Sofia Legg

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Mr T Williams Please ask for E-Mail

Senior Coroner Julian Wooster Po

Office of the Coroner

Old Municipal Buildings Direct Dial Date

Corporation Street 01823 359024 28 November 2017
Taunton

TA1 4AQ

Dear Sir

Concluded Inquest into the Death of Sofia Ann Legg
D.O.D 26 September 2016

| write with reference to your letter dated 5 October 2017, in response to the
Regulation 28 report in relation to Sofia Ann Legg.

The multi-agency Child Death Overview Panel (CDOP) held on 16 November
fully considered the circumstances of Sofia’s death. CDOP considered that
there were a number of modifiable factors to reduce the risk of future child
deaths. The following recommendations have been made:

1. Communication of crisis plans needs to be clearer for parents, with clear
instructions about who to contact if there are further urgent concerns.

2. There needs to be earlier liaison with schools so that staff can be aware
of issues in a school setting, particularly if a crisis plan has been put in
place. Urgent support can then be sought if required.

3. CAMHS staff need to have easier access to senior medical staff so they
can discuss cases that cause concern more easily.

4. SUI reports need to be phrased in a sensitive manner bearing in mind
they will be made available to parents.

In discussion with the Chair of Somerset Safeguarding Children Board, the
death of Sofia has been considered for a Serious Case Review (SCR). The
decision of the Chair is that Sofia’s death does not currently meet the threshold
for an SCR.

| can however confirm that the Chair of Somerset Safeguarding Children Board
has decided that Sofia’s death will be the subject of a Learning Review under
Working Together 2015. The scope and overview report author are in the
process on being determined.

| trust this response is helpful to you, should you require any further information,
please do not hesitate to contact me in the future.

Yours sincerely

Director of Children’s Services

Our Ref: NR/dr/rjb/011217-39

NHS}

Somerset
Clinical Commissioning Group

1 December 2017 Wynford House
Lufton Way
Luft
Mr Tony Williams Yeovil
Senior Coroner Somerset
Old Municipal Buildings an
Corporation Street Tel: 01935 384000
TAUNTON Fax: 01935 384079
Somerset
TA1 4AQ somccg.enquiries@nhs.net

Dear Mr Williams
Concluded Inquest in to the Death of Sofia Legg, Regulation 28 Report

Thank you for your letter dated 6 October 2017. We were very saddened to hear about the
death of Sofia and the distress of her family. Within your Regulation 28 report, you have noted
five areas of concern. We have responded to each area below:

1 Access to CAMHS. Sofia was rejected for referral in April 2015. Might a lower
threshold and earlier proactive interventionist policy have been of positive
benefits to Sofia?

1.1 In line with NHS England requirements the NHS Somerset Clinical Commissioning
Group (CCG) commissions CAMHS in Somerset for children and young people
with severe and/or persistent mental health disorders. Within the available funding
(as is the case nationally) it would not be possible at the present time to lower the
CAMHS threshold. Since the original referral for Sofia in April 2015, there has
been a significant change regarding CAMHS provision and referral process. As
was noted at the Inquest, there is now a single point of access (SPA) for CAMHS,
outlining improved access for young people, families and health professionals with
clear oversight and governance arrangements mandated. For referrals which do
not reach the access threshold, the SPA service now aims to signpost to other
services which can be accessed to provide appropriate and timely support, rather
than the previous simple 'no' that referrers, patients and family previously received.
This is an area of developing practice for the SPA team as we work towards greater
integration between tiers of mental health service provision and health and care
services more generally.

1.2 There is also a need to consider the provision of Tier 2 services. In recognition of
this, as part of our Somerset Local Transformation Plan funding for Children and
Young People’s Mental Health and Emotional Wellbeing monies have been
invested in the commissioning online counselling via Kooth (https://kooth.com/). in
addition, the CCG has recently made a successful bid for national funding to

Chair: Dr Ed Ford | Chief Officer: Nick Robinson

vi MINDFUL
EMPLOYER Working Together to Improve Health and Wellbeing
www.somersetccg.nhs.uk

1.3

1.4

2.1

3.1

3.2

support new counselling provision in Cheddar provided by the voluntary sector.
This service is in process of being established.

Somerset CCG and NHS England Specialised Commissioning are jointly funding a
CAMHS Enhanced Outreach Service which is now fully operational to support
young people and families in similar situations. This service is available 7 days a
week from 8.00am to 8.00pm and is a Multi-disciplinary Team, which includes a
Psychiatrist.

We recognises the importance of supporting children and young people at all tiers
and to that end we are in the process of reviewing our current commissioning
arrangements which includes, enhancing our joint commissioning with Somerset
County Council Children and Family Services and Public Health. We would expect
the outcome of this to lead to further improvements for our Somerset children and
young people.

Availability of CBT. Sofia was placed on a 6 month waiting list for CBT. This
delay appears considerable.

It is highly regrettable that there was a considerable delay in the availability of CBT
for Sofia. During October 2016, Somerset CCG invested additional funding in order
to improve access to CBT. The CCG has now changed the way it monitors the
CAMHS contract, data is received for new 8 week referral to assessment and 18
week assessment to treatment standards which clearly show us if the Provider has
children and young people waiting longer than 18 weeks for therapy. This
enhanced surveillance will address a previous concern about the visibility of waits,
for example, where Care Co-ordinators were ‘holding’ cases in lieu of evidence -
based therapy. There are also standards now in place to monitor referral to
assessment time for urgent and emergency referrals.

Sofia's care co-ordinator at CAMHS did not obtain the urgent input of a
psychiatrist in accordance with NICE guidance.

The Care Co-ordinator identified the need of and sought the opinion and support of
a Psychiatrist, however, there was no-one immediately available. Regrettably, the
on-call Psychiatrist was not contacted to offer advice for Sofia. Support was sought
from a Line Manager and the crisis plan was developed as an interim measure
pending a psychiatric appointment.

Since the implementation of the Single Point of Access Programme (SPA),
practitioners have open access to the Multi-disciplinary Team (including a
Psychiatrist). The enhanced Outreach Team (out of hours CAMHS Team) is also
now established and working 8.00am- 8.00pm Monday to Sunday and will take
urgent referrals and offer intensive home support as needed. Additionally, the
process around availability of the on-call psychiatrist has been strengthened by
ensuring the rota is distributed electronically to the whole service.

The recollections of Sofia's Care Co-ordinator and Sofia's mother as to the
meeting of the 19 September were at odds with each other. Sofia’s Care C-
ordinator recollected in her evidence telling Sofia's mother that Sofia was not
to be left alone. Sofia's mother deemed the impression from Sofia's Care Co-
ordinator's evidence was of Sofia being an extremely vulnerable and
dangerous position but this was not reflected in Sofia's care plan which made
no mention of her not being left alone and it was not reflected in the Care Co-

ordinator's actions in not urgently contacting Sofia's school, where she
would be during the following days to a psychiatrist. Her care plan appears
to be the critical written record of the outcomes of this meeting as it was not
of sufficient detail to safeguard Sofia.

41 Following receipt of your report the CCG has discussed the apparent dissonance
between Sofia’s care plan and the accounts of both Sofia’s mother and the Care
Co-ordinator with the Somerset Partnership NHS Foundation Trust’s Head of
Governance. It has been agreed that the Trust will undertake further lines of
enquiry (within the investigation conducted by the Trust under the National NHS
Serious Incident Framework, and overseen by Somerset CCG), to establish if the
content and robustness of the care plan were adequately addressed within the
investigation and subsequent action plan.

5 Language used in the SIRI Report was felt to be inappropriate. The SIRI
Report effectively said if the care plan had been followed the outcome might
have been different and that no change in clinical practice would have
resulted in any different outcome. | do not believe either of these statements
was true.

5.1 We understand from our discussions with the Somerset Partnership NHS
Foundation Trust in our oversight of the investigation and action plan they have
reflected and are making changes:

° to the manner in which they shared the findings of their investigation with
Sofia’s mother, as part of their strategy for involving families, and

° the need to ensure there is a clear understanding between professionals and
families when formulating safety plans

The issue of sharing documented ‘safety plans’ with patients’ and their families, where this is
identified as something beyond sharing the agreed care plan with the patient, is an issue
which the CCG is currently working with the Trust to ensure this becomes part of routine
practice for people with identified immediate risks.

As a CCG we are committed to ensuring that the services we commission for children and
young people’s mental health are both responsive and of high quality and we are grateful to
you for raising your concerns with us.

| hope that our response has fully addressed the concerns that you have raised, if not please
do not hesitate to contact me.

Yours sincer

Nick Robinso@n

Copy:

FY Deputy Chief Officer and Director of Commissioning and Governance
HEE Acting Director of Quality and Patient Safety

a: Lead - Mental Health and Learning Disabilities

Somerset Partnership INHS|

NHS Foundation Trust

Our Ref: SL 2016/25064 ~ 9d Figgr
Mallard Court

29 November 2017 Express Park

Bristol Road

PRIVATE AND CONFIDENTIAL Bridgwater

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Senior Coroner

Old Municipal Buildings www.sompar.nhs.uk

Corporation Street

TAUNTON

Somerset TA1 4AQ
Dear Mr Williams
CONCLUDED INQUEST INTO THE DEATH OF SOFIA LEGG

| am writing to respond to the Regulation 28 (Preventing Futures Deaths) Notice that you
issued to Somerset Partnership NHS Foundation Trust on 5 October 2017.

My predecessor, Dr Nick Broughton, as Chief Executive, met with Mrs Legg in October
of this year and offered our sincerest condolences and an unreserved apology for the
areas of Sofia’s care and the handling of the investigation that were not of the high
standard expected. Whilst we cannot begin to imagine the pain Sofia’s family have
experienced, we would like to express the sadness that we, as an organisation, and our
CAMHS staff in particular, have experienced as a result of Sofia’s death.

Somerset Partnership provides a Tier 3 community CAMH Service. Tier 3 services are
frequently referred to as Specialist CAMHS. These are multi-disciplinary teams which
work in the community with children and young people who present with the most
complex mental health presentations and severe levels of risk. This would include
severe mood and anxiety disorders, eating disorders, the impact of complex trauma as
well as serious self-harm and suicide risk. The treatments offered by a Tier 3 services
include a range of specialist psychological interventions and medication which can only
be delivered by staff who have a high degree of specialist training and experience.
What is known as Tier 2 CAMHs is the level of service, based primarily in schools and
the wider community, providing early detection of emotional and mental health difficulties
and offering timely, preventative interventions.

You will be aware that there has been national publicity and Government recognition of
the need to invest further in children’s mental health services. The organisation
welcomed this national investment which has been translated locally into the CAMHS
Transformation Plan for Somerset and has led to considerable service improvements
over the last year.

Somerset
Partnership

Chairman: Stephen Ladyman Chief Executive: Peter Lewis

However, Somerset continues to be in the lower quartile for investment and we believe
that further service development will be needed if we are to address the increase in
demand and the complexity of the mental health presentations we are seeing in young
people.

The Trust's response is intended to convey the range of actions that have already been
taken since the tragic death of Sofia in September 2016 and to provide reassurance that
the proposals for further action are to prevent future incidences of suicide for children
and young people in our care.

1. Access to CAMHS. Sofia was rejected for referral in April 2015. Might a
lower threshold and earlier proactive interventionist policy have been of
positive benefits to Sofia?

1.1 Itis certainly true that a lower threshold might have allowed Sofia to access the
service earlier. However, for the reasons described above, capacity within the
Tier 3 CAMH Service is limited.

1.2 Over the past year the Trust has introduced a Single Point of Access (SPA) for
CAMHS and the remit has been to more consistently screen referrals, allow more
time for advice and discussion with referrers and to maintain and monitor service
thresholds. We believe this is making a difference by improving access as well as
improving the quality of the advice and guidance that is given.

1.3. Whilst, the introduction of the SPA has been a significant step forward, it has
highlighted the unmet need in what we refer to as the CAMHS Tier 2 resources.

1.4 Our specialist CAMHS team has raised concerns that the Tier 2 options in
Somerset are not equitable with much of the rest of the country. An increase in
the Tier 2 resource would be an important and effective investment decision to
improve the long term mental health of children and young people.

1.5 The Trust has raised this concern with Somerset Clinical Commissioning Group
and the Local Authority and is working closely with these colleagues on a gap
analysis, which is anticipated will assist in informing future funding priorities. The
need for a Tier 2 early intervention service was also raised directly with the
Secretary of State for Health when he visited the Trust on 24 November 2017 and
he indicated that a new green paper will soon be published which sets out plans
to transform services in schools, universities and for families. The Trust welcomes
this focus on children’s and young people’s mental health and the plans to
address the current gap in Tier 2 service provision.

1.6 As part of this review we are also currently undertaking work to benchmark our
own internal threshold processes for CAMHS Tier 3, with the national definition of
what a Tier 3 service is expected to provide, and with what is commissioned: to
ensure that we have our threshold in the right place, and that if it is set too high
that we can identify that, to ensure that we look to get the right level
commissioned.

2.1

2.2

2.3

3.1

3.2

3.3

Availability of CBT. Sofia was placed on a six month waiting list for CBT.
This delay appears considerable.

The Trust agrees that a six month waiting time for CBT is unacceptable and has
been working hard to reduce this. Waiting times for all specialist therapies have
been successfully reduced and CBT waiting times in the Trust are now measured
in weeks, rather than months. However, CBT is not an emergency intervention
and a review of Sofia’s care has led us to conclude that she should have been
offered a more generic, therapeutic intervention with more frequent appointments
at an earlier stage. This would involve using psychoeducation and a range of
therapeutic techniques to engage and build a trusting relationship with a focus on
understanding and managing risk.

The way the CAMHS teams operate has been changing to ensure that there is a
much greater focus on generic interventions, relationship building and increased
frequency of contact when suicidal thoughts are one of the main presenting
problems.

During 2017 the way initial assessments are performed has also changed. This
includes the re-structuring of clinics to better support all staff in their decision
making and to include psychiatrists and senior clinicians at an earlier stage.
Weekly multi-disciplinary meetings with psychiatrists in attendance have been
implemented to guide staff through complex case discussions and identify those
cases which may need their input.

Sofia's care co-ordinator at CAMHS did not obtain the urgent input of a
psychiatrist in accordance with NICE guidance.

The guidance for urgent and emergency response times also involves making
complex clinical judgments and these are made by staff on an individual patient
basis. Within CAMHS the decisions are made not only by psychiatrists but by
other experienced senior clinicians who are able to assess and intervene to
manage suicidal presentations safely as part of the urgent care pathway. If a
referral to a psychiatrist is considered as urgent the family are seen within 24
hours of the referral and if the assessment results in an emergency referral these
are made within 7 days. The numbers of psychiatrists within the Trust is limited
and they would be unable to see all cases where suicidal ideation is a feature.

The care coordinator did view Sofia’s presentation as sufficiently concerning to
take advice from senior staff, including her clinical supervisor on the day of the
appointment, while Sofia and her mother waited in the building. The outcome of
those discussions was that the situation was deemed as urgent and the care
coordinator should complete a safety plan and seek an urgent psychiatric
appointment. The Trust has reviewed its escalation procedures and introduced
new service provision since this tragic incident.

The last year has seen a transformation in the urgent care pathway for CAMHS.
An Enhanced Outreach Team (EOT) is in place. This team can, where necessary,
do daily home visits and seek to provide more frequent monitoring of young
people’s mental state. Sadly, this service did not exist in this form at the time of

3.4

4.1

4.2

4.3

Sofia’s death but it is envisaged that young people will benefit from an increased
crisis and home treatment provision in the future.

In addition the Trust now has a team of highly experienced psychiatric liaison
nurses based at both acute hospitals in Somerset, these nurses assess young
people who self-harm or experience suicidal thoughts on presentation to an
emergency department. If the child/young person is discharged and they require
further CAMHS input this information is communicated to the relevant local team
for follow up. This team can also admit to the paediatric ward if they need to keep
a young person safe and this would prevent a delay in care if the young person
could only be seen by a psychiatrist to undertake these assessments.

The recollections of Sofia's Care Co-ordinator and Sofia's mother as to the
meeting of the 19 September were at odds with each other. Sofia's Care
Coordinator recollected in her evidence telling Sofia's mother that Sofia was
not to be left alone. Sofia's mother deemed the impression from Sofia's
Care Co-ordinator's evidence was of Sofia being an extremely vulnerable
and dangerous position but this was not reflected in Sofia's care plan which
made no mention of her not being left alone and it was not reflected in the
Care Co-ordinator's actions in not urgently contacting Sofia's school, where
she would be during the following days to a psychiatrist. Her care plan
appears to be the critical written record of the outcomes of this meeting as
it was not of sufficient detail to safeguard Sofia.

It has been recognised that the recollections of Mrs Legg and Sofia’s care co-
ordinator are not in agreement with regards to the level of detailed safety advice
given. Mrs Legg herself has told us that we, as a service, may not fully
understand how challenging this situation was for her as a parent. She was being
asked to absorb new information about her daughter’s mental state and her risk of
ending her life, which was new and shocking for her. | extend again my own and
the Trust's sincere apologies to Mrs Legg for this. The Trust appreciates and fully
understands this feedback given by Sofia’s mother and realises that services
need to work much harder to help families understand the impulsive and
fluctuating nature of suicide risk in young people. CAMHS practitioners have been
made aware of the importance of ensuring care plans are explicit and information
is written clearly. This work will continue to be monitored through staff clinical
supervision.

The information about suicide risk needs to be given in a number of different ways
and the Trust is creating a range of information leaflets that give general advice
about suicide risk, as well as continuing to develop the knowledge and skills of
our CAMHS teams in assessing, managing and communicating around risk. The
Trust is working with Public Health in Somerset County Council on Suicide
Prevention and it is expected that these leaflets will be launched in 2018.

It has been fully recognised that family members need to be involved at the
earliest stage when young people are expressing suicidal ideation and given time
to absorb information and to process advice. The CAMH service is continuing to
work with staff through risk training and via local team business meetings to
emphasise the importance of crisis plans which give advice to both the young

4.4

5.1

5.2

5.3

5.4

5.5

person and parent as to the level of supervision needed, in clear language. These
directions are reinforced in training and supervision for staff.

A recently conducted review of Sofia’s care has highlighted the issue of
communication with the school as one of the most significant areas of learning for
the service. It has been concluded that the school might have been able to take
different actions in their care of Sofia had they been aware of the increased risk. It
has not been standard for CAMHS staff to share risk assessments and crisis
plans with schools and has been a matter for individual clinical judgement. We
believe that in cases where young people are expressing suicidal ideation then
this information should be shared with schools as standard practice. This will
involve cultural and practical changes and will have implications for our education
colleagues. We are starting a process of talking with the CCG, schools and our
staff to work towards implementing this approach as standard.

Language used in the SIRI Report was felt to be inappropriate. The SIRI
Report effectively said if the care plan had been followed the outcome might
have been different and that no change in clinical practice would have
resulted in any different outcome. | do not believe either of these
statements was true.

The Trust wishes to apologise unreservedly for the poor and extremely
distressing choice of words within the investigation report which it acknowledges
has caused considerable anxiety for Sofia’s family. A review of the investigation,
which took place following the inquest, did not support the statements as
described above made in the report. The Trust has identified several areas for
improvement to ensure that this does not happen again.

The Trust has prioritised the need for all investigators to have the knowledge and
ability to conduct a thorough, accurate and reliable investigation using national
tools and techniques. Training of key staff in the use of these national tools and
techniques has already commenced and by the end of 2017 a cohort of trained
investigators will be in place.

The scope and terms of reference for the investigation will be clearly defined to
include the needs of families and there will be oversight throughout the process to
ensure key questions are asked and answered, this will ensure that the Trust
achieves credible investigations. This new process has already been
implemented.

The investigation process will seek to review all aspects of care and treatment
that may have had an impact on an event such as this. The Trust has recognised
that the involvement of families is essential right from the beginning of the
investigation until the eventual sharing of findings. Work to embed this process is
underway with revised documentation and education.

Bereaved families are being asked to meet and contribute to the learning by
sharing their own experiences, in order to inform current and future working to
ensure that openness and support is in place. Initial meetings with family
representatives who wish to be part of this have taken place.

5.6 In addition the Trust will further review the investigation into the death of Sofia.
This review will seek to challenge the statements made and provide a balanced
and sensitive report. This is due to complete by the end of January 2018.

Yours sincerely

PETER LEWIS
Chief Executive

Somerset Safeguarding

_/ Children Board

==

Tony Williams Please ask for: j ial
Senior Coroner for Somerset Sally Halls
Fax: Email:

Sent by email to:
Coroner@somerset.gov.uk

Your reference: Our reference:
SH/jmr

22" November 2017

Dear Mr Williams,

Thank you for sending Somerset Safeguarding Children Board a copy of your Regulation
28 report, dated 4th October 2017, in respect of the death of Sofia Ann Legg, aged 14
years, who died on 26th September 2016.

For your information, Somerset Safeguarding Children Board is proposing to commission a
thematic learning review (additional to the CDOP process) to establish whether there are
any specific issues that need to be addressed by organisations in Somerset with regard to
preventing such tragic occurrences in the future. This is because of the Board's concern
about this and a small number of similar incidents of young people taking their own life
over recent months and years.

Yours sincerely

Sally Halls,
Independent Chair,

Somerset Safeguarding Children Board
Director of Children’s Services, Somerset County Council

ce.
ae: Director of Quality and Safety, Somerset Clinical
issioning Group
Chief Nurse, Taunton and Somerset NHS Foundation Trust and

Somerset Partnership NHS Foundation Trust (fao Head of Service, CAMHS)

Somerset Safeguarding Children Board, PP2 B3W, County Hall, Taunton TA1 4DY