Benjamin Williamson

Addaction Cornwall

Mr Andrew Cox Western House
Coroner for Cornwall & Isles of Scilly Tabernacle Street
The New Lodge Truro

Newquay Road Cornwall TR1 2EJ
Penmount

TRURO TR4 9AA 13/02/2019

Dear Mr Cox

Re: Regulation 28 letter (12° December 2018) ref AUC / KC

Addaction recognises the importance of confidentiality which is essential to the effective
running of our services. We recognise the right of individuals in having their personal
information protected and as such operate strict practices to ensure that personal
information is held securely and shared appropriately. We seek consent from clients in order
to share this information with other organisations and people, including their General
Practitioner and we have a duty to inform our clients and service users of how we process,
store and share this data under the GDPR 2016.

Many people are apprehensive about engaging with addiction services and there is a real
concern within the field that routine information sharing with GPs could create a barrier to
accessing treatment for some individuals. People who use our services have a right to
expect that information about them will be held in confidence by their workers and that they
will be treated with discretion and sensitivity when accessing Addaction’s services. Our
Confidentiality and Consent policy is based on the principle that the client's wishes and
rights are of fundamental importance and draws upon guidance produced and published by
Public Health England (Confidentiality Toolkit v6.3).

Following the inquest into the death of Mr Benjamin Colin Williamson on November 8" you
wrote to , Operations Manager asking that Addaction review the
processes/procedures in place for dealing with consent and the sharing of information with
Primary Care providers. In addition you asked that we involve [Eso that lessons
learned would be identified and shared.

| am writing to confirm that we have internally reviewed and improved how we record
confidentiality and consent reviews, shared copies of Addaction’s consent and confidentiality
policy (DQ225) and met with land colleagues at the Mullion Health Centre on
30" January 2019 to identify lessons learned and agree any required improvements.

Improvements to recording confidentiality and consent reviews within Addaction
Since December 2018 we have introduced a monitoring function into our patient
management system (Halo). This will ensure that the three monthly reviews are conducted
and recorded in line with our policy requirements. We now have ability to run reports,

identify where reviews are required and monitor this through line management/supervision
processes.

Review consent and information sharing procedures with Primary Care.

In the Mullion Health Centre a Summary Care Record (SCR) is created for all patients that
enables staff providing care for patients in an emergency, from anywhere in England, are
made aware of any current medications or allergies the patient may suffer from. This
information from every patient record is sent automatically. If patients wish their information
to be withheld from the SCR, they can choose to stop this from being shared (i.e. Opt-out).

At Addaction clients are asked for consent, usually by signing a consent form, detailing with
whom information can be shared, what information will be shared and for what purpose (i.e.
Opt-in). Consents should be reviewed and updated regularly, normally every three months
for adult services as part of the client’s recovery plan review.

In addition when Addaction provides a regulated activity, such as a home detoxification, a
BBV vaccination or a treatment for hepatitis C this is conditional on information being
routinely shared with the GP. Likewise the GP is required to provide Addaction with a SCR
and regular updates.

Some Addaction staff work from a number of GP practices across the county, including the
Mullion Health Centre, to improve accessibility and to ‘normalise’ obtaining help from
specialist services. However we recognise that there are a number of patients who prefer to
be seen away from their local Health Centre and that barriers to treatment could be created
were other provision not made available.

Addaction encourages workers to gain consent to share information with GPs and generally
most people do not object to this. We examine those who decline to share information with
their GP to ensure that risks are identified, assessed and managed. However Addaction
does not operate a policy of absolute confidentiality and there are a number of
circumstances that legally or ethically override the need for confidentiality.

Our colleagues in Primary Care recognise that some patients will be reluctant to allow
information to be shared with their GPs or attend specialist provision within the practice,
preferring to access help and support in other locations. In Benjamin’s case decisions
around information sharing with his GP and where he accessed sessions may have been
influenced as his mothe i worked at the Mullion Health Centre.
Addaction is clear that the informal communication between a parent and their employer
should not replace formal communication channels between those involved in a clients care
and we have reinforced this with all our staff members.

Whilst no policy changes were recommended through the review process, moving forward
the following actions have been agreed

1. Addaction has agreed to provide the Health Centre with the numbers of clients registered
at the practice who are accessing our services.

2. In order to improve communication our designated practice worker will attend the
practice multi-disciplinary team meetings. They will also be able to access the patient

management system (SystemOne) to improve information sharing between the services
and update records as required.

3. Where consent to share information with a GP exists, Addaction will inform them at an
earlier stage regarding plans to cease structured treatment / move to support that the
client initiates (known as Recovery Support)

In summary Addaction has reviewed the processes and procedure in place for dealing with
consent and the sharing of information with primary care practitioners. Since December
2018 we have implemented a number of changes to improve the timely review and recording
of client consent and information sharing permissions. We have shared our policies and
improved awareness of our approaches with our Primary Care Colleagues and how they
differ to those routinely implemented in General Practice. We have agreed a number of
actions to improve information sharing particularly for clients like Benjamin who are not in
receipt of a regulated activity.

We hope that this response demonstrates the importance Addaction attaches to learning
and continuous improvement. If you need any additional information please contact me.

SM CLE

Contract Manager
Addaction Cornwall

NHS)

Kernow
Clinical Commissioning Group

Private and Confidential

Mr A Cox Chief Officer

Her Majesty's Assistant Coroner for NHS Kernow Clinical Commissioning Group

Cornwall & the isles of Scilly Sedgemoor Centre

Cornwall Coroners’ Service Priory Road

The New Lodge St Austell!

Penmount Cornwall

Newquay Road PL25 5AS

Truro

TR4 9AA Tel: clo 01726 627612
Email:

By Email: cornwallcoroner@cornwall.gov.uk

4 February 2019

Dear Mr Cox,

Prevention of future death report following inquest into the death of Mr Benjamin Colin —
Williamson

Thank you for your Regulation 28 Report to Prevent Future Deaths pertaining to Mr Benjamin
Colin Williamson. In your report you identify considerations to be taken by NHS Kernow'as
joint commissioners of mental health in Cornwall, alongside Cornwall Council. Considerations
have also been asked of Addaction which is a service commissioned by Cornwall Council.

As commissioners of Cornwall Partnership NHS Foundation Trust you have asked NHS
Kernow to consider whether the system is sufficiently ‘joined up’ to meet the needs of people
like Mr Benjamin Williamson. You have asked NHS Kernow to bring any gaps in the system to
your attention and to contact so that his experiences and insights can be
taken into account. We have made contact with and noted his concerns.

We can confirm there is a Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults
covering the period 2016 - 2019. This is a multi-agency co-produced strategy that has been
developed by members of Safer Cornwall and providers of services. Safer Cornwall is a
partnership made up of statutory organisations and a wide range of other public sector,
voluntary, community and private organisations. The responsible authorities include NHS
Kernow, Cornwall Council, Devon and Cornwall Police, Cornwall Fire and Rescue Service,
National Probation Service and Dorset, Devon and Cornwall Rehabilitation Company.

The purpose of this strategy is to assist the delivery and experience of integrated and
inclusive service delivery for people with co-existing mental health and substance misuse
problems, and their associated complex needs through consistent collaborative working.

Chair: Dr jain Chorlton
Chief Officer: Jackie Pendleton
Head office:

01726 627800
kecg.contactus@nhs.net
www.kernowccg.nhs.uk

eoe0 80

Sedgemoor Centre, Priory Road, St Austell,
Cornwall, PL25 5AS

/nhskernow

NHS}

Kernow Clinical Commissioning Group

A wealth of evidence, both local and national, points to numerous challenges in engendering
a culture of shared responsibility as well as integrated operational and clinical working which
can leave people struggling to gain access to evidence based interventions as well as
targeted support for substance misuse. Locally we have seen evidence of specialist services
working in isolation and not adopting the principles set out in the strategy meaning individuals
may not get access to the services they need.

Whilst the local Mental Health Crisis Care Concordat has made some progress with
implementing actions linked to the strategy, a formal implementation plan had not been
developed to ensure the strategy was delivered and monitored in its entirety. The Crisis Care
Concordat is coordinated and chaired by NHS Kernow and includes a multiagency group of
system wide representatives. It is a national agreement between services and agencies
involved in the care and support of people in crisis and sets out how organisations will work
together better to make sure that people get the help they need when they are having a
mental health crisis.

NHS Kernow has met with relevant providers (including Cornwall Partnership NHS
Foundation Trust, Valued Lives, Outlook South West; as well as those commissioned by
Cornwall Council such as Addaction), partners and commissioners towards the end of 2018
and in January 2019. The aim of the meetings was to escalate concerns regarding gaps in
provision where individual’s mental wellbeing is not always being seen as part of ‘everyone’s
business’ and is often considered the domain of highly specialised and often medicalised
approaches which comes at the expense of emotional and shared support of the whole
person.

An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The
meeting was well-attended by the relevant statutory organisations and providers. The purpose
of this meeting was for providers to agree a way forward and specific actions have been
identified to review the Dual Diagnosis Strategy and implement a robust multi-agency
implementation plan. A draft implementation strategy completed by NHS Kernow provided the
focus of the meeting. The providers of services will chair a monthly Implementation Steering
Group in order to develop the draft implementation plan. The chair will rotate quarterly
between the various providers ensuring a sharing of responsibilities and commitment to
improving integrated working.

It is expected that the review of the strategy and comprehensive development of the
implementation plan will be completed in six months. Whilst this is being undertaken priority
will be given to actions that can be undertaken immediately and will support individuals with a
dual diagnosis. For example, the development of a dynamic risk register so that people at risk
can be identified and reviewed collaboratively. A similar register has been implemented for
another group of people who have specific needs and has provided positive outcomes.

The progress of the Multiagency Implementation Steering Group will be reported to the Crisis
Care Concordat in April 2019 with a future proposal to establish this reporting line to Safer
Cornwall.

NHS Kernow is reviewing the contract requirements for new contract commencing April 2019,
in relation to providers supporting individuals with a dual diagnosis. Whilst current contracts
and the multi-agency strategy already specify how providers should meet the needs of people

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INHS

Kernow Clinical Commissioning Group

with a dual diagnosis, any contractual amendments will strengthen the monitoring of
engagement with the implementation plan.

| hope that this response provides you with satisfactory information that we are committed to
and are already working closely with all partner agencies to take measures to prevent future
deaths as set out in the Regulation 28 Report.

We have sent a letter to the Coroner's officer to share with the family to invite them to be
involved should they wish to be. We have-not been contacted by the family at the time of
sending this letter. We are aware that this response may be shared with them and | do hope
that this information will provide them with assurance that actions are being taken in relation
to the concerns’ identified in relation to Mr Williamson's death. We would like to extend our
sincere condolences to the family.

Please do not hesitate to contact me if you require anything further in relation to this case.

Yours sincerely

Vesuclicloe

Chief Officer

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