Louise Locke

21 March 2016 Southern Health INHS|

NHS Foundation Trust

Mr G Short Legal & | Services T
: . ega insurance Services Team
Senior Coroner for Central Hampshire 6 Sterne Road
Castle Hill Tatchbury Mount
The Castle Calmore
Winchester Southampton
$023 8UL $040 2RZ
Tel: 02380 874147
Fax: 02380 874382
Dear Sir www.southernhealth.nhs.uk

Regulation 28 Report — Louise Dawn Locke

| write further to the above issued on 29 January 2016, following the conclusion of the inquest into the death
of Louise Locke.

| note your areas of concerns, which | will address in turn, are as follows:

1. The Community Mental Health Service discharged Louise Locke prematurely and without carrying out
a proper risk assessment of offering her adequate support.

You heard evidence from Kate Brooker-Corcoran, Associate Director for Adult Mental Health Services, and
Carole Adcock, Head of Nursing who agreed with the concerns you raised in relation to premature
discharge without a risk assessment in the context of patients being invited to attend appointments for
second opinions away from their home area, with no means of support to get there.

The Adult Mental Health Management Team have discussed this and an action has been assigned to the
Clinical Service Directors in each area to formulate a standard plan to ensure that patients requesting
second opinions have access to these, and are not prematurely discharged if they advise that they are
unable to attend their appointment. There is agreement across all areas that a second opinion offer
should be individually negotiated to the needs of the service user, and that if someone alerts us that they
cannot attend the appointment then other arrangements will be made to facilitate the appointment
either through a different venue or through the consultant travelling to another area. The standard
process will depend on the geography of each area and consultants working arrangements. These plans
will be brought back to the Clinical Director J for sign off on the 21* April at the directors
meeting. Risk assessments should take place prior to any discharge and this has been communicated
through all learning events related to this RCA. The disengagement policy will be amended to reflect the
process to follow disengagement from a second opinion.

2. There was no adequate system in place to collate and assess information from other agencies such
that her risk profile could be reviewed and appropriate support offered.

Since the inquest we have amended our Standard Operating Procedure (SOP) in relation to patients who
attend an Emergency Department, for a self-harm or overdose incident on 3 occasions within a four week
period. These people will now be flagged within the Acute Mental Health Team (AMHT) and will be
discussed within the MDT to review safety, risk and need and to agree whether any changes to their
current care plan is required.

The wider information from other agencies that also have frequent and escalating contact with individuals
will be collated and actioned through the High Intensity Usage Group and systems associated with this
forum, as described below. There is two way sharing of information about this group of individuals
between agencies in these forums.

Trust Headquarters, Sterne 7, Sterne Road, Tatchbury Mount, Calmore, Southampton SO40 2RZ

3. The systems already in place in some parts of Hampshire for a multi-agency approach to high risk
individuals do not apply to Winchester and so opportunities to recognise these people are being
missed. There should be a consistent approach by Southern Health to suicide prevention across all of
the areas it serves.

These High Intensity User Groups are multi-agency forums and include representation from Police,
Ambulance, Community Mental Health, Hampshire County Council Safeguarding and Emergency
Department staff. The revised SOP also ensures that AMHT staff will engage with the High Intensity User
groups in their local areas to support consistent care planning.

Any patients identified as having presented to ED on three or more occasions are discussed at a High
Intensity User Group (HUG). As discussed at the inquest these were already in place in the South and East
areas, but are now developed within the North and West Areas — thus covering the whole Southern
Health NHS Foundation Trust area.

The detail of the SOP has been communicated at team levels through a variety of means including email
and team meetings and will be shared to all staff via the Divisional Team Brief in March. The practice is
now in operation across all AMHT services in Southern Health NHS Foundation Trust and will be
monitored through the Adult Mental Health Acute Care Forum.

In order to ensure that learning from this case was shared across the whole of Adult Mental Health
services the Root Cause Analysis (RCA) into the care and treatment that was provided to Miss Locke was
discussed within the Adult Mental Health Service Development session on 3 February 2016. This was
attended by Clinical Service Directors, Area Managers, Heads of Nursing and Quality for all areas. In
addition also present were the Associate Director, Clinical Director, Associate Director of Nursing and Italk
Clinical Director. Communication took place in relation to the learning that came from the RCA and
discussion followed regarding the Action Plan which received full commitment from them.

Further, an Adult Mental Health Services learning network event took place on 9 March 2016 at which 47
staff attended from across all Adult Mental Health services including inpatients, community and | talk -
this included medical staff, team managers, team leaders and frontline clinicians. | understand that you
were invited by ME Associate Director AMH to attend this Learning Network and have therefore
seen the agenda. | have enclosed within this response the actions and learning taken from the day that
has been shared across all teams and the implementation of these will be monitored through the
appropriate community and acute care forums and the AMH Quality and Strategy Board in order that we
can provide ongoing improvements and assurances around reducing the likelihood of a recurrence of a
similar nature with other patients.

Foundation Trust on the 11" April 2016 ill be presenting the Louise Locke RCA, learning
and actions taken to date with the Hampshire Wide Crisis Concordat Steering Group in order that any
actions which require a multi professional approach can be included in the action plan for 2016 /17 and
once these minutes are available | will share these with you for your information and assurance.

Finally, given that we recognise that this is not i about sharing learning within Southern Health

Yours sincerely

Katrina Percy
Chief Executive

Encs.