Kathleen Rosemary Dixon

ae

| Department
of Health

POCL 821412

Your Ref: 2012-891/DP

From the Rt Hon Jeremy Hunt MP
Secretary of State for Health

Richmond House
79 Whitehall
London

SWIA 2NS

Tel: 020 7210 3000
Mb-sofs@dh.gsi.gov.uk

Mr I Smith

Senior Coroner

Central Police Station

Market Street

Barrow-in-Furness

Cumbria 10 DEC 2013
LAI4 2LE

De he tah,

Thank you for your letter following the inquest into the death of Kathleen Rosemary
Dixon. She had been in the care of Cumbria Partnership NHS Foundation Trust (the
FT) and drowned herself in the local river on 19 December 2012.

You found that she had a history of mental health problems, had been in the care of.
the FT and was assessed and released into the community. She committed suicide
shortly afterwards.

You raised your concerns that:

i) this case mirrored the circumstances of a number of other cases, within the same
FT, where the mental health of either an in-patient or a community patient has been
wrongly assessed and within a very short time of being released into the community
the person committed suicide;

ii) these deaths have occurred sufficiently frequently to cause you to question
whether this is a symptom of a deep rooted problem within the FT.

You have also written to the Care Quality Commission (CQC) about this matter.
My officials have discussed this case with CQC and have confirmed that the CQC is
aware that there are problems of the nature you describe at the FT.

In October 2013 the CQC issued two warning notices to the FT in relation to the
care and welfare of people who use services and staffing and has told the FT that it
must make improvements to comply with national standards of quality and safety.

On 28 November 2013 the CQC published an inspection report following the
inspection of the FT’s Ramsey Unit, an adult mental health facility at Furness
General Hospital, Barrow, which identified shortfalls against three of the national
standards reviewed.

The FT has agreed to fully address all areas of concern and CQC, working closely
with NHS England, Monitor and commissioners, will monitor the position to ensure
that the required improvements are implemented.

This Government is committed to ensuring that the health and care system prevents
problems, detects problems quickly and takes action promptly where they occur.
Since the publication of the Mid Staffordshire NHS Foundation Trust Inquiry, the
Government has instigated a number of changes which will improve inspection,
increase transparency, put a clear emphasis on compassion, standards and safety,
increase accountability for failure, and build capability, “Hard Truths”, the
government’s response to the Mid Staffordshire NHS Foundation Trust, set out
additional actions to improve patient safety.

In relation to the care of mental health patients generally, we would advise that
everyone referred to secondary mental health services should receive an assessment
of their mental health needs. If it is agreed that the person’s needs are best met by a
secondary mental health service, a care plan should be devised. Services should
aim to develop one assessment and care plan that will follow the service user
through a variety of care settings to ensure that correct and necessary information
goes with them.

In reviewing a care plan as part of discharge planning from hospital or other
residential settings, appropriate liaison with mental health services in the
community is essential. The period around discharge is a time of elevated risk, and
particularly of self-harm. This underlines the need for thorough review and
assessment prior to discharge and effective follow-up and support after discharge.

Mental health trusts should ensure that individuals with higher support needs are
identified and appropriately supported. All care plans must include explicit crisis
and contingency plans. This includes arrangements so that the service user or their
carer can contact the right person if they need to at any time with clear details of
who is responsible for addressing elements of care and support.

ae

Department
of Health

I hope that this response is helpful and I am grateful to you for bringing the
circumstances of Kathleen Dixon’s death to my attention.

Ne sar
ey

a
JEREMY HUNT