David Hamilton

248 { 2017

Grosvenor Medical Centre

62 Grosvenor Street

Stalybridge

Cheshire —
SK15 1RZ

Tel 0161 303 4313 He

Fax 0161 303 8377 aes eae

18-06-17

Ms Alison Mutch
HM Senior Coroner
Coroner’s Court
Stockport — SK13AG

Re: Regulation 28 Report for David Ian Hamilton
Inquest held on 01-06-17

Dear Ms Mutch

Thank you for your report dated 05-06-17, which outlined the actions to be taken as per Regulation
28.

I attended the inquest on 01-06-17 and it is very helpful to have your report. I have since, fed back
to my colleagues in the practice and also raised concerns about mental health support with
colleagues in the Clinical Commissioning Group. Your report has also been read by all my
colleagues. We have tried to address the concerns. The actions taken are as below:

1) Referral to Psychiatrist and escalation of matters by health professional:

There is guidance for Tameside GPs on the referral pathway to the Psychiatrist. I enclose evidence
of letter from Consultant Psychiatrist, which outlines the pathway. (Attached).The main route of
referral for non -urgent patients is the Single Point of Entry, Access Team and Healthy Minds, and
patients have to wait a minimum of 12 weeks.

Any escalated referrals which need the intervention of a Consultant Psychiatrist, will be reviewed
within two weeks of referral being made by GP and will be seen in outpatient clinic within eleven
weeks,

Urgent Referrals will be seen within 48 hours.

As this pathway leaves GPs in a very vulnerable position, with no help (potentially for eleven
weeks), we have escalated the matter to the Mental Health Clinical Lead for Tameside CCG,

Po and Head of Mental Health and Learning Disabilities, PF

We have learnt that there are plans underway to develop a new model of care for people with
complex needs that should improve provision for patients such as Mr Hamilton in the future.

2) Referrals to Sleep Clinics:

Based on the information that the RAID team is advising patients to ask for sleep clinic referrals
and their letter to us advising us to refer, we have since found out that there is no sleep clinic for
insomnia within Manchester.

The nearest sleep clinic for insomnia is Blackpool and there is a 20 week waiting list. The Choose
and Book referral system also offered sleep clinic in Sherwood, Nottingham, and the waiting list is
20 days.

There is no other therapy being offered within Manchester for Insomnia. It would therefore be
helpful in informing the RAID team of the lack of this service within Manchester area, if they are
already not aware, so that patients can be guided appropriately by them.

Again, we have escalated this matter to the Head of Mental Health and Learning Disabilities in
Tameside & Glossop CCG who has advised us that she will reinforce the need for Pennine Care
MH Services to support GPs to make referrals for extraordinary services through the use of the
Individual Funding Request Form. This will significantly support timely and appropriate referrals.

3) We have also written to the Mental Health Lead to ask for improved communication
between the Healthy Minds and the GPs.

I hope these answers address the concerns you have raised.

Please do not hesitate to contact us if you need any further information.
Many thanks.

Yours sincerely

Ws

GP

246/20! |

Pennine Care [i'/a hy

NHS Foundation Trust

25h July 2017 Corporate Governance
Trust Headquarters
225 Old Street
Ashton-under-Lyne
Lancashire
OL6 7SR
PRIVATE & CONFIDENTIAL
Ms A Mutch Telephone: 0161 716 3000
HM Senior Coroner
Coroner's Court Our Ref: KB/RC
1 Mount Tabor Street Department: Trust Headquarters
Stockport
SK1 3AG
Dear Ms Mutch,

Re: David lan Hamilton (Deceased)

Thank you for your Regulation 28 report dated the 5" June 2017, and for bringing to
my attention the concerns you had after hearing all the evidence. Your concerns
relevant to Pennine Care have been reviewed, and the Trust's response is outlined
below.

Concern 1:

Healthy Minds has no documentation or system of recording the selection process
for therapy, including the options given and rationale for the choice of therapy.

Response:

Patients who are referred to the Healthy Minds Service are triaged by the Access
Team (Single Point of Entry) and allocated to the appropriate treatment step within
the Healthy Minds Service. Where there has been no or limited previous contact
with the service (and this is also felt to be clinically appropriate in terms of
presentation, history and current risk), patients are invited to attend a ‘treatment
options’ group session where a presentation is given about the service and the
treatment options available.

Patients are then asked to identify their preferred treatment modality (from a range of
interventions including one to one therapy, Group Interventions and on-line
treatment). Patients are asked to endorse this preference on a standard document
along with the completion of outcome measures PHQ9 and GAD7. The patients are
offered advice and guidance from staff to support with the selection of the
appropriate treatment option where required. The forms are then returned to the
clinician.

Where a group is requested, patients can select a date and time to attend the group
and an appointment is provided during this attendance, which allows the patient to

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select a date and venue that is most convenient to them. This information is also
recorded on the session attendance forms.

The forms are returned to the team administrators who transfer the information from
the documents into the clinical records, adding patients to either a treatment waiting
list, or the selected group within the electronic record system.

An additional process will be initiated whereby a case note shall clearly state in the
patients clinical records that the patient has completed a treatment options session
and has chosen 1:1/cCBT/Group Interventions (identifying the treatment selected)
and has been allocated to the appropriate treatment pathway.

Concern 2:

There was a lack of clarity of triggers for referrals other than group therapy.
Response;

Patients are triaged and allocated treatment based on the LIFT (least intervention
first time) principle within the stepped care model. Patients are referred into the
single point of entry for mental health services which sits within the Access Team.
The referral is then reviewed and triaged based on current presenting difficulties,
previous psychiatric history and risk.

Where a patients difficulties are deemed appropriate to be met at step 2 this is
recorded in the triage notes and the information is passed to the Healthy Minds
Service who then invite the patient for a treatment options session where a range of
interventions including group, online and one to one guided self-help therapy are
presented and the patient is supported where necessary to consider their needs and
identify their preferred treatment option.

Where a patient presents with a higher level of need (which may include specific
exclusion criteria for step 2 for example, complex difficulties or having completed a
course of treatment at step 2 which was unsuccessful in the past) the patient may be
triaged to Step 3 in the stepped care model. Again the patient would be invited to
attend a range of interventions including High Intensity Group provision or one to one
therapy in a range of modalities depending on presenting need.

Where a patient is felt to have needs which would not be appropriately met by
psychological therapies at step 2 or 3 other options including secondary care or
acute care can be considered.

Concern 3:

The system of sharing information between health professionals (GP and Healthy
Minds) to identify if the correct services were being accessed or if a referral to a
psychiatrist was required was limited and meant that those involved did not have a
full picture of his mental health.

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Response:

The service has a standard method of communicating information to GPs using an
electronic document transfer system. This allows information to be delivered to GPs
reducing the risk of the loss of information and reducing the time it takes to share
information between health professionals. Risk faxes are also used to provide
urgent information to GPs where there is a concern about the risk a patient has
presented with and how this risk is being supported and managed. This may include
requests for support from the GP, for example to review the patient in clinic or
consider a review of medication or provide information regarding an ongoing
management plan. Where a GP does not have access to this system the information
is communicated by fax or post depending on the urgency of the information. Post,
fax or email communication is also used for other health professionals and referrers
where appropriate.

During the therapy journey a patient may be assessed by the clinician as potentially
requiring a review by a psychiatrist. In these instances the case is presented to the
secondary care mental health team for consideration including all information
gathered during assessment and within the ongoing treatment. Advice may be
provided to the GP or an assessment may be offered where it is felt that the patient
meets the criteria for secondary care intervention. Where this is not indicated the
clinician within Healthy Minds will continue to offer therapy and monitor the progress
within treatment.

Should a GP feel that a review with a psychiatrist is required or feel that a patient
would benefit from Community Mental Health Team involvement within secondary
care a referral to request this can be made via the Access Team. These requests
will be triaged and discussed within the secondary care meeting where appropriate.

Concern 4:
Referrals were not made to sleep clinic services to assist with insomnia.
Response:

The patient presented at the emergency department on 30.10.2016. The emergency
department practitioner provided a triage assessment with advice being given to the
patient regarding support pathways and a request for a referral to a sleep clinic being
sent to the GP within the management plan.

The patient self-referred and presented to Healthy Minds with clinical symptoms of
depression and anxiety. These can include (amongst others) loss of appetite, loss of
motivation to engage in daily routines, lack of concentration and impact on sleep
patterns. The patient completed a self-rating measure and endorsed that they had
‘trouble falling asleep or staying asleep, or sleeping too much’ which is a common
difficulty within the context of mild to moderate mental health difficulties. The patient
initially identified that this was a problem for more than half the days in a two-week
period endorsing 2 out of 3 on the PHQ9 questionnaire for this question. This
reduced to several days 1 out of 3 within a two-week period during therapy but
fluctuated between these two levels during the course of treatment. The patient did

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not score 3 out of 3 (rating this to be a problem nearly every day) at any point within
their contact with the service.

A referral to a sleep clinic for insomnia was not considered during the time that the
patient engaged with the Healthy Minds Service. The group intervention that the
patient elected to attend included (in session 2 of 6) information on sleep hygiene,
relaxation and controlled breathing in addition to how food, diet and exercise can
improve wellbeing and impact on symptoms of low mood, stress and anxiety.

Concern 5:

There was no evidence of a clear formal escalation process where concerns were
held by a health professional.

Response:

The primary care service works within a model of risk enablement, supporting
patients, the clinician and other involved individuals (including where possible and
appropriate other health and social care professionals, family and any identified care
givers) to work collaboratively to understand and manage risk taking into account
the interaction between likelihood, harm and imminence. Within group delivery this
risk enablement strategy includes providing information regarding crisis care
pathways at each contact and offering support for individuals to access at the end of
each session should a patient feel that they require support in addition to the weekly
group contact.

The health professional involved in the patients care, identified concerns regarding
the patients’ level of risk during the group sessions. As a result additional support
was offered and provided following and in addition to the weekly group sessions.
The clinician was STORM trained (a suicide prevention training package) and
applied the STORM principles when assessing risk and these principles were also
evident in the risk management plan. The clinician sent frequent risk faxes to ensure
the GP (as responsible medical officer) was aware of the presenting risk and asked
the patient to contact the GP to discuss medication, which they agreed to do. When
the patient did not attend the planned appointment with the clinician, they contacted
the GP surgery and established that the patient had engaged with this plan and
during this contact with the surgery was able to identify that the patient had spoken
to the GP on two occasions and had a further review appointment planned. Risk
faxes were sent to inform the GP of the patients’ non-attendance at the planned
appointments with the Healthy Minds practitioner.

The clinician agreed with the patient at each contact that should they feel unable to
maintain their own safety, that they would attend the emergency department for
support as they had done in the past. The patient is said to have agreed with this
plan. Following non-engagement with the planned appointment, attempts to engage
by telephone and a further appointment being sent by letter (which was also not
attended) a decision was taken in line with service policy and in agreement with the
clinicians line manager to discharge the patient to the care of the GP with a risk fax
again being provided outlining the concerns and the detail of unsuccessful attempts
to contact the patient. The correspondence also requested ongoing monitoring of
risk.

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Should a patient disclose imminent risk and then fail to engage with a management
plan, practitioners can request support from the Duty Worker who is a qualified
mental heaith practitioner (RMN or Social worker) for support and may request a
welfare check from the emergency services to establish if the patient is able to
remain in the community.

During the course of therapy, should a patients clinical presentation indicate a higher
level of need than the current step allocated (which is identified at triage) within the
stepped care model (for example due to the presenting problem i.e. Trauma),
patients can be ‘stepped up’ to high intensity therapy or be referred for consideration
for input from secondary care should there be an indication of a severe mental
illness. The clinician involved can request further support and assessment from the
teams duty worker (who is a senior mental health practitioner) where needed or can
discuss the case with the team managers for presentation at the secondary care
meeting.

At any point in the care pathway, the GP can request that a patient is considered for
assessment by a Psychiatrist or for provision of care coordination should they have
concerns regarding a significant change in presentation when the patient presents to
the GP Surgery. This request is made via the Access Team, providing the function
of the single point of entry for mental health services. The team would triage the
request and where appropriate present the case for consideration at the secondary
care referrals meeting.

In cases where there is evidence of immediate risk to self or others a referral can be
made to the emergency department to be seen by the RAID team for further
assessment where consideration can be given regarding the need for input from the
home treatment team, or an acute admission.

| hope this response assures you that the Trust takes seriously any concerns that
you raised.

Yours sincerely,

/

Acting Chief Executive

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