Angela Brealey

South Staffordshire and Shropshire Healthcare NHS)

NHS Foundation Trust

A Keele University Teaching Trust

ih Neil Carr
18" February 2016 Chief Executive
Our Ref: Trust Headquarters

St George’s Hospital

STRICTLY CONFIDENTIAL i

Mr. A.A. Haigh
H.M Senior Coroner ST16 3SR

Coroner's Office PF
No. 1 Staffordshire Place

Stafford

S116 2LP

Dear Mr Haigh

RE: Angela Catherine BREALEY (Deceased)

Thank you for your letter dated 24'" December 2015, reporting concerns to us, in accordance
with Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013.

Following discussions within the Mental Health Division, | am now in a position to respond to
your specific concerns as outlined below:

1. At the inquest | heard various evidence about what should happen to information
received from third parties conceming a person receiving treatment from the Trust. This
does feature in the action plan prepared following the inquest but | think the process
should be looked at on quite a wide basis.

a) Should information received from a third party be acknowledged at all? If so, how?

The Trust may not respond to information from third parties as we adhere to Caldicott
Principles in the management of all service user information. Where these principles
would be breached the recipient of the information would not acknowledge, to the third
party, that the service user was known to the service.

Only in the case, that the service user has agreed with the care co-ordinator that receipt
of the information can be acknowledged, will this be carried out. If the third party has
asked for the information not to be shared with the service user, then receipt of the
information will not be confirmed.

b) How much of lengthy communications received from third parties should be recorded?
Is entry on the Rio medical notes sufficient in itself?

We accept that at the time we were working with Angela, the Rio system was just being
rolled out and therefore there was some lack of clarity around the electronic storage of
correspondence from third parties.

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South Staffordshire and Shropshire Healthcare NHS)

NHS Foundation Trust

A Keele University Teaching Trust

The Trust now has a clear policy and process for receiving and storing third party
information in RiO which is in line with national policy. Lengthy written communications
are uploaded to RiO as sent, so are available to the care team and a note made in the
progress notes to identify they have been stored and the location. Verbal communication
is recorded in progress notes in line with policy.

c) How is patient confidentiality protected in these circumstances and what about
circumstances where third parties request confidentiality for the information they have
provided?

Third party information is treated as confidential and is only made available to members
of the care team. It is not shared with the service user.

As stated in 1a) above, the Trust follows Caldicott Principles in the management of all
service user information. Where these principles would be breached the recipient of the
information would not acknowledge, to the third party, that the service user was known to
the service other than with the explicit agreement of the service user.

2. During the period that Angela was receiving assistance from the Trust there is minimal
evidence of a multi-disciplinary team being involved. Predominantly one community
mental health nurse took responsibility. While it may not have affected the outcome in
this case a feam approach involving a number of professionals. |s this something that
the Trust needs to look at?

The Trust mental health teams are all multi-professional and the model of working within
all teams is multi-disciplinary, the care and treatment provided to all service users is
overseen by the teams so even in circumstances where a person may be receiving
interventions associated with a care plan from a single professional the individual
practitioner will be discussing the care with other members of the team in caseload and
team supervision.

Upon referral all new patients are discussed at the FACT (Functional Assertive
Community Treatment Model) meeting which is held 4 times a week. All professions are
represented at each meeting. Key information is recorded in the individual patient’s health
record were it can be accessed by team members in the absence of key workers.

In Angela’s case the community mental health nurse did see Angela with the team medic
and they worked together to medically manage Angela’s symptoms. The community
mental health nurse was working closely with Angela to develop a therapeutic relationship.
The direct intervention of multiple different professionals at this time would have had a
detrimental effect on the therapeutic relationship being developed.

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South Staffordshire and Shropshire Healthcare NHS}

NHS Foundation Trust

A Keele University Teaching Trust
3. Generally the serious incident review process is a very helpful one. In this case
however a number of concerns about Angela’s treatment were not picked up by the
review. Is the pressure on those carrying out this process reducing the effectiveness
of the reports?

Thank you for your comments regarding the overall helpfulness of the Serious Incident
Review Process. | can confirm that since the time of this specific Serious Incident
Review, the process has been reviewed and amended. The Serious Incident Review
Process follows a structured and robust process with internal and external governance
arrangements in place.

The Trust now employs full-time Serious Incident Review Co-ordinator and Administrator
to support Investigating Officers in the review process. The Serious Incident Review Co-
ordinator works within the Trust’s Quality and Risk Department to help improve
processes that are used to ensure the quality production of reports relevant to serious
incidents. They support Investigating Officers in the completion of Serious Incident
Reports and Significant Event Reviews and are responsible for the completion of
Chronological and concise reports.

The Serious Incident Review Co-ordinator supports and encourages an open and fair
approach to incident identification and investigation, supported by a learning culture.

In addition the reports now go through an additional governance process in that our
commissioners carry out a challenge review prior to signing the report off for release.

| hope this response helps to address your concerns. However if you require any further
information please do not hesitate to contact me

Yours sincerely

Neil Carr
Chief Executive

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