Wendy Telfer

Devon Partnership INHS|

NHS Trust

Trust Headquarters
Wonford House Hospital

Dryden Road
Exeter
EX2 SAF
ne Crown Coroner Telephone: 01392 208866
Exeter and Greater Devon Coroner's Office Web: www.devonpartnership.nhs.uk
Room 226
Devon County Hall Your Ref: LCBSJ File No: 733 2016
Exeter
Our Ref: STEIS 2016/19764
EX2 4QD

10 April 2017

Dear Ms Brown

Re: Wendy Louise Telfer (deceased) — DOD 20/03/16 - Inquest 11 to 12 January 2017
Regulation 28 Report to Prevent Future Deaths

Thank you for your letter of 15 February 2017 which we received on the 17 February 2017 following
the inquest into the death of Wendy Louise Telfer. As an organisation we are committed to learning
from these tragic events and have since receiving your report and recommendations taken the
opportunity to share your findings with the service involved as well as across the wider trust.

The Trust has in collaboration with the Royal Devon and Exeter NHS Foundation Trust (RD&E)
undertaken a Root Cause Analysis Investigation following the death of Wendy; the report was shared
at the inquest and | can confirm that the action for Devon Partnership Trust resulting from the report
has been completed and is now part of regular management supervision.

What should have happened? | What Happened? Rectifleation- (Including Person Completion CCG Sign off date
links to existing work Responsible Date
‘streams and initiatives)
{Job Role)

(Link to numbered recommendations) :
Accurate and detailed records Standards of Monitored by the CTL via line | Clinical Manager | 31/01/17
should be maintained at all times in | documentation particularly | management supervision Liaison Psychiatry
accordance to DPT policy, & MNC telating to recording of systems and documentation | Team,

responsibilities and regulations. telephone conversations audits
and multidisciplinary
discussions were not
recorded robustly within the
clinical records.

The Liaison Psychiatry teams in Exeter have recently completed the self-review within the Psychiatric
Liaison Accreditation (PLAN) process. PLAN is an initiative of the College Centre for Quality
Improvement. PLAN works with services to assure and improve the quality of psychiatric liaison in
hospital settings. PLAN engages staff and patients in a comprehensive process of review, through
which good practice and high-quality care are recognised and services are supported to identify and
address areas for improvement. Accreditation assures staff, patients and carers, commissioners and
regulators of the quality of the service being provided. PLAN includes core areas common for all
teams, such as assessment and care planning. Record keeping is an essential part of this process
and is scrutinized by completion of a case note audit. The final review of the three liaison psychiatry

Chair: JulieDent CBE - Chief Executive: Melanie Walker

services by PLAN is in May 2017. The Liaison services are continuously reviewing processes and
adapting to make service quality improvements. This is also supported by managerial supervision and
all clinicians are actively encouraged to seek personal clinical supervision.

It is clear following review of your report and consideration of your recommendations that there are
continued improvements that can be made to prevent future deaths of this nature. The actions we
have taken or plan to take are described below.

Availability of in-patient beds and Crisis Resolution and Home Treatment teams

The Trust is acutely aware of the pressure upon our available bed stock and has raised the issue with
our commissioners through both our contract monitoring meetings and via a formal letter from our
Board level clinicians highlighting the very real risk to patient safety.

We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home
Treatment teams and they have now extended their operational times to midnight 7 days per week
with a view to supporting more people at home and facilitating early discharge from our inpatient
wards. We have also agreed with both Devon County Council and both of our CCGs to take
responsibility for and to streamline the current application and review process for both social and
continuing health care funding which significantly adds to the length of time a person stays in hospital.

We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down
care for those people no longer requiring acute inpatient care on a temporary basis while we work on
providing further alternatives to admission including possible crisis houses, a purpose commissioned
step down facility and looking at how we may better support people with certain conditions in the
community rather than admitting to hospital.

We now have in place a central trust wide bed management team to proactively manage and secure
beds for those in need as quickly as we possibly can. We have temporarily secured additional
contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than
rely on ad hoc arrangements as we are in competition with other NHS providers for private beds.

| think it is important to note that securing additional capacity is compounded by both the ever
tightening financial position of our commissioners, ourselves and the reducing availability of staff
across the country. | would very much like to assure you that we as a Trust are doing everything we
can to use our available resources in the most efficient way we can to meet the increasing demand we
are facing. | would also like to assure you that we will always put the safety of our patients first and will
continue to do our level best to ensure someone needing a bed is provided with one as soon as we
are able to source either internally or externally via the private sector.

Training of physical healthcare staff

There has been a great deal of work in recent years with the site management team at the RD&E
regarding the use and application of the Mental Capacity Act (MHA). This work has developed having
recognised through our joint working that there had been a need to increase the awareness of the
MHA and the importance it has in a hospital which is registered to take detained patients under the
Act. We agreed that wider training across the hospital for nurses and medical staff was unrealistic
given that the majority of staff would only come into contact with the Act infrequently, we agreed that
all the training and expertise would be held by the site management team and our MHA office and
liaison team regularly meet the site manager to discuss incidents, share learning, update in relation to
any amendments to the Act and deliver rolling training to the site managers who run a 24 hour, 7 day
a week rota across the whole hospital.

All of the RD&E wards are instructed to contact the site manager with any MHA related issue. The site

manager's office has all of the paperwork and guides and contact details for further support if needed.

This has been successful in that most wards/staff know to ring site management for MHA advice. This

system is now well embedded and generally works well. Due to the high turnover of staff and medical
Chair; JulieDent CBE - Chief Executive: Melanie Walker

staff in training it has been the best way we have been able to disseminate learning and develop a
degree of expertise into the hospital.

As described by our Liaison Psychiatry Clinical Team Leader during the inquest we have continued to
support the training of the staff within the RD&E, | have described below the general role of the Liaison
Psychiatry Team in training and the specific work undertaken during the last year.

Part of Liaison Psychiatry’s role is to offer training to staff in the general hospital, this is undertaken
both formally and informally. During 2016 the team have formally trained at least 496 staff, having
delivered 175 teaching sessions. The regular formal training delivered includes:

*« Aweekly slot in the Emergency Department (various topics, including Mental Health Act)

« Regular slots to the Site Management Team focussed on the Mental Health Act

¢ One of our consultant Psychiatrists, EEEEEEEEclivers training regarding the Capacity Act &
MHA at least twice yearly to foundation doctors, Core Trainees and Consultants

e Mental Health Champion Training (5 full days to RD&E clinicians who have volunteered
themselves as Mental Health Champions.

e Other regular slots to the Emergency Department and as part of the foundation doctors training on
the role of Liaison Psychiatry in the hospital, this includes use of the Mental Health Act.

¢ A full day package has just been developed called ‘Management of Challenging Behaviour — Rapid
Tranquilisation - a last resort!’ and this began monthly roll-out in March 2017, this refers to use of
the MHA and Mental Capacity Act in its content.

e Dementia & Delirium full days training once a month.

| hope that the actions described demonstrate our commitment to the learning we have undertaken
and that the Trust is committed to this continued positive work with within our services and with the
Royal Devon and Exeter NHS Foundation Trust. If you require any further information please do not
hesitate to contact me.

Yours sincerely

ota le Wig ee KW Ooo

Chief Executive

Chair: JulieDent CBE - Chief Executive: Melanie Walker

NHS;

Northern, Eastern and

Western Devon
Clinical Commissioning Group

Private & Confidential The Annexe
Ms L Brown County Hall
Exeter and Greater Devon Coroner's Office Topsham Road
Room 226 Exeter
Devon County Hall EX2 4QL
Topsham Road

Exeter

EX2 4QD

Date: 31/03/2017

Dear Ms Brown

Re: Wendy Louise TELFER Deceased D.O.D. 20/03/2016
Inquest held on 11-12 January 2017 at Devon County Hall, Topsham Road,
Exeter
Regulation 28 Report

| write with reference to your letter dated 15 January 2017, in which you ask health
commissioners to consider the untenable situation of delayed discharges from acute
mental health wards. Devon Partnership NHS Trust (DPT) had indicated to you as
part of the inquest that delays in discharge were due to difficulty in ensuring sufficient
acute mental health bed capacity.

NHS Northern, Eastern and Western Devon Clinical Commissioning Group (NEW
Devon CCG) is aware that the rate of delayed discharges from all DPT acute mental
health wards is higher than should be expected. This is influenced by a range of
factors including for example, discharge planning from other Provider organisations,
funding approval processes and the availability of suitable accommodation and
onward care.

In order to address the issue of delayed discharges, the following approach has
been taken by health commissioners:

Monitoring of timely discharge performance data

1. The local Northern and Eastern Devon A&E Delivery Board monitors delayed
discharge data for all Trusts in the area including DPT;

2. The DPT contract review meeting also monitors the rates of delayed
discharges from mental health wards through data reported to NEW Devon
CCG by DPT;

a
Chief Officer: Janet Fitzgerald

Newcourt House, Old Rydon Lane, Exeter, EX2 7TJU
Tel. 01392 205205
www,newdevonceg.nhs.uk

3. The Northern and Eastern Devon A&E Delivery Board also has oversight of
improvement plans which aim to reduce delayed discharges. DPT has
submitted a plan to this Board for the reduction in delayed discharges from
older people's mental health wards and a plan for working aged adults is
expected.

A number of actions have been agreed with the aim of reducing delayed discharges:

4. DPT has temporarily diverted unused capacity within its rehabilitation unit to
utilise as short term step down bed capacity;

5. NEW Devon CCG, with Devon County Council representatives have
participated in a series of workshops facilitated by DPT aimed at mapping
current and future discharge and panel approval processes. NEW Devon
CCG is awaiting the final report and recommendations for improvement in
these processes from DPT;

6. NEW Devon CCG is already leading a process, working in partnership with
Devon County Council to streamline current processes for the approval of
joint funding of 8117 aftercare and are working towards a simplified $117
aftercare funding agreement,

7. DPT have indicated a need for additional step down beds to be made
available in the Exeter area and NEW Devon CCG is working with DPT to
identify solutions for this need;

8. NEW Devon CCG has offered DPT additional management and consultative
support from its urgent care commissioning team and who have had success
in working with acute hospital providers to reduce delays in discharge;

9. NEW Devon CCG is working closely with Devon County Council with regard
to care home commissioning and market sufficiency for older people.

Further work is also required with Devon County Council and DPT's Individual
Patient Placement and Adult Social Care teams who commission a range of care
and housing options for individuals leaving hospital in need of accommodation or
specialised support, in order to fully assess need and match local supply to that
need. DPT is shortly to commence a consultation on Mental Health recovery
pathways which should also provide further intelligence about this need.

| trust that this response addresses the matters that you have raised in your report,
however should you have any further queries please do not hesitate to contact me.

Yours sincerely

4
XM

RSET CRRTPE IST SAI

Chief Nursing Officer/Caldicott Guardian
NHS Northern, Eastern and Western Devon Clinical Commissioning Group

RECEIVED 0 4 APR 2017

Royal Devon and Exeter INHS|

NHS Foundation Trust

PRIVATE & CONFIDENTIAL Royal Devon and Exeter
Ms Lydia Brown Hospital (Wonford)
HM Assistant Coroner Barrack Road
Exeter and Greater Devon Coroner’s Office EX2 5DW
Room 226

Devon County Hall Tel: 01392 411611
Topsham Road

Exeter

EX2 4QL

Our Ref: ST/LV CHIEF EXECUTIVE’S OFFICE
Direct Dial:

3 April 2017 Direct Fax:
Email:

Dear Ms Brown

1am writing further to your letter dated 15 February 2017, enclosing your Regulation 28 Report to
Prevent Future Deaths.

in my response, | will address your first matter of concern. | understand that Devon Partnership Trust
(DPT) is responding to you separately on the issues raised.

It might be helpful to summarise some of the mental health training that is currently being delivered
at the RD&E, both with the assistance of staff from DPT and from other sources.

Part of the role of the DPT Liaison Psychiatry team is to offer training to colleagues in the acute
hospital. This is done both formally and informally. In 2016, the Liaison Psychiatry Team has
formally trained at least 496 staff, having taught 175 teaching sessions.

The regular formal training delivered by the Liaison Psychiatry team includes:
e Aweekly training programme to the multi-professional team in the Emergency Department on
various topics, including the Mental Health Act 1983 (“MHA”)
e Regular training to the Site Management Team focussed on the MHA as they have oversight
of this and its application in the acute trust.

Both of these training programmes are specific, targeted training sessions to areas where there is
the highest volume of contact of patients with mental health issues.

e One of the DPT Consultant Psychiatrists, delivers training on the Mental
Capacity Act 2005 (“MCA”) & the MHA a ly to Foundation doctors, Core
Trainees doctors and Consultants

« Mental Health Champion Training (x5 full days) to RD&E clinicians who have volunteered
themselves as Mental Health Champions for the RD&E. This helps support staff with patients
in practice.

¢ Other regular training sessions are delivered to the Emergency Department and to the
foundation doctors in training on the role of the Liaison Psychiatry Team in the RD&E. This
training includes use of the Mental Health Act

Chairman: James Brent Chief Executive: Suzanne Tracey
WZK856 11/16

¢ Awhole day’s package has just been built and is due to start being delivered later this month
called “Management of Challenging Behaviour — Using Rapid Tranquilisation as a last resort”
— this refers to use of the MHA in its content. This is being delivered to the medical wards and
targeted at registered and non-registered staff where patients with mental health needs
alongside physical needs are being nursed.

¢ A full days training on Dementia & Delirium once monthly for registered and non-registered
staff

Other mental health training being undertaken by RD&E staff from other providers includes:

e The Cavendish Care Certificate for unregistered staff has a module on Mental Health is
delivered by the Trusts Learning and Development Team and covers application of the MHA.

¢ The Trusts Learning and Development team deliver the Level 3 Health Care Diploma which
has a unit on Mental Health.

¢ All medical staff have MCA training on their programme which can overlap and lead to
discussion on the MHA.

* University accredited Mental Health related modules which is usually undertaken by ED staff
at the University of Plymouth

Further, the RD&€E is training a specialist pool of nursing staff for specific mental health input. This
will lessen the need to use agency staff. This will allow the Trust to have better control over the
training and expertise of the specialist mental health staff. It will also improve communication
between the physical and mental health care professionals.

You will see from the list above that there is a lot of training already being provided across the RD&E
on the Mental Health Act. Most of this is specifically targeted at the groups of staff who have the
most contact with vulnerable patients such as ED/AMU staff and Site Management.

With regards to future development, there is a general consensus that a greater awareness and
understanding of the MHA would be beneficial to all staff. Ensuring that this training is of a suitable
level, proportionate and appropriate to staff grading is essential. We are looking at the best ways to
target resources most effectively and efficiently.

A Training Needs Analysis is being done to ascertain what further training is necessary and where
and how it should be targeted. Specific consideration is being given as to whether the module of
training delivered to the high intensity areas such as the Emergency Department and Site
Management staff could also be helpfully delivered to the medical overflow wards, which includes
Culm Ward. The relative volume of queries being made to the Liaison Psychiatry team from these
overflow areas is being looked at, to ascertain the need in these areas. If such a need is found, the
level of training, to which levels of staff, can then be determined.

Consideration is also being given to the viability a ‘leaflet drop’ with payslips. This has recently been
done by the Child Protection/Safeguarding Team to good effect. This would ensure that all staff in all
grades and positions have some basic training and an information resource on the MHA. Further
‘catch all’ training may also include information being added the RD&E intranet as a must-read
document. It is hoped that the new ‘Mental Health Champions’ being trained could assist with any
new training.

An Action Plan setting out what steps will be taken to assess the training need is enclosed.

Royal Devon and Exeter INHS|

NHS Foundation Trust

All of the current MHA training requests that if staff have any concerns about a patient’s mental
health, then they should contact the specialist Psychiatric Liaison Team for advice on how to
manage that patient in normal working hours and the psychiatric on call Crisis Team out of hours.
The escalation process also includes contacting the Devon Partnership Trust on call team both in
and out of hours if an issue is unresolved. The next stage of the process includes contacting the
Devon Partnership Trust on-call Director if required. This is what is practiced throughout the RD&E
at the moment. This would also be our first line of advice in any future training.

With respect to Wendy Telfer’s case, she had been formally assessed on two occasions by specialist
practitioners from the DPT and they did not consider she should have been under a formal MHA
section. On the day of her discharge, there was some uncertainty about her MHA status and her
current presenting symptoms. Therefore, RD&E staff sought specialist advice from the Psychiatry
Liaison Team on two separate occasions. They were not advised to use the MHA to detain the
patient if she tried to leave. It was on the basis of this specialist advice that she was allowed to
leave.

Whilst we are always keen to improve practice, in this case RD&E staff had been clearly guided with
professional, specialist advice about the use of the MHA in these circumstances. We would be
circumspect about any training which meant staff, who used the powers under the MHA very
infrequently, acted in direct contravention of the expert advice.

| hope that the above satisfies you that we are looking at ways to improve MHA training within the
Trust. We are aware of the need to improve the knowledge and understanding of staff around the
MHA while still expecting staff to rely on the specialist service for advice.

Yours sincerely

Suzanne Trace
CHIEF EXECUTIVE

Enc. Action Plan

RECEIVED f 1 APR 2017

Chairman: James Brent Chief Executive: Suzanne Tracey
W2ZK856 11/16