Stuart Campbell

Addiction

Dependency
Solutions A progressive 21st century addiction charity

Service Delivery Director
R ECE IVE ADS (Addiction Dependency Solutions)
13 DEC 2017 135-141 Oldham Street
Ch Manchester
www ee Nk M4 1LN

11" December 2017

Alison Mutch OBE, Coroner
The Coroner's Office

The Coroner’s Court

1 Mount Tabor

Stockport

SK1 3AG

Dear Ms Mutch,

Regulation 28 Report to Prevent Future Deaths following the inquest of Stuart Michael Campbell
who died, at 41 Agecroft Road, Bredbury, Stockport, on 5th March 2017.

1. | am writing to you to respond to the matters of concern raised by your investigation into the
circumstances surrounding the death of Stuart Campbell. On 9! March 2017 you commenced your
investigation into Stuart's death and this concluded on 28! September 2017.

2. As you are aware, Addiction Dependency Solutions (ADS) is currently the lead provider for a
partnership of organisations delivering One Recovery Oldham Substance Misuse Services. The
contract for the delivery of services was awarded by Oldham MBC in April 2015. The One Recovery
Partnership led by ADS includes Pennine Care NHS Foundation Trust, Sodexo Justice Services and
ACORN Recovery Projects, which is part of the Calico Housing Group.

3. ADS takes very seriously its responsibility to act swiftly and across the whole organisation on what
it learns from deaths in our care. Our response focuses on the operational delivery areas for which
we are responsible. Additionally our response will attempt to explain how we will make the changes
you seek and use our role as lead provider to cascade learning throughout ADS and lever changes
with our sub-contractors.

4. During your inquiry you highlighted two principle matters of concern for Addiction Dependency
Solutions (ADS). The inquest was told that the shared care standard operating protocol between
ADS and Pennine Care NHS Foundation Trust had an escalation policy to be followed where an
ADS worker felt the needs of an individual could not be met in shared care.

Patrons: Mr} Kennedy, CBE, DL Mr N Stoller, BCE, CStJ, DL Lord Lieutenant Warren Smith JP
Chairman: Janusz Karczewski-Slowikowski Chief Executive: Lady Rhona Bradley, OL

Head Office: 135-141 Oldham Street, Manchester M4 1LN

20161 8312400 #5 01 2 1 wi headoffice@adsolutions.orp.uk
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5. It is acknowledged that this escalation had not taken place in Stuart’s care and case management.
The GP (Responsible Medical Officer) had not seen Stuart in the 3 months before his death and it
was unclear to you how shared care discussions were facilitated and documented.

6. Furthermore, it was also unclear to you what guidance was available to ADS workers and you ask
for clarification regarding the provision for clinical support for ADS workers.

7. As you know, Stuart Campbell was seen in One Recovery by an ADS worker from 24 November
2016 to his death in on 5 March 2017. His care was delivered as part of the shared care
arrangement with General Practices and Pennine Care NHS Foundation Trust. Stuart had been
previously treated by Pennine Care NHS Foundation Trust since 1993. His care was transferred to
ADS from Pennine Care as part of making changes to the shared care offer to ensure more
integrated partnership delivery across Oldham.

8. It should perhaps be explained that GPs play a pivotal role for patients who are considered suitable
to receive their drug treatment in primary care. In these cases, the GP may be the keyworker or that
role can be provided, as in Stuart's care, by a drug worker supporting the GP in a shared care
arrangement. The keyworker should still work within the recommended treatment and recovery care
planning framework. The treatment and recovery care plan is based on a comprehensive
assessment and describes how the specific roles, responsibilities and actions of the GP, the shared
care worker and any others involved, will be shared in delivering coordinated care in this setting.

9. Shared responsibilities will often include monitoring of compliance and ensuring communication and
continuity of care. The RMO/GP generally leads on prescribing interventions, changes and additions
to medication, and addressing other healthcare needs. A shared care worker generally leads on
monitoring progress against treatment goals, developing a holistic treatment plan and ensuring
multidisciplinary discussion when appropriate. For GPs working at a more specialist level (for
example, a GP with a special interest) the role may be somewhat different but in all cases this should
be clear in the treatment and recovery care plan.

10.A standard operating protocol was developed by clinical staff (Clinical Nurse Manager) from Pennine
Care NHS Trust prior to transfer which detailed the mechanisms used for managing this change in
working practice. This standard operating protocol mirrored relevant clinical guidelines, including
relevant National Institute for Health and Care Excellence guidance and the 2017 update to Drug
misuse and dependence: UK guidelines on clinical management.

1

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-A number of shared care clinics were identified as suitable for transfer to ADS. Three senior ADS
workers were identified to manage these clinics alongside the primary care Responsible Medical
Officer (RMO). Joint working, shadowing and a phased hand over of clinical care commenced in the
first week of October 2016 (18 months after contract award) with 2 full day clinics in Failsworth and
Royton. The Responsible Medical Officer for the clinical care of shared care clients is the General
Practitioner regardless of which partner operates the clinic.

Patrons: Mr) Kennedy, CBE, DL Mr N Stoller, BCE, CStJ,DL Lord Lieutenant Warren Smith JP
Chairman: Janusz Karczewski-Slowikowski Chief Executive: Lady Rhona Bradley, DL
Head Office: 135-141 Oldham Street, Manchester M4 1LN

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12. Appropriately sharing information is recognised as a key factor in supporting the safety and wellbeing
of patients. As part of this transfer a copy case summary file for each case was given to the relevant
ADS worker taking over the clinic. This comprised; a clinical case summary, 6 months copies of
current case notes, a risk assessment and care plan and any recent relevant correspondence sent
or received about the service user. Contacts and case management records and drug screening
results are recorded on the GP Primary Healthcare IT system (EMIS) which the ADS workers have
access to as well as on the core service case management system.

13.The three ADS shared care workers are co-located in Oldham with Pennine Care medical and
nursing staff and all ADS staff have ad hoc access to advice and guidance as required. All ADS
shared care had undertaken the Pennine Care NHS Foundation Trust Competency Assessment
Framework (CAF) training for giving out prescriptions and completed the relevant self-assessment
Paperwork before the clinics were transferred.

14.The ADS workers had also been trained in taking urine samples and doing instant drug testing.
Clinical notes for all clients transferred to the ADS worker shared care clinics were all recorded on
the ADS case management system (Nebula).

15. The standard operating protocol clarified how to manage patients who became unstable in their drug
use and who might require transfer back to core services. In these specific cases, a clinical
discussion should take place with the RMO (GP) about the need to transfer back to core services
before a referral is made. A further clinical discussion should then be had with a Pennine Care NHS
Trust medical officer regarding suitability for transfer back to core services. The client would then be
booked into a new starter session at the secondary care core service for a joint review with both the
ADS shared care worker and Pennine Care staff.

16.When clinical care is transferred back to the secondary care core service, the keyworker and case
management responsibility changes to Pennine Care NHS Trust workers along with a transfer letter
to the prescribing GP. The RMO for this phase of treatment reverts to Pennine Care NHS Trust
under its governance systems until the client is transferred back to shared care where the GP would
resume medical responsibility for the substance misuse treatment.

17. There is no requirement for ADS staff to complete any additional paperwork to transfer a service
user back to Pennine Care. Case notes continue to be kept on the case management system by
Pennine Care staff. A risk assessment and care plan is placed on the case management system.
ADS staff should give the prescription records to Pennine staff for future management. If the patient
has previously been open to Pennine Care, their notes are retrieved from archive to ensure that any
historical risk and clinical information informs the future treatment episode.

18. The standard operating protocol also covers management of controlled drugs and prescriptions and
it specifies how to manage patients who are being removed from their GP practice due to challenging

Patrons: Mr J Kennedy, CBE,DL Mr N Stoller, BCE, CStJ,DL Lord Lieutenant Warren Smith JP
Chairman: Janusz Karczewski-Slowikowski Chief Executive: Lady Rhona Bradley, DL

Head Office: 135-141 Oldham Street, Manchester M4 1LN

J (161 8312400 94 0161 832 7971 doffice@adsalutions org uk
© www adsolutions.org uk
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behaviour. It details procedures to follow when patients miss their appointment in the GP clinic or
contact to say they can't attend and it covers the transfer of clients from core service to GP shared
care clinics.

19.As part of our detailed response to your concerns ADS will ensure that all our shared care staff
receive additional training and re-training with regard to the standard operating protocol. We will re-
train all staff in managing shared care and in the escalation procedure. This will also include specific
guidance on multi-disciplinary shared care discussions. ADS will ensure that this re-training is
completed by 20" December 2017.

20.ADS will also undertake to carry out full care plan reviews with all shared care patients across the 2
full day clinics in Failsworth and Royton (59 patients in total) in conjunction with the local GP/RMOs
and this will be completed by 31% March 2018.

21.ADS has re-negotiated with the Pennine Care NHS Trust senior manager in Oldham One Recovery
to provide ongoing clinical supervision via medical and nursing staff for all 3 ADS shared care staff
on a monthly basis. This will ensure regular ongoing opportunities for case reviews and discussions
for clinical advice and planning with medical specialists from 30 November 2017.

22.Furthermore, ADS has commissioned Applied Suicide Intervention Skills Training (ASIST) across
the organisation. ASIST is a two-day interactive workshop in suicide first aid. It teaches participants
to recognise when someone may have thoughts of suicide and work with them to create a plan that
will support their immediate safety. Studies show that the ASIST methods help reduce suicidal
feelings in those at risk and is a cost-effective way to help address the problem of suicide. It trains
Staff to be suicide alert - identify people who have thoughts of suicide. Understand the reasons
behind thoughts of suicide and the reasons for living. Assess risk and safety - develop a plan to
increase the safety of the person at risk of suicide. Recognise invitations for help and potential
barriers of seeking help. Key ADS staff in Oldham who work in shared care will attend by December
31st 2017.

23.1 have summarised the 4 actions in table form as appendix 1 below. The delivery of these reforms
and actions by ADS in Oldham will be fully completed by 31st March 2018. The implementation
process and timetable has taken into account the fact that the substance misuse contract for Oldham
and Rochdale has now been awarded to Turning Point by Oldham MBC and Rochdale MBC from
1st April 2018.

24.1 wish to re-assure you that we are committed to the delivery of appropriate, safe and effective
services, particularly in relation to the competence of staff to meet and safely manage complex
needs.

25.1 hope that the actions and information we have provided offer you some assurances in relation to
the findings of your investigations. The areas you have highlighted for the prevention of future deaths

4.

Patrons: Mr! Kennedy, CBE, DL Mr N Stoller, BCE, CStJ,DL Lord Lieutenant Warren Smith JP
Chairman: Janusz Karczewski-Slowikowskt Chief Executive: Lady Rhona Bradley, DL
Head Office: 135-141 Oldham Street, Manchester M4 LLN

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will be cascaded throughout ADS via our Board of Trustees and via our Safeguarding and
Effectiveness Committee and shared with all One Recovery sub-contractors. We will also undertake
to share the recommendations and actions with Oldham’s Suicide Prevention Working Group.

26.Your report has prompted action and it is the focus of our continuing commitment to improving
services for the support of vulnerable people.

Yours Sincerely

Chay Cw.
a

Service Delivery Director
cc
Carolyn Wilkins OBE, Chief Executive, Oldham Council

PE ‘on suttant in Pubic Heaith (Health & Wellbeing), Oldham Council

Appendix 1

Action

ADS will ensure that all our shared care | ADS will ensure that this re-training is |
staff receive additional training with regard | completed by 20'" December 2017.
to the standard operating protocol. We will

re-train all staff in managing shared care

and in the escalation procedure. This will

also include specific guidance on

escalation and multi-disciplinary shared

care discussions.

ADS will also undertake to carry out full] ADS will ensure that this will be
care plan reviews with all shared care | completed by 31! March 2018
patients across the 2 full day clinics in

Failsworth and Royton (59 patients in total)

in conjunction with the local GP/RMOs

Patrons: Mr J Kennedy, CBE, DL Mr N Stoller, BCE, CStJ, DL Lord Lieutenant Warren Smith JP
Chairman: Janusz Karczewski-Slowikowski Chief Executive: Lady Rhona Bradley, DL

Head Office: 135-141 Oldham Street, Manchester M4 1LN
OO # 0161 8327971 & doffice@adsolutions org uk
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Dependency
Solutions A progressive 21st century addiction charity

ne, Ci.

ADS has re-negotiated with the Pennine
Care NHS Trust senior manager in Oldham
One Recovery to provide clinical
supervision via medical and nursing staff for
all 3 ADS shared care staff on a monthly
basis.. This will ensure regular ongoing
opportunities for case reviews and
discussions for clinical advice and planning
with medical specialists from  30t
November 2017.

ADS will ensure regular ongoing
opportunities for case reviews and
discussions for clinical advice and ;

planning with medical specialists from |
30" November 2017

ADS will ensure that ADS staff in
Oldham who work in shared care will
attend by December 315 2017.

Furthermore, ADS has commissioned
Applied Suicide Intervention Skills Training
(ASIST) across the organisation. ASIST is
a two-day interactive workshop in suicide
first aid. It teaches participants to recognise
when someone may have thoughts of
suicide and work with them to create a plan
that will support their immediate safety.
Studies show that the ASIST methods help
reduce suicidal feelings in those at risk and
is a cost-effective way to help address the
problem of suicide. It trains staff to be
suicide alert - identify people who have
thoughts of suicide. Understand the
reasons behind thoughts of suicide and the
reasons for living. Assess risk and safety -
develop a plan to increase the safety of the
person at risk of suicide. Recognise
invitations for help and potential barriers of
seeking help.

Patrons: Mr J Kennedy, CBE, DL Mr N Stoller, BCE, CStJ, DL Lord Lieutenant Warren Smith JP
Chairman: Janusz Karczewski-Slowikowski Chief Executive: Lady Rhona Bradley, DL

Head Office: 135-141 Oldham Street, Manchester M4 1LN
J 01618312400 «4 01618 97 eadoffice@adsolutians org.uk

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BBE ADSolutonsUK Requstered Charity Number. 7025 y Reman Cvplanel 1990365 INVESTOR IN PEOPLE

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