Catherine Kennedy

45 APR 1019 INHS|

Greater Manchester

Mental Health
NHS Foundation Trust

PRIVATE & CONFIDENTIAL Trust Headquarters
HM Senior Coroner Mr Nigel Meadows Bury New Road
Manchester City Area Prestwich
HM Coroner’s Court Manchester

M25 3BL

Royal Exchange Building
Exchange Floor, Cross Street
Manchester M2 7EF

Recorded Delivery

Telephone number: 0161 358 1546
www.gmmbh.nhs.uk

11" April 2019

Dear Mr Meadows,
Catherine Anne KENNEDY (Deceased) Regulation 28 Report GMMH Response

Further to The Regulation 28 Report issued to GMMH highlighting your concerns following Ms
Kennedy's Inquest please see below the Trust’s response to these concerns:

To carry. out a thorough review of the issues raised and prepare a coherent and
understandable action plan to deal with the serious failings. The action plan included
within the SUI report does not indicate exactly when all the actions actually identified
in the report should be completed by and to.check that have been so completed. This
is vital to ensure that improvements are made.

GMMH apologise that an up to date action plan was not shared at the time of the inquest, to
demonstrate the action taken to date by the service involved. The action plan has since been
updated and attached with this response.

Based on the concerns raised within Regulation 28 Report, we have developed an action plan
that specifically relates to the points raised by you during Ms Kennedys inquest. These actions
are detailed within the attached action plan.

It is well established psychiatric knowledge that when patients with chronic and
relapsing mental health conditions who disengage with psychiatric and/or general
health services, it is a strong indicator of a deteriorating mental health state Lack of
concordance of medication will put the patient’s mental and physical health at further
risk of serious deterioration.

As part of the re-design of Community Mental Health Services within Manchester, Standard
Operating Procedures (SOP) that describe how our services should function have been
revised and developed over the past 12 months.

The Trust is committed to safeguarding children, young people and vulnerable adults and
requires all staff and volunteers to share this commitment.

Greater Manchester Mental Health NHS Foundation Trust, The Curve, Bury New Road,
Prestwich, Manchester M25 3BL (Tel: 0161 773 9121)

Improving Lives

In addition, a trust-wide procedure is being developed by the Trust to support staff to work
more effectively with service users who present at higher risk of disengagement from services

There appears to be a serious lack of recognition about the importance of her
disengagement with services, and particularly with GMMH. This was not escalated by
anyone; including the deceased’s consultant psychiatrist

Since revision of our Standard Operational Procedures (SOP) across our Manchester
Community Mental Health Teams in September 2018 the Trust continue to monitor how well
the changes to practice are being adopted in the teams Regular audits are carried out to
monitor individual and team practice against standards set out in the SOP

Disengagement of service users has been highlighted within the revised CMHT SOP and has
been incorporated into the Zoning meeting guidance and CMHT Assertive Outreach pathway

The Zoning meeting occurs daily where the care of service users presenting with more acute
needs and/or risks is reviewed and plans developed to manage these needs and monitor them
on a daily basis until the situation resolves or that level of monitoring ts no longer indicated. A
person’s case Is brought to that meeting by their worker and the decision to step the level of
intervention up to this meeting or indeed down is made through MDT discussion; which takes
into account a person’s specific needs and risks, as well as their personalised care plan
informed by their needs and risk assessments

Decisions made within the daily zoning meetings are recorded, therefore service users remain
visible until a situation is resolved and the team are aware of plans in place as this |s also
recorded within the clinical records system (PARIS) This Is a recognised change to practice
since the development of the original RCA action plan (Action 7/ DATIX16310) which
references a meeting where ‘CMHT allocations and concerns’ were discussed and that a
checklist would be in place to ensure the service took the correct response to disengagement

The Assertive Outreach pathway now operates 7 days a week, 365 days a year within each
of our CMHTs It provides a method of reaching and helping people with severe, often complex
and long term mental health problems who do not easily engage or struggle to maintain
contact with services It encourages clinicians to understand reasons why someone may not
engage consistently and interventions on how to respond to this creatively and flexibly This
pathway is being embedded into the Manchester CMHTs, after moving from a standalone city-
wide service

As part of assurance that the changes In processes and practice described above are being
adopted, the content of zoning meetings and their records are to be audited against SOP
practice standards initially monthly and then at least quarterly. Action will be taken by the
CMHT Operational and Team Managers as required based on the outcome of the audits This
will include how well disengagement Is recognised and responded to in comparison to practice
guidance within the SOP

In addition to revisions to the CMHT SOP, guidance on how to respond to missed contacts or
disengagement has been incorporated into the 7 Day Follow Up Procedure, where teams
ensure face to face contact is made with a person during the 7 day period immediately
following discharge This is monitored weekly within each division at a service level and any

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occasions where this Is not done, this is specifically investigated to understand if the person
Is safe and well and what further action Is required by the Trust

Furthermore, a trust-wide task and finish group has been set up and is in the process of
developing procedural guidance applicable to all GMMH services on how to respond to
disengagement This ts with the aim of providing consistency in practice across all of our
services and we anticipate this will be a standalone procedure, referenced within all service
operational procedures

There were missed opportunities to obtain information and liaise with the GP practice

We recognise that as communication did not occur consistently or at necessary points in time,
this resulted in missed opportunities to use any information from Ms Kennedys GP to inform
how we should have responded to her disengagement

Standards expected within practice are now described within the revised CMHT SOP, in
relation to the need to communicate to GPs and referrers at key points in a person’s care
Specifically, when a referral is triaged, following assessment, sharing of care and treatment
plans as needs changes, transfers between services and finally at discharge

A referral tracker document Is now used within clinical meetings enables service users to
remain visible to the Team Manager and Is a means of checking that the required steps in
their care that should be completed are not missed, including communication

The maintenance of the tracker Is reviewed daily at the team level by the Team Manager and
monthly by the CMHT Operational Manager. Completion of any outstanding actions that arise
from this review will be overseen by the Operational Manager but are completed by the Team
Manager

Repeatedly sending her letters or offers of appointments without response was futile.

GMMH recognise and apologise for the breakdown of communication which led to a situation
where either no correspondence or multiple letters were sent to Ms Kennedy and her GP Itis
also recognised that no action was taken when no response was received, to understand the
potential reasons for this

Equally, at the point of initial assessment our duty workers are now prompted to consider the
reason why a person does not engage in an initial assessment appointment and whom should
be contacted to inform how this is responded to, eg referrer, other agencies or individuals
involved

The launching of the revised CMHT SOP will further raise awareness within the team clinicians
of the component parts of the service which relate to the timing of communication and
disengagement The Community Service Manager will lead on promoting this This will be
achieved through face-to-face communication within individual supervision, team Business
Meetings and team and leadership development sessions.

The teams will also repeat on a monthly basis, the audit of GP communication completed
within the original action plan However, this will be expanded to include communication at

Page 3 of 5

key points Specifically, at tage, assessment and discharge This will be led by the Team
Manager in collaboration with Outpatient and CMHT administrators

There was a serious failure to engage with other family members who may well have
been able to contact her and encourage her to re-engage with services.

GMMH recognise that due to the change in Ms Kennedy's consent not being communicated
or updated, that staff did not speak with Ms Kennedy's brother about her care and the
difficulties they were experiencing in seeing Ms Kennedy in the CMHT or Outpatients clinic.

As acknowledged above, there is a renewed emphasis on the role of communication to inform
how we plan the care we deliver to our service users, particularly in relation to disengagement.

More specific instruction Is being made to regularly review any information sharing agreements
that are in place with service users This will ensure they are up to date and accurate This will
be reviewed within individual line management supervision with care coordinators and
therefore monitored by Team Managers Staff will be directed to ensure that where a service
user does not consent for carers to be involved in their care and treatment that this issue is
regularly revisited with service users and the outcome of these conversations are recorded on
the clinical database ’

There were repeated and serious failures of internal communication within GMMH,
which are set out in more particulars in the SUI report.

GMMH recognise and apologise for the internal communication breakdowns identified within
the SUI report Actions were developed at the time of the report to improve and change
practices in relation to communication Specifically to ensure staff were aware of the SOP,
their responsibilities and the circumstances where clinicians should review who they need to
liaise with, particularly where engagement is a recognise problem that requires action

There were numerous opportunities missed in order to resolve the situation.

GMMH recognise that in reviewing Ms Kennedy’s care during the time described within the
SUI report, there were a number of occasions where staff should have acted differently
GMMH apologise unreservedly for this This included how GMMH should have communicated
with others and also how GMMH should have responded to Ms Kennedy’s lack of
engagement, including the involvement of her brother

Overall, the standard of her psychiatric care and management from the end of August 2016
until her death fell below any reasonable standard of care which could be expected

GMMH acknowledge that there were a number of care delivery concerns in relation to Ms
Kennedy’s care and recognise the further concerns expressed by her family and the court
GMMH apologise for this

| would like to assure you that the reasons for the omissions and care delivery concerns, have
been thoroughly investigated and are understood at the service and Trust level This has been
achieved through a Positive Learning Event where the final report, learning and action plan
were reviewed with front line staff The report, learning and action plan were also reviewed
corporately by the Trusts internal Post Incident Review Panel

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The progress of actions being completed will also be monitored locally by services and at a
Trust level, using the electronic incidents system (DATIX) ,

All our Manchester CMHTs have undergone significant change within the past 12 months
Whilst this does not seek to excuse the concerns that have been highlighted here, the service
redesign and new structures aim to reduce the risk of such care delivery concerns arising
again

It seems that GMMH accept that there were failings and that her family should be offered
an apology but that it was understood by the date of the inquest hearing this had still
not been offered to them.

It is with regret that Ms Kennedy’s brother did not receive a formal apology from the Trust in
our letter to him | would like to assure you that a written apology has now been provided to
Ms Kennedy’s brother by the Head of Operations for our South Manchester and Trafford.

I suggest that there are periodic reviews by the Medical Director of GMMH to ensure
that appropriate standards are being met.

The specific actions described within this letter are incorporated in the enclosed action plan ;
for ease They will be entered into the Trust DATIX system and will be monitored locally by
the senior leadership team within South Manchester and Trafford .Division and by the
corporate Governance Team :

Through ongoing audit, our services and the wider Trust will monitor adherence to practice
standards within South Manchester CMHT and Outpatient services This will ensure we are
consistently working In line with the revised SOP and that the learning following Ms Kennedys
death ts sustained

Mr Meadows, | hope you and Ms Kennedy's family are satisfied with the response we have
provided. If you have any further questions in relation to the contents of this letter, please don't
hesitate to contact me

Yours sincerely,

CY. Gr
nn

Gill Green
Executive Director of Nursing & Governance

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Pennine Care

NHS Foundation Trust

Trust Headquarters

225 Old Street
Ashton-Under-Lyne
Lancashire
OL6 7SR
08 May 2018
Mr C Morris
HM Area Coroner Our Ref: CM/KH
Coroners Court Coens Trust Headquarters
Sk for: Claire Molloy
1 Mount Tabour Extension: 0161 716 3006
Stockport Fax: 0161 716 3037
SK1 3AG

Dear Mr Morris

Re: Catherine Kennedy (Deceased)

Thank you for your Regulation 28 report dated 13 March 2018, and for bringing to
my attention the concerns you had after hearing all the evidence. Your concerns
have been reviewed and the Trust’s response is outlined below:

Matters of Concern

“In the course of the inquest, evidence was heard about a telephone conversation
between a nurse on Norbury Ward and the on-call junior doctor for the wards.
Miscommunication in the course of that conversation in combination with other
factors, played a part in the fact that over 14 hours elapsed between staff first being
informed of the overdose and Mrs Kennedy being reviewed by a doctor.

Whilst the Trust has taken a number of actions in response to its internal
investigation into the circumstances of Mrs Kennedy's death, it is a matter of residuat
concem that sufficiently robust measures have not yet been taken to adequately
reduce the risk of future deaths arising from miscommunication and assumptions
occurring in the context of telephone conversations between ward staff and on-call
doctors.

In particular, it is a matter of concern that the Trust does not appear to consistently
have used a communication paradigm (such as the SBAR paradigm introduced by
the United States Navy and widely of application across the NHS) as to the content
and documentation of key communications, particularly arising in the context of
seeking action from an on-call member of staff not based on the ward”.

Response:

The Trust can confirm that the Situation, Background, Assessment,
Recommendation (Decision) tool is currently taught within the following courses
within Pennine Care NHS Foundation Trust:-

e SBAR(D) has been included within Intermediate Life Support training for
approximately 18 months.

e SBAR(D) has been taught as part of Clinical Risk Formulation Training for two

years. It is taught as part of emergency management and how to verbally
communicate the risk formulation when the risk is high and immediate.

e SBAR(D) has been taught as part of STORM Suicide Prevention Training for

the past 12 months.

e SBAR(D) has been taught as part of the MVA 4 courses to summon
assistance around post effects of restraint and or rapid tranquilisation. We

have done this for over 18 months to also support the Modified Early Warning

Sores (MEWS) training,

e SBAR(D) is taught as part of the Modern Matron Clinical Skills Course for
ward nursing staff.

e Organisational Learning and Development have been supplying learners with
a copy of the AS SBAR(D) telephone pads, to write on as handing over. The

pads are placed by the telephone to provide a prompt to anyone making the
call to an on-call medic.

However, to further support the use of this communication tool the context of ward
staff seeking action from an on-call doctor not based on the ward, the following
recommendations have been made:

e 7 minute briefing to be developed to further support the use of this

communication tool in the context of ward staff seeking action from an on-call

doctor not based on the ward. This is to be shared with mental health
inpatient services across the Trust.

e Consideration to the SBAR(D) being added to the Trust Physical Health
Policy.

e Wards to have a copy of the SBAR(D) poster displayed by the office
telephone for staff reference.

* SBAR(D) to be included within the Handover Guidelines being developed for

ward staff by the Modern Matron.

« SBAR(D) to be added to junior doctor induction pack.
| hope this response assures you that the Trust takes seriously any concern that you

raise.

Yours sincerely

(Ak.

Cb sie Molloy

Chief Executive

e-mail: Claire.molloy1@nhs.net