Thiago Araujo

Dear Coroner Irvine Re: Inquest into the death of Thiago Araujo Prevention of Future Deaths repott am writing further to the inquest for Araujo which was heard on 4* 6th January 2021 ad concluded on Thursday 28 h January- Following the inquest YoU issued a Prevention of Future Deaths report to a number of organisations including the Trust will address the matters of concern raised in this report in turn. On 24th January 2020 Mr Araujo had discharged himself from psychiatric inpatient care; he was to be supervised by the Camden and Islington NHS Foundation Trust crisis team: Mr Araujo failed to engage with the crisis team and following a meeting on 30 January 2020 the crisis team closed Mr Araujo' $ referral: In the course of this closure no arrangements were made to address the risks presented by Mr Araujo. Following the initial 3 days of this inquest the Trust wrote to you to provide some additional assurance around the Serious Incident (SI) investigation report and the recommendations made, which were updated and strengthened in light of the issues raised at the hearing: One of the additional recommendations concerned this matter is as follows Additional Recommendation: service user of the Crisis Team who is being considered for discharge because of non-engagement must be discussed in the Crisis Service Multi- Disciplinary Meeting with senior overview of the decision to discharge. The decision and rationale to discharge because of non-engagement must be clearly communicated to the Youi parnor in CR coio Improvomonl ISLINGTON Ca"entaaal purdr cntelald pezpie InIng In Camden end iuinosdre0 Tdole Tdi E Won Thiago and Anv

NHS community and carers and this must be clearly documented in the clinical notes. When a service user is discharged because of non-engagement the Community Team must update the Crisis and Contingency Plans to ensure the service user and carers are aware of the support available following discharge. This action was due to be completed by the end of February and can confirm that this practice is now in place_ Following Mr Araujo' $ death it has become clear that the closure of his case by the crisis team was not permanent had Mr Araujo or his family approached the crisis team to reopen his case, steps could have been taken to reinstate crisis team support: Mr Araujo' $ family were unaware of this facility: On discharge it is the crisis team' $ standard practice to advise service users that they may re- refer themselves, be re-referred, should the need arise. We can only sincerely apologise to Mr Araujo' $ family if this was not made clear to them in this case. All crisis team staff have been reminded of the need to ensure that this information plus relevant contact details is passed on: This is also covered by the recommendation at point 1, where the updating of crisis and contingency plans is required. Families and corers of potients diagnosed with emotionally unstable personality disorder do not receive support or education upon management of this diognosis from Camden and Islington NHS Foundation Trust; unless the patient hos received for treatment by the personality disorder service: The Trust has a duty to assess carers need for support as part of its responsibilities under the Section 75 Agreement with the Local Authority When the Personality Disorder Service identify a carer who may be in need of support, either at the point of referral, assessment or during the treatment of a patient; a Carers Assessment at the service is offered A Carers Lead is employed to fulfil this role. When the Personality Disorder Service is not directly involved carers are directed to Local Authority services Support for carers Camden & Islington Carers Hub Supporting unpaid carers in Islington: Carers assessments are also carried out by other community teams within the Trust, including the community rehab team,who can support carers to access appropriate support The Trust recognised that a theme in the report was that carers had lost confidence in the teams working with the deceased did not feel their views were taken on board: As a result of this feedback the Trust has revised the action plan with an additional recommendation relevant to carers involvement. To provide assurance that this is consistently happening; the strengthened action plan includes a requirement for community teams to carry out 6 monthly audits, checking that carers are routinely offered an assessment and support plan, and that information, support and psychoeducation are available: Plans will be developed to address any gaps identified as a result of these audits which are now underway within the teams team and been key " and

NHS By 4 February 2020 the Camden and Islington Recovery Team identified an acute risk of suicide in Mr Araujo, faced with his noncompliance with community treatment they considered an admission into inpatient care: No actions were taken to affect this plan: In evidence the community recovery team indicated that 0 factor in their inaction was the knowledge that arranging a section 135 Mental Health Act 1983 warrant and assessment would take two weeks Such an assessment requires actions from an approved mental health practitioner from the local authority, two section 12 Mental Health Act approved doctors, the assistance of the Metropolitan police and the local magistrates court to secure a warrant delay of 14 days in securing 0 Mental Health Act assessment is in view unacceptable The AMHP service, which coordinates and carries out assessments under the Mental Health Act; is a local authority service, although physically based on Trust premises The Trust has liaised with our local authority partners in regard to this important issue ad we can report as follows: The average wait for a community assessment at the moment is around 14 days: February 2020 when the incident took place the average wait time was closer to 18 days, so we are seeing some improvement but acknowledge further is required. This issue is part of our CQC action plan and ongoing monitoring is in place as part ofthis via our Mental Health Law Committee Reducing average time There have been a number of actions by the AMHP service and the police to reduce wait time over the last year. Very often delays have been due to police availability/capacity in providing a time slot when are able to attend in support of an assessment: The police now have a permanent team in their mental health department ad the size of this team been maintained. also have a more robust management structure so we have a clear reporting mechanism if we have concerns This has enabled the team to continue to support us throughout the year. The AMHP team is responsive to the challenges of the Covid 19 pandemic, including the management of staff absence, to ensure all resources across the boroughs are used to maximum effectiveness and response to service user needs: In mid-2020 both boroughs made additional investment in their staffing: Prioritisation Although the average wait time for a community assessment is 14 response is managed with individual risk assessment and prioritised response At the point of referral for a Mental Health Act assessment the referral is discussed with the referrer and an understanding of the risks and urgency of the assessment are established. Any assessments my regard they has Thev days,

[HS with significant risks are flagged to the duty manager and service manager and an early conversation is had with the police- It is established practice to communicate with the referrer so that the AMHP team are aware of and can respond to changes in the service user' $ level of assessed risk The inquest has highlighted the need to ensure Trust services are aware of the AMHP service' $ capacity to prioritise waiting times and the AMHP service' $ commitment to ongoing information sharing with referrers: In the days leading to Mr Araujo'$ death his family became aware that he had made an online purchase of sodium nitrite which was to be delivered to his father s home. Despite these issues with Camden and Islington NHS Trust, the Metropolitan police and employees of the Post Office there appeared to be no process available to the family to escalate their concerns to prevent delivery of this package: It was apparent from the evidence given at the inquest that at the time of this incident Trust staff were unsure how to respond to this situation and what actions if any were available to them. The Trust has since sought advice from its legal team ad guidance to staff on this issue, as well as reiteration of previous advice around access to means to self-harm generally; has been circulated across the organisation. The legal advice we have received is that the Royal Mail do potentially have powers to intercept and destroy packages containing items which are either prohibited or restricted from being sent in the mail. Therefore, as part ofthe response to concerns of this nature, teams should consider reporting any concerns about potentially dangerous packa_ to the Royal Mail (via the local sorting office) and also to the police and must ensure that discussions and actions taken are documented in the clinical records It would be very helpful in informing our actions going forward, if we can be provided with a copy of the Royal Mail' $ response to the PFD as we are keen to work with them in regard to these challenging situations that my response clarifies the position and provides you with the necessary reassurance . If you need any further information, please do not hesitate to contact me.

Dear Mr Irvine

Thank you for your letter of 29 January 2021 about the death of Thiago Araujo. I am responding as Minister with responsibility for mental health and suicide prevention and I am grateful for the additional time in which to do so.

I would first like to say how deeply saddened I was to read of the circumstances of Mr Araujo’s death and I offer my most heartfelt condolences to his family and loved ones at this difficult time.

In relation to the concerns you raise about the use of Section 135(1) of the Mental Health Act, it is not clear from your report whether the delay professionals expected lay in the magistrate issuing a Section 135(1) warrant; in securing an approved mental health practitioner and a doctor to be present when the officer actions the warrant; or in securing two doctors to carry out an assessment under the Act after the patient has been taken to hospital. However, we expect local organisations, including the police, local authority services, and the NHS, to have robust systems and agreements in place to ensure these actions are carried out swiftly.

I am aware that the Camden and Islington NHS Foundation Trust has provided a response to your report in which it has explained the action that is being taken to improve the responsiveness of the assessment process involving the police and Approved Mental Health Practitioners. I have also been advised that the Trust has taken further learnings from the findings of your investigation, in particular, in relation to decision making and communication with carers when patients are discharged from the Crisis service due to non-engagement; as well as greater assurance that carers and families are routinely being offered the support and information they need.

It is essential that the Trust and local partners take action to learn from Mr Araujo’s death to improve the safety and quality of care locally.

My officials have brought your report to the attention of the CQC which, as you will know, is the independent regulator for care quality in England responsible for monitoring and inspecting health and care services against the fundamental standards of quality and

safety, with the ability to take action where providers of services are not meeting their legal obligations.

I would like to assure you that we are taking action nationally to ensure that people with severe mental illnesses and people in crisis can access timely support.

We remain committed to expanding and transforming mental health services in England. This commitment is backed by an additional £2.3 billion by 2023/24 through the NHS Long Term Plan. This funding will ensure that at least 370,000 adults with severe mental illness have greater choice and control over their care and are supported to live well in their communities by 2023/24.

On the wider matters of your report, you may wish to note that we are working with a broad range of stakeholders to tackle emerging suicide methods, including the use of chemicals such as Mr Araujo took, and a process has been established with a range of stakeholders and across Government to rapidly flag emerging methods and take actions through a multi-agency approach. This includes but is not limited to, limiting access to the method, reducing or removing material that promotes its use as a method of suicide, and providing clearer warnings of risk.

With specific regard to the chemical that Mr Araujo used, officials have met other Government departments and bodies, academic experts on suicide prevention and self- harm, and third sector stakeholders, to look at how to tackle the use of this and similar chemicals in suicides.

Officials are informed through these meetings that the chemical used in this case is covered by existing guidance from the Home Office on the sale of explosives precursors and poisons. The Home Office regularly engages with suppliers of such chemicals to provide detailed guidance in relation to any additional safeguarding steps they may wish to take. Generally, online marketplaces maintain their own policies on prohibited items, many of which will include a prohibition on the sale of poisons. It is the seller’s obligation to check that items they are listing are permitted by their own policies and to take any action where it is appropriate.

Significant progress has already been made on limiting the availability of the chemical used in this case, for example, in tackling supply of the chemical for non-industrial use. A chemicals supplier is working with Government to alert us of suppliers of this chemical on a number of large, online retail platforms. I am aware also that eBay has decided to prohibit globally the sale of this chemical after receiving a report of its potential use as a suicide method, and it has improved its block filter algorithms to ensure there are no similar listings.

In addition to work within Government, Samaritans are working regularly with the media to educate and improve how incidents of suicide are reported. This includes working with the media on how it reports novel suicide and, in this case, the importance of omitting details that raise awareness of suicide methods. We are aware also that there are websites that promote, or provide information on, suicide methods. The Department for Digital, Culture, Media and Sport (DCMS) published its

Online Harms White Paper1, which set out a range of legislative and non-legislative measures detailing how the Government is planning to tackle online harms, including harmful materials on self-harm and suicide.

On 15 December 2020, DCMS published its response to the White Paper consultation, setting out how the proposed legal duty of care on online companies will work in practice and gives them new responsibilities towards their users. DCMS also announced that the Government has asked the Law Commission to examine how criminal law will address the encouragement, assistance and incitement of self-harm.

NADINE DORRIES

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH

1 https://www.gov.uk/government/consultations/online-harms-white-paper