Georgia Nelson

23 May 2019

Private and Confidential
To be opened by Addressee only

Professor Fiona J Wilcox
Westminster Coroner's Court

Central and
North West London

NHS Foundation Trust

4° Floor
Gordon Hospital
Bloomburg Street
London SW1V 2RH
Email:
Tel 020 3317 2987

65 Horseferry Road
London
SW1P 2ED

Dear Professor Wilcox

Re: CNWLCOM59279

Dear Professor Wilcox,

Re: Georgia Sylvia Nelson, Prevention of Future Deaths Notice

| am writing in response to your correspondence to Robyn Doran, Chief Operating Officer
CNWL NHS Foundation Trust, dated 29" April 2019.

As a Trust, we are very saddened by Miss Nelson's death and take an incident of this
severity very seriously. Through our investigative and learning lessons process we will
ensure that changes are embedded at both a local and Trust wide level, providing the level
of reassurance that is expected of the Trust.

In your Report, you set out the following concerns:

1.

2.

That there is no suitable housing specifically for young patients with severe
and enduring mental illness in RBKC

There are no long term placements, potentially life long, for any patients
requiring supported housing in RBKC with such mental illness

There is a severe shortage of rehabilitation housing placements in RBKC for
patients who require them

That there should be a system to ensure that there is proper discharge
planning and referral on for all patients discharged after admission with mental
illness

That whilst mental health patients are in hospital all opportunities are used to
improve their care and treatment and that where possible, they are not
discharged before these have been appropriately addressed, rather than
discharging them as soon as they are deemed no longer at active risk to
themselves or others

. That rehabilitation should be more actively considered as a discharge option

for patients especially where there are pre-admission concerns about their
housing.

Central and North West London NHS Foundation Trust, Trust Headquarters, 350 Euston Road,

Regent’s Place, London NW1 3AX
Telephone: 020 32145700 www.cnwl.nhs.uk

Concerns 1, 2 and 3 are within the domain of the Royal Borough of Kensington & Chelsea,
who develop and commission housing provision, including a range of supported
accommodation. Whilst the Trust does not commission these services, as the major
provider of NHS mental health care within the Borough, we do work closely with the local
authority to inform and assist them in developing new services. We think however, they will
want to respond to these 3 points separately as the responsible organisation, and we are
aware they are currently in the process of responding to you in this respect.

Points 4, 5 and 6 are areas over which we have responsibility, and | will address these
points below:

4: That there should be a system to ensure that there is proper discharge planning
and referral on for all patients discharged after admission with mental illness.

The Trust has specific policies (CPA Policy 2015 and the Discharge and Transfer of
Patients, 2015) in place that set out the expectations and requirements of discharge
planning and referral for patients leaving hospital are completed. These policies underpin the
important principle of the need for community teams work to closely with inpatient teams to
ensure that planning is carried out to ensure as seamless a transition as possible from our
inpatient services to the community in recognition of the well-known vulnerability of this
period.

Practice currently in place at ward level to ensure these policies actually impact on practice
includes the following:
- At the point of admission immediately plan for discharge through daily use of a
discharge tool to anticipate needs post discharge.
- Rapid notification of the care coordinator and family members of the admission
and invite to attend the ward for pre-discharge meetings

To further support this critical point in the pathway we will:

- The Crisis and Home Treatment Teams now attend the daily handover meeting
on each ward to ensure they are aware of any planned discharges and contribute
to discharge planning for all patients on the wards.

- Ensure we deliver on the National CQUIN that people leaving hospital have face
to face contact within 72 hours of discharge by an identified worker

- That all patients leave hospital with a clear plan of who to contact in crisis and
where to get help if they need it as well as the details of the above appointment
This will help this critical period of adjustment and support longer term ongoing
care and communication.

- Ensure the learning from this case is shared across all in-patient, crisis and
community teams

5. That whilst mental health patients are in hospital all opportunities are used to
improve their care and treatment and that where possible, they are not discharged
before these have been appropriately addressed, rather than discharging them as
soon as they are deemed no longer at active risk to themselves or others

We agree that patients should not be discharged simply by virtue of presenting no risk to self
or others. The emphasis from mental health legislation and policy is that the aim of inpatient
treatment is to optimise their recovery time and allow patients to return to their life and
engage in treatment outside of hospital as soon as possible. However we recognise that this
must be supported through a holistic assessment during the admission to inform the ongoing

care needs after discharge effective and that robust discharge processes are in place to
deliver this safely.

To ensure that this is the case we will:

- We have successfully piloted a new trauma-informed approach to in-patient care
delivery in one of our units and this is being implemented across all sites. This
will support the development of a more personalised approach to in-patient care

- The Crisis and Home Treatment Teams attending the handover meeting on each
ward daily will ensure they are aware of any planned discharges and contribute to
discharge planning for all patients on the wards

- Every community team has a daily ‘zoning’ meeting and we will ensure that all
inpatients are discussed in the relevant team so community teams are aware of
all current in-patients and their progress and can contribute meaningfully to the
intended aim of the admission

~ Community team leads will attend the daily bed management meeting huddles
where forthcoming discharges are discussed to ensure they are sighted on these
and can support better communication

- We have a range of support and interventions for patients outside hospital
settings which we will ensure are maximised in the discharge planning process.
For example the Recovery College offers a range of person-centred interventions
and the Trust has a well-developed Vocational service, offering Employment
Support using the Individual Placement and Support Model, a User Employment
Programme and a strong programme of Peer Support.

6. That rehabilitation should be more actively considered as a discharge option for
patients especially where there are pre-admission concerns about their housing.

We acknowledge your concern about rehabilitation needing to be actively considered as a
discharge option. Rehabilitation can take place in a wide range of settings and modalities,
such as that described in Point 5 above.

NICE are due to produce guidelines on Rehabilitation in adults with complex psychosis and
related severe mental health conditions that we know are likely to propose a wider range of
options to provide patients with rehabilitation not just in an inpatient setting. This is the
national direction of travel, with patients being brought back from out of area placements to
their local community and rehabilitation being provided in high supported accommodation or
even in patients’ independent accommodation. We are working with our commissioner and
local authority to ensure that services are commissioned for our patients that give the widest
choice of rehabilitation options and keep up to date with modern ways of working. This will
mean that as discharge planning starts at admission, we will follow the new NICE guidance
on considering rehabilitation as appropriate.

1 do hope | have been able to address the areas of clarification that you have asked for and
that | have given you sufficient assurance that our services do thrive to provide the best
possible care, taking into consideration the legal framework in which we work, local and
national policy and the views of our service users when planning care and aftercare from
hospital. .

Yours sincerely

Claire Murdoch
CEO

Re

City of Westminster

THE ROYAL BOROUGH OF

KENSINGTON
AND CHELSEA

Director of Law

Dr Fiona J. Wilcox
HM Senior Coroner
The Coroner's Court,
65, Horse Ferry Road,
London
SW1P 2ED
24 June 2019
Dear Dr Fiona J. Wilcox,

INQUEST RE GEORGIA SYLVIA NELSON (GN)

RESPONSE TO REPORT, PARAGRAPH 7, SCHEDULE 5 CORONERS AND JUSTICE
ACT 2009 AND REGULATIONS 28 AND 29 CORONER’S (INVESTIGATIONS)
REGULATIONS 2013

| refer to the regulation 28 report (Report to prevent future deaths) in relation to the above

matter.

| am a Principal Lawyer in the Bi-Borough legal team and | am sending the response on
behalf of the Council.

A response to the Regulation 28 report has been prepared by senior officers in both the
housing team and adult social care teams at the Royal Borough of Kensington and Chelsea
(hereinafter referred to as RBKC).

The Council would like to offer its sympathy to the relatives of GN and our deep regret that
GN felt that she had to take her own life. The Council strives to ensure our most vulnerable
people are supported and we welcome every opportunity to learn how we can best achieve
this.

The Council was not an Interested Person in the Inquest and therefore do not know what
information the Coroner took into account, other than referred to in the Coroner's

Regulation 28 report.

Ena
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX

The Coroner listed the following concerns:

1) That there is no suitable housing specifically for young patients with severe and

enduring mental illness in RBKC.

2) There are no long-term placements, potentially life long, for any patients requiring

supported housing in RBKC with such mental illness.

3) There is a severe shortage of rehabilitation housing placements in RBKC for

patients who require them.

4) That there should be a system to ensure that there is a proper discharge planning

and referral for all patients discharged after admission with mental illness.

5) That whilst mental health patients are in hospital, all opportunities are used to
improve their care and treatment and that, where possible, they are not discharged
before these have been appropriately addressed, rather than discharging them as

soon as they are deemed no longer at active risk to themselves or others.

6) That rehabilitation should be more actively considered as a discharge option for

patients, especially where there are pre-admission concerns about their housing.

Concerns 1 to 3 relate to housing and this letter provides a detailed response to points 1
to 3.

. That there is no suitable housing specifically for young patients with severe and

enduring mental illness in RBKC.

The Council and the West London Clinical Commissioning Group (WLCCG), recognise
that continuous improvement is vital in delivering safe and effective services for young
people with support needs, including mental health issues. Although Adult Social Care and

Housing, in partnership with WLCCG, commission a range of housing and support options

Email:
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX

for clients with mental health needs, including those with severe and enduring mental
health, all agencies need to identify how we will build on and strengthen existing processes

in order to learn from the review of all serious or significant incidents.

Young adults (aged 18-25) make up around one tenth of the resident population in the
three Boroughs (12.2% in Hammersmith and Fulham, 9.6% in Kensington and Chelsea
and 10.7% in Westminster) and a slightly smaller proportion of GP registered patients in
Hammersmith and Fulham Clinical Commissioning Group (9.3%) and West London CCG
(8.1%). In Central London CCG this age group constitutes 16% of GP registered patients.

Despite this, very little evidence has been gathered about their health and wellbeing needs.

In RBKC, children with mental health needs place demands on personal social services,
education, health, youth justice services and families. About 7000 to 8000 children and
young people will benefit from mental health support at any one time in this area. Of these,
approximately 1900 children aged 5-16 are likely to experience some type of mental
disorder, with less than 100 having a severe mental health problem. This is in line with

inner London.

Out of this number of young people with severe mental health issues, there may be a few
who can be referred to supported housing services through the Single Homeless Team.
The Housing Department agrees with and will continue to work with Adult Social Care, WL
CCG and colleagues in the Central North West London NHS Foundation (CNWL) in any
decision-making process in regard to the type of support and accommodation needed,
ensuring decisions are made through an assessed process and agreed through a multi-
disciplinary approach and monthly panel meeting. The Mental Health Placement Panel
consists of Adult Social Care representatives and the Clinical Commissioning Group
commissioners and care co-ordinator. Where services are not available within the borough,
specialist placements outside of the borough can be purchased to best meet the
individual’s needs. It is acknowledged that within the relatively small borough that is RBKC,

it is not possible to have services that provide for all presentations of need.

Through Adult Social Care and Housing and in partnership with WLCCG, there is a range
of housing and support options that are commissioned in the borough, supporting those

from 18 plus with a range of mental health needs, including those with severe and enduring

Ena:
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX

mental health. This offer includes residential care, complex and high support supported

accommodation, step down supported accommodation and floating support services.

Currently there are 62 units of mental health high support services, and 645 units of high
to low supported housing services. The services supporting people with the most complex
needs are staffed 24 hours a day and all include key-working and one to one support, with
additional support from care coordinators from the Community Mental Health Teams
(CMHT). All service users have reviews and support plans ensuring links with other
additional support services, such as Drug and Alcohol Well-Being Service. Access to these
services is also through an assessment of need carried out by the CMHT and agreement

at the Mental Health Placement Panel.

There is no single dedicated housing service specifically for young patients with severe
and enduring mental illness in RBKC. However, as is noted in the report, GN was placed
in supported housing which is commissioned by the Housing Department and provided by
an independent specialist housing provider. The service is at the higher level of intensive
supported housing, is staffed 24 hours day and on average 11 support hours a week are
provided to each young person in that service. All service specifications have a recovery

focus with personalised plans to support each individual’s needs.

The service GN was placed in has a strong focus on assertively supporting this vulnerable
and challenging client group to engage in meaningful daytime activities and to access
education, vocational training and volunteering and employment opportunities. They offer
alternatives to previous lifestyles, which have often included anti-social behaviour and

social exclusion.

As part of the support provided, the staff will conduct the following:

e Needs and risk assessment — staff will assess the needs of the clients, such as
housing, mental health, well-being, finance, etc.

e Support Planning — staff will then draw up a support plan, such as supporting clients
with their independent living skills, in accessing mental health services, in attending

appointments, etc.

Email:
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX

e Review - staff will review the support plan, risk assessment at regular intervals in
order to monitor progress and check they are meeting their agreed goals.

e The clients who are care managed will be assigned to care co-ordinators from the
Community Mental Health Team. The staff work in partnership with other external
agencies, such as the Community Mental Health Team, Home Treatment Team and

Community Safety Team.

GN was being supported to develop such skills and, as you note in the report, was being
fully supported by the service in which she had remained. She was also awaiting a
placement review following leaving hospital to ensure the ongoing accommodation and
support which would meet her needs. The Coroner has commented in her report that GN’s
care was provided by staff operating above and beyond their professional responsibility
and that the placement would have been untenable without this dedication. At the time of

the placement the Council was content that the provider was able to meet GN’s needs.

We would like to offer you this joint response, to outline where the Housing Department,
Adult Social Care and West London Commissioning Group colleagues, in partnership with
Central North West London Trust, can work together to influence some of the changes you
seek from your concerns. As part of the broader commissioning of services, we would like
to strengthen the following regular partnerships meetings to look at need and demand ,to
support what services are jointly or singularly commissioned within the borough along with
development of specifications to ensure key outcomes such as tenancy sustainment and
the performance of the providers in enabling resident to be independent where possible is
managed and monitored in each of the services. This is done through formal contract

monitoring arrangements and placement review processes which are set out below: -

e Monthly Placement Project Group meetings consider overall data as to the
movement of borough residents through all the types of provision offered, changes
in the general pattern of need, and steps which may be taken at a strategic level to
ensure new needs are met.

e Monthly Placement Project Board meetings will follow the findings from the
placement project group regarding any specific gaps or improve the throughput of
the supported housing services in the borough. This may also examine specific

services necessary to meet the needs of the clients.

Email:
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX

e Quarterly Providers’ Strategy Group meetings will be organised to bring together
the support providers and other stakeholders to discuss issues surrounding and any

strategic development of support housing services.

This information feeds into needs assessment work and commissioning strategies.

. There are no long-term placements, potentially life long, for any patients requiring

supported housing in RBKC with such mental illness.

The Housing Department and Adults Social Care has an aspiration for any clients, where
possible, to work on their recovery and enable them to move towards more independent
lifestyles. However, we also acknowledge that for some clients, this may not be possible
and may continue to struggle with their daily living. In such cases, we understand that
short-term recovery focussed supported housing may not be the service that particular
client needs. Instead, we need to review the support needs of that client and find a longer-

term placement solution.

The Council acknowledges that there are no long-term placements, potentially life long, for
any patients requiring supported housing in RBKC with such mental illness as the focus is
on recovery and improving wellbeing and independence. Adult Social Care commissions
residential care and supported accommodations which are provided with a focus on
delivering a flexible and personalised approach to support each individual’s needs and their
recovery. Any move on is determined by a personalised approach to recovery and for some
this may be short stays in services and for others longer with many years based on needs
and their recovery journey and capacity. These services are flexible and support each
person by working with them and their goals and aspirations, involving a range of agencies
and support to best achieve outcomes for the individual. This is managed through support
plans and key working ensuring partners across health, social care, housing and support

services are engaged to support at best the broader needs of the individual.

We would like to take the following action when addressing the prevention of future deaths.
If the client may need long term or life long supported housing, the case will be brought to
the funding and placement panel to decide what kind of long term or life-long support and

accommodation will be commissioned through an evidence-based assessment by the

Email:
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX

multi-disciplinary team. Most likely, the purchasing specialist placements outside of
borough will best meet the individual’s needs as it is acknowledged that within RBKC, at

present, it is not possible to have services that meet all needs.

. There is a severe shortage of rehabilitation housing placements in RBKC for

patients.

In RBKC we currently have 707 units providing supported accommodation to people with
a range of mental health needs, each with an individualised support plan which would
include rehabilitation to enable people to develop greater independence. This would
include, for example, developing daily living skills, managing medication, accessing
specialist services, budgeting, managing own tenancies, developing peer relationships and
accessing universal services including training and getting back into employment. This is
supported by the key workers along with Community Mental Health Teams, through a
process of reviews and assessments. Within our offer, we do not consider there is a severe
shortage, but we recognise the need to continually assess demand and capacity, which

we do through the various placement boards and project groups.

Rehabilitation can be defined as to prepare someone to resume normal life after an illness.
Traditionally it can be service provided by health. However, supported accommodation also
undertakes a similar function, supporting people with mental health needs to stabilise their
lives, recover and live more independently. The Royal College of Psychiatry believe
rehabilitation services help people recover from the difficulties of longer-term mental health
problems. It will help and support people who still find it difficult to cope with everyday life
or get on with other people. It will aim to help you deal with problems, to get your confidence
back, and to help you to live as independently as possible. Many NHS regions in the UK
have mental health rehabilitation units. Just over half are based in the community and the
rest are based in hospital sites. Around half of NHS Trusts in England also have community
rehabilitation teams who work with people after they have left hospital and moved to
supported accommodation.

These services support people who have made the move from a rehabilitation unit to some
form of supported accommodation, but who require ongoing support with their day-to-day

lives, both social and personal.

Email:
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX

The community rehabilitation team can give more specialised support than the more
general community mental health teams. The team will continue the work of the
rehabilitation unit. They will work with you to update your care plan and make sure that it
progresses. They will support residents with managing medication, looking after the home,
and social and leisure activities. It is this type of model that may be considered as part of

the review described below.

West London and Central London CCGs have been commissioning inpatient ‘open’
rehabilitation beds for Kensington & Chelsea and Westminster residents, at Horton
Hospital, which is a site providing a range of different rehabilitation services on the outskirts
of Epsom in Surrey. This has been a historical arrangement and these beds have provided
a safe and rehabilitative environment in which to develop people’s independent living skills,
normally after an acute episode, for those with complex and enduring mental health needs.

The goal is to prepare people to move towards more independent living.

It is important to bear in mind, however, that one size will not fit all; there are a number of
different categories of mental illness, and differing numbers of service users within each
group, each requiring specialised rehabilitation services and input and it is not possible to
meet the needs of all of these groups within one service or indeed within the local area.
Where possible, the Inner London CCG’s will work together to commission rehabilitation
as close to home as possible, but at present, there will always be situations where some
service users will require specialist rehabilitation in a setting which it is not possible to
provide for locally. The CCG, with partners, is also looking at the wider rehabilitation
pathway, demand across the pathway and potential solutions for longer term
commissioning of additional capacity to help manage demand, including some specialist

out of area placements.

The CCG continuously reviews all of the services commissioned, to ensure they are
responsive to changing population needs; the current service is good quality and provides
value, however it is provided in a hospital setting, with all of the limitations in terms of lack
of independence that this entails. It is also provided at some geographical distance from
the originating boroughs. Wherever possible it is preferable for patients to be treated within
the community, preferably close to or within their own community and support networks.

Community based services can deliver improved outcomes and are in line with how

nai
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX

patients tell us they would like to be supported. The aspiration is, where people are well
enough, we support their recovery and enable them to move towards more independent

accommodation, closer to family and support networks.

The CCG are working with Central & North West London (CNWL) NHS Trust to arrange
move on for residents currently in the rehabilitation inpatient beds at Horton. This work
includes ensuring that the residents themselves are at the centre of any move-on decision
making and there has been on-going engagement with the service users and their families

to date. The clinical view is that this will take until the end of this calendar year to complete.

As part of the review, the two CCG’s, RBKC, Westminster City Council and CNWL are all
working together to identify and explore any on-going needs and service developments
within the local areas which may arise from this. We all recognise the need to move service
users closer to their homes for mental health rehabilitation placements, to ensure better
connections are maintained with family, friends, and local mental health services that can
support service users on discharge. This is in line with best practice guidance, working
collaboratively to align with GP practices, health and support services, and existing
accommodation pathways across both boroughs, to create smoother step-down and step-
up transitions for people and contributing to a better experience and outcomes for service
users. The focus will be on improved quality and best value across the partnership. One of
the options being considered is the development of a local ‘wrap around community rehab
offer’, with support and rehabilitation services provided in a supported accommodation
setting. It is hoped that, if this is the preferred option, a service would be up and running

within 18 months.

Should the Coroner have any queries arising from this report or require any information to

be clarified they should not hesitate to contact me.

Yours sincerely

Principal Lawyer
Bi-Borough Legal Services

Royal Borough of Kensington and Chelsea, Westminster City Council

Email: hbest@westminster.gov.uk
DX: 84015 Kensington High Street 2
Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street, London W8 7NX