Dear Mr Walker,

Re: Mr Jonathan Daniel Zucker (Regulation 28 Report - Action prevent Future Deaths).

Thank you for sending me the report pertaining to the above dated June 26,
2017.

The Royal College of Psychiatrists (RCPsych) is the professional medical body responsible for supporting psychiatrists. The College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. The College does not work on the care of individuals and I am not able to comment on the specific circumstances surrounding the case of the death of Jonathan Daniel Zucker. We were given very little detail in this case, and when we asked for more were told our only option was to pay for an audio recording of the coroner’s inquest. This was not something we were able to do. However, I have considered your findings of fact in this case, and have the following comments to make in relation to the important issues that they raise.

The difficulties surrounding transition occur at many junctures, not just transfer between private and NHS patients. For example: when patients move house; transition from CAMHS to adult services; transfer between teams; more politically relevant now - discharge from out-of-area admissions. These difficulties are best overcome by holding to good practice on communication, accountability and effective co-ordination of care. These key topics are discussed below.

Care co-ordination

The co-ordination of care should be undertaken by the care co-ordinator with the policy of the Care Programme Approach (CPA) guiding this work. The College is aware that CPA policy can be interpreted and applied differently across the country. Ideally a care co-ordinator will be able to negotiate patient discharges and their integration into the care of a new team. However, there are

circumstances in which this is not straight-forward, e.g. if a section is ending or a person is being discharged from hospital.

Communication with colleagues

The GMC recommends all doctors ‘share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers’.i This information sharing with colleagues is a key part of good practice that will help ensure that patients are kept safe.

Communication with family and carers

Communication with families is also key to patient safety, as laid out in the consensus statement on information sharing and suicide prevention: ‘Obtaining information from and listening to the concerns of families are key factors in determining risk. We recognise however that some people do not wish to share information about themselves or their care. Practitioners should therefore discuss with people how they wish information to be shared, and with whom. Wherever possible, this should include what should happen if there is serious concern over suicide risk’.ii

Accountability and continuity of care

Good practice, which should apply in transfers from private sector to NHS, is to have a clear care plan stating when one team takes over the care, and when the psychiatric responsibility is handed over, which is not necessarily the same time. The GMC are clear that ‘doctors should establish clearly with their employing or contracting body both the scope and the responsibilities of their role. This includes clarifying: lines of accountability for the care provided to individual patients; any leadership roles and/or line management responsibilities that they hold for colleagues or staff; and responsibilities for the quality and standards of care provided by the teams of which they are a member. This is particularly important in circumstances in which responsibility for providing care is spread between a number of practitioners and/or different agencies’.iii

There is also guidance on best practice for psychiatrists provided in RCPsych’s ‘Good Psychiatric Practice:

‘A psychiatrist must refer patients to other services or colleagues as indicated by clinical need and local protocols: (a) the psychiatrist should facilitate the smooth transfer of care between services, and provide a comprehensive summary of the clinical case to the receiving doctor/professional to enable them to take over the safe management and treatment of the patient (b) when discharging from care, the psychiatrist should inform the patient, the referrer and the primary care team about the possible indications for future treatment and how to access help in future (c) if there are disagreements or difficulties about transfer arrangements, the psychiatrist must ensure that the safety of the patient and others remains the first concern and must facilitate the swift resolution of any difficulties.’iv

Actions that will be taken by RCPsych

Patients should only have one psychiatrist, and particularly only one responsible clinician. This is the best way to ensure good accountability, continuity of care and communication. Unfortunately, the College has limited power in this area, but will do what it can to address the problems outlined above. I have discussed this issue with our Dean, , and we are both of the opinion that our Professional Practice and Ethics Committee are in the best position to take forward the College’s actions on these issues. The next meeting of the committee is on 2nd November 2017 and the specific issues of: consultant accountability; ownership during transitions; and care where more than one team is involved will be on the agenda and the college’s next steps will be decided.

From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Care and Mental Health Department of Health Richmond House 79 Whitehall Our reference: PFD-1094055 London SWIA 2NS Mr Andrew Walker HM Senior Coroner Northern District of Greater London North London Coroners Court 29 Wood Street Barnet ENS 4BE 27 September 2017 (eau ( Ucul Thank you for your letter of 26 June, received by the Department of Health on 8 August about the death of Mr Jonathan Daniel Zucker: I have been asked to respond. Iwas very saddened to read of the circumstances surrounding Mr Zucker'$ death. Please pass my condolences to his family and loved ones I appreciate this must be a very difficult time for them. In your Report you raise concerns that there was no requirement or system in place for a lead clinician from either the private or NHS mental health services to oversee and co-ordinate Mr Zucker' $ care_ You issued your Report to the Royal College of Psychiatrists, as well as the Department; and officials have liaised with the Royal College on this matter of concer: While it is difficult to comment without further detail on the individual circumstances that have given rise to this area of concern, I can set out the expectations and guidance in place around care planning and continuity of care for patients receiving mental health care. To ensure a smooth transfer when patients transition through care pathways and settings, including between private and NHS services, we expect clinicians and their teams to follow best practice on communication; accountability and effective CO- ordination of care. Esq:

Department of Health where appropriate. The Royal College of Psychiatrists points to the General Medical Council (GMC) guidance on Continuity and coordination of care published in 2013, and the consensus statement on information sharing and suicide prevention published in 2014. Finally, Iam aware that the Royal College of Psychiatrists intends to ask its Professional Practice and Ethics Committee to consider the concerns you have raised, and to determine if more can be done in the areas of consultant accountability, ownership during transitions and care where more than one team is involved Ihope this information is helpful. Thank you for bringing the circumstances of Mr Zucker' s death to our attention. Qqluq JACKIE DOYLE- PRICE