Dear Madam Re. Regulation 28 Report to Prevent Future Deaths following the inquest touching the death of Alan Macdonald (date of death 29.08.17) write in response to your Regulation 28 (PFD) Report dated 21 February 2018. This has been carefully reviewed and now set out my response below: Addcounsel's clinical director; non-medically qualified counsellor, continued to visit Mr MacDonald while Mr MacDonald was being treated as an inpatient at the Nightingale by a consultant psychiatrist_ The daily Addcounsel visits inevitably entailed further cost to Mr MacDonald, as well as the additional cost of going through Addcounsel to the Nightingale in the first place, without giving treatment in return. As set out in your Report; this issue has been addressed and the actions set out in Client Death Review undertaken following Mr MacDonald's death have now been put in place. Our system has changed in the following ways: If a client is not going to be treated by Addcounsel they are discharged entirely to the care of the service that is deemed more suitable at the time (in Mr MacDonald's case this would have been the Nightingale Hospital) and this is recorded clearly in the client's notes_ At Addcounsel we now only case manage clients to whom we are delivering services. If Addcounsel services are later requested, for example following discharge from a psychiatric hospital, then a new referral will need to be made_ When a client is discharged to the care of another service are clearly recorded in our record as 'discharged' _ The record will need to be reopened if return to Addcounsel services at a later date Where Addcounsel are not providing any immediate care, the financing of any onward referral and treatment is now handed over entirely to the new provider who will deal with this directly. the they they

written to the Medical Director at the Nightingale Hospital and requested to meet with him in order to discuss the changes t0 our processes; and to ensure that there is a clear communication channel between us and that everyone has a clear understanding of how our referral process will work will also be writing to the other organisations to which we refer patients to ensure our process is clearly set out and understood; and that everyone has a common understanding of how we will work going forwards.
2. One of Mr Macdonald's worries; expressed at consultation with psychiatrist when Addcounsels clinical director was present; did centre on his financial situation. He was very anxious that his money was running out and he was not earning while he was in hospital (After discharge from hospital, he told a friend that he had paid Addcounsel E20,000, and was not going to pursue follow Up treatment) Despite the fact that the Addcounsel clinical director knew %f Mr MacDonald s money worries; he neither brought this to the attention f Addcounsels relationship director; the person responsible for charging Mr MacDonald to enable consideration to be given to reducing the charges; nor did he highlight to Mr MacDonald the potential to access care via the NHS would like to take this opportunity to highlight that our understanding of the evidence was that Addcounsel's clinical direator_Michael Ishmail, was present on one occasion when Mr MacDonald tola hat financial concern was sometimes a trigger for his depressionlanxiety; this was during initial assessment on the day of admission to the Nightingale Hospital: The reference in the PFD report to Mr MacDonald stating that 'he Was very anxious that his money was running out and he was not earning while he was in hospital' is presumably a reference to a comment made later on hisperiod astan inpatient; to an employee of Nightingale Hospital and, would say, not in presence; Further; it is important to highlight that the reference to E20,000 includes the cost of Mr MacDonald'$ stay and treatment at Nightingale Hospital and is not representative of the cost of Addcounsel's services alone. When Addcounsel was set up we made a conscious decision to keep the discussion of finances separate the therapeutic process to avoid the latter compromised. We still maintain that it is not the role of the clinician/therapists to discuss the cost of treatment with a client and this is why we employ a dedicated relationship manager to do this. However; we do recognise and appreciate that in a situation such as Mr MacDonald s there needs to be a system in place to make sure that clinicians/therapists are able to bring relevant financial concerns to the attention of the relationship manager We are therefore in the process of writing a new policy to cover such situations. This policy will create a 'red-flag' in relation to a client making any reference to concerns about finances; the cost of treatment etc. The policy wili state the following: reference is made to finances this is to be documented and (with the consent of the client) communicated in wrtina td or Addcounsel's clinical operations manager Iwilldiscuss this with our relationship director, will then be able to have a discussion with whoever is PaylngtorAdacounsel services (either the client themselves or sometimes a third-party) in order to look at possibilities in terms of reducing costs andlor have his the during from being Any time

finding an alternative treatment provider which might; in some situations, be the NHS This system would ensure that the client's financial concerns are addressed and an opportunity is given for them to reduce the services provided by Addcounsel andlor seek treatment by an alternative provider; This policy will need to be agreed by our Independent Governance Committee and we hope to have it in place by the end of May 2018. It will then be distributed to each member of our multi-disciplinary team (MDT) by Michael Ishmail with a clear reminder of the process to follow in relevant situations Pending ratification of the policy we have already in place interim measures to ensure our MDT is aware of this change in practice. Discussions have taken place and Iwill write to every member 0f our MDT to advise them about the new policy which will be coming into place at the end of 2018 and to give them instructions as to how to approach relevant situations in the meantime Members of the MDT will be told to bring any concerns tc o be dealt with appropriately (and in a way which reflects the new system coming into place): We are also exploring ways in which we can put in place increased investigation into a client's ability to pay for Addcounsel services when first approach us. We are in the process of re-writing our 'Terms and Conditions', which are provided to all clients when first register with Addcounsel; and consideration is being given to including information within this document about the bespoke nature of the treatment provided by Addcounsel and the resulting financial implication of this. We always aim to ensure that" all clients are fully aware of the type %f service they are signing up to and the likely costs involved, so that can withdraw if feel it is not suitable for them: you are reassured by my response to the concerns you have raised in relation to MrcMacDonald"s sad death; the circumstances of which have been discussed at length and the implications for Addcounsel acknowledged.