Dear Senior Coroner Connor,

Inquest into the death of Dr Jaipreet Panesar Report on Action to Prevent Future Deaths Response of Oxford Health NHS Foundation Trust Thank you for your letter of 25th November 2024 following your conclusion into the tragic death of Dr Panesar. I write to respond to your concerns. The matters of concern that you identified are –

1. The Trust’s own internal investigation highlighted the fact that no care coordinator or key worker was provided to Jai after her discharge from hospital on 7th of September
2022. The Trust’s initial plan was to review this by June 2024, and the aim now is for January 2025, almost two years from Jai’s death.
2. It is still not possible for teams using RiO and the BTT systems to access each other’s clinical notes.

I understand that the Trust provided you with some documentation at the inquest relating to these issues, in particular a statement made by the team manager of the Trust’s Chiltern Crisis Resolution & Home Treatment team, a statement made by the Head of Inpatient Services for Buckinghamshire, an email from the Deputy Clinical Lead of Buckinghamshire Talking Therapies (BTT) and a copy of BTT’s standard operating procedure.

In relation to your first concern, I acknowledge that a delay in the completion of an action that arises from a patient safety incident investigation is a concern. I have asked to receive a report from the Oxford Healthcare Improvement Manager by the end of January 2025. In the meantime, I am satisfied that the Quality Improvement project has been progressing well. The purpose of this project is for us to ensure that the changes made are sustainable and Trust wide and that they do indeed mitigate against the risk of a similar event. I have been informed that a meeting takes place every fortnight in order to review progress (the most recent meeting was on 17th December 2024). The Trust is clear about the critical importance of the process by which a patient’s care is transferred from a ward to community teams. It is a process that will always remain under scrutiny by Trust governance and audit.

I understand that your second concern relates to records held by Buckinghamshire Talking Therapies (BTT). It was the case that members of our secondary care services did not have access to those records in 2022 and 2023. That remains the case, in that staff in secondary care services cannot log into BTT’s electronic records system direct. The position is that

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secondary care services have access to a system called Thames Valley & Surrey (TVS) Shared Care Records/Graphnet, to which system BTT has uploaded patient information dating back to 1st May 2022. This upload concluded in November 2024. Subsequently, all patients accessing BTT will have information of their involvement with BTT uploaded on TVS each day (unless they have universally opted out of information sharing).

More generally, our Intranet contains guidance on the use of Thames Valley & Surrey Shared Care Records and this guidance was most recently updated on 12th December 2024.

For their part, some BTT staff have direct access to RiO, which is the electronic health records system used by the Trust’s secondary care services. Those staff include the admin team, referral co-ordinators in SPA, and supervisors. BTT’s standard operating procedure records the procedure for BTT staff to do so. I understand that you have received a copy of that operating procedure. I am satisfied that BTT’s access to RiO is established and effective for their purposes.

I hope that this response provides you with the information that you require, but of course please do not hesitate to contact me if I can assist further.