Andrew Aitken

Dear Madam Inquest touching upon the death of Andrew Aitken (dod 10.08.14) This is a formal response to your Regulation 28 Report dated 15/h December 2014 in which you set out your concerns relating to the care Mr Aitken received from East London NHS Foundation Trust and Bart's Health NHS Trust. You have set out four areas of concern in your report: Two relating to Mr Aitken's care under this Trust and two relating to his care under Bart's Health NHS Trust The areas of concern set out at point 2 and 3 relate to the actions of East London NHS Foundation Trust and will respond to these below. A separate response will be provided by Bart's Health NHS Trust: At the Inquest you heard that Mr Aitken had been seen and assessed on three occasions during his admission to the Royal London Hospital by the Rapid Assessment; Interface and Discharge (RAID) Service, which is based within the Emergency Department at the Royal London Hospital_ The Service provides a one- stop shop for individuals who require mental health assessments in the Emergency Department or who are inpatients at the Royal London Hospital, Mile End Hospital or the London Chest Hospital: The aim of the service is to prevent unnecessary admission to inpatient mental health care, reduce length of on acute general wards and to resolve immediate issues and concerns and direct patients to primary and secondary services that can provide ongoing care, treatment and support: Mr Aitken had been admitted to the Royal London Hospital following a serious overdose on 8"h June. He was referred to the RAID Service on 11 June and was seen and assessed by the Service on 12th, 13th and 14th June: During the Inquest you heard direct oral evidence from the Duty Psychiatric Doctor who had undertaken the third and final assessment on 14"h June_ Chair: Marie Gabriel Chief Executive: Dr Robert Dolan Fax: stay

You heard that during assessment Mr Aitken had informed staff that he was not registered with a GP but he had disclosed an admission to a Psychiatric Hospital in Prestwich at the age of 16, some 14 years earlier_ Your first concern related to the decision by staff not to contact services in Prestwich to obtain collateral information regarding Mr Aitken, as in the absence of a GP this provided the only source of history from healthcare professionals. am in complete agreement with you regarding the importance of gaining collateral information from any available sources: As you are aware the Trust undertook a Serious Incident Review (SIR) looking at the care and treatment of Mr Aitken and the Review considered this issue_ Sources of collateral information in the absence of a GP can be; healthcare professionals previously involved with a patient and family and friends_ Our SIR agreed that clinical staff had limited information and history regarding Mr Aitken in light of the fact that he did not have a GP. Senior staff in the RAID Service are clear that would expect staff to follow up and try to obtain all information available regarding an individual. The RAID Operational Policy is currently being finalised and the importance of obtaining collateral information will be included within this_ The Review found that staff had clearly explored sources of collateral information with Mr Aitken However, Mr Aitken had informed staff that both his parents were dead and that he had no contact with his siblings. Staff did ask Mr Aitken's consent t0 contact his ex-partner but he was clear that he did not want staff to do s0 and there was no indication for staff to go against his wishes It was therefore not possible for staff to pursue these avenues in order to obtain collateral information. The Review considered whether the decision taken by staff not to pursue services in Prestwich for information was reasonable. In considering this it was relevant to consider that RAID involvement with any patient is short term and the SIR concluded that it was highly unlikely that such historical information would have been obtained during the short time he was under their care to inform their assessment of him: It was therefore felt that the decision not to contact services in Prestwich had been reasonable_ The Review was satisfied that staff had explored other potential sources of collateral information: You also heard evidence at the Inquest regarding the outcome of the assessments by RAID staff who concluded that Mr Aitken would benefit from a referral t0 primary care talking therapies and he had been advised that he should register with a GP in order to pursue such a referral: At the Inquest a friend of Mr Aitken stated her belief that primary care talking therapies would not have accepted such a referral given such a recent and serious overdose and asked why a referral to secondary mental health services had not been undertaken: You explored this with the doctor who had undertaken the final assessment, You were concerned having heard the evidence that a referral to secondary mental health services had not been considered and this was particularly of concern in light of the fact that the deceased did not have a GP The SIR considered this point noting that the RAID Service is able to make direct referrals to secondary mental health services and where indicated can refer a patient to the Home Treatment Team, Crisis Services or the Community Mental Health Team: Community Mental Health Teams manage those patients with enduring mental health problems and the SIR found that the assessments undertaken had been comprehensive and that there had been no indication that this level of input was necessary for Mr Aitken Chief Executive: Dr Robert Dolan they

Whilst the appropriateness of a referral to primary care talking therapies (delivered by IAPT) is not raised in your report thought it would be helpful to address this in my response, particularly in light of the fact that our SIR did not conclude that a referral to the CMHT had been indicated: Improving Access to Psychological Therapies (IAPT) is a NHS programme of talking therapy treatments recommended by the National Institute for Health and Clinical Excellence (NICE) which supports frontline mental health services in treating depression and anxiety disorders_ The SIR considered that the recommendation by RAID staff that Mr Aitken would benefit from this service was an appropriate plan: recent serious overdose should not preclude into an IAPT service. Following referral a thorough assessment would take place and this would determine the extent of suicidal ideation, plans that may be present;, access to means, protective factors and additional risk factors such as and alcohol use. The outcome of this assessment will determine whether the individual is safe to be treated using a psychological therapy within primary care by a single practitioner. The SIR found that psychiatric staff are unable to register a patient with a GP and it was considered to have been good practice for a letter to be sent to Mr Ailken following his discharge to remind him to register with a GP. Whilst it is preferable for patients to be referred to IAPT services by their GP to ensure that appropriate support and follow up is available this is not compulsory and it is possible for patients to self-refer; Taking into account your concerns believe that this information should be provided to patients who have been assessed would benefit the IAPT service; Whilst it is clear, with the benefit of hindsight, that Mr Aitken is unlikely to have self-referred | do think that it is important to ensure that our staff are aware that patients are able to do this and senior staff in the RAID team will ensure that this is brought to the attention of staff by way of their regular business meeting: In addition to this consideration is currently being given on the best way to ensure that all staff working in Tower Hamlets have access to this information: The issue that did arise in our SIR was in relation to a review by a Consultant Psychiatrist It is an expectation that all patients under the care of the RAID Service should be reviewed by a Consultant Psychiatrist either face to face or as part of a clinical discussion or supervision of junior doctors The Review identified that all patients were discussed on a daily basis (Monday to Friday) at the Service's Clinical Team meeting which always involves at least one Consultant Psychiatrist along with junior Drs on duty, the nurse consultant and a nurse from the Emergency Department; with staff Occupational Therapy and Psychology attending once a week; However, the SIR identified that there was no documentation of the discussion which had taken place on this occasion and a recommendation has been made to ensure that there is a system in place so that clinical discussions from the daily clinical meeting are always recorded within the patient's medical records. In addition the SIR has made a recommendation in relation to the processes in place to ensure that junior doctors discuss patients seen during liaison duties in Consultant Supervision: Chief Executive: Dr Robert Dolan entry drug from key from

hope that the above information provides the necessary assurance that the Trust has appropriate policies and procedures in place and that we will be taking action to appropriate steps to address the shortcomings identified.