements with our clients and any other contractual agreements applicable to the work being undertaken and proactively strive to avoid these wherever possible or promptly alert the people with the power or responsibility to resolve these contradictions.

Where BACP receives a complaint that a member is not practicing in line with the Ethical Framework, BACP will conduct a thorough assessment under its robust Professional Conduct Procedure. Any member of the public may make a complaint about a member’s conduct to BACP.

In addition to BACP’s comprehensive Ethical Framework and Professional Conduct procedure, BACP also provides all its members with access to a range of Good Practice in Action (GPiA) resources. Our GPiA resources are based on current research and evidence and reviewed by member-led focus groups and experts in the field. We provide four guidance documents that relate to the keeping of records:

• Confidentiality and record keeping within the counselling professions GPiA 065
• What do we mean by records and record keeping within the counselling professions? GPiA 066
• Record keeping within organisational settings in the counselling professions GPiA 068
• Practical aspects of record keeping within the counselling professions GPiA 067

2. Can it be right that suicidality is completely omitted from BCAP accredited psychotherapy training?

BACP accredited courses, must meet all the course requirements set by BACP. These requirements ensure that all students on accredited courses must be trained in evidenced- based risk assessment strategies and must be taught to negotiate an appropriate therapeutic contract which may include referral.

These requirements mean that all students are taught how to refer to suitable referral agencies, such as mental health crisis teams, emergency services when required, and that students are taught how to cover the circumstances whereby they may need to take that action as part of the contracting phase.

B4.7 Formal course time must be given to:

i. Training in assessment procedures consistent with the rationale and British Association for Counselling and Psychotherapy www.bacp.co.uk philosophy of the course. This must include the important elements of a risk assessment strategy informed by evidence-based practice and relevant research.

ii. Teaching the students to conceptualise the nature of the clients’ issues and to negotiate an appropriate therapeutic contract, which may include referral.

This is also underpinned by the requirements set out in BACP’s Ethical Framework, which all courses must cover with students.

B4.6 The course must ensure that students are formally introduced to the Ethical Framework before starting client work. The course must demonstrate that it assists its students to develop as ethical, accountable and reflective practitioners.

3. …can it be right that contacting the police in such a situation is not taught as part of psychotherapy planning.

According to the BACP Accreditation of Training Courses, all students enrolled in BACP- accredited courses must be trained in making informed decisions about breaching confidentiality when necessary. This includes understanding when it is appropriate to refer clients, particularly in situations requiring emergency intervention.

Furthermore, the BACP Ethical Framework for the Counselling Professions emphasises the ethical responsibility of practitioners to prioritise client safety, including making referrals and contacting emergency services when there is a significant risk of harm.

Counsellors and psychotherapists on accredited courses are taught to take such decisions based on their assessment of what intervention is needed. Balancing this alongside the need to maintain client confidentiality (unless there are justifications for breaching confidentiality). A course would not teach students to contact police solely based on an assessment undertaken by a third party, which we are given to understand was the situation in this case.

4. Should there be a mechanism of ensuring that a psychotherapist who is unable to deal with suicidality does not practise with clients who may experience this? An individual who does not pass the accredited course or the equivalent certificate of proficiency is not eligible for Registration with BACP. Given the robust training and assessment requirements in place, it should be expected that all members on the BACP Register are trained to support clients who express suicidal ideation, in safety planning and how to apply the balance of confidentiality against client safety.

5. Mr Holloway was seen and fully assessed by Northwest London clinicians when he was taken to hospital by police following an episode of self-harm on 30 June 2024. Police attendance had been prompted by Mr Holloway’s brother, calling from abroad.

Mr Holloway’s brother was particularly disappointed that it seemed as if Mr Holloway’s care was not joined up between the different agencies.

BACP acknowledges the disappointment expressed by Mr Holloway’s brother.

As the psychotherapist contracted was a private practitioner there is currently no ability for them to be included in any integrated care planning that may have been available. Mr Holloway was under no obligation to inform his GP or any other care provider that he was seeking private psychotherapy. Consequently, it may have been that other agencies were unaware of this. BACP has no knowledge as to whether Mr Holloway did share this information or not. I hope that this letter provides the necessary clarification but if you have any further questions, please do not hesitate to contact me.

Dear Ms Hassell

Re Inquest touching the death of Duncan Holloway

I am writing further to the inquest for Mr Duncan Holloway which concluded on 16th January 2025 and following which you issued a Prevention of Future Death report to the British Association for Counselling and Psychotherapy (BACP) and North London NHS Foundation Trust (note, not North West London NHS Trust). The inquest found that Mr Holloway died by suicide after at around 5am on 18th July 2024. The matters of concern raised in your report in regard to the Trust are as follows:

Mr Holloway was seen and fully assessed by North West London clinicians when he was taken to hospital by police following an episode of self harm on 30 June 2024. Police attendance had been prompted by Mr Holloway’s brother, calling from abroad. Mr Holloway’s brother was particularly disappointed that it seemed as if Mr Holloway’s care was not joined up between the different agencies.

We would like to begin by expressing our deepest sympathies to Mr Holloway’s family and loved ones. We are very sorry to hear that Mr Holloway’s brother has concerns with regard to the communication that took place between the agencies involved. It is unfortunate that we only learned of this concern at the end of the inquest hearing which meant that there was not an opportunity to explore the nature of this concern in more detail.

Mr Holloway was assessed by the Trust’s Mental Health Crisis and Assessment Service (MHCAS) on 30th June 2024 after emergency services, having been alerted by Mr Holloway’s brother calling from abroad, attended his property and brought him to A&E. This was the extent of the Trust’s involvement in his care. As the assessing clinician explained in evidence, she was concerned about the circumstances leading to Mr Holloway’s attendance in the department and the risk he might pose to himself when under the influence of alcohol or substances. However, he was capacitous and very clear that he did not wish to engage

Better Mental Health. Better Lives. Better Communities. with mental health or alcohol services. He did not meet the criteria for compulsory detention under the Mental Health Act. The clinician did her best to engage him but ultimately Mr Holloway made the choice to decline any ongoing involvement with services.

The Trust entirely recognises the importance of communication between its services and service users’ professional and personal support networks to support joined up care and manage risks. Service users are vital partners in their own care. However, with the exception of key support networks (such those offered by a service user’s GP or next of kin), and although we enquire, the Trust relies on service users to expressly alert it to the involvement of any other networks. In accordance with our standard process when anyone is brought to A&E and a mental health assessment is carried out, a summary was promptly sent to Mr Holloway’s GP.

The Trust was not aware that Mr Holloway had sought the support of a private therapist and was only made aware of this involvement during the inquest hearing. It appears that the therapist’s involvement postdates the Trust’s assessment of Mr Holloway at A&E. The Trust always seeks to involve all relevant parties in a patient’s care. However, this only possible with their consent and, although we enquire, the Trust is reliant on service users making it aware of who the relevant parties are. It is therefore difficult to see what the Trust could have done differently in this case. Notwithstanding this, the Trust will continue to reflect on this incident, which it will share through its various governance forums as part of its commitment to learning and improvement.

I hope that this response provides the necessary assurance. Please contact me if you have any queries.