Keith Nottle

Chief Executive’s Office 
The Resource 
Duncan Macmillan House 
Porchester Road 
Nottingham 
NG3 6AA 

Reference: 
E-mail: 

Date:  3 August 2022. 

Private and Confidential 

Mr. 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. Nottle. In responding, we have worked closely in 
conjunction with Turning Point. 

The Matters of concern raised within the report:  

1.  Clarifying the role of telephone workers and the steps necessary to ensure that the 

government guidance regarding access to mental health services is followed so far as is 
possible within the available resources. 

Nottinghamshire Healthcare and Turning Point are jointly commissioned by Nottingham and 
Nottinghamshire Clinical Commissioning Group (CCG) to provide a 24-hour Urgent Access Mental 
Health telephone service. The purpose of the telephone line is to provide support, advice and triage 
across Nottingham and Nottinghamshire to people requesting help with any aspect of mental health. 
This includes practical immediate support and guidance or assistance to navigate any further support 
needed; and immediate transfer to Crisis Resolution and Home Treatment (CRHT) staff if required.  

The first point of contact are Recovery Workers employed by Turning Point and co-located in the City 
Crisis Resolution and Home Treatment (CRHT) team office at Highbury Hospital. The staff are co-
located so that they may have immediate assistance from CRHT staff if required. The Turning Point 
Team Leader and CRHT staff have the ability to listen in to calls if necessary. This is carried out via a 
dual listening device that allows a second set of headphones to be plugged in. The UK Mental Health 
Triage Scale (Appendix 1) is utilised to guide staff as to when a call should be transferred directly to a 
CRHT member of staff  

During the evidence at the inquest the Turning Point staff member stated that Turning Point staff may 
be placed on the line within their first week of starting work, after shadowing a small number of shifts. 
It was also stated that there are frequent times when calls are not transferred to CRHT in line with the 
UK Mental Health Triage Scale  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 In order to respond to the PFD senior members of Adult Mental Health and the Deputy Director for 
Mental Health Services have met with national and local senior staff from Turning Point. We have 
sought assurance from Turning Point regarding the training that staff receive. All staff complete the 
Turning Point Mental Health Foundation Programme which includes mandatory e-learning modules 
alongside face-to-face training sessions facilitated by the Turning Point Learning and Development 
Team. 

The Recovery Workers also undertake a competency assessment to ensure they have a high level of 
competence in managing calls, using correct systems and utilising appropriate escalation protocols in 
relation to risk and safety management. The competency assessment has been updated in light of this 
inquest. The updated competency assessment is attached (Appendix 2).  

As well as the Turning Point training, staff also receive a face-to-face training session from the CRHT 
staff as part of their induction. This is based on the Trust’s e-learning package for risk assessment and 
management. 

We have been assured by Turning Point that in her evidence regarding transfers to CRHT the staff 
member was referring to June 2021 when the Urgent Access line was first set up, where there were 
some initial issues with the transfer of calls.  The local guidance for the UK Mental Health Triage Scale 
has been reviewed with a more robust escalation process should there be any difficulty encountered in 
transfer of a call.   

The Standard Operating Procedure (SOP) (Appendix 3) for the Urgent Access line has been reviewed 
and shared with all relevant staff via email and also during supervision and team meetings.  

A new digital telephony system is being introduced into the Trust which will provide greater insight into 
call activity. All calls will be recorded which will enable the roll out of regular audit. It is anticipated that 
the telephony system will be operational by Mid-August 2022.  

An audit system is being introduced whereby telephone recordings of a sample of telephone calls will 
be listened to monthly and utilised for audit and training purposes. This will include monitoring if the 
calls are being handled in accordance with the SOP and taking remedial action if needed.  

2.  Steps to ensure that, for individuals with complex mental health needs involving a range 
of providers, there is co-ordination of care to ensure that appropriate care is in place 
and, where necessary, a consistent approach is taken to patients by different 
organisations or teams working with the patient; and 

3.  Review of the multi-disciplinary team’s decision-making process in light of the issues 

identified by Mr Nottle’s circumstances. 

Our response to issues 2 and 3 will be taken together as these represent issues in regard to the 
decision making within the LMHT. We acknowledge that the team conflated the two issues of Mr 
Nottle living remotely and a clinical decision as to whether secondary care services were the right 
place for Mr Nottle to receive his care. There was not a comprehensive care plan, there was a lack of 

The Resource, Duncan Macmillan House,    
Porchester Road, Nottingham NG3 6AA 

Chair:

,                                 

Chief Executive: 

 
 
 
 
 
 
 
 
 
 liaison with the GP, with Mr Nottle’s parents and with Mr Nottle himself. In addition, multiple re-
referrals of Mr Nottle to the team were not acted upon. These concerns highlighted that expected 
systems and protocols had not been complied with and therefore indicated that a poor culture has 
developed within the team which has led to poor decision making and, at times, a loss of compassion. 

In order to address these issues of culture and practice within the team a programme of Quality 
Assurance work is planned. This will consist of a Culture Review and a Quality Standards review. 

The Culture Review will be based on the closed culture indicators set out by the Care Quality 
Commission (CQC) (Appendix 4). This commences on 3rd August 2022 over a 3-month period. During 
this period there will be regular contacts by the Quality Assurance team to monitor improvement.  

The Quality Standards review, led by the Quality Assurance Team, will take place on 19th September 
2022. This will look at the 5 key areas and fundamental standards of the CQC, namely is the service 
Safe, Effective, Caring, Responsive and Well Led. 

Both of these reviews will include:   

•  a thematic review of serious incidents and complaints involving the team 
• 

live observation of Multi-Disciplinary team meetings and decisions which are made with in the 
meetings. This will involve how referrals are managed and how discharge decisions are taken  
review of care plans including involvement of patients and carers, and where multiple out of 
hours calls are made to the CRHT 

• 

•  Views of staff, service users and carers about the service 

The Person-Centred Care audit tool (Appendix 5) will be another key element of this review. 

Following both these reviews an improvement plan will be developed to assist the team in making 
required changes in a supportive and achievable manner.  The improvement plan will be monitored to 
completion on a monthly basis, overseen by the local management team (Service Manager, 
Operational Manager and Matron). Once considered complete, the improvement plan will be 
presented at the Quality and Risk meeting and signed off by the General Manager. An audit will then 
be developed and carried out twelve months later in order to understand the efficacy of changes 
made. 

I  hope  the  information  above  provides  the  assurance  that  we  have  and  continue  to  consider  your 
recommendations seriously, that we are actively seeking to clarify and improve the services we provide 
by implementing the actions outlined. The Trust will be able to share the findings of the review and initial 
improvement plan with you by 30 November 2022 and agreement made at that point in relation to any 
further updates on progress of the implementation of the plan you may wish to receive. 

Yours sincerely  

The Resource, Duncan Macmillan House,    
Porchester Road, Nottingham NG3 6AA 

Chair: 

Chief Executive: 

 
 
 
 
                                 
 
 
 
 
 
 
 
 
 
 Chief Executive 

Enc  Appendix 1 – UK Mental Health Triage Scale 

Appendix 2 – Access Line Competency Assessment Form 
Appendix 3 – Standard Operating Procedure for the Access Line 
Appendix 4 – CQC Closed Cultures Guidance  
Appendix 5 – Person-Centred Care Self-Audit Tool 

The Resource, Duncan Macmillan House,    
Porchester Road, Nottingham NG3 6AA 

Chair: 

Chief Executive:

Turning Point  
The Exchange 
3 New York Street 
Manchester 
M1 4HN  

T 
F 

www.turning-point.co.uk 

9th August 2022 

Prevention of Future Deaths Notice for Keith Nottle – Turning Point Response 

It is our understanding that Turning Point is only being asked to give consideration to paragraph 1 in 
section 5 of the regulation 28 report, jointly with Nottinghamshire Healthcare Trust; we have 
discussed this with colleagues from the Trust and they agree with this interpretation of the report. 

We have reviewed and refreshed the key factors in the role of the helpline (telephone) workers with 
colleagues in Nottinghamshire Healthcare Trust, including when and how referrals are escalated to 
the Crisis Team, training, supervision, monitoring and audit. 

We are also working with commissioners and the Trust to refresh the service specification. 

We have met with our colleagues from Nottinghamshire Healthcare Trust on a number of occasions 
and agreed a Standard Operating Procedure (SOP) for the flow of referrals from the helpline workers 
to the Crisis Team. This SOP is in line with the service specification and national guidance regarding 
access to mental health services. 

We have met with the team of helpline workers and their team leader and ensured that they are 
familiar with the detail of the SOP. 

We have introduced additional monitoring and audits to ensure that all helpline workers are 
following the SOP and any variance is addressed in a timely way. 

The audits will check a sample of cases each month against the SOP and our additional monitoring 
incudes regular listening in to the calls by a manager or team leader. 

We have also agreed a competency framework to provide assurance that our staff are confident in 
their ability to handle calls and the escalation process regarding risk, amongst other areas.  

We, alongside our colleagues in the Trust, are also introducing a new digital telephony system which 
will give both organisations better insight into call activity. 

We believe that these steps will effectively address the concerns that were raised regarding ‘culture 
and practice’ in the helpline service. 

CHIEF EXECUTIVE: LORD VICTOR ADEBOWALE CBE 
TURNING POINT IS A REGISTERED CHARITY, NO. 234887, A REGISTERED SOCIAL LANDLORD AND A COMPANY LIMITED BY GUARANTEE NO. 793558 (ENGLAND & WALES) 
REGISTERED OFFICE: STANDON HOUSE, 21 MANSELL STREET, LONDON, E1 8AA. T:020 7481 7600  F:020 7481 7620  www.turning-point.co.uk