Dear Ms. Persaud

Regulation 28 Report Response arising from the inquest into the death of Conrad Colson

Thank you for your Regulation 28 Report dated 26 May 2023 setting out your concerns to be addressed. I would like to begin by expressing my deepest condolences to the family and friends of Mr Colson.

Following the conclusion of the inquest on 18 May 2023, you requested an update on the matters outlined below. The concerns you raised in your Regulation 28 Report in respect of South London and Maudsley NHS Foundation Trust (‘the Trust’) were as follows:

1. ‘A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT. There was a lack of full information sharing around risk and joint risk assessment/risk management planning on discharge’;

2. ‘Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis’; and

3. ‘The Inquest heard that there is a need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with it’.

The Centre for Anxiety Disorders and Trauma (‘CADAT’) has updated its discharge policy (enclosed with this letter), to explicitly state the expectations of liaison between local teams and CADAT. The updates to this policy confront the issues faced in Conrad’s case. The updated policy was circulated to all team members at CADAT and was discussed in the clinic’s team meeting on 1 June 2023. This

Date: 20.07.2023

PRIVATE & CONFIDENTIAL

Ms Nadia Persaud Walthamstow Coroners Court Queens Road, Walthamstow London. E17 8QP

Our ref: WEB143633 CADAT

policy is also in line with that of the Trust’s Anxiety Disorders Residential Unit. The updated policy was reviewed and ratified by the PMOA Leadership Team on 12 July 2023. The policy will again be discussed and shared in CADAT’s business meeting on 3 August 2023.

The updated CADAT discharge policy also includes how staff are expected to communicate with skin clinics regarding patients seeking aesthetic dermatological/cosmetic treatment which includes seeking consent from the patient to liaise with local services/GP, and if this is refused how to manage the situation.

It would not be possible for the CADAT to provide training on BDD to all referring services nationwide due to the logistics and capacity within the clinic itself. The CADAT clinic is in the process of offering training on BDD to local services. In addition, the CADAT has agreed to provide more support to local services who have referred patients. The CADAT will now include a detailed one page BDD information guide (enclosed with this letter) prepared by Professor David Veale, Consultant Psychiatrist in Cognitive Behaviour Therapy at the CADAT, to referring services in their communication following referral.

The PMOA Leadership Team has reviewed the response by North East London NHS Foundation Trust (‘NELFT’) to your Regulation 28 Report which it received on 17 July 2023. Following receipt of this document, the CADAT has been in communication with NELFT with regard to recommendations 1 and 3 of its Action Plan (which were contained in its response provided to you) to ascertain how best the CADAT can assist NELFT going forward in implementing the recommendations it has made.

Please do let me know if you have any additional queries.

Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Conrad Richard James Colson who died on 2 March 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26 May 2023 concerning the death of Conrad Richard James Colson on 2 March 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Conrad’s family and loved ones. NHS England is keen to assure the family and the coroner that the concerns raised about Conrad’s care have been listened to and reflected upon.

NHS England’s Highly Specialised Severe Obsessive-Compulsive Disorder and Body Dysmorphic Disorder Service

The NHS England Highly Specialised Severe Obsessive-Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) Service (Adults and Adolescents) (hereafter “Service”) is resourced and commissioned via the provision/service specification C09/S(HSS)/a (Publication Date: 2012/2013): https://www.england.nhs.uk/wp- content/uploads/2018/08/Severe-obsessive-compulsive-disorder-and-body- dysmorphic-disorder-service-adult-and-adolescent.pdf. The Service is a national service and treats patients with severe BDD who have failed to respond to evidence-based treatment in locality-based and regional centres according to need. It comprises five integrated centres based at the following Trusts; South London and Maudsley NHS Foundation Trust (SLAM) adults, SLAM children and adolescents, Hertfordshire Partnership NHS Foundation Trust (HPFT), the Priory Hospital North London and South West London and St George’s Mental Health NHS Trust (SWLSTG). Each centre is led by a consultant psychiatrist and a multidisciplinary team specialising in the treatment of BDD, and each centre specialises in different aspects of care – some offer inpatient care, others residential, home-based or outpatient-based care. The Service covers children, adolescents, and adults with no upper age limit. Referral pathways into the service emanate from secondary or tertiary care. Patients are ordinarily referred to the Service by a senior member of their local mental health team. They are expected to have a care coordinator and consultant psychiatrist National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

18 July 2023

actively involved for managing their overall psychiatric care and associated risks at the time of referral and during the waiting phase. The care coordinator and consultant are expected to remain involved throughout the care under the service, who liaise closely with them throughout care planning and discharge. The national Service operates a monthly case allocation meeting at which new referrals are allocated to the centre that best meets their clinical need. Following referral, the patient is assessed, and a decision made as to whether the service is clinically appropriate. If they are accepted, there may be a further wait before treatment starts. Waiting times for assessment and for treatment vary across the service, depending on the centre and the kind of treatment provided. For example, inpatient care usually has a longer waiting time than outpatient-based care and cognitive behaviour therapy has a longer waiting time than pharmacotherapy. Current waiting times for assessment range from 1-4 months (SLAM adults, HPFT, Priory Hospital, SWLSTG inpatient care) to around 7 months (SLAM child and adolescents), measured from the date of referral. Waiting times for treatment range from 1-6 months (HPFT outpatient or home-based care, Priory H outpatient care, SLAM outpatient care, SWLSTG inpatient care) to around 16 months (SLAM child and adolescents service, SWLSTG home based care) from referral. Waiting times are kept under regular review and, where possible, patients are allocated to the centre where the waiting time is the shortest e.g., for home-based care. While there has recently been a perceived increase in the overall number of referrals to the NHS England Highly Specialised Severe OCD/BDD Service for children and adolescents at SLAM, a similar pattern of increased BDD referrals has not so far been seen in the adult Service, but it may simply be a matter of time before the perceived increased occurrence in younger people filters through to adult mental health services, highlighting a probable need to consider building greater capacity for treating BDD at primary and secondary mental healthcare levels, which we will continue to monitor. The clinicians in the NHS England Highly Specialised Severe OCD/BDD Service consider this issue highly important because BDD is common, estimated at 0.5-3.2% in the general population, 1.3-5.8% in student cohorts, 4.9- 21.1% in general dermatology cohorts, and 2.9- 57% in cosmetic surgery cohorts. It is also a dangerous condition with a markedly high suicide rate; 0.3% per annum prospectively end their life and about 25% have made a past attempt on their life, and it can be very difficult to treat. The Service therefore engages in education and training activities for relevant healthcare professionals and aspires to expand these education and training activities as well as the future development of regional specialist centres, to disseminate best practice more widely, conditional on additional resourcing. Aesthetic and cosmetic treatment risks and BDD Regarding your concern that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and that, wherever possible clinics who are providing treatments should be made aware of the BDD diagnosis, there is clear guidelines from the National Institute for Healthcare Guidance (NICE) on this issue. The guidelines (NICE Clinical guideline [CG31]) include the following paragraphs:

2.6.5.4 For people known to be at higher risk of BDD (such individuals with symptoms of depression, social phobia, alcohol or substance misuse, OCD or an eating disorder), or for people with mild disfigurements or blemishes who are seeking a cosmetic or dermatological procedure, healthcare professionals should routinely consider and explore the possibility of BDD.

2.6.5.6 People with suspected or diagnosed BDD seeking cosmetic surgery or dermatological treatment should be assessed by a mental health professional with specific expertise in the management of BDD.

2.6.5.9 Specialist mental health professionals in BDD should work in partnership with cosmetic surgeons and dermatologists to ensure that an agreed screening system is in place to accurately identify people with BDD and that agreed referral criteria have been established. They should help provide training opportunities for cosmetic surgeons and dermatologists to aid in the recognition of BDD. [GPP]

10.3.1.3 Specialist OCD/BDD teams should collaborate with people with OCD or BDD and their families or carers to provide training for all mental health professionals, cosmetic surgeons and dermatology professionals. [GPP]

There can however be barriers to implementation of the NICE guidance, where patients do not consent for private providers and their mental health professionals to disclose information to each other.

NHS England’s existing national Clinical Reference Group (CRG) for OCD & BDD is intending to convene with relevant wider stakeholders in light of the concerns raised in your Report. This will include consideration at a national level of the issues of patients with BDD who access aesthetic dermatology treatments.

Other concerns

In terms of the matters of concern specific to Conrad, NHS England are unable to comment on the absence of liaison between the Centre for Anxiety Disorders and Trauma (CADAT) team at SLAM and the stepdown services provided by North East London NHS Foundation Trust (NEFLT), nor the adequacy of communication, information sharing between the two Trusts or the training of staff employed by NELFT, who are the appropriate organisations to respond to your concerns. NHS England has however been sighted on NELFT’s Serious Incident Report into the matters surrounding Conrad’s death and note that there have been learnings and recommendations made, including improvements to information sharing. We have also asked to be sighted on the response to you Report from both NEFLT and SLAM and will consider these carefully.

I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.

Regulation 28 action plan

Safely NELFT Action Plan: 12/06/2023 Action Plan Title: D150069 Start Date Action Plan Owner :

Priority: High Service/Team: Mental Health Services Target Date: 01/12/2023 Business Unit: Waltham Forest Directorate: Waltham Forest Source: Complaints Clinical Audit External Inspection Internal Inspection Internal Audit Safeguarding

Serious Incident X Medicines Management Infection Control QPS H&S Serious Case Review Safety Thermometer

External Inspection Dashboard Other x Regulation 28

Concerns of the Coroner:

1. Joint working (information sharing): A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT. There was a lack of full information sharing around risk and joint risk assessment/risk management planning on discharge.

2. Risk management: Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis.

3. Training: The Inquest heard that there is a need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with it.

Concern raised by the Coroner Act ion no. Action (short form) Action (long form) By Whom By When Office Ref: 1208

Regulation 28 action plan

Joint working (information sharing): A concern arose at the Inquest hearing in relation to the absence of liaison between the highly specialist services of the CADAT team and the stepdown services provided by NELFT. There was a lack of full information sharing around risk and joint risk assessment/risk management planning on discharge.

1) Improve working relationship between the highly specialised services of the CADAT team and the stepdown services provided by NELFT. This should include the need for full information sharing around risk and joint risk/management planning and discharge
• Joint working protocol to be developed between the CADAT team and the stepdown services provided by NELFT. This should highlight the need for full information sharing around risk and joint risk/management planning and discharge.
• The joint working protocol to be shared with all staff and discussed in team business meetings.

Assistant director 31 /09/2023

31/09/2023

Regulation 28 action plan

Risk management: Both mental health services were aware that Conrad was accessing aesthetic dermatology treatment. There was a concern that neither service adequately highlighted the risks of accessing such treatment to Conrad or attempted to share information with the skin clinic. The inquest heard that patients with BDD should be fully informed of the risks of seeking aesthetic dermatology treatment and wherever possible, clinics who are providing treatment should be made aware of the BDD diagnosis.

2) Learning event to be arranged on BDD for all staff Short Term
• Learning event to be arranged on this case with specific reference on BDD and the importance of working with partner agencies.

• Learning event on completing risk assessments arranged for 05/07/2023. This learning event will cover updating risk, the parameters to consider when completing a risk assessment and when to update a risk assessment.

Long Term
• The Trust is planning to undertake a Quality Improvement Project on understanding why there are gaps in risk assessment and risk management processes (a couple of examples of reoccurring themes), particularly when there are poor outcomes associated with care provided. The project will focus on working with users of service, clinical and operational teams, as well as senior leadership and other identified key stakeholders to understand the structural, process and cultural factors which contribute to poor outcomes and use improvement methodology and framework to address the areas which can result in process changes to improve outcomes. It may be that a break through series collaborative methodology could be used across various teams at NELFT. This approach could potentially standardise variation through testing a change package which includes evidence based approaches to ensure care provision meets those standards and teams have a realistic chance of providing the care that is required to avoid future untoward outcomes. There is also a workstream which is leading on the development of risk formulation to ensure the implementation of robust risk assessment and risk management process to improve patient safety and move away from the current risk stratification model.

Assistant Director

Assistant Director 31/08/2023

05/07/2023

30/09/2024

Regulation 28 action plan

Training: The Inquest heard that there is a need for training to be provided to step-down service teams in relation to the diagnosis of BDD and the risks associated with it.

3) Body Dysmorphic (BDD) training to be offered to all staff
• Training department to arrange training on BDD for all staff this to be in conjunction with SLAM who offer training in this specialised area. Head of Learning services 01/12/2023

Dear Madam Thank you for sending a copy of the Prevention of Future Deaths report dated 26 May 2023 following the inquest into the death of Conrad Colson. We would like to reiterate our condolences to Conrad’s family and friends. The investigation process has provided a valuable learning experience for our organisation and we are grateful for the opportunity to improve our processes. We have noted the concerns raised by you and have considered these within the organisation. Our response to these concerns is set out below.
• We have updated our ‘BDD policy’ so that all new patients presenting to the clinic are formally screened for BDD using the validated, and published COPS questionnaire. The COPS score is then clearly documented in a dedicated page of the patient’s electronic medical notes. Further that if there is a COPS score of 30 or more, or if there are any clinical concerns of BDD, that this information is shared with the GP (subject to patient consent). Please find attached updated BDD policy with edits in red font.
• We have also updated the policy to ensure that clinical assessment of BDD incorporates communications sent by patients to clinic, for example patient concerns over cosmesis, treatment results or impact on well-being. Please find attached updated BDD policy with edits in red font.
• We have ensured that the BDD policy is embedded by: o Delivering in-depth, mandatory training on the revised BDD policy to all our team. Training was carried out on 14th June 2023. o Commencing a daily team brief at the beginning of each day, where all patients to be seen are discussed amongst clinicians and patient coordinators. There is a focus on highlighting all new patients that are to undergo the formal BDD screen. During this Dr Tatiana Aesthetic Dermatology Clinic | 2 Devonshire Place | London W1G 6HJ

meeting, any patient concerns raised by patients, in person or via email/telephone are discussed, and it is checked that these communications have been uploaded into the medical notes. This will help ensure clinicians consider concerns raised by patients during their upcoming consultations and incorporate these concerns into their decision making processes. Discussion summaries and outcomes are recorded. This is outlined in our updated ‘patient journey policy’ (edits in red font). o Initiating an annual audit to ensure that the updated BDD policy is being followed. This audit will assess whether: a) patients are being screened appropriately b) whether documentation is adequate c) for patients where there are clinical concerns of BDD, that they are managed appropriately, and relevant information is being shared with GPs/other relevant healthcare professionals. The findings of the audit will be presented during our weekly team meeting and any areas of improvement will be highlighted and relevant action taken. The first audit will be carried out in 3 months (September 2023)
• Clinicians have been reminded to ensure that documentation is full including making use of the free text options in the electronic records. This includes all assessments/discussions regarding BDD and patient concerns. This will also include ensuring that communications from patients where concerns are raised are discussed with the patient in a clinical setting, where appropriate, and documented in the electronic records. We will carry out an annual audit of patient consultations. Please find attached the updated ‘patient journey policy’ with edits in red font.
• We have now updated our ‘patient journey policy’ so that all communications where patients raise concerns are uploaded into the electronic medical notes. Further that these communications are highlighted to the responsible clinician within 24 hours and patients receive a response within 24 hours. Clinicians must document in the notes how these concerns have been considered and addressed. Please find attached the updated ‘patient journey policy’ with edits in red font.
• We have updated our ‘patient journey policy’ to provide clear guidance on when to share/request patient clinical information to/from GPs or other relevant healthcare Dr Tatiana Aesthetic Dermatology Clinic | 2 Devonshire Place | London W1G 6HJ

professionals. We have also specified that communication with patient GPs or other healthcare professionals should be in writing and that an electronic copy of correspondence must be kept in the patient’s electronic records. Please find attached the updated ‘patient journey policy’ with edits in red font.
• All our clinical team have received training on the revised policies, and we will ensure that our team receive refresher training on at least an annual basis. We hope that this provides reassurance to you of the steps taken by the Dr Tatiana Aesthetic Dermatology Clinic and the steps taken by way of continuous improvement.