Allan Joslin

NHS}

Professor Stephen Powis
National Medical Director
Skipton House

80 London Road

SE1 6LH

Lydia Brown

HM Coroner for Exeter and Greater Devon

Greater Devon

Room 226

County Hall

Topsham Road

Exeter

Devon Ex2 4QD 11 October 2019

Dear Ms Lydia Brown,

Re: Regulation 28 Report to Prevent Future Deaths — Mr Allan Graham Joslin, deceased
23.05.2018

Thank you for your Regulation 28 Report (hereinafter the ‘report’) dated 17" July 2019
concerning the death of Mr Allan Joslin on 23 May 2018. Firstly, | would like to express my
deep condolences to Mr Joslin’s family.

| note that your recent inquest into the death of Mr Joslin concluded that Mr Joslin died as a
result of drug intoxication. The inquest found that Mr Joslin did not receive an appropriate
service in accordance with his needs and presenting vulnerabilities, and there were missed
opportunities to diagnose and treat his mental ill-health and dependency on drugs and alcohol.

Following the inquest you have now raised concerns in your report for the attention of the Chief
Executive of NHS England regarding the following:

1) The unavailability of an adequate mental health care facility or safe room within the
treating NHS Trust to deal with a patient who presented with complex needs, including
the need for a mental health assessment, and drug and alcohol dependency issues,
who was ‘potentially violent; and

2) Despite the Trust in question having now put in place new policies and _ facilities to
safely treat patients with a history of violence, the evidence still | suggested that this is
an ongoing concern and difficulty for other Trusts across the country.

It is unclear from your report if a copy has been sent to the Trust; it is likely to be useful for the
Trust to see your report if they have not already had it. Given the concerns you have raised in
your report | can confirm that | have ensured that a copy alongside this reply has been sent to
the NHS England and NHS Improvement Safeguarding Lead for the South West region.

The Health and Social Care Act 2012 transferred statutory responsibility for the commissioning
of public health services, including drug and alcohol services, to local authorities. NHS England
and NHS Improvement do recognise it is a very important issue, with significant implications for

NHS England and NHS Improvement

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the mental health of individuals, particularly for those affected by coexisting severe mental
illnesses (SMI) and substance use, like Mr Joslin. We also recognise the importance of
ensuring closer working between mental health services and substance use services to ensure
that people’s needs are met in an integrated, holistic and timely manner.

In recognition of the above, including the specific concerns you raise regarding the provision of
secondary care to those most vulnerable in society, | can confirm we are taking specific steps
to improve access to, and quality of, support for people with co-existing SMI and substance
use. The NHS Long Term Plan, published earlier this year, details how new and integrated
models of primary and community health services will transform the delivery of mental health
care for adults and older adults with SMI, including people with complex needs and co-existing
substance use. As the NHS Mental Health Implementation Plan 2019/20 — 2023/24 sets out,
-this new community-based offer is backed by significant investment over the next five years.
The Implementation Plan is available here: —https://www.longtermplan.nhs.uk/wp-

content/uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-2023-24. pdf.

NHS England and NHS Improvement have also committed to investing up to £30 million over
the next 5 years to establish 20 new specialist mental health services for rough sleepers. These
new services must be trauma informed, (i.e. they must reduce harm and promote healing,
especially in individuals who have already experienced trauma’), and part of an existing
approach to supporting rough sleepers, which includes existing drug and alcohol support.” It is
important that all Mental Health Trusts, regardless of whether they receive this funding, work
closely with local authorities and partners from the Voluntary, Community and Social Enterprise
(VCSE) sector to better support rough sleepers.

To support improvements in the commissioning and provision of services for people with co-
existing SMI and substance use in the community, the National Institute for Health and Care
Excellence (NICE) published a national guideline (NG58) in November 2016, which is available

online here: https://www.nice.org.uk/quidance/ng58.

NICE has also published a specific national guideline (CG120) on ‘Coexisting severe mental
illness (psychosis) and substance misuse: assessment and management in healthcare
settings’. This sets out guidance on how referral processes between primary and secondary
care should work, and specifies the need for a joined-up, holistic approach that ensures people

1 Bowen, E.A. and Murshid, N.S. (2016) Trauma-informed social
policy: A conceptual framework for policy analysis” and advocacy.
American journal of public health
2 The Centre for Mental Health notes that a trauma informed care incorporates:
¢ Listening to the experiences of people accessing, and working for, the service;
¢ Seeking to understand and respond in ways that are appropriate to a particular
person or situation;
* Welcoming dialogue;
* Being willing and able to have difficult conversations;
¢ Reflecting on what is working and what is going wrong, in order to learn and
improve;
* Being open to change when things are no longer working.
Please see the following link for more details:
https://www.centreformentalhealth.org.uk/sites/default/files/2019-
04/CentretorMH EngagingWithComplexity.pdf ;
NHS England and NHS Improvement

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are not excluded on account of their drug or alcohol use.

)
NICE is also expected to publish a new quality standard on this topic soon to provide further
detail to clinical teams as to how they can best meet the needs of this group of people. Its draft
standard is available online here: https://www.nice.org.uk/quidance/gid-
qs10078/documents/draft-quality-standard.

In 2016, the Royal College of Psychiatrists produced a guide on the ‘Assessment and
management of risk to others’ (httos:/Avww.rcpsych.ac.uk/docs/default-
source/members/supporting-you/managing-and-assessing-

risk/assessmentandmanagementrisktoothers.pdf?sfvrsn=a614e4f9_ 2) for use by psychiatrists
and other healthcare professionals. This is based on the College’s report, first produced in 2016

and updated in 2017, ‘Rethinking risk to others in mental health services’

(https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-

reports/college-report-cr201.pdf?sfvrsn=2b83d227_ 2). Both the guide and report make clear
that understanding an individual's history of violence or risk to others is vitally important in

informing the way in which risk is assessed, managed and mitigated overall. The guide sets out
detail as to the ways in which mental health staff assessing an individual and formulating a care
plan should enquire about evidence of violence or thoughts of violence. This includes the nature
of its past or potential future interaction with someone’s illness, current mental state, and drug
and alcohol use. It adds that clear communication of the outcome of risk assessment and the
management plan is essential between clinical teams and other mental health provider staff.

In light of the concerns you have raised, | have arranged for this guide and report to be drawn
to the attention of all NHS mental health trusts in England. This will be communicated via NHS
Improvement’s provider bulletin in October 2019. :

Thank you for bringing these important patient safety issues to my attention and please do not
hesitate to contact me should you need any further information.

Yours sincerely,

——z

Professor Stéphen Powis
National Medical Director
NHS England and NHS Improvement

NHS England and NHS Improvement

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