David Knight

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

Department

i" Aa|T Richmond House
of Health 79 Whitehall

London
SWI1A 2NS

Dr E.E Carlyon

Senior Coroner

Cornwall and Isles of Scilly
The New Lodge

Newquay Road

Penmount

Truro TR4 9AA

eae Be Cellgen

Thank you for your letter of 14 November 2016, following the inquest into the death
of Mr David Knight. I was very sorry to hear of Mr Knight’s death in May 2015 and
wish to extend my sincere condolences to his family.

020 7210 4850

18 JAN 2017

You have raised concerns about the availability of acute mental health beds
nationally. As you will know, acute mental health 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 may be 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 acute mental health
beds was not so much an issue of bed capacity but rather a problem of discharge
policies and providing 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 steadily reduced reflecting
the shift toward more provision of care in the community. However, we
acknowledge that provision of effective community services varies. The lack of high
quality community care in some areas, 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 will eliminate clinically unnecessary out of area placements for adult acute
mental health care by 2020/21 and will reduce significantly delayed transfers of care.

This will help people move easily between hospital and care in the community,
ensuring that beds are available for those most in need. I appreciate that this will not
happen overnight but we are committed to delivering change. 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 the risk assessment that was
undertaken and the limited contact with Mr Knight’s family by the mental health
provider to support Mr Knight’s leave in the community. These matters are the
responsibility of the local health services. However, you may be aware that the
Department published a revised Mental Health Act 1983 Code of Practice in 2015
which strengthened the guiding principles of the Code.

This included better involvement of patients’ family, carers and friends in care to
provide much needed support for patients to manage their conditions and to support
recovery and independent living in the community. The Code of Practice is clear on
the importance of undertaking robust risk assessments of patients to support care,
including leave of absence. I expect all mental health providers to adhere to the Code
of Practice.

I am encouraged to see the action that has been taken to improve pre-section 17
discharge planning by ensuring that local care teams and patients’ families are
involved in these arrangements. However, I would also expect the Kernow CCG to
take action to improve local risk assessment processes where necessary to prevent a
similar tragedy occurring in future.

I hope this response is helpful and I am grateful to you for bringing the circumstances
of Mr Knight’s death to my attention.

es Sn

NICOLA BLACKWOOD

Dr Elizabeth Emma Carlyon

NHS}

England

Professor Sir Bruce Keogh
National Medical Director
Skipton House

80 London Road

SE1 6LH

Senior Coroner for Comwall & Isles of
Scilly

The New Lodge

Newquay Road

Penmount

TRURO

TR4 9AA 6M January 2017

Dear Dr Carlyon,

Re: Regulation 28 Report to Prevent Future Deaths - David Knight,
deceased

Thank you for your letter of 14" November 2016 and the enclosed Regulation 28
Report to Prevent Future Deaths following the tragic death of David Knight. | was
very sorry to read of the circumstances around David’s death, and would like to
express my deep condolences to his family.

Every death by suicide of a patient under the care of NHS services is deeply
regrettable and must be fully investigated and learnt from to prevent similar
occurrences in the future - | note the letter from Kernow Clinical Commissioning
Group providing assurance that the key issues identified during the inquest into
Mr Knight's death are being addressed locally in Cornwall.

In terms of national policy, | want to highlight some key developments which I
believe are relevant to the issues you have identified regarding the lack of
available acute inpatient beds and the reliance on out of area admissions for
people requiring inpatient care, which your report concludes had a bearing on Mr
Knight's death.

NHS England recently established an adult mental health programme which is
taking a whole system approach comprising crisis, acute, and community/primary
care work streams. The acute care work stream has been developed in response
to a number of recommendations set out by The Commission on Acute Adult
Psychiatric Care (February 2016) and The Five Year Forward View for Mental
Health (February 2016), and is particularly relevant to the concerns outlined in
your report.

The work stream's key commitments include working with relevant partners to
develop access and quality standards for acute mental health care. Integral to
High quality care for all, now and for future generations

these standards is the expectation that care is provided in the least restrictive
manner and as close to home as possible, with the practice of sending people
out of area for non-specialist acute inpatient care due to local acute bed
pressures eliminated entirely by 2021. These commitments recognise the
importance of continuity of care and close proximity to existing support networks
on the experience and clinical outcomes for people requiring acute mental health
care.

To deliver on these commitments, NHS England is working with the National
Collaborating Centre for Mental Health (NCCMH) at the Royal College of
Psychiatrists (RCPsych) to develop an evidence-based treatment pathway and
accompanying commissioning support tools for adult acute mental health care
from referral through to discharge. This work is led by a multi-stakeholder Expert
Reference Group (ERG) convened by the NCCMH involving patient experts,
carers, and professionals from different NHS services, social care, public health,
policing and the voluntary sector. As noted in the report published by The
Commission on Acute Adult Psychiatric Care, the problems with accessing acute
psychiatric care are not just a reflection of the number of beds, but the result of
system-wide issues associated with inadequate community-based provision, poor
multi-agency and partnership working, which all increase pressure on the acute
care system. As such, the scope of the pathway comprises both inpatient and
community settings, reflecting the need to ensure services are commissioned
and delivered in the context of a whole system approach based on clinical need
and the safe management of patients. It has a focus on the safe provision of
alternatives to admission, transition and interface with other services, multi-
agency working, involvement of carers, and system-wide demand and capacity
management, which promotes the provision of care close to home and in the
least restrictive appropriate setting, increasing the availability of inpatient beds for
those that need them.

This work will draw on and share learning from identified areas of best practice
such as Bradford and Sheffield that have managed to significantly improve both
acute system flow and quality of care through multi-agency working and taking a
whole system approach when redesigning their local acute care pathways.
Significantly these areas have completely eliminated acute out of area
placements (OAPs) whilst also reducing their bed numbers and average bed
occupancy, yielding significant financial savings which have been reinvested to
continue local service improvement.

We aim to publish the acute evidence-based treatment pathway and
accompanying commissioning support tools by April 2017. To support the
implementation of the pathway locally, NHS England is committed to ensuring
that all areas have Crisis Resolution Home Treatment Teams (CRHTTs)
providing a high-quality, 24/7, community-based crisis response and intensive

High quality care for all, now and for future generations

home treatment in line with clinically based evidence by 2020/21. This
commitment is supported by over £400 million of investment following the
Government's Autumn 2015 Spending Review, which will be made available to
local areas over four years from 2017/18, and is intended to address the
considerable pressures and high bed occupancy in the acute mental! health
pathway.

Further, we have been working with the Department of Health, NHS Digital and
NHS Improvement to gain a better understanding in relation to where and why
out of area placements happen. As a first step, we have published a national
definition of an acute OAP following extensive consultation. As well as the
distance patients have to travel, the definition is about whether someone is
admitted to an inpatient bed where their usual network of support (e.g. family,
pets, care coordinator from their community mental health team) is unable to
engage as often as if they were admitted in a local bed. Further to this, we have
recently established the first national data collection dedicated to better
understanding non-specialist adult acute OAP activity. The first report was
published in December 2016, but we expect to have a reliable national baseline
position for OAPs by the end of Q4 16/17, when data quality has improved after
the adjustment period following the introduction of the new collection is over.
Going forwards, this will allow us to monitor progress against the national
ambition to eliminate inappropriate OAPs for non-specialist adult acute mental
health care by 2020/21, enabling targeted support to be provided to local areas
as required.

In addition to the work currently being progressed by the acute care work stream,
The Five Year Forward View for Mental Health set the national ambition of
significantly reducing the number of people taking their own lives. To support this
aim, all Clinical Commissioning Groups are expected to contribute to the
development and delivery of local multi-agency suicide prevention plans,
together with their local partners by 2017 in line with guidance provided by Public
Health England (available from
httos:/Avww.gov.uk/government/uploads/system/uploads/attachment_data/file/56
4420/phe local suicide prevention planning a practice resource.pdf). This
expectation has been underlined in guidance for local areas regarding the
development of their Sustainability & Transformation Plans, and the NHS
planning guidance for 2017-19, and will be supported by further national
investment of £25 million from 2018/19, which is additional to the £400 million
identified for expanding Crisis Resolution Home Treatment Teams.

In line with recommendation 57 of The Five Year Forward View for Mental
Health, NHS England is working with NHS Improvement and the Care Quality
Commission to ensure that learning from all deaths by suicide of people in the
care of NHS services is used to try to prevent repeat events. Moreover, NHS

High quality care for all, now and for future generations

England will continue to play its part in wider national partnership work as a
member of the Department of Health's National Suicide Prevention Strategy
Advisory Group.

For further detail on how the transformation of mental health services will be
delivered over the next five years, please see Implementing the Five Year
Forward View for Mental Health (https://www.england.nhs.uk/wp-
content/uploads/2016/07/fyfv-mh.pdf), published by NHS England on 19 July

2016.

| trust you find this information is helpful.

Yours sincerely,

Bale.

Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP
National Medical Director
NHS England

High quality care for all, now and for future generations