Toby Nieland

Mr  Paul Smith 
HM  Senior  Coroner 
County  Of Lincolnshire 
4 Lindum Road 
Lincoln 
LN2  1NN 

Your  reference – 01388-2018 

8 October 2020 

Dear Mr Smith 

Regarding:  Regulation  28  report  to  prevent future deaths following the inquest 
of Toby Peter Edward Nieland 

Thank  you  for  affording  me  the  opportunity  to  respond  to  the  areas  of  concern 
highlighted  within Mr  Brennand's regulation  28 report  to prevent  further deaths. 

I  am  responding  to  the  report  as  the  substance  misuse  lead  for  the  Public  Health 
Division    a  part  of  the  Adult  Care  and  Community  Wellbeing  Directorate  at 
Lincolnshire  County  Council.  My  responsibilities  encompass 
the  programme 
management  of  substance  misuse  activity  within  the  directorate including overseeing 
substance  misuse  treatment  and  recovery  contracts  with  We  Are  With  You  and  any 
commissioning  activity    on  behalf  of  the  Director  of  Public  Health,  Professor 

.  

1. The concerns of the immediate family were not communicated to any of 
the agencies  charged  with the responsibility  of caring  for the deceased, 
nor were their views sought  (directly or indirectly)  as to the suitability  of 
the deceased's  accommodation and/or circumstances  and/or pathway of 
treatment and care; 

Mr  Nieland  was  not  receiving  structured  treatment  with  We  Are  With  You at the time 
of his death  but was accessing the Needle  Syringe  Programme (NSP).  

Public  Health  commission  the  NSP  using  NICE  guidelines  PH52  Needle  and Syringe 
Programmes which details the provision  required  including: 

  Advice  on minimising the harms caused by drugs 

  Help  to  stop  using  drugs  by  providing  access  to  drug  treatment  (for  example, 

opioid  substitution  therapy) 

  Access to other  health  and welfare services 

For  those  receiving  structured  treatment  it  would  be  good  practice  to  involve  the 
family  (if  appropriate  to  do  so).  However  the  NSP  is  designed  to  attract  those 

 
 
 
 
 
 
 
 
 undertaking  high  risk  behaviour  so  they  can  be  accessed  anonymously  and  only 
basic 
information  is  gathered  for  reporting  purposes.  This  encourages  those 
reluctant  to  access  service  to  obtain  clean  equipment  and  minimise  the  spread  of 
blood  borne viruses such as hepatitis  C and HIV. 

During  the  period  Mr  Nieland  was  struggling  with  his  illnesses  the  family  may  have 
benefitted  from  accessing  the  carers  support  service  commissioned  by  the  council. 
This  service  has  a  substance  misuse  provision  to  support  families  and  carers  of 
those  suffering  from  drug  or  alcohol  misuse.  It  is  recognised  this  did  not  take  place 
and  many  people  in  this  situation  do  not  see  themselves  as  carers  and  may  not 
access  the  service,  this  situation  is  being  addressed  by  the  current  service  and  will 
form part of the considerations  when re-commissioning. 

Future commissioning  considerations  and actions 

i.  The  NSP  is  commissioned  in  line  with  NICE  PH52  guidelines.  Public  Health 
will  continue  to  undertake  this  responsibility  and  family  members  will  be 
engaged  as  part  of  the  pre-procurement  work  that  builds  the  service 
specification  and future delivery  model 
Timeframe October 2023 

ii.  The  council  will  consider  commissioning  a  specific  substance  misuse  family 
service  to  offer  specialised  support  to  the  families  and  carers  of  people  with 
drug and alcohol  problems  
Timeframe June  2022  

2. Unequivocal  evidence  established  that the deceased  suffered from an 
advanced  progressive  addiction overlaid  with a vulnerable  personality 
amounting to a complex Dual Diagnosis  – the significance  of which was 
not appreciated  and therefore not managed adequately  or appropriately; 

The  substance  misuse  services  commissioned  by  Public  Health  with  We  Are  with 
You  are  voluntary.  I  believe  numerous  attempts  were  made  to  encourage  Mr Nieland 
in  to  the  service  but  this  was  unsuccessful.  NICE  guidelines  PH52  state  NSP 
services should   

  Offer  (or  help  people  to  access):  secondary  care  services  (for  example, 

mental health  services)  

This  is  dependent  on  the  client  wanting  to  access  the  support.  Engagement  cannot 
be forced as this can have a profound  effect on long term outcomes. 

We  Are  With  You  are  commissioned  to  work  in  partnership  with  other  agencies 
including  mental  health  services,  and  should  a  referral  be  received  from  mental 
health  services  it  is  expected  that  holistic  joint  working  is  undertaken  and  clear 
pathways  should be in place for joint  working.   

Future commissioning  considerations  and actions 

i.  A  joint  working  protocol  is  in  place  but  has  not  been  widely  implemented 
across  all  services.  The  CCG,  LPFT,  We  Are  With  You  and  Public  Health 
should  work  together  to  review  this  protocol  and  implement  a  more  robust 

 
 
 
 
 
 referral  pathway  between  services  to  ensure  timely  and  appropriate  services 
can be accessed by all. 

Timeframe – Review  to commence October 2020 

3. In any event,  even on the basis  upon which community care was 
deemed appropriate,  there was an absence  of any co-ordination 
between mental health service  provision  and addiction  services; 

Mr  Nieland was not in structured treatment with substance misuse services. If he had 
been,  the  substance  misuse  provider  is  commissioned  to  work  in  partnership  with 
mental  health  treatment  services  to  ensure  that  a  comprehensive package of care is 
delivered.  This  process  is  not  currently  working  universally  across  all services which 
needs  to  be  addressed  by  both  commissioners  and  providers  to  ensure  everyone 
with  coexisting  mental  health  and  substance  misuse  issues  receives  timely  and 
appropriate  care packages. 

Future commissioning  considerations  and actions 

i.  There  needs  to  be  greater  strategic  and  operational  coordination  between 
commissioners  and  providers.  A  group  led  by  mental  health  commissioners 
should  review  and  revise  the  existing  protocol  to  ensure  all  managers  and 
staff  have  clear pathways to follow within mental health and substance misuse 
services 

Timeframe – Review  commenced October 2020 

ii.  The  council  and 

the  CCG  should  consider  different  approaches 

to 
commissioning  services  that  cater  for  those  with  dual  diagnosis,  this  should 
form  part  of  the  commissioning  cycle  and  include  alternative  models  and joint 
commissioning opportunities 

Timeframe - October 2023  

4. There was an absence  of any adequate  "Care Programme Approach" (a 
package  of care used to plan mental health care) resulting in no care 
coordinator  being appointed to monitor the deceased  within the auspices 
of an appropriate  care plan; 

This  concern  is  linked  to  the  services  commissioned  by  the  Clinical  Commissioning 
Group  and  provided  by  Lincolnshire  Partnership  NHS  Trust.  If  Care coordination is in 
place  it  is  imperative that the substance misuse services work in partnership with the 
mental health  team to provide  a comprehensive  individually  tailored  care package. 

5. Inadequate  evaluation  of the deceased's  previous  history; his purported 
non-concordance  (repeated  assertions  of not wanting treatment/support 
that ought to have been interpreted  as an increase  in his risk); 
progression  of his complex vulnerabilities;  his personal  circumstances 
(reaction  to accommodation and relationships);  events  suggestive  of on-going 
misuse of drugs - all gave rise to a missed opportunities  to appreciate  a 

 
 
 
 
 
 
 
 
 
 
 series  of ascertainable  relapse  signatures; 

The  services  commissioned  for  substance  misuse  treatment  have  embedded 
assessment  processes and re-engagement polices that all staff are expected to work 
to.  Unfortunately  in  this  case  Mr  Nieland  was  not  in  structured  treatment  and  the 
needle  syringe  programmes  are  designed  to  attract  those  reluctant  to  access  main 
stream  services  to  ensure  people  do  not  feel  pressured  while  doing  so.  Service 
users  may  use  many  different  NSP  sites.  The  specialist  sites  such  as  the  one 
commissioned  with  We  Are  With  You  in  Grantham  offer  a  wider  choice  of  services 
including  more  in  depth  harm  minimisation  and  onward  referral  to  any  agency 
including  mental  health  services. 

Future commissioning  considerations  and actions 

i.  Services  will  continue  to  be  commissioned  in  line  with  NICE  guidelines  PH52 
Needle  and  syringe  programmes.  That  said,  We  Are  With  You  are  looking  to 
enhance  the  questions  asked  when  people  attend  NSP's  with  immediate 
effect.  These  changes  will  be  considered  when  developing 
future 
commissioning  models  to  ensure  service  match  the  needs  specific  to 
Lincolnshire.  This  process  will  apply  to  both  NSP  and  the  wider  treatment 
service 

Timeframe  –  October  2020  for  the  changes  to  questionnaire  and  October  2023  for 
re-commissioning 

6. The absence  of any "assertive  outreach"  to the deceased  when 
discharged  into the community (that is to say,  no face to contact, no 
alternative  welfare checks  being organised,  undue reliance  being placed 
on the informal supervisory  role of the landlord  or other agencies)  gave 
rise to a total disconnect  between patient and healthcare  provider, 
thereby creating  a series  of missed opportunities  to assess  the 
deceased,  identify possible  relapse  signatures  and potentially  escalate 
care; 

This  concern  is  linked  to  the  services  commissioned  by  the  Clinical  Commissioning 
Group  and provided  by Lincolnshire  Partnership  NHS  Trust. 

7. The circumstances  of this case evidences  a gap in the provision of care 
to a patient with a Dual Diagnosis in Lincolnshire  by reason of there 
being no dedicated  and/or commissioned drug and alcohol  recovery 
team/service; 

Substance  misuse  dual  diagnosis  provision  is  not  commissioned  as  a  separate 
service  but  is  included  within  the  main  treatment  contract  with  We  Are  With  You. 
Within the current contract the service is asked to: 

  Work  in  partnership  with  mental  health  teams  and  other  Providers  of  mental 
health  services  to  provide  the  best  co-ordinated  care  possible  to  manage 
Service Users with dual  diagnosis 

 
 
 
 
 
 
 
   Develop  strong  partnerships  and  where  appropriate 

joint  working 
arrangements  with  mental  health  services  to  ensure  that  all  clients  requiring 
support  and  treatment  for  any  identified  mental  health  needs  can  access  and 
are engaged  in appropriate  services 
Involvement  in  the  writing  and  delivery  of  training  to  generic  and  specialist 
staff regarding  mental health  and dual  diagnosis 

 

  Ensuring  staff  have  appropriate 

training  and  competencies,  which  are 

appropriately  recorded, to enable  them to address dual  diagnosis 

To  achieve  this  We  Are  With  You  have  developed  their  staffing  model  to  include  a 
mental  health  trained  nurse  and  specialist  recovery  worker  who  is allocated any dual 
diagnosis  cases.  This  process  has  worked  well  within  inpatient  settings  but  is  still 
developing  across community mental health  services. 

Future commissioning  considerations  and actions 

i.  All  commissioners  and  providers  should  review  current  models and revise the 

joint  working  protocol  

Timeframe  –  To  commence  October  2020  –  to  be  completed  by  April  2021 
dependent  on Covid 19 impacts 

ii.  The  substance  misuse  provision  for  dual  diagnosis  will  be  a  central  point  of 
the  next  service  evaluation;  this  inspection  should  determine  if  current 
provision  is  adequate  and  appropriate  to  meet  the  needs  of  those  accessing 
the  service  and  make  recommendations  to  the  provider  and  commissioner 
regarding  provision  and future commissioning potential. 

Timeframe  -  September  2021  to  complete  the  review  (Covid  19  restrictions  may 
delay  this action)  

8. The Lincolnshire  Partnership NHS Trust document – "Crisis Assessment 
and Home Team Protocol" (Exhibit reference  IJ2)  makes no adequate  or 
appropriate  provision for a patient with Dual Diagnosis; 

This  concern  is  linked  to  the  services  commissioned  by  the  Clinical  Commissioning 
Group  and provided  by Lincolnshire  Partnership  NHS  Trust. 

9. The National Institute  for Health and Care Excellence  (NICE) Guideline 
Scope document "Severe  mental illness  and substance  misuse (dual 
diagnosis):  community health  and social care services  stipulates  that 
there should be a Dual Diagnosis  protocol setting out specifically  the 
roles of the mental health provider and the drug and alcohol  service 
provider (no such protocol being in place at the material time) and that 
whilst it is apparent that some thought has been deployed  to re-install a 
bridge between mental health provision  and drug and alcohol  services 
this does not address the needs of a patient  suffering from a complex 
Dual Diagnosis  in Lincolnshire  due to: 

a. The lack of interface  between senior or experienced  care providers  to 

 
 
  
 
 
 
 
 
 
 deal with multi-faceted  or nuanced  cases; 

The  current  protocol  was  developed  between  Public  Health,  Lincolnshire  Partnership 
NHS  Trust  and  We  Are  With  You (previously Addaction) in December 2016 (included 
as a separate attachment to this letter titled;  2016-12  DD Protocol V1.3.docx)   

This  protocol  takes  a  'no  wrong  door'  approach  to  engaging  with  dual  diagnosis 
patients  and  places  an  expectation  on  both  providers  to  work  together  and  develop 
integrated  care pathways.   

The  Regulation  28  report  has  allowed  all  parties  involved  to  review  and  reflect  on 
previous  shortfalls  in  delivery  and  a  new  impetus  to  resolve  the  remaining  delivery 
gaps is now evident. Work has commenced in October 2020 to review and revise  the 
protocol  and look at a system wide approach  to improve provision  even  further. 

Future commissioning  considerations  and actions 

i.  There  needs  to  be  greater  strategic  and  operational  coordination  between 
commissioners  and  providers.  The  existing  protocol  will  be  reviewed  and 
revised  to  ensure  all  managers  and  staff  have  clear  pathways  to  follow  within 
mental health  and substance misuse services 

Timeframe  –  Review  commenced  October  2020  to  be  completed  by  April  2021 
dependent  on Covid 19 impacts  

b. The absence  of specialist  Dual Diagnosis  workers to be deployed  in 
complex cases; 

The  response  to  question 7 details the provision in place from We Are With You. The 
specification for the service is outcome focussed and expects the provider to meet all 
relevant  guidance  and  provide  the  support  and  care  appropriate  for  those  using  the 
service  to  make  a  full  and  sustainable  recovery.  This  includes  dual  diagnosis.  The 
current  provision  is  sufficient  to  manage  need  however  if  joint  working  grows 
significantly  this  will  be  reviewed  as  part  of the on-going management of the contract 
between  Public Health  and  We Are with You. 

Future commissioning  considerations  and actions 

i.  Consider  different  approaches  to  commissioning    substance  misuse  services 
including  more joined  up initiatives  with the CCG's and  other key partners 

Timeframe – October 2023 

c.  The  absence  of  adequate  and  robust  guidance  and  training,  in particular for 
mental  health  practitioners  to  be  aware  of  substance  misuse  issues  and  a 
patient  suffering  from  Dual  Diagnosis  that  impact  on  appropriate  pathways  of 
treatment and care; 

The substance misuse treatment specification states: 

  Providing  advice,  support,  training  and  skills  transfer  to  the  wider  workforce in 
identification,  brief  advice,  early  intervention  and 

to  prevention, 

relation 

 
 
 
 
 
 
 
 
 
 
 
 appropriate  referral  into  specialist  treatment.'  This  provision  is  in  place  and 
available  for Lincolnshire  Partnership  NHS  Trust to access. 

In  addition  to  the  training  available  through  We  Are  With  You,  Public  Health  in 
partnership  with  We  Are  With  You  run  four  Royal  Society  for  Public  Health  (RSPH) 
accredited  courses  per  annum  on  Understanding  Substance  Misuse  and 
Understanding  Alcohol  Misuse.  These  courses  are  open  to  anyone  interested  in 
raising  their  awareness  of  alcohol  or  drug  issues.  Unfortunately  due  to  the  Covid  19 
Pandemic  these  courses  are  currently  suspended  but  will  be  resumed  as  soon  as 
possible. 

Conclusion  and future considerations 
The  provision  to  support  those  with  a  dual  diagnosis  has  improved  over  the  last  18 
months  with  many  organisations  working  closely  together  and  joint  meetings  taking 
place.  However  this  is  not  currently  uniform  and  work  still  remains  to  embed  dual 
diagnosis  best practice across all service areas 

Public Health  see the following  as the main points for action going  forward 

i.  Ensure  any  engagement  work  which  informs  future  commissioning  includes 

dual  diagnosis support and fully  involves  clients and  their families 

ii.  Consider  redesigning  the  support  service  for  families  of  those  suffering  from 
substance  misuse  issues  so  they  can  access  support  to  help  cope  with  and 
aid the recovery  of their loved  one 

iii.  Participate  in  a  joint  working  group  to  review  and  implement  a  new  working 
protocol  led  by  mental  health  services  and  incorporating  all  aspects  of 
substance misuse and mental  health 

iv.  Continue  to  take  into  account  current  local  and  national  best  practice  for  joint 
working  across  mental  health  and  substance  misuse  services  when  re-
commissioning future  drug and alcohol  services 

v.  Undertake  an  operational  level  review  of  dual  diagnosis  provision  within 

substance misuse services as part of the next  annual  inspection 

vi.  Consider  different  approaches  to  commissioning    substance  misuse  services 
including  more  partnership  commissioning  with  the  CCG  and  other  key 
partners 

The  Coexisting  Severe  Mental  Illness  and  Substance  Misuse:  Community  Health 
and  Social  Care  Services  guidance  acknowledges  there  is  a  national  system  wide 
issue with the commissioning of services that cater for dual diagnosis,  It states: 

 

In  the  UK,  service  configurations,  treatment  philosophies  and  funding  streams 
act  as  barriers  to  providing  coordinated  care.  Separate  mental  health  and 
substance  misuse  services  are  usually  provided  by  different  organisations, 
have  different  organisational  and  managerial  structures,  and  staff  within  each 
service  often  lack  the  knowledge  and  skills  needed  to  work  effectively  with 
people  from another  organisation. 

We  recognise  this  is  a  national issue and Public Health is not complacent in trying to 
navigate  complex systems to support those who are vulnerable   

 
 
 
 
 
 
 I  hope  the  above  has  provided  some  reassurance  that  Public  Health  take  its 
responsibility  to  commission  substance  misuse  services  very  seriously  and  that  a 
stronger  emphasis  on  dual  diagnosis  has  a  part  to  play  in  current  and  future 
commissioning.  We  will  work  with  all partners to develop services further and embed 
best practice in areas where this is not yet fully  implemented.   

Yours sincerely 

Programme Manager 
Public Health  Division 
Adult  Care and Community Wellbeing 
Lincolnshire  County  Council

Our ref:  SC/DC/HMC/2020 

Mr Paul Smith  
HM Senior Coroner – Lincolnshire  
4 Lindum Road 
Lincoln  
LN2 1NN 

Office of the Chair and CEO 
Trust Headquarters 
St George’s 
Long Leys Road 
Lincoln 
LN1 1FS 

Email: 

Tel: 01522 309200 
@nhs.net  

15 October 2020 

Dear Mr Smith  

In  the  matter  of  Toby  Nieland  deceased  -  REGULATION  28  REPORT  TO  PREVENT 
FUTURE DEATHS - Response of Lincolnshire Partnership NHS Foundation Trust  

The  Trust  wishes  to  express,  once  again  its  sincere  condolences  to  Mr  Toby  Nieland’s 
family  and  loved  ones  on  his  untimely  death.  Owing  to  the  seriousness  of  the  concerns 
raised  by  both  HM  Senior  Coroner  and  the  deceased’s  family  at  the  inquest  hearing,  the 
Trust  immediately  began  communicating  with  its  commissioning  and  provider  partners  to 
highlight  the  matters  raised.  The  Trust  is  grateful  to  HM  Senior  Coroner,  Mr  Timothy 
Brennand, for his report of 26 August 2020.   

The Clinical Commissioning Group, as the commissioning body, is submitting a coordinated 
response; this letter will be included as an appendix. 

Following consultation with the Trust’s Executive Directors, I respond to each of the points 
raised  in  Mr Brennand’s  report  as  stated  below.  I  have  further summarised  our actions at 
the end of this response, with the responsible leads for each action.  

1.  The  concerns  of  the  immediate  family  were  not  communicated  to  any  of  the 
agencies  charged  with  the  responsibility  of  caring  for  the  deceased,  nor  were 
their  views  sought  (directly  or  indirectly)  as  to  the  suitability  of  the  deceased's 
accommodation and/or circumstances and/or pathway of treatment and care. 

Trust Response:  

The  Trust  appreciates  the  importance  and  benefits  of  understanding  the  views  of 
patients’  families  and  carers.  It  is  also  recognised  that  concerted  efforts  need  to  be 
made  to  support  staff  to  consider  the  voice  of  carers.    To  address  this,  the  Board  of 
Directors  and  Council  of  Governors  have  given  a  clear  message  of  expectation  that 
carers are seen as a priority and that their needs are considered.  The Trust has put in 
place  a  range  of  services  that  support  carers  and  provide  helpful  information  on  a 
routine basis:- 

  Upon inpatient admission, the Trust provides information to a patient’s family and/or 
carer.    The  information  document  is  also  publically  available  to  view  and  download 
from the Trust’s website https://www.lpft.nhs.uk/download_file/1876/0  

Chair: 
Chief Executive: 
www.lpft.nhs.uk 

                                            
 
 
                                              
 
 
 
 
 
 
 
   The  Trust  offers  a  dedicated  email  address  for  family  and  carers  to  communicate 

with the patient’s clinical team.  lpft.carers@nhs.net  

  A carers’ newsletter is produced and circulated on a monthly basis.    

  At the time of writing, 93 trust staff are trained in Meriden Behavioural Family therapy 
and a further 50 staff members are scheduled to receive this specialist training by the 
end  of  January  2021.  This  is  a  dynamic  training  programme  that  educates  staff 
regarding  the  importance  of  involving  families  and  carers;  it  also  teaches  ways  in 
which family and carers members can be supported. 

  The Trust has introduced a dedicated member of staff as a ‘Carer Lead’ for each of 
its  inpatient  units  across  Lincolnshire.    The  Carer  Lead  is  available  on  the  ward  to 
patients,  families  and  carers  and  is  identified  through  the  wearing  of  an  orange 
lanyard. 

  The Trust offers specialist individual support to carers and families in times of crisis.  

The referral for this level of support is received via the patient’s clinical team. 

  The Trust offers fortnightly education and support groups based in both Lincoln and 
Boston.  During the Covid-19 pandemic, the groups continue to operate temporarily 
via virtual meetings.    

  Dedicated  ‘Family  and  Carers’  notice  boards  have  been  introduced  on  every 

inpatient ward offering a wide range of information.  

  A  smartphone  ‘WhatsApp’  group  has  been  set  up  to  provide  another  source  of 

information sharing and communication. 

  Accreditation  under  the  Triangle  of  Care  initiative,  with  the  Trust  having  been 

awarded two stars under this national scheme. 

  A Carers Strategy that has been co-produced with carers and with Trust Governors. 

  An Executive Director sponsor who has executive oversight and is a member of the 

Board of Directors.  

In cases where explicit consent has not been given by a patient to share their sensitive 
personal  information;  the  Trust  has  taken  action  to  remind  clinicians  that  information 
from families and carers can still be received.  The Carers Lead for the Trust continues 
to  work  with  the  Divisional  Leads;  Learning  and  Development  and  also 
the 
Communications  Team  to  reinforce  the  message  to  staff  that  they  can  still  receive 
information from Carers and Families even when consent is not given from  the patient 
to share information.  In Mr Nieland’s case it was unfortunate the Trust were not made 
aware  of  any  concerns  held  by  the  family,  however  there  is  the  clear  commitment  to 
learn from this and to consider what needs to be in place to strengthen communication 
and to actively encourage feedback.   

2 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 As  a  provider  of  specialist  mental  healthcare,  the  Trust  recognises  the  role  of 
appropriate  accommodation  in  a  patient’s  recovery,  although  was  not  aware  of  the 
details of Mr Nieland’s accommodation to which he was discharged in 2018. 

The  Trust  recognises  the  need  for  appropriate  communication  between  partner 
agencies to provide collaborative health and social care and support to patients and is 
committed  to  continuously  reinforce  this  message  to  all  staff.    The  Trust  now  works 
closely with a number of partners from the Voluntary, Community and Social Enterprise 
sector  in  Lincolnshire  including  Carers  First  and  Everyone,  and  has  developed  good 
working relationships, which have led to identified placement options for patients being 
discharged from hospital. 

The  Trust  is  working  with  Local  Authority,  District  Councils,  Commissioners  and  NHS 
England/Improvement  on  a  joint accommodation  strategy  for those  with  mental health 
and  social  care  needs,  to  ensure  the  system  is  working  together  on  more  responsive 
and effective housing solutions for our service users.  

2.  Unequivocal evidence established that the deceased suffered from an advanced 
progressive  addiction  overlaid  with  a  vulnerable  personality  amounting  to  a 
complex  Dual  Diagnosis  –  the  significance  of  which  was  not  appreciated  and 
therefore not managed adequately or appropriately. 

Trust Response:  

The  term  dual  diagnosis  can  be  used  to  cover  a  broad  range  of  coexisting  mental 
health  conditions  alongside  problems  with  drug  or  alcohol  use,  the  common  theme 
being the presence of both drug/alcohol and mental health conditions at the same time. 
This  means  that  a  person’s  presenting  needs  can  vary  significantly.    There  are 
recognised  challenges  in  providing  effective  treatment  for  this  group  of  patients;  most 
notably, the individuals’ willingness and ability to engage.  

Due to Mr Nieland’s fluctuating mental health needs and the fact that he was deemed to 
have capacity to make his own life choices, there were times when he was not engaged 
with mental health services and the Trust was not legally able to enforce any treatment 
upon him.  When Mr Nieland was engaged with the Trust’s services, there is evidence 
that  his drug  and  alcohol issues  were  being  appropriately  considered  and  advice  was 
being  given.  However,  successful  treatment  for  drug  and  alcohol  addiction  requires 
continued engagement, and in Mr Nieland’s case unfortunately the Trust was limited in 
its powers to enforce any treatment. 

3. 

In  any  event,  even  on  the  basis  upon  which  community  care  was  deemed 
appropriate,  there  was  an  absence  of  any  co-ordination  between  mental  health 
service provision and addiction services. 

Trust response: 

There  is  evidence  from  the  clinical  record  that  Trust  staff  believed  Mr  Nieland  was 
effectively engaging with Addaction (as it was known then) and that he was happy with 
the support he was receiving. Based upon information available at the time there was 

3 

 
 
 
 
 
 
 
 
 
 no known need for the Trust to pursue any additional support for his drug and alcohol 
problems. 

Upon  reflection,  subject  to  explicit  consent, the Trust  accepts  that  it  would  have  been 
best  practice  for  the  Trust  to  have  proactively  contacted  Addaction  to  ascertain  Mr 
Nieland’s level of engagement as it is evident from the subsequent information provided 
by Addaction that Mr Nieland was not engaged in the level of structured treatment that 
the  Trust  staff  believed  he  was.  More  proactive  contact  with  Addaction  would  have 
identified this mismatch between what Mr Nieland was reporting and his actual level of 
engagement.  In  turn,  this  would  have  enabled  Trust  staff  to  challenge  Mr  Nieland’s 
claims  about  his  drug  and  alcohol  treatment  and  provide  an  opportunity  for  further 
encouragement to seek out appropriate support, although it would not have been able 
to enforce or change any such treatment without Mr Nieland’s engagement.  

The  Trust  has  in  place  a  policy  which  provides  guidance  in  cases  where  patients 
present with high severity of mental health and substance misuse…  

 “…Service  users  should  be  engaged  with  secondary  mental  health  services.  This 
would include Integrated Community Teams, forensic, rehabilitation and acute services. 
Case  management/care  coordination  would  rest  with  these  services  with  additional 
support from substance misuse services. This support can include consultation, advice 
or direct intervention to the service user and their care network”. 

The  Trust  and  ‘We  Are  With  You’  (as  Addaction  is  now  called)  will  work  together  to 
ensure  the  implementation  of  robust  communication  systems;  agree  appropriate 
information  sharing  arrangements  and  ensure  alignment  of  clinical  pathways  and 
protocols,  with  the  aim  to  make  collaborative  working  between  the  two  organisations 
standard  practice.  The  Trust  confirms  this  is  part  of  its  work  plan  over  the  next  six 
months,  led by  the  Clinical  Director for the  Community  Services  Division  working  with 
the Quality lead for the Division. 

4.  There was an absence of any adequate "Care Programme Approach" (a package 
of  care  used  to  plan  mental  health  care)  resulting  in  no  care  coordinator  being 
appointed  to  monitor  the  deceased  within  the  auspices  of  an  appropriate  care 
plan. 

Trust Response:  

The Trust has in place a comprehensive clinical care policy which sets out the criteria 
and  process  for  assessing  and  putting  in  place  care  arrangements.    In  Mr  Nieland’s 
case,  following  his  discharge  from  inpatient  services,  in  accordance  with  Trust  policy 
and national guidance, the Trust made arrangements with Mr Nieland to meet with him 
to assess his needs.  It is possible that Mr Nieland could have been placed on a Care 
Programme Approach, however he  did not attend and sadly the opportunity to assess 
his needs  in  this regard  did  not  take  place.    Whilst  he  was  not managed  on  the  Care 
Programme Approach framework, a lead professional was assigned to Mr Nieland and 
risk assessment was formulated together with a care plan. 

Learning  from  the  death  of  Mr  Nieland,  the  Trust  will  strengthen  the  policy  in 
accordance  with  the  guidance  issued  by  the  Department  of  Health,  to  ensure  where 
patients identify as having a dual diagnosis, they are provided with an enhanced Care 

4 

 
 
 
 
 Programme Approach.  Clear guidance will be given to staff regarding procedure in the 
case  of  persons  with  dual  diagnosis.  The  Head  of  Quality  and  Safety  will  lead  on  the 
review  and  strengthening  of  the  policy,  working  towards  the  policy  update  being 
approved by the Trust’s Quality Committee, within the next 6 months.   

5. 

Inadequate  evaluation  of  the  deceased's  previous  history;  his  purported  non-
concordance (repeated assertions of not wanting treatment/support that ought to 
have  been  interpreted  as  an  increase  in  his  risk);  progression  of  his  complex 
vulnerabilities;  his  personal  circumstances  (reaction  to  accommodation  and 
relationships);  events  suggestive  of  on-going  misuse  of  drugs  -  all  gave  rise  to 
missed opportunities to appreciate a series of ascertainable relapse signatures. 

Trust response: 

factors  mentioned  above 

Learning from the tragic death of Mr Nieland, the Trust has taken steps to enhance the 
training offered to staff about assessing risk of suicide to reinforce the complex interplay 
of 
including  previous  history,  accommodation  and 
employment  needs,  substance  and  alcohol  misuse  patterns  and  relationships.  This 
revised suicide prevention training will be rolled out to all staff commensurate with their 
role and clinical responsibility, within the next 6-12 months.  

The  Divisional  leads  are  working  closely  with  the  Learning  and  Development  Lead  to 
develop a time table and identify appropriate staff for training.    

6.  The  absence  of any  "assertive  outreach"  to  the  deceased when discharged into 
the  community  (that  is  to  say,  no  face  to  contact,  no  alternative  welfare  checks 
being organised, undue reliance being placed on the informal supervisory role of 
the  landlord  or  other  agencies)  gave  rise  to  a  total  disconnect  between  patient 
and  healthcare  provider,  thereby  creating  a  series  of  missed  opportunities  to 
assess  the  deceased,  identify  possible  relapse  signatures  and  potentially 
escalate care. 

Trust response: 

The  Trust  was  informed  by  the  out  of  area  inpatient  unit  that  Mr  Nieland  had  been 
discharged into the community.  In accordance with Trust policy and national guidance, 
the  Trust’s  Crisis  Resolution  and  Home  Treatment  Team  offered  timely  follow-up 
appointments with Mr Nieland to assess his risk and care arrangements.  Based upon 
the  information  available  at  the  time,  a  clinical  decision  to  request  a  police  welfare 
check was not considered necessary.   The Trust appreciate the importance the views 
of  family  and  carers  has  in  formulating  appropriate  care  arrangements  for  patients.  
With  the  benefit  of  hindsight,  it  is  accepted  that  the  knowledge  and  concerns  of  Mr 
Nieland’s family would have better informed assessment of risk. The Trust is continuing 
to support staff and to emphasise the importance of working and supporting patients to 
include  family  and  carers  in  their  care.    The  response  under  section  1  of  this  letter 
outlines the initiatives behind this.      

5 

 
 
  
 
 
 7.  The  circumstances  of  this  case  evidences  a  gap  in  the  provision  of  care  to  a 
patient  with  a  Dual  Diagnosis  in  Lincolnshire  by  reason  of  there  being  no 
dedicated and/or commissioned drug and alcohol recovery team/service. 

Trust response: 

The Trust recognises there is currently a commissioning gap in the provision of care to 
patients  identified  as  having  a  dual  diagnosis.  Currently  mental  health  services  and 
substance  misuse  services  are  commissioned  separately  in  Lincolnshire  with  the 
services  provided  by  two  organisations.    The  Trust  is  a  provider  of  specialist  mental 
health  services  and  is  not  commissioned  to  provide  substance  misuse  services.  The 
local  Clinical  Commissioning  Groups  (CCG)  and  the  Local  Authority’s  Public  Health 
department commission ‘We Are With You’ (formerly ‘Addaction’) to provide substance 
misuse services.   

Learning  from  the  death  of  Mr  Nieland,  as  stated  above,  the  Trust  commits  to  the 
strengthening of its policy in accordance with the guidance issued by the Department of 
Health, to ensure where patients identify as having a dual diagnosis, they are provided 
with an enhanced Care Programme Approach which will include working together with 
‘We  Are  with  You’.    Clear  guidance  will  be  given  to  staff  regarding  policy  and 
procedures  in  the  case  of  persons  with  dual  diagnosis.    Further,  the Trust  commits to 
working  with  its  partner  agency  ‘We  Are With  You’,  to  review  and  strengthen  working 
arrangements. 

Further, as stated above, the Trust and ‘We Are With You’ commit to working together 
to  ensure  the  implementation  of  robust  communication  systems;  agree  appropriate 
information  sharing  arrangements  and  ensure  alignment  of  clinical  pathways,  with  the 
aim  to  make  collaborative  working  between  the  two  organisations,  standard  and 
practice. The Trust confirms this will be part of its work plan within the next six months, 
led by the Clinical Director for the Community Services Division working with the Quality 
lead for the Division 

8.  The  Lincolnshire  Partnership  NHS  Trust  document  –  "Crisis  Assessment  and 
Home  Team  Protocol"  (Exhibit reference  IJ2) makes  no adequate  or  appropriate 
provision for a patient with Dual Diagnosis. 

Trust response 

The Trust confirms, as stated above, that it will review its clinical policies and protocols 
relating to dual diagnosis and that it  will continue to work with its partner agency, ‘We 
Are  With  You’  to  review  and  strengthen  robust  communication  systems;  to  agree 
appropriate  information  sharing  arrangements  and  ensure  alignment  of  clinical 
pathways  through  the  use  of  a  jointly  agreed  protocol.    The  aim  is  to  make 
collaborative, integrated working between the two organisations standard practice.  This 
will be part of its work plan within the next six months, led by the Clinical Director for the 
Community Services Division working with the Quality lead for the Division. The policies 
and protocols will equally apply to patients being treated within its inpatients and crisis 
and home treatment services too.  

6 

 
 
 
 
 
 
 9.  The  National  Institute  for  Health  and  Care  Excellence  (NICE)  Guideline  Scope 
document  "Severe  mental  illness  and  substance  misuse  (dual  diagnosis): 
community health and social care services stipulates that there should be a Dual 
Diagnosis protocol setting out specifically the roles of the mental health provider 
and the drug and alcohol service provider (no such protocol being in place at the 
material time) and that whilst it is apparent that some thought has been deployed 
to  re-install  a  bridge  between  mental  health  provision  and  drug  and  alcohol 
services  this  does  not  address  the  needs  of  a  patient  suffering  from  a  complex 
Dual Diagnosis in Lincolnshire due to; 

a. The lack of interface between senior or experienced care providers to deal with   

multi-faceted or nuanced cases. 

b. The absence of specialist Dual Diagnosis workers to be deployed in complex 

cases. 

c.  The  absence  of  adequate  and  robust  guidance  and  training,  in  particular  for 
mental  health  practitioners  to  be  aware  of  substance  misuse  issues  and  a 
patient suffering from Dual Diagnosis that impact on appropriate pathways of 
treatment and care. 

Trust response: 

Learning from the death of Mr Nieland, as stated above, the Trust is committed to the 
strengthening  of  its  policies  and  protocols  in  accordance  with  the  guidance  issued  by 
NICE and the Department of Health, to ensure where patients identify as having a dual 
diagnosis,  they  are  provided  with  an  enhanced  Care  Programme  Approach  which  will 
have  joint  working  with  We  Are  with  You’,  utilising  expertise  of  workers  from  both 
services in a collaborative manner.  The Trust has already begun conversations with its 
Commissioning  partners  and  We  Are  With  You,  to  identify  commissioning  gaps  and 
ways of ensuring workers with the right skills are deployed in both agencies.   

The Trust is committed to a review of the training provided to staff to ensure they are 
appropriately  equipped  with  the  knowledge  and  ability  to  care  for  patients  with  dual 
diagnosis.    The  Learning  and  Development  Lead  is  working  with  Divisional  staff  to 
develop the appropriate training package, over the next 6-12 months.  

We have summarised below the actions the Trust will take to learn from Mr Nieland’s death 
and  enhance  services  for  patients  with  a  complex  dual  diagnosis  presentation:  To  review 
internal policies and protocols as well as work together with  “We Are With You” to embed 
care pathways between the two organisations to address gaps in services. (Leads: Clinical 
Director for Community Division and Quality Lead for the Community Division) 

i.  To embed care pathways between the Trust and “We Are With You” to address gaps 
in services. This will also be accompanied by a discussion with the Commissioners 
to  advocate  for  the  right  level  of  investment  in  the  system  to  meet  the  needs  of 
people  with  a  dual  diagnosis.  Leads:  Quality  Lead  for  the  Community  Division  and 
Clinical Director for Community Division – by 31 April 2021.  

7 

 
 
 
 
 
 ii.  To  review  Information  sharing  arrangements  between  the  Trust  and  “We  Are  With 
You”  to  remove  barriers to  information  sharing  while  complying  with  legal guidance 
Lead: Trust Caldicott Guardian – by 16 November 2020. 

iii.  Education and Training: The Trust commits to reviewing and updating its training and 
competencies  programme  on  offer  to  ensure  a  focus  on  dual  diagnosis,  including 
clinical  presentations,  risk  assessment  and  information  sharing.    We  have  recently 
developed  a  refreshed  suicide  prevention  training  matrix  which  addresses  risk 
assessment  but  will  work  on  the  other  areas.  Leads:  Learning  and  Development 
lead, People Directorate – by 31 October 2021   

iv.  To  reinforce  and further embed  the  important  role of  carers and family  members in 
providing  the  right  quality  care  to  patients  and  to  support  carers  in  getting  involved 
with  their  loved  ones’  care,  including  receiving  information  from  carers  and  sharing 
information with consent from patients. Lead: Service Manager for Carers and Peer 
Support – Ongoing  

v.  To  review  the  Care  Programme  Approach  to  ensure  the  right  decisions  are  made 
about allocating care coordinators to patients and also to ensure that all patients with 
a  dual  diagnosis  are  allocated  a  care  coordinator.    Lead:  The  Trust  Quality  and 
Safety Lead – by 31 April 2021. 

vi.  To continue to engage with Commissioners and all system partners including primary 
care,  acute  care  services,  and  housing  partners  (not  named  in  the  letter  but  we 
recognise  the  importance  of  all  partners  in  the  system)  to  ensure  the  services 
required  for  patient  with  dual  diagnosis  are  appropriately  funded  –  clinical, 
management and leadership and administrative support. Lead: Director of Strategy, 
Planning and Partnerships - on-going 

vii.  Promote appropriate data gathering, benchmarking with other services, opportunities 
for  research  and  learning  from  Serious  Incidents  as  a  system  working  in  an  open, 
collaborative manner.  Lead: Medical Director - on-going       

Yours sincerely  

Acting Chief Executive  

8

Mr. Paul Smith 
HM Senior Coroner 
4 Lindum Road 
Lincoln 
Lincolnshire 
LN2 1 NN 

LincsCoroner@lincolnshire.gcsx.gov.uk 

14th October 2020 

Dear Mr Smith 

REF: Mr Toby Peter Edward Nieland, Regulation 28 Report 

I am writing in response to the Regulation 28 report which Mr. Brennand  sent to the South 
Lincolnshire Clinical Commissioning Group, Public Health Lincolnshire, Lincolnshire Partnership 
NHS Foundation Trust (LPFT) and to 
(formally Addaction). 

, Deputy Chief Executive at We Are With You 

(Ref 01388-2018 dated 24th August - which has been 

In Mr. Brennand’s  letter to Mr 
shared with us as the commissioned treatment service of substance misuse in Lincolnshire) he 
said that the  report was  designed to emphasise the need for collaborative services to meet the 
health and social care needs of those suffering from Dual Diagnosis. He  indicated that he  was 
anticipating a response that addressed the integrated approaches being considered involving 
statutory, community and voluntary sector mental health and substance misuse services, with 
agreed local pathways to meet wider social care needs.  He  said that  he  anticipated a response 
that confirmed the expectations that mental health services would be leading on, and helping 
with, access to other health and social care services (including primary healthcare, housing and 
employment as well as substance misuse services). 

I can confirm that we have participated in  ‘Planned Dual Diagnosis Work” meetings with LPFT and 
our respective commissioners.  And we have jointly agreed to review Dual Diagnosis pathways 
across the treatment system. 

The report outlines a number of concerns identified through the inquest and following further 
submissions from LPFT  and the Lincolnshire  Clinical Commissioning Group.   I would like to 
provide you with a summary of actions undertaken to improve our overall effectiveness of  joint 
working, engagement, and care of our service users:-

1 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 ●  We understand that a balance regarding questioning  people whilst encouraging them to 
continue to engage in  NSP services is required. The  potential risk of ‘over questioning' is 

that service users  may decide to  attend alternative NSP provision where such questions 
will not be asked, or even stop using services.  In this case  specialist service providers may 
lose the opportunity to monitor and assertively attempt to engage those individuals into 
structured treatment. 

●  Our staff now use a ‘prompt system’  at each visit. These include discussions around the 
persons initial presentation, mental and physical health, housing needs, harm reduction, 
more in depth substance use and clarifying and discussing referrals into structured 
treatment should it be required and consented to. 

●  We have introduced better identification of those with complex health issues.  We have 

implemented an enhanced standard questionnaire for our NSP service users. It 
incorporates questions to ascertain concerns individuals may have on their own mental 
health and current engagement with mental health (or any other relevant) services.  The 
aim is to enable the key-worker to make better informed decisions of any immediate 
concerns / risks surrounding an individual’s mental health, based on presentation  and 
information disclosed. 

●  We have reviewed our staff structures and introduced specialist Dual Diagnosis roles. We 
have taken steps to employ staff who can lead on complex cases, including a  dedicated 
Mental Health Nurse and a Recovery Worker who is allocated Dual Diagnosis cases. Our 
Clinical Lead is a registered (NMC) Mental Health Nurse and Independent Prescriber with 
MSc level qualifications in substance misuse, neuropsychiatry and trauma.   These roles 
work in partnership with mental health providers to enhance the care provided service 
users. They also  train and support the wider substance misuse team at LFPT in early 
identification of those individuals with complex health issues. 

●  We have enhanced our reciprocal training to LPFT and regularly attend interface meetings 
for Dual diagnosis patients and ensure we have  input into community release plans. 
Additionally, we provide opportunities for staff from  LPFT , the Police, Probation and 
Children's Services as well as housing providers. to spend time within our teams to further 
their experience of substance misuse interventions.  We have commenced delivery of 
group work interventions within the Mental Health units in Lincoln (Discovery House and 
PHC) for those with a dual diagnosis. 

We recognise that there is further work to do between ourselves, LPFT and the wider partnership 
to enhance pathways and joint  care for those with complex health issues.   We are committed to 
achieving  this through  working collaboratively with our relevant partners and respective 
commissioners for Mental Health and Substance Misuse.  Should you  require any further 
information or clarification on any of the points included in this summary please do not hesitate to 
contact me. 

Yours Faithfully 

Director of Operations 

@wearewithyou.org.uk 

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