Paul Barton

NHS

Nottinghamshire Healthcare
NHS Foundation Trust

Chief Executives Office

The Resource
Duncan Macmillan House
Porchester Road
Nottingham
NG3 GAA
Mr Gordon Clow
HM Assistant Coroner for Nottingham and Nottinghamshire
Nottinghamshire Coroner's Office
The Council House
Old Market Square
Nottingham
NG1 2DT
Dear Mr Clow

Please find below the organisational response to the recently received Preventing Future
Deaths Report following the unfortunate death of Mr. Paul Barton, the inquest of which was
concluded on 15 September 2021 We offer our sincere condolences to Mr. Barton’s family.

Concerns raised within the Report:

(1) The approach of the Crisis Resolution Home Treatment Team of considering their
role to be limited to avoiding the need for patients to receive inpatient treatment.
The primary role of any medical professional ought to be the protection of life, but
within the written and oral evidence from the CRHTT the focus was on prevention of
hospital admission alone.

CRHT teams were originally set up to provide urgent and intensive support for individuals who
had serious mental health problems and who would otherwise be likely to require inpatient
hospital admission. This remains a core function of the service. The key aims of the service
as outlined in the service specification are:

e Act as a ‘gatekeeper’ to mental health services for functional all age mental health
admissions.

e Provide immediate multi-disciplinary, community-based treatment 24 hours a day, 7
days a week, including a face-to-face assessment within 4 hours.

e Ensure that individuals experiencing acute, severe mental health difficulties are treated
in the least restrictive environment as close to home as clinically possible.

* Remain involved with the patient until the crisis has resolved, or the patient is well
enough to be linked in/discharged to the appropriate care pathway.

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If hospitalisation is necessary, be actively involved in discharge planning and provide
intensive care at home to enable early discharge.

A detailed assessment should be undertaken as below:

The aim is to help to reduce service users’ vulnerability to crisis and maximise their resilience.
In line with the Royal College of Psychiatrists (RC PSYCH) best practice guidance and core
fidelity standards, the initial assessment gathered from multiple sources includes:

¢ An investigation into the nature of the crisis and the presented problems.

¢ The identification of immediate social stressors and social networks.

e Psychiatric history including past records and family history.

« A comprehensive evidence-based assessment which includes: Mental health and
medication; Psychosocial needs; Strengths and areas for development.

* The identification of the clinical signs and symptoms, including ability to self-care, if
mental health problems are found.

« A physical health review takes place as part of the initial assessment, or as soon as is
practically possible. The review includes but is not limited to: Details of past medical
history; Current physical health medication, including side effects and compliance with
medication regime; Lifestyle factors e.g., sleeping pattems, diet, smoking, exercise,
sexual activity, drug and alcohol use.

« Anassessment of practical problems of daily living.

« Adocumented risk assessment and management plan which is co-produced and shared
where necessary with relevant agencies (with consideration of confidentiality). The
assessment considers: risk to self; risk to others; risk from others.

© The identification of the person for whom itis a crisis, other people affected by the crisis
and associated risk to them.

« Identification of dependents and their needs, including childcare issues, and any young

or adolescent carers.

A social assessment including education and employment.

A multidisciplinary assessment of the service user's needs.

A multidisciplinary assessment of the service user's level of risk.

Planning for supported transition to other services.

All service users have a documented diagnosis and a clinical formulation.

The service user and the team can obtain a second opinion if there is doubt, uncertainty

or disagreement about the diagnosis, formulation or treatment.

* Written information about the service, its role and contact details are provided to all
service users and carers present at initial assessment

Based on the detailed assessment, a decision will be made as to whether the individual will
benefit from CRHTT input or if an altemative service is required, which may include inpatient
admission, onward referral, and discharge.

The service specification describes the process as below:
« The team begins discharge planning at the point of assessment and this is

communicated to relevant parties.
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« Involvement is time limited, and people are promptly discharged when acute care is no
longer needed. At least 90% of service users stay less than 6 weeks (length of stay =
active treatment not phone support pre/post discharge) and service users and involved
family are given at least 48 hours’ notice before discharge from the CRHTT (excluding
hospital admissions).

Prior to discharge the team should ensure that:
« There is good understanding (service users, family, carers, relevant others) of why the
crisis occurred and how it could be avoided in future.
* Coping strategies have been explored with the service user and family/carers.
A Relapse prevention plan is in place.
« Service user/family/carer have had an opportunity to express their views about the
service and contribute to service improvement.

The team must faciitate discharge and transfer of care to an appropriate service, dependent
‘on clinical situation and local provision. This could include Primary Care, Assertive Outreach
Team, Early Intervention in Psychosis, Continuing Health Care, and other mental health
services.
A clear discharge plan is given to the service user on discharge, and sent to all other relevant
parties within 48 hours and must include details of:

* On-going care in the community/aftercare arrangements.

« Crisis and contingency arrangements including details of who to contact.

* Medication, including monitoring

* When, where and who will follow up with the service user as appropriate.

Clinical outcome data is collected at assessment and discharge as a minimum.

Post discharge service users or families may contact the CRHTT directly for support or advice
for at least 2 weeks following discharge.
As demonstrated, the expectations of a CRHTT assessment and plan are clear and require
detailed information gathering and consideration of a wide variety of factors on which to base
care planning and decision making. This should include whether a hospital admission is
required but this cannot be the sole determining factor.
To ensure that all staff are aware of these parameters, the CRHTT operating procedure will be
updated by 31 December 2021 to include more detailed explanation as above. The updated
procedure will be shared with all staff via email and discussed with all staff via team meetings.
This will highlight the broader considerations for CRHTT support as part of a safety plan, and
individual discussions as part of ongoing supervision will also support a broader understanding.
(2) This inquest was one of a number of inquests I have conducted where staff members
from Nottinghamshire Healthcare NHS Foundation Trust have placed great reliance
upon their interpretation of a patient's intention and / or a patient's denial of ongoing

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suicidal intention. This is so even where, as was the case for Mr Barton, there is a
clear and established pattern of fluctuating and contradictory intentions and desires
towards suicide.

There are a range of measures in place and planned to address practice in this area including
training and reflective practice opportunities. All clinicians must complete mandatory annual
training in suicide awareness and prevention. This training outlines the many factors that should
be considered when undertaking a risk assessment in a potentially suicidal patient. This
includes not only the immediate presentation, but corroborating evidence from family members,
recent events, and patterns of behaviour, thinking and underlying factors such as established
mental health conditions, compliance with medications and substance misuse. From this
comprehensive gathering of information, a formulation should be developed based on this
range of evidence on which to base the care planning and safety planning. This plan should
never be based solely on an individual denying suicidal intentions at the time of the assessment.
Rather, it should weigh this in the context of recent events and known facts. This current
training is only available online for Adult Mental Health staff.

A priority of the Trust's Towards Zero Suicide Strategy (2020-2023) was to review the Trust's
suicide prevention training offer and implement a new training model to bring this into line with
the Trust's Towards Zero Suicide approach (2020) and Health Education England's Suicide
Prevention Competencies. A paper to agree the proposed training, method of delivery and
resource requirement was presented to the Trust’s Senior Leadership Team on 26 November
2021 for approval.

This paper proposes three levels of training:

« Level 1 — Suicide Awareness Training for non-clinical staff, online 3-yearly.

Level 2 — Suicide Awareness Training for all clinical staff, online 3-yearly

« Level 3 — Suicide Response Training for clinical staff required to provide a clinical
response to suicidality, 3-yearly, either face to face or via Microsoft Teams.

It is however recognised that training alone does not achieve embedding of leaming into
practice or operational and quality improvements. Therefore, the Trust is proposing that the
required resources not only deliver training but also support embedding training into practice.
This would i :

« Clinically based engagement and support: Bespoke / tailored training and facilitated
team leaming (including discussion and reflection) to further adapt the training to clinical
areas and embed leaming and the use of appropnate clinical tools.
aoe: Such a8 investigations and Coroner inquests), clinical tools and safety

ining.

« Prioritisation for teams who experience greater exposure to suicide and self-harm (as
identified through Trust data) and be based on related learning to promote safe and
responsive services which can also be evidenced.

« Reviewing and further development of related resources.

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¢ Involvement in evaluation and improvement relating to risk assessment and safety
planning.

Following approval of the proposals, an implementation plan will now be developed, which will
be shared with the CQC and Coroner on completion.

The CRHTT operating procedure will be updated by 31 December 2021 to include more
detailed guidance about risk assessments and the clear expectation that the presenting
information at the time of the assessment is evaluated, considering recent events.

Further training is needed for all staff working in CRHTT as this forms a core part of their role.
The training offer includes some team training sessions facilitated by the Trust wide Clinical
Lead for Suicide Prevention. Three of these sessions have already been delivered and these
will continue as a regular space for teams to reflect on cases and access senior supervision.

In addition to this, there is a four-day training programme facilitated by one of Adult Mental
Health's Clinical Nurse Specialists, which all CRHTT staff will be offered. Three sessions have
already been completed and there will be three sessions running each year. This covers
attachment and trauma, stabilisation skills, overview of Mentalization- Based Therapy (MBT),
Structured Clinical Management (SCM), Dialectical Behavioural Therapy (DBT) and crisis role
in these interventions, managing crisis telephone calls and working with young people in crisis.
The Learning and Development Department have also been providing sessions relating to
culture and values (Appendix 4). This begins with a diagnostic tool (Appendix 5) completed
confidentially by team members to elicit the strengths of the team and areas that need to be
worked on. There will then be sessions facilitated by the Leaming and Development team to
assist in achieving the identified improvements.

in January 2022 bespoke training workshops will be provided for each CRHTT by I
the Leaming and Development Department and will be used as continuous leaming

and reflective practice spaces to augment and embed this leaming.
There are monthly interface meetings between CRHTT and the LMHTs. During these meetings,
case examples are presented in order to jointly share leaming and discuss practice issues, as
well as developing and maintaining good working relationships.
Carer peer workers are being recruited into each team. The Job Description is enclosed as
Appendix 6. These roles will ensure there is a specific focus on the needs of carers, including
discussion of expectations and inclusion in discussions about assessments and care plans.
Leaflets and information sources will also be reviewed and regularly updated for carers. In
addition, peers will link to wider carer networks in the Trust.

The teams are working on the core fidelity principles (Appendix 7) and part ofthis activity s an
annual feedback process that includes patients, carers, staff and key stakeholders. These
retums measure progress and enable adaption of actions needed.

A dashboard is in development so that the Key Performance Indicators (KPIs) can be reviewed
routinely on a monthly basis. This is currently operational but is being updated with a final
version expected by 31 December 2021.

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(3) The quality of the Trust's own investigation into the circumstances of Mr Barton's
death. It failed to identify themes of concern. It included many false and inaccurate
statements, failed to challenge false assumptions made at the time and introduced
new false information which was not taken from any available records. It caused
distress to the family and did not reassure me that the Trust had taken an
appropriate response to the concerning facts of this case.

we unreservedly apologise for the distress and disruption caused because of our mistakes.

The Operational Manager has reviewed this report and the relevant themes have been
identified. The Quality improvement Plan is being updated to ensure these are captured and
acted upon. We will share this with you on completion.

A final version of the report is enclosed (Appendix 1), ‘along with the attachments (Appendix 2
and 3). Following on from correspondence with your office in October 2021, we have not yet
shared this amended report with the family, or a copy of this response. We understand from an
email dated 20" October 2021 that the family preferred not to hear directly from the Trust at
this time. We are very willing to share the documents directly with them should they wish to
receive information in tis way and remain open to meeting wah any of tr Barton's volaives in
the future to discuss his care, investigation content or processes, or to try and answer any
outstanding questions they may have, should this be something they would find helpful.
This has been shared with the investigator for their learning and reflection. In the short-term,
this will also be raised as a more general lessons leamed to remind all staff of the importance
of factual accuracy.

These actions set out will be monitored within the Trust through a specific Quality Improvement
Pian with General Manager EEE as the nominated lead.

In addition, it has been identified that key themes regarding the quality of our Serious Incident
Reports have required a more robust and Trustwide review and action plan.

The Trust's Govemance arrangements to oversee the management of serious incidents (SIs)
is outlined below:

Accountable to Quality | The group meets weekly to discuss all new Sis, ensure
(Operational Group

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Seals of a SIs popes on
fare and were appropnate

As a Trust over the past two years, we have looked to further strengthen the governance and
assurance in relation to the management of Serious Incidents through the overall review of
team structures, systems and process and policy revision. This includes:

Establishment of a Centralised Patient Safety Team:

As a result of an organisational wide review of govemance, during 2019/2020 we created a
Trustwide Patient Safety team. (Previously there were teams in each division which led to
inconsistent approaches). There is now a Trustwide Head of Patient Safety (also the Trusts
nominated Patient Safety Specialist). The Head of Patient Safety reports to the Associate
Director of Quality and has open access to the Director of Nursing, AHPs and Quality.

The Patient Safety Team has responsibility for the overall co-ordination of incidents and
investigations across the Trust. By undertaking this review, it has enabled us to eliminate
variation in the management of incidents/serious incident investigations between
directorates/divisions. It also enables a consistent approach in the appointment of investigators,
preparation of terms of reference and ensuring investigators have points of contact to discuss
investigations and concems.

We have also taken the opportunity to develop a centralised Investigation Team, at present this
is a small team of 2 SI Investigation Leads who will primarily be apportioned the most significant
and time critical cases. However, we are looking to support this centralised team with the
employment of a limited number of experienced bank SI investigators, again these individuals
are independent of the divisions/services and will have significant experience of being involved
Establishment of Family Liaison Team:

As a Trust we looked at the opportunity to significantly improve the communication and
interaction we have with families and patients when an incident occurs, and more particularly a
serious incident. With this in mind our investment group has approved the funding of a Family
Liaison Service. The team will comprise of 3 full time posts. The family liaison team will work
across all Trust services to support patients/families/carers through the difficult process of

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serious incidents, inquests and investigations into serious incidents. The purpose of this role is
to provide explanation and support through what can be a difficult process for families.

The three posts are currently out to advertisement and we would envisage making an
appointment in November, to commence in post early 2022. As a Trust we see this as an
important and pivotal team to ensuring a consistent support mechanism for families through
what is a stressful and difficult time for them and to also ensure their voice and questions is

Medi Team:

Although our Medico-Legal team is well established, the Trustwide governance review gave us
Medico-Legal team and in particular the Inquest function now covers all Trust services.
The inquest team provides a strong link between the coroner's office and the trusts operational
services. They provide support in the preparation of court papers/statements and also
supporting staff through what can often be a difficult process. They also provide a link to the
families involved, and of course with the development of the Family Liaison service, it will be
imperative that these two teams work closely and seamlessly together.
Review of Trust Policy:
With the appointment of our Director of Nursing, AHP and Quality (Executive Lead for Patient
Safety) in January 2020, there was also the opportunity to review and refresh existing practices
in relation to the process for the management of serious incidents. Some of the immediate
Changes made were:
All Comprehensive (Level 2) investigations would be approved by an Executive
Director.
« Terms of reference for a comprehensive investigation would be approved by an
Executive Director
¢ All Concise (Level 1) investigations would be approved by an Associate Director of
Nursing.
We also took the opportunity to work with our intemal auditors, to review our processes and
polices related to incident reporting and serious incident management and as a result changes
to the Managing Serious Incidents (SI) and Reporting and Leaming from Deaths policy (15.02),
were made which formally reflected the changes made by the Director of Nursing, AHPs and
Quality shortly after her appointment.
Review of Staff training
Inci i —
We have worked with external partners to ensure that staff undertaking serious incident
S are trained and knowledgeable in investigation techniques. We are now providing
a new 2-day training event for investigators based on a “Systems Based Approach”. This
approach is advocated by the Patient Safety Incident Response Framework (PSIRF) which will
be implemented within NHS Organisations from April 2022. The role of SBA is to identify the

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systems-based problems when an incident occurs, rather than focusing on the individuals
involved. Our aim is to train 100 investigators year on year.

We have recognised that whilst the centralised investigation team gives us a consistent
approach to investigations, the volume of investigations means we must utilise operational staff
as part of the overall investigation process, hence the provision of incident investigation training.
However, in training these people we also need to ensure we continue to eliminate variation,
go to azote wiih tis wo have pat in place support and mentoring which will be provided through
the dedicated centralised investigation team

Qu: Assurance of I igati
We also recognised that we also needed to strengthen our overall review of our investigation

reports and ensure those individuals who are approving/authorising the final report have the
skills to critically appraise the report and ensure it is fit for purpose.

With this in mind, as part of our training offer, we have also worked with our providers to
establish a Quality Assurance training course for people who approve or sign of
Conci: reports. The course provides the attendees with skills to critically
access the investigation report and ensure in concentrates on Systems Based outcomes and
SMART actions. Our aim is to train at least 50 people each year. The purpose of this training is
to provide senior individuals who have responsibility for approving reports to with the skills to
analysis the report, ensure fairness, that systems-based leaming has been applied and that the
report and findings refiect the agreed terms of reference and any questions raised by the patient
or family.

Implementation of Just and Restorative Culture

As a Trust we had significant progress in embedding a Just and Restorative Culture by ensuring
we act with compassion, treating people fairly and justly and embracing a leaming culture;
where if something goes wrong, we seek first to understand. When things do go wrong in all
cases we should:
e Seek first to understand before taking action
who was responsible
« Consider the psychological impact on all individuals involved
In Notts Healthcare there are many ways we are already working together to create a Just and
Restorative Culture (JRC), and we can demonstrate that it is the overall Culture linked to
Compassionate Leadership that will ultimately enable colleagues to feel safe enough to speak
up without fear of reprisal or blame, to fee! heard and supported.
.
There is recognition that this overall review, restructure and development of both teams and
training has been necessary to strengthen the governance in relation to serious incident
investigations. Whist some of these changes have been established for a little while others have
either come online in the last few months or will do in the very near future. We believe that
through the governance review and significant investment for centralised investigators and
family liaison service we will be able to ensure:

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« Strong governance in relation to serious incidents
o Oversight through our meeting structure
o Approval of Terms of reference
o Final approval and sign-off of Concise and Comprehensive investigations
* Elimination of variation
« Development of expertise through training in the use of Systems Based Approach (SBA)
to SI investigations
* Providing SI approving managers, the skills, and techniques to critically appraise

e Support and guidance for all our staff attending and involved within the coronial process.
« Through the implementation of the Family Liaison service, we will be able to ensure
families have:

o An identified point of contact

o Their voice and questions are represented within the investigation process

o Clear lines to ensure the outcome of the investigation is fed back to them and

they have the opportunity to comment
o The appropriate level of support throughout the SI process and inquest.

| hope the information above provides the assurance that we have considered your
recommendations seriously and are actively seeking to improve the services we provide by
implementing the actions outlined.

Yours sincerely

o

Chief Executive

Enc Appendix 1 — Final Version of the Trust's Concise investigation Report
Appendix 2— Document embedded within the Quality Improvement Plan
Appendix 3 — Email embedded within the Quality Improvement Plan
Appendix 4 -— Creating Capability Changing Culture Document
Appendix 5 — Diagnostic Tool linked to Team Culture Training
Appendix 6 — Job Description for Carer Peer Support Worker
Appendix 7 — Core Fidelity Principles Scale

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