Lindsey Bailey

ote MPFT

x

NHS
Midlands Partnership
WHS Foundation Trust

A Keele University Teaching Trust

St Georges Hospital
Corporation Street
Stafford

ST16 3SR

5” August 2019

Dear Mr Haigh,
RE: Li Bai

Report to prevent future deaths

Thank you for your letter, dated 11 July, reporting a matter to us in accordance with the
Regulation 28 of the Coroner's (Investigations) Regulations 2013.

Following discussions with the teams involved, | am now in a position to respond to your
concerns stated in your letter around a significant lack of information being shared with
Miss Bailey's parents.

Following Lindsey’s death, can | assure you we have undertaken a thorough investigation
into the care delivered by the Trust.

We have considered carefully the difference between confidentiality whilst a patient has
capacity versus the engagement of families or carers where the patient has declined for
their information to be shared. We acknowledge that as a Trust we need to ensure all our
staff are actively embedding family involvement within their daily practice whilst
maintaining confidentiality. Whilst carer / family involvement (including gaining informed
consent to share information with families) is written into all of our Standard Operating
Procedures for assessment, we have identified that clear guidance and advice in engaging
with families where the patient has declined for information to be shared is required.

There is evidence from our electronic patient record system (RIO) that Lindsey had
requested appointments away from the family home as she wanted some privacy and didn’t
want information shared. A review of the notes confirms that Lindsey wanted privacy and

whilst there were appointments where she was happy for her family to be present and
involved, she had requested that she didn’t want her family to know all the detail around
what had been discussed. At times, Lindsey disclosed some delicate information which she
wanted kept in confidence, the notes state that this was troubling her and she found it
difficult talking to the team when the family were at home. From the notes, it is recorded
that Lindsey did not want to worry her family.

There is evidence that a carer’s pack was given to the family to support them throughout
Lindsey’s treatment and that both her mother and father utilised support from the CRHT
team via our client support line and issues were discussed and resolved by the team.
However there is no evidence in the notes to confirm that discharge plans and next steps
were discussed with the family prior to discharge.

Below is an outline of the actions implemented from this investigation alongside updates on
existing pieces of work related to improving the quality of interventions which families and
carers receive across our Trust.

1) To develop a standard letter template which is sent out to families and carers whose
family member have agreed for contact to be made. The letter will form part of our
Standard Operating Procedures for assessment across our Mental Health Pathways
and each letter will be modified to reflect the individual needs of the patient and
their family member.

The letter whilst respecting patient confidentiality will offer family members / carers
an opportunity to engage with services and receive support around their needs. This
maybe by providing information to aid care plan development and /or offer
education and reassurance to family members of the interventions that are planned
where sharing of information has been agreed and offer a contact point should any
concerns arise.

This development is being supported by the Trust Involvement and Experience
Team. Once agreed this letter will be included in all mental health pathways
Standard Operating Procedures. This will be implemented by November 2019.

2) As part of the work to improve Carer Engagement the Trust is in the process of
developing a Carer Engagement Standard Operating Procedure for Crisis Response
Home Treatment Services which details the standards expected in respect of holding
conversations with patients around family and carer involvement at first contact,
and this then to be re-visited at every future appointment with the patient to ensure
opportunities are not missed. Once developed this will be rolled out across all

Mental Health Pathways. This will be completed and implemented by December
2019.

3) A bespoke training programme to be introduced to staff around engaging with
families and carers. The programme is currently be developed and led by our
Involvement and Experience Team. A Steering Group has been established, first
meeting on 237 August 2019, with service users and carers to plan for workshops
that will be held in October to design and develop the training package. This will be
delivered via face-to-face training for teams but also an e-learning package. We plan
to involve carer leads in the organisation, external carers’ organisations, Information
Management and Technology, Quality Improvement Team and the Information
Governance Team. Once the workshops are complete, we plan to roll the training
out from 1° January 2020 onwards organisation-wide.

4) All these actions will be monitored through the Performance Plus electronic action
tracking system and will be discussed at local Governance team meetings and where

appropriate escalated to the monthly Quality Governance Sub-committee.

| hope this response helps address your concerns however if you require any further
information please do not hesitate to contact me.

Yours Sincerely