Anthony Buckingham

§ JUN 2019

NHS)

Norfolk and Suffolk

NHS Foundation Trust

Our Ref: JW/ML Trust Management
1° Floor Admin
Hellesdon Hospital

Drayton High Road

Private and Confidential
Mr Danie! Sharpstone

Assistant Coroner for Suffolk Hellesdon
The Coroners Court and offices Norwich
Beacon House NR6 5BE
Whitehouse Road

Ipswich 30 May 2019
IP1 5PB

Dear Mr Sharpstone
Re: Mr Anthony Buckingham

write in response to your prevention of future deaths report dated 15 April 2019 following the

conclusion of the inquest into the death of Mr Anthony Buckingham. | know you will share a copy of this
response with Anthony's family and | would like to express my condolences for their loss. Anthony’s
death is a tragedy and it is essential the Trust takes all opportunity to learn.

The report listed five areas that could have been done to try and prevent his death. | will respond to
these in order.

1.

wits, Working together
“¥~ for better mental health

Daily visits from the mental health team

The Trust's internal investigation identified that Anthony had no contact with mental health services
prior to February 2018. Following referral to the Trust he was provided with support by the Home
Treatment Team. This team provides short term support for people experiencing acute mental health
needs, through visits and telephone calls. From the period 16 February 2018 to 13 March 2018 the
team completed seven face to face contacts and seven telephone contacts. The decision as to the
frequency of contact is considered by the multi-disciplinary team in conjunction with the service user,
based on their presenting needs. The multi-disciplinary team approach assists to ensure all
perspectives are considered and the judgement is a shared decision. Through this process contact
can be increased and decreased on a flexible basis. Additionally, where an individual’s needs
require an admission to hospital the home treatment team are able to initiate the actions required to
complete this.

. Involvement of the next of kin

The Trust's internal investigation confirmed that the next of kin details were not obtained from
Anthony, thereby impacting on their ability to engage his family. This was not picked up during the
period of contact with the Home Treatment Team. A recommendation of work was made by the
internal investigation resulting in the care team evaluating their processes. The clinical team leader
monitors this taking action where required. The Trust obtains assurance of this improvement through
means such as audit and its quality and safety reviews.

Formal mental health act assessment

The report doesn’t identify at which stage of care a request for a mental health act assessment may
have been appropriate. Following the initial assessment, Anthony was accepting treatment and
engaged with the appointments and telephone calls offered. This was in keeping with the principle
of least restrictive treatment.

Chair: Marie Gabriet CBE Chief Executive: Professor Jonathan Warren
Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE
Tel: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk

4. Involvement of the practice nurse

The Trust’s internal investigation identified learning regarding the need to liaise and work with other
agencies involved in the care of the service user. The team’s current working process is to allocate

an individual staff member to each service user; they have some additional responsibilities to ensure
the care package is comprehensive and includes all other agencies. In addition, the multi-disciplinary
team meetings help identify key others involved in care and allocate action of who will engage them.

5. Use of Corner House care facility

It is critical that Trust services engage with other agencies to ensure there are comprehensive

packages of care in place for our service users and carers. Such support needs are individual based

on assessment. The range of statutory and non-statutory support that is available is significant and
ever evolving. Thinking of this wider partner network and the requirement for close working, our
suicide prevention lead has hosted two events bringing together non-statutory and statutory
agencies, service users and Trust services in order to open channels of communication and raise
awareness what each other provides. These events of introduction have been well received leading
to the building and strengthening of networks. We have more planned for all areas of the Trust over
the coming months.

In support of all the above actions the Trust is strengthening its clinical and service leadership to ensure
they have the necessary breadth of skills and resource to lead safe and effective services. Of particular

note, the Trust will be introducing Patient Participation Leads for each locality, who will work alongside
new Clinical Directors to lead the components of quality and patient experience. The Trust is finalising
the recruitment to these roles which will be fully effective from September 2019. A key function of this
new approach will be the accountability to share learning, implement and monitor recommendations
from serious incidents. Their role is to support the local clinical services function effectively, working
alongside their network of partner agencies.

The Trust will gain assurance these interventions are working through a number of indicators. This will
include audit, user feedback and the outcomes of quality and safety reviews. To support an effective
assurance system, the Trust is implementing a new governance structure enabling a combined and
tiered approach that will provide the culture and conditions for improvement.

Thank you for providing this report to the Trust.

Yours sincerely

Jonathan Warren
Chief Executive