Paul Allan

Pennine Care
NHS Foundation Trust

Corporate Governance
Trust Headquarters
225 Old Street
Ashton-Under-Lyne
Lancashire

th :
20" September 2018 OL6 7SR

PRIVATE & CONFIDENTIAL

Russell Caller

HM Assistant Coroner : Our Ref:KB/ELD
Inner West London Department: Trust Headquarters
Westminster Coroner's Court ;

65 Horseferry Road

London :

SW1P 2ED. -

Dear Mr Caller,
Re: Regulation 28 Report — Paul Robert Allan (Deceased) ,

Thank you for your Regulation 28 report dated the 25" July 2018, and for bringing to
my attention the concerns you had after hearing all the evidence. Your concerns
relevant to Pennine Care have been‘reviewed, and the Trust’ s response is outlined.
below.

‘Concern 1:

The Rochdale Community Mental:Health Team discharged Paul Robert Allan from
their care instead of transferring him to the Community Mental Health Team in Stoke
where Paul Robert Allen was moving to. :

Response:

)
The Trust takes very seriously its dutiés around discharging clients from services in
line with. Trust approved policies and national guidance. Paul Robert Allen was under
The Caré Programme Approach (CPA) framework at the time of discharge.. The
CPA framework was introduced in 1990 as the approach for the care of people with
mental health needs in England. Under the CPA policy section 7.11.2 states “All
health and social care organisations have the duty to collaborate to ensure proper .
co-ordinated care is delivered to people with mental health needs, Each district
Local Authority Social Services Department and Health Trust will jointly operate a
Care Programme Approach (CPA) Policy. Whilst-the detail of local CPA’ policies may
differ the core principles will be the same. A Key. objectivé of the CPA is to ensure
individuals most in need of care do not slip through the net of service provision.”

As a Trust we will circulate a reminder to all staff. regarding the policy to include how
to access. the policy and its use in practice. It is a duty of all responsible clinicians
and registered practitioners to take accountability for clinical decision making
adhering to nation and local policy and guidance. The Trust have also ensured that
CPA is included on clinical audit programme 2018/19 :

Concern 2:

The Rochdale Community Mental Health Team failed to consult or work with the
Drug and Alcohol advisory services in relation to Paul Robert Allen as it is required to
do so.

Response:

The Trust has recognised the gap in services for dual diagnoses clients and the
difficulties experienced in Rochdale as a result of the commissioning arrangements
around Drug and Alcohol services being delivered by third sector ofganisations. As
such. the Trust has recently been successful in.their application for Greater
Manchester funding from the transformation fund, to develop new posts to bridge this
gap.. The new posts will develop and establish pathways between Mental Health and:
Drug and alcohol services and work with the most complex clients and develop
effective working practices. Further development meetings with the operational
manager of the drug and alcohol services and Rochdale mental health services are
supporting and enhancing this model.

Our Rochdale services also form part of the Greater Manchester Strategic

- Transformation Partnership (groups of NHS and Local Authorities — STP) who will be
accessing improvement work in relation to suicide prevention across the Greater
Manchester area. Previous National Confidential Inquiry into Suicides and
‘Homicides work has shown that the implementation of their recommendations was
associated with reduced suicide rates in mental health trusts. The NCISH ‘10 ways. °
to. improve safety’. (below, and linked) summarises recommendations from 20 years
of research that could make a difference to. suicide rates in our STP. Identifying
which of the '10 ways’ could be improved in your STP is-the first step to an evidence-
based quality improvement plan. The NCISH team would expect to see some of '
these recommendations incorporated into a locally co-produced suicide prevention -
driver diagram‘as part of the QI plan. The QI plans should focus on the main:priority
areas of (1) mental health services, (2) self-harm services, (3) suicide prevention i in. ,
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At a visit to our STP, the project team will provide bespoke data for our STP-and
Pennine Care NHS trust, benchmarked against national data. The team will discuss
any concerns specific to our local area, and help us to incorporate these into our QI
‘plans. Services for dual diagnosis is an identified area by the NCISH and project’.
team that can reduce deaths by suicide. . ;

Pennine Care-NHS is a signatory to the Greater Manchester Strategic suicide
’ prevention strategy and will be working collaboratively and closely with.partner -
agencies to, bring the NCISH recommendations to practice. :

|-hope this response assures you that the Trust takes seriously any concerns that
you raised. . .

Yours sincerely,

Conse Ma

Claire Molloy
Chief Executive