Dear Mr Irvine,

Re: Inquest touching upon the death of Steven Paul Gary Stout

I refer to your letter dated 3 March 2021 and the enclosed Regulation 28 report issued in respect of your concerns regarding record keeping and the referral to Home Treatment Team (HTT), from Turner Ward at Goodmayes Hospital.

The Trust has taken into consideration concerns highlighted in the Regulation 28 report and agreed to take a number of actions to address your concerns. This includes:

 Provision of record keeping training to staff on Turner Ward to ensure that staff are reminded about the Trust’s expectations in respect of the record keeping.  Development and implementation of a discharge checklist to ensure that the discharge procedure safeguards patients’ clinical needs more robustly and supports healthcare staff.  Audits to monitor implementation of the discharge checklist.  Update of the HTT Service Operational procedure to ensure that the patients are not discharged without HTT or ACAT assessment, in the cases where there is a suggestion that the patients may benefit from HTT service input.  Update to Trust’s Clinical Handover of Care and Discharge Policy to ensure that the discharges take place more safely and effectively, and the referrals have been effectively completed to address the clinical needs of the patient as required.

Please find enclosed Trust’s action plan for further detail.

I wish to assure you that learning from incidents is a priority for the Trust and I am very grateful for your contribution to the improvement of our services, by way of raising your concerns to me.

Chair: Chief Executive:

I hope that the enclosed action plan provides reassurance to you that the Trust has taken this sad incident very seriously and that it reflects our commitment to improve care quality and patient safety. If you have any further queries, please contact my office on

Dear Mr Irvine

Thank you for your letter of 3 March 2021 about the death of Steven Stout. I am replying as Minister with responsibility for mental health services and I am grateful for the additional time in which to do so.

To begin, I would like to say how very saddened I was to read the circumstances of Mr Stout’s death and I would like to offer my most heartfelt sympathies to his family and loved ones. It is so desperately sad to lose a loved one and to do so in circumstances where there is concern about the care they received must be particularly devastating.

We must do all we can to take learnings from Mr Stout’s death and, in light of your concerns, I expect the North East London NHS Foundation Trust to look carefully at the care provided to Mr Stout and to take the actions needed to improve the care of mentally-ill patients and prevent future deaths.

It is important that NHS organisations keep accurate medical records from admission and discharge and ensure that they are accessible to those involved in an individual’s care as is appropriate.

More generally, I would like to assure you that we continue to take action nationally to support people with severe mental illnesses and to prevent suicide and self-harm.

The NHS Long Term Plan and NHS Mental Health Implementation Plan 2019/20 – 2023/24, commits to new and integrated models of care between crisis, acute, primary and community services. These new and integrated models aim to ensure that people with severe mental illnesses can access the right level of support, advice and guidance wherever they present in the system. This includes providing care and support for people with co-existing substance use needs.

On 27 March 2021, we published our COVID-19 mental health and wellbeing recovery action plan, backed by £500million to support people’s mental health in 2021/22.

£58million of this will be used to accelerate the roll-out of the community mental health framework to treat adults and older adults with serious mental illness, including. This includes bringing forward the expansion of integrated primary and secondary care for adults and older adults with serious mental illness; embedding mental health practitioner roles in Primary Care Networks across the country to better meet the needs of people living with severe mental illnesses in primary care; and, expanding peer support and non- clinical workforce to boost the capacity of community mental health services.

The recovery action plan also includes £6million funding to boost support for specific suicide prevention work. £1million will bolster NHS England and NHS Improvement’s work on suicide prevention and £5million is being made available to support voluntary sector organisations that prevent suicide in the community. This extra funding is in addition to the £57million investment for suicide prevention through the NHS Long Term Plan between 2019/20 and 202324, which will see investment in all areas of the country to support local suicide prevention plans and establish suicide bereavement support services.

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

NADINE DORRIES

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH