Gillian Taylor

Kent and Medway NHS

NHS and Social Care Partnership Trust

Trust Headquarters
Farm Villa
Hermitage Lane
Maidstone

Kent ME16 9PH

Christopher Morris

Assistant Coroner for Central and South East Kent
C/O Senior Coroner for Central and South East Kent
Elphicks Farmhouse

Hunton

Kent

ME15 OSB

By post and email

Dear Mr. Morris,

Julie Margaret Rose deceased
Regulation 28 — Prevention of Future Deaths Report

| refer to your letter of 14 December 2015 enclosing the Prevention of Future Deaths Report,
arising out of the inquest into the Death of Julie Margaret Rose, which was received by my
office on 22 December 2015. | am most grateful for you bringing these matters to my
attention. | am also very grateful for you having agreed to an extension for the Trust
providing its response as it now means that | am able to confirm what action has been taken.

In your letter you set out the following concerns, which | will deal with in turn.

1. Although the Trust’s Unable to make Contact Protocol (“the Protocol”) had
been reviewed since Miss Rose’s death, | am concerned that it is insufficiently
clear as to when the Crisis Resolution Home Treatment Team members should
request a police welfare check in respect of patients who have been identified
as ‘Red’ for the purposes of the Trust’s R A G rating system.

In particular, | am concerned the Protocol does not specifically stipulate
circumstances where a request for a welfare check is mandatory (for example,
after a certain period of time has elapsed since contact was last, and/or after a
certain number of attempts at contact and/ or after attempts at telephone
contact and a home visit have been unsuccessful.

i) | am aware that at the inquest you heard evidence from EEE Acting
Assistant Director for East Kent Acute Mental Health Services about the
considerable efforts the Trust had begun implementing to mitigate the risk of
similar deaths occurring. Following the inquest, the Trust continued in this
work in addition to taking further steps, in particular, making changes to the
‘Unable to Make Contact’ Protocol. The Protocol has been subject to a further

Chairman - Andrew Ling
Chief Executive - Angela McNab

Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, Kent, ME169PH Tel: 01622 724100 Fax: 01622 724165

ii)

ii)

iv)

v)

vi)

vii)

viii)

ix)

xi)

review and amended. | enclose a copy of the new Protocol which is now in
use and which is subject to a three month pilot.

You will note that that the new Protocol gives clear guidance to staff, setting
out details of the steps that they must take when a service user has missed a
planned contact/call with the Crisis Resolution Home Treatment Team
(CRHT), starting from those required within the initial hour.

The protocol highlights the importance of involving family members, friends,
carers and other professionals where a concern is raised to try to make
contact and to gain collateral information.

The next step is for a risk assessment to be reviewed and a plan of next steps
agreed. Where following these initial steps (including contacting family) has
occurred but they have still been unable to make contact, the Protocol
requires that the team make a home visit and take the risk assessment with
them.

The protocol is clear that if no contact is made then staff must attend the
home address as soon as clinically indicated and that staff should prioritise
workloads accordingly, based on risk assessment and taking with them a hard
copy of the most recent risk assessment. Staff may want to try to arrange to
meet a carer or next of kin at the address that may have been previously
agreed, as a means of accessing the address.

If, after attendance at the service users home, they still cannot be reached,
they have the option of asking the Police for support. Staff will need to do that
via a 999 call where the risk indicates the need for this, and wait for police at
the scene with the risk assessment hard copy to share with them.

The new Protocol needs to be read in conjunction with the recently finalised
‘Acute Service Line Welfare Check Protocol’ which is a document that has
been jointly developed with Kent police. A copy of this is enclosed for ease of
reference. The ‘Welfare Check Protocol’ is applicable to in-patient’s and
people under the care of the Crisis Resolution Home Treatment team.

The priority and focus is that the right people with the right information will
take urgent steps to reach the service user. This may or may not be with the
assistance of the police and there is an expectation by the police that we as a
Trust have taken all necessary steps to make contact first.

The ‘Welfare Check Protocol’ describes how Police will carry out a ‘welfare
check’ when a request is made to police about an individual, if it is an
emergency and there is a real concern that something serious is about to, or
has already, occurred to the relevant individual on those premises.

The police will respond because it enables a professional intervention if an
individual is in need of immediate assistance due to a health condition, injury
or some other life threatening situation. Unless this threshold is reached,
police have no duty, and therefore no power, to take any action once outside
those premises.

This is why the Trust ‘Welfare Check Protocol’ now focuses on the up to date
information on risk, being available to those who attend properties in an
attempt to establish contact.

Chairman — Andrew Ling
Chief Executive - Angela McNab

Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, Kent, ME16 9PH Tel: 01622724100 Fax: 01622 724165

2.

ii)

rm)

v)

vi)

In the course of the hearing, | heard evidence that the Protocol has been
‘reinforced’ across the Crisis Resolution Home Treatment Team.
Notwithstanding this, a shift coordinator who gave evidence was clearly not
conversant with the Protocol, raising questions as to the adequacy of the steps
taken by the Trust to date in this respect.

Louise Clack, who was the senior member of Trust management at the inquest
has briefed about the evidence given by the shift coordinator. The lack of
conversance with the policy was disappointing. An immediate action from this was
taken to ensure that the contents of the policy are highlighted to staff in shift
handovers and team meetings, and where necessary, for this to be dealt with during
individual supervision.

There have also been recent changes in the structure of the Crisis Resolution
Home Treatment teams, meaning that there is an experienced practitioner in the form
of a clinical manager who are on shift for extended hours, including up to midnight
and at weekends, that operational staff in the CRHT can seek advice from. This is in
addition to the On Call Manager and Consultant rotas that were already in place.

The new ‘Unable to Make Contact’ Protocol was launched at the Acute
Leadership Forum, with training given on 8 March 2016, cascaded to all CRHT
teams. This has also been circulated to all matrons and managers and training is
being provided at minuted team meetings. It has also been highlighted in the Acute
Service Line Lessons Bulletin. The same process was used to launch the Acute
Service Line Welfare Check, which has been effective.

The new Protocol is being piloted in CRHTs trust wide for 3 months to help the
teams to understand what changes may need to be made, in order to make this a
robust and workable process. All CRHT staff have been asked to provide details to
their manager each time the protocol is used during the pilot period with details of
how it worked and of the outcome of events so that these can be audited. The
outcome of this monitoring will be collated in mid June and will then report back into
Patient Safety.

The auditing process will also help ensure consistency of use and help us identify
if there are any issues relating to the understanding of application of the Protocol with
certain staff so that this can be picked up in supervision.

The results of the audit of this pilot can also be fed into the overarching policy
that we are currently finalising with the Kent Police to cover all of the Trust's working
with them and to ensure a consistent approach based on the identified risk with that
employed by the community teams.

Chairman — Andrew Ling
Chief Executive - Angela McNab

Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, Kent, ME16 9PH Tel: 01622 724100 Fax: 01622 724165

| hope that the above shows that the Trust does take very seriously the matters that have
been raised in the PFD report and that we are continuing to work hard to deal with these
issues.

Yours sincerely

| Wb

gela McNab
Chief Executive

Chairman - Andrew Ling
Chief Executive - Angela McNab

Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, Kent, ME169PH Tel: 01622 724100 = Fax: 01622 724165

Cadeirydd / Chai
Ffon / Phone: “i “ Q G | G Bwrdd lechyd
E-bost / Email: (>,

Addysgu Powys

Chief Executive Powys Teaching

Ffon / ~~ 0 Health Board
E-bost / Emait

Our Ref: WM/LC/GRT(WEB28778)
Your Ref: AB/CE/3-2016 1 July 2016

Carol Shillabeer, Y Prif Weithredwr Dros Dro / HAjP N H S

Mr Andrew Barkley

HM Senior Coroner
South Wales Central Area
Rock Grounds

First Floor

Aberdare

CF44 7AE

Dear Mr Barkley
Re: Regulation 28: Report to Prevent Future Deaths

Thank you for your letter of the 11 May 2016, received 18 May 2016, issuing a
Regulation 28 form in respect of the death of Gillian Rose Taylor.

| note the matters of concern that you have identified through the course of the
inquest and that, in your opinion, you felt there was a risk that future deaths would
occur unless action was taken.

In summary, having considered the matters you have raised, we have taken action
as described below to put in place robust, high quality, safe services for our Powys
population. As you will read, these actions are continuing reflecting the current work
within Powys Teaching Local Health Board to repatriate adult mental health services.

In responding to the matters of concern that you have raised, | have outlined below
my responses to the four areas you have identified:

(1) There is no acute facility in Powys for the treatment of acutely unwell
patients, which, the evidence showed, often leads to patients being
moved the length and breadth of the country to an establishment where
a bed can be found. The evidence also showed that the local acute unit
at Redwood Centre in Shrewsbury had recently experienced a
significant reduction in the number of acute beds available
compounding and exacerbating the problem.

It is important to clarify that there is acute adult mental heath provision within Powys
in addition to the services we commission from other providers close to our borders.

Prior to the 1 December 2015, four different health boards were responsible for the
48 adult mental health beds in Powys hospitals. These beds include the Felindre
ward on the Bronllys Hospital site, which is an acute adult mental health unit. in
addition Crisis Resolution Home Treatment Teams (CRHTT) are in place within
Powys which provide evidence based hospital level care at home.

In North Powys, in addition to the services above, in-patient mental health services
for Powys residents are also commissioned at Wrexham Maelor Hospital, Redwoods
in Shrewsbury and independent sector hospitals. We also commission individual in
patient beds at the independent hospital at Phoenix House which is geographically
within Powys.

As Powys is one of the most sparsely populated counties in England and Wales it is
not possible to provide the full range of specialised in-patient services here. It is clear
that PTHB would not be able to comply with all the requirements of the Royal
College of Psychiatry needed to run some specialised services safely.

In 2014 detailed work was undertaken with clinicians to work through some of the
difficulties being experienced in North Powys, where services were being managed
by Betsi Cadwaladr University Health Board. Montgomeryshire was found to have
much higher levels of admission than would be expected for the population using
national benchmarks for England and Wales. On a daily basis it was found that
Montgomeryshire should have access to about 12 mental health beds for older
people and about 12 for working age adults. At the time as the graphs show it was
admitting about 35 patients. It must be emphasised that benchmarks are not a “cap”
or a “target”. Benchmarks just help show how the service compares to others across
England and Wales. Admissions are based on assessment of clinical need.

A series of steps was taken. This involved establishing a fully functioning CRHTT
which reduced the need for admissions out of county. Weekly discussions were put
in place between Redwoods and local services to help get patients admitted to
Redwoods when needed. Additional funding was allocated to the local service in
Montgomeryshire, including for additional care co-ordination to help address out of
county admissions. This was monitored on a weekly basis. The graphs attached at
Appendix 1 (enclosed) show that the difficulties with admission significantly reduced
for a sustained period. As the second graph indicates, acute admissions had been
falling during October 2015 although they started to rise during November. In the
same period in South Powys there were vacancies on Clywedog Ward in
Llandrindod Wells Hospital (run by Aneurin Bevan University Health Board (ABUHB))
which can admit older adults with functional mental illness.

The management of adult mental health services in Montgomeryshire and
Ystradgynlais has now transferred back to PTHB. It is hoped that the acute unit in
South Powys will return to Powys management in the Autumn 2016. However this
depends on securing permanent medical staff to fill vacant posts, the latter relating to
to a recruitment issue and not a funding issue.

(2) As a consequence of 1 above there is often a lack of continuity of
treatment which can be to the detriment of the patient concerned.

(3) The evidence showed that, on balance, it is likely that the experience of
being sectioned in these circumstances had an adverse effect upon Mrs
Taylor which fuelled an unwillingness, on her part, to engage with
Mental Health professionals thereby increasing her risk of self harm/
Suicide.

As explained above additional funding was provided to strengthen care co-
ordination. A Crisis Resolution Home Treatment Team was also implemented
providing acute hospital level care at home with which Mrs Taylor engaged. Mrs
Taylor would have had a statutory care co-ordinator and care and treatment plan
under the Mental Health (Wales) Measure 2010. As set out in Paragraph 3.19 of the
Code of Practice to Parts 2 and 3 of the Mental Health (Wales) Measure 2010 it is
not necessary to change the care co-ordinator when a patient is admitted to hospital.

We acknowledge that when a North Powys patient is admitted out of area this can be
disruptive for both patient and their family, and prior to admission out of county we
seek to explore every in county treatment option first. We continue to commission
inpatient provision in the Redwoods centre, however across the UK access to
specialist beds is limited and unfortunately we share the same challenges in
securing in patient beds close to home as many of our neighbouring Health Boards.

We regret that at the time of Mrs Taylor's detention under the Mental Health Act that
the nearest bed available to meet her needs was in Bristol, however a detailed
assessment of Mrs Taylors mental health care needs determined that the safest
care optnion was to detain her (under the Mental Health Act). At the time of her
detention, had a suitable placement been available more locally, this would have
been commissioned.

Our work to repatriate Mental Health Service to direct delivery by Powys Teaching
Health Board will directly improve our ability to admit and treat more patients within
Powys, and it is our expectation that in future significantly fewer Powys residents will
be treated out of county for their mental health care needs.

(4) It is believed that Powys Health Board is the only Health Board in the
country that has no facility available to it for the treatment of acute
admission patients in the position of Mrs Taylor.

| have answered Question 4 above as part of Question 1.

To aid your further understanding of this information | have provided the key graphs
with regard to admission and a summary of mental health services in Powys
(Attachment 1). | hope this information provides you assurance that we are working
towards appropriate pathways of care for Powys residents requiring mental health
care,

We wish to formally offer our sincere condolences to Mrs Taylor's family and we
continue to repeat our offers of support to her family as they continue to adjust to life
without her.

If you have any further questions, please do not hesitate to contact me.

Yours sincerely

Ono Stettn Bots

Carol Shillabeer
Chief Executive

Prif Swyddog Meddygol Dros Dro/ sy, WE,

Acting Chief Medical Officer

GrwWp lechyd a Gwasanaethau Cymdeithasol/ WA ae
Health and Social Services Group

Llywodraeth Cymru Cymru
Noh Welsh Government
Mr Andrew Barkley avtaltd.
Coroner for South Wales Central Area Plear. Prent Ae fhe tos 4 hey Cones tM ;

5 July 2016

Thank you for your bringing to our attention the regulation 28 report following the
investigation into the death of Gillian Rose Taylor. | have been sighted on Powys
Teaching Health Boards response to address the concerns you have raised.

Under the Mental Health (Wales) Measure 2010 (the Measure) all patients in Wales
receiving secondary mental health services must have a care coordinator and a care
and treatment plan. This applies to Welsh patients who are placed ‘out of area’. It is
the responsibility of the ‘home’ health board to ensure the person receiving care and
treatment has a care co coordinator and a holistic statutory plan. The care
coordinator would normally attend reviews wherever a patient is, whether in England
or Wales, this safeguard should assure continuity of care for all Welsh patients.

It is for Powys which is a very rural county to commission services for their smaller
and dispersed population and in fact they do have acute mental health beds
provided in Bronilys Hospital. There are also beds commissioned from neighbouring
Trusts and Health Boards to minimise distances travelled by the population, or to
provide expertise that require a level of critical mass and to meet professional
guidelines that a population the size of Powys could not be expected to reach.

Since your report a meeting between all Health Boards mental health mangers
facilitated by Welsh Government has been held to discuss using Welsh NHS beds
whenever possible if local beds are not available. It was accepted that proximity to a
patients home would have to be considered in this context.

| hope you find this information helpful.

Yours sincerel

Prif Swyddog Meddygol Dros Dro
Acting Chief Medical Officer

Parc Cathays/ Ffon/Tel: 029 2082 3505

“y BUDDSODDWYR | INVESTORS Cathays Park Ffacs/Fax: 029 2082 3982
¥ Caerdydd/Carditf Ebost/Email
7 MEWN POBL IN PEOPLE a GF10 3NQ chris jones@wales gsi.gov.uk