Gaia Pope-Sutherland

Association ofBritish Neurologists 

Coroner's Support Officer 
The Coroner's Office for the County of Dors~t 
Town Hall, 
Bournemouth BH2 6DY 

1ath  October 2022 

Dear 

Ra:  Regulation 28 Report to Prevent Future Deaths 

I am responding  on behalf of the Association of British Neurologists (ABN) following  your 
letter of 21 st July 2022  regarding the Coroner's report following the Inquest around the 
death of Gaia Kima  Pope-Sutherland. 

The ABN  is a professional organisation with the overarching aim to  improve the health and 
well-being of people with neurological disorders by advancing the knowledge and  practice 
of neurology in the British Isles. 

There were two specific concerns regarding the tragic circumstances of the death of Gaia 
Klma Pope-Sutherland listed: 

2i:  "there could be future deaths locally and across the country due to the lack of 
resourcing of epilepsy services.  I request consideration is given to a review of nursing 
services in epilepsy care locally -in  Dorset Epilepsy Service,  and generally across England 

, and Wales." 

Neurology and epilepsy services across the country are stretched,  and these workforce 
issues are no different from other medical specialist services across the UK. This includes 
neurologist and specialist nursing roles.  For the latter the assessment of numbers is more 
complex as some are employed by acute medical NHS trusts and  others by community 
NHS Trusts,  but it is likely there are regional  differences. 

The ABN does not have access to the numbers of epilepsy nurses but the ABN  Epilepsy 
Advisory Group may be able to comment on numbers and the level of resourcing.  To this 
end I have asked the Epilepsy AG for comment on this and  how the system could work 
with  more resource. 

2ii: "further I am concerned that there could  be future deaths as a result of the lack of 
communication between neurology and  psychiatric teams and  request that there is 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 consideration as to how to ensure effective lines of communication between the 2 
disciplines." 

 who gave evidence at the inquest regarding  lack of 

I would  agree with Prof 
communication between community psychiatric and neurology teams.  He highlighted the 
role that GPs had previously played as "communication hubs" to have an overview of the 
specialists involved, but that they do not now have the time or resources to fulfil this role. 
The use of different IT systems between Primary care,  NHS Hospital and Mental Health 
Trusts also does not help this situation. 

We have suggested the following  actions that could be helpful: 

- Ensuring all communication from psychiatry is copied to the treating neurologist 

(clinic letters and discharge summaries) and vice versa. 
The neurologist treating  the epilepsy is informed if a patient is admitted to acutely to 
psychiatry. This will help inform care as some of the treatments used in  psychiatry 
may have an impact on the seizures. 
Hospital neurologists include a line in their clinic letters to GP with a statement 
along these lines of "I would be grateful if you  could forward copies of letters and 
discharge summaries from any psychiatric appointment, admission or other 
epilepsy-related admissions". 

I will also bring communicate these views with Prof 
College of Psychiatrists, to discuss how to improve these lines of communication. 

 President of the Royal 

Any new outcomes from the actions above will be communicated to you. 

Please send any communication regarding  this  directly to myself rather than via my NHS 
secretary to avoid any unnecessary delay. My email is 11!!!!!111!  1!111111••• Please 
also copy to the ABN  using the contact details on page  1. 

Yours sincerely 

President 
Association of British Neurologists 

15

Chief Executive 
BCP Council Civic Centre 
Bourne Avenue 
Bournemouth 
BH26DY 

Rachael Griffin 
Senior Coroner 
Her Majesty's Coroner for the 
County of Dorset 
Civic Centre 
Bournemouth 
BH26DY 

Date: 

26 August 2022 

: 

Dear Ms Griffin 

Re Regulation 28  Report to Prevent Future Deaths - Ref:  167554 

Thank you for your letter dated 21  July 2022 and the attached report relating to the very 
sad circumstances surrounding Gaia Pope-Sutherland's death. 

I and my colleagues in Adult Social Care Services have followed the case as it was heard 
and appreciate having the opportunity to respond to your points. 

Having reviewed your Report,  I note that one of the keys issues relates to the sharing of 
information, and in particular the outcome of a Mental Health Act assessment.  I have 
referred to concerns 2x and 2xi in particular to inform this response. 

The BCP Council Approved Mental Health Professionals (AMHP) Service uses the  Mental 
Health Act 1983 (amended 2007) and the Code of Practice to inform practice standard, 
which are monitored through an AMHP Quality Assurance Framework. 

The Code of Practice is very clear about the need to record and share information after an 
assessment has been completed,  regardless of the outcome,  and the BCP Quality 
Assurance Framework makes specific reference to this code. 

Regardless of whether an admission is facilitated,  AMHP are expected to comply with the 
following: 

• 

If an admission has been facilitated,  the AMHP's must produce an outline report 
detailing the outcome of the assessment and other key  pieces of Information at the 
point the person  is admitted.  The report must be given to the person receiving the 
application for detention or to the receiving ward. 

'BCP Council' is the operational  name for Bournemouth, Christchurch  and Poole Council. 

bcpcouncll.gov.u k 

36 

 
 
 
 
 
 
 
 
 
 
 Chief Executive 
BCP Council Civic Centre 
Bourne Avenue 
Bournemouth 
BH2 SOY 

•  The AMHP must then complete their full (or final) report within  2 hours of completing 
their assessment (or by the end of their shift If they are an out of hours worker) and 
again distribute this to the receiving Ward (if relevant),  the Mental Health Legislation 
office,  General Practitioner, Care Co-ordinator, the Medics involved in the assessment 
and the AMHP Lead within 72 hours. 

There may be rare occasions when the standard of 72 hours for distributing the Report 
cannot be met,  for example when the AMHP cannot detennine which GP surgery the 
person is registered with.  In such circumstances, AMHPs have dedicated business support 
assistance to expedite the matter. 

We are actively engaging with  Dorset Healthcare Trust to agree the necessary 
amendments to the  Pan-Dorset Standard Operating Procedure. We are of the view that the 
Standard Operating Procedure standard for distributing information is too slow and we will 
continue to apply the requirement of 72 hours. 

We are also in the process of discussing with AMHP's how they could  succinctly share 
information with GP's,  and in  particular highlighting that information which  is of most 
Immediate relevant to them. 

It is worth noting that the reason we required AMHP's to send the AMHP Lead  a copy of 
their final report is to carry out a Quality Assurance check which provides assurance that 
standards, including timescales, are being met. 

I hope that this letter gives you reassurance about our procedures and would invite you to 
let me know if you have any further concerns regarding  our policies and  practices. 

Yours sincerely 

Chief Executive 
BCP Council 

'BCP Council' is the operational  name for Boumemouth,  Christchurch  and  Poole Council. 

bcpcouncll.gov.uk 

37

Working together 
to keep  people safe 

College  of Policing 
Leamington Road 
Ryton-on-Dunsmore 
Coventry, CVS 3EN 

Rachael C. Griffin 
Senior Coroner 
Her Majestys Coroner for the County of Dorset 
By email-

15 September 2022 

Dear Ms Griffin, 

Re;  Consideration of epilepsy and mental health illness training for all staff and officers in police 
forces and update to the new recruit curriculum. 

Firstly, on  behalf of everyone at the  College of Policing  I wish to convey our deepest sympathy to  Ms. 

Pope-Sutherland's family and friends for their loss and the tragedy of the circumstances of her death.  I'd 
also like to thank you for your work to ensure learning  results from this tragic incident. 

We recognise that policing must have some medical knowledge and this is provided through our first aid 

programme.  This  programme and medical knowledge makes explicit links to our vulnerability training. To 
ensure police responders are equipped to effectively respond to missing persons, our training 

focuses on  managing the full spectrum of vulnerabilities through effective and proportionate risk 
management.  In  reality, th is means that College standards require front line responders to ask good 
questions that enable an informed  understanding of the range of risks affecting a missing  person,  on a 

case by case basis, to identify their severity and  impact. Additionally,  police responders should  seek 

information from informed sources, such as family or doctor, to understand the impact and degree of any 

medical conditions potentially effecting a missing person.  When this training is combined with the 
guidance we set as Authorised Professional Practice the standard is proportionate and  appropriate. 

Additionally,  the College is committed to providing the  highest standards of training for those working in 

policing however, that training also must be accessible and  practicable.  Medical conditions can  be  very 
complex, those conditions in themselves can  be variable and  they do not exist in isolation.  Different 

conditions have differing levels of severity that interact with the myriad of circumstances in which people 

go missing. The quantity of variables is simply too great to reasonably and effectively train . 

•  The number of medical conditions,  the varying degrees of those medical conditions  and  and the 

complexity of the circumstances in which people go missing persons, are too great to be trained 

to non-medical personnel. 

I 

' 

' 
'. 

t., 

I 

I 

\ 

,· 

38 

 
 
 We have recently considered this question in relation to other conditions,  such as neuro diversity, and 

further concluded that seeking to give a higher level of expertise is unfortunately not practical. Policing 

deals with an almost limitless variety of incidents, some situations or medical issues may only being 
encountered by officers very rarely - their training would be almost irrelevant because of the time that 
had lapsed  between the training and the time the knowledge was needed to deal with the incident. 

•  Additionally,  such training would have to be subject to continuous professional development to 

ensure advancements are shared which would also be  unrealistic. 

I do appreciate this is not the response you were hoping for but after very careful consideration we have 

concluded that that our current approach is correct for policing. We believe that by encouraging better 

investigation of vulnerability and  identification of the risks of harm that may arise,  policing can  better 

respond and deal more effectively with the needs of the  public. 

Yours sincerely 

Chief Executive Officer 

39

• 

Department 
of Health & 
Social Care 

Rachael Clare Griffin 
Coroner's Office for 
County of Dorset 
Town Hall 
Bournemouth 
BH26DY 

Dear Ms Griffin, 

From Maria Csulfisld
Psrlismentsry Under Secretary of Stats for 
Mentel Health end Women's Health Strategy 

39 Victoria Street 
London

14 November 2022 

Thank you for your letter of 21  July 2022 to the Secretary of State for Health and Social 
Care,  about the death of Gaia Pope-Sutherland.  I am replying as Minister with  responsibility 
for Mental Health and thank you for the additional time allowed. 

Firstly, I would  like to say how deeply saddened  I was to read  of the circumstances of Ms 
Pope-Sutherland's death.  I can appreciate how distressing her death must be for her 
parents and those who knew and loved  her and I offer my heartfelt condolences.  It Is vital 
that we take the learnings from what happened  in this case in  order to prevent future deaths. 

The circumstances your report describes are very concerning and I am grateful to you for 
bringing these matters to my attention.  In preparing this response, Departmental officials 
have made enquiries with Health Education England (HEE),  NHS England (NHSE),  as well 
as the relevant regulator,  which  in this instance is the Care Quality Commission. 

The Government is committed to supporting people with epilepsy and ensuring they receive 
the support that they need from statutory services and that that they are referred to specialist 
services as appropriate.  Once diagnosed, and with a management strategy in  place,  most 
people with epilepsy can be cared for through routine access to primary and secondary care 
services commissioned locally by Integrated Care Boards (ICBs). 

Those whose epilepsy cannot be satisfactorily controlled,  or whose condition cannot be 
appropriately diagnosed, should be referred to specialised neurological services, 
commissioned nationally by NHSE.  NHSE has published 1 adult and paediatric specifications 
setting out what providers must have in place to offer specialised care for patients with 
neurological problems,  including epilepsy. 

You may wish to know that in order to support systems to understand the priorities In 
epilepsy care and improve service quality, NHSE have developed the RightCare Epilepsy 
Toolkit2.  This toolkit, which was developed in partnership with stakeholders such as 
Epilepsy Action,  provides expert practical advice and  recommendations on several key 
areas. These include ensuring that all people living with epilepsy know how and where to 

1 httos:/twww,eoa1and.nhs.uk/speciallsed-comm1ss;onlna-dooument-11brarv/seNice-specificat10ns/ 
2 httos://WVMl.england.nhs.uk/riahtcare/toolklts/eplleosv-toolkit/ 

9 

 
 
 
 ) 

access mental health and wellbeing support, and having policies in place to identify those 
most at risk of avoidable premature mortality and prevent epilepsy related deaths.  The 
Toolkit makes clear the importance of ensuring that right systems are put in place to support 
the appropriate referrals for all patients3

• 

You  may also flnd it useful to know that there is a guidance available from the National 
Institute of Health and Care Excellence (NICE) regarding "Epilepsies in children,  young 
people and adults'4
support for people with all types of epilepsies. 

,  which sets out best practice in the diagnosis, treatment,  care and 

The NICE guidance sets out that all children, young  people and adults should be  referred 
urgently (for an appointment within 2 weeks) for an assessment after a first suspected 
seizure.  The guidelines further describe the best practice that should be taken fully into 
account in the care and treatment of individual patients,  however, this is not mandatory and 
therefore does not override the medical practitioner's clinical judgement. 

Moreover, the Government is taking action at a national level to improve services for those 
with neurological conditions, including epilepsy.  NHSE has established the Neurosciences 
Service Transformation Programme,  a multi-year, clinically led programme within NHSE, to 
develop a new model of integrated care for neurology services, including the care of people 
affected by epilepsy.  The development of the optimal clinical pathway for epilepsy has been 
overseen by the Transformation Programme in conjunction with the National Neurosciences 
Advisory Group (NNAG) - a collaboration  of professional bodies,  patient groups,  national and 
local policy and commissioning leads, that aim to improve treatment, care and  support for 
people with neurological conditions.  This work has been led by epilepsy specialists including 
representatives from the Association of British Neurologists.  The pathway sets out what 
good treatment,  care and support looks like. 

In addition,  NNAG have developed a series of best practice optimal pathways for 
neurosurgery and neurology.  These pathways are being used by NHSE's Neuroscience 
Transformation Programme to support neurosurgery networks with transformation and 
implementing high impact changes.  This work is building on the optimal pathways that have 
been developed in  partnership with stakeholders to support Integrated Care Systems and 
their neurology services to deliver the right service,  at the right time for all  neurology 
patients. 

With regard to your concerns related to the availability of training on access to community 
mental health services, including discharge planning - you  may wish to note that NHSE 
provides funding and resources for continuous professional development for community 
mental health practice, together with supporting good care in all settings.  HEE, working in 
partnership,  also provides a range of quality training and resources for health care 
professionals, at all stages of their career,  this Is intended to support good practice.  The 
training and resources provided by HEE align with policy direction and legislative 
frameworks, together with national clinical guidance such as that published by  NICE 
(Transition between Inpatient mental health settings and community or care home settings5
which acknowledges as its starting point. 

), 

With  regard to Ms Pope-Sutherland's discharge from hospital,  my officials have informed me 
that the Trust has introduced a Standard Operating Procedure in  May 2022, which covers 
the provision of information following  Mental Health Act assessments. 

In addition, the 

3  More information about the toolkit can be found here:  https://www.england.ohs,uk/rightcare/wp-
content/uploads/sites/40/2020/03/rightcare-epllepsy-toolkit-v2.pdf 
4 https://www.nice.org .uk/guldance/ng217 
6 https://www.nlce.orq.uk/gujdance/ng53 

10 

 Mental Health Act 1983: Code of Practice6 covers communicating information following an 
assessment by the Approved Medial Health Professional (AMHP).  Section 14.100 related to 
the commutating of the outcome of the patient's assessment specifically states that: "Having 
decided whether or not to make an application for admission, AMHPs should inform the 
patient, giving their reasons". 

The Code of Practice provides statutory guidance to registered medical practitioners, 
approved clinicians,  managers and staff of providers, and  approved mental health 
professionals on how they should carry out functions under the Mental Health Act in practice. 
It is statutory guidance for registered medical practitioners and other professionals in relation 
to the medical treatment of patients suffering from mental disorder. 

Finally, the Department takes the matters raised in this report seriously and will continue to 
engage with NHSE and  local  provider in order to improve the treatment of mental health 
patients. 

I hope this response is helpful. Thank you for bringing these concerns to my attention. 

) 

Kinds regards, 

MARIA CAULFIELD MP 

) 

8hUos://assets.publlshina,servlce.aov.uk/qovernment1uotoads/system1ucloads/attachment  datalfite/43 
5512/MHA  Coda  of  Practice.PDF 

11

Dorset 
Council 

Senior Leadership Team 
Dorset Council,  County Hall, Colliton Park,
Dorchester, Dorset DT1  1XJ 

-1J  www.dorsetcouncil.gov.uk 

Mrs Rachael C Griffin 
Senior Coroner 
The Coroner's Office for the County of 
Dorset 
Town Hall 
BOURNEMOUTH 
BH26DY 

Date:  9 September 2022 

Dear Madam 

Regulation 28:  Prevention of Future Deaths Report Response 
Deceased:  Gala Klma Pope-Suthertand 

I write following the Inquest that concluded on 15th  July 2022 into the death of Gaia Kima  Pope-
Sutherland and the Regulation 28 report issued to Dorset Council. I would firstly like to offer my 
condolences to the family and friends of Gala Pope-Sutherland for their loss. 

The Regulation 28 report raised the following concern about the Standard Operating Procedure, 
following  a Mental Health Act assessment: -

• 

" ...  in  respect of feeding back of information to the GP by the AMHP which is detailed at 
paragraph 2.1 Oof the Standard Operating Procedure for the flow of Information following a 
Mental Health Act assessment, I would recommend that consideration is given by  Dorset County 
Council (now known as Dorset Council),  BCP Council and OHUFT to reducing the timeframes 
from 7 days to 72 hours. Although this is the decision for Dorset County Council and BCP 
Council, the document Is a DHUFT document and  so will require their consideration too.' 

Operational and strategic leads from Dorset Council have been communicating regularly since 21  July 
2022 with colleagues from BCP Council and DHUFT, now referred to as Dorset Health Care, about the 
procedure. 

In addition to this Dorset Council have prioritised and completed an  internal review of its pathways and 
what is recorded by the AMHP's on the social care management recording system,  Mosaic. This 
Included ensuring that we adhere to the Mental Health Act Code of Practice, in particular, 14.100 which 
states: -

"Having decided whether or not to make an application for admission, AMHPs should inform the patient, 
giving their reasons. Subject to the normal considerations of patient confidentiality, AMHPs should also 
give their decision and the reasons for it to: 
• the patient's nearest relative 
• the doctors involved in the assessment 
• the patient's care co-ordinator (if they have one), and 
• the patient's GP,  if they were not one of the doctors involved In the assessment. 

Dorset Council has considered the recommendation to reduce the timeframe from 7 days to 72 hours to 
forward the completed AMHP report to the assessed  persons GP.  From the 191  of August 2022 Dorset 
Council put in place a new Internal data reporting system.  This system now enables the AMHP duty 
manager and business support, for the AMHP's, to monitor that the initial AMHP report Is completed and 
emailed to the GP within 72 hours. This also ensures that there is tracking of the full AMHP report, which 
is then sent by secure e-mail to the GP within 7 days of a person having had a Mental Health Act 

34 

 
 
 
 
 
 
 
 
 assessment. The e-mail to the GP will also confirm that a Mental Health assessment has been 
undertaken,  the outcome of the assessment and provide the contact details for the AMHP service, 
should further information be required  by the GP.  A monthly performance report of this activity is then 
shared with senior managers. 

The initial AMHP report provides the following  information: 

•  Referral details, including events leading up to referral 
• 
•  Risks identified to the person's health, their own  safety and the safety of others, environmental 

Information about the persons Nearest Relative. 

risks  i.e.,  property,  pets 

•  The Mental Health Act Assessment, date and time,  location,  professionals involved and  contact 

details,  legal grounds for decision making,  outcome and follow up actions required. 

The full AMHP report includes information about: 

•  Relevant background information i.e.,  previous psychiatric admissions, substance misuse, MHA 

assessments,  criminal justice contact. forensic history etc. 

•  The AMHP's recording of the interview with the person 
•  Alternative options considered e.g ., referral to the Home Treatment Team 
•  Views of those involved in  the assessment 
•  Person's responses 
• 

Issue encountered i.e., ambulance/ transport delay,  Police delay, lack of S.12 doctors etc 

The AMHP service in  Dorset Council has a different operating model to that of BCP Council AMHP 
service.  Dorset Council has a twenty-four-hour service over seven days,  and  BCP Council have a 
separate daytime (9 - 5 p.m. Monday to Friday) and  out of hours service.  Dorset Council has shift 
patterns of twelve hours with varying  start times i.e., Bam-Bpm,  9am-9pm,  11 am-11 pm and  8pm to 8am. 
There is an  8-week rota so the AMHP's do not always work on consecutive days,  hence the reason  why 
full reports are not completed within 72 hours. 

From our internal review the managers within the AMHP service, through ongoing  supervision, will also 
ensure that the AMHP's,  before undertaking a Mental Health Act assessment,  review any records held 
on the Dorset Council recording system,  Mosaic. There is also now a mandatory field on  Mosaic to notify 
the  allocated adult social care practitioner that a Mental  Health Act assessment has been undertaken. 

There is  a Continuing Professional Development record which  all AMHPs must complete to evidence 
their registration  and approval as an  AMHP.  The Council also now requires AMHPS to have internal 
mandatory training about the sharing of confidential information in  relation to the Mental Health Act 
assessment. 

I hope that the steps outlined to enhance the sharing and  scrutiny of the AMHP statutory functions will 
provide assurance to the Chief Coroner of Dorset Council's commitment to mitigate the risks of future 
deaths of Dorset residents. Designated operational and strategic leads will continue to work closely with 
BCP Council and Dorset Health Care in  all future  reviews of key standard operating procedures where a 
person has a Mental Health Act assessment. 

Yours faithfully 

Chief Executive 

35

DORSET 
POLICE 

I! 101 Non-emergency 
D 999 In an emergency 
El www.dorset.pollce.uk 
B 101@dorset.pollce.uk 

D Dorset Pollce 
a @dorsetpollce 
GJ dorset_pollce
II DorsetPollceHQ 

Mrs Rachael Griffin 
Senior Coroner for Dorset 
Town Hall 
Bourne Avenue 
BOURNEMOUTH 
Dorset BH2 6DY 

Dorset Police 
Force Headquarters 
Winfrith 
DORCHESTER 
DT2 802 

15 September 2022 

Dear Mrs Griffin 

Re:  Regulation 28 Report to Prevent Future Deaths 

I write  to provide  a response  on  behalf of Dorset  Police  to the  Regulation  28  Report,  ("the 
Report")  received  on the 21 81  July 2022, followlng the conclusion  of the Inquest touching the 
death of Gala Kima Pope-Sutherland. 

I  have  carefully  considered  the  entirety  of  the  Report  and  wish  to  reiterate  that  as  an 
Organisation we  continue to take  seriously the  need  to  reflect meaningfully on  the evidence 
heard  during  Gala's  inquest and  are  committed  to  ongoing  service  improvement that goes 
beyond  the  content  of your  Report.  However,  for the  purpose  of this  response  I will  focus 
specially on the points at Section 5, paragraph 2(iii - v) of the Report and address them in tum 
below. 

Knowledge and training about life-threatening  illnesses,  such  as epilepsy and  mental  health 
conditions 
 at the College of Policing.  I wish to 
This concern is directed to Chief Constable 
formally  record  my  support  for  the  learning  from  the  inquest  in  relation  to  life-threatening 
illnesses to be shared  with  the College to  inform  National knowledge and  understanding.  I 
have  personally  written  to  CC  Marsh  to  offer  to  support  this  work  and  to  utilise  the 
Organisation's  teaming  from  Gala's  inquest  to  inform  and  enhance  any  National  training 
provision.  I am aware that any updates to training and Information relating to medical  issues 
would  go through the College of Policing clinical governance group for appropriate oversight 
and to ensure guidance was implemented. 

I appreciate that this particular concern comes from the need for staff and officers, specifically 
including call handlers through  to senior officers with  oversight of an  Investigation, to identify 
and appreciate the specific risk that a diagnosis of epilepsy and a dependency on medication 
can cause to an individual's welfare. 

To  provide  reassurance  from  a Dorset  Police  perspective  the  Organisation  has  delivered a 
series  of training  Inputs  through  bespoke  Missing  Persons  Training  and  the  Vulnerability 
continuous professional development programme since 2019.  This training programme has 
targeted  front  line  officers  through  to  Commanders  with  a specific  module  focused  on  the 

16 

 
 DORSET 
POLICE 

g 101 Non-emergency 
II 999 in an emergency 
IJ www.dorset.police.uk 
B 101@dorset.pollce.uk 

D Dorset Police 
D @dorsetpollce 
II dorset_pollce
El DorsetPollceHQ 

Identification  of vulnerability  and  heightened  risk  factors  such  as  medical  conditions.  This 
programme  remains  a  priority  and  provides  a  good  foundation  for  the  ongoing  continued 
professional development and learning. 
Review  of policies  relating  to  concern  for welfare  reports,  missing  person  reports  and  call 
handling, grading and deployment of resources 

The Missing Person Policy has been  reviewed on two occasions since Gala's death in  2017. 
Firstly  in  2018  and  then  more  recently  in  2021.  This  policy  like  other  police  guidance 
documents  respond  to  updates  following  Or!~anisational  and  National  learning  through 
reviews, 
inform  ongoing 
improvements to our policing response. 

inquiries  that  advance  understanding  and 

Inspections  and 

The  latest  review of the missing  person  policy was  In  the  process  of being  finalised  during 
Gala's Inquest.  I enclose  a  copy of the finalised  policy,  which  is now adopted,  and  work Is 
ongoing to embed  the changes in working  practice.  I highlight a few aspects of the  updated 
policy that were relevant to the matters explored in the course of Gaia's inquest: 

a) 

b) 

c) 

d) 

A detailed flow chart for assessing the low, medium and high-risk categories has been 
re-Introduced,  (p.36) this provides clear guidance on  how to  understand and  afford a 
risk grading to a person who Is missing. 

The 'Absent' category Is no longer in use within Niche, (p.6); The Dorset Pollce policy 
clearly states that this category Is not to  be used. 

Increased guidance for staff and officers on the use of PPNs, (para 3.9.2,  p.27).  The 
upgraded guidance focusses on the purpose of a PPN, requirements for staff and  the 
importance of multi-agency engagement 

The  existence  and  availability  of  specialist/additional  resources  is  highlighted, 
(paragraphs  3.2.4 and  3.6  at p.19),  to ensure that  we  utfllse  officers  and staff,  both 
internally and externally to inform our investigations, with the ability to seek advice from 
experts. 

e) 

The  roles  and  responsibilities  of those  involved  in  each  stage  of the  handling  of a 
missing person report Is clearly defined, (paragraphs 3.3-3.4, p.5-7). 

In  addition,  the  Organisation  commissioned  a  review with  the  independent  charity  Missing 
People  UK  which  is  now  complete.  This  is  enabling  the  Organisation  to  expand  the  work 
conducted so far and involves the implementation of a number of recommendations Including 
improvement areas such as: 

a} 

b) 

c} 

Continuing to ensure that missing people are an Organisation-wide priority.  A plan will 
be  overseen  by  senior  leaders  to  implement  and  review  progress  within  the 
Organisation  and  also  from  partner  agencies  such  as  Children's  Services  and 
education providers; 

Adopting a person-centred approach to service delivery, investigations and Incidents; 

Victim  Service  Assessments  (VSA)  are  being  conducted  through  Organisation 
Inspections  in  line  with  HMICFRS  methodology  6  times  a  year,  focusing  on  our 
Investigative approach and victim servlce; 

17 

 DORSET 
POLICE 

D 101 Non-emergency 
D 999 In an emergency 
ID www.dorset.pollce.uk 
B 101@dor$et.police.uk 

0  Dorset Police 
D @dorsetpolice 
II dorset_pollce
l!I DorsetPollceHQ 

d) 

e) 

f) 

g) 

Continuing to embed and promote the Missing Person teams across the Organisation, 
to encourage awareness and understanding of how the teams work and to emphasise 
the Importance of an efficient frontline response to missing person reports; 

The missing person coordinator meeting daily with partners to discuss current missing 
persons and those missing from the previous 24 hours; 

Enhancing  cross  border  information  sharing,  to  better  communicate  and  safeguard 
people travelling and  reporting missing people in different police areas; 

Continuing to  Improve the  engagement  and  communication  with  families  of missing 
people. 

The  Dorset  Police  concern  for  welfare  policy  is  designed,  in  consultation  with  partner 
agencies, to ensure that the public get the right service to meet their specific needs at the first 
point of contact.  The current version is subject to a review led  by the Prevention  Department 
to capture the latest physical and mental ill health trends and guidance from key professionals. 
The initial draft of the policy is close to completion. 

The Organisation  reviewed  and  updated the call  handling,  deployment and  grading policy in 
2021  and  implemented changes In  March  2022.  The  Deployment  Policy has  been  recently 
reviewed  In  llne with national guidance to ensure that each public contact Is risk assessed to 
inform  the  appropriate  pollce  response.  The  revised  grading  of  Incidents  Is  now  a  key 
performance measure with  regular reviews  and  evaluation  to ensure compllance.  As  part of 
the Implementation process, we  have now moved to the evaluation  stage to understand how 
the changes In the pollcy have translated Into deployment decision making.  The Organisation 
has commissioned  an  external  audit conducted  by  the  South West Audit Partnership which 
has  been  taking  place  over the  summer.  A full  report Is due this  Autumn  which  wlll  Inform 
ongoing developments. 
Training on each of these ooncies 
The  next  stage  of  the  Vulnerablllty  Programme  is  the  'Vulnerability  4'  training  package, 
scheduled for delivery between January and April 2023. The Vulnerability 4 training will include 
updates  on  the  concern  for  welfare,  missing  people  and  the  call  handling,  grading  and 
deployment policies. It will be provided to police officers and staff,  including control room call 
handlers, senior officers up to the rank of Chief Inspector and role-specific training to the ranks 
above Chief Inspector. 

In  the  meantime,  the  updated  version  of the  missing  person  policy  has  been  disseminated 
locally  through  Commanders  and  Inspectors,  who  are  cascading  the  learning  to  frontllne 
officers and ensuring the policy has been read and understood.  Force Contact Centre training 
on  the  new missing  person  policy  begins from  the  19th  September on  the  current  10 week 
cycle for all  staff.  Every training  cycle will  Include  refresher training  on  missing  people and 
concern for welfare matters for the foreseeable future. 

The  content  of Vulnerability  4  will  also  be  bullt  into  initial  training  for  Police  Officers,  Call 
Handlers  and  PCSO's  to  ensure  ongoing  development  of new  staff into  the  Organisation. 
Furthermore, in 2023,  there will be a similar opportunity to raise awareness further In relation 
to epilepsy, psychosis, medical conditions, medication and the effect of such on and individual 
and  subsequent  risks.  The  Organlstlon  will  work  with  the  clinical  lead  to  ensure  such  are 
covered in the First Aid  Training which  is rolled out to operational officers and staff. 

18 

 DORSET 
POLICE 

II 101 Non-emergency 
1,1 999 In an emergency 
D www.dorset.pollce.uk 
151 101@dorset.pollce.uk 

D Dorset Police 
D @dorsetpollce 
DI dorset_pollce
El DorsetPoliceHQ 

Contact Management staff have received vulnerability training since 2019 specifically tailored 
to  meet  call  handling  and  dispatch  requirements  including  enhanced  risk  assessments 
(Threat,  Harm,  Risk,  Investigative  opportunities,  Vulnerability  and  Engagement),  identifying 
the  'voice of the  child'  within  incidents,  and  knowledge  of support agencies for signposting. 
They also have continual  professional development training as  part of their shift pattern with 
additional opportunities through  power hours to ensure refreshed guidance is cascaded.  The 
Contact  Management  Quality  Assurance  team  conduct  live  time  dip  sampling  of calls  and 
Incidents providing Immediate feedback ensuring a continual learning culture. 

The  Make the Difference Team, a small team of officers who are commissioned wl1h scrutiny 
and  review activity on  behalf of the  Organisation,  regularly  review and  scrutinise a selection 
of our missing person investigations and have had bespoke 'masterclass' sessions with child 
protection  specialists  from  HMICFRS.  This  has  allowed  the  Organisation  to  Improve  our 
standards and understand how to maintain good practice in these types of Investigation whilst 
also reflecting HMICFRS methodology in their review of investigations. 
Review of record  keeping and training on record keepfng 
The  Organisation  has  carefully  considered  a  proportionate  and  targeted  response  to  the 
concerns raised through Gaia's inquest In relation to record  keeping,  The Organisation holds 
millions  of  records  and  works  across  multiple  systems  and  processes  Organisation-wide, 
regionally  and  working  with  partner agencies.  These  processes  are  carefully  mapped  and 
overseen by business owners, with  some areas inspected by  HMICFRS and the Information 
Commissioner in  relation to crime data integrity, record  keeping and data protection. 

The  Organisation  has focused  improvements  on  the  key  systems  and  processes that gave 
rise to a concern  during Gala's inquest and the  upgrade of the Niche system and developing 
IT solutions  has also provided  opportunities to  design  out risks  of retrospective  entries and 
updates  to  logs  and  documents.  The  Organisation  has  sought  to  reinforce  standards  and 
promote  the  Individual  responsibility  of  staff,  officers  and  volunteers  to  maintain  clear  and 
accurate records as part of their business and service delivery. Organisation-wide messaging 
on  the Importance of accurate and transparent record  keeping and the Integration of records 
management Inputs Into existing training will deliver the learning identified through the inquest 
and Preventing Future Deaths report.  This will reinforce people's understanding and individual 
responsibility  to  keep  accurate  records.  This  approach  is  deemed  a  necessary  and 
proportionate response to the recommendation, a wholesale review of record  keeping across 
the entirety of systems In Dorset has not taken place. 

The Organisation's record  management system,  'Niche' was upgraded  In  August 2022.  The 
Niche  training  has  been  utilised  to  reinforce  the  expectations  and  Importance  record 
management and  data  quality.  POLSA  and  LPSM  trained  staff have  been  directed to use 
Niche to log their decisions and  key Information.  Niche can be accessed  remotely via  mobile 
technology and  once an  entry is made  it  cannot  be  amended  retrospectively.  If Information 
changes  or  details  are  recorded  In  error  an  additional  chronological  entry  can  be  made 
highlighting  any amendments  and  this  can  be  cross  referenced  to  the  original  entry.  Once 
created,  logs  are  also  locked  and  cannot be  amended.  As  previously noted  Vulnerability 4 
training will Include a session on  log keeping and recording. 

The Organisation has reviewed Its approach to the management of training activity as several 
areas of Improvement were Identified in relation to the process, governance and systems.  As 
a result,  revised  processes remain  In  place, to monitor the Identification of training  need, the 
effectiveness  of roll  out,  evaluation  of training  and  officer  and  staff  attendance.  Rates  of 

19 

 DORSET 
POLICE 

D 101 Non-emergency 
D 999 In an emergency 
IJ www.dorset.poUce.uk 
B 101@dorset.pollce.uk 

D Dorset Police 
D @dorsetpolice 
II dorset_pollce
II DorsetPollceHQ 

training  completion  and  escalatlon  procedures  are  in  place  with  strategic  oversight  and 
recorded decision making through the Joint Workforce Supply Group. 

At the submission of the Organisation's response  to  the  Preventing  Future  Deaths  Report  I 
propose to send out a further Organisation-wide message to all staff and officers providing a 
reminder  along  with  guidance  about  the  Importance  of  accurate  and  transparent  record 
keeping. 

Whilst progress  has  been  made on  a number of the  matters discussed  above,  I appreciate 
that there Is further work to be done.  On  behalf of Dorset Police I provide an assurance that 
improvement work continues as a priority to ensure the Organisation continues to keep people 
safe.  This commitment will continue far beyond the conclusion of these Inquest proceedings. 

Yours sincerely 

Acting Chief Constable 

20

wm 

Dorset HealthCare 
Unlverslly 
NH~ faun<l•lk>n  rn»I 

Corporate Office 
Sentinel House 
Nuffleld Industrial Estate 
4-6 Nuffield Road 
Poole, Dorset 
BH17 ORB 

14 September 2022 

Mrs Rachael Griffin 
HM Senior Coroner 
Bournemouth Coroner's Court 
Town Hall 
Bournemouth 
BH16DY 

Dear Madam, 

Re:  Regulation  28:  Prevention  of  Future  Deaths  - Miss  Gaia  Kima  Pope-Sutherland 
Inquest 

(Gaia).  The 

I  write  further  to  your  Prevention  of Future  Deaths  report  dated  2i81  July  2022,  issued  in 
response  to  evidence  heard  during  the  inquest  into  the  death  of Miss  Gaia  Kima  Pope  -
Sutherland 
incredibly  sad  and  distressing  events  surrounding  Gaia's 
disappearance  and  untimely and tragic death  have  been  the  subject of a Trust  Root Cause 
Analysis  (RCA)  investigation  and  a  number  of  changes  in  practice  have  already  been 
implemented,  of which  I understand you are  aware.  We,  as a Trust,  are committed to taking 
forward the further learning identified during the course of the inquest. 

I appreciate you  bringing the  six additional  specific issues  of concern to  our attention,  and  I 
hope that this response provides assurance as to the action we have initiated to address those 
issues. 

I  am  also  grateful  to  the  court  for  providing  clarification  that  the  following  specific  concern 
relates to national bodies,  as opposed to Dorset Healthcare University NHS Foundation Trust 
("the Trust"),  and therefore I will not comment further on this as  part of my response: 

Further I  am  concerned that there  could be  future  deaths  as a result  of the  lack  of 
communication  between  neurology  and psychiatric  teams  and request  that  there  is 
consideration  as  to  how to  ensure  effective  lines  of communication  between  the  2 
disciplines. 

Please find below our response to the six concerns raised in respect of the Trust 

1)  As per paragraph  1(ix) above,  the occurrence of sexual harassment or assault whilst 
an  inpatient at one  of DHUFT's inpatient  um1s  could have  a detrimental  effect on  a 
I  request  that 
person's  mental  health  which  could  have  fatal  consequences. 
consideration is given to a policy being put in place to provide guidance to staff as to 
how to deal with this situation. 

21 

 
 
 I note that in her letter to you dated 11 th July 2022, 
, Service Director, outlined 
the following Trust action being taken in response to the evidence she gave during the course 
of the inquest.  I reproduce the relevant paragraph of 

 letter below: 

1.  To  introduce  a  Trust procedure  that deals  with  victims  of sexual  violence  when  they 
come onto  wards,  in  terms of safeguarding them  from  future  incidents I  deterioration 
on the  ward.  In addition ta  consider specific guidance for staff as to how to support a 
patient following a sexual incident. 

,  Deputy Chief Nursing Officer,  on 8th 
I can confirm that I have written to 
July 2022 to ask that he identify a member of the Sexual Safety working group to lead 
on drafting a procedure that deals with how to best support victims of previous sexual 
violence  when  they are  admitted to  an  inpatient unit.  The  procedure  will  also  cover 
what staff need to do upon a patient reporting a sexual assault or incident to them (both 
within an inpatient and a community setting).  I have asked 
 to ensure that the 
procedure  is  finalised,  approved  and  disseminated  by  31 st  October  2022.  I  would 
therefore  suggest that I update  you  on  this  matter by Friday  11th  November 2022,  if 
that is acceptable to you. 

In addition to the above, the Trust also already works to the  Bournemouth, Christchurch  and 
Poole  and  Dorset Multi-Agency  Safeguarding  Adults  Procedures,  which  detail  definitions  of 
sexual  abuse  and  exploitation  and  how  to  raise  a  concern.  That  procedure  includes  an 
appendix  on  the  roles  and  responsibilities  of  other  agencies  and  includes  details  on  the 
responsibilities of employees and managers in respect of harm,  neglect and exploitation.  We 
welcome your recommendation to strengthen these procedures with supplementary guidance 
specific  to  sexual  harassment,  assault  and  abuse,  and  believe  the  above  forementioned 
actions, which are underway,  address this point. 

2)  As per paragraph 1(x) above,  there is no specific policy in place wllhin DHUFT around 
contact with  the  family or dealing  with  the  Think  Family  approach.  A lack of contact 
with family members,  who know the patient best,  could lead to information gaps,  which 
could lead  to  future  deaths.  I  request  that  consideration  is  given  to  a policy  being 
created around contact both to,  and from,  a patient's family. 

,  Interim 
In  response to this concern,  we will  establish  a working  group  led  by 
Deputy Chief Nursing Officer,  to develop a policy on  Working  with  Families  and Carers.  The 
policy  will  cover  expectations  in  respect  of communication  and  engagement  with  and  from 
families  and  carers that a patient wishes to  involve in their care.  The  policy will  also explain 
clear1y  what the  Think  Family  safeguarding  approach  is  and  how  staff can  work  within  this 
approach when there are safeguarding concerns. The development of the policy will  be  a co-
produced  piece  of  work  between  professionals  working  in  services  and  people  with  lived 
experience  of using  mental  health  services  and  of supporting  someone living  with  a mental 
health  condition.  The  working  group will  also  include  the Trust's  Carers  Development  Lead, 
the Lead for Recovery and Social Inclusion, and a member of the Trust's Safeguarding team. 
The working group will ensure the development, ratification and circulation of the policy to staff 
by 31st January 2023. 

3)  As per paragraph  1(xi)  above,  information  could be  lost on lengthy RiO records  held 
by  DHUFT if there  is  a  significant  number of records,  and  I  therefore  request  that 
consideration is given to a guidance document dealing with how and what information 
should be flagged on RiO which could be provided to all staff at DHUFT.  I would further 

-

22 

 request consideration  is given to  training  staff on  how to  record information,  so  it  is 
flagged on the record. 

In  response  to this  concern,  the Trust will  develop a guidance  document on  viewing,  adding 
and removing alerts on RiO and upload this to the Trust intranet by  30th  September 2022.  The 
existing  RiO  e-leaming  and  classroom-based  learning  courses,  which  are  a  mandatory 
requirement for new staff who  will  be  using  RiO  as  part  of their role,  will  also  be  updated  to 
orientate staff to the existence of the guidance  and to demonstrate how and  when to use the 
alerts  system  on  RiO.  This  will  be  updated  by  31 81  October 2022.  This  training  will  also  be 
available as  a standalone a-learning module,  which  will  be available to all existing  RiO users 
in  the Trust.  The a-learning module will be promoted to  staff via  email  and via dissemination 
at the CMHT Team Leaders workshop. This will be available and disseminated by 31 at October 
2022.  This  work  will  be  led  by  our  Clinical  Systems  Team  and  Patient  Safety  Team  in 
partnership. 

Please  note  we  have  focused  our  action  on  the  alerts  system  on  RiO.  As  outlined  in  the 
,  there  is  also  a separate  function  on  RiO  of flagging  a 
evidence  given to  you  by 
progress  note  as  a  significant  event  so  that  it  informs  the  risk  assessment.  We  have  not 
identified  any further  actions  for this  function,  as  this  already  forms  part  of our  RiO training 
programme. 

4)  As per paragraph 1(xii) above,  I would request that consideration is given to providing 
training to all staff on the  access to  Community Mental Health  services which  could 
also  cover the  processes regarding  discharge  planning from  the  care  of the  mental 
health teams. 

I  and  my  team  note  your  concerns  that  you  considered  there  to  be  "some  ambiguity  and 
inconsistency during the evidence regarding the content of the Integrated Community Mental 
Health  Teams  (CMHT's)  operational policy,  and the understanding and application of it" The 
Trust team has considered carefully your recommendation that training be provided to all staff 
on access to Community Mental Health Services, including the process for discharge planning. 

It is  our view that there is not a misunderstanding  or ambiguity  amongst staff with  regards to 
accessing  CMHT's  or in  respect of discharge from  the service,  but that clinical judgement  is 
used  by staff.  It is our belief that the  issues that arose during the evidence of Trust witnesses 
reflect a national problem that was described in the evidence provided by 
As you 
may  know,  CMHT's were  commissioned  some thirty  years  ago,  to  work with  a population  of 
people with what was previously clinically defined as userious Mental Illness". The service .was 
primarily  set  up,  and  resourced,  as  a specialist,  secondary  care  mental  health  service  for 
people  with  severe  and  enduring  mental  illnesses  such  as  schizophrenia,  bipolar,  and 
treatment resistant severe depression.  The threshold for the service was therefore set many 
years  ago  and  was  designed  for  people  who  had  significant  mental  health  needs.  We  fully 
recognise  that  in  2022,  this  model  is  not  well  placed  to  meet  the  wider  mental  health  and 
wellbeing  needs  of  our  patient  population.  What  is  now  needed  is  a  mental  health  and 
wellbeing  system  that  offers  a range  of support  from  varying  organisations that can  provide 
advice, guidance, information, signposting, education, support, care and treatment that meets 
a  broader  range  of  needs.  Some  of those  needs  fall  into  what  we  would  recognise  as  a 
diagnosable mental illness,  that will benefit from  an evidenced based,  clinical treatment,  and 
many  of those  needs  benefit from  a non-medical  or non-clinical  model  of support  and  care. 
Dorset is  not  alone  in  trying  to transform  its  community  mental  health  services.  It is  in  this 
context that access to CMHT's has increasingly come under scrutiny,  as our local population 
look for a service to meet the full range of needs that come under the broad umbrella of mental 
health.  Not  all  of  these  services  exist,  and  for  those  that  do,  they  are  currently  not  well 
coordinated  as  a system,  but considerable  effort is  being  made ta integrate  and  meet wider 
need. 

-

23 

) 

 In respect of the care provided to Gala, the Trust remains of the view set out in the RCA report 
(and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care 
on  the  occasions she was discharged from  CMHT care in  December 2016  and  March 2017, 
and also at the point she was assessed under the Mental Health Act ("MHA") in October 2017. 
That is  not to diminish the  difficulties Gaia faced,  or her level of distress. We  do  not dispute 
that the failure  to  refer  Gaia  to  Steps  to  Wellbeing  ("STWB")  for her  Post Traumatic  Stress 
Disorder in  December 2016 was a missed opportunity.  There were also  missed opportunities 
in terms of the assessment and onward plan of care following the MHA assessment in October 
2017,  which  are  acknowledged  by  the Trust  and  formed  part  of the  jury's  conclusions.  The 
Trust has taken  action to  address these issues as  detailed  in 
 witness statement 
of 16 June 2022,  and as set out in the evidence she gave to you,  namely through: 
the CMHT/STWB interface/screening meetings and  updated SOP;  and 
the updated SOP for Flow of Information following MHA Assessments 

(i) 
(ii} 

For these  reasons  and  the  transformation  work  being  carried  out  as  described  in  this  letter, 
the Trust does not consider that  implementing  an  action  to train Trust  staff on  the  access to 
CMHT's would  resolve the issues raised. 

) 

It is  our belief that the  issues  highlighted will  be  addressed through the  transformation  work 
. 
that the Trust is closely engaged with,  which was touched  upon in the evidence of 
The  NHS Long Term  Plan and the Commissioning Framework for Community Mental Health, 
sets out a new vision of mental health  support provided by health,  social  care and voluntary, 
community  and social enterprise (VCSE) organisations,  beyond the  model of CMHT care.  In, 
Dorset,  the  multi-agency,  coproduced  project  to  deliver this  vision  is  known  as  the  Mental 
Health  Integrated  Community  Care  (MHICC)  programme.  The  programme  has  reached  the 
stage  where  it is  co-designing  a new operational  model  of care,  to  begin  implementation  in 
2023 / 2024. 

One  of the  key  areas  the  MHICC  is  working  to  address  is  providing  better  mental  health 
support and care at a primary care level (beyond STWB, which offers psychological treatment 
for a specific range  of conditions).  The transformation  programme is looking  at how we  can 
implement a new model of care, so that we can provide open access to mental health services 
at a primary care  level to meet someone's needs, without eligibility criteria or thresholds.  We 
have tested  a virtual multi-disciplinary team  in  Poole  between GP's,  social  care,  STWB,  the 
VCSE  sector and  CMHT's,  and  you  may  be pleased to  note that we  are working together to 
discuss the  needs of patients and how best those are met in a coordinated way.  We  are also 
piloting  a  Peer  Specialist  (person  with  lived  experience  of  mental  health)  working  in  a GP 
surgery  in  North  Dorset,  offering  support to  anyone  who  wishes to  see  a professional  about 
mental  health  need,  with  support  and  supervision  from  the  GP,  STWB  and  CMHT.  If 
successful,  these  are some of the ideas that may be  rolled  out across  primary care,  to  meet 
patient mental health need. 

The  Trust believes that the transformation  programme will  be the  most effective approach to 
addressing  the  concerns  raised  in  respect of CMHT care and  the wider issues of access  to 
mental  health  support,  as  opposed to  implementing training  on  the  existing CMHT model for 
staff.  The  Trust  would  be  happy  to  keep  you  updated  and  provide  information  about  the 
MHICC transformation programme if you would welcome that. 

5)  As per paragraph  1(xiii)  above,  when  a Mental Health Act assessment is  undertaken, 
there is a possibility that information may not be fed back to the GP in the best way or 
in  a timely manner,  if it is  not fed back by those  from  the  Mental Health  team,  and I 
therefore request that consideration is given to the DHUFT representatives forwarding 
information,  directly to the  GP,  rather than through  the  discharging team  at the  acute 
hospital.  This may include their RiO record notes,  or their assessment notes. 

24 

 This requirement has been considered by 
Deputy Chief Medical Officer.  You 
heard during the course of the inquest (and as part of Dorset Council's evidence) that relevant 
information and a report following the assessment will be provided to the GP by the Approved 
Mental  Health  Professional  (AMHP),  who  is  part of and  coordinates the  assessing team.  Dr 
  has  met  with  his  clinical  colleagues  and  it  has  been  agreed  that  (in  addition  to  this 

information provided by the AMHP): 

i) 

ii) 

iii) 

iv) 

A RIO template will be designed to enable a section 12 Doctor to complete and 
set  out  key  summary  patient  information  following  a  MHA  Assessment 
conducted in an acute hospital setting; 
All doctors undertaking Section 12 work will be written to,  to advise them of the 
template and provide them with guidance on how to use it. 
The  completed  template  will  be  sent  to  the  patient's  GP  following  a  MHA 
assessment taking place in an acute hospital setting;  and 
A blank copy of the template, and details regarding the requirement for its use, 
will be added to the SOP for Flow of Information following a Mental Health Act 
Assessment. 

The Trust has agreed with your helpful  recommendation and will  formally amend the  SOP to 
remove  the  paragraph  previously  inserted  at  section  3.2  during  the  course  of  the  inquest, 
which outlined the following requirement: 

3.2  In addition and specific to MHA assessments undertaken in an acute hospital setting (e.g. 
Poole  Hospital,  Royal  Bournemouth  Hospital,  Dorset  County  Hospital),  the  Doctor(s) 
taking  part  in  the  MHA  assessment  must  provide  a  written  or electronic  copy  of the 
outcome  of their  assessment  ta  the  acute  hospital  ward  Doctor  responsible  for  the 
person's  care  whilst  in  the  acute  hospital,  so  that  this  information  can  be  reflected 
accurately in  the  acute hospital discharge  summary.  This  will ensure a comprehensive 
discharge  summary  detailing  the  physical and mental health  care  and assessments  a 
person received whilst in the acute hospital. 

This will be replaced with suitable wording to reflect the need to write to the GP directly using 
the  new  RiO  template  following  a  Mental  Health  Act  assessment  taking  place  in  an  acute 
hospital  setting.  This  template  will  be  developed  and  made  live  in  the  RiO  system  by  31 st 
January 2023,  and the SOP updated by this date and  issued to staff. 

8)  As per paragraph 1 (xiv)  above,  in respect of the feeding back of information to the GP 
by the AMHP which is detailed at paragraph 2. 10 ofthe Standard Operating Procedure 
for the flow of information  following  Mental Health  Act assessments,  I would request 
that consideration  is  given  by Dorset  County Council,  BCP Council  and DHUFT to 
reducing this timeframe from  7 days to 72 hours.  Although this is a decision for Dorset 
County  Council and BCP  Council,  the  document is  a  DHUFT document and so  will 
require their consideratt'on too. 

 has written to Dorset Council and BCP Council on  27th  August,  31 81  August and 9th 
September 2022 in respect of this matter.  BCP have confirmed they are in agreement with the 
72  hour  timescale  and  tell  us  that  they  already  work to  this,  and  the  Trust  awaits  Dorset 
Council's response.  I can  confirm  that the  Trust supports the recommendation to reduce the 
timeframe in question from 7 days to 72 hours and we will update the SOP accordingly,  upon 
Dorset Council's agreement. I am grateful for your acknowledgement that this is a decision for 
the two councils in question, as opposed to the Trust. 

I  hope  that  In  respect  of the  concerns  raised,  the  actions  I have  detailed  above  addresses 
those matters. I plan to provide a further written update to you regarding the progress of these 

1111 

25 

 action by 31 81  May 2023.  Once again,  I am again grateful for you bringing these Issues to my 
attention. 

Yours sincerely 

Acting Chief Executive 

) 

26

r~1:k1 
University Hospitals Dorset 
NHS  Foundation Trust 

Poole Hospital 
Longfleet Road 
Poole 
Dorset 
BH15 2JB 

www.uhd.nhs.uk 

7th  September 2022 

HM  Senior Coroner Mrs R Griffin 
The Coroner's Office for the County of Dorset 
Town  Hall 
Bournemouth 
BH26DY 

Dear Madam, 

Re:  Gaia Kima Pope-Sutherland 

Thank you for your letter of 21'1 July 2022 enclosing the Regulation 28 Report to Prevent 
Future Deaths following the conclusion of the Gala Pope-Sutherland inquest. 

You may recall that 
evidence and was present for many additional days of the evidence that you  heard. 

,  Head of Litigation and  Inquests, attended all the Trust 

I welcome your letter seeking to ensure that future deaths are prevented and that any risks 
to patients around epilepsy care are minimised. 

I understand that your concern arises from the evidence of Specialist Epilepsy Nurse 

who indicated (point 1 (iii)) that there are  10,000 patients in  Dorset with 

) 

epilepsy who  are overseen by twCJ  specialist epilepsy nurses, and felt that there were 
insufficient resources to treat the patients. 

and Specialist Nurse 

I have asked my Senior Management Team to analyse the epilepsy data, and they 
discussed the matter further with Dr 
the figures outlined to you during evidence.  The data itself comes from the Dorset Epilepsy 
Dashboard. The Dashboard draws in information from  GPs and relates to clinical coding, 
capturing information such as the types and groups of patients,  including socio-economic 
background,  pregnancy and  patients suffering with learning disabilities. As at 19th  August 
2022 the Dashboard showed there were 10,749 patients with epilepsy in  Dorset (9,916 
adults).  Of these patients it is estimated that 50-60% are seizure free, giving figures of 3,966 
-4,958 adults with active epilepsy. The Dashboard is a live programme and figures will 
change daily.  The information•it captures continues to be developed with the next iteration 
planned for Autumn 2022. 

in  order to understand 

 has confirmed that in terms of these active patients, contact with them can  be 

Nurse 
via telephone, emails or seeing them  in the  nurse led clinic.  Frequency of contact from  a 
patient however can be very variable,  and is difficult to capture accurately in statistics.  Nurse 
 has explained that for some patients, they may call just when they have a crisis, 

whereas others may call weekly or even more frequently, which means the nature of the 
demand for the service is unpredictable.  Nurse 

estimated that in terms of nurse led 

29 

 
 
 
 
 
 
 clinics,  each nurse would see approximately  1,300 patients each year in  clinic (i.e. a total of 
2,600 for the service) in addition to telephone and email contacts.  We hope this is helpful 
clarification. 

Turning to your specific Preventing Future Death concerns: 

2 (i) Lack of resourcing of epilepsy services 

I am  pleased to  inform you that since the Gaia Pope-Sutherland inquest concluded the Trust 
has appointed a new full time Band 4 epilepsy co-ordinator to the team,  who directly 
supports the two epilepsy specialist nurses.  It is anticipated that the successful candidate 
will commence in  post on  1st  October 2022.  The main duties of this role  include: 

1.  To work without direct supervision with individual patients as delegated by the qualified 
Nurse to ensure that treatment plans have been implemented and to monitor the impact 
of medication changes including looking at seizure recording . To also help implement 
lifestyle changes which may impact on  seizure control. 

2.  To work using a holistic approach to identify patient's goals for care and agree a 

personalised care and support plan. 

3.  Emailing - as appropriate - referrals to other teams and agencies e.g.  Steps to wellbeing, 

social services,  Community Learning  Disability Team and Homestart. 

4.  Monitoring patient attendance at appointments and following up vulnerable patients who 
do not attend as appropriate.  Work closely with the frequent attender team based in  the 
emergency department and the ambulance service. 

5.  Following up patients who present to  the emergency department with seizures and 
ensuring that a pathway is in place for future nurse or consultant appointments as 
appropriate and signposting to  advice for patients waiting to be seen. 

6.  Reviewing and typing updated protocols,  policies,  patient information leaflets and other 

) 

documents as required.

7.  Setting up a webpage for the service and monitoring it's use and update as required. 

8 .  Assisting in running patient wellbeing groups,  and training as required under the direction 

of the Qualified Nurse. 

9.  Helping patients to access self-management education courses,  peer support or other 

interventions that support them  in  managing their long term  condition  and improving their 
health and wellbeing. 

The Band 4 epilepsy co-ordinator will report directly to the two epilepsy nurses and  Dr 

In  addition, the Trust is currently in  the process of recruiting to the epilepsy team a part time 
1 day a week Band 7 specialist nurse. This is a temporary post with funding for 12 months. 
The successful candidate has a long track record of dealing with Children & Young Persons 
who suffer from epilepsy which will  be  of great assistance to  young people transitioning to 
adult epilepsy care.  Whilst this  individual is employed through our bank,  we will  be  reviewing 
the impact, with the aim of developing a substantive model and funding,  as  part of the 
system working through the Integrated Care  Board's review. 

30 

 
 
 
 In relation  to your request for consideration of a review of the nursing resources in epilepsy 
care locally in the  Dorset Epilepsy Service,  I can confirm that the Integrated Care Board 
(ICB) are carrying out an 8 week review which started on  11  August 2022. The review team, 
informed by the Getting It Right First Time (GIRFT) reports for neurology and epilepsy, are 
looking at the entire Epilepsy and Neurology service. This will be specifically considering: 

•  Local GIRFT review of Dorset Neurology Services in 2019 
•  National GIRFT Review of Neurology Services 2021 
•  Relevant NICE Guidance 
•  MHRA Drug Safety Updates 
•  Neurology Clinics 
•  Paediatric to Adult Services Transition 
•  Neurology and Mental Health 
•  Workforce resources 

We have shared our GIRFT reviews of 2019 and 2021  and are currently working 
collaboratively with the ICB to assist the review.  Those involved in the review include the 
UHD Chief Medical Officer, senior members of the Neurology team  and our Productivity and 
Efficiency lead.  We are awaiting the timescales to be confirmed for the ICB to share the 
findings of the review.  However, it  is envisaged that the review will  be followed  up by a 
longer term joint working group to take forward the recommendations. 

2(ii) Communication between neurology and psychiatric teams 

I am grateful for the clarification received on 26 July 2022 that the concern  in relation to 
communication does not relate to the Trust at a local level and is directed at the position 
nationally and the national body for neurology services. 

I plan to update you  on progress in approximately  12 months to allow time for the 
recommendations of the ICB to be considered  and actions identified.  I hope this is 
acceptable and in the meantime if you have any further queries please do not hesitate to 
contact 

) 

Yours faithfully 

Chief Executive Officer 

I 

lRE<CIE OVIEln 
12 SE~-~~~--- I
--------

. 
.

Chair:  Rob Whiteman CBE 

Chief Executive:  Siobhan Harrington 

31

Clim 
Dorset Healthcare 
University 
NWS  rOIU'dlli6n TIII\I 

Children, Young Person & Family Services, 
Alt Age Mental Health & Learning Disabilities Services 
Sentinel House 
Nuffield Road 
Poole 
Dorset 
BH17 ORB 

11 th  November 2022 

Mrs Rachael Griffin 
HM Senior Coroner 
Bournemouth Coroner's Court 
Town Hall 
Bournemouth 
BH16DY 

Dear Madam, 

Re:  Inquest touching upon the death of Miss Gaia  Pope-Sutherland 

I write further to my letter dated  11 th  July 2022 to provide you  with an  update on  the 
following  action,  which  I committed  to  updating  you  on  by  11 th  November 2022.  As 
you  will  recall,  this  area  formed  part of the  agreed  actions to  be taken  following  my 
evidence  during the  inquest,  and  this  action  also  forms  part of Dorset  HealthCare's 
formal Regulation 28 Preventing Future Deaths notice response dated  14 September 
2022. A full update on the wider Regulation 28 notice response from the Trust will be 
,  Acting  Chief Executive  Officer,  by 
provided  as  previously  noted  by 
31 81  May 2023. 

'- ) 

Please find my update on this matter below: 

1.  To  introduce  a  Trust  procedure  that  deals  with  victims  of sexual  violence 
when  they  come  onto  wards,  in  terms  of safeguarding  them  from  future 
incidents I deterioration on the  ward.  In  addition to  consider specific guidance 
for staff as to how to support a patient following a sexual incident. 

As outlined previously,  I wrote to Mr 
  Deputy Chief Nursing  Officer, 
on 8th  July 2022 to ask that he identify a member of the Sexual Safety working 
group  to  lead  on  drafting  a  procedure  that  deals  with  how  to  best  support 
victims  of previous  sexual  violence  when  they  are  admitted  to  an  inpatient 
unit.  The procedure was also  required  to  cover what staff need  to  do upon  a 
patient reporting  a sexual assault or incident to them  (both within  an  inpatient 
and  a community setting).  I asked 
 to ensure that the procedure  was 
finalised, approved and disseminated by 31st October 2022. 

-

27 

 has  asked  me  to  confirm  to  you  that  he  is  satisfied  that  he  has  met this 
action.  The  Trust's Safeguarding  policy  has  been  updated  to  highlight the  response 
needed  when  an  adult discloses they  have experienced  sexual  abuse.  This  may be 
in  a  hospital or community  setting.  In  addition,  two  appendix documents  have been 
added  to the  policy setting  out further details which  I enclose for your reference. 

 has advised  me that the 'guidance for staff in relation to historical sexual abuse 
fits  in  with  the  'Making  Safeguarding  Persona/I  agenda.  It's important to  determine 
what  an  individual  wants  to  do,  while  encouraging  them  and  supporting  them  to 
report it.  £very situation is different so care for patients who disclose historical abuse 
will be planned on a case by case basis'. 

As  per  my  previous  letter,  this  is  my  final  update  on  actions  pertaining  to  my 
evidence.  Should  you  have any queries  in  respect of this  update, 
 would  be 
happy to assist you with these. 

I can  confirm  that  I  am  happy  for  this  letter to  be  shared  with  the family  and  other 
Interested Persons involved in the case should you wish to do so. 

Yours sincerely, 

Service Director 
Children,  Young  Person  and  Family  Services,  All  Age  Mental  Health  and 
Learning Disabilities Services 

-

28

,.,,:f1 

Dorset 
Integrated care Board 

Vespasian House 
Barrack Road 
Dorchester 
Dorset 
DT11TG 

04 August 2022 

PRIVATE AND CONFIDENTIAL 

Mrs RC Griffin 
Senior Coroner 
The Coroner's Office for the County of Dorset 
Town Hall 
Bournemouth 
BH26DY 

Mrs R C Griffin 

RE:  REGULATION  28 REPORT TO PREVENT FUTURE DEATHS 

,  Chair of NHS Dorset, 
I am  writing to  you  In  response  to  your  letter to 
regarding your investigation into the circumstances surrounding the tragic and untimely death 
of Gaia Kima Pope-Sutherland. 

We take our responsibility to  act on  the  learning from  serious  incidents seriously  and  I offer 
you this response to outline where NHS Dorset can use its role to support and influence some 
of the changes you seek. 

1.  As per Paragraph 2 (i) of your report outlining your concerns,  a review will  be undertaken 
of the nursing resources  in epilepsy care locally within  the  Dorset Epilepsy Service.  The 
review will: 
a)  Encompass  the  full  epilepsy  health  provision  in  Dorset  including  primary  and 

secondary care for adults and children 

b)  Cover  interaction  with  other  specialities where  pertinent to  patient care  and  service 

improvements 

c)  Specifically,  address the following health care service concerns raised: 

Concern  Description 

Recommendation 

I. 

ii, 

Lack of resourcing in epilepsy 
care services 

Review of the nursing resources: 

•  In the Dorset Epilepsy service 
Across England and Wales
• 

Lack of communication between 
neurology and psychiatric teams 

Review of communication processes 
between neurology and psychiatry 

32 

 
 
 
 The Epilepsy Service review will not include other health care concerns raised.  These will 
be covered by other teams/workstreams.  The expectation is for the review to take around 
eight weeks. I would  be happy to  share the progress of this review with you  if that would 
be helpful. 

2.  The  Regulation  28  Report  will  be  shared  and  reviewed  with  NHS  partners  at  the  Pan 
Dorset Mortality Group. This will  facilitate an overview of the Improvements suggested for 
NHS providers to take,  as the ICB holds commissioning responsibility for these services. 

I  hope  the  information  I have  offered  provides  some  assurance  that  the  findings  of your 
investigation  and  the  areas  you  have  highlighted  for  the  prevention  of future  deaths  has 
prompted action and remains the focus of our continued commitment to supporting the safety 
and wellbeing of everyone who uses NHS services. 

As  you  may  be  aware  NHS  Dorset Integrated  Care  Board,  is  a newly  formed  organisation, 
which came into being on 1st July 2022, taking over the responsibilities from NHS Dorset CCG. 
I was  appointed  as  Chief  Executive  for  this  new  organisation  and  would  therefore  be  the 
primary contact for any future communications. If it would be helpful to have a conversation to 
outline  the changes that are taking  place in  the NHS  in  Dorset,  I would  be very happy to do 
so. 

Yours sincerely 

Chief Executive Officer 
NHS Dorset 

33

Ms Rachael Griffin 
Senior Coroner 
Dorset 

Dear Ms Griffin, 

RC 
PSYCH 

RO(A  CO  LEG[ Of 
PSYCHIATRISTS 

Re:  Caia Kima Pope-Sutherland (Regulation 28: Report to Prevent Future 
Deaths). 

On behalf of the Royal College of Psychiatrists, I am most grateful for the 
opportunity to comment upon this report in the context of the aspects you raised 
in your Regulation 28 Report regarding care for epilepsy.  I would like to extend 
my deepest sympathies to Gaia Kima Pope-Sutherland's family. 

The Royal College of Psychiatrists {RCPsych)  is the professional medical body 
responsible for supporting psychiatrists. The College sets standards and 
promotes excellence in psychiatry; leads, represents and supports psychiatrists; 
improves the scientific understanding of mental illness; works with and 
advocates for patients, carers and their organisations. The College does not work 
on the care of individuals and I am not able to comment on the specific 
circumstances surrounding the case of the death of Gaia  Kima Pope-Sutherland. 

However, I have considered your findings, and  have the following comments to 
make in relation the concerns that you raise. 

The College very much recognise the issues you raise in relation to the lack of 
effective and consistent communication between services for people with 
neurological conditions and mental illness. 

The particular brisk for this patient group that we believe needs to be addressed 
through resources, training, increased workforce is that Neurologists and 
neuroscience services commonly do not have the expertise or resource to 
manage the neuropsychiatric aspects of neurological disease and community 
mental health teams will consider that they do not have the expertise to manage 
people with organic mental illness or neurological comorbidity 

A recent paper that outlined the neuropsychiatric problems associated with 
epilepsy including the increased rate of suicide in people with epilepsy.  It also 
showed a high incidence and prevalence of mood and anxiety disorders, 
psychosis and suicide in this group. 

Whilst neuropsychiatry services can provide assessment, treatment and 
rehabilitation for the most complex people with neurological and mental illness, 
there has been no resolution of the longstanding workforce issues for 
neuropsychiatry despite the hope that a GMC credential could allow for 

12 

 neurologists and psychiatrists to develop expertise in this area.  There is currently 
no funding for such a credential. 

Whilst neuropsychiatry services can provide assessment, treatment and 
rehabilitation for the most complex people with neurological and mental illness, 
there has been no resolution of the longstanding workforce issues for 
neuropsychiatry despite the hope that a GMC credential could allow for 
neurologists and psychiatrists to develop expertise in this area.  There is  no 
currently no funding for such a credential. 

As a College, we have been starting through our Neuropsychiatry Faculty to work 
on building the relationships in order to start a dialogue about the inequality of 
access to appropriate health services for people with neurological conditions. 

There are some solutions to the poor integration and communication between 
services that we have been supporting as a Faculty. The NHSE National 
Neurosciences Advisory Group will be publishing the Optimum Pathways for 
Neurological Conditions imminently (https://w ww.nnaq.orq.uk/optimum-clinical-
pathways).  These include exemplar pathways for epilepsy and also a Mental 
Health Crosscutting Theme that highlights where the interface between 
neuroscience and mental health services needs to be considered, what good 
looks like and some of the evidence for treatment and rehabilitation.  It is hoped 
that these publications will provide support to commissioning of integrated 
services in neuroscience centres in ICSs. 

There is an opportunity as  ICSs develop for primary and secondary mental health 
services to consider how they integrate with community neurorehabilitation and 
neurology provision so that there is joined up provision when this is required. 

Please do not hesitate to contact me if I can be of any assistance. 

Yours sincerely, 

Registrar 
Royal  College of Psychiatrists 

13