Dear Mrs Hunt

Re: Gurdeep Dundhal; Regulation 28 Report to Prevent Future Deaths

I write in response to your Regulation 28 Report issued to Birmingham Women’s and Children’s NHS Foundation Trust, Walsall Metropolitan Borough Council, Birmingham City Council and Priory Group of Hospitals on 10 September 2019, following the inquest into the tragic death of Gurdeep Dundhal. We would like to express our sincere condolences to the family of Gurdeep, who sadly have lost a very special young man. The matters of concern you raised in your Report are as follows; “There was a delay in organising the assessment of Mr Dundhal when he was detained on S5(2) of the Mental Health Act on 11/04/19. The evidence confirmed there appeared to be confusion as to who was to undertake the assessment between Walsall MBC and Birmingham City Council. In addition there was a lack of resources to enable the assessment to be carried out in a timely manner. This meant the assessment was carried out just a few hours before the time period for the S5(2) was to expire.

Evidence at the inquest from the approved Mental health practitioner confirmed that key Dr Fiona Reynolds Chief Medical Officer Executive Team Birmingham Women’s and Children’s NHSFT Steelhouse Lane Birmingham B4 6NH

information and documentation were either unavailable and/or not asked for during the mental health act assessment on 14/04/19. I was unable to confirm which at the inquest. This meant the true nature of Mr Dundhal’s long term condition was not known and the assessors were unable to see the “bigger picture”. The delay in arranging the assessment contributed to the lack of available information.

When Mr Dundhal was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3. No explanation was available for this. Evidence at the inquest suggested this was a decision made by the Approved Mental health practitioner from Birmingham City Council. Consideration needs to given as to why a S3 was not put in place in accordance with the recommendation.

Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19. They have also failed to engage with other agencies to ensure lessons are learnt. It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others.”

In preparing this response, we have obtained the call logs from 14 April 2019, providing the telephone numbers which called in to the Access Centre on that day. We were concerned to hear at the inquest that the request for Mr Dundhal’s records was made and not complied with. Unfortunately, we have not been able to establish the telephone number which the Approved Mental Health Practitioner called from and as such we are limited in our investigations on this point.

We understood from the evidence provided at the inquest that the Approved Mental Health Practitioner made a call to the Access Centre on 14 April 2019 in order to make attempts to obtain Mr Dundhal’s records held by FTB. Whilst it is the case that the Access Centre is closed at weekends, I can confirm that calls made to this number out of hours are routed to FTB’s urgent care team. Therefore any call made to the Access Centre would have been picked up by the shift coordinator in the adult crisis team. All calls to this number are recorded as a relevant clinical record. All calls that came through the Access line to urgent care on 14 April 2019 have been reviewed and we have not been able to identify the call on our audio file.

I would like to reassure you, however, that FTB records are held electronically and these are easily available to be shared where appropriate. Although we are unable to establish the precise circumstances of this call, as a direct result of your report, we have redistributed the safer inter agency information sharing guidance within the urgent care team and at the local governance meetings to ensure that any lessons to be learnt are implemented.

Since the issue of your Report, we have been contacted by Walsall MBC and have been invited to participate in a multi agency meeting to discuss this matter. We await a date for the meeting, following which further actions may become apparent. I will write to you again to provide the details of the outcome of this meeting.

I hope this letter serves to reassure you that the concerns you raised have been acted upon.

We will continue to engage with other agencies to enable the Trust to learn from incidents and improve patient care.

Dear Ma'am ReMr Gurdeep Dundhal (deceased) I write to you in response to the Regulation 28 Prevention of Future Deaths Report dated Tuesday 10 September 2019 that you issued following the Inquest touching the death of Mr Gurdeep Dundhal: We note that your report was addressed to Walsall MBC, Birmingham City Council, Birmingham Women's and Children's NHS Foundation Trust and the Group of Hospitals (PGH) You will appreciate that in respect of points 1, 3 and 4, PGH is not in a position to comment and that (0) any delays in arranging the MHA assessment; (ii) the use of Section 2 rather than a Section detention on admission; and (iii) the failure by Walsall MBC to undertake an investigation are matters for the other interested persons noted above to address_ In respect of point 2 and the concern in relation to information unavailable or not asked for, please note that clinical staff at Lakeside View have considerable experience in liaising with professionals undertaking Mental Health Act assessments and have advised that relevant information relating to Mr Dundhal was made readily available to the assessing team: Additionally, Mr Dundhal's responsible clinician;B made himself available on the of the assessment and in fact was contacted by ward staff who asked him to speak to the assessing doctor , PGH has also enquired as to whether there was an IT systems outage on Sunday 14 April 2019 at Lakeside View which may have impacted on the to retrieve electronic clinical notes (CareNotes) for the assessment thereby making them 'unavailable" but has found no evidence to suggest the hospital's IT systems were not working normally on that

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WALSALL COUNCIL RESPONSE TO REGULATION 28 REPORT

Walsall Council has carried out an investigation into the events which took place whilst Gurdeep Singh Dundhal was detained by reason of s.5 (2) of the Mental Health Act
1983. The detention took place between 11.50am on Thursday 11 April 2019 and the late morning of Sunday 14 April 2019 when a decision was made, after an assessment of him, that it would not be appropriate for him to be detained in hospital. That investigation was conducted by the Mental Health Team Manager who reported to the Head of Community Care Partnerships. The Head of Community Care Partnerships has also held meetings with senior staff and the solicitor to the council to carry out a review of what had occurred to identify the causes of any shortcomings, and to put into place measures to prevent the recurrence of the shortcomings. The review has also opened discussions with a partner authority to consider improvements that can be made.

Matters of concern:

The delay in organising the assessment of Gurdeep Singh Dundhal

Gurdeep Singh Dundhal was detained under s.5 (2) of the Mental Health Act 1983 at
11.50am on Thursday 11 April 2019. Walsall Council was not then told of his detention. Lakeside View Hospital, where Gurdeep Singh Dundhal was detained, had informed Birmingham City Council of his detention. This was not only an understandable move but a sensible one. Lakeside View Hospital had been treating Gurdeep Singh Dundhal since mid-March 2019. He had been referred there by the Mental Health Team from Birmingham City Council who had been providing his care in the community for approximately 3 years. As his home authority it was Birmingham City Council which was responsible, in March 2019, for arranging his detention under s.2 of the Mental Health Act 1983 for assessment. It was Birmingham City Council who knew about Gurdeep Singh Dundhal, both from caring for him for approximately 3 years and because they held his records. He was wholly unknown to Walsall Council.

In the afternoon of Friday 12 April Lakeside View Hospital telephoned Walsall Council to tell it that an assessment of Gurdeep Singh Dundhal had not yet been carried out. Lakeside View said that it had requested Birmingham City Council to co-ordinate the assessment. Walsall Council advised Lakeside View to call back if Birmingham City Council did not undertake the assessment. On the 12th April 2019 at 14:15pm

(AMHP) was on duty in the AMHP Hub Walsall Council. He received a call from (AMHP, Birmingham City Council) requesting a Walsall AMHP to undertake a Mental Health Act assessment of Birmingham Resident Mr Gurdeep Singh Dundhal who was a patient of Lakeside View Hospital (Priory Group) Walsall Walsall Council said that it did not have sufficient resources to carry out the assessment. The investigator could find no good reason why this had been said. There were at that time three Approved Mental Health Professionals (AMHPs) on duty. They were not at that time dealing with any other referral. Nevertheless Birmingham City Council agreed to carry out the assessment. This arrangement was reached at 14:51.

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There was no further contact with Walsall Council for over 24 hours until Saturday 13 April 2019 at 17:35 when Lakeside View telephoned the Emergency Duty Team at Walsall Council to explain that the assessment had not yet been carried out. There were further telephone conversations which led to Walsall Council speaking to an AMHP from Birmingham City Council. The AMHP from Birmingham City Council explained that there had been a difficulty in carrying out the assessment. She was provided with the telephone numbers of the psychiatrists in Walsall approved under
s.12 of the Mental Health Act 1983. A few minutes later at about 18:20 Birmingham City Council informed Walsall Council that it would not be completing the assessment, even though it had been commenced.

It was at this point that Walsall Council assumed the responsibility for carrying out the assessment. The AMHP on duty knew that Walsall Council had no direct access to Gurdeep Singh Dundhal’s records held by Birmingham City Council or by the mental health trust in Birmingham. Whilst those records could be obtained there would be a significant delay before they were available. He made a decision that it would be unreasonable to carry out an assessment late on a Saturday evening unless it was essential for it then to be carried out. It would be more difficult to carry out an assessment late in the evening and the results could be affected by the hour of the day at which it had been conducted. It was his view that it would be better for the assessment to be carried out the next morning.

On Sunday 14 April 2019 , an AMHP employed by Walsall Council, was due to come on duty at 9am. The AMHP who had been covering the night shift, and who had made the decision to defer the assessment until that morning, contacted shortly before 08:00 to advise him of the need to carry out an assessment on Gurdeep Singh Dundhal and that the time for doing so expired at 11:50. started work immediately, an hour before his shift began. He contacted Lakeside View to arrange for the assessment to be carried out. He obtained the contact details of Gurdeep Singh Dundhal’s parents, his GP and the names of the two doctors who had provided the medical recommendations that Gurdeep Singh Dundhal should be detained.

was told that neither of those two doctors could be contacted and that one of the doctors, who had come from Birmingham, was unknown to Lakeside View Hospital. He was given a small amount of background information. He made enquiries of Birmingham City Council’s Emergency Duty Team to obtain information about Gurdeep Singh Dundhal. The Emergency Duty Team said that they had closed his referral and did not have information about him. He was given the telephone number to Birmingham and Solihull Mental Health Trust and was told that Oaklands Centre was overseeing Gurdeep Singh Dundhal’s care. Contact was made with the crisis team of Birmingham and Solihull Mental Health Trust. Mr Panesar asked for information about Gurdeep Singh Dundhal. He was told that all information about him had been sent to Lakeside View and that no doctors from his clinical care team or Birmingham services were available to talk to him. asked to speak to the home treatment doctors, but was told they were not available. In the absence of any other doctor being available, contacted the on call s.12 psychiatrist, who was at Dorothy Pattison Hospital. He arranged for to attend Lakeside View with a view to carrying out the assessment. Those arrangements were relayed to Lakeside View. had already spoken to Gurdeep Singh

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Dundhal’s parents over the telephone and obtained information from them about his background. They were in a position to give this information as Gurdeep Singh Dundhal lived at home with them.

arrived at Lakeside View at 10.30am where he met . They interviewed a psychiatric nurse on the ward who had for some while been looking after Gurdeep Singh Dundhal. She was able to give a history of him since his admission there on 15 March 2019. met other members of staff who provided the documents setting out the medical recommendations in support of Gurdeep Singh Dundhal’s detention under s.3 of the Mental Health Act 1983. He was also provided with the report written by an AMHP for the same purpose. Further records were requested from the staff, who attempted to obtain them. There appeared to be technical difficulties in the staff being able to obtain the records, so further oral information was sought from the staff.

Gurdeep Singh Dundhal was interviewed by in the presence of

and , a support worker from Lakeside View Hospital. After the interview further enquiries were made of the hospital staff and a discussion was held with them of ’ initial assessment of Gurdeep Singh Dundhal. There was no objection from them to his preliminary view. They told him that Gurdeep Singh Dundhal had been compliant with his care plan and treatment. was then able to speak over the telephone to , a consultant from Lakeside View Hospital, who had been treating Gurdeep Singh Dundhal and recommended he be detained under s.3 of the Mental Health Act 1983 for treatment. asked for the contact details of , the other doctor who had provided a medical recommendation, but was told his contact details were not available. There was then a further conversation with the nurse to whom he had spoken to earlier. It was at this point that the assessment was concluded.

Walsall Council points out that it did not know that Gurdeep Singh Dundhal was in Lakeside View Hospital and needed to be assessed, and could not reasonably have been expected to have known that, until after more than 24 hours had elapsed since his detention under s. 5 (2) of the Mental Health Act 1983 when it was contacted about him. That contact came from Birmingham City Council in a telephone call. During that telephone conversation Birmingham City Council agreed to carry out the assessment of Gurdeep Singh Dundhal. Walsall Council had no cause for concern about the assessment being carried out until Saturday 13 April 2019 at 17:35 when it was contacted by Lakeside View who said that the assessment had still not been carried out. It was approximately 45 minutes later that Walsall Council assumed the responsibility for assessing Gurdeep Singh Dundhal when Birmingham City Council said that it would not be further attending Lakeside View Hospital. As the assessment was unlikely to be able to be carried out until late that evening the AMHP on duty decided that it would be preferable, in the interests of the patient, for the assessment to be carried out the following morning. He therefore notified the Sunday morning duty AMHP of the need for an assessment to be carried out. The Sunday morning duty AMHP lost no time in making arrangements for, and seeing that, the assessment was carried out. The delay in carrying out the assessment whilst it was the responsibility of Walsall Council was from 18:20 on Saturday 13 April 2019 until just before 08:00 on Sunday 14 April 2019 when the duty AMHP took steps to make arrangements for the assessment to take place. That delay was as a result of the considered decision of the

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AMHP on duty taking the view that conducting an assessment late in the evening may lead to disadvantages to the patient. If the assessment were to be conducted the following morning those disadvantages could be avoided. Until 18:20 on Saturday 13 April 2019 Birmingham City Council had agreed to carry out the assessment. It was not until 17:35 on Saturday 13 April 2019 that Walsall Council was alerted by a telephone call from Lakeside View to the fact that the assessment had not yet been carried out.

Steps taken to make improvements

The staffing levels have been increased. There is therefore a provision for a duty AMHP to be able to call for additional staff if they should be needed. In addition to that an on call manager is now available to provide assistance. A procedure is being developed which will request all hospitals in Walsall to notify Walsall Council as soon as there may be a need for an assessment to be carried out on any patient in their hospital, whether or not that patient is ordinarily resident in Walsall.

A procedure is also being developed to ensure that whenever another authority agrees to undertake an assessment of a patient in Walsall that the progress of the assessment is notified to Walsall Council and that Walsall Council’s staff will take action in any case in which it appears that there may be a delay in the carrying out of an assessment. In addition to that a procedure is being developed for Walsall Council’s staff to request information from other authorities and other parts of the NHS whenever it appears that a patient may need to be assessed by Walsall Council. This is to avoid delays which may be occasioned by the need to wait for information.

In addition to that Walsall Council has opened discussions with other agencies to develop a practice to be adopted whenever a patient from another authority needs to be assessed by Walsall Council.

The obtaining of information

Walsall Council has no direct access to any records held by other parties. In view of the need for confidentiality and the data protection legislation it is unlikely that third parties would be in a position to allow Walsall Council direct access to their records. At present the only steps which can be taken by Walsall Council to ensure that records are available is to see that they are requested at the earliest opportunity. In this case it would have been better if the AMHP on duty on the evening of Saturday 13 April 2019 had, instead of merely requesting the following day’s duty AMHP to carry out the assessment, he himself made the requests for the records to be provided. Instructions have therefore been given that not only should records be sought at the earliest opportunity, but whenever an assessment is postponed the period of postponement is used for the purpose of requesting records to be made available. Walsall Council proposes to keep this matter under review. Despite this, Walsall Council has opened discussions with a neighbouring authority to see whether records can be more readily available.

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The admission to hospital on 15 March 2019

Walsall Council played no part in this admission and did not know of it. It is thus unable to assist on this matter.

Internal investigation by Walsall Council

Walsall Council has carried out an investigation led by a Mental Health Team Manager. That investigation could not begin until Walsall Council had received information about Gurdeep Singh Dundhal’s death. Although there had been earlier conversations with other agencies, it was not until the documents were provided by the Coroner’s officer on 3 September 2019 that Walsall Council was sufficiently informed about the matter to begin an investigation. Results of the investigation have been set out earlier in this document. In addition to the investigation there has been a review led by the Head of Community Care Partnerships, who has consulted not only within the mental health team but also Legal Services. The review is looking into any deficiencies or perceived deficiencies which there may have been in the provision of services in April 2019. There has been an increase in AMHPs employed by Walsall Council. There have been changes in working practices to avoid the previous practice of an AMHP being on duty for 12 hours followed by a period of being on call for a further period of 12 hours. In addition to that AMHPs will be available on call to assist the AMHP on duty whenever that may be needed. There will also be a manager on duty or on call, and thus available to provide assistance, at all times of the day and night. Walsall Council has opened discussions with its neighbouring authorities to formalise practices of asking neighbouring authorities to carry out reviews within the borough of Walsall. There will be a procedure for staff to ensure that the assessment has been carried out and completed in good time and for staff to be called on to assist if need be. It is intended that Walsall Council should meet regularly with other agencies to identify areas where improvements can be made.

List of abbreviations
s.12 psychiatrist – a psychiatrist approved for carrying out assessments under the Mental Health Act 1983 AMHP – Approved Mental Health Professional