Andrew Nixon

Musgrove Park Hospital  
Parkfield Drive 
Taunton 
TA1 5DA 

Private & Confidential 
Mr Richard Thomas Middleton 
Assistant Coroner for The County of Dorset 
The Coroner’s Court 
Town Hall 
Bournemouth  
Dorset 
BH2 6DY 

Dear Mr Middleton, 

Thank you for your report under Regulation 28 for the prevention of future deaths, following 
the inquest on the unfortunate death of Mr Andrew Nixon.  

We have now had time to review your comments and we are able to respond to your concerns.  

We  will  begin  with  a  broader  outline  of  our  current  service  commitment  to family  and  carer 
involvement before responding to your concerns in detail. 

Commitment to Family & Carer Involvement  

Triangle of Care  

Somerset NHS Foundation Trust (SFT) Mental Health and Learning Disabilities Directorate 
has been part of the Triangle of Care accreditation scheme since it began. On 12 May 2016, 
the Trust was awarded a second quality star by 

 of the Carers’ Trust. 

We have 42 Triangle of Care Leads working across Mental Health Inpatient wards, 
Community Mental Health Services (adults), Home Treatment Teams, Older Persons 
Community Mental Health Services, our Perinatal Mental Health Team, and our Intensive 
Dementia Support Service.  Their role is to achieve better collaboration and partnership with 
carers in the service user and carer journey through a typical acute episode.  

The objectives of the triangle of care are the implementation of the six key elements  

1.  Carers and the essential role they play are identified at first contact or as soon as 

possible thereafter.  

2.  Staff are ‘carer aware’ and trained in carer engagement strategies. 
3.  Policy and practice protocols re. Confidentiality and sharing information are in place. 
4.  Defined post(s) responsible for carers are in place. 
5.  A carer introduction to the service and staff is available, with a relevant range of 

information across the acute care pathway. 
6.  A range of carer support services is available 

 
 
 
 
 
 
 
 
 
 
 
 
 The Triangle of Care Team are a small team who support the Triangle of Care Leads, 
providing regular supervision and updates. The most recent event was focussed on the topic 
of family and carer involvement in suicide prevention.  

The Triangle of Care Steering Group has been paused during Covid which coincided with 
something of a hiatus at the Carer’s Trust which oversees the national Triangle of Care 
programme. The Carer’s Trust have since re-invigorated the national programme, and the 
Trust have booked dates to recommence the local steering group with a refreshed 
membership in September 2022. The Regional Triangle of Care group is chaired by the 
Trust’s Director of Mental Health and Learning Disability Care who is also a representative at 
the national group led by the Carer’s Trust.  

The Triangle of care eLearning remains available to all staff but is due a review and refresh to 
take account of learning from feedback and incidents.  

The table below illustrates the uptake of Triangle of Care Training, as of February 2022, in our 
Mental  Health  and  Learning  Disabilities  Directorate  and  the  Trust’s  Primary  Care  & 
Neighbourhoods Directorate where the Older People’s Community Mental Health services are 
managed.  

Directorate 

Number 
to be 
Trained 

Number 
Trained 

Number 
Expiring 

Training 
Require
d 

Percentag
e Trained 

Mental Health and LD 

Primary Care & Neighbourhoods 

460 

100 

367 

88 

7 

3 

Triangle of Care Substantive 
Staff Totals  

560 

455 

10 

86 

9 

95 

81.3% 

91.0% 

83.0% 

A Quality Improvement Project is currently being launched to refresh the Triangle of Care 
strategy beginning in Community Mental Health Services. This project has support from 
corporate and directorate colleagues who attend the mental health Serious Incident Review 
Group and includes the Trust’s Medical Director for Mental Health and Community Services 
as well as the Trust’s Associate Medical Director for Mental Health and Learning Disability 
Care. Preliminary meetings are scheduled during August to support the QI project and the 
Triangle of Care Steering Group. 

Within the Triangle of Care, there are a range of family/carer/social network-based 
approaches available in Somerset FT which include Family therapy, brief systemic 
intervention, Family intervention for psychosis, Triangle of Care meetings in Community 
Mental Health Services and Home Treatment Teams, and family liaison on inpatient wards, 

Carers charter 

The Somerset NHS Foundation Trust carers charter is available on our website. 

Our carers' charter - Carers - Somerset NHS Foundation Trust (somersetft.nhs.uk) 

Carers service 

Page 2 of 12 

 
 
 
 
 
 
 
 The Carers Assessment Service covers patients in older persons, adults and children’s 
services with an establishment of 10.9 full time assessment workers and 1.6 full time 
managers (12.47 full time staff excluding admin). Patients within our primary care mental 
health services can access support and signposting via Somerset Carers. Free support & 
information for Carers just like you. - Somerset Carers 

The SFT carers service has a webpage on the SFT website and has developed a booklet on 
caring for people with mental health conditions. NEWInformation-for-Carers-of-People-with-
mental-health-conditions-2022.pdf (somersetft.nhs.uk). 

The service, established in 2002, supports families and carers of people with mental health 
issues in Somerset and is committed to the principles of the Triangle of Care. The Triangle 
of Care is the cornerstone on which the trust is building and developing its carers policy and 
carers charter for the future.  

The report showed that between February 2021 and January 2022 the Carers assessment 
service received 1,353 referrals, the table below breaks the referrals down by area. 

Team 

Referrals 

Mendip  

Sedgemoor 

South Somerset 

Taunton 

Somerset Coast 

Total 

342 

267 

374 

243 

127 

1353 

Suicide prevention training 

The Mental Health and Learning Disability Directorate is currently launching Connecting with 
People suicide awareness, and suicide response training for Mental Health clinical staff.  

This training makes explicit reference to the Triangle of Care and a significant aspect of the 
training is focussed on collaborative care/safety planning and the need for family and carer 
involvement. The SAFETool which is a suicide assessment framework which staff are 
introduced to in this training includes prompts for inclusion of family and carer views about 
risk. 

Clinical risk assessment and management training  

The mandatory clinical risk training which is delivered to all mental health staff includes 
content (taught and case studies) about involving families and carers, confidentiality and 
consent, sharing information and collaborative risk assessment. 

Page 3 of 12 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 Response to your specific points: 

In your report, you raised the following concerns: 

1.  There should be criteria to be applied as to who should be considered for a 
Carer’s assessment at the earliest appointment with the Home Treatment 
Team.  

2.  Such criteria should include whether the patient has given permission to share 
information, whether the patient and/or the carer have been involved with 
mental health services previously; whether the carer has been/will be present 
during consultations; the level of understanding of the of the carer in relation to 
steps taken and decisions made and whether they need further help. 

3.  Such criteria may lead to a full carer’s assessment. It is noted that there will 

always be a delay between assessments and the drawing up of care plans etc 
which will then be sent out to the patient. By establishing an early process of 
engaging with carers the medical professionals may build in further protective 
factors for the patient 

CONCERN  1.  Criteria  to  be  applied  as  to  who  should  be  considered  for  a  Carer’s 
assessment at the earliest appointment.  

We appreciate the impact that a person’s mental illness may have on their families and carers, 
as well as wanting to support families and carers to be as involved as much as it is possible 
in the care of their loved ones. As such, Carer’s assessments are a routine part of the services 
we offer.   

1.1  Current referral criteria for Carers assessments 

The Carer’s Assessment service operating procedure was last reviewed in July 2020 and is 
due to be reviewed in 2023.   

The service operates under broad referral criteria, defining a carer as someone who: 

•  Looks  after  a  relative,  partner,  friend  or  neighbour  who  needs  support  because  of 

mental ill health. 

•  Who  may  be  under  18  years  of  age  and  caring  for  a  parent  or  relative with  mental 

health problems. 

•  Who may not live in the same house or area as the person they care for. 
•  May provide full-time or part-time support to the person they care for. 
•  May not be the only person looking after the person they care for, they may be one of 

several people, both professional and non-professional. 

The service  has  deliberately  chosen  to offer flexibility  in its  response  to  people who  define 
themselves as having a caring role. It is the view of the service that all carers should have the 
opportunity to access support in their caring role if the carer and the patient consider that they 
might benefit from it.  

Carers may be referred by mental health staff or may self-refer to the service. The consent of 
the patient to whom the carer is linked is not required for referral to be made. Carers can also 
be signposted to carer support and resources without a formal carers assessment.   

Page 4 of 12 

 
 
 
 
 
 
 
 Current position 

We acknowledge that that in this case, 
assessment during her contact with our service.  

 was unfortunately not offered a carers 

It  is  important  that  staff  make  available  to  all  carers  the  opportunity  to  have  a  carer’s 
assessment or signpost to other stakeholders for support. Whilst carers assessment may not 
be indicated in all cases, and our service capacity means we would only be able to include 
providing  carers  assessments  to  main  carers  only,  it  is  possible that  staff  may  not  be  fully 
aware of the availability of the resource or of who might benefit from it.  

What we are already doing 

• 

In 2021/2 we conducted a Quality Improvement project on involving families and carers 
in suicide prevention (2020-21) where it was noted that misunderstandings about the 
use of the word ‘carer’, both on the part of the patient/ their family and friends and the 
staff member may limit the number of referrals to the carers assessment workers.  

•  The above project also identified via staff focus groups that that there are difficulties 
with the processes required in our electronic record system for carer registration and 
referral.  

•  A follow-on Quality improvement Project which arose from these findings is currently 
in progress to address the issue of simplifying the process of registration and referral 
for clinicians. (see action plan) 

•  The carer information webpage on the Trust website has recently been updated with 
information and signposting resources. Carers - Carers - Somerset NHS Foundation 
Trust (somersetft.nhs.uk) 

•  A QR code to link to the webpage is currently in development for distribution to patients 

and their carers.  

•  The carers assessment service has developed leaflets for people caring for a young 
person, adult or older adults  ‘Are you caring for someone’ and a carer’s information 
pack. TEMPLATE_PIB_Booklet_APRIL_2020.indd (somersetft.nhs.uk) 

What we plan to do: (please also refer to action plan) 

•  The ‘Are you caring for someone?’ leaflet will be sent out routinely with all first 
appointment letters so that patients can pass the information to their carers as 
soon as possible.  

•  The Home Treatment Team plan to include carers assessment in their checklist 
for clinical review meetings so that carers assessment is reviewed on a weekly 
basis, as well as to their caseload boards where carers assessment will be 
marked as complete once families and carers have been asked about their carer 
needs and been signposted to relevant information. The team currently review 

Page 5 of 12 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 whether family liaison has been offered, and this standard will be added to this 
process.  

•  Home Treatment Teams are in the process of recruiting peer support workers 

who will undertake to perform an outreach function to families and carers on the 
caseload, checking attendance and understanding of the plan of care.  

•  We will provide an update to all clinical staff about ensuring patients and their 
carers are aware of carers support resources and to explore with patients and 
their carers whether assessment is indicated, for example where a carer is 
expressing difficulty and stress because of their caring role. 

•  We will add more specific reminders to explore carers assessments with patients 

and their families/carers in our clinical risk training.  

•  We will include the standard that carers assessment has been considered and 

discussed with family and carers in the caseload management tool. 

•  We will design a Quality Improvement project which is co-produced with experts 
by caring, experts by experience and experts by training to explore further 
mechanisms by which we can ensure greater and earlier family and carer 
involvement in care planning, and decision making, and sharing risk information.  

•  We will use our learning from the above QI project to inform revisions to the Carer’s 

Assessment service operating procedure when it is reviewed in 2023.   

CONCERN 2.“Such criteria should include whether the patient has given permission to 
share information, whether the patient and/or the carer have been involved with mental 
health  services  previously;  whether  the  carer  has  been/will  be  present  during 
consultations; the level of understanding of the of the carer in relation to steps taken 
and decisions made and whether they need further help” 

2.1  Consent by the patient to share information 

Regrettably, a clinician was not aware that the patient had given consent to the trust to 
discuss Mr Nixon’s care with 
staff who was not familiar with this process.  

. It is understood that this was a new member of 

Current position: 

Consent to share information in line with the Trust confidentiality policy is recorded in the 
electronic patient record (RiO) on the patient front page which is accessible to all staff. 
Completion of the confidentiality statement is reviewed in the caseload management tool 
which staff are asked to complete as a routine monitoring process. 

It is recognised that current recording of consent to share information on the electronic 
system focusses on exclusions (who the person does not want to share information with) 
rather than allowing recording of detailed wishes about confidentiality (what is acceptable to 
share, and with whom). 

Page 6 of 12 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 What we have already done 

The recent  quality  improvement  project  (2020-21)  which focussed  on  initiatives to increase 
family and carer involvement led to the development of a poster campaign about consent and 
confidentiality  (enclosed),  based  on  the  SHARE  document  Documents  ::  Zero  Suicide 
Alliance. 

Recommended wording from the above ‘SHARE’ document has been incorporated into our 
Dialog+ care planning tool to establish with patients who they would like to be involved in their 
care and who their emergency contact should be (this may not be their Next of Kin). 

We have also included the standard that ‘Confidentiality statement has been completed on 
Rio during this care episode’ into our caseload management tool. 

What we plan to do (please see action plan) 

•  Develop 7-minute briefing and redistribute to all staff with poster about consent and 
confidentiality, reminding all staff to update the consent to share information screen, 
and reminding them where to access information about consent in Rio.  

•  Explore improved/broader recording for consent to share information in Rio to include 
who can be involved, how much can be shared and what, plans and agreements 
about who in the patient’s social network we should contact in the event of 
nonattendance.  

• 

Include reminder about confidentiality statement location in electronic record system 
in Clinical Risk Assessment and Management training. 

2.2 

Information gathering about whether the patient and/or the carer have been 
involved with mental health services previously 

We will be able to gather information about previous patient involvement from our electronic 
records and we will add carer involvement as a recommendation to frontline staff 
undertaking assessments.  

2.3  Recording whether the carer has been/will be present during consultations 

Recording who is present during a consultation should be a routine part of record keeping 
and we will ensure that staff are reminded of this. Dialog+ also includes a tick box and free 
text box with the prompt to establish at an early stage who the patient would wish to involve 
in their care. 

2.4  The level of understanding of the of the carer in relation to steps taken and 

decisions made and whether they need further help. 

Where a carer has been referred for a carers assessment, carers assessment workers 
already check with clinicians where they have become aware of the carer not being clear 
about decisions made and where they require further help. 

Page 7 of 12 

Make Consent Count v2.4.pptx 
 
 
 
 
 
 
 
 
 
 
 Our service relies on our clinicians to build relationships with patients and their carers in 
order to check whether the carer feels fully included in care planning and decision making 
and can understand the rationale for any decisions taken.  

We recognise that we need to explore this further, and this will be an explicit focus for the 
co-produced away day, to involve experts by caring, by experience and by learning which we 
will be convening in September to launch our next Quality Improvement Project to improve 
Family and Carer involvement in patient care.  

CONCERN 3: “Such criteria may lead to a full carer’s assessment. It is noted that 
there will always be a delay between assessments and the drawing up of care plans 
etc which will then be sent out to the patient. By establishing an early process of 
engaging with carers the medical professionals may build in further protective factors 
for the patient.”  

As a Trust we are committed to ensuring that family members and carers are involved in the 
risk assessment and care planning process. We appreciate that on this occasion and although 
Ms  Greenwood  was  present  in  many  appointments  that  Mr  Nixon  had  with  Mental  Health 
Services, an escalation and safety plan did not involve her sufficiently in understanding that 
Mr  Nixon  had  had  suicidal  thoughts,  or  in  helping  her  support  her  partner  though  a 
safety/escalation plan.  

3.1 

Involving families and carers at the earliest opportunity 

What we have already done: 

To ensure the participation and engagement of families and carers the following processes 
have also been introduced: 

•  All  appointment  letters  currently  include  a  standard  invitation  to  bring  family 
members/friends or carers and we have ensured that this is also included in invitations 
for online appointments using ‘Attend anywhere’, our online platform. 

•  As  well  as  peer  workers  in  home  treatment  teams,  we  are  currently  recruiting 
Engagement workers to Community Mental Health Services who will also provide an 
outreach  function  to  families  and  carers  to  encourage  attendance  at  assessment 
meetings.  

•  As  part  of  our  Directorate  governance  processes,  The  Mental  Health  Directorate 
expects  all  staff  to  complete  a  routine  caseload  management  tool.  This  includes 
monitoring  of family  and  carer  involvement  in  care  planning (in Dialog+),  family  and 
carers  involvement  in  safety/escalation  planning,  collecting  Next  of  Kin  and  carer 
contact details, and to check that confidentiality is discussed and reviewed regularly 
with the patient.  

3.2 

Involving families and carers in care planning and developing safety/escalation 
plans 

Best practice would indicate that wherever possible and where consent permits, families and 
carers should be routinely involved in the sharing of risk information, in the co-production of 
safety and escalation plans, and should understand the rationale for decisions in the patient’s 
care.  

Page 8 of 12 

 
 
 
 
 
 What we have already done 

•  Since Mr Nixon’s death we have introduced a new care planning tool, Dialog +, which 
replaces the previous Care Planning Approach. Dialog + encourages the involvement 
of  families  and  carers  by  explicitly  requesting  their  views  and  encouraging  the  co-
development and sharing of the care plan with identified families and carers. 

•  A  recent  quality  improvement  project  (2020-21)  focussed  on  initiatives  to  increase 
family and carer involvement and has led to the roll out of a plan to share care plans 
with families at discharge from hospital, and check understanding of care/safety plans, 
and a shared safety planning initiative in Children’s services.  

•  The involvement of families and carers in safety/escalation plans is already monitored 

within the Trust case notes audit.  

What we plan to do: (refer to action plan) 

•  All patients discharged from the service should have a co-produced safety plan which 
is  shared  with  consent  wherever  possible  with  identified  family/friend  of  carer.  Our 
routine record keeping audit includes this as part of its assurance. 

Thank you in advance for your consideration of this preventing future deaths response. We 
hope that you are assured by our response and our ongoing commitment to strengthening our 
involvement with families and carers.  

Yours sincerely, 

Chief Executive 

Page 9 of 12 

 
 
 
 
 
 
 
 
 
 
 
 Somerset NHS Foundation Trust 

Action Log for PFD  

1. 

 a. 

b. 

c. 

d. 

e. 

f. 

Action 

 The ‘Are you caring for someone?’ leaflet will be sent out routinely 
with all first appointment letters  
 The Home Treatment Team (HTT) will include carers assessment 
in their checklist for clinical review meetings so that carers 
assessment is reviewed on a weekly basis. 
Carers assessment offer will be added to HTT caseload boards 
where carers assessment will be marked as complete once 
families and carers have been asked about their carer needs and 
been signposted to relevant information. The team currently 
review whether family liaison has been offered, and this standard 
will be added to this process.  
 HTT  peer support workers  will undertake to perform an outreach 
function to families and carers on the caseload, checking 
attendance and understanding of the plan of care.  
 All clinical staff to be made aware of carers support resources and 
the process for carers assessment. 

Clinicians to explore with patients and their carers whether 
assessment is indicated, for example where a carer is expressing 
difficulty and stress because of their caring role. 

 We will add more specific reminders to explore carers 
assessments with patients and their families/carers in our clinical 
risk training.  
 We will include the standard that carers assessment has been 
considered and discussed with family and carers in caseload 
management tool. 

Action 
by 

TW 

Due 
Date  
01/09/22 

Update 

LH/TY  01/09/22  20.07.22 

This has been circulated to team 
managers for dissemination. 

LH/TY  01/10/22  20.07.22 

Recruitment successful, awaiting 
recruitment checks and start dates 

TW/TY  01/09/22  21.07.22 

Memo to staff drafted, to be shared when 
manager returns from planned leave.  

AvL 

30/9/22 

The clinical risk training content is 
reviewed regularly and is next due for 
review on 5th September 2022 

CM 

01/09/22  22.07.22 

Complete.  

Status 
(RAG) 

B 

B 

B 

B 

B 

G 

Page 10 of 12 

 
 
 
 
 
 
 
 
 
 
 
 Action 

Action 
by 

Due 
Date  

Update 

Status 
(RAG) 

g. 

h. 

 We will design a Quality improvement project which is co-
produced with Experts by caring, experts by experience and 
experts by training to explore further mechanisms by which we can 
ensure greater and earlier family and carer involvement.  
 We will use our learning from the above QI project to inform any 
revisions to the Carer’s Assessment service operating procedure 
when it is reviewed in 2023. 
1. 
We will continue our Quality Improvement Project to simplify carer 
referral processes in Rio 

2. 

 a. 

 Develop 7-minute briefing and redistribute to all staff with poster 
about consent and confidentiality, reminding all staff to update the 
consent to share information screen, and reminding them where to 
access information about consent in Rio.  

b. 

 Explore feasibility of changes to electronic recording system to 
permit improved/broader recording for consent to share 
information in Rio to include who can be involved, how much can 
be shared and what, plans and agreements about who to contact 
in the event of nonattendance.  

JY 

31/10/22  20.07.22 

An away day is being scheduled for 
September 2022 to launch this project. 

CM/SP  July 
2023 

SP 

01/01/23 

DW 

30/9/22 

DW 

31/10/22 

c. 

 Include reminder about confidentiality statement location in 
electronic record system in Clinical risk assessment and 
management training. 

AvL 

30/9/22 

The clinical risk training content is 
reviewed regularly and is next due for 
review on 5th September 2022 

3. 

 a.    All patients discharged from the service should have a co-

DW/TY  01/09/22  21.07.22 

produced safety plan which is shared with consent, wherever 
possible, with identified family/friend of carer.  

Memo to staff drafted, to be shared when 
manager returns from planned leave.  

Page 11 of 12 

B 

B 

B 

B 

B 

B 

B 

Copy of Caseload Management Tool - FINAL.xlsx 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Initial 

Name 

Job Title 
Associate Director of Mental Health 
& Learning Disability Care 
Deputy Head of CMHS & LD 
Suicide Prevention Lead 
Service Director, Mental Health & 
LD 
Operational Service Manager, 
Home Treatment Team 
Head of CMHS & LD 
Head of Inpatient & Urgent Care 
Manager carers service 
Deputy manager carers service 

Status  

Complete 

On plan 
Risks slippage 

Green 

Blue 
Amber 

Barriers – not achieved 

Red 

Page 12 of 12