Conor Crutchley

NHS

Pennine Care
NHS Foundation Trust

20" March 2019 Legal Department
Trust Headquarters:

225 Old Street
Ashton-under-Lyne
Lancashire
+ . L
Strictly Private and Confidential lelisttAsis2

Mr Christopher Morris Telephone; 0161 716 3000
HM Area Coroner j
Coroner's Court

41 Mount Tabor Street

Stockport

SK1 3AG

Dear Mr Morris

Ref: Regulation 28 report to prevent future deaths following the Inquest of Conor
Crutchley who died on the 14" January 2018.

| am writing to respond to the concerns raised by your investigation on the 9 January 2019
into the circumstances surrounding the tragic death of Conor Crutchley.

The matters of concern raised and the actions we will take to address these concerns are as
follows:-

Concern

The Early Intervention Team does not include specialist drug and alcohol workers and that
access to the substance misuse service that is provided outside of the trust is dependent on
self-referral.

Response

‘Approximately 40% of people with psychosis misuse substances at some point in their
lifetime, at least double the rate of the general population’ (nice.org.uk/guidance/cg 120).

In an audit that was completed with the Tameside Early Intervention Team (EIT) in 2016 it
was identified that 44% of service users were using both alcohol and substances and 22%
using substances alone. (Audit of Substance Misuse Needs input for Tameside Early
Intervention Team 2016). This audit identified that out of the 63 people who were in need of
alcohol and/or substance misuse intervention:

34.9% had their need met
e 32% of these interventions were successful.
e 45% of these interventions had been commenced but the outcome was unknown
e 23% of these interventions had been unsuccessful due to the individual relapsing
to alcohol and/or substance abuse or the individual stopped engaging.
- 57.1% of the individuals were offered intervention but refused to uptake the intervention.

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- 8% of the needs were unmet.

The self-assessment completed by Tameside EIT in 2017/18, facilitated by the Early
Intervention in Psychosis Network for all EIT’s across England, identified that:

e 46% of people on the EIT caseload at the point of data collection used alcoho! in the
last 12 months and 26% of these individuals were assessed as engaging in harmful
or hazardous use of alcohol.

e Of the total number of people on the caseload

o 2% received brief intervention and advice

2% received motivational interviewing

2% were referred to a specialist services

5% refused any interventions

85% did not need any interventions for alcohoi use

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e 24% of people on the EIT caseload at the point of data collection misused
substances.
e Of the total number of people on the caseload.
o 2% received brief intervention and advice
o 7% were referred to a specialist services
o 10% refused any interventions
co 80% did not need any interventions for substance misuse

The Tameside Early Intervention Team does not employ a specialist drug and alcohol
worker. Specialist drug and alcohol services within the Tameside & Glossop area are
commissioned from an external provider, currently Change Grow Live (CGL). This service is
accessed by referral; with the expectation that a Care Coordinator from the EIT would
support a service user to self-refer to this service and/or, with consent, complete the referral
on their behalf. This can be completed on-line, by letter or telephone. There is a further
expectation that the Care Coordinator would offer any required support to attend the initial
assessment with CGL. NICE guidance (nice.org.uk/guidance/cg120) recommends
consideration of seeking specialist advice and initiating joint working arrangements where
individuals with psychosis are known to be; severely dependent on alcohol; dependent on
both alcohol and benzodiazepines or dependent on opioids and/or cocaine or crack cocaine;
where substance misuse is difficult to control and/or leads to significant impairment of
functioning: family breakdown or significant social disruption such as homelessness. EIT
practitioners undertake joint working arrangements with CGL where substance and/or
alcohol misuse is identified and individuals are willing to engage with support to address this.

Care Coordinators and other professionals within the EIT are expected to be competent in
the recognition, treatment and care of those with psychosis and coexisting alcohol and/or
substance use. Recognition includes an exploration of particular substance use, quantity,
frequency and pattern of use and the history of and route of administration. Supplementary
information regarding alcohol and substance use is also gathered from family, carers and
friends with the service user consent. The assessment of alcohol and substance use is also
undertaken during physical health assessments completed by the team, followed by the
provision of brief interventions where appropriate. In order to enhance the assessment of

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alcohol and substance use the team are in the process of scoping available validated
measures to assess dependency, such as the Drug Abuse Screening Test (DAST), for
utilisation as part of the physical health assessment process.

Training is provided to care coordinators and other professionals within the EIT in relation to
co-morbid alcohol and substance use. Training includes dual diagnosis training, motivational
interviewing (techniques to assess the person's readiness for change and movement
forward on level of change), updates on new and emerging substances and risk
assessment. This has been provided in-house and by external providers. The majority of .
care coordinators within the team have previously undertaken dual diagnosis training and
will attend refresher training as required. The EIT team manager will ensure that staff who
have not completed training in this area will access appropriate training opportunities as
soon as they are available. This will be monitored through the management supervision
process.

The Tameside EIT are in the process of developing roles for dual diagnosis champions
within the team who will be supported to undertake additional training in relation to
substance and alcohol use and cascade these skills within the team through a ‘train the
trainer’ model. This will support the team to provide a comprehensive offer in relation to
assessment of alcohol/substance use, risk assessment including impact of use on illness
and other risks including risk to self, other, neglect, vulnerabilities and exploitation,
education, motivational work, harm minimisation and encouraging and supporting referral to
and engagement with specialist drug and alcohol services.

Where service users give incorrect or inconsistent information around suspected substance
and/or alcohol use, for example denying use where there is suspicion of use, the relationship
between the individual, their supporting network including their family and carers, and the
care coordinator is utilised to work towards a point of reflection and acknowledgement of use
in order to encourage engagement with appropriate interventions.

The EIT aims to offer evidence based interventions to individuals with needs pertaining to
substance and/or alcohol misuse. A Cochrane review based on 25 Randomised Controlled
Trials compared the effectiveness of psychosocial interventions offered (Psychosocial
Interventions for People with both Severe Mental Illness and Substance Use; Cleary et al
2008). These included Cognitive Behavioural Therapy (CBT), motivational interviewing, 12
step recovery, skills training and psycho-education. The review found no compelling
evidence to support any one psychological treatment over treatment as usual.

A further study explored a mode! of integrating care/intervention which found that compared
with standard care, integrated treatment for co-occurring disorders led to significant
improvements in psychiatric symptoms and levels of met need but not in substance use or
quality of life. (Integrated care for Co-occurring Disorders; Psychiatric Symptoms; Social
Functioning and Service Costs at 18 months; Craig et al 2008) A suggestion from this study
was to create a single role on each team dedicated to the delivery of psychological therapy,
with time set aside to deliver therapy and supervise a broadly trained workforce. The EIT
currently has a dedicated psychological therapy resource to support individuals through
provision of a range of psychological interventions.

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Concern

At times there can be a significant wait for individuals to access talking therapies and that
this is associated with difficulties in recruiting and retaining suitably qualified therapists.

Response

The waiting list for talking therapies that was in place at the time that Conor was being
supported by the EIT was as a result of not having sufficient capacity within the team to
provide the level of psychological therapies required rather than difficulties in recruiting and
retaining qualified staff.

Tameside Early Intervention Team is working towards achieving the NICE Early Intervention
in Psychosis Access and Waiting time standards. This includes the offer of Cognitive
Behavioural Therapy for Psychosis (CBTp) and family therapies. Nationally there are
different levels of attainment of these standards, linked to a planned incremental
improvement by providers and commissioners over a period of time to work towards the
standards set for achievement by 2020/2021. The standards for provision of NICE
recommended interventions for people experiencing a first episode psychosis include the
following:

e more than 24% of EIT service users will take up individual CBTp.
© more than 16% of families will take up family intervention.

These standards take into account that it may not be appropriate to offer interventions to all
service users, for example those that joined the service recently, and that not all service
users offered interventions will take them up. All service users and families who are
supported by an EIT will be offered access to psychological therapy.

The self-assessment completed by Tameside EIT in 2017/18 facilitated by the Early
Intervention in Psychosis Network for all EIT's across England identified that:

e 68% of individuals with a First Episode Psychosis of people on the EIT caseload at
the point of data collection started a course of CBTp. This was a 16% improvement
from 2016/17. The national average for this standard was 34%. Tameside EIT was
rated as one of the top performing teams in the country against this standard.

e 2% of individuals with a First Episode Psychosis of people on the EIT caseload at the
point of data collection started a family intervention. This was a 4% reduction from
2016/17. The national average for this standard was 18%. Tameside EIT was rated
as one of the teams requiring greatest improvement against this standard.

The Tameside EIT actively promote uptake of psychological interventions as there is a good
evidence base for their effectiveness. This is a popular intervention with service users
supported by the team and a high percentage of the service users supported by the team
accept the offer of this intervention which can lead to a wait for the appropriate therapy to
commence. In order to support the reduction in the wait for psychological interventions for
individuals supported by the EIT, Tameside and Glossop CCG provided funding for an
additional psychological therapist post within the team. This post was successfully recruited
to and the practitioner commenced in post in December 2018. The practitioner is trained to

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provide both individual and family interventions. This has resulted in a reduction in the
waiting times for therapy within the team. The current wait for CBTp for individuals with first
episode psychosis is approximately 10 weeks and there is only 1 person waiting for CBTp
who is being managed on the ‘At Risk Mental State’ (ARMS) pathway. In addition to this a
practitioner within the team has also undertaken ‘train the trainer’ training in Family
Intervention and has completed a 5 day training programme within the team to equip
practitioners with the skills to offer this intervention in order to improve capacity to respond to
requests for this intervention in a timely manner. There is currently no wait for family
intervention. The management of the waiting list for psychological interventions in the team
has also been reviewed and now includes a process of making monthly contact with
individuals on the waiting list to ensure they still wish to access therapy and to provide an
update on current waiting times.

| hope that the information provided offers assurances that the findings of your investigations
and the areas highlighted for the prevention of future deaths have been considered and
prompted action.

Please do not hesitate to contact me should you require any further information.

Yours sincerely

CBr

Clare Parker
Executive Director of Nursing, Healthcare Professionals & Quality

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