Thomas Wall

alco

Brighton & Hove
City Council

Private and Confidential
Miss Veronica Hamilton-Deeley LLB
Her Majesty’s Senior Coroner for the

City of Brighton

Coroner's Office

Woodvale

Lewes Road

Brighton

BN2 3QB
Date: —
Phone:
e-mail:

Dear Ms Hamilton-Deeley

Re: The late Thomas Wall Regulation 28 report

Public Health

Brighton & Hove City

Council

Second Floor, Hove Town Hall
Norton Road

HOVE

BN3 3BQ

26th September 2017
(01273) 292115

Brighton & Hove City Council was not named in the Regulation 28 report for the late Mr
Wall, but as Brighton & Hove City Council’s Public Health department is the responsible
commissioner for the adult and substance misuse in-patient detoxification beds | have
been asked to respond as well to the report. | will address each statement in turn.

No local inpatient bed detoxification service

In December 2015 Sussex Partnership NHS Foundation Trust gave notice that they would
be terminating their substance misuse in-patient detoxification service from the 31st March
2016. The in-patient detoxification services at Mill View Hospital were no longer financially
or Clinically viable, following the withdrawal of London Boroughs from their contract with
Sussex Partnership NHS Foundation Trust. There was no alternative equivalent service in
Brighton and Hove. The.public health department elected to work with Cranstoun, the lead
provider in the Pavilions Community Substance Misuse Services partnership, and to refer
patients to their inpatient detoxification unit in London. Cranstoun have been providing this
service from the City Roads location in London for a significant period of time, and patients
come from many areas of the country. It is important to note that the inpatient
detoxification beds were not included in the re-procurement of the community drug and

alcohol service.

The change to the arrangements was presented to the Health and Wellbeing Board on
15th March 2016. An update was provided to the Overview and Scrutiny Committee on
the 23rd March 2016 and an update provided to the Health Overview and Sonutiny

Committee on 7th December 2016.

A considerable amount of preparation work took place before the new service was

Acting Director of Public Health
Web: www.brighton-hove.gov.uk
Telephone: (01273) 290000

Printed on recycled, chlorine-free paper

i

Public Health
cde chy Brighton & Hove City
Se Council

Brighton & Hove Second Floor, Hove Town Hall
City Council Norton Road
HOVE
BN3 38Q

launched. This included service user consultation on the key areas of concern, patient
pathway planning and visits to the new service base. Although service users from Brighton
and Hove now have to travel outside of the city to access inpatient detoxification services
this is similar to what happens in other areas of the country, as local availability of this type
of service is limited. The average length of stay is ten days. Contact with the outside world
is usually restricted when a person is undergoing detoxification, and therefore being
situated in an area that is not their home city may make detoxification more successful.

After detoxification the individual returns to Brighton and Hove,.and is supported to
continue their recovery by linking to the existing local recovery community.

Waiting times for inpatient detoxification

In general patients are admitted to City Roads within ten days of having their assessment
by the Pavilions doctor. All referrals to City Roads are reviewed at a multidisciplinary team
meeting where a pre-admission checklist is completed. This includes service preparation
work to ensure that an individual understands what will be required of them once they are
in residence at the unit. This preparation work aims to ensure that people are referred at a
point in their recovery journey where they are most likely to be successful. The aftercare
support plan for once a person has successfully completed detoxification is also developed
before the individual goes to City Road. This helps to ensure that the ongoing support a
person will need to continue their recovery is in place.

If following the assessment it is felt that City Road is not suitable for the client an
alternative provider is offered. Since the closure of the inpatient beds in Brighton and
Hove, East Sussex refer their clients to a unit in Tunbridge Wells and West Sussex use a
range of providers including Cranstoun.

The number of patients with Dual Diagnosis

This is not straightforward. NICE guideline NG58 “Coexisting severe mental illness and
substance misuse: community health and social care services” published in November
2016 states that “It is not clear how many people in the UK have a coexisting severe
mental illness and misuse substances, partly because some people in this group do not
use services or get relevant care or treatment”.

The evidence review used to prepare the NICE guidance states “Dual diagnosis refers to
people with a severe mental illness (including schizophrenia, schizotypal and delusional
disorders, bipolar affective disorder and severe depressive episodes with or without
psychotic episodes) combined with misuse of substances (the use of legal or illicit drugs,
including alcohol and medicine, in a way that causes mental or physical damage). Recent
studies have estimated prevalence rates of 20-37% in secondary mental health services
and 6-15% in substance misuse settings. However, methodological challenges including
differing definitions of dual diagnosis, varying timescales for assessing comorbidity,

Public Health

Brighton & Hove City
Council
— Second Fioor, Hove Town Hall

Brighton & Hove Norton Road
City Council HOVE
BN3 3BQ

difficulties with diagnosis including diagnostic overshadowing, and the lack of a good
theoretical model of the association between severe mental illness and substance misuse,
mean that it is still unclear how many people in the UK have a severe mental illness and
comorbid substance misuse problems.

To estimate the number of local people living with dual diagnosis, data for the period
01/09/2016 to 31/08/2017 from the local drug and alcohol treatment services is provided.
To complicate matters further the definition used in the data set changed on ist April 2017.
Until the change the question asked was “Does the client have a Dual Diagnosis? (Is the
client currently receiving care from mental health services for reasons other than
substance misuse).” From 01/04/2017 the question was “Does the client have a mental
health treatment need?” Using the former definition results in approximately one in five
(340/1914) local service users having a dual diagnosis. With the later definition this
increases to two in every five (223/540) service users having a mental health treatment
need. Overall for the year 563 (23%) of the 2454 people assessed had a dual diagnosis or
mental health treatment need.

Please let me know if you require any further information.

Yours sincerely

a

Acting Director of Public Health

Acting Director of Public Health
Web: www.brighton-hove.gov.uk
Telephone: (01273) 290000

Printed on recycled, chlorine-free paper

Brighton and Hove
linical Commissioning Group

Private and Confidential Hove Town Hall
Ms Veronica Hamilton-Deeley Norton Road
HM Senior Coroner for Brighton & Hove Hove
The Coroner's Office BN3 4AH
Woodvale
Lewes Road Tel: 01273 238783
Web: www. brightonandhoveccg.nhs.uk
28 September 2017

Dear Ms Hamilton-Deeley
The late Thomas Wall

Thank you for your recent Regulation 28 Report arising out of the sad death of the above.

As a CCG we are very keen to reflect on the services we commission with a view to making
improvements and avoiding future patient harm. Brighton & Hove City Council’s Public Health
department is the responsible commissioner for the adult and substance misuse in-patient
detoxification beds. [ interim Director of Public Health has therefore
provided a reply although he and his team were not named in the report.

A Joint Strategic Needs Assessment for Dual Diagnosis was completed in 2012 and made a
number of recommendations for improving service response to those with a Dual Diagnosis
including greater recognition, identification and recording of Dual Diagnosis (DD) to
understand the prevalence and need within the city and to ensure improved response to DD
and the delivery of strengthened integrated care and service delivery across agencies.

A multi-agency Steering Group with representation from service users, housing and hostel
providers, commissioners and providers of primary and secondary care mental health and
alcohol and substance misuse services has been meeting since the Joint- Strategic | Needs
Assessment publication to take forward these recommendations.

Progress has been made in a number of areas including the implementation of a Dual
Diagnosis integrated model through the re-procurement of substance misuse services. 3.5
whole-time equivalent DD workers are now co-located with mental health services to increase
joint working, engagement with support, and ensure smooth transition. Clinicians within
substance misuse services can now access Sussex Partnership electronic patient records
and vice versa. There are now agreed pathways between the services with regular meetings
where complex cases are discussed to ensure that people receive appropriate support and
care and do not fall between the gaps.

: Better. health for our city

Agreed referral and care pathway protocols are now in place for those with dual needs
including increased awareness and training and increased access to primary care mental
health support for those with dual needs which are no longer an automatic exclusion. The
new service specification for primary mental health services supports a more proactive
approach.

Provision of accommodation with support has been increased for those with high support
needs, including those with DD and the inclusion of DD in medium support housing. The
Fulfilling Lives project run by Brighton Housing Trust is focussed on patients with multiple and
complex needs

There has been a successful Department for Communities and Local Government bid for
Rough Sleepers, which will enable an additional Homeless DD worker to be located within the
Mental Health Homeless team.

Current Measures

There has been an increase in the number of people in contact with both secondary Mental
Health and Substance Misuse services measured using the Public Health England fingertips
tool. Service user feedback is regularly reviewed with the most recent Service User report
being produced in May 2017. Drug Related Death audits are being undertaken — examination
of cases to review if people still falling through gaps in services. The next meeting of the Dual
Diagnosis Steering Group will review the latest Public Health England guidance for better
care of people with co-occurring mental health and alcohol and drug use conditions and the
local Service User report.

Despite the above | am aware the service needs ongoing review and development. Our
mental health commissioning team are aware of this case and | will ensure that your [and the
CCGs] concerns are fed back and discussed at the next Dual Diagnosis Steering Group
meeting and will also ensure the CCG has direct discussions with the provider.

| hope this is helpful and please do not hesitate to contact me if any further information is of
help.

Yours sincerely

CCG Clinical Chair
NHS Brighton & Hove Clinical Commissioning Group

A member of:

Association of UK University Hospitals Sussex Partnership

NHS Foundation Trust

Your ref: VHD/TS
Our Ref: INQ/17/031

21 August 2017

Miss Veronica Hamilton-Deeley LLB ouasveen
Her Majesty’s Senior Coroner for the City of Brighton & Hove
' . Arundel Road

The Coroner's Office .
Woodvale Worthing
L Road West Sussex

ewes BN13 3EP
Brighton
BN2 3QB

Dear Miss Hamilton-Deeley
Re: The Late Thomas Wall

Thank you for your letter enclosing your Regulation 28 Report of 2 August 2017, to the
Clinical Commissioning Group, Sussex Partnership NHS Foundation Trust, and Pavilions.

My sincere condolences and sympathies go to Mr Wall’s family and friends on the sad loss
of Mr Wall. | was struck by the text message sent to Mr Wall to his supportive ex-wife and
can only begin imagine the pain felt.

We as a Trust share your concerns that there is no local inpatient detox facility, patients,
family, friends and carers are having to travel to London, and are subject to long waiting
lists. It is important that there is a collaborative approach taken to dual diagnosis patients
and we try to achieve this by working closely with our partner organisations such as _
Pavilions. As the inquest heard, Mr Wall had a joint assessment with Sussex Partnership
NHS Foundation Trust and Pavilions and was open to both services for support and
treatment.

The commissioning of local substance misuse services is undertaken by Brighton and
Hove City Council. The iocal substance misuse services in Brighton and Hove were being
provided by Sussex Partnership NHS Foundation Trust. In 2014 the service was put out to
a tendering process by Brighton and Hove City Council. Sussex Partnership put in a full
proposal and bid to keep the local substance misuse services as we recognise the value
for patients and their families for services to be local to their homes, and the high number
of service users who have mental health needs and substance misuse needs.
Unfortunately, Sussex Partnership NHS Foundation Trust were not chosen by the
commissioners of the service, Brighton and Hove City Council, to continue to provide this
service. Sadly, it is not within our gift to provide these services if we are not commissioned
to provide them by the commissioners. We would welcome you to write to Brighton and
Hove City Council with your concerns.

interim Chair: Richard Bayley Chief Executive: Samantha Allen
Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP

www.sussexpartnership.nhs.uk

A teaching trust of Brighton and Sussex Medical School

Head of Legal Services, briefed me fully on the inquest of Mr Wall and
| was heartened that you praised the substantial input to Mr Wall's care from the Trust’s
Assessment and Treatment Service, the Mental Health Rapid Response Service, the
General Practitioner and Pavilions and acknowledged the difficulties faced by these
services as mental health and substance misuse services are not managed by one local
provider such as the Trust. Following the inquest, ensured that the informative
Public Health England guidance shared at the inquest by] was provided
to the Clinical and Service Director for Brighton and Hove, NS and the
General Manager for Community Services for Brighton and Hove J to ensure
their teams are aware of the recent guidance to aid them in delivering services.

Thank you once again for your report and for highlighting your concerns, we welcome your
input in assisting us to provide a more collaborative approach to dual diagnosis patients in
Brighton and Hove.

Yours sincerely
” Yoo S : 7
Ct,
- Sam Allen
Chief Executive