Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0219, written 28 Oct 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Oct 2020 |
|---|---|
| Reference | 2020-0219 |
| Deceased | Darrell Sharples |
| Coroner | Andrew Cox |
| Coroner area | Cornwall and the Isles of Scilly |
| Category | Suicide (from 2015) · Mental Health related deaths |
| Organisation named | Cornwall Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: CONTROLLED Information Classification: CONTROLLED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mr CORONER 1 , Assistant Chief Constable, Devon & Cornwall Constabulary I am Andrew Cox, the Acting Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 12 October 2020, I concluded an inquest into the death of Darrell Sharples who died on 21 July 2018, then aged 49. . The medical cause of death was recorded as: 1a) Asphyxia; 1b) Hanging 1c) II) I recorded a Conclusion of Suicide. 4 CIRCUMSTANCES OF THE DEATH The circumstances leading up to Mr Sharples death are set out in the attached summing up and judgment. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. May I please direct your attention to pages 21-23 of the attached summing up. ViST forms. These generate a lot of data about potentially vulnerable individuals. I consider deaths may be prevented in the future where that data could be appropriately shared with partner agencies. I have in mind, in particular, Cornwall Partnership Foundation Trust and Kernow Clinical Commissioning Group (on behalf of GPs.) I recognise there is a need to limit or prioritise the data shared so that it is manageable and targeted to the most vulnerable and/or those at greatest risk of harm or self-harm. I further recognise that there may well be legitimate concerns about data protection. I was told this may be overcome where a particular individual consents to the sharing of data. Where someone refuses to consent, however, I accept sharing may be more problematic and legal advice may be required. 1 Information Classification: CONTROLLED Information Classification: CONTROLLED Custody Access to CJLDT Assessments and Consideration of Ramifications of Imposing Bail Conditions on Vulnerable Individuals. At his assessment by CJLDT in May 2018, it had been recognised that was a strong protective factor keeping Darrell from harming himself. After his release from custody in July 2018, a bail condition was (correctly) imposed that he was not to contact his wife. This had the unintended consequence of removing that strong protective factor. In the event those in custody had known of the assessment in the CJLDT records, that may have had an influence on assessing Darrell’s risk to himself at the point of release. It may have led to a request to an HCP or CPFT to re-assess Darrell’s risk to himself. It may be that the standard questions completed by custody sergeants could be amended to require an Officer to review or have reviewed any assessment in CJLDT prior to the imposition of a bail condition on a vulnerable individual and his release from custody. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23/12/20. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [ interest being Dr Deputy Director of Primary Care in KCCG. While it is a matter for you, it may be that you will feel there would be some value in exploring these issues on a multi-agency basis. ]. I am also sharing this letter with those who I think may have an , Joint Interim Medical Director at CPFT and Ms , I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 [DATE] [SIGNED BY CORONER] 28/10/20 2 Information Classification: CONTROLLED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Dr , Interim Joint Medical Director, Cornwall Partnership Foundation Trust 1 CORONER I am Andrew Cox, the Acting Senior Coroner for the coroner area of Cornwall and the Isles of Scilly. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 12 October 2020, I concluded an inquest into the death of Darrell Sharples who died on 21 July 2018, then aged 49. . The medical cause of death was recorded as: 1a) Asphyxia; 1b) Hanging 1c) II) I recorded a Conclusion of Suicide. 4 CIRCUMSTANCES OF THE DEATH The circumstances leading up to Mr Sharples death are set out in the attached summing up and judgment. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. At inquest, I heard evidence from a Mr telephone triage assessment of Mr Sharples. I have set out where I felt that assessment was inadequately conducted in the attached judgment. who, on behalf of CPFT, conducted a Of particular concern was the fact that Mr was, at best, vague about whether he was familiar with the Trust’s Operational Policy to which, at Appendix 1, were attached the relevant eligibility criterea. Of further concern was that he was not aware of the Triage guidance the Trust had produced. I made clear my view that any clinician performing that role had to be familiar with both documents. I have been told that the Trust has moved to a ‘needs-based’ evaluation system and that fresh guidance is being produced to assist those performing triage assessments. You may feel that the Trust needs to be confident that all those performing triage assessments in the future will be familiar with the revised triage guidance and Operational policy and has a robust system in place to ensure this is the case. 1 Information Classification: CONTROLLED 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23/12/20. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [ ]. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 [DATE] [SIGNED BY CORONER] 28/10/20 2
3 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr Andrew J Cox
Senior Coroner
Cornwall & Isles of Scilly Coroners’ Area
Dr
Interim Medical Director
Head Office
Beacon Technology Park
Dunmere Road
BODMIN
PL31 2QN
14 December 2021
Dear Mr Cox
Re: Inquest into the death of Darrell Francis SHARPLES, concluded 12/10/2020
Regulation 28 Report to Prevent Future Deaths - update
With regard to the concerns you raised following the inquest identified above, and further to the
my response of 16/02/2021, and the joint response with partner agencies of the 17/02/2021, I
write to provide an update of the actions taken by Cornwall Partnership NHS Foundation Trust
(the Trust) to date.
The Trust’s Initial Response Service has now been launched. This service provides a single
point of access for people presenting in mental distress with the aim of quickly identifying an
individual’s needs and ensuring they are referred to the most appropriate service. Since its
launch in May 2020 this service has shown continued growth, and, as of November, handles an
average of 66 calls per a day (please see appendix A for further detail).
This has been further supported by the development of a standardised triage tool to be used by
adult mental health services throughout the Trust, and is based on the UK Mental Health Triage
Scale. A training package to support those clinicians undertaking triage assessment is currently
being developed by the Community Mental Health Team (CMHT) Single Point of Access Team
Manager, and this is further enhanced by clear operational policies, guidance and assessment
tools ensuring that access to services is consistent throughout the county.
As part of the Trust’s joint response with Devon and Cornwall Police and NHS Kernow, I advised
that the Trust would build on the provision of the Mental Health Connect service with the
development of the ‘Professionals Helpline’. This commenced on 01/11/2021 as a 24/7
telephone-based service to provide access to health information and advice to professionals
involved in an individual’s care, be that health partners, social care or the Police. The line dealt
with over 90 calls in the first month (please see appendix A for further details)
Cornwall Partnership NHS Foundation Trust is committed to improving the health
and wellbeing of patients, carers, staff, and visitors. We have a Smokefree Policy.
This means smoking is not allowed on Trust premises. This includes our buildings,
grounds and vehicles. If you smoke and want to stop, please ask any member
of staff for free support.
We are a research active trust, to get involved in a research project, please email
cpn-tr.CFTresearch@nhs.net
For information on mental health medication visit choiceandmedication.org/cornwall
Head Office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN
Tel: 01208 834600 Email: cpn-tr.enquiries@nhs.net
www.cornwallft.nhs.uk
As part of our commitment to improved joint working with the police you will be aware that
, former Police Superintendent, was appointed to the newly created role of Mental Health
Liaison Officer (MHLO) within the Trust at the time of the Inquest. This substantive role has now
been fully embedded within the Trust’s mental health services and
shares considerable
knowledge and expertise across both health and Police services. The role primarily focusses
on information sharing, with access granted to both the Trust’s and the Police’s computer
systems, enabling ‘live’ information to be shared in a timely manner to improve information
sharing and joined up working to ensure provision of an efficient and effective service to persons
presenting with a mental health disorder in the criminal justice setting.
This work has developed organically, with the MHLO identifying opportunities for further
initiatives such as a pilot in the Penwith area whereby a police member of staff attends the CMHT
weekly multi-disciplinary meeting, and this is reciprocated by a member of the CMHT attending
the fortnightly Police Tactical Meeting, to share intelligence regarding persons of concern. This
may be as simple as confirming address details, through to dealing with safeguarding concerns
before they become issues, e.g. checking allegations of ‘Cuckooing’. Additionally, this approach
has also served to build professional relationships between these partner agencies. If
successful, this pilot will be rolled out throughout the county.
Further, the ‘136 Project’ is also currently being developed by the MHLO, with a view to providing
training to 30 Police Officers to become Mental Health Tactical Advisors within the force who in
turn will support their colleagues with a greater understanding of the Trust’s mental health
services, Mental Health Act legislation, and Police powers under this Act.
An additional post of Neighbourhood Beat Manager for Mental Health has also been established,
where a serving police officer, jointly funded by the Trust and Police Crime Commissioner,
further strengthens information sharing between agencies and is currently developing a ‘Police
Passport’ to support a more holistic Police response to incident management involving
individuals in mental health crisis. This new initiative is being trialled with the Trust’s Community
Child and Adolescent Mental Health Service (CAMHS) and focuses on creating a crisis plan with
a young person, and their family and/or carers, which is then shared with the Police to provide
advice and guidance on how best to support the young person should they come into contact
with the police, e.g. a plan may contain details like “I am autistic, please do not handcuff me”.
Once tested, this will be expanded to incorporate adult mental health services and there is a
local desire to extend the work of the National Record Locator – a national project led by NHS
Digital Services which enables an authorised clinician, care worker and/or administrator, in any
health or care setting, to access an index of patient information to support that patient’s direct
care – to be inclusive of the Police service.
I hope this update provides some assurance of the Trust’s ongoing dedication to making
improvements within its services and working with partner agencies to develop an effective and
proportionate response to those individuals who may find themselves in need of support due to
their mental health illness.
Page 2
If you require any further information, or would like to discuss any of these points further, please
do let me know.
Yours sincerely
Dr
Interim Medical Director
Page 3
MH Connect and Professional’s Line data
Appendix A
Mental Health Connect Line
Since launch in May 2020, calls to the MH Connect 24/7 helpline have been growing. This
month, to 21st November excluding professional’s line calls, the line is receiving an average of
66 calls per day. This represents an increase of +164% vs. the same period last year and
+20% vs. last month.
MH Connect monthly call volume and
average calls per day
1st May 2020 to 21st November 2021
61 59 60
67 65
66
55
48 51
39
34
28 26 27
19 19 20 22 23
80
70
60
50
40
30
20
10
0
2500
2000
1500
1000
500
0
0
2
-
y
a
M
0
2
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u
J
0
2
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2
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u
A
0
2
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e
S
0
2
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c
O
0
2
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o
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2
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e
D
1
2
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a
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e
F
1
2
-
r
a
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1
2
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p
A
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2
-
y
a
M
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1
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avg/day
Number Calls
Figure 1 – Monthly calls to MH Connect and average calls per day, Netcall (01/05/2020 to 21/11/2021)
Professional’s Line
Since launch on 1st November, the professional’s line has received 90 calls, an average of 4
per day (to 23rd November 2021).
Professional's line call volume
1st to 23rd November 2021
11
9
6
5
5
4
3
3
4
2
2
3
2
2
1
5
5
4
4
4
3
2
1
12
10
8
6
4
2
0
Figure 2 – MH Connect professional’s line call volume, Netcall (1 – 23/11/2021)
Page 4
By Cornwall Partnership Kernow a sallhaline NHS Foundation Trust CJinical Commissioning Group Your ref. | Mr A Cox Senior Coroner Cornwall Coroners' Service The New Lodge Newquay Road Penmount Truro TR4 9AA 17'" February 2021 BY EMAIL ONLY TO: Dear Mr Cox INQUEST INTO THE DEATH OF DARRELL FRANCIS SHARPLES: REPORT UNDER REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 We are writing in relation to the above inquest, and in the particular the above-mentioned report of 28 October 2020 (‘the Regulation 28 report”) that we have received from yourself. Considering the nature of the issues that you have raised within the Regulation 28 report, and giving particular recognition to the fact that your concerns are in part related to the sharing of information, it has been decided between us that a joint response to the report would be appropriate. In the first instance, we want to take this opportunity to express our collective condolences to the family and friends of Darrell, and to anyone else who may be affected by his loss. Secondly, we thank you for forwarding us a copy of the Regulation 28 report that was made following the inquest into Darrell’s death. We always welcome opportunities to consider whether there is potential for our organisations to improve the service that they provide to the public. Thirdly, we are grateful for the additional time that you have allowed outside of the statutory time period for our response. We have now had the opportunity to consider the issues that you have raised within the Regulation 28 report. Please therefore treat this correspondence as our formal response to the same. The majority of this response will serve as an overview of the various developments that have taken place between and on behalf of the organisations that we represent since the inquest. Since the conclusion of the inquest, Cornwall Partnership NHS Foundation Trust has recruited former Police Superintendent as Mental Health Liaison Officer to provide advice, guidance and direction to mental health and community staff, police officers and police staff on best practice in providing a service to persons suffering with a mental health disorder in a criminal justice setting; in order to meet their individual needs in line with Cornwall Partnership NHS Foundation Trust polices and up to date legislation. The Mental Health Liaison Officer provides a single point of contact for the police as mental health advisor / specialist trainer and promotes understanding and good practice relating to mental health within criminal justice and in addition will help implement and embed the Criminal Justice Liaison Service within Devon and Cornwall Police. This is a newly-created role which in itself represents a significant step forward in terms of creating potential for meaningful collaboration on the issues of concern that you have raised. In addition, in January 2021 representatives from NHS Kernow, Cornwall Partnership NHS Foundation Trust and Devon and Cornwall Police met to discuss information sharing arrangements and_to learn from the case. Representatives included Detective Superintendent I, Head of the Public Protection Unit, and Superintendent Head of Criminal Justice, from Devon and Cornwall Police: Deputy Director of Primary Care and , Deputy Director of Quality trom NHS Kernow and , Mental Health Liaison Officer from Cornwall Partnership NHS Foundation Trust. The learning identified at the inquest was considered and discussed with a focus around information sharing. The following actions were agreed and are now in the process of being implemented: 1. A review in relation to how police access medical information out of hours regardin persons in custody at risk. This review is currently underway. Dr ; Consultant Clinical Psychologist, outlined in his evidence at the inquest that Cornwall Partnership NHS Foundation Trust has introduced a 24/7 mental health telephone support line for anyone worried about their own or someone else’s mental health. A project is underway to develop this further to provide a professionals helpline, which will support information sharing and increase professional access to mental health services, which we hope will be implemented in April 2021. Once implemented, this will provide another option for people working in police custody to seek guidance in relation to mental health services that are available. 2. Inspector FY Force Mental Health Lead for Devon and Cornwall Police, and YY Mental Health Liaison Officer, will now be able to discuss and Page 2 consider solutions regarding information sharing between the police and mental health services. 3, A meeting was arranged between Devon and Cornwall Police and NHS Kernow to discuss the process for adult GP referrals from the police Central Safeguarding Team (“CST”) and closing the feedback loop with consideration for education of all GP’s including working with GP lead for suicide prevention and dissemination via other forums. Of particular note is that the meeting referenced in the latter point above has now taken place. At this meeting it was discussed and agreed that the sending of all ViSTs to GPs would overwhelm GPs, and create the risk of the higher risk referrals being overlooked as a result of the volume. We recognised that more work could be done in the CST to improve organisational recognition of risk over time; in particular, where risk in relation to a particular individual is escalating. This work has been progressing since 2020 and in November 2020, Detective Inspector (“DI”) J from the CST launched a trigger process to identify escalating risk in adults (including following the submission of a certain number of ViSTs). Part of this process is to include a more focused letter to GPs to advise them of and alert them to the potential escalating risk. The CST already shares information from ViSTs with GPs via GP letters. The trigger process is specifically for escalating risk where for example there have been a number of ViSTs or where the CST has already written to a GP regarding ViSTs. A draft letter has been prepared and will now be subject to a process of consultation led by including local GPs. D! MMM is also to produce guidance notes to accompany the letter, in addition to drafting an article for publication in the GP Bulletin to increase awareness. The GP Bulletin will also be shared with safeguarding leads within GP practices. The learning points will be further raised at the Safeguarding Adult conference. In short, DI || and will ensure that the GP letter process, which follows the CST trigger process, Is Improved by increasing awareness of the reasons that the letters are sent, what good practice should be, and what the expectations are for GPs. In summary, while further work in relation to these matters is still to be progressed, we would like to emphasise that the work undertaken to date represents significant progress in the various parties collaborating in response to your concerns. Accordingly, we hope that this demonstrates that we have taken your concerns seriously. We are again grateful for you bringing these issues to our attention, particularly as it has provided us with an opportunity to reflect on and identify opportunities for our organisations to further enhance the service that we provide to the public. Page 3 Yours sincerel Assistant Chief Constable Joint Interim Medical Director Deputy Director of Devon & Cornwall Police CPFT Primary Care KCCG Page 4
Mr Andrew J Cox
Acting Senior Coroner
Cornwall & Isles of Scilly Coroner’s Area
Email:
16th February 2021
Dear Mr Cox
Darrell Francis Sharples, deceased
Prevention of Future Deaths
Interim Joint Medical Director
Head Office
Carew House
Beacon Technology Park
Dunmere Road
Bodmin
PL31 2QN
Tel:
Email:
As outlined at the inquest Cornwall Partnership NHS Foundation Trust has introduced a 24 hour
response telephone line and is in the process of developing a single point of access for people
presenting with mental distress, which we are calling an Initial Response Service.
We have worked across the whole health system to develop the model for this service which is due to
be launched in the coming months. The service brings together voluntary and third sector
organisations, the Improving Access to Psychological Therapy Service (Outlook South West) and the
secondary care mental health services such as the Community Mental Health Teams into one place,
for anyone wishing to refer themselves or anybody else for help.
The aim is to provide an immediate response in a way that will enable us to identify quickly a person’s
needs and to ensure that an introduction or referral is made to the appropriate organisation or service.
A Senior Operational Lead has been appointed to the Initial Response Service. This role includes
oversight of the Home Treatment Team; Crisis Hub and the 24 hour response telephone line, Mental
Health Connect. In addition, six Band 7 Clinical Leads have also been appointed (equivalent seniority
to ward Leaders and Clinical Nurse Specialists) to provide 24 hour clinical support to the service.
A dedicated Manager for the Single Point of Access within the integrated Community Mental Health
Teams has also been appointed to manage the triage assessors across the county in addition to the
development of processes and protocols for referral management. Previously the assessment teams
were managed separately by the respective community mental health team mangers. The change in
management structure provides additional governance and consistency to the assessment teams.
Nurse triage assessors within the Single Point of Access teams are senior clinicians of Band 6
grading. Core competencies for nurses working at this level requires consolidation of specialist
knowledge and skills in mental health practice, demonstrating a depth of knowledge, understanding
and competence that supports evidenced, informed, complex, autonomous and independent decision
.
Cornwall Partnership NHS Foundation Trust is committed to improving the health and wellbeing
of patients, carers, staff and visitors and operates a Smokefree Policy. This means smoking is
prohibited in all Trust premises ie buildings, grounds and vehicles. If you are a smoker ask any
member of staff for free support.
We are a research active trust, to get involved in a research project, please email
cpn-tr.CFTresearch@nhs.net
For information on mental health medication visit choiceandmedication.org/cornwall
Acting Chair:
Head Office: Carew House, Beacon Technology Park, Dunmere Road, Bodmin, PL31 2QN
Tel: 01208 834600 Email: cpn-tr.enquiries@nhs.net
Chief Executive:
www.cornwallft.nhs.uk
making. There will be occasions when Band 5 Clinicians will need to triage referrals in their capacity
as duty desk clinician. This too is within the scope of competencies for a Registered Nurse, using their
core professional qualification and training to conduct assessments in line with the Nursing Midwifery’s
code and standards. A senior Clinician is available to the Band 5 Clinician should they require any
support in guidance in complex situations.
All new members of staff are required to attend a corporate welcome day induction and each member
of staff, including bank and agency staff, are required to complete statutory training depending on their
role.
The Single Point of Access Manager has taken immediate action to ensure anyone performing this
role within the Community Mental Health Teams has access to the Operational Policy and Triage
Guidelines.
A Task and Finish group, consisting of the Initial Response Service Manager, Community Mental
Health Team Clinical Lead, Associate Director for Mental Health and Learning Disabilities Nursing,
Suicide Prevention Lead and involving Quality Leads from both Community Mental Health and
Inpatient services; representation from Crisis Services including the Psychiatric Liaison Service with
support from our governance team, is expected to commence later this month. The group will review
and redesign how assessments are conducted and will include ongoing work around developing a
standardised triage tool covering all adult mental health services, based on the UK Mental Health
Triage Scale, as well as developing a training package for anyone performing a triage and
assessment role within the Community Mental Health Team to ensure they are familiar with the
assessment guidance and relevant policies and that there is a robust system in place to ensure this is
the case. The Single Point of Access Manager has already commenced work with the Quality Lead
for Community Based Mental Health services in reviewing the assessment team Operational Policy
and triage process.
I hope that the above provides assurance in respect of the areas of concern identified in your report to
prevent future deaths. On behalf of the Trust I would like to extend my sincere condolences to Mrs
Sharples and to Mr Sharples’ family.
Yours sincerely
Dr
Interim Joint Medical Director
Page 2
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