Richard Jones

Avon and Wiltshire INHS|

Mental Health Partnership NHS Trust

lan Singleton Jenner House
Assistant Coroner for Wiltshire and Langley Park
Swindon Chippenham
Wiltshire & Swindon Coroner's Office Wiltshire
26 Endless Street SN15 1GG
Salisbury Tel:(01249) 468214
Wiltshire Fax:(01249) 468073
SP1 1DP

3 March 2015

Dear Mr Singleton

Thank you for sending me a Prevent Future Deaths report regarding Richard Jones deceased
following his recent inquest.

Your report was considered by our Critical Incident Review Group, which is chaired by my
Medical Director, a on 2 March 2015. It was decided that to best explore the

issues you have raised, we should conduct a root cause analysis investigation jointly with
Salisbury District Hospital and the Armed Forces. This will enable staff from the different
agencies to collaborate and identify the best solutions to the problems you have raised
concerns about, to include a review of any relevant policies and procedures.

| will happily update you on the outcome of that joint work in due course.
Thank you very much for bringing your concerns to my attention.

Yours sincerely

lain Tulley
Chief Executive

Chair Trust Headquarters Chief Executive
Anthony Gallagher Jenner House, Langley Park, Chippenham, SN15 1GG lainTulley

‘We are a teaching, learning and research trust: we aim to inform you about relevant opportunities,
unless you tell us otherwise.’

Department
of Health
POCS 922067

Mr I Singleton

Assistant Coroner

Wiltshire and Swindon Coroner’s Office
26 Endless Street

Salisbury

Wiltshire

SP1 1DP

From Dr Dan Poulter MP
Parliamentary Under Secretary of State for Health

Richmond House
79 Whitehall
London

SWI1A 2NS

Tel: 020 7210 4850

24 MAR 2015

Thank you for your letter following the inquest into the death of Richard Jones.

I was very sorry to hear of Mr Jones’ death and wish to extend my sincere

condolences to his family.

You are clearly concerned about the current provision of mental health care for
members of the armed forces. In addition, the circumstances of this specific case have
prompted you to raise the following matters for our attention:

e the way in which information obtained from such a patient is recorded, with
especial reference to the perceived level of risk and the degree of urgency in

carrying out an assessment;

e how that information is shared with other agencies involved in the care of that
patient to ensure that it is accurately passed on, particularly as to the level of risk

and degree of urgency; and

e who has primary responsibility for the care of that patient and how that is recorded
by all those involved, particularly where there is a transfer of care.

You ask for review of the policy and procedures in place to deal with referral to
another agency of a member of the armed forces who appears to be suffering from
mental health issues, having regard to the above concerns.

Firstly, I would expect the mental health providers named in your report to provide
comment on the detail of this particular case and to address your concerns from their

local perspective.

The Ministry of Defence (MoD) has responsibility for the provision of primary care
services for serving personnel. The MoD also provides additional mental health care
for serving personnel delivered through fifteen military Departments of Community
Mental Health (DCMHs) located in military centres in the UK, as well as centres
overseas.

DCMHs are staffed by psychiatrists, mental health nurses, clinical psychologists and
mental health social workers. The aim is to treat personnel with mental health needs at
the unit medical centre and, with the patient's permission, involve the GP and senior
officers in managing the condition. A wide range of psychiatric and psychological
treatments is available, including medication, psychological therapies and a change of
environment where appropriate.

Inpatient care, when necessary, is provided by the NHS in contract with the MoD.
Service patients receive treatment much closer to their units than previously, when the
armed forces operated their own psychiatric hospitals. A close relationship is
maintained between local DCMHs and the NHS to make sure inpatient care is the best
it can be.

Where MoD services are unavailable serving personnel are able to use NHS services
on an emergency basis in the same way as other NHS patients.

Armed Forces veterans access NHS mental health services in exactly the same way as
the wider population. In order to help and encourage Armed Forces veterans with
mental health problems to seek care, NHS England has put in place 10 veteran mental
health teams across England — one of which is based in the South West.

At a national level, the Department of Health (DH) works closely with the MoD and
with NHS England to ensure that service personnel receive the right health services.
Medical notes relating to an individual patient must pass readily from the MoD to the
NHS and back again as appropriate. This will become increasingly important as the
number of Armed Forces reservists is increased, as these personnel will access health
services from the MoD when mobilised, and from the NHS at other times.

Discussions are already in place between DH, MoD and NHS England on this issue
and these will address the specific concerns you have raised in your report.

In addition, the DH is in discussion with the MoD to secure MoD’s commitment to the
Mental Health Crisis Care Concordat. This is a national agreement between services
and agencies involved in the care and support of people in crisis. It sets out how
organisations will work together better to make sure that people get the help needed in
a mental health crisis. In February 2014, 22 national bodies involved in health,

policing, social care, housing, local government and the third sector signed the
Concordat. It focuses on four main areas:

* Access to support before crisis point - making sure people with mental health
problems can get help 24 hours a day and that when they ask for help, they are
taken seriously.

¢ Urgent and emergency access to crisis care — making sure that a mental health
crisis is treated with the same urgency as a physical health emergency.

* Quality of treatment and care when in crisis — making sure that people are
treated with dignity and respect, in a therapeutic environment.

¢ Recovery and staying well — preventing future crises by making sure people
are referred to appropriate services.

Although the Crisis Care Concordat focuses on the responses to acute mental health
crises, it also includes a section on prevention and intervention. The Concordat builds
on and does not replace existing guidance. It is expected that the MoD commitment to
the Concordat will be in place by the end of April 2015.

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

Bk Wty

DR DAN POULTER

MINISTRY OF DEFENCE
FLOOR 5 ZONE B MAIN BUILDING
WHITEHALL LONDON SW1A 2HB

se RECEIVED
® 13 APR 2015

Ministry -----~--------- Telephone: 020 7218 9000 (Switchboard)
of Defence

ANNA SOUBRY
MINISTER OF STATE FOR DEFENCE PERSONNEL, WELFARE AND VETERANS

P| 7 evi 2015

Yew Tuy Singleton |

Thank you for your letter of 20 February 2015 in which you enclose a copy of the
Regulation 28 Report following the Inquest into the death of Lance Bombardier
Richard Jeffrey Jones.

| was very sorry to hear of Lance Bombardier Jones’ death and | would like to offer
my condolences to his family. As you will be aware, my Department takes its
relationship with HM Coroners extremely seriously and we fully recognise how
important it is that we learn all possible lessons to ensure that deaths in similar
circumstances in the future are prevented.

You are concerned about the current provision of mental health care for members of
the armed forces, in particular:

e The way in which information obtained from such a patient is recorded, with
special reference to the perceived level of risk and the degree of urgency in
carrying out an assessment;

¢ How that information is shared with other agencies involved in the care of that
patient to ensure that it is accurately passed on, particularly as to the level of
risk and degree of urgency; and

e Who has primary responsibility for the care of that patient and how that is
recorded by all those involved, particularly where there is a transfer of care.

With regards to the above, you asked for a review to be undertaken of the policy and
procedures in place to deal with referral to another agency of a member of the armed
forces who appears to be suffering from mental health issues.

| understand that Health Minister Dr Dan Poulter will be writing to you separately with
his Department's response to your concerns. | would therefore like to set-out what
my Department is doing.

Mr lan Singleton

Wiltshire & Swindon Coroner's Court
26 Endless Street

Salisbury

Wiltshire

SP1 1DP

Medical Information (as defined at Annex A) is collected directly from the individual
who is presenting to a clinician within the Defence Medical Facility, the Department
of Community Mental Health (DCMH) or other clinical setting. If it is deemed
pertinent by the individual concerned or the clinician the individual's significant other
will also be invited to take part in the assessment/review as well as all other relevant
information (referral letter, discharge letter, medical reports).

The Chain of Command are also included in the gathering of information either by
them providing information to the GP/Medical Officer or the Commanding Officer
being requested to provide an official occupational report to the mental health
specialist. At each assessment/review the safeguarding of the individual and others
are assessed, considered and reported upon in reports and clinical notes. The
findings of which are consolidated into the individual's Defence Health Record.

When information needs to be shared internally or externally, the mode of transfer is
dependent upon the urgency and associated risk. The following modes of transfer
are used to convey information between agencies in descending levels of risk:

a. in Person
b. _ telephone — followed by an electronic report to the identified clinician
c. E-mail - ensuring Caldicott Principles are observed

d. Letter

| can confirm that we are now updating leaflet 2-7-2 of the Department’s medical
policy document (Joint Service Publication (JSP) 950) which covers the provision
and management of Defence mental health services. This will include new guidance
and policy on the principles of transfer, which will include addressing both internal
transfers of care between different Defence Medical Services (DMS) care providers
and the transfers between DMS providers and external agencies.

The updated leaflet will also set-out clearly who has the primary responsibility of an
individual. To summarise, this will state that the responsibility of the patient remains
with their current clinician until the care of that individual is officially transferred to the
care of another clinician who will be taking over their care. In general, this will mean
that the responsibility for a patient will be retained by any referring clinician until the
receiving clinician has seen the patient, or has specifically communicated their
acceptance of responsibility to the referrer.

This addition to JSP 950 Leaflet 2-7-2 will also include guidance on:
° Entitlement of Service Personnel to NHS services

e — The need for DCMHs to liaise with local NHS services to promote good
working relationships

. Information NHS services ideally require in order to provide care for
Service Personnel

e The need for DMS facilities to be informed about NHS care provided to
Service Personnel

e How NHS care providers can access advice from DMS about
occupational or other military specific issues

Annex A to JSP 950 leaflet 2-7-2 also outlines the provision of out of hours Defence
mental health services by an on-call Service Liaison Officer. The Service Liaison
Officer offers out of hours telephone advice 365 days a year and is to provide:

a. administrative/procedural advice to clinical staff wanting to admit a patient
into an.in-patient service (e.g. at an NHS hospital).

b. alternative case-management options, including arranging urgent
appointments at the individuals local DCMH the next working day

c. an accurate log of actions taken during the out of hours period and to
pass this information to the patient's unit, local DCOMH, Medical Officer/GP
and/or in-patient service the next working day.

It should be noted that the Service Liaison Officer Service is not a clinical one. The
on duty SLO is not expected to carry out an assessment or take responsibility for
someone in crisis or discharged from hospital.

The Ministry of Defence has recently become a signatory to the Mental Healthcare
Crisis Concordat. This means the Defence Medical Services will engage with the
aims of the Concordat to improve care for those in mental health crisis, and in
particular the MOD will seek to improve joint working with NHS providers.

| hope that my response adequately explains the steps my Department has taken to
address your concerns.

Ru 8 OW, Winterset

?

ANNA SOUBRY

RECEIVED
2- APR 2015

Public Health
England

Protecting and improving the nation’s health Public Accountability Unit T +44 (0)20 7654 8000
Public Health England
Wellington House www.gov.uk/phe
133-155 Wellington House
SE1 8UG

Mr lan Singleton

Assistant Coroner, Wiltshire & Swindon Coroner's Office
26 Endless Street

Salisbury, Wiltshire

SP1 1DP

1 April 2015
Our Ref: 150207113

Dear Mr Singleton,
RE: Regulation 28 report to prevent future deaths — Richard Jones

Thank you for your letter of 20 February toi regarding the unfortunate
circumstances of Mr Jones’ death. | have been asked to reply on his behalf.

Public Health England (PHE)’s role in mental health is to help the public health system
achieve ‘public health parity’ for mental health. An example of how we assist local authorities
is the National Mental Health Dementia and Neurology Intelligence Network (NMHDNIN);
they help commissioners, policy makers and clinicians collate information and data on three
pathways through health services that affect millions of people in England. This information
is also available to the public, service users and their families.

| am aware you have also written to the Department of Health (DH), and | understand that
DH, the Ministry of Defence (MoD) and NHS England (NHSE) work closely together to
ensure that service personnel receive the right health services. These organisations are also
aware of the need for effective patient note transfer between the MoD and the NHS.

| also understand that DH is in discussion with MoD to secure commitment to the Mental
Health Crisis Care Concordat, and it is expected that MoD commitment to the Concordat will
be in place by the end of April 2015.

DH will continue their discussions with MoD and NHSE on this issue and these discussions
will address the specific concerns you have raised in your report. Unfortunately, PHE are not
in a position to advise on this matter further.

Finally, | have been advised that the mental health providers named in your report are
expected to provide comment on the detail of this particular case and to address your
concerns from their local perspective.

Yours sincerely,

Correspondence and Public Enquiries Officer
Public Health England |

Salisbury NHS}

NHS Foundation Trust

Salisbury NHS Foundation Trust Reponse to Regulation 28 Report Touching the deat!
Richard Jeffrey JONES

RECEIVED
20 APR 2015

Respondents Name & Position

My name is Peter Hill and | am the Chief Executive Officer at Salisbury NHS Foundation Trust (SFT).

Purpose of the report

| have received the Regulation 28 report prepared by lan Singleton, Assistant Coroner for Wiltshire
and Swindon, following the investigation into the death of Richard Jeffrey Jones who received
treatment at Salisbury NHS Foundation Trust in October 2012. This response is required by 20" April
2015.

Introduction

The inquest touching the death of Richard Jeffrey Jones concluded on the 27" January 2015. The
Regulation 28 report, arising from the inquest expresses three concerns summarised as:

a) As to the way in which information from such a patient is recorded, with especial reference
to the perceived level of risk and the degree of urgency in carrying out an assessment.

b} As to how that information is shared with other agencies involved in the care of that patient
to ensure that it is accurately passed on, particularly as to the level of risk and degree of
urgency.

c) As to who has primary responsibility for the care of that patient and how that is recorded by
all those involved, particularly where there is a transfer of care.

Additionally, Mr Singleton asked us to review the policy and procedures that we have in place to
deal with the referral to another agency of a member of the armed forces who appears to be

suffering from mental health issues having regard to the above concerns.

Response to Coroner’s Concern

The way in which information from such a patient is recorded, with especial reference to the
perceived level of risk and the degree of urgency in carrying out an assessment.

Since the death of Mr Jones, and following review of the case in collaboration with AWP, an
immediate action taken by SFT Emergency Department was to implement a new mental health risk
assessment tool as recommended by the College of Emergency Medicine. This tool provides a more
accurate assessment of the risk of suicide or self harm than the SADPERSON score we were
previously using. It enables clinical staff to risk assess patients and document their findings prior to
referring the patient to the mental health team with an indication of the appropriate urgency for
their response. (Mr Jones fell within the low risk category using the old and new tools). The tool is

Salisbury NHS|

NHS Foundation Trust

contained in the ‘ED Handbook’ which contains clinical guidelines and is provided to all new clinical
staff at their induction.

The service for mental health patients is provided by Avon & Wiltshire Mental Health Partnership
(AWP) on terms agreed with the Wiltshire Clinical Commissioning Group (CCG). A liaison psychiatry
team is available 9am to 5pm seven days a week, and operates within standard operating
procedures agreed by the Trust and AWP. All patients for assessment are discussed with the liaison
team and a response timeframe agreed. During the operating hours of the service, emergency or
high risk patients are seen within 60 minutes of referral.

Outside the hours of operation of the liaison team the referral for high risk and medium/high risk
patients is made to the on-call team who have a response time of 4 hours. Advice can also be sought
from the on-call team for medium/low risk patients where there are persisting concerns about
mental health issues preventing discharge.

These services and the response that AWP / the liaison service provide are detailed in the
department ‘Action Card’ which has been agreed in collaboration with AWP. The mental health
‘Action Card’ will be included in the next edition of ED Handbook later this year.

Action Summary —
|. Implementation of mental health risk assessment completed following review of case.

I. Standard Operating Procedure amended in collaboration with AWP.

How information is shared with other agencies involved in the care of that patient to ensure that
it is accurately passed on, particularly as to the level of risk and degree of urgency.

The sad death of Mr Jones led to considerable reflection as to the way in which information is shared
with other agencies.

Within the hours of 9am and 5pm assessment of mental health patients is made by the liaison
psychiatry team. This team attends the ED on arrival in the morning to obtain referrals, review
patient records and agree a timeframe for assessment. Telephone contact is made to the liaison
team to make them aware of additional patients who attend the ED during the day and require
assessment. The liaison team have access to the patient’s ED records including risk assessments
completed.

Outside of these hours telephone contact is made with the on-call team and agreed actions
documented in the patient’s ED record.

To ensure robust recording of information to the out-of-hours AWP service a proforma will be
generated for clinician use. This will include information such as the assessed level of risk as per the
mental health risk assessment tool, the agreed timeframe for assessment, the name of the accepting
mental health practitioner, and any other agreed actions from the telephone referral conversation.
The proforma will safeguard against any misunderstandings between an ED clinician to an AWP

Salisbury NHS}

NHS Foundation Trust

mental health worker and vice versa. Once completed, the information will then be faxed or emailed
to an agreed secure number or address for AWP to place with the AWP patient record, and the
original will be held within the ED patient record at SFT. This will be incorporated within the ED
upgraded electronic system by the end of the year so that it can be transferred and stored

electronically.

Action Summary —
I To implement the use of a ‘Mental Health referral proforma’ in collaboration with AWP.

ll. To include the proforma within the ED electronic system by the end of 2015.

Who has primary responsibility for the care of that patient and how that is recorded by all those
involved, particularly where there is a transfer of care.

Whilst a patient is cared for within the ED the Duty ED Consultant has primary responsibility for
them. Transfer of care occurs when the patient has been referred to and accepted by another
speciality. The relevant consultant within that specialty then has primary responsibility for the
patient. In the same way, the transfer of care from the ED to a mental health practitioner is made
when a referral is accepted by the mental health liaison team or the on-call team.

Should the patient leave the ED before assessment by the mental health liaison team or on-call
team, immediate steps are taken by staff in ED to safeguard the patient. An assessment is completed
by the most senior clinician on duty at the time. Where a patient is assessed as high risk, action then
might include calling security / the police, and attempting to engage with the patient and/or next of
kin.

For both high and low risk patients SFT ED would make contact with the mental health team to
inform them that the patient was no longer in the department / on site and to update them with the
information available. The follow up of a mental health assessment for a patient who had absconded
would be led by, and be the responsibility of, the specialist mental health team which had accepted
the referral. The GP would also be informed of the patient's failure to wait for assessment.

As an additional safeguard, all patients who do not wait to be seen in ED are recorded as
‘absconders’ and reviewed the following day by the duty ED Consultant. The assessment made and
actions taken at the time are reviewed by this senior clinician who decides whether any further
action is required.

Review the policy and procedures that are in place to deal with the referral to another agency of a
member of the armed forces who appears to be suffering from mental health issues having regard
to the above concerns

SFT treats patients presenting with mental health needs in the same way, regardless of their
employer background. Therefore referral occurs in line with the Standard Operating Procedure of
referring all patients to mental health services at AWP as commissioned for us. With regard to

Salisbury NHS)

NHS Foundation Trust

onward referral for a member of the armed forces we understand that this would be undertaken by
AWP if required, as they have an established working relationship with the armed forces.

A discharge letter is sent by the ED clinicians to the relevant GP, whether civilian or military by
background.

Conclusion

It is hoped that the measures detailed above will offer reassurance that Salisbury NHS Foundation
Trust has addressed the matters of concern raised by Mr Singleton.

We strive to continue to improve the service that we offer patients with mental health needs. The
case of Mr Jones saddened the staff involved and those who attended the inquest. They have all
directly contributed to the improvements we have made since the incident in 2012, the inquest in
2015, and the Regulation 28 report.

Peter Hi
Chief Executive Officer
Salisbury District NHS Foundation Trust