Dear Madam,

Re: Inquest touching upon the death of Jamie Agius

I refer to your Regulation 28 report, dated 7 October 2024, detailing your concerns about the risk of future deaths in light of the findings of this Inquest.

I should like to extend my sincere condolences to the family of Mr James Agius. This must have been an extremely difficult time for them, and I hope that my response provides them, and you, with assurances that the North East London Foundation Trust (NELFT) has taken action to address the issues set out in your report.

I note that your concerns relate to:

1. The medical record documentation for Mr Agius had significant omissions that included an incomplete risk assessment in February 2022 for Mr Agius following his transfer following crisis intervention with the Home Treat Team to avoid admission to hospital when Mr Agius attempted to take his own life.

2. The evidence of assessments of Mr Agius’s mental state provided to the inquest indicated a difference of opinion as to whether Mr Agius was displaying hypomanic esymptoms on 12 and 13 February 2022.

3. Evidence was heard that there is new national training for assessing risk for patients with mental health concerns but there was no evidence that the Trust has implemented this training.

Chair:

Chief Executive:

The Trust acknowledges your concerns and wishes to advise that prior to, and following, the sad passing of Mr James Agius, a number of changes have been put in place, and I would like to highlight that these include the following:

1. Medical Record Documentation

The Trust has completed a thematic review of patient safety incidents with the intention of identifying themes and patterns occurring within these. Resulting from this was the establishment of Trust wide workstreams aimed to address the identified gaps and then embed learning around these across the Trust. Of pertinence to the concerns raised in this instance, is the Improving Quality of Record Keeping and Clinical Documentation workstream.

The aim of this workstream is to establish any system weaknesses associated with poor record keeping, understand the behaviour associated with this and to improve recording keeping and create a healthy record keeping culture. The Quality Improvement initiatives around this workstream have so far been successful in creating a Trust wide intranet page accessible to all staff offering direction on the importance of accurate and good record keeping. In addition to this, the Trust has develoepd quick access to guidance and information on issues such as cut and paste and commonly used acronyms and clinical abbreviations. Readily accessible links to good record keeping practice are also available and consequences of failing to comply with this and guidance on how to escalate concerns are also captured and available to all staff within this platform.

Revised training packages have also been put in place that cover the principles of good record keeping standards. These are essential training for all staff and are covered as part of the induction to NELFT.

To support good record keeping practice in the Home Treatment Teams (HTT) in NELFT, all staff completing home visits to service users are expected to complete their records utilising an agreed template. This ensures that the visit and documentation of what took place will cover areas including (though not limited to), mental state examination, social situation, physical health concerns, risk assessment, safeguarding and that these lead to a clear plan to be followed by the team. Adherence to this is monitored within through a fortnightly progress note audit that is completed. The last audit that was completed for the Barking and Dagenham HTT was on 3rd November 2024, with the team scoring 100% for adherence to use of the correct template. All entries reviewed also included a full Mental State Examination and risk assessment.

2. Varying opinion on diagnosis

Mr Agius was under the care of the Barking and Dagenham HTT (BDHTT) for a period of three days over the weekend of 11th - 13th February 2022. The concern highlighted was in reference to the difference of opinion regarding whether Mr Agius was displaying hypomanic symptoms on the 12th and 13th February 2022.

According to his electronic care records, on 12th February 2022, Mr Agius reported feeling elated in mood, but it was the opinion of the HTT staff member that visited that there was no objective symptoms observed in the interaction that took place to confirm this. The staff member, it appears made this conclusion based on Mr Agius’ speech being considered normal in all modalities and a general perception that he appeared to be settled. When Mr. Agius was again visited on 13th February 2022, he reported his mood to be fluctuating and that he was “hyper manic” and suffering from BiPolar Disorder. The opinion of the staff member on this day was that other than appearing slightly anxious he was again otherwise considered settled in mental state with reference to an absence of any speech abnormalities or psychotic symptoms.

Chair:

Chief Executive:

Mr Agius’ medical records would suggest that there was consistency in the opinion of the two staff members that visited, in as much that they both did not see evidence of an elated mood. Had Mr Agius been under the BDHTT for a period longer than the three days he was, he would have been reviewed by the medical team, in line with the HTT Standard Operating Procedure and greater clarity regarding his diagnosis would have been achieved.

When HTT staff complete their mental state examinations, where there is a potential concern regarding a mood disorder, staff will make reference to a service user’s speech and observation of any psychotic symptoms. This is completed as abnormalities within these domains can be common features of a manic episode (International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)).

3. Incomplete Risk Assessment

The final concern raised related to the risk assessment completed and NELFT’s progress in transitioning from the previous risk stratification model of assessing risk to that of risk formulation. As correctly referenced in your report, this change will reflect national recommendations on the most effective means of assessment of the risk suicide and self-harm (NICE NG225 Self Harm: assessment, management and preventing recurrence).

The Trust does have a programme in place to roll out training in relation to this. The Acute and Rehabilitation Directorate (ARD, which the HTTs are part of) was identified as the first directorate to engage in this risk formulation training. This roll out began in September 2024. All qualified clinical staff within the directorate will be trained in this approach by the end of December 2024. The roll out of this will then be extended throughout the Trust, with all areas fully trained by April
2026. Within the Barking and Dagenham HTT, 16 of the 19 qualified staff have been trained, with the remaining staff all booked to complete this training in December of this year.

I hope this response gives assurance that the Trust continues to take learning from Inquests very seriously and has put actions in place following Mr Agius’s sad death.

If I can be of any further assistance or if you would like a further update on the progress made to address your concerns, please do not hesitate to contact me.