Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Mr Jada Monoja who died on 17 November 2020

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 May 2024 concerning the death of Jada Monoja on 17 November 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jada’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Jada’s care have been listened to and reflected upon.

Your Report raised concerns over the Risk Assessment Tool used in Jada’s case and that it was not used in line with Oxleas NHS Foundation Trust (Oxleas) policy.

One of the key actions set out in the Government’s Suicide Prevention Strategy (published on 11 September 2023) was that NHS England would identify opportunities to improve the quality and culture of risk management and safety planning within mental health services. The position regarding risk assessments was included in the NHS England guidance to improve the culture of care for mental health inpatient services in April 2024: Culture of care standards for mental health inpatient services.

The Suicide Prevention Strategy also stated that NHS England would scope and start delivery of training and quality improvement programmes. It is important that culture and practice across mental health services reflects an individualised, person-centred approach to safety-planning and risk management, and that access to appropriate support is not closed off as a result of assessments of risk.

Following engagement from my London regional colleagues, Oxleas have advised the South East London Integrated Care Board that that they designed a clinical risk training workshop, for clinicians who work with people with mental health illness, on risk assessment and formulation. The training supports teams to apply a personalised approach to risk assessment and risk formulation based on data and recommendations from The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). The training addresses the emerging concerns about over- reliance on risk assessment tools and risk rating in predicting suicide risk, offering important clinical messages for daily practice. Oxleas are also an active participant in National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

25 July 2024

the Royal College of Psychiatrists’ Culture of Care Programme, which is a programme aimed at improving the culture of inpatient mental health, learning disability and autism wards so that they are safe, therapeutic and equitable places in which to be cared for. I note that you have also addressed your Report to Oxleas, who may be able to provide you with further information around your concerns.

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 Jada, 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 Mr Mooyart,

Thank you for your Regulation 28 report to prevent future deaths dated 17 May 2024 about the death of Mr Jada Monoja. I am replying as the Minister with responsibility for mental health and patient safety.

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

Your report raises concerns over how the risk assessment tool on the Trust’s Electronic Patient Journey System (EPJS) is used.

The specific details of your concerns should be addressed in the responses from the Oxleas NHS Foundation Trust and NHS England. However, we recognise the issues associated with the use of risk assessment tools in the care of people who may be at risk of suicide. The ability of clinicians to identify and manage an individual’s risk of suicide is critical to enabling treatment and longer-term support that can help to reduce suicidal risk. However, risk assessment tools and scales, used in isolation, cannot accurately predict risk of self-harm or suicide and any use of such tools must only be as part of a wider, person-centred conversation to best understand and assess an individual’s suicidal risk.

In September 2022 the National Institute for Health and Care Excellence (NICE) published updated guidance on Self-harm: assessment, management and preventing recurrence (NG225). This states that risk-assessment tools and scales should not be used to predict future suicide or repetition of self-harm and should not be used to determine who should and should not be offered treatment. Furthermore, NICE’s guidance is clear that the focus of assessments should be on the needs of the individual and how to support their immediate and long-term psychological and physical safety.

In September 2023, the 5-year Suicide Prevention Strategy for England was published, which included over 130 actions aimed at reducing the suicide rate within two and a half years. As part of this, a number of groups were identified for consideration for tailored or targeted action at a national level, including people in contact with mental health services.

It is important that culture and practice across mental health services reflects an individualised, person-centred approach to safety-planning and risk management, and that access to appropriate support is not closed off as a result of assessments of risk. One of the key actions set out in the strategy is that NHS England would identify opportunities to improve the quality and culture of risk management and safety planning within mental health services. The position regarding risk assessments was included in wider guidance to improve care standards for mental health inpatients published in April 2024 and available at: Culture of care standards for mental health inpatient services. The strategy also stated that NHS England would scope and start delivery of training and quality improvement programmes.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Dear Assistant Coroner Mooyaart

Re: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS I write in response to the Regulation 28 Report to Prevent Future Deaths dated Friday 17th May 2024, which you sent following the inquest into the death of Mr J Monoja.

In the report, you raised the following concerns:

Risk Assessment Tool on the online system (EPJS) is not used in line with Trust policy. The detailed indicators informing the risk assessment were not updated. A longer narrative assessment of the patient was instead placed in the patient chronology.

(1) If the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete and/or out of date, and therefore misleading, information.

(2) Absent the above, and dating of revisions within a compound document, it is not clear on what indicators any risk assessment is in fact based. (3) To the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent viewer is then likely to be incomplete and misleading. (4) The potential benefit of using the tool to establish a point of benchmarking/ comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted (as was the case in this inquest). (5) If the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the risk assessment tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient.

The Trust’s response to these concerns is as follows:

As you have noted, following the investigation into this very sad death, the Trust is committed to improving our approach to risk assessment, formulation and safety planning. To this effect, leads have been appointed to start this work and last month the Trust was successful in a bid to be one of the second wave pilot sites to work with the National Culture of Care team to adapt our risk assessment and formulation tool. The purpose of this is to train staff in current best practice with regards to risk, and to embed sustained change in practice across the Trust. This is a major piece of work over the next 18 months, with significant service user involvement and using quality improvement methodology. Progress will be tracked by regular meetings and review of data with the culture of care team.

It is recognised that at times risk assessment documents are partially updated and the communication with regards to risk is of the utmost importance to ensure we provide safe and clinically effective care.

As a result, we will be issuing a blue light bulletin to all clinical staff by Friday 9th August 2024 reminding them of the need to ensure risk assessment documents are updated at appropriate intervals including at the time of assessment in line with the Trust risk assessment policy.

Teams will ensure this is being completed through regular audits of risk assessments on the Trust Audit Systems ‘Tendable’. From June 2024, the Trust has made changes to the auditing system of Risk assessments for inpatients, crisis and community services to ensure that this is a now stand-alone audit tool to ensure the quality and accuracy of risk assessments for patient within our care.

I hope that this response addresses the concerns which you have raised and explains why the trust has chosen to take the steps it has. I thank you for bringing these issues to our attention.