Stephen Tidey

INS)

Surrey and Borders
Partnership
NHS Foundation Trust

Nursing Directorate
Trust HQ

18 Mole Business Park
Randalls Road
Leatherhead

Surrey KT22 7AD
Tel: 01372 216008

xX 01372 203360
Email:

Dear Ms Loxton

Stephen lan William Tidey (deceased)
Regulation 28 Report to Prevent Future Deaths (PFD)

am writing further to the PFD report that you sent to Surrey and Borders Partnership NHS
Foundation ‘Trust (the Trust) in relation to Mr Stephen Tidey, who sadly died on 22™ December
2016.-Thank you for taking the time to investigate his death so thoroughly and for bringing the
matters of concern you have to our attention.

In response to your concerns, the Trust has actioned the following:

4. We have met with our Multi-Agency Safeguarding Hub (MASH) colleagues from Surrey
County Council to discuss this case and the learning that can be taken from it.

2. Since Mr Tidey’s death, we have already implemented a standardised log across all of our
Community Mental Health Recovery Service (CMHRS) teams, which must be used to
record all of the 39/24 forms (now referred to as Single Combined Assessment of Risk
Form (SCARF)) that are received by the CMHRS. The log must record the date the SCARF
is received, the name to whom the SCARF relates and what action has been taken in
response. | have received assurances that these logs are now being completed by the

CMHRS teams.

3. However, we have also devised a new checking system between the MASH and the
CMHRS teams. In the future, when the Trust’s practitioner within the MASH receives a
SCARF -form which indicates a high risk to an individual and which the practitioner
considers requires urgent action by the CMHRS team, a phone call will be made by the

. MASH practitioner to the relevant CMHRS to check that the SCARF has been received and
to notify the CMHRS that action is required urgently.

_. "We discussed whether a phone call could be made by the Trust’s MASH practitioner to the
« GMHRS every time a SCARF form is sent from the MASH to the CMHRS, however due to
the volume of SCARF forms received and processed this was not considered to be a
workable solution.

4, |t should be borne in mind that the MASH was originally designed as an initial point of
contact for reporting concerns about the safety of children, young people and adults. It is
not a crisis response service, and that is reflected in the MASH’s operational hours
(Monday — Friday, 9am — 5pm).

We have therefore written to Surrey Police, who complete the SCARF forms, to remind
them of the purpose of the MASH and to reiterate its operational hours. We have advised
Surrey Police that, should they become aware of an urgent concern about the safety of a

child, young person or adult outside of, or near to the closing of, the MASH'’s operational
hours, it would not likely be appropriate for the police to document these concerns on a
SCARF form and send it to the MASH. This is because the SCARF form will not be looked
at by the SABP MASH practitioners until the following working day, and therefore no urgent
action will be taken.

In the case of urgent concerns that arise either outside of, or near to the closing of, the
MASH's operational hours, we have advised Surrey Police to contact either:

e Surrey County Council's Emergency Duty Team (EDT), which provides an
emergency social work service for urgent situations which arise out of normal office
-- hours and which cannot be left with an appropriate degree of safety until the next
normal working day. The-EDT operates Monday to Friday from 5pm to 9am, 24
hours at weekends and over all bank holiday periods.

° The Trust's Crisis Mental Health Helpline, which provides advice-and assistance in
-relation to persons who are in a mental health crisis. The Crisis Line operates
Monday to Friday from 5pm'to 9am, 24 hours at weekends and over all bank holiday
periods. a : : of

° The Trust’s Safe Havens, which provide out of hours.help and support to people
and their carers who are experiencing a mental health crisis or emotional distress.
There are five Safe Havens open in town centre locations across Surrey and north
east Hampshire, and we have provided the police with the details of all of these.

5. We have set up an automated email reply, which is sent from the Mental Health/Drug &

~~’ Alcohol inbox within the MASH. This automated email details the MASH’s operational hours
and advises of the out of hours services that are available. The automated email is sent in
response to any email that is received outside of the MASH’s operational hours, so that ~
anybody sending a SCARF form to the MASH Mental Health/Drug & Alcohol inbox will be
aware that the SCARF form will not be processed until the next working day, and will know
where to seek urgent advice or assistance if required. .

6. The Trust will soon be introducing a Single Point of Access (SPA), which will be phased in
from October 2018. The SPA will operate 24 hours a day, 7 days per week and will be
contactable for advice or to discuss concerns about a person who has a mental health —

need. We:have advised Surrey Police that they will, in due course, be’able:to contact the
SPA if they need to obtain any urgent, out of hours advice. : ‘

- On behalf-of the Trust, | would like to offer our'sincére ‘condolences to Mr Tidey’s relatives for their

‘ loss‘and ‘hope that our actions outlined above assures you and them that we-have learnt-and
continue to‘learn from his death. Please do not hesitate to contact me or Chief
Medical Officer, should you require any further information. me a 7

Yours sincerely,

Jonathan Warren
Acting Chief Executive

Our Ref: NE/AJ

Hr een Court SURREY
‘oroner’s Cour

Station Approach POLICE
Woking With you, making
GU227AP Surrey safer

www.surrey.police.uk

Nick Ephgrave QPM
Chief Constable

4" July 2018

Dear Ms Loxton,

| write in response to your letter dated the 9" of May 2018 regarding the Inquest touching the death
of Stephen lan William TIDEY and the Regulation 28 Report — Action to Prevent Future Deaths. In this
report you posed 3 questions which | will respond to in turn.

Qi. How Multi Agency Safeguarding Hub (MASH) reports are processed by the MASH team upon
receipt?

Police Officers submit a risk assessment form called a Single Combined Assessment of Risk Form
(SCARF) to the Police MASH where it is triaged.

A triage will include:

e Checking the content of the referral itself to ensure it reflects factual information rather
than opinions or assumptions.

e Review the content of the referral to assess whether there are any unidentified risks or
vulnerabilities. Staff are trained to assess risk and will consider primary, secondary and
tertiary risks. If identified, these are referred immediately back to the original officer for
appropriate action.

e Checking for hidden crime/s. If crimes are identified, the officer will be notified and
requested to record and further investigate. This will not delay the sharing of the SCARF
which will be shared in the usual way

e If the referral is related to Domestic Abuse (DA), the DASH (Domestic Abuse, Stalking and
Harassment assessment) section of the SCARF is completed by the officer. This will be
reviewed as part of the SCARF as described above. The DASH section is however removed
from the SCARF before sharing as this remains confidential but significant information which
may impact on risk will be written into the main section of the SCARF for partners to be
aware. The outcome of DA related referrals will also be shared

e Checking whether there are any warnings on our Surrey Police records management system
for those involved.

© Checking for previous SCARF referrals. An escalation process exists whereby, if a 4" referral
is received into MASH within a 90 day period, the risk of the 4" referral is automatically
increased by one level and shared, highlighting the frequency of referrals. This will prompt
partners to consider underlying concerns and appropriate support or intervention.

Surrey
CRIMESTOPPERS
800 555 111

Surrey Police, PO Box 101, Guildford, GU1 9PE

e Noting of officers initial risk assessment level and consideration throughout the triage
process as to its appropriateness. MASH staff have the ability to increase or decrease the
risk rating as a result of their triage but, if changed, a rationale must be included as to why.

e Check Early Help Management (Surrey County Council Children’s Services system) to confirm
if child subject of referral is known/open to them. If they are currently working with the
child, then the referral is shared directly with the team involved. This process is not in place
for Adults so all adult referrals are sent to the MASH Adult Social Care.

e Review and assign one of four Police MASH Risk level/Level of Need.These are defined as;

o Red (level 4) High Risk — requiring Specialist intervention — these are dealt with
within 4 working hours.

o Amber (level 3) Medium Risk — requiring Targeted and Timely Intervention — dealt
with within 24 working hours.

o Green (level 2) Standard Risk — requiring Early Help — dealt with within 72 hours.

© Blue (level 1) No/Minimal risk — Not shared — no set target as not requiring Local
Authority intervention or support.

e Bring to the attention of MASH Detective Sergeant anything that may need escalating or
requires fast time action, for example where a MASH officer considers a child or adult to still
be at risk of harm

Once triaged, the SCARF referral is shared electronically via secure email. This process is the same
irrelevant of risk as the mail boxes are monitored throughout the working day.
All adult referrals are shared directly — with MASH Adult — Social Care
Childrens referrals are shared either directly with Social Care teams already working with the
children (as above) and the remainder to MASH Childrens Social Care
Referrals relating to Missing Children or those who’s parents/carers are involved in a domestic
dispute where police have been called are also shared with Education and Health
The Niche report is updated with a record of triage and sharing and an individual staff ‘tracker’ is
completed with action taken for future audit trail and statistical requirements.

Q2. Whether there is an effective system in place to ensure that MASH reports are followed up by
appropriate Community Mental Health Team (where necessary)

Once a referral is made from Surrey Police to a partner agency via the MASH there is no current
means for Surrey Police to ensure it is being acted upon and this would be outside of the existing
agreement between Surrey Police and Surrey County Council. A partners response to a referral is not
monitored by Surrey Police and unfortunately we are unable to respond in detail to this question.
Surrey Police therefore respectfully request that this question is passed onto the SABP and Adult
Social Care for their response.

Q3. Whether there is an effective system in place to deal appropriately with MASH referrals
received outside normal weekday office hours, and that those completing the MASH referral
forms (e.g. Police officers) know where these should be sent outside normal working hours when a
high risk is identified

The Police MASH is in operation seven days a week (08:00 — 17:00 Monday to Friday and 08:00 —
16:00 Saturday and Sunday). There is only ever approximately one day’s worth of backlog and this is
risk assessed at the start of each working day.

Red risk graded SCARFS (refer to risk grading and timescales in Q1) submitted after the end of
business on any given day are prioritised at the start of the next working day and the timescales
outlined above are adhered to.

Procedures are in place that allows Police Officers, outside of normal working hours, to refer directly
to the Emergency Duty Team (EDT) when a high risk situation is identified. This can include, for
example, where a child needs urgent accommodation or coordination for contact with an Approved
Mental Health Practitioner (AMPH) in the case of a vulnerable adult with urgent mental health
needs. These out of office hours referrals are made by the officer directly by telephone but will
always be followed up with a detailed SCARF referral

Please let me know if | can be of any further assistance.

Yours sincerely

flepore