Elizabeth Godwin

Avon and Wiltshire NHS

Mental Health Partnership NHS Trust

Mr I Singleton

Assistant Coroner for Wiltshire and Swindon Jenner House

26 Endless Street Langley Park
Salisbury RECEIVED Chippenham
Wiltshire Wiltshire
SP11DP 17 AUG 2015 SN15 1GG

Tel: 01249 468020

13 August 2015

Dear Mr Singleton
Elizabeth Godwin (deceased)

Thank you for sending me a Regulation 28 report in relation to this lady’s care. In response to your concerns |
would like to provide you with a summary the processes the Trust now has in place to manage referrals and
mental health assessments. _ | will respond to each of your concerns in order:

a) As to the way in which information is gathered from the family and others involved where there is a
need for an individual to have a mental health assessment.

The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in
the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical
risk assessment which also outlines that effective engagement and communication with and between the
service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.

The Trust CPA and Risk Training highlights the need for staff to include the views of service users and carers in
undertaking any assessment. All registered clinical staff are required to undertake this training and to refresh
this on a 3 yearly basis.

Where a Mental Health Act Assessment is undertaken it is requirement of the Approved Mental Health
Professional, (AMHP), to recognise the value of involving other people in the decision-making process,
particularly the patient’s carers, family members and advocates, who are often able to provide a particular
perspective on the patient's circumstances. In so far as the urgency of the case allows, AMHPs should consider
consulting with other relevant relatives, carers or friends and should take their views into account.

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

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

b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored.

When an individual is referred to our services a triage process is undertaken to establish the urgency with
which an assessment is required. The Trust has developed a Standard Operating Procedure for Primary Care
Liaison Services, (PCLS), which outlines the process for receiving referrals and carrying out a phone triage
system to establish risk and therefore urgency of response. All referrals are now made through the PCLS.

The Trust has developed a triage tool to support decision making in PCLS. The response to urgent referrals is
addressed in the Trust Access to Mental Health Care Assessment and Treatment General Policy. All urgent
assessments should be carried out within 4 hours by the Intensive Support team. Those requiring face to face
routine assessment will be seen by PCLS workers within an appropriate time frame indicated by the triage
process, with an expected maximum of 4 weeks.

The outcome of the triage process is recorded in the electronic patient record for the service user, if the service
user has had contact with the Trust Mental Health Services before this would be added to the existing record or
anew record started if one does not already exist.

The Trust services in Wiltshire have recently audited the records of the PCLS service recently and have found
these to be comprehensive.

In the event of a Mental Health Act Assessment the AMHP would conduct a risk assessment to determine the
urgency and proceed to set up the mental health act assessment. The AMHP service record the time of
referrals and the time of assessments and monitor any significant delays between the two.

c) As to how that information is shared with other agencies involved in the care of that patient.

The Trust CPA and Risk Policy outlines the requirement that referrals not requiring assessment will be returned
to the referrer with referral outcome decision and recommendations for further intervention.

In addition the outcome of all triage processes and assessments will also be communicated to the referrer, the
service user and their family or carer if appropriate.

The audit of PCLS services in Wiltshire included if the outcome of triage and any face to face assessment was
communicated to the referrer and other agencies, again this was found to be comprehensive.

If a Mental Health Act Assessment is carried out then as part of the assessment the AMHP is required to
communicate with all other agencies involved at that time in the service user’s care.

d) As to who has responsibility for the care of that patient including the carrying out of the mental
health assessment and any treatment arising from it.

From the point at which the triage process has indicated that the service user requires a face to face
assessment the responsibility for the care of that service user sits with the Trust. Should the service user

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

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

require emergency or urgent care the PCLS will refer to the Intensive Support Service who will provide further
assessment and any treatment required, including admission to hospital if necessary.

If a Mental Health Act Assessment is requested and a referral not made to the Trust services, it is the
responsibility of the local authority to make arrangements for an approved mental health professional to
consider the patient’s case on their behalf. Only once the assessment is completed would it be the
responsibility of the Trust to provide treatment arising out of the assessment.

e) As to how a transfer of that care between the agencies is communicated and acknowledged so that
there is a clear audit trail.

Where a referral is made to the local authority for a Mental Health Act Assessment, it is only at the point that
either the service user is detained in hospital and therefore further assessment or treatment is required that
they become the responsibility of the Trust, or if the service user is not detained the AMHP makes a referral to
the Trust.

These decisions are recorded on the Mental Health Act paperwork which forms part of the service user’s
electronic patient record.

Where a referral is made by an AMHP to the Trust this will be received by the PCLS who will undertake the
triage process outlined above. A record of the referral and outcomes of this will be made in the service user’s
electronic patient record. Referrals between Trust services are monitored in the electronic patient record.

| trust this response addresses your concern, but if | can be of further assistance, please do not hesitate to let
me know.

Yours sincerely

lain Tulley
Chief Executive

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

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

Royal United Hospitals Bath INHS|

NHS Foundation Trust

Directors’ Office

Mr | Singleton a ; Royal United Hospitals Bath

HM Assistant Coroner for Wiltshire and Swindon NHS Foundation Trust

26 Endless Street a Park

Salisbury 3

Wiltshire RECEIVED BAT SNG

SP1 1DP oe
12 AUG 208 Pe
US

10" August 2015

Dear Sir

Re: Regulation 28 Report in Relation to Elizabeth Godwin

Please accept this letter as the Royal United Hospitals Bath NHS Foundation Trust’s
(RUH) response to the Regulation 28 Report dated 19" June 2015.

Mental Health Services at the RUH are provided by Avon and Wiltshire Partnership. At the
time of Mrs Godwin’s admission the duty psychiatrist and the liaison team were only
available at weekends between 9am and 5pm. Additional resource has been put in place
by Avon and Wiltshire Partnership enabling the provision of a seven day service which
facilitates the referral, of all patients who have self-harmed, to the Mental Health Team.

A retrospective review has confirmed that Mrs Godwin was correctly assessed, utilising the
Mental Health Assessment Matrix available at the time, as being of low risk, the
amendment to the Matrix ensures that future patients, who present with a similar history to
that of Mrs Godwin, would flag as an “amber” risk and would receive an assessment by a
mental health professional before leaving the Emergency Department.

All junior doctors receive training in the use and application of the mental health matrix at
induction. Emergency Nurse Practitioners and Nursing staff also have matrix training.
The Emergency Department keep a record of training attendance of medical and nursing
staff at teaching sessions. In addition, Consultant in Emergency Care, is a
member of both the Operational and Strategic Mental health groups and feeds back any
issues identified.

The RUH recognises it has a key role to play in the sharing of information with other
relevant agencies. The Emergency Department referral to Psychiatric Liaison is verbal with
the conversation documented in the patient's medical records. A letter to the patient's GP
detailing the attendance is generated on the same day.

The Emergency Department continues to raise awareness of the importance of family
involvement and relatives’ valuable knowledge of the patient's wider situation. Teaching
sessions, including seven one hour sessions delivered by the clinical psychologist on
removing the obstacles to communication with carers and patients, have been delivered.

Chairman, Brian Stables
Chief Executive, James Scott

In addition, there is an allocated space on the self-harm proforma for information about the
patient’s next of kin, their relationship and the patient's wishes in relation to whether they
should be contacted.

The RUH is confident that, together with Avon and Wiltshire Partnership, sufficient
changes in process, documentation and resource, have been implemented to minimise the
risk to future patients.

Yours Faithfully
Uae Trwdove

Sarah Truelove

Deputy Chief Executive

in the absence of the Chief Executive
Royal United Hospitals Bath

NHS Foundation Trust

Wiltshire Council

<a. Where everybody matters

Corporate Directors Office

County Hall
Bythesea Road
Trowbridge
Mr lan Singleton Wiltshire
Assistant Coroner for Wiltshire & Swindon BA14 8BS
Wiltshire & Swindon Coroner's Office
26 Endless Street
Salidsbury Your ref:
Wiltshire SP11DP Our ref: MR/kw

RECEIVED
17-AUG 2015

11 August 2015

Dear Mr Singleton
With reference to the enclosed Regulation 28 Report, please find enclosed our response.
Please do not hesitate to contact me, if | can be of further assistance.

Yours sincerely

Maggie Rae MScPh DipEd FRSPH FFPH
Corporate Director

Tel: 0300 456 0100 www.wiltshire.gov.uk Ei facebook.com/WiltshireCouncil W @wiltscouncil

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

This response from Maggie Rae, Corporate Director, Wiltshire Council, on behalf of
the Approved Mental Health Professional/Social Work Service is being sent to:

lan Singleton, Assistant Coroner for Wiltshire and Swindon, Wiltshire and Swindon
Coroner’s Office, 26 Endless Street, Salisbury, Wiltshire, SP1 1DP.

Regarding Elizabeth Godwin, aged 48.
To address concerns about the following matters:

a) As to the way in which information is gathered from the family and others
involved where there is a need for an individual to have a mental health
assessment

b) As to how the urgency of carrying out that assessment is assessed, recorded
and monitored

c) As to how that information is shared with other agencies involved in the care
of that patient,

d) As to who has responsibility for the care of that patient including the carrying
out of the mental health assessment and any treatment arising from it.

e) As to how a transfer of that care between the agencies is communicated and
acknowledged so that there is a clear audit trail

| would ask you to review the policies and procedures that you have in place to deal
with the referral to another agency of a patient who appears to be suffering from
mental health issues having regard to the above concerns. Your response must
contain details of action taken or proposed to be taken, setting out the timetable for
action. Otherwise you must explain why no action is proposed.

a) As to the way in which information is gathered from the family and others
involved where there is a need for an individual to have a mental health
assessment.

The requests/referrals on 20" and 21* January 2013 to the Approved Mental Health
Professional (AMHP) service were for a Mental Health Act Assessment to be undertaken
under the Mental Health Act 1983 (amended in 2007).

The AMHP has a legal obligation under the Code of Practice 2015 (Mental Health Act) to
consult widely with the service user/patient; their family and specifically the Nearest Relative
(Husband); others who might be involved —on this occasion a close personal friend; other
professionals which would include the GP, staff within secondary mental health services

(Avon and Wiltshire Mental Health Partnership NHS Trust, namely AWP) and any other
person who might hold relevant information or have had recent contact.

This information can be gathered by telephone, in person or by accessing electronic patient
information. In January 2013 the AMHPs were based with health staff at Red Gables
Community Mental Health Team (CMHT) and accessing and recording on the AWP patient
information system RiO. Information from the out of hours AMHP service (Emergency Duty
Service, Wiltshire Council) was communicated by fax.

Systems have been reviewed and there is a clear policy on how information is recorded. All
information is now stored on the council’s customer information system, CareFirst, which can
be accessed 24 hours a day. If the AMHP undertakes a Mental Health Act assessment a
copy of that report is sent to AWP to be uploaded on RiO and is also sent to the GP.

After discussion with the GP on 21* January 2013 the decision was made not to undertake a
Mental Health Act assessment and this was clearly recorded on RiO as was the
management plan, namely, that the GP would review his patient again on 25" January 2015.
Following this review on the 25" January the GP made a referral to the primary care liaison
service (AWP) at Green Lane Hospital for an urgent and full mental health assessment.
Unfortunately AWP initially thought that the AMHP had been allocated to the case when in
fact she had only dealt with the request for the Mental Health Act Assessment and not for
the ongoing care.

The guidance for AMHP’s in terms of information gathering is very clear and no action is
proposed in this area. However, in terms of communication with other organisations, actions
to be taken are covered in d) and e).

b) As to how the urgency of carrying out that assessment is assessed, recorded
and monitored.

The urgency of carrying out an assessment is determined by how unwell the person is and
how high the risk is perceived to be by all those consulted. A Mental Health Act assessment
would be the last resort and less restrictive alternatives should always be considered first,
such as treatment in the community or informal admission.

AWP are most likely to be the first point of contact for the mental health assessment
particularly if the request is made by the GP. AWP would then refer to Wiltshire Council and
the AMHP Service if there was a need to consider a Mental Health Act Assessment. A
request may be made to the AMHP service first which was the case on Sunday 20" January
2013 when a Mental Health Act Assessment was requested with a view to compulsory
admission to hospital.

The request for the assessment is recorded on CareFirst (Wiltshire Council’s customer data
base). If the Mental Health Act Assessment needs to be handed over between day time and
out of hours there is a clear procedure for hand over between the social work teams on
CareFirst. Progress is closely monitored by the AMHP on duty until the decision is made
either to undertake the Mental Health Act Assessment or an alternative management plan is
put into place (informal admission without the use of the Act or support in the community).

There needs to be very good communication between the AMHP service, AWP, the GP and
the family about who should be doing what. The role of the AMHP is quite clear. Once a
request for a Mental Health Act Assessment has been made their role is to co- ordinate the
assessment, by finding the Doctors, the hospital bed and the transport and consulting with
the Nearest Relative/family.

If the service user is detained the necessary papers are handed to the ward and the AMHP
report completed and uploaded on RiO. A copy is also sent to the GP. The outcome of the
assessment is also shared with the Nearest Relative. If the decision is made not to
undertake the Mental Health Act assessment this also needs to be communicated to the
referrer, the family and AWP.

It is not unusual for Mental Health Act Assessments to be stepped down to mental health
assessments at the end of a weekend when there are more services available or if the
immediate crisis has passed.

An action from this section would be a clear message to health and social care that the
responsibility for the service user is shared until the mental health crisis is over. A protocol
has been written to this effect and needs to be rolled out across the health and social care
teams. (Multi-agency protocol for working together when Mental Health Assessments are
requested, including situations where resources are unavailable).This is a standing agenda
item for the monthly meeting between mental health managers in Wiltshire Council and AWP
managers and for them to cascade to teams. This policy also takes into account other
problems such as the unavailability of doctors and beds and emphasises the joint
responsibility of health and social care to manage the situation until the necessary resources
have been identified.

c) As to how information is shared with other agencies involved in the care of
that patient.

There is a need to continue to share information confidentially and appropriately.

Each organisation is aware of the other’s structures and how staff can be contacted and how
to make a referral during the day and out of hours. There is an agreement in place that
allows both organisations to access information held by the other.

There have been regular monthly meetings between the 2 organisations to look at the
interface between the two services (health and social care), and systems to improve
communication, enhance patient care and facilitate good access to the most appropriate
services.

d) As to who has responsibility for the care of that patient including the carrying
out of the mental health assessment and any treatment arising from it.

The majority of referrals into specialist mental health services are from GP’s and are likely to
be referred into AWP for an initial assessment and recommendations about treatment
options or signposting to other services. However if there were a rapid deterioration in their
mental health which required urgent intervention and use of the Mental Health Act the
referral from the GP, from families, or other agencies managing the emergency could be
made either directly to the AMHP service or via AWP.

The AMHP would have the defined role of co-ordinating the Mental Health Act assessment
(in conjunction with AWP in terms of the bed and doctors) but would then hand back the care
to AWP if admitted. A social worker may have a future role in their discharge from hospital.

If a less restrictive alternative to detention under the Act (into hospital) was considered, such
as a temporary residential/nursing home placement or other funded support in order to keep
the person safe then the AMHP/social worker would remain involved. Other care in the
community would be co-ordinated by the Care Co-ordinator within AWP.

An action from this should be further discussion between the two organisations (WC and
AWP) - there is an established forum to do this on the third Friday in the month - about the
distinction between mental health assessments and Mental Health Act assessments and
where the responsibility sits at different stages throughout the assessment process. More
urgent situations should be dealt with by telephone contact between the 2 organisations.

e) As to how a transfer of that care between agencies is communicated and
acknowledged so that there is a clear audit trail.

Any assessment under the Mental Health Act which results in detention under the Act and
admission to hospital clearly defines the transfer of care from GP and community services to
the in-patient unit (AWP). The AMHP report written following the assessment and admission
and the receipt of the section papers are also evidence of that transfer. The AMHP reports
are uploaded onto both RiO (AWP) and CareFirst (Wiltshire Council) and also sent to the
GP.

Any other transfer of care should be documented in the same way as a clear statement of
who is doing what - across the different teams in Wiltshire Council and AWP and across
daytime hours and out of hours — which has been agreed by both organisations and needs
to be clearly communicated to the families and the GP and anyone else who needs to be
informed. This should be clearly recorded on the health data base RiO and the social care
system CareFirst and via any other correspondence that is required.

Should further clarification be required please do not hesitate to contact again.

10°" August 2015.