Dear Ms Hodes Regulation 28: Report to Prevent Future Deaths am writing to you following receipt of the Regulation 28: Report to Prevent Future Deaths dated 28th September 2017 regarding the sad death of Mrs Gillian OKeefe as a result of an overdose of medication: You have requested South West London and St Georges Mental Health NHS Trust respond to five matters of concern that you have detailed in your correspondence_ In order to examine all of the concerns meeting was convened on October 2017 by] Associate Director of Governance and Risk, with Clinical Director of the Community, and Head of Nursing and Quality for the Community Adult Services The meeting reviewed the details of the case and whether there were missed opportunities, as well as the possibility of gaps in our services with regard to care and treatment that may have prevented Mrs O'Keefe's death_ have responded to each of your concerns as were raised in your correspondence: Chief Executive, David Bradley Chairman, Peter Molyneux Respectful Open Collaborative Mh Compassionate Consistent 31st they

NHS] South West London and St George's Mental Health NHS Trust
1) That the decision to discharge Mrs O'Keeffe 'for non-engagement' from the local Mental Health NHS Foundation Trust care in January 2017 appeared illogical when it was likely, having regard to the facts, that she was in greatest need of their help: she was a service user of long standing; she had an acute deterioration in her mental state in March 2016, that there had been concerns raised by her family in October 2016 and that no professionals had been able to make visual contact with her since October 2016. The decision to discharge was based on the following: Mrs O'Keefe had never expressed suicidal thoughts nor abused alcohol or taken illicit drugs the GP confirmed that Mrs OKeefe had picked up a prescription on 6th of January (4 days before the decision to discharge) the Care Co-ordinator noted that Mrs OKeefe appeared stable in her mental state when last seen on November and that she had reasonable self-care the Care Co-ordinator had not noticed any hypomanic symptoms outside of some emails Mrs O'Keefe sent to Members of Parliament the risk to Mrs O'Keefe and to others was assessed as low_ It is stated in your correspondence that no professionals had been able to make visual contact with Mrs 0'Keefe since October 2016. This is incorrect as visual contact was made with Mrs O'Keefe on November 2016 by the Care Co- ordinator who recorded that she appeared stable in mental state. We have provided rationale for the decision to discharge but also acknowledge that more engagement should have taken place with stakeholders prior to Mrs OKeefe's discharge. Since this incident; our Clinical Disengagement/Did Not Attend Policy has been updated: The updated version is more prescriptive with regards to what actions need to be taken before patient can be discharged and this includes engagement with the GP and inclusion of the GP in the decision to discharge Adherence to this policy is audited through our clinical audit programme.
2) In view of her history and the inability of the Trust or GP surgery to make contact with Mrs OKeeffe it was highly unlikely that she would self-refer: The Trust agrees with this statement. Attempts had been made to engage Mrs OKeeffe by telephone and through home visits. The team were of the opinion that her risk to self and others was low (although they acknowledged she was vulnerable)_ The discharge summary was sent to Mrs O'Keefe's GP, with the request Chief Executive, David Bradley Chairman, Peter Molyneux Respectful Open Collaborative Compassionate Consistent 22nd 22nd key

WHS South West London and St George's Mental Health NHS Trust that re-refer the patient if it was required. However, crisis plan including relapse indicators was not sent to the GP or Mrs O'Keefe on discharge, nor was there liaison with the family at the point of discharge. The importance of sending the Trust approved template for a crisis plan to GPs will be re-enforced to staff through team and local governance meetings and via the Trust's dissemination of learning mechanisms such as the monthly bulletin, etc. This will again form part of the clinical audit cycle. The importance of family Iiaison and engagement forms part of our triangle of care programme. This programme is just about to start its round of 'self-assessments' and with the community services this learning will be cascaded through this process.
3) There was no pre-discharge multidisciplinary meeting to include and inform the GP before discharge nor attempt to ensure that there was a seamless transition to the GP surgery: Mrs OKeefe did not attend the CPA (Care Programme Approach) meeting on 10th of January 2017 . The Consultant Psychiatrist and Care Co-ordinator reviewed the care and treatment in her absence The Care Co-ordinator had made several attempts by telephone and home visits to contact Mrs O'Keefe. The care plan documented that the GP should continue the prescription of Quetiapine and should follow up with Mrs OKeefe and re-refer her if required. A letter outlining the care plan was sent to the GP There is no evidence that the GP was invited to this meeting: The Trust recognises that the decision to discharge would have benefitted from an early discussion and review between the RST and the GP prior to a formal discharge letter being sent out: The Trust's revised Clinical DisengagementIDid Not Attend Policy states that the team should liaise with the GP and invite them to be involved in the decision to discharge the patient The importance of involving the GP in the decision to discharge will be re-enforced to staff through team and local governance meetings and via the Trusts dissemination of learning mechanisms such as the monthly bulletin, etc. The clinical audit cycle will reinforce the importance of this being in place.
4) Evidence was given at the inquest that there was no procedure or policy in place at the Trust to follow up on GP concerns or referrals particularly where there was likely to be degree of urgency Chief Executive, David Bradley Chairman, Peter Molyneux Respectful Open Collaborative Ih Compassionate Consistent they

NHS] South West London and St George's Mental Health NHS Trust The GP raised a concern with the Trust Consultant after a GP Liaison meeting at the Practice in February 2017 . The GP was advised to re-refer the patient in writing: The Trust understands that the GP drafted referral letter but that this was not sent to the Trust at the time_ The referral was never sent by the GP but this concern highlights the need for some clear guidance for GPs regarding concerns may have The Trust is in the process of formalising this with the lead CCG GP involvement: It will be shared with GP colleagues once it has been signed off. It is also worth noting that the Trust is in the process of developing a primary care liaison team with the objective of improving communication between GPs and the Trust.
5) There appeared no easy or appropriate way that the family were able to share information and their concerns about Mrs O'Keeffe's mental health with the professional team, consequently, notwithstanding the family's continual and concerted attempts to notify Mrs O'Keeffe's care coordinator; felt that the professionals were unaware of the parlous state of Mrs O Keeffe's mental health and the family's serious concerns The occasions when the team were contacted by the family and their responses are detailed below: October 2016: Concerns were raised by Mrs O'Keefe's sister. In response to these concerns, the Care Co-ordinator made an unannounced visit to Mrs O'Keefe on the same day but she was not at home. The Care Co-ordinator attempted to contact Mrs O'Keefe's sister but was unable to speak with her so left a message The Care Co-ordinator also contacted the GP surgery who confirmed that Mrs OKeefe had collected her monthly prescription on October 2016. 25th October 2016: The Care Co-ordinator made another unannounced visit but Mrs O'Keefe was not at home_ The Care Co-ordinator made telephone contact with Mrs O'Keefe who explained she was in cafe and planning to visit her mum in Lincolnshire and that she would meet the care Co-ordinator at the team base on October 2016. 28th October 2016; Mrs O'Keefe did not attend the appointment: The Care Co- ordinator made contact with her by telephone and Mrs O'Keefe explained she was still in Lincolnshire The Care Co-ordinator left a message on Mrs OKeefe's sister's telephone to update her and confirm whether she saw her sister at their mum's home_ Chief Executive, David Bradley Chairman, Peter Molyneux Respectful Open Collaborative hl Compassionate Consistent they they 24th 17th 28th

NHS] South West London and St George's Mental Health NHS Trust The Trust was disappointed to learn that the family felt that there wasn't an easy way to share information and their concerns about Mrs O'Keefe with the team: The Clinical Director is currently scoping a quality improvement project in relation to Care Programme Approach (CPA) focussing on the engagement of familieslcarers and liaison with primary care_ In addition to this the Head of Nursing for the service is organising learning event so that each of the actions identified in the plan can be shared with the team, with the event providing an opportunity for reflection and learning: As referred to earlier the trust is also committed to the triangle of care principles and is just about to undertake the next round of self-assessments. Enclosed with this letter is a plan detailing the actions taken already or the proposed actions to be taken along with timetable for action_ Our deepest sympathies are extended to the family and friends of Mrs OKeefe. The conclusion that we have reached indicates that there is more work to be done with our teams regarding communication with familieslcarers and the inclusion of key stakeholders with regard to decisions around discharge.

From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Care and Mental Health Department of Health Richmond House 79 Whitehall London SWIA 2NS Angela Hodes 020 7210 4850 HM Assistant Coroner Inner West London 65 Horseferry Road LONDON SWIP 2ED Our reference: PFD-1100360 23rd November 2017 Jeak 4eoks Thank you for your Report dated 28 September to the Secretary of State for Health about the death of Mrs Gillian O Keeffe. I am responding as mental health sits within my portfolio. I was very saddened to read of the regrettable circumstances surrounding Mrs O Keeffe's death. Please pass my condolences to her family and loved ones. [ appreciate this must be a very difficult time for them: Your Report details concerns around the decision to discharge Mrs O Keeffe from mental health services; the lack of communication with Mrs O Keeffe's GP; the difficulties faced by the family in making their concerns known to mental health services; and the absence of policies in place at the South West London and St George's Mental Health NHS Trust to follow up the GP's subsequent concerns. The matters raised are operational and relate to the South West London St George's Mental Health NHS Trust. However; it is important to make clear the national policy expectations in relation to the issues you have raised. The Mental Health Act 1983 Code of Practice; whilst statutory guidance for providers of services under the Act should be observed as best practice by all commissioners and providers of services to people who may become subject to the Act: We revised the Code of Practice in 2015 and set out guiding principles to improve the care for patients. The principles include mental health providers involving patients ' carers and families in decisions about their care. The Code of Practice also makes it clear that we expect multi-disciplinary teams involved in care being

planning and discharge to include all relevant professionals and agencies which may be involved in a person'$ care_ My officials have made enquiries and [ am encouraged that the Trust is taking action to respond to these concerns in your Report; as well as those raised by the in addition to learning identified through its own investigations into Mrs O Keeffe'$ care and treatment _ While the Trust has explained the rationale for the decision to discharge Mrs O'Keeffe from its services, it acknowledges that more engagement should have taken place with stakeholders in reaching this decision: Learning lessons where have gone wrong is essential to ensuring the NHS provides safe, high quality care. You will know from the response provided by the Trust on 21 November that the Trust has identified actions to take in response to the concerns you have raised. This includes updating the Trust'$ clinical disengagement/did not attend policy to be more prescriptive in the actions to take and engagement with stakeholders when taking & decision to discharge a patient: The Trust advises that it will take action through staff learning mechanisms to promote the importance of the involvement of GPs in pre-discharge multi- disciplinary meetings. Further; the Trust is working to produce guidance for GPs in how can raise concerns and referrals and is looking to strengthen the engagement of families and carers and liaison with primary care. My officials also made enquiries with the Wandsworth Clinical Commissioning Group (CCG) and [ understand the CCG will review the Trust'$ action plan for addressing the concerns you have raised Wandsworth CCG advises that it is satisfied that the GP Practice took action to raise concerns about Mrs O Keeffe through the correct processes (i.e-, the GP quarterly Iiaison meeting with the Trust). However; when considering learning points from this case, I am informed that the CCG and Practice have identified other processes and routes the Practice could have used to raise concerns_ These include the GP Alert System that enables GP practices and other health professionals to raise concerns about patient care directly to the CCG, and the GP clinical lead for the Trust; who can raise concerns directly at clinical review meetings within the Trust; Iam advised that a learning event will be undertaken to review the system-wide issues that the case has identified and to ensure that the system is able to allow family, key things key they

Department of Health families easier access to health professionals should need to raise care issues about their relatives: I hope this information provides assurance that there are processes available to families ad GPs to raise concerns about patient care in such circumstances. Such processes are the responsibility of individual NHS trusts and you have taken the correct course of action in addressing your concerns to the South West London & St George' s Mental Health NHS Trust; and I hope the Trust'$ response is helpful . Thank you for bringing the circumstances of Mrs O Keeffe's death to our attention: CUuQ JACKIE DOYLE-PRICE they -

CRICKET GREEN MEDICAL PRACTICE GP Registrar: Westminster Coroner's Court 11lh December 2017 FAO: Susan Lord (Clerk to HM Coroner) Inner West London Horseferry Road London SWIP 2ED Re: Gillian O'Keeffe DOB 31/05/1966 Coroners Report 1100360_ Thank you for your letter; sincerely apologise that you have had to contact us again regarding this enquiry: We sent out the original correspondence 2 weeks ago which unfortunately seems you have not received, have printed off the report again and enclosing with this letter: If you require any further information please do not hesitate to contact me direct on 020 8685 2345.