Victoria Halliday

From Nicola Blackwood MP
Parliamentary Under Secretary of State for Public Health and Innovation

Richmond House
79 Whitehall
London
SW1A 2NS

020 7210 4850

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Mrs L C Brown
HM Coroner —Leicester City and South Leicestershire
The Town Hall
Town Hall Square
Leicester
LEL 1 9BG

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Thank you for your letter to Secretary of State about the death of Victoria Halliday. I
am responding as the Minister with responsibility for mental health policy at the
Department of Health (DH).

I was saddened to read of the circumstances surrounding Ms Halliday's death. Please
pass my condolences to her family and loved ones.

You have raised concerns about the availability of psychiatric intensive care beds
locally for women. Psychiatric intensive care beds are commissioned locally by
clinical commissioning groups (CCGs) as they are best placed to assess and meet the
needs of their local communities.

You maybe aware that the Commission to review the provision of acute inpatient
psychiatric care for adults, led by Lord Crisp, published its review in 2015. The
review found that access to mental health beds nationally was not so much an issue of
bed capacity but an issue of discharge policies and alternatives to hospital admission
in the community. We are committed to providing a full response to the review by
the end of 2016/17.

Over the past decade acute mental health bed capacity has been steadily reduced,
reflecting the shift toward more provision of care in the community. However, we
acknowledge that effective community provision is variable across the country and in
some areas the lack of high quality community care, including crisis resolution home
treatment care, as a viable alternative to hospital admission has placed pressure on
beds. This has resulted in more people being admitted to hospital out of area.

We are committed to delivering the vision set out in the Five Year Forward View for
Mental Health published last year. The Prime Minister reaffirmed the Government's

 commitment to this aim this month when she set out the Government's response to
the Five Year Forward View and further mental health reforms.

We want to eliminate unnecessary out of area placements for adult acute mental
health care by 2020/21 and reduce significantly delayed transfers of care so that
people can move from hospital to care in the community, ensuring that beds are
available for those most in need. We appreciate that this will not happen overnight
but we are committed to delivering change. Also, through the Five Year Forward
View, we will implement a comprehensive set of community-based mental health
pathways of care so that people have access to care at the right time in the right place.

You have raised concerns about the quality of local community mental health
provision. We recognise that the quality of community mental health provision can
vary and this is unacceptable.

The Government announced an additional £400m investment up to 2020/21 to
improve the quality of community mental health provision as an effective and safe
alternative to hospital admission. This builds on the successful National Mental
Health Crisis Care Concordat which has seen every local area develop a crisis care
action plan to ensure that no-one in crisis is turned away.

You may also be aware that the Govermnent made available £15m to develop more
health based places of safety as appropriate places for people with mental health
problems who are detained by the police. The Prime Minister announced this month
that we will make further additional funding available, up to £15m, to build on this
successful work.

You have raised concerns about the quality of care planning in Victoria Halliday's
case. We published a revised Mental Health Act 1983 Code of Practice in 2015
which strengthened the guiding principles of the Code. This included strengthening
the rights of patients and better involvement of patients' family, carers and friend in
their care so that they can provide the much needed support for patients to manage
their condition and support recovery and independent living in the community.

The Code of Practice is clear that we expect mental health providers to take a multi-
agency approach to robust care planning, through the Care Programme Approach, to
ensure that people are supported while in hospital and when they are discharged.

I expect all mental health providers to adhere to the Code of Practice and I would
expect the local mental health commissioner and mental health provider responsible
for Victoria Halliday's care to take necessary action where shortfalls have been
identified in their approach to care planning.

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I hope that this information is useful. Thank you for bringing the circumstances of Ms
Halliday's death to our attention.

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NICOLA BLACKWOOD

East Leicestershire and Rutland
Clinical' Commissioning Group
cc~ we~dqu~~ters
Room Gap, Pen Lloyd Building
County Hall
Glenfield
Leicester
LE3 8TB

Telephpne:
Email:
Our ref:
Your ref.

Mrs L C Brown
Assistant Coroner
HM Coroner —Leicester City &South Leicestershire
The Town Hall
Town Hall Square
Leicester
LE1 9BG

9 December 2016

Dear Mrs Brown,

Re: Victoria Georgia Halliday

Thank you for your letter dated 20th October 2016.

The number of female PICU beds required in Leicester, Leicestershire and Rutland (LLR) at any one
time in the last three years has averaged approximately three.

In line with the national picture, there is recognition that the availability of general acute mental health
and PICU beds is under pressure. This continues to be the case despite extensive efforts to minimise
out of area placements. Since April 2016, there have been 10 female out of area placements made
with an average length of stay of 45 days.

East Leicestershire and Rutland CCG, as the lead commissioners for mental health in  LLR would
prefer, if  possible, for this service to be provided within the LLR border. However, we need to take
account of demand, patient quality, cost and provider availability. With this in mind, we are unable, at
present, to commission a local service that meets all of these requirements.

We are in discussion with potential provider organisations in an effort to try and resolve this.  We are
also working with regional commissioning colleagues in an effort to provide a wider range of options.
If these initiatives  prove successful, this should reduce the distance that both patients and family
carers would have to travel.

The quality and safety of LPT services are specified in our contract with LPT, which includes CPA and
follow up standards.  These are monitored through review of quality and safety indicators at the
Clinical Quality Review Group meetings and quality visits with commissioners. Quality indicators are
reviewed  and assurance on actions to  improve areas of  underperformance are discussed  and
monitored on a continuous basis.
With regard to a local network for the support of patients diagnosed with a personality disorder, this
was recently discussed at the Mental Health Clinical Forum which is led by CCG GP and LPT Clinical

 
 
 
 Leads.  A suggested  model is  currently  being developed by Clinicians and will  be submitted for
consideration during the early part of 2017.

Yours sincerely

Managing Director
East Leicestershire &Rutland CCG

Leicestershire Partnership 
IVHS Trust 

A University Teaching Trust 
Corporate Affairs 
Room 170, Penn Lloyd building 
County Hall 
Leicester 
LE38TH 

www.leicspart.nhs.uk

14 December 2016 

Lydia Brown 
Assistant Coroner 
Leicester City and South Leicestershire 
The Town Hall 
Town Hall Square 
Leicester LE1 9BG 

Dear Mrs Brown 

Re: Victoria Halliday 

Further to  your report dated 20 October 2016, in  accordance with  paragraph 7, 
Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the 
Coroners(Investigations) Regulations 2013,(offer-the following response. 

We have investigated the matters of concern that have arisen during the course of 
the inquest of Victoria  Halliday. Leicestershire Partnership NHS Trust (LPT) takes 
these matters very seriously and I  hope that you and Victoria's family will be satisfied 
that we have taken  the appropriate  measures to  prevent such an occurrence 
happening again. 

The matters of concern you have raised are as follows: 

1. There are currently no local psychiatric intensive care unit beds forfemale 
patients and this means all female patients can only be placed out of area, 
potentially many miles away from home and local support. 

Service Response 

LPT is  not currently commissioned to  directly  provide  Female Psychiatric 
Intensive  care  beds (PICU). Our commissioners  are  in  the  process  of 
procuring  a local,  medium to  long  term  solution, for female  Psychiatric 
Intensive  Care  Unit (PICU) placements  in  Leicester,  Leicestershire  and 
Rutland. The procurement process is unlikely to be resolved until 2017/18. 
For patients who are placed out of area, through our Adult Mental Health 
(AMH)Bed Management Team, we keep in touch on a weekly basis with the 
placement providers to ensure that length of stay out of area is for an agreed 
period of time, and that repatriation back to Iocal services is facilitated at the 
earliest opportunity.  In Victoria's case, referrals to PICU were made from the 
Bradgate inpatient area due to her challenging presentation and its impact on 
staff.  We have since  tailored  and  structured  psychological .support  and 
reflective  sessions for  ward  staff  who manage patients  with  personality 

 
 
 
 
 
 
 
 
 disorder and are in the process of recruiting more psychologists to strengthen 
the psychological minded approach to care. This will ensure that NICE clinical 
guidance 78 is followed for inpatient stays. 

We have also appointed a Band 7 nurse to lead on the implementation of the 
"Positive and Proactive Care: Reducing the Need for Restrictive Interventions" 
guidance across all inpatient areas of the Trust. This is anticipated to reduce 
the need. for higher environmental restrictions (in Victoria's case, referral to 
PICU)and better management in acute ward settings. 

2. There was no, or no effective, community psychiatric nurse involvement, and 
this was a missed opportunity to monitor and assist Victoria when she was in 
the community 

Service Response 

A standard community service exists within LPT for people with personality 
disorder  in  the form  of community  mental  health  team (CMHT), Crisis 
Resolution Team (CRT) and Specialist Personality Disorder Service (FDL). 
Victoria was accessing all these services during the course of her contact with 
t~PT. An identified Community Psychiatric Nurse(CPN)from the CMHT,CRT 
was present during professional and CPA meetings whilst Victoria was an 
inpatient. Due to the nature of Victoria's presentation of presenting in different 
areas of the country in a crisis covering CPNs and CRT professionals tried to 
ensure~continuity as much as possible. 

In this case, the lack of effective CPN input during the time Victoria was a 
community patient was an isolated incident, with the assessing CPN failing to 
follow the standard operating team process, whereby the assessing worker 
accepts the person onto their case load if they have capacity. If they don't 
have capacity the assessing  worker should  present the outcome of the 
assessment at the next Multi-Disciplinary team (MDT) meeting in order to 
allocate to a Community Worker/CPN within the Team. 

This issue was a finding of the Trust's investigation report, and as a result 
action has been taken, and is ongoing, in relation to the individual CPN under 
the Trust'sformal performance and conduct procedures. 

The CMHT Team Manager has ensured that all staff within the Team are 
aware of the current process for allocation of a Community worker following 
assessment. This information forms part of the induction process for all new 
starters to the team. 

3. The "community support" referred to by the in-patient clinicians does not exist 
in reality for patients with this challenging presentation, leaving discharged 
patients and theirfamilies without adequate support. 

Service Response 

As stated in response 2, LPT provides a standard community service in the 
form of CMHT, CRT and specialist personality disorder service {FDL) for 
people with personality disorder to access. The community support available 

 
 
 
 at the time of Victoria's discharge would have been predominantly from the 
CMHT, with the allocation of a CPN and clinical review via the Consultant 
Psychiatrist.  For people with a challenging presentation this supportfrom the 
CMHT  would  usually  con#inue  whilst  a  patient  is  waiting  for 
assessment/follow-up from Francis Dixon Lodge (FDL) our therapy services 
for people with  personality disorders. The CMHT will  continue to support 
patients while undergoing treatment at FDL. A referral to the Crisis Team is 
an option at any time for any patient and would be made by the CPN as 
required. 

For patients not open to a CMHT who are identified as requiring CMHT input 
while an inpatient, a referral can be made to the locality CMHT for allocation 
to a community worker. This could be a CPN or an Occupational Therapist 
(OT) dependant on assessed need. All CMHTs have access to the Crisis 
Team and can refer patients in  the event of a crisis  situation for home 
treatment. This can be provided for up to six weeks, dependent on the needs 
of the individual patient. During this time CMHT involvement will cont(nue. 

However the community support as mentioned by the inpatient consultants 
refers  to  an "enhanced  service" for  people  with  severe  and  complex 
personality disorder (SCPD) who are difficult to maintain in the community 
with existing standards services and they inadvertently access acute services 
(inpatient and crisis services). LPT is currently not commissioned to provide 
this"enhanced service". Some Trusts have adopted innovative practice which 
is commissioned to address this gap and LPT is doing the same with our 
Commissioners in proposing testing a bespoke service for people with SCPD 
as part ofa wider Personality Disorder service development. 

4. The care  programme approach (CPA) was not  adhered  to  and  NICE 
guidelines were not followed, specifically in ensuring there was a review after 
2 admissions within 6 months, and to ensure the roles and responsibilities of 
all health and social care professionals involved were identified. 

Service Response 

All  inpatients are subject to a Care Programme approach (CPA)and during 
their stay in  hospital  professional  meetings are  held  which  would  have 
addressed  NICE CG 78's 1.4.1.4 requirement of "Arrange a formal CPA 
review for people with borderline personality disorder who have been admitted 
finrice or more in the previous 6 months". 

However we acknowledge that it  was a missed opportunity that the social 
worker was not invited to these inpatient professional meetings and that the 
CPA process was not followed through once she was discharged to the 
community. 

In  order to  ensure  roles  and  responsibilities  of  health  and  social  care 
professionals involved in the CPA process are clear, understood and adhered 
to, a Standard Operating Procedure(SOP)is under development. Included in 
this SOP it will confirm and clarify the process to identify a Care Co-ordinator 
for patients in in-patient services, and will confirm and clarify the transfer and 
allocation  process for the  identification  of the  Care Co-ordinator  in  the 
community team,and associated reviews required. 

 
 
 
 A formal bi-annual CPA audit across AMH in-patient and community services 
has recently been completed and action plans developed.. There are specific 
questions within the audit in relation to the CPA Care Plan, showing a clear 
description of needs and there being a description of the action to be taken 
and by whom.The audit completed in 2014 showed good compliance in these 
areas. 

5. There is no local network for the community support of patients diagnosed 
with  personality disorder, although evidence suggested such networks were 
effective when adopted elsewhere. 

Service Response 

Further to our response to concern 3, L.PT is not commissioned to provide an 
"enhanced services to provide support and treatment for people with a severe 
and complex personality disorder(SCPD)in the community. A group of our 
senior clinical and operational leaders, with support from Commissioners, are 
working together to develop an integrated clinical pathway and model for care 
for people with Personality Disorders.  As part of this proposal a dedicated 
team to provide this enhanced service is proposed,the purpose of which is to 
provide an intensive community based treatment support for both patients in 
treatment, and in  crisis.  The aim is to  link  the  pathway together with 
supporting services in primary care, social care, and Police.  We continue to 
work  with  our commissioners to  negotiate  our 2017/2018 contracts for 
provision of services, of which this remains an ambition to provide. 

All ofthe actions au#lined in this response will be monitored through the service's 
clinical governance arrangements. 

We hope this reassures you that we have taken appropriate action in response to the 
issues you have raised under Regulation 28 and that we are committed to provide 
safe and effective care in order to reduce the risk to ourfuture patients. 

You  sincerely 

Chief Executive