Tyla Cook

*§ Norfolk County Council Fe cioar

County Hall
Martineau Lane
Norwich

NR1 2DH

PRIVATE AND CONFIDENTIAL
Ms Jacqueline Lake Tel: 0344 800 8020
’ Senior Coroner for Norfolk
Norfolk Coroner Service Ena: i _ 7
Carrow House
301 King Street : 11 November 2019
Norwich
NR12TN

Dear Ms Lake

Thank you for your Regulation 28 report of 17 September 2019 and your considered
recommendations. This letter provides an overview of the actions we have taken
following Tyla’s death and responds to the specific points in your report.

Following Tyla’s death the Norfolk Safeguarding Children Board (naw Norfolk
Safeguarding Partnership) commissioned a Serious Case Review to ensure that all
learning from the circumstances of Tyla’s death has been captured and that all
agencies take the necessary steps to put this learning into practice. The decision to
undertake a serious case review was agreed at the Serious Case Review Group of
12 February 2018.

Following the appointment of an independent lead reviewer the first scoping meeting
took place on 1 May 2018 and the multi -agency panel have provided single-agency
chronologies and undertaken interviews with all of the professionals involved with
Tyla.

The final draft report, with findings and recommendations will be signed off today, 11
November 2019 at the Safeguarding Practice Review Group. Children’s Services
havé a Service Director and a Senior Officer as members of this group and ensure
the governance arrangements are robustly upheld and implemented. Once the final
report is published we will ensure that a copy is also sent to your office.

There are five overarching learning themes from the review. They relate to better
adolescent care pathways, to embed an environment where the fundamental issues
in relation to contextual safeguarding are better understood, for a holistic family
approach to be better understood and for courageous conversations to take place
throughout and across organisations. In essence a whole system approach to
working with children, young people and their families.

Although these are recommendations from this particular review, they are all areas

of work that are currently underway and being adopted in our eae poge to working
with children and families.

www.norfoik.gov.uk

The majority of the specific points made in your report relate to actions to be taken
by our health partners. We have been in liaison with health colleagues on these
matters and the various health partnerships will be providing you with their joint
response to the recommendations pertinent to them.

The specific recommendations for Children’s Services was in relation to attending a
learning review in relation to the case. A task and finish group has been established,
coordinated by West Norfolk CCG to oversee the learning review with your
recommendations in mind. | can confirm that a formal learning event took place on 7
November 2019 whereby all professionals and their managers who worked with Tyla
were invited. !n addition, a further event will take place in early February 2020.
Invites will go out to NCC Social Care, NSFT staff, East of England Ambulance and
QEH.

| hope | have been able to assure you that we are taking all recommendations
seriously and continue to work collaboratively with our partners to learn the lessons
highlighted in this case.

Head of Paid Service

www.norfolk.gov.uk

INHS

‘Norfolk and Suffolk

NHS Foundation Trust

Private & confidential Trust Management
Ms Jacqueline Lake 1° Floor Admin
Senior Coroner for Norfolk Hellesdon Hospital
Norfolk Coroner Service Drayton High Road
Carrow House ‘ ' Hellesdon
301 King Street Norwich
Norwich NR6 5BE
NR1 2TN

5 November 2019
Dear Ms Lake
Re: Regulation 28: Report to Prevent Future Deaths (17/09/2019) — Tyla Katherine Joan Cook

In response to the concerns raised in the above report in relation to Norfolk and Suffolk NHS
Foundation Trust, | have provided details below of actions taken or proposed to be taken to address
these issues. ,

Concern 1:

It was agreed at the CETR meeting on 9" August 2017 that Tyla was to be seen by the Eating
Disorder Service. He was not seen until 25" October 2017. The evidence was the 11 week delay in
seeing Tyla was due to a heavy caseload and the practitioner ‘having to remove other cases from his
caseload before he was able to work with Tyla. ,

Trust response to concern 1:
In order to prevent delays accessing care when a service user presents with complex
co-morbid mental health conditions the following process has been developed.

The care coordinator will ask other teams to joint work and/or provide consultation to ensure all
relevant expertise is promptly accessed. Input from another team will be prioritised according
to risk and not held on a waiting list if there is an urgent need. Any concerns regarding capacity
and access to care will be escalated to the locality operational manager.

A service user may have a care co-ordinator from one team, such as Youth, and a co-worker
from another team, such as Eating Disorders. The teams will work closely together to ensure
that relevant interventions and treatments are offered in line with the service user’s care plan.
Reviews and meetings will include professionals from all the care teams involved. The service
user and family/carer will be kept informed throughout.

Concern 2:

There were no written up-to-date care and crisis plans in place. The most recent written care plan
related to Tyla being an inpatient at the Dragonfly Unit, from where he was discharged on

9 August 2017: The written plans were therefore several months out of date. This is against

Trust Policy. , : ;

Evidence was heard that at a CETR meeting on 6 November 2017 a period of a further’3 months was
requested to prepare an up-to-date written care plan. In the event, and despite the family's repeated
requests for plans in writing, it was decided that the care plan could be commenced by

30 November 2017, on the basis Tyla’s input into the care plan was important and it would take time to
gain his meaningful input. The evidence was that there were oral plans in place which were relayed to

+ @ i + : Chair: Marie Gabrie| CBE Chief Executive: Jonathan Warren a
Bl) em Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE
“ for better mental health Tet: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk

=

the-parents (including at times of distress), who continued to request plans in writing. The high level of
distress and anxiety within Tyla’s home was recognised. An interim written plan was not considered
nor that a written plan may have helped the family in providing support to Tyla. Steps have been taken
by the Trust to recognise when up-to-date written care plans are not in place and it is understood that
staff have undergone some work in improving the quality of care plans. However, in this case an
active decision was made not to update the written plan for some time. Further evidence did not reveal
any insight into the support a written plan could have given the family to support Tyla.

Trust response to concern 2:

NSFT recognises the importance of care plans for all service users and that these need to be
done in collaboration with the service user and their families / carers if possible. However, in
some circumstances this can take time in which case an interim care plan will be put in place
whilst a more comprehensive and collaborative plan is being developed.

In addition Tyla’s discharge from Dragonfly was not planned and so there was not an
opportunity at that point to adjust the care plan or crisis plan in preparation for his return to
community services. We have recognised that we did not have a robust process in place to
ensure this does not happen in the future.

We have developed the attached process whereby in the future, for any service user who is
discharged from an inpatient unit without the normal discharge planning process happening,
we will ensure that on leaving the ward the service user and their family / carers are provided
with written emergency contact information and an interim safety plan.

The care co-ordinator must arrange to review the service user within 7 days as per national
standards. At this meeting they will review the care and crisis plan and update accordingly.
They will provide written copies to the service user and their family / carers as appropriate. _
There will be a CPA meeting arranged within 28 days to further review the care and crisis plan
with the whole team working with the service user.

In some circumstances service users do not wish to share confidential information with their
families or carers. However, we recognise the importance of still sharing emergency contact
information and a safety plan with families and carers.

A programme of training being rolled out offers training in care planning and crisis or safety
planning with all staff which will ensure the above changes are embedded within teams.

Concern 3: :

The review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended
a multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust,
Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be
developed and implemented to train staff on how to apply good non-technical skills (teamwork,
leadership, task prioritisation and communication) when responding to an emergency. At the inquest it
became clear that no steps have been taken to organise this event and there is confusion as to who is
responsible for arranging this learning event. The care providers indicated it was for the West Norfolk
Clinical Commissioning Group. The West Norfolk Clinical Commissioning Group do not appear to
accept responsibility for organisation of the event. Tyla died on 15 November 2017. The West Norfolk
Clinical Commissioning Group review was published 8 May 2019. No steps have been taken with
regard to this learning event, save East of England Ambulance Service Trust who has been in contact
with the West Norfolk Clinical Commissioning Group. There is concern that a multi-disciplinary
learning event will not be organised and will not take place.

Trust response to concern 3:

There is a multi-agency meeting fixed for the 4th November which our Head of Patient Safety,
Saranna Burgess, will attend with representatives from all the other organisations involved to
plan this. :

at Ss Worki g together Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren
asVe2 ms oe a Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE
i for better mental health tet: 01603 421421 Fax: 01603 421341) www.nsftnhs.uk

Itrust that the above responses address your concerns.

Yours sincerely

Jou Ver
Jonathan Warren
Chief Executive

ails kj Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren
<0) ee Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich b NR6 SBE

“= for better mental health Tel: 01603 421421 Fax: 01603 421341 www.nsft.nhs.uk

Ve

INHS

TT hy e The Queen Elizabeth
19 _ Hospital King’s Lynn

NHS Foundation Trust

The Queen Elizabeth Hospital
Gayton Road

Kings Lynn

Norfolk

PE30 4ET

www.qehkI.nhs.uk

8 November 2019

Mrs J Lake

HM Coroner for Norfolk
Carrow House

301 King Street
Norwich

NR1 2TN

Dear Mrs Lake

Inquest - Tyla Katherine Joan Cook — Regulation 28 Reply

| am writing in response to your report made under Regulation 28 of the Coroners
(Investigations) Regulations 2013 where at paragraph 5(3) you refer to a recommendation
contained in the West Norfolk CCG’s Review in May 2019 that there should be a multi-
disciplinary learning event arranged between the participants. Your concern was that no clear
steps had been taken to organise the event by the time of the inquest in September.

| am pleased to be able to advise you that on 4° November a meeting was held at Chatterton
House in King’s Lynn and present were senior staff from all of the key participants, namely the
Director of Nursing and Quality Assurance - West Norfolk CCG (Chair), the Deputy Director for
Patient Safety and Quality - Norfolk & Suffolk NHS Foundation Trust, the interim General
Manager - East of England Ambulance NHS Trust, the Approved Mental Health Professional
(AMHP) Team Manager - Norfolk County Council, and the Deputy Director of Patient Safety from
this Trust. Other support staff were in attendance. One of the main agenda items was for the
learning event to be arranged and it was decided that a date would be selected in February 2020
and that the West Norfolk CCG would take the lead in organising the venue and facilitating the
event with support and contribution from the other participants. | hope very much that the
event will be a success and will play its part in reducing clinical risk in future.

Please let me know if you require any further information.
Yours sincerely
CAN.

Caroline Shaw
Chief Executive

Private and Confidential
Mrs Jacqueline Lake
Senior Coroner for Norfolk
Norfolk Coroner Service

INHS)

West Norfolk

Clinical Commissioning Group

King’s Court

Chapel Street

Norfolk

PE30 1EL

Tel: 01553 666900
www.westnorfolkccg.nhs.uk

Carrow House
301 King Street
Norwich

NR1 2TN

11 November 2019

By post and

Dear Mrs Lake

Re: The late Tyla Katherine Joan Cook

Regulation 28 Report to Prevent Future Deaths dated 17 September 2019: West Norfolk
CCG’s response

| refer to the Report to Prevent Future Deaths (PFD) dated 17 September 2019 issued following
the Inquest into the death of the late Tyla Katherine Joan Cook.

The PFD Report was sent to West Norfolk Clinical Commissioning Group (CCG) together with the
Chief Executives of Norfolk and Suffolk NHS Foundation Trust (NSFT), The Queen Elizabeth
Hospital King’s Lynn NHS Foundation Trust (QEH) and Norfolk County Council (NCC). It was also
copied to East of England Ambulance Service NHS Trust (EEAST) as an Interested Person for the
Inquest.

Point 3 of section 5: Coroner's matters of concern in the PFD Report relates to a multi-disciplinary
learning event involving participants from NSFT, QEH, NCC and EEAST. This matter of concern is
jointly addressed to West Norfolk CCG, NSFT, QEH and NCC (‘oint addressees’) who are under a
duty to respond by 12 November 2019.

This letter comprises West Norfolk CCG’s response to the Point 3 of section 5 of the PFD Report.
Copies of this letter will be sent to the Chief Executives of the joint addressees and also, for
information, to the Chief Executive of EEAST.

Commissioning NHS Services for West Norfolk
Chair: Dr Paul Williams Accountable Officer: Melanie Craig

Point 3 of Section 5: Coroner’s concerns

For ease of reference, Point 3 of Section 5 is set out below (using the above abbreviations for the
stakeholders):

“3. The Review carried out by the West Norfolk CCG in May 2019 recommended a multi-
disciplinary learning event involving participants from NSFT, QEH, NCC and EEAST
be developed and implemented to train staff on how to apply good non-technical skills
(teamwork, leadership, task prioritisation and communication) when responding to an
emergency.

At the inquest it became clear no steps have been taken to organise this event and
there is confusion as to who is responsible for arranging this learning event. The Care
providers indicated it was for West Norfolk CCG. The West Norfolk CCG do not
appear to accept responsibility for organisation of the event.

Tyla Cook died on 15 November 2017. The West Norfolk CCG Review was published
8 May 2019. No steps have been taken with regard to this learning event, save
EEAST who has been in contact with the West Norfolk CCG. There is concern that a
multi-disciplinary learning event will not be organised and will not take place.”

West Norfolk CCG response

Background and context

The Review referred to at point 3 of Section 5 comprises Recommendation 2 of the Action Plan to
the independent Investigation Report dated 08 May 2019 (the ‘Action Plan’ and ‘Investigation
Report’) compiled by an independent reviewer commissioned by West Norfolk CCG.

The key points of Recommendation 2 are summarised as follows:

1. A multi-disciplinary learning event (‘the learning event’) involving participants from NSFT,
NCC, EEAST and QEH must be developed and implemented to train staff on how to apply
good non-technical skills when responding to an emergency.

2. QEH to set up a pan-Trust and West Norfolk CCG task and finish group (‘the task and
finish group’) to develop the learning event designed for NSFT, QEH, NCC, West Norfolk
CCG and EEAST.

3. The task and finish group to be led by QEH’s named Deputy Director of Patient Safety with
the group's members from each organisation to include NSFT, EEAST and NCC with their
representatives also named.

4. The task and finish group led by QEH’s Deputy Director of Patient Safety to deliver the
learning event.

5. The target dates for implementation of the task and finish group and delivery of the fearning
event were 30 June.2019 and 31 October 2019 respectively.

6. West Norfolk CCG has associated monitoring responsibilities for Recommendation 2 (via
our Serious Incident Review Panel) to include that the learning event has taken place.

The Investigation Report was issued in the week before the initial date for the Inquest to
commence in May 2019 and provided to the Coroner at that time. The proximity of the dates of the
issue of the Investigation Report and Inquest aside, the plan was that the learning event would
take place after conclusion of the Inquest. This was in order for any learning or other issues from
the Inquest to be captured in one event.

In the event, as the Inquest was deferred from the initial date of May 2019 to September 2019, the
date of delivery of the learning event was in turn deferred. However this did not preclude initiating
and undertaking the action required to set up the task and finish group and preliminary
arrangements for the learning event.

Issues
The issues in point 3 of section 5 comprise:

° Issue 1:
Clarification and confirmation of the lead organisation with responsibility for organising the
learning event

° Issue 2:
The organisation and delivery of the learning event to ensure and assure that it takes place

Issue 1: Lead organisation for the learning event

Recommendation 2 clearly states that firstly, the task and finish group is responsible for the
implementation of the recommendation (i.e. is the ‘action owner’). Secondly, that QEH and its
Deputy Director of Patient Safety are the organisational and individual leads respectively for this
recommendation.

The CCG was not aware that there was any issue about the lead for Recommendation 2 until we
received QEH’s submissions dated 15 September 2019 made to the Coroner in respect of
prevention of future deaths via our solicitors on 16 September 2019. This was despite requesting
each of the 3 NHS trusts to provide an update to us on the relevant actions for their organisation
by Friday 30 August 2019. This was both to monitor progress but also in anticipation that the
Coroner may require and request this information.

Neither NSFT nor QEH responded to us specifically as regards Recommendation 2. On 30 August
2019, EEAST advised us that it was taking part in ‘a workshop with all involved’ and was awaiting
dates to be shared and further information.

Paragraph 25 of the QEH submissions states that a meeting took place on 24 June 2019 between
QEH’s Medical Director and Deputy Director of Patient Safety and the CCG’s
Director of Nursing and Quality Assurance (QA) and Deputy Director of Nursing and QA to discuss
the taking forward of a ‘joint training event’.

Further information regarding this meeting was provided in the statement of QEH’s Deputy Director
of Patient Safety dated 16 September 2019 which we received after the conclusion of the Inquest
and receipt of the PFD Report. In the statement, the Deputy Director of Patient Safety refers to
Recommendation 2 Action 1 of the Action Plan and that he had been given an action to set upa
task and finish group and arrange a learning event. He references a meeting on 24 June 2019
which QEH's Medical Director J and he attended with the CCG’s Director of Nursing
and QA and Deputy Director of Nursing and QA. He states that this action was discussed and the
CCG agreed to facilitate and lead on it.

Having reviewed this statement, the CCG’s Director of Nursing and QA has confirmed that the
meeting on 24 June 2019 was set up in response to her letter of 10 May 2019 sent to QEH'’s then
Medical Directo Chief Nurse Advisor and Acting Chief Nurse. The letter referenced
the Investigation Report and assurance on the learning and associated actions and requested a
meeting with all QEH addressees to discuss the care and service issues identified for QEH in the
Investigation Report.

The CCG’s Director of Nursing and QA has confirmed that:

e Whilst she attended the meeting on 24 June 2019 with QEH’s Medical Director J
and Deputy Director of Patient Safety, the CCG's Deputy Director of Nursing and
QA was not present in relation to the discussion regarding the Investigation Report — also
confirmed by the Deputy Director of Nursing and QA.

¢ Her recollection of the meeting is that the CCG and QEH agreed that QEH would
commence or complete their actions on the Action Plan. Also that the CCG would defer its
action on Recommendation 7 — after-action review (i.e. until after Inquest). There was no
discussion regarding a {joint training event’ and/or Recommendation 2.

° Given the nature of the meeting, there was no requirement (or request) for formal minutes
to be taken, approved and circulated. She did not receive any written follow up from QEH
as to the outcome and actions from the meeting.

Accordingly there was no agreement by the CCG at that time or subsequently that the CCG would
take the lead on any training event or Recommendation 2.

In summary on this point relating to Recommendation 2:

e West Norfolk CCG has always understood and proceeded on the basis that QEH and its
Deputy Director of Patient Safety were the leads for Recommendation 2 and, prior to the
contact from the Coroner's officer during the Inquest, was not aware that there was any
issue relating to this.

e At no point did the CCG agree to take over from QEH as the lead on Recommendation 2
and/or any training event referred to in the Action Plan.

Given the specific and frontline nature of the action under Recommendation 2 which relates
to providers, the CCG would not have been an appropriate lead on this action and, for this
reason, would not have agreed to this. Our participation and involvement in the action and
task and finish group relates to advising the providers on the commissioning of any
services necessary to complete the action.

e Had QEH provided a written update of the outcome and actions to the CCG following the
meeting on 24 June 2019, any issues about the lead for Recommendation 2 could have
been identified and resolved at that point.

Similarly, this would have been identified and resolved if QEH had responded within the
deadline to the CCG’s request in mid-August 2019 for an update on its actions under the
recommendations in the Action Plan and specifically Recommendation 2. In the event, the
Deputy Director of Patient Safety responded on 16 September 2019 solely in relation
Recommendation 9 — Duty of Candour.

e Neither NSFT nor EEAST have indicated to the CCG at any point their understanding is
that the lead for Recommendation 2 was transferred from QEH to the CCG.

¢ In relation to the reference (in point 3 of Section 5) to EEAST’s contact with the CCG,
EEAST has confirmed that the only contact it has received centrally throughout the process
is from the CCG and the independent reviewer commissioned by the CCG. This is in
relation to the investigation or progress on the Action Plan.

On reflection, West Norfolk acknowledges that:

e The CCG having initiated the meeting with QEH on 24 June 2019, arrangements should
have been put in place for the outcome and actions from the meeting to be documented
and circulated within a reasonable timeframe for agreement by the attendees; and

e As QEH's response for an update on its actions on the Action Plan was not received by the
deadline of 30 August 2019, the CCG should have sent a further request soon after this
date and then escalated within QEH.

Actions

In relation to the lessons learned on this aspect and with the aim of preventing similar events
occurring:

1. The CCG will contact QEH as regards the implementation of agreed governance
arrangements for the management of less formal meetings.

Specifically that the outcome and actions from meetings will be documented and circulated
by a named person within a reasonable timeframe for agreement by the attendees (also
within a reasonable timeframe).

Action date: The CCG has identified a proposed CCG lead and a potential QEH lead for
this action. The CCG will contact QEH by Monday 25 November 2019 (i.e. after QEH has
received a copy of this letter).

2. The CCG will implement more robust governance arrangements for tracking QEH’s
responses to prescribed deadlines and action where these have not been met.

Action date: This action was commenced by the CCG on 06 November 2019 — a proposed
CCG lead and options for taking this forward have been identified.

Issue 2: Delivery of the learning event

In order to progress Recommendation 2 to completion, the action taken and proposed by West
Norfolk CCG comprises the following.

The CCG has:

e Arranged for the task and finish group (with attending representatives from NSFT, EEAST,
QEH, NCC and West Norfolk CCG) to meet on 04 November 2019 to discuss the
development of the learning event. Action completed 04 November 2019.

e Requested QEH (Risk and Safety team) to draw together the leaming from the
Investigation Report for consideration by the task and finish group (in line with Action 1 of
Recommendation 2). Action completed 01 November 2019.

The task and finish group meeting on 04 November 2019 was attended by representatives (the
‘group members’) from NSFT, EEAST, QEH, NCC and the CCG and chaired by the CCG.

The actions (with provisional timescales to be confirmed by the group members) agreed at the task
and finish group meeting are ongoing and include:

e Tyla’s parents are to be updated by the CCG as to the action that has been taken and is
proposed in relation to Recommendation 2.

e The learning event is to be arranged to take place for mid-February 2020 (this broadly
equates to the same period for implementation of the learning event in the Action Plan in
relation to the Inquest date).

e An External facilitator for the learning event has been identified by West Norfolk CCG and
is available for the proposed date of the learning event.

e The materials to be developed for the learning event are to include a pen portrait of Tyla
(his parents are to be invited to share their wishes on this), changes made by NSFT and
QEH in light of the incident and key messages from the staff involved in the incident.
Information regarding the relevant Lessons Learnt will also be included e.g. Lesson Learnt
12 - Monitoring of acute physical health deterioration.

e As part of the sharing and dissemination of the outcomes of this incident and the
Investigation report, the invitees to the learning event are to include senior operational staff
from the Emergency Department at Norfolk and Norwich University Hospitals NHS
Foundation Trust (NNUH) and James Paget University Hospitals NHS Foundation Trust.

| hope that this response addresses the issues raised in the PFD Report as these relate to West
Norfolk CCG and is of assistance to you.

Should you require any further information or wish to discuss with me, please may | request that
you contact i, my PA, in the first instance, who will make the necessary arrangements.

BB c2n be contacted on (IED by emcil: Sa

In the meantime, | propose to update you about the outcome of the learning event when it has
taken place early next year.

Yours sincerely

Gh

Cath Byford

Chief Nurse

The NHS Clinical Commissioning Groups for Norfolk and Waveney
CC:

Professor Jonathan Warren, Chief Executive, NSFT

Andrew Proctor, Executive Leader, NCC

Caroline Shaw, Chief Executive, QEH

Dorothy Hosein, Interim Chief Executive, EEAST

Melanie Craig, Chief Officer, NHS Clinical Commissioning Groups for Norfolk and Waveney

} Associate Director of Nursing and Quality, NHS Clinical Commissioning Groups for
Norfolk and Waveney