Dear Coroner Lambert

Re Inquest touching the death of Claire Homer (date of death 05/05/2023)

I am writing further to the inquest for Claire Homer which concluded on 11/11/2023 and at which you issued a Prevention of Future Deaths report. The matters of concern raised were whether more robust protocols need to be in place to address the scenarios of (a) patients who are not initially deemed to require handover care but deteriorate during a member of staff’s leave and (b) both key points of contact being on leave at the same time.

Thank you for raising these points which have been carefully considered from a service improvement perspective. I can advise that the following actions have now been taken:
1) The importance of ensuring robust ‘Out of Office’ responses when on leave was discussed with staff in an Early Intervention Service-wide meeting on 24/11/2023. This meeting was chaired by , Service Manager. Minutes have since been sent to the whole service. Staff were asked to ensure their automated ‘Out of Office’ replies clearly signpost if the matter is urgent or requires an urgent response a) how to escalate a concern and b) to whom.
2) This has been followed by issuing a template that was circulated on 11/12/2023. Within this template, it makes clear that if the matter is urgent or requires a more rapid response, the sender should re-send to the relevant EIS team duty phone (Mon-Fri 9-5pm) and/or the team email inbox (Mon-Fri 9-5pm). As EIS is not an emergency service, the expected response time is within 24 hours. Contact details for the crisis line should also be provided for use in an emergency situation.

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3) The service manager has also requested this same practice is robustly followed for voicemail messages when a member of staff is absent from work.
4) The service manager has checked that the information is correct for both EIS teams online and has had this amended to include the duty mobile numbers of the two EIS teams, in addition to the switchboard number and team Inboxes which were already present.
5) With regards key contacts being on leave at the same time, the need for cover arrangements for doctors to be in place and communicated clearly with the team has been reiterated. These cover arrangements should always be clearly signposted via ‘Out of Office’ messages.
6) The service manager has reiterated to team managers the importance of balancing service need and cover with requests for annual leave.
7) The service manager has reiterated the necessity to provide the team with a clear handover of patients prior to taking leave. This practice is robustly in place already. However, when a patient deteriorates whilst they are away, the expectation is that the person alerting the team to this follows the signposting indicated on their ‘Out of Office’ reply and escalates to the team inbox and/or duty phone.

For the record we wish for it to be noted that in this case staff email accounts have been checked and robust Out of Office messages were in place signposting recipients to the EIS duty team. Whilst the above actions are now in place within the EIS team, we will also be ensuring that this learning is shared and implemented across the Camden division and the wider Partnership.

I trust that this offers you the necessary reassurance in regard to these matters but if you have any further queries, please do not hesitate to contact me.