Ryan Vout

Bod From Jackie Doyle-Price MP

D ep artm ent Parliamentary Under Secretary of State for Mental Health and Inequalities
of Health 39 Victoria Street
London

SW1H OEU

020 7210 4850

Our reference: PFD-1112047
23 FEB 2913
Mr Andrew McNamara
HM Assistant Coroner, Nottinghamshire
Office and Main Court
The Council House
Old Market Square
Nottingham NG1 2DT

Seo, Me hac vomeve

Thank you for your letter of 18 December to the Secretary of State about the death of
Mr Ryan James Vout. I am responding as minister with responsibility for mental
health.

I was very saddened to read of the circumstances surrounding Mr Vout’s death.
Please pass my condolences to his family and loved ones. I appreciate this must be a
very difficult time for them.

Your report raises three areas of concern. Firstly, around discharge planning;
secondly, the ability to pre-book appropriate transport for conveyance of a patient
being sectioned under the Mental Health Act; and thirdly, the risk assessment
conducted by the police prior to the exercise of a section 135 warrant.

The latter area of concern is one for the police and I will not address this in my
response.

The other two areas of concern fall to health services. The matters raised are
operational and relate to the Nottinghamshire Healthcare NHS Foundation Trust and
the ambulance service and I trust the responses you will receive from those
organisations will be helpful. My response will focus on the national policy
expectations in relation to the issues you have raised.

With regard to discharge planning from inpatient to community care, I have noted
your concerns around the lack of co-ordinated discharge planning in Mr Vout’s case.
This is clearly regrettable.

Learning lessons where things have gone wrong is essential to ensuring the NHS
provides safe, high quality care. I am advised that the Nottinghamshire Healthcare
NHS Foundation Trust conducted a serious incident investigation that identified a
number of recommendations for learning from this case. I understand the report of
the investigation has been shared with you, and I am assured that Nottingham City
Clinical Commissioning Group (CCG) is liaising with the Trust through its quality
assurance processes.

In terms of national policy, I would like to assure you that we recognise that robust
discharge planning and follow-up support are crucial to ensuring that people have a
good experience of acute mental health care and can be stepped down to the most
appropriate and least restrictive setting for their needs, safely and at the earliest
opportunity.

The Mental Health Act 1983 Code of Practice, whilst being statutory guidance for
providers of services under the Act, should be observed as best practice by all
commissioners and providers of services to people who may become subject to the
Act. We revised the Code of Practice in 2015 and set out guiding principles to
improve the care for patients. The principles include mental health providers
involving patients’ carers and families in decisions about their care. The Code of
Practice also makes it clear that we expect multi-disciplinary teams involved in care
planning and discharge to include all relevant professionals and agencies which may
be involved in a person’s care.

Additionally, over the last 12 months, NHS England has been working closely with
the National Collaborating Centre for Mental Health and a number of local areas to
identify and share best practice in relation to the acute mental health care pathway,

which includes well-managed discharge.

The following principles have been identified and are now being communicated as
key components of robust discharge processes:

e ifthe person agrees, and in accordance with the Mental Capacity Act 2005,
Mental Health Act 1983 (amended 2007) and Care Act 2014, their family,
carers and significant others should be engaged throughout their care. They
should be involved in care decisions from the very start of the pathway through
to the end of care and given information about the care plan, discharge
decisions and changes to treatment. Families and carers should be supported
throughout;

ae

Department
of Health

e the discharge destination should be considered early on in admission to acute
care, particularly for people with housing needs, and everyone should have a
clear discharge plan in place, including an estimated date;

e all inpatient wards should have an effective interface with other services,
particularly community-based acute mental health services, to facilitate access,
transfer of care and discharge back into the community; and

e crisis resolution and home treatment teams operating in line with the evidence-
base should have the means to facilitate safe discharge from inpatient settings
and support people to go home on leave from wards.

With regard to the second area of concern, that of the conveyance of patients being
sectioned under the Mental Health Act, I should point out that the Mental Health
Code of Practice is clear that local policies should be agreed between services:

16.30 Local authorities, NHS commissioners, hospitals, police forces and ambulance
services should have local partnerships in place to deal with people experiencing
mental health crises. The objective of local partnership arrangements is to ensure
the people experiencing mental health crises receive the right medical care from the
most appropriate health agencies as soon as possible. The police will often, due to
the nature of their role, be the first point of contact for individuals in crisis but it is
crucial that people experiencing mental health crises access appropriate health
services at the earliest opportunity.

16.31 It is also important to ensure that a jointly agreed local policy is in place
governing all aspects of the use of section 135 and section 136. Good practice
depends on a number of factors. For example:

e local authorities, hospitals, NHS commissioners, police forces and ambulance
services Should ensure that they have a clear and jointly agreed policy for use
of the powers under sections 135 and 136, as well as the operation of agreed
places of safety within their localities;

® all professionals involved in implementation of the powers should understand
them and their purpose, the roles and responsibilities of other agencies
involved and follow the local policy;

e professionals involved in implementation of the powers should receive the
necessary training to be able to carry out fully the role ascribed to their
agency; and

e the parties to the local policy should meet regularly to discuss its effectiveness
in the light of experience and review the policy where necessary, and partner
agencies should decide when relevant information about specific cases can be
shared between them for the purposes of safeguarding the person and the
protection of others, if there is thought to be a risk of harm.

The Code of Practice is available at:

www.gov.uk/government/uploads/system/uploads/attachment_data/file/28 1242/3635
3_Mental_ Health Crisis_accessible.pdf.

You may also be aware that we launched the Mental Health Crisis Care Concordat in
2014 which has been signed by all services, including the police service and the
NHS, involved in providing care for people who may experience a mental health
crisis. The Crisis Care Concordat is clear that every local area should have agreed
clear protocols for local services responding to a mental health crisis which clearly
identify roles and responsibilities. Every local area has a Mental Health Crisis Care
Concordat Action Plan in place and we continue to work with these areas to embed
and improve their plans.

You will appreciate that arrangements within Nottinghamshire are a matter for local
NHS commissioners and providers and the police service to determine.

Finally, as you may be aware, the Government has commissioned an independent
review of mental health legislation and practice to tackle the issue of mental health
detention.

Professor Sir Simon Wessely, former President of the Royal College of Psychiatrists,
will lead the review which will deliver recommendations for change to the
Government. Sir Simon will look at the evidence, review practice, and above all
consider the needs of service users and their families, and how best the system can
help and support them. He will identify improvements in how the Act is used in
practice, as well as how we might need to change the Act itself. Vice Chairs will be
appointed to work with Sir Simon and ensure the leadership of the review has
comprehensive professional expertise whilst also being representative of service users
and others affected by the Mental Health Act.

The review is currently gathering evidence with a view to producing an interim report
on its priorities by the spring, and a full report by the autumn, with recommendations
to Government and other relevant organisations.

ae

Department
of Health

Further detail on the independent review, including its Terms of Reference, are
available at www.gov.uk/government/news/prime-minister-announces-review-to-
tackle-detention-of-those-with-mental-ill-health.

I hope this information is helpful. Thank you for bringing the circumstances of Mr
Vout’s death to our attention.

“JO

JACKIE DOYLE-PRICE

CONFIDENTIAL
Our Ref RH/NH/Vout
6 February 2018

Mr A McNamara

HM Assistant Coroner
Office and Main Court
The Council House
Old Market Square
Nottingham

NG1 2DT

Dear Mr McNamara

East Midlands

Ambulance Service
NHS Trust

Trust Headquarters

1 Horizon Place

Mellors Way

Nottingham Business Park
Nottingham

NG8 6PY

Telephone: 0115 884 5000
Fax: 0115 884 5001
Website: www.emas.nhs.uk

Re: Report to Prevent Future Deaths: Mr Ryan James Vout (deceased)

Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 6 November
2017 (received on 18 December 2017), bringing to my attention HM Coroner's concerns
arising from the Inquest into the death of Mr Ryan James Vout.

| would like to assure you that within the East Midlands Ambulance Service (EMAS) all
matters related to patient safety are taken extremely seriously. In particular, matters
arising from Coroners’ Inquests from which lessons can be learnt, including Prevention
of Future Death Reports, are discussed within the Incident Review Group and Lessons

Learned Group.

This process has been applied to the Prevention of Future Death Report pertaining to
the Inquest into the death of Mr Ryan James Vout.

Emergency care | Urgent care | We care

The MATTER OF CONCERN specific to EMAS is as follows:

e The inability to pre-arrange attendance of an ambulance when police officers
exercise a 5.135 (1) MHA Act 1983 warrant

All interested parties, especially the police, expressed frustration that within
Nottinghamshire there is no alternative, dedicated, fully equipped ambulance,
capable of being pre-booked for attendances such as the one in this case for
the execution of s135 MHA 1983 warrants (or detention under s136 MHA 1983).

| set out below the actions that EMAS proposes to take and our response to HM
Coroner's concerns as detailed in the PFD notice.

EMAS acknowledges its responsibility to enact a duty of care to all patients.

The ability to pre-book an ambulance to attend an incident with a police officer or
approved mental health practitioner (AMHP) to exercise a Section 135 or Section 136
warrant under the 1983 Mental Health Act has always been available. The conflicting
priorities of operational demand often require EMAS to prioritise patients according to
the presenting complaint. Therefore clinical presentations often take precedence and
need a more urgent response.

As there are conflicting challenges around response times, EMAS recognises the
importance of ensuring that patients presenting with acute psychotic disorders also get
an urgent response. The Trust plan is to adapt its operating model with an urgent care
tier, which will enable patients with a more urgent care requirement, to be responded
to appropriately and safely in a timely manner. This will go live across all five counties
on 2 April 2018 and should allow us to better meet the needs of our patients with
mental health disorders.

We continue to work collaboratively with our mental health providers and
stakeholders to improve our services for patients with mental health problems.

| hope that the measures set out in this letter provides you with the appropriate level
of assurance in relation to EMAS’ commitment to continuous improvement in the
management of mental health issues.

Please do not hesitate to contact me should you require any additional information, or
any clarification, in connection with the above.

Yours sincerely

Richard Henderson
Chief Executive

##MAILMERGE - Do not delete this text or change the colour from white 

This matter is being dealt with by: 

Reference: 
T 0115 977 4876 
E 
W nottinghamshire.gov.uk 

Private and Confidential 
To be opened by addressee only 

Mr McNamara 
Assistant Coroner 
HM Coroner for Nottinghamshire 
The Council House 
Old Market Square 
Nottingham        NG1 2DT 

Dear Mr McNamara 

12th February 2018 

Re:  

In the matter of the death of RYAN JAMES VOUT 
Regulation 28: Report to Prevent Future Deaths 

We  write on  behalf  of Nottinghamshire  County  Council  (“the  Council”)  in  response  to  the 
Regulation  28  Report to  Prevent  Future  Deaths  issued  on  18  December  2017  (“the  PFD 
Report”). 

The  Council  has  carefully  considered  the  PFD  Report  and  in  particular  the  matters  of 
concern raised by the Coroner and would respond to these specific concerns as follows: 

(1) The  lack  of  a  co-ordinated  discharge  from  in-patient  psychiatric  care  into  the 
community, in particular the failure of appropriate professionals from hospital and 
community to liaise and for family to be informed as a pre-requisite for discharge; 

The Council’s response: 

There is an established multi-disciplinary process for referring from the hospital ward to 
the  social  care  Community  Mental  Health  Teams.  This  ensures  that  a  person  is 
considered for social care services to assist with safe discharge. People who are eligible 
for s117 aftercare services and who need follow up services in the community are also 
subject  to  an  assessment  to  consider  joint  responsibility  for  funding  and  services 
between the Local Authority (LA) and the relevant Clinical Commissioning Group (CCG).  

(2) The  inability  to  pre-arrange  attendance  of  an  ambulance  when  police  officers 

exercise a s.135 (1) MHA Act 1983 warrant; 

The Council’s response 

The current process in place for an AMHP to call EMAS to arrange for an ambulance in 
this situation is to call after the assessment is completed.  The response time should be 
one hour. 

Continued/….. 

Nottinghamshire County Council, County Hall, West Bridgford, Nottingham NG2 7QP 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Page 2 

As EMAS response times have been taking longer, the general issue of how to improve 
conveyance and ambulance provision for Mental Health Act work has been escalated to 
the Crisis Concordat Task and Finish Group and has also been discussed with health 
commissioners via the East Midlands Local Authority Mental Health Leads Networks.  

The  Crisis  Concordat  work  is  exploring  whether  the  Trust  could  provide  a  separate 
dedicated  conveyance  service  for  people  detained  under  the  Mental  Health  Act.  This 
would  allow  the  AMHPs  to  pre-book  an  ambulance  for  the  purposes  of  s135  (1). 
Discussions are underway about how this could be commissioned and funded.    

Due to further recent significant demand for EMAS services over the winter period, the 
lead  Clinical  Commissioning  Group  (CCG)  Commissioners for  the EMAS  contract  are 
currently exploring, (with advise from the  Nottinghamshire County Council AMHP team), 
an interim solution utilising short term winter pressures money.   The aim is to identify a 
rapid solution that avoid delays for all organisations and protects the patient, until the 
above work is completed. 

(3) The lack of formality to the ‘briefing’ or risk assessment exercise before officers 

enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant. 

The Council’s response 

A more robust process for communicating demographics and essential risk information 
in relation to the s135 (1) warrant between AMHPs and the Police has been developed 
jointly.  

This will include a typewritten document that is completed initially for the magistrate and 
then sent electronically by the AMHP when requesting police assistance under s.135 (1).  
This  will  ensure  that  clear  communication  to  all  agencies  including  recent  risk 
assessments  and  environmental  factors  are  taken  in  to  account  with  regard  to  the 
specifics of the situation. 

Should you require any further information or clarification regarding the above, please come 
back to us. 

Yours sincerely 

Service Director – Mid Nottinghamshire 
Nottinghamshire County Council