Mark Kinzley

Dear Mr Irvine, Response to Regula-on 28 Report following inquest into the death of Mark Wolfe Kinzley We write to acknowledge receipt of the Regula:on 28 report ('the Report’) dated 26 March 2024 concerning the tragic death of Mr Mark Wolfe Kinzley. Firstly, we extend our deepest condolences to the family of Mr Kinzley. As a Surgery, we were shocked and saddened to learn of Mr Kinzley's death. His death has deeply affected us, and we are commiPed to learning to prevent such tragedies in the future. Regarding the concerns outlined in the Report, we would like to provide the following clarifica:ons and addi:onal ac:ons taken by the Surgery:

1. Appropriateness of the Nursing Home: We acknowledge the concerns regarding the suitability of the nursing home for Mr Kinzley's needs. We understand that his care needs were assessed by the appropriate agencies and Mr Kinzley consented to the placement in Cambridge Nursing Home. We wish to clarify that the Surgery does not have authority over the placement decisions of individuals in nursing homes. Likewise, the Surgery would not be involved in the assessment of placement suitability.

On the 26 October 2023, one of our clinicians, , reviewed Mr Kinzley. Mr Kinzley declined any support from at this :me regarding his physical or mental health. AZer this consulta:on, discussed with the care home nursing staff about considering whether Mr Kinzley’s placement needed to be reviewed by the appropriate agencies.

2 We would like to take this opportunity to assure you that all our clinicians have appropriate safeguarding training and that the Surgery staff would raise safeguarding alerts if there were concerns about the care being provided by a care home.

2. Capacity Assessments: We understand that this concern relates to Mr Kinzley not having a formal capacity assessment undertaken and documented and not having the appointment of an advocate.

Our clinical staff conducted mul:ple assessments of Mr Kinzley's capacity during his interac:ons with our Surgery. Capacity assessments are ques:on and :me specific. At the :me of Mr Kinzley’s assessments by our clinicians, he was deemed to have capacity. There are various decisions that Mr Kinzley made regarding his physical and mental health detailed in the medical record. We detail these below:

On 12 Jan 2023 consent was obtained from Mr Kinzley to refer him to the neurology service regarding his cerebellar ataxia. On 27 April 2023, Mr Kinzley consented to a referral to the ‘first fit’ (seizure) clinic. On 7 September 2023, the surgery received a request to complete a best interest decision to give Mr Kinzley the COVID-19 vaccina:on. This request was received as part of a request for authorisa:on for mul:ple residents of the home. One of our clinicians has commented in the medical record at the :me that Mr Kinzley had previously refused this vaccina:on and that our clinician felt he had capacity to make decisions about this. Our clinician reviewed this with Mr Kinzley on 12 September 2023 and he then consented to receiving the COVID-19 and influenza vaccina:on.

Regarding his mental health, on the 16 March 2023, Mr Kinzley was assessed with regard to anxiety and agita:on. He was offered medica:on and he declined this. Similarly, on the 1 August 2023, Mr Kinzley was assessed by regarding erra:c behaviour. It was felt that this behaviour could be related to anxiety. Mr Kinzley declined any medica:on for this. On the 26 October, he was calm but had shown erra:c behaviour in the preceding days. Mr Kinzley declined any form of support from the Surgery. At the :me of these consulta:ons, there was no evidence that Mr Kinzley did not have capacity to make the decisions he did about his care.

We have noted that there is no documenta:on that a referral to mental health services was offered. We have reflected as a Surgery that it is important to document in the medical record all of the management op:ons discussed with a pa:ent.

At the Surgery’s last consulta:on with Mr Kinzley, was informed by the nursing staff (who are also capable of capacity assessments) that Mr Kinzley had capacity. During this consulta:on and assessment of Mr Kinzley, there was no indica:on that Mr Kinzley lacked capacity or needed further formal assessment of his capacity.

3 Independent of the Surgery assessments, Mr Kinzley had a Depriva:on of Liberty safeguarding (DOLS) assessment (circa July 2023) aZer he was prescribed an emergency medica:on to be used if Mr Kinzley had a prolonged seizure. If he did have a seizure, by defini:on, he would not have capacity to make decisions about his care and this medica:on would be indicated in his best interest. It is our understanding that the DOLS assessment should include an assessment of capacity to make decisions. We remain unaware of this assessment outcome.

We do consider Mr Kinzley’s past medical history to be significant and in future, we will endeavour to encourage pa:ents to follow the medical advice whilst respec:ng their autonomy to make their own decisions. We recognise that Mr Kinzley was socially isolated despite living in a nursing home. We agree that support from a next of kin or advocate can oZen help pa:ents make decisions about their own care. We have taken steps as a prac:ce to iden:fy and help pa:ents who we iden:fy as not having such support, which we explain in more detail later.

This case has been formally discussed with the whole clinical team at a surgery wide clinical governance mee:ng on the 23 April 2024. We have a weekly prac:ce mee:ng as a forum to discuss cases and pa:ent care. At the governance mee:ng we agreed that clinicians would bring any similar cases to the weekly mee:ng to discuss them with the wider team to support gefng a collec:ve opinion on the case. Individual cases could also be discussed at the monthly care home mul:disciplinary team (MDT) mee:ng that the Surgery is a member of. The care home MDT is a mee:ng between local health agencies (GP, Geriatricians, Mental Health Services) and local care homes focusing on learning specific to care home pa:ents care and also an opportunity to discuss individual cases.

We have also agreed that in any similar cases in future, we would formally document the capacity assessment. At our next prac:ce Governance mee:ng (23 July 2024), we are providing an educa:onal session to the whole clinical team on capacity assessments, with a par:cular focus on more complex capacity assessments.

3. Referral to Mental Health Services: Whilst we recognise the importance of mental health assessments and referrals for individuals with a history of mental health issues, we emphasise that any referral to mental health services in this situa:on would have required Mr. Kinzley's consent. He was deemed to have capacity at the :mes he was assessed, and therefore any referral would have been con:ngent upon his willingness to consent to such services.

Following the inquest, our named clinician, Dr Barker, for the care home has made the care staff aware that the local mental health teams, also accept referrals from pa:ents, carers, and other medical professionals, in addi:on to referrals from a GP. This may be appropriate for any future cases as it would allow the care home to make a referral without wai:ng for a GP assessment, such as pa:ents with fluctua:ng capacity or emergency situa:ons.

4

In our wider Surgery prac:ce, we regularly share mental health crisis support details with a pa:ent's next of kin or rela:ve, provided we have the pa:ent's consent. Since the inquest, we have updated our Surgery text message that we send to pa:ents and their next of kin. Previously, it included informa:on about talking therapy services and crisis support. Now, it offers more comprehensive details about the various mental health services available in Redbridge and how pa:ents can access them. This updated message also serves as a readily accessible reference resource for clinicians when needed.

We would also like to take this opportunity to highlight the following further ac:ons taken by our Surgery since the inquest:
• Any new registered pa:ent that resides in a care home already has an ini:al formal comprehensive assessment by our clinician within a week of registra:on. We use the Comprehensive Geriatric Assessment (CGA) as a template for this. This is a holis:c assessment of the health and wellbeing of an individual, with formula:on of a care plan addressing any needs iden:fied. We have agreed at the Surgery Governance mee:ng that all care home pa:ents at this assessment would also be specifically assessed for social isola:on. We have agreed that this would include iden:fying if they have a next of kin, rela:ve or someone else they would like to be involved in their care. This will then be documented in their care plan. If there is concern around social isola:on, more support could then be provided. The support can be tailored to the needs of the individual and this could include referral to befriending services (a support program that connects volunteers with individuals who are lonely or socially isolated) or more formal advocacy service.

• We have agreed that our Surgery’s social prescriber could be more involved with our care home pa:ents. We recognise that this may help to support pa:ents in the future who are iden:fied as being socially isolated. Our social prescriber has access to various support services including the befriending services men:oned above.

• We have contacted and arranged for VoiceAbility, who provide formal and more general advocacy services in Redbridge, to come and speak to the Surgery team about the services they offer and how they can help us with the care of our pa:ents. VoiceAbility are running this training session for the Surgery on the 10 June 2024.

• Wider determinants of health – the wider determinants of health are a diverse range of social, economic, and environmental factors which influence people’s mental and physical health. The surgery has recently started asking newly registered pa:ents for informa:on about this to support the care we provide them. We are looking to expand this to all our currently registered pa:ents in the near future.

• We have asked that nursing staff at the nursing home provide the ABC behaviour chart to the clinician on the care home round if they have concerns about a pa:ent's behaviour. The ABC behaviour chart is an observa:on tool that helps to detail and understand the causes of certain behaviours. It records what happened before, during and aZer episodes of par:cular behaviours. This will allow our

5 clinicians to have more detailed informa:on about any behaviour allowing prompt assessment and appropriate interven:on.

• We will be sharing this case and our learning with our Primary Care Network (the collec:on of 11 prac:ces in Wanstead and Woodford) and care home mul:disciplinary mee:ng (MDT) to support wider learning and discussion among healthcare professionals. The date of this is not yet confirmed but discussions are taking place with the appropriate individuals to facilitate this in the near future.

In conclusion, we would like to assure you that we take the concerns raised in the report seriously and are commiPed to pa:ent safety and providing the best medical care to our pa:ents. Please do not hesitate to contact us if you require any further informa:on or clarifica:on about our response.