Emma Burbury

21st January 2022 

Andrew Cox 
Senior Coroner 

Dear Mr Cox 

Medical Director 
Head Office 
Carew House 
Beacon Technology Park 
Dunmere Road 
Bodmin  
PL31 2QN 

Regulation 28 - Prevention of Future Deaths report following the inquest into the death of Ms 
Emma Burbury (concluded 9 November 2021) 

Cornwall  Partnership  NHS  Foundation  Trust  (the  Trust)  noted  the  Regulation  28  Report  issued  to 
Cornwall Council and Kernow Clinical Commissioning Group (NHS Kernow) following the Inquest into 
the death of Ms Burbury. 

I would first like to offer my sincere condolences to Ms Burbury’s family and to say that I am truly sorry 
for  their  loss.    Every  death  in  these  circumstances  is  such  a  tragic  experience  for  a  family.  The 
implementation of learning from this is an absolute priority for me and for the Trust. 

The Trust would appreciate the opportunity to contribute to responding to the concerns that you have 
raised  and  I  have  discussed  these  with  the  Trust’s  Associate  Director  for  Community  Mental  Health 
Services, and the Trust’s Chief Information Officer.  I set out below the Trust’s response to the matters 
you have raised. 

Dual Diagnosis Policy 

The Trust has engaged with partner agencies in contributing to the implementation of the systemwide 
Cornwall and Isle of Scilly Dual Diagnosis Strategy (Adults) 2019 to 2022.  The purpose of this strategy 
is to improve the delivery and experience of services for people with co-existing mental health, alcohol 
and drug problems; and recognises that these vulnerabilities do not exist in isolation, and that residents 
affected,  will  also  have  other  associated  complex  needs,  which  require  integrated,  co-ordinated  and 
consistently collaborative working.   

Having recently ‘signed-up’ to this strategy, the Trust is fully committed to its delivery across all services 
and are active members of the Cornwall Council led multi-agency steering group.  The Trust is currently 
planning “what this means to me” workshops to support patient facing staff groups embed the principles 
of the strategy into their clinical practice and this is regularly reviewed as part of the directorate’s Clinical 
Quality Assurance Group. 

Additionally, the Trust’s Medical Director and Associate Director for Community Mental Health Services 
are keen to work closely with We Are With You (WAWY) colleagues in implementing the principles of 
the strategy across both services. 

.  

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 

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 

     
 
 
 
 
 
 Access to Medical Records 

There are clearly benefits to partner agencies accessing an individual’s health record and, in addition to 
the National Record Locator project led by NHS Digital, the Trust is currently working on the Shared 
Care Record project, for which phase one trials commence in the spring of 2022.   

A shared care record is a collection of patient information, stored in one area, that care providers both 
contribute to and have access to, giving a full picture of those in their care.  Care providers that typically 
contribute to a shared care record include GPs, hospitals, community and mental health trusts and social 
care providers.  By implementing a shared care record, professionals have all the information they need 
at the point of care, enabling them to make informed decisions, not only in hospitals and GP surgeries 
but also in the community. 

There  are  of  course  caveats  around  record  sharing  not  least  of  which  are  the  visiting  agency’s 
understanding  of  the  Caldicott  Principles,  information  governance  framework  responsibilities,  data 
privacy and Data Protection Act requirements.  There are a number of formal processes in support of 
providing access to records to partner agencies and delays may occur at any point if requirements are 
not met.  Medical records should also be viewed with caution as there may be a lack of understanding 
of the clinical information recorded. 

We Are With You were provided with access to the Trust’s medical record system in the past under their 
previous name (Addaction) and this was a reciprocal arrangement.  The Trust has requested an updated 
Data Sharing Agreement and Memorandum of Understanding to allow this access to continue – to date 
this  is  still  outstanding.    The  Trust  intends  to  set-up  a  task  and  finish  group  with  WAWY  to  look  at 
resolving these issues, along with how best to remind staff that this access is available. 

Additionally,  the  Trust  has  worked  with  WAWY  to  implement  regular  multi-disciplinary  team  (MDT) 
meetings where care and treatment pathways for patients may be discussed.  This has been met with 
a  varied  uptake  across  the  county  and  the  Trust  is  eager  to  engage  with  WAWY  to  embed  this 
consistently.    An  escalation  route  has  also  recently  been  provided  to  WAWY  via  the  mental  health 
Matrons and / or operational leads where concerns can be reviewed if a patient is not receiving care or 
their risks are not being considered. 

The  newly  created  role  of  the  Primary  Mental  Health  (PMH)  Practitioner  will  also  provide  a  valuable 
conduit in sharing medical information across organisations.  These Trust employed members of staff 
will  be  co-located  in  GP  surgeries  and  will  work  alongside  community,  mental  health,  social  care, 
pharmacy,  hospital  and  voluntary  sector  colleagues  focusing  on  a  personalised  care  approach  to 
achieve the best possible care outcome for patients.  Whilst this role is still in its infancy, relationships 
with primary care colleagues have already been enhanced where PMH Practitioners are in post. 

Discharge process from Community Mental Health Team and signposting to wider services 

The  Trust’s  Integrated  Community  Mental  Health  Team  (ICMHT)  aims  to  meet  the  needs  of  eligible 
patients (those who are in an acute mental health episode and / or have a severe and enduring mental 
health  condition)  within  the  commissioned  framework  and  services  are  provided  in  line  with 
recommended National Institute for Health and Care Excellence (NICE) guidelines, legislation and good 
practice.  The ICMHT recognises the need to work in partnership and form collaborative relationships 
with  patients,  however,  there  are  situations  where  patients  may  have  difficulties  engaging  with  the 
ICMHT.    In order to achieve successful engagement the ICMHT ensures that it is providing a service 
that  meets  the  individual  needs  of  the  patient,  respecting  their  qualities,  strengths,  rights  and 
responsibilities.  Having a mental health difficulty does not in itself negate an individual’s right to make 
the same decisions as any other member of the community.  This includes the right to make decisions 
that others would not necessarily agree with, for example refusing any mental health care by the ICMHT. 

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 The  decision  to  discharge  a  patient  follows  a  robust  process  as  described  in  detail  in  the  ICMHT 
Standard Operating Procedure, and this includes discussion at a MDT meeting which will consider the 
reasons why the patient has not engaged / attended, their existing needs and alternative ways in which 
engagement could be achieved; and the referring clinician and the patient’s GP must be informed of the 
patient’s disengagement to enable the exploration of alternative methods to encourage engagement in 
partnership with other key stakeholders in the patient’s care and any on-going need to risk management. 

Where discharge does occur, it is the Trust’s expectation that this is followed up in writing to both the 
patient,  the  referral  agent  and  the  patient’s  GP  and  that  this  should  include  advice  and 
recommendations, with the relevant contact information, so that the person could access support from 
wider services in the future if they chose to. 

The continued Community Mental Health transformation work, currently underway in the Trust, will work 
to address the collaborative and joint working between the ICMHT and other partners, but primarily the 
issues  are  culturally  related  in  a  complex  health  system,  which  will  take  time  to  solve  through  the 
development and strengthening of relationships with one another.  Processes and policy will support 
this  and  our  commitment  to  the  multi-agency  steering  group  demonstrates  our  willingness  and 
commitment to work with other agencies. 

Thank  you  for  considering  the  Trust’s  response  to  the  concerns  you  have  raised  -  they  are  clearly 
relevant and important issues around a crucial aspect of care regarding information sharing between 
partner organisations.  I trust that this response provides assurance that action is being taken by the 
Trust to address the matters that you have raised. 

Yours sincerely  

Dr 
Medical Director 

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Information Classification: CONTROLLED 

Accountable officer 
NHS Kernow Clinical Commissioning 
Group 
Room 210, Cornwall Council offices 
39 Penwinnick Road, St. Austell 
PL25 5DR 

24 January 2022 

Private and Confidential 
Mr Andrew Cox  
Cornwall Coroners Service 
The New Lodge 
Penmount 
Newquay Road 
Truro  
Cornwall     
TR4 9AA 

Dear Mr Cox 

Prevention of Future Death Report following inquest into the death of Emma Burbury 
(EB) 

Thank you for your Regulation 28 Report to Prevent Future Deaths pertaining to EB. 

In your report you identify a number of concerns and the action to be taken by NHS Kernow 
as the commissioners of mental health services. The matters of concern you have raised are 
as follows: 

1. You heard that community mental health team’s (CMHT) staff at Cornwall Foundation
Partnership NHS Trust (CFT), have read-only access to We Are with You (WAWY)
notes and records, but this fact is not widely known amongst Trust staff. It was
recognised that a reciprocal arrangement allowing WAWY clinicians to have read-only
access to the Trust’s RiO records would be of benefit. You understand a formal
request in this regard has been made and is receiving due consideration. You stated
that one of the most common concerns you hear at inquest is the difficulty with
communication between separate organisations and this may also be an initiative you
felt we would be able to support in delivering for a more integrated service.

www.kernowccg.nhs.uk 

@nhskernow 

Shaping services we can all be proud of

Accountable officer: 

Head office: 

NHS Kernow Clinical Commissioning Group 

Room 210, Cornwall Council offices 

39 Penwinnick Road, St. Austell PL25 5DR 

 
 
 
 
 
 
 Information Classification: CONTROLLED 

2.  There was concern raised on the part of WAWY that clients referred to CFT were too 

easily discharged, for example, where they failed to attend for two appointments. It was 
felt a more assertive approach towards engagement would be beneficial. You asked us 
to consider whether we feel it would be desirable to try and minimise the amount of 
wasted and limited CMHT/WAWY resource through non-attendance at appointments or 
otherwise and consider reflecting on how this can best be achieved through a more 
joined up approach.  

3.  It was felt patients referred to the CFT who did not fall within the strict parameters of a 
severe and enduring mental illness were discharged without sufficient thought being 
given by the Trust’s clinicians to whether another agency such as Valued Lives may be 
able to provide support. You suggested it may be a worthwhile exercise to consider 
how to join up the wider services available within CFT, the voluntary sector or 
elsewhere. 

 has been in close dialogue with 

Since receiving your initial correspondence, NHS Kernow Clinical Commissioning Group’s 
(CCG) Associate Director for Strategic Commissioning for Mental Health and Learning 
Disability, 
, Cornwall Council’s Joint 
Commissioning Manager for Communities and Public Protection/Public Health, who we are 
aware you also wrote to regarding these recommendations.  In addition, and as was agreed 
by yourself, CFT have also contributed to this response given many of the concerns raised in 
the report directly relate to CFT, namely the sharing of records between CFT and We Are with 
You (WAWY); the approach to engagement and discharging patients who do not attend 
appointments and onward referrals where patients do not have a severe and enduring mental 
illness. 

This report therefore represents a collective response to the Regulation 28 provided on behalf 
of CFT, Cornwall Council and NHS Kernow CCG, where CFT will provide a response from an 
operational perspective whereas Cornwall Council and NHS Kernow CCG will respond from 
their strategic perspective. 

Cornwall and the Isles of Scilly has witnessed a significant programme of transformation and 
improvement since 2018/19 with a particular focus on ensuring that mental health and 
wellbeing shares a parity of esteem with physical health. An ambitious programme of 
transformation was established to deliver both national strategy as well as a local response to 
the needs of our urban, rural and island communities and this includes the integration of 
several existing services and the development of new networks of community-based support 
particularly with the voluntary, charitable and social enterprise (VCSE) sectors.  

As previously reported to your office, the Dual Diagnosis (DD) strategy for Cornwall and the 
Isles of Scilly was re-launched in 2018/19 after a period of review. This work was led by NHS 
Kernow CCG and Cornwall Council and culminated in a co-produced and jointly owned 
document supported by a range of multiagency partners and stakeholders including people 
with lived experience, carers and professionals from across statutory as well as the voluntary 
and third sectors. In 2021 the strategy was updated to incorporate emergent best practice 
guidance and executive level signatures from representative organisational leads, including 
CPFT and WAWY, demonstrate a clear commitment to continue to deliver the journey of 
change and improvement.   

In 2021 a dedicated role was jointly funded by both the NHS and local authority, to specifically 
provide additional oversight and scrutiny of the implementation and delivery of the dual 
diagnosis strategy. This work is ongoing and regular reporting serves robust governance 

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including formal oversight of the plan, maintenance of risk log and mitigations plan with 
onward reporting to Safer Cornwall Partnership within Cornwall Council. 

Alongside this and associated with elements of the existing dual diagnosis strategy, the Adult 
Mental Health strategy, ‘Future’s in Mind’ for Cornwall and the Isle of Scilly was formally 
launched in 2020. The joint strategy, and associated implementation plan, set out the key 
ambitions and outcomes including a clear focus on preventions and integration. A clear 
commitment was made across the NHS and local authority to, amongst many other things, 
ensure that care and support was holistic, personalised and joined up. One of the overarching 
principles was to develop a culture of inclusivity and hands-on support, which sees ‘no wrong 
door’ for those trying to access care and support. Service providers from across all sectors 
are now working in close collaboration to jointly plan and share information in a timely fashion, 
deliver the most meaningful and personalised support, and promote an environment where 
people’s mental health and wellbeing is felt to be ‘everybody’s business’ no matter what 
health or care organisation they work for.  

In respect of your first concern, it is acknowledged that messaging and training is of vital 
importance in ensuring continuity and equity of approach. We can report that a task and finish 
group, which includes WAWY and all NHS and Local Authority Commissioned mental health 
providers, are developing a revised Data Protection Impact Assessment (DPIA), to provide 
additional governance and ensure continuity of approach and adherence to system 
operational and strategic intention. The DPIA makes clear the justification and rationale for 
access to, and/or the process of,  personal information to enhance existing information 
sharing agreements between organisations. It will help to address the request for reciprocal 
access to data and specifically RIO clinical records systems operated by CFT. CFT will work 
with WAWY to include them in relevant regular meetings and to embed this access to data as 
business as usual.  

In the meantime, there is an escalation route via the Associate Director of Operations and the 
CMHT matrons, when there are concerns from WAWY that someone is not receiving care, or 
they feel risks are not being considered. This provides a two-way flow function and 
demonstrates integrated operational working to maintain safe and timely service responses. 

On your second concern, it has been acknowledged that our system is experiencing 
unprecedented demands amidst the backdrop of the national COVID-19 pandemic. Front line 
services are experiencing significant workforce challenges with a higher-than-normal vacancy 
rate. Commissioners (NHS Kernow and Cornwall Council) receive regular updates and 
receive risk and mitigations plans which include workforce expansion plans many of which 
have been supported by additional investment to bolster numbers and provide a more robust 
safety to ensure future continuity. In addition, CMHT’s carry out regular case load risk 
analysis and reviews and have been working closely with VCSE partners to ensure that 
additional follow up support is available and maintain a robust waiting list management 
process. Other response plans include complex case review panels, which again, represents 
improved integrated working to the benefit of patient level outcomes and experiences. 

We can report that the CFT policy for discharge after 2 missed appointments is primarily for 
the assessment team, and at point of discharge notification is made to partners and referrer 
organisations which includes advice and recommendations including contact points. Both 
WAWY and CMHT policies include specific detailed on the discharge process and operational 
procedures, with specific reference to those who are hard to engage. Discharge is not 
enacted in isolation but rather via a Multi-Disciplinary Team (MDT) discussion, a discussion 
with the GP and other involved parties to ensure risks and understand the person’s ability and 

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 Information Classification: CONTROLLED 

capacity to make decisions are considered. This is further supported by WAWY outreach, 
which seeks to engage those who are not yet able to utilise office or appointment-based 
systems. Further safeguards are maintained by ensuring that all letters and associated 
correspondence from assessment team’s, include advice and recommendations alongside 
clearly stated contact information and detail to enable individuals to re-establish contact with 
services and access support again should they so choose. For further assurance on these 
matters, please refer to the attached Annex 1. document, provided by Dr 
Medical Director, CFT.   

, 

Finally, in response to your third concern we can confirm that we are currently working 
through an exciting period of transformation in community mental health across our counties. 
Significant funding has been made available to Cornwall and the Isles of Scilly to bring about 
transformation in the collaboration and delivery of community mental health support to 
improve the outcomes and experiences of those utilising care and support. Much of that 
funding is aimed at additional provision being developed in partnership with Voluntary, 
Community and Social Enterprise (VCSE) sectors, as key delivery partners in larger scale 
integrated mental health workforce transformation.  

Robust governance via a transformation board and steering group committee, provides 
oversight on a number of working groups focused on bringing about positive and sustainable 
change. The transformation will offer a better way of providing mental health help and support 
to people in the community based on bringing together all current health services, including 
GP surgeries, with voluntary organisations and social care services. It will enable the 
provision of a larger range of options that are available quickly and more conveniently for 
everyone.  

With specific regard to alcohol and drug treatment services, Cornwall Council have identified 
that that across Cornwall and the Isles of Scilly we have a slightly lower number of opiate 
users than the national average for people entering treatment who have an assessed mental 
health need, but much higher rates of non opiate users. Investigation is underway into this 
matter in an attempt to better understand key factors.  One hypothesis is that this cohort is 
made up of the higher rates of crack cocaine users, and that we now have high rates of illict 
benzodiazepines. 

In addition,  numbers and rates of people who have both drug and alcohol dependency with 
mental health needs is low. Significant numbers of people already open and engaged with our 
CMHT and other mental health services. Our Improved Access to Psychological Therapies  
(IAPT) service ensures people have access to and are receiving NICE recommended 
psychosocial interventions. There also  appears to be a  higher percentage of people with a 
treatment need but where no treatment is being received and/or treatment is declined. This is 
the second cohort being investigated to better inform system planing and decision making.  

In terms of inclusion and a more holistic approach to care and support, WAWY are specified 
to work with depression, anxiety and sleep problems, and have an extensive toolkit to do so. 
People with complex emotional difficulties (formerly known as personality disorder) and 
psychotic conditions will be referred to CFT, with an undertaking to joint work. WAWY attend 
the DD Implementation Group to progress joint working with these individuals.  

As a fundamental element of ongoing improvement to standards of care and support, WAWY 
are required to routinely report on the compliance and numbers of staff who have completed 
the following training via a workforce reporting template provieded to commissioners, which is 
governed via standard contract review processes with a clear expectation that all staff will 
have completed the following modules to improve knowledge and skills: 

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 Information Classification: CONTROLLED 

•  Mental Health First Aid (MHFA) 
•  Suicide Prevention and ASSIST 
•  Dual Diagnosis 

We trust that this response adequately addresses the concerns set out in your letter of 
recommendation, but should you require further detail, clarification or assurance please do 
not hesitate to contact us. 

Yours sincerely  

Chief nursing officer 
NHS Kernow Clinical Commissioning Group 
On behalf of 

Accountable officer 
NHS Kernow Clinical Commissioning Group 

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