Dear Madam Inquest touching upon the-death of~ Dunne This is 2 formal response to your Regulation 28 Report dated 20 August 2019in which you set out your concems relating to the care Mr Dunne received East London NHS Foundation Trust (the Trust) Your concerns related to Mr Dunne'8 assessment carried out by ihe registered mental health nurse (RMN) when Mr Dunne-called the City and Hackney Crisis and Resolution Home Treatment Team'8 (City and Hackney HTT} crisis Iine on 20 February 2019 at22.51, In particular; you note that it was only Over an hour since Mr Dunie was discharged from A&E, the RMN did not: ask Mr Dunne jf hefelt sulcidal Lam aware that you heard evidence during the course Of the Inquest that the RMN believed that she had asked Mr Dunne if he was-suicidal during her assessment as i was her usual practice, However; she couid not specifically recall If she:had. Further; she had.not madeza full recording in Mr Dunne s medical notes of her assessment; We understand that without & full note-yOu cannof be reassured that & full risk assessment Was undertaken and that Mr Dunne was asked if he was suicidal. Given the concern you raised was not identified in the Trust's Sl-report we reviewed this matter in more detail We further Identified that the RMN went off sick shortly 'after her phone call with Mr Dunne and that this likely impacted upon the quality of hermedical note. Chair: Marie Gabriel: Chief Executive: Dr Navina Evans Tony from yet

The importance ofgood quality; full_ complete and appropriate risk assessments is a skill for all our clinical staff atthe Trust_In order to reinforce this, the City and: Hackney HTT will be providing additionai training during its away days scheduled for and 5 December 2019. Thls will include:
1) Reviewing the core competencies and standard of risk assessment required By clinicians operating the crisis Iine in line With the Trusts Competency Framework for Mental Healthi Crisis Lines; and
2) Reinforcing standard of medical record taking expected by the crisis line clinicians in accordance with the Trusts Menial Health Crisis Line Standard Operating Procedure: Good guality handover of patient care is also expected of our: clinical staff at the Trust inclding i acases 9i sudden illness The City and Hackney HTT will also be providing: training in relation -to this topic, in accordance with the Trust s Managing Sickness Absence Policy on its away days on 4 and 5 December 2019. Additionally: the Trust appreciates that in cases of sudden-illness, circumstances may arise beyond staff members' control impacting the quality of their handover: In order to ensure continuity of care for-all of its patients; City and Hackney HTT will be rolling out a new protocot-on checking outstanding work following sickness: forward, ii a clinician manning the crisis line is suddenly ill, at the first opportunity; that staff members' immediate line manager will review their case load for that shift and ensure that ali appropriate actions have been takeri and that this Is reflected in: the medical notes_ hope that the information above reassures You that the Trust has taken your concerns seriously and that the taken has adequately addressed those concerns: Ifyou do require any further information please do not hesitate to contact me_ Youre sincerely Dr Paul Gilluley Chief Medical Officer Chair Marie Gabriel Chief Executive: Dr Navina Evans key the the Going action