Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0186, written 5 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2023 |
|---|---|
| Reference | 2023-0186 |
| Deceased | Jonathan Cole |
| Coroner | Sophie Cartwright |
| Coroner area | Derby and Derbyshire |
| Category | Other related deaths |
| Organisation named | Nottinghamshire Healthcare NHS Foundation Trust · Lincolnshire Partnership NHS Foundation Trust · Derbyshire Healthcare NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS . THIS REPORT IS BEING SENT TO: 1. The Ministry of Defence [care of GLD Defence Private Law and Inquests Team] for the attention of: a. The Rt Hon Dr Andrew Murrison MP, Parliamentary Under Secretary of State (Minister for Defence People, Veterans and Service Families) b. The Rt Hon Johnny Mercer MP. The Minister for Veterans’ Affairs c. The Rt Hon James Heappey MP, Minister for Armed Forces d. The Rt Hon Ben Wallace MP, Secretary of State for Defence 2. Nottinghamshire Healthcare NHS Foundation Trust [for the , Chief Executive; - Executive attention of Director of Mental Health; Executive; Mental Health Services; People and Culture] [care of Newham- Deputy Chief - Executive Director of Community - Executive Director of ] 1 CORONER I am Sophie Cartwright KC, Assistant Coroner for the Coroner area of Derby and Derbyshire Area 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST In 2018 an investigation was commenced into the death of Jonathan “Jonny” Philip Cole [JC], aged 39. The investigation concluded at the end of the Inquest on 25 April 2023. The conclusion of the Inquest was a Narrative Conclusion namely: Narrative Conclusion a. JC developed Post Traumatic Stress Disorder as a result of 1 at least three traumatic experiences whilst serving in the British Army in Afghanistan on operational tour in 2009 one of which represented a direct threat to his life (where he also suffered physical injuries including hearing loss and tinnitus, shrapnel injuries following a Rocket-Propelled Grenade attack (RPG); [Note: This service had been with 2 Rifles as part of Operation Herrick 10.] b. JC had made multiple attempts at suicide and self-harm beginning in January 2010 which were caused or materially contributed to by his unresolved symptoms of PTSD, culminating in a final and successful suicide attempt in August 2018; [EMDR] c. JC did not receive Eye Movement Desensitisation and Reprocessing those symptoms of Post for Traumatic Stress before the summer of 2012, it consisted of no more than 8 sessions of EMDR, which on balance of probability proved latterly to be insufficient albeit the EMDR did provide JC with temporary improvement and some alleviation of symptoms of PTSD in 2012/2013; d. JC’s intrusive memories of the RPG incident were not verified as having been fully processed in the presence of JC’s treating CPN before EMDR was discontinued in 2012 albeit JC had confirmed his belief in 2012 that he had managed to self-process that memory; e. JC received no psychological trauma therapy from 2013 onward up until the time of his death other than the EMDR provided whilst still in the British Army; f. JC left the Army in 2013 without a formal diagnosis of having had PTSD as a result of operational trauma. This was a failure and a diagnosis of PTSD was appropriate at that time; g. JC’’s unresolved symptoms of PTSD caused or contributed to episodic periods of profound mental health crisis, often preceded, and accompanied by, thoughts and attempts to end his life by way of overdose, and latterly hanging. His unresolved symptoms of PTSD also contributed to use of 2 alcohol and drugs to manage the symptoms which in turn led to marital and relationship problems and financial problems; h. JC’s PTSD was accompanied by alcohol and drug use, exacerbating the severity of the underlying condition; i. The of any lack official continued recognition, acknowledgment, or diagnosis on the part of the MOD of his PTSD in the context of JC’s attempts to access financial compensation for his condition, was a failure and materially contributed to a deterioration in his mental health state in the period following his discharge from the Army up until his death and resulted in JC making contact again on 8th June 2018 which was not responded to before his death; j. The Risk assessment and Care Plan completed on 28th January 2018 was inadequate and under estimated the risk of suicide for JC; k. There was a failure to conduct a psychiatric review in January 2018 despite a referral for psychiatric review this failure also caused unnecessary delay before a medication review took place; l. The Risk assessment and Care Plan completed on 14th May 2018 was inadequate and underestimated the risk of suicide; m. JC’s mental health had deteriorated significantly in 2018 and deterioration continued whilst under care of local mental health that no psychological trauma therapy was being provided; team and with knowledge n. By the beginning of 2018 JC’s medication was no longer proving effective as he became increasingly depressed, as well as socially, and occupationally isolated. This led to a change in June 2018, which whilst appropriately indicated was not effectively managed and ineffective on 28th July 2018 when documented as consideration should have been given to appropriately increasing the dose of Paroxetine to assist JC’s low mood; in medication o. Further risk assessments and Care plans should have been completed when Fluoxetine was reduced and removed and Paroxetine introduced; p. A further risk assessment and care plan should have been completed on 26th July 2018 in light of having elicited JC’s recent arrest and changes in his psycho social position 3 including issues of accommodation and financial pressures. This consultation underestimated the risk of suicide. There was a failure of the treating mental health professional to identify that JC was to appear in court 8.8.18. There was a lost opportunity therefore to make contact with the police/ CPS and to liaise with the criminal justice liaison and divergence with relevant information as to the medication review underway and relevant factors of JC’s mental health. There was an under estimation of the risk of suicide on 26.7.18 by not identifying the upcoming court date of 8.8.18 and offering support to JC; q. There was a missed opportunity throughout 2018 to refer JC to the Transition Intervention and Liaison Service [TILS] and the Centre for Trauma Resilience and Growth. 4 CIRCUMSTANCES OF THE DEATH On the 9th August 2018 at a location of Old Stone Bridge, Butterley Park, Codnor Park, Ironville, Derbyshire Jonny Cole was found hanging having acted with the intention to end his life. Jonny had PTSD, anxiety, suicidal ideation and was under the care of his local mental health trust. Jonny had not been seen since leaving his home on the afternoon of 7th August 2018 and was due in court on 8th August 2018 to face charges of criminal damage but did not attend. 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Ministry of Defence 1. I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel. This concern extends to ensuring a soldier receives access to appropriate treatment including diagnosis. Diagnosis is also important as under the Armed Forces 4 Compensation Scheme, mental disorders must be diagnosed by a relevant accredited medical specialist, namely, a medical practitioner whose name is included in the specialist register kept and published by the General Medical Council as required by section 34D of the Medical Act 1983. At the time Jonny Cole was accessing the DCMH Lisburn, gave evidence that there was just one psychiatrist for the whole of Northern Ireland who also had duties in the DCMH Kinloss, Scotland and no psychologist. 2 Rifles was based in Northern Ireland and at this time issues relative to Operation Herrick 10 and traumatic combat experience were being identified. told me relative to the impact of Operation Herrick 10, “Well all I can say is that we knew that we had a problem with post traumatic stress disorder and there were several suicides in Northern Ireland before I arrived. I can’t comment on that too far because there was a board of inquiry and the regiment was moved from the isolated position of Ballykinler to Lisburn because of that. In order to make them less vulnerable,” Following the evidence given by expectations for the number of psychiatrists covering Northern Ireland and Scotland in 2010-2013 and now, and was provided with the following response from Defence Medical Services. , I queried the Service . The staffing of mental “NI is now covered by DCMH health posts is however now lower that that at the time the Coroner is concerned with. This is partly due to reducing military population in NI which would not justify a full-time consultant and partly due to significant difficulties in staffing mental health posts. Recruiting more mental health clinical staff is something that the DMS is working hard to do; however, the pool of mental health workers for both the DMS and NHS to draw from is finite. Additionally, the DPHC Standard Operating Procedure on management of referrals makes some reference to this. Though it does not specify a manning ratio, it does give guidance on waiting list management (para 13). In essence it states an Officer Rank 7 or Civil Service Band 6 has day to day responsibility for monitoring waiting lists and has direct access to the clinical lead, they are also responsible for all review arrangements and Multi-Disciplinary Team actions which are in place. It would follow from this if waiting lists are becoming unmanageable the named individual would be able to escalate the problem”. Chief of Staff at Defence Medical Services Headquarters, 5 gave evidence when asked about the current position as to whether there was shortage of consultant psychiatrists and psychologists within the DCMHs, that, “we certainly have a shortage of mental health clinical staff at the moment. There are a lot of initiatives in place to try and continue to recruit those both military and civilian and we are working very hard at producing a more resilient and enduring so that we can actually build a career structure for our mental health practices going forward, something we have lacked in defence up until now.” This concern also extends to the knock-on effect that this apparent shortage of psychiatrists and psychologists has upon later claims for compensation by veterans as mental disorders must be diagnosed by a relevant accredited medical specialist, namely, a medical practitioner whose name is included in the specialist register kept and published by the General Medical Council as required by section 34D of the Medical Act 1983. 2. I have a concern that the Vulnerability Risk Management Process [Suicide Vulnerability Risk Management as was] is Unit led and that DCMH clinicians do not have a greater role in influencing the Army’s vulnerability risk management (VRM) process for suicidal soldiers. 3. I have a concern about: a. the training and experience of the Medical Advisors at Veterans UK providing advice under the Armed Forces Compensation Scheme. b. rejection of claims for PTSD under the Armed Forces Compensation Scheme if there is not a formal diagnosis by a consultant psychiatrist or psychologist but evidence of PTSD within medical records from other medical professionals. was a retired GP who went on to work as a part-time medical advisor at Veterans UK in October 2013 and rejected Jonny’s claim for compensation for PTSD and psychological injury under the armed forces compensation scheme. had no specialist knowledge of psychiatric or mental health issues and had had no specialist training in that area. accepted that there was an issue with the In evidence advice he gave that resulted in Jonny’s claim for compensation being rejected. In evidence “Q. Can I ask you: The approach that you adopted on Jonny Cole’s case, in respect of his claim to PTSD, would you have applied a similar approach to other files or claims of veterans in respect of PTSD? told me: 6 A. Q. A. It’s possible, I suppose, but I suppose as you gain experience and understanding of how the scheme is to be applied, then it changes. When I looked at this a week ago, which is when I first saw the documents, I could see straightaway the issue, but obviously I didn’t see that in December 2013. So, then, can I ask you: Obviously, when you reviewed the file as part of your preparation to give evidence, and to be fair to you, you had not had that opportunity when you provided your statement, you say you saw straightaway what the issue was. Can you tell us what it was that you saw when you reviewed the file, and what that issue is? That there was a consultant diagnosis1. Q. Would there ever have been a scenario where you had rejected a claim, as part of the advice that you had given to the case workers, where a veteran would come back and say… Be raising issues again about PTSD, would it come back to you to review or would it go to a different medical adviser? It could be either, and in fact if a review was requested or an appeal requested, I think it had to be a different case worker, but I don’t think it necessarily had to be a different medical adviser. A. Q. Just so then I am clear about you reviewed the file with obviously then the knowledge… Admittedly you do not work for Veterans UK anymore, but you had had the number of years then working and giving advice. But when you saw straightaway what the issue was, and there was a consultant diagnosis, if you had reviewed Jonny Cole’s case nearer to the end of your time at Veterans UK, what would your advice have been in respect of Jonny Cole’s claim, to the case workers? A. Well, it would have been a different approach, because I would… Once you have accepted that there is a diagnosis, then the next stage is what’s the cause of that, and is that predominantly caused by factors of service? And then, if the answer to that is yes, on the balance of probabilities it is caused by factors of service, then I would have recommended an award. Q. A. Q. Then, in terms of what you have effectively told us, that if you had reviewed this case later down your experience with Veterans UK, Jonny certainly would have got over the hurdle of a consultant diagnosis–– Yes. ––but again, having reviewed the documentation, and obviously you were the individual that was asked to provide advice as to 1 Adjustment Disorder. PTSD in remission. also gave evidence that he would have applied the diagmosis of 7 causation, to provide advice as to whether or not on the balance of probability it is linked to factors relating to service… Have you gone on to consider that aspect also? Not particularly no, but I would have thought there’s enough there to say yes it was.” A. indicated that the “narrow look” he undertook in respect of Jonny’s claim for compensation was due to, “Certainly not lack of time. I think it would be fair to say possibly lack of experience, and lack of training. And I think the emphasis I think was quite strong on that principle, even within the table tariff for the AFCS, on the section 3 I think it is, which is for psychological things, I think it does state it there, that a diagnosis can only be accepted by accredited consultant psychiatrist, so I suppose that in a sense emphasises it, and perhaps that’s why it was so prominent in my thinking.” gave expert evidence to me about the impact of the denial of compensation by Veterans UK for psychological injury and decisions where there is a denial of payments to which a veteran is entitled which, invalidates psychological injury, can cause hostility and being aggrieved and lead to self-destructive behaviour by the veteran. Jonny Cole himself raised by email to Veterans UK in June 2018, and shortly before his death in August 2018, the ongoing issues he was having with his PTSD that was getting worse and the impact it was having on his mental health, which had led to hospital admission due to overdose, and included a letter that identified that Jonny had reported thinking of suicide on a daily basis. Jonny Cole did not receive a response to this email before his death but when this response was provided by letter dates 20th August 2018 it stated; “We cannot take any further action on your claim at the moment. This is because the scheme rules state when considering a claim for a mental disorder, we require a diagnosis made by a clinical psychologist or psychiatrist at consultant grade. We are unable to accept a diagnosis made by a GP or community psychiatric nurse. Evidence we have considered so far: We have looked at the evidence we already have but it does not include confirmation of a formal diagnosis. What happens next: In order for us to be able to fully consider your claim, please could you provide us with evidence of a diagnosis from a consultant psychologist or psychiatrist. We are unable to take any further action until we hear from you. If we do not receive a response from you within 3 months of our request, your claim will be closed.” 8 suggested that thought needed to be given to having a Panel that is more representative of all stake holders not just the MOD and for more credibility to be given to civilian diagnosis and evidence and for there to be someone independent to review the cases. Nottinghamshire Healthcare NHS Foundation Trust [The Trust] 4. I have a concern that the Trust is doing too little to identify and address the risk of suicide for Veterans. A 2021 Nottinghamshire Suicide Prevention Action Plan to which the Trust was a partner identified for Veterans the need to, “undertake evidence review on the needs of veterans in relation to mental health and suicide, to inform future developments. Promote and raise awareness of the Op Courage MH Pathway and Armed Forces Health eLearning (commissioned by NHSE/Improvement Armed Forces Health). Ensure an ongoing dialogue with NHSE/Improvement around provision of mental health, suicide prevention and postvention. bereavement support to veterans and engage in any NHSE Midlands masterclass with Integrated Care Boards (ICBs) - date to be agreed. Identify veterans within the local Suicide Cluster Response Plan Guidance in the first annual refresh Review learning from the NHSE/Improvement review/investigation of Serious Incidents.” Despite this, the Trust’s Suicide Prevention Strategy and Suicide Prevention Annual Plan 2020-2023 provided to me and due to be reviewed this year does not specifically touch upon Veterans. I am told that there is a commitment to ensure this is a key feature of the review already commencing within the organisation. 5. I have a concern that there is: a) a lack of understanding as to the appropriate services to make referrals to for Veterans by Trust mental health practitioners; b) a lack of understanding as to services available for Veterans; c) too much emphasis on Veterans being solely responsible for self-referral, with no assistance to assist in accessing appropriate services; d) A lack of understanding (or effort) as to how to request and obtain military DCMH medical records. 9 I acknowledge that steps have been made recently by the Trust to, “liaise directly with Operation Courage in order to request their attendance at staff team events to further improve liaison and staff understanding of their pathways and exactly what their offer to Veterans”, however it is essential that these pathways are known by all mental health practitioners and engagement undertaken with the services to which a Veteran is referred, to check if this is an appropriate referral. This needs to include an understanding by mental health practitioners of what is in fact offered by: Operation Courage; the Centre for Trauma Resilience and Growth; Help 4 Heroes; Combat Stress and other charities and in particular what can be offered by way of psychological and trauma therapy. I was not reassured from the Trust witnesses who gave evidence to me who had involvement with Jonny that they had this understanding or of the specific needs of Veterans. As told me, it takes a lot for a veteran to put their hand up and ask for help and tend not to ask for help until things are really bad and there is a need to act quickly and as compassionately as possible to work with that window of opportunity and to assist the Veteran in making the referral. 6. I have a concern as to the quality of the Trust’s Investigation Report and that the process of review is not sufficiently robust I acknowledge that the Trust recognises that the investigation reports provided in respect of Jonny Cole’s death were unsatisfactory and also and that the review of Rapid Response Liaison Psychiatry involvement in 2022, the investigation in its entirety”. However, it is of concern that the 2022 review was also insufficient and inadequate. “was a missed opportunity retrospectively review to The concerning information relating to the attempt Jonny made to ligate in told me that an attempt on life a tree was not analysed. by suicide increases the risk 100-fold that you would die by suicide in the next 12 months and is the most significant risk factor in Jonny’s history that massively elevated the risk until that period of time has lapsed which requires clinical risk assessment]. 10 The Investigation report and the updated report following review failed to identify themes of concern2, and did not reassure me that the Trust had taken an appropriate response to investigate the concerning facts of this case and to ensure lessons were learned and not repeated for other patients and appropriate audit undertaken. I am told that the Trust is, “committed to continuing our improvement journey in this area”, however, I remain concerned that the Trust’s investigation was insufficient, lacked robustness and did not fully engage with the duty of candour. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st July 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - Jonny’s wife. – Jonny’s partner. -Jonny’s father. Ministry of Defence Nottinghamshire Health Care Foundation Trust 2 By way of example the issue as to the failure of a medication review by a psychiatrist in January 2018 despite a request for the same with no proper analysis as to how Jonny’s name was removed from the board; no robust analysis as to the change of Jonny’s medication and why medication had not been increased or addressed by an updated risk assessment and care plan; no analysis of the missed opportunity relating to risk assessment around Jonny’s arrest and lack of liaison with criminal justice partners to inform risk assessment. 11 Derbyshire Constabulary Derbyshire Healthcare NHS Foundation Trust I have also sent it to: Op Courage Midlands Lincolnshire Partnership NHS Foundation Trust – who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Sophie Cartwright Assistant Coroner Derby and Derbyshire Area 5th June 2023 12
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
SECRETARY OF STATE MINISTRY OF DEFENCE FLOOR 5, ZONE D, MAIN BUILDING WHITEHALL LONDON SW1A 2HB 31 July 2023 4.4.3 Dear Miss Cartwright KC, Thank you for your Regulation 28: Report to Prevent Future Deaths dated 05 June 2023 which detailed concerns identified during the inquest into the very sad death of Army veteran Mr Jonathan ‘Jonny’ Cole. I am grateful to you for your very thorough investigation. The inquest was informed of the significant changes which have taken place over the last decade in the areas of mental health support for military personnel, transition to civilian life and assistance to veterans. I would like to focus briefly on more recent developments in each of these three areas which address the important issues you have raised. Last year saw the publication of the ‘Defence People Health and Wellbeing Strategy 2022-2027’1 with the objective to create, promote and maintain the conditions for Defence People to live healthy lifestyles in healthy environments, reducing injury, illness and suicide as far as possible. Aligned to this effort, the first ever Armed Forces Suicide Prevention Strategy and Action Plan was published in April this year2, detailing the strategic framework within which Defence will take further action to reduce suicide and better support those affected by it. In October 2021 the mandatory Annual Mental Fitness Brief was released, adding to the ‘through life’ mental resilience and stress management training available to personnel. The brief covers the themes of mental health, wellbeing and resilience and details where personnel can seek appropriate help. In 2019 we implemented a holistic transition policy, and this has recently been 1 https://www.gov.uk/government/publications/defence-people-health-and-wellbeing-strategy-2022- to-2027 2 https://www.gov.uk/government/publications/armed-forces-suicide-prevention-strategy-and-action- plan Miss Sophie Cartwright KC HM Assistant Coroner Derby and Derbyshire Area St Katherines House St Mary's Wharf Derby DE1 3TQ updated3. The policy introduced a streamlined referral process to assist service personnel leaving the military, and their immediate families, in accessing the support required. The Office for Veterans’ Affairs (OVA) works across government and with private sector organisations, charities and other public sector organisations to support and deliver services to veterans. Its ‘Veterans' Strategy Action Plan’4 sets out commitments the UK Government will deliver to support the objective of making the UK the best place in the world to be a veteran. The OVA has also worked closely with the Department of Health & Social Care and NHS England on the development and promotion of Op Courage, which was launched by the latter in 2021 to provide a broad range of specialist mental health and wellbeing care and support for service leavers, reservists, veterans and their families. This year the MOD and OVA jointly commissioned an Independent Review of UK Government welfare services for veterans5. The review investigated the role, scope and breadth of UK Government welfare provision for veterans, including by the MOD under the Veterans UK banner. The report, published earlier this month, has identified several recommendations to improve welfare provision for veterans across a variety of channels. The recommendations are being closely considered and a formal response is to be published later this year. I have provided below further details in response to the Matters of Concern raised in your report. I hope that this response will illustrate the determination held across Defence to provide the very best support to our people whilst in service and as they transition into civilian life. Our thoughts remain with Mr Cole’s family and friends. Yours sincerely, THE RT HON BEN WALLACE MP 3 https://www.gov.uk/guidance/help-and-support-for-service-leavers-and-their-families 4 https://www.gov.uk/government/publications/veterans-strategy-action-plan-2022-to-2024 5 https://www.gov.uk/government/publications/the-independent-review-of-uk-government-welfare- services-for-veterans Matter of Concern 1 - I have a concern as to the number and availability of psychiatrists and psychologists within the Ministry of Defence and accessible to serving personnel. This concern extends to ensuring a soldier receives access to important as appropriate treatment including diagnosis. Diagnosis under the Armed Forces Compensation Scheme, mental disorders must be diagnosed by a relevant accredited medical specialist, namely, a medical practitioner whose name is included in the specialist register kept and published the General Medical Council as required by section 34D of the Medical by Act 1983. is also The Defence Medical Services’ (DMS) mental health workforce position reflects the national and international shortage of healthcare workers that has worsened since the covid pandemic. The current Defence workforce position for psychiatrists and psychologists is summarised in the table below. As some positions involve job shares and part time working, figures are to one decimal place, representing the number of full-time equivalent (FTE) staff. 1 in 8 (13.2%) of UK Armed Forces personnel were seen in Military healthcare for a mental health reason in 2022/23. This presents an increase compared to previous years (2021/22 = 12.5%, 2020/21 = 10.5%). 2.2% of UK Armed forces personnel were seen by a specialist mental health clinician in 2022/23, which remains consistent with previous trends.7 6 Civilian In Lieu of Military. Where a military postholder is deployed or otherwise unavailable for a significant period, a suitably qualified civilian can be posted into that position to ensure continued patient care until military personnel are able to re-fill the role 7 20230629_MH Annual Report_O (publishing.service.gov.uk) This picture presents a challenge to Defence. In response, the DMS has instituted a number of projects under its transformation portfolio that aim to improve the employment offer, maximise retention and ensure the workforce is efficiently used. To improve recruitment outcomes, efforts are focussed on expanding the approach to advertising beyond the use of the NHS Jobs Platform, delivering bespoke adverts to intelligently target Mental Health professionals, including psychiatrists and psychologists. Complimenting the findings within the Haythornthwaite review8, this relates to wider work in the recruitment attraction space on better communication of the total reward offer, maximising advertising opportunities and strengthening the Employee Value Proposition (EVP) which can improve both attraction and retention. The Defence Health Care Recovery Group (DHRG) is a new organisation, working to HQ Defence Primary Healthcare (DPHC)9, which will provide direct oversight and integration of Mental Healthcare (MH), Occupational Health (OH) and Rehabilitation delivery. The HQ element of DHRG reached Initial Operating Capability in Oct 2022, with a projected Full Operating Capability in Mar 2024. DHRG’s role is to transform extant Mental Health Delivery Services to ensure: a. b. c. d. e. f. Improved timelines for patient recovery Improved patient care Increased workforce satisfaction Reduction in onward referrals to intermediate care Improved patient satisfaction of care Improved patient safety and governance Establishment of the DHRG is an integral part of the wider Healthcare Improvement Programme (HIP) and aims to move ‘referred to’ services in DPHC10 away from regional management towards a nationally managed, locally delivered model. This change will make better use of capacity and deliver standardisation of care, maximising the use of remote consultations and reducing variability in waiting times. Subordination of the Mental Health Services workforce to DHRG has already enabled full oversight of extant resources, gaps and clinical capability and therefore the ability to prioritise effort. In conjunction with the activity above, a DMS Mental Health Service Improvement Project (MHIP) commenced in May 23 and is projected to be completed by Dec 24. It will be led by Commander DHRG and is designed to achieve the following: Transform Mental Health delivery to ensure patient outcomes and Design and deliver a new Mental Health care pathway (pilot launched May 23) Improve both patient and workforce access to services to enhance delivery and a. responsiveness b. c. satisfaction 8 Agency and agility: Incentivising people in a new era (publishing.service.gov.uk) 9 Headquarters Defence Medical Services is the functional lead organisation for all healthcare in Defence. The HQ DMS is led by a 3* Director General. The subordinate Defence Primary Healthcare is a 1* delivery organisation within the DMS. All non-Operational Primary Medical Care, Dental Care, Rehabilitation, Occupational Health and Mental Health is delivered by DPHC 10 Mental Healthcare (MH), Regional Rehabilitation (RRU) and Occupational Health (OH) services Standardise business processes and integrate near real time data to improve d. responsiveness e. f. Develop a Caseload and Workforce Management Tool Improve workforce agility and resilience in delivery of care Fundamentally the establishment of the DHRG and the associated MHIP will assist DMS to optimise its use of available mental health workforce, improving access, end- user experience and staff workloads. The final body of work of relevance to this concern is the Unified Career Management (Medical) (UCM (Med)) which has been introduced within Defence. All DMS mental health personnel were moved to this model on 01 Jul 23. This system enables DMS, through Strategic Command, to career manage the workforce across the three services, resulting in a more agile and informed approach to workforce planning which will lead to a greater ability to mutually support and proactively prioritise workforce gapping where it exists. Matter of Concern 2 - I have a concern that the Vulnerability Risk Management Process [Suicide Vulnerability Risk Management as was] is Unit led and that DCMH clinicians do not have a greater role in influencing the Army’s vulnerability risk management (VRM) process for suicidal soldiers. The Vulnerability Risk Management (VRM) process was completely overhauled in 2014 and again in 2020. The major change in 2014 was the introduction of a Management Information System (Vulnerability Risk Management Information System (VRMIS)) as a Unit’s Vulnerability Risk Management Register, moving away completely from the previous paper-based system. Since its creation and roll-out in 2014/2015 the VRMIS specifically allows for clinicians, and other third parties who are supporting an individual, such as pastoral and welfare services, to be given read-only access to the Care Action Plan11 (subject to the individual’s explicit consent). The system and process were updated and aligned to follow a multi-disciplinary approach. Whilst the VRM process is a command-led tool under which the Chain of Command are the lead in identifying, assessing, and managing their personnel who are considered to be vulnerable to, or at risk of suicide and self-harm behaviours, the input and involvement of medical, pastoral, welfare and other third parties are an essential requirement. The central policy, AGAI 11012, acknowledges that whilst suicide and self- harm behaviour may be unrelated to mental ill health, consultation for medical advice and referral is mandatory for any individual deemed to be at risk of suicide or self-harm behaviour. Medical professionals (normally the Medical Officer or an empowered medical representative) are amongst the key personnel required to attend the initial risk conferences and subsequent formal reviews that take place whilst an individual is on the Unit’s Vulnerability Risk Management Register (held on VRMIS). 11 The CAP is a live document held securely on VRMIS which is used and maintained for the duration that the individual is considered to be at risk. It is a chronological version of events that records how the individual is being actively managed and supported 12 Army General and Administrative Instructions, Volume 3, Chapter 110, Vulnerability Risk Management AGAI 110 and AGAI 5713 - Army Health & Wellbeing Committees - mandate that formal monthly reviews must take place; known as the “Commander’s Monthly Case Review” (CMCR) these comprise of the respective Chain of Command, Medical representative/s (the Medical Officer/GP or a designate) Welfare and Pastoral personnel plus other third-party professionals involved in an individual’s care. The medical attendee will usually represent the entirety of the medical function, which can include information from Specialist services, such as Departments of Community Mental Health (DCMH). This, however, does not preclude other clinicians being present at Unit level meetings by invitation/exception where required. The formal CMCRs are supplemented by “Individual Case Management Reviews”, undertaken at a frequency to suit the requirements of a particular case and involving discussions and updates from those supporting and caring for the Service Person who has been identified at risk. Defence Primary Health Care (DPHC) Guidance Note (G/N) 15/15 details the support which is to be provided to single service health committees by DPHC personnel. This confirms that attendance at unit health committees by the Medical Officer, GP or designate is to be ‘considered the norm’. DPHC Op Order 22/011 ‘Routine Firm Base Healthcare Support to Defence’ details that medical support and input to VRM conferences and reviews is priority one activity for DPHC staff, considered as urgent clinical care. Aligned to single service policy on the management of personnel identified at risk of suicide and self-harm behaviours, Defence Medical Services (DMS) has put in place Standard Operating Procedures (SOP) for all medical personnel on the management of vulnerable patients. This is designed to promote best practice and deliver effective safeguarding procedures (initially in G/N 07/18, superseded in 2022 by Defence Primary Healthcare Standard Operating Procedures 2022DPHCSOP03-01-002 for the Managing of Vulnerable Patients). This SOP strengthens the previous advice provided by DPHC in 2018 to medical facilities on the management of vulnerable patients. In particular, it directs that: all patients who are under a Chain of Command-led case conference are read-coded and alerted on DMICP14 as vulnerable; all medical centres and DCMHs are to maintain a register and run monthly searches to identify vulnerable patients; all facilities are to hold an appropriate meeting, at least monthly, to discuss all vulnerable patients; each facility is to ensure there is a process in place for handing over patients, and identifying new ones on registration. This SOP and its intent align with both AGAI 110 - Vulnerability Risk Management and AGAI 57 - Health and Wellbeing Committees. Since 2014 with the introduction of VRMIS and the overhaul of policy, training and education has been provided to users of the VRMIS and the VRM Process as detailed in AGAI 110, specifically at career and pre-employment courses (such as the Unit Welfare Officers Course, the All-Arms Adjutants Course and the Sub Unit Commanders Management course). In addition, ad-hoc training is delivered to units as requested. 13 Army General and Administrative Instructions, Volume 2, Chapter 57, Army Health & Wellbeing Committees 14 The Defence Medical Information Capability Programme (DMICP), a centralised electronic record system Matter of Concern 3a - I have a Concern about the training and experience of the Medical Advisors at Veterans UK providing advice under the Armed Forces Compensation Scheme. The Medical Advisors are a group of doctors who sit under the operations umbrella of Defence Business Services (DBS). Some are trained in the Service Pensions Order (SPO), some in the Armed Forces Compensation Scheme (AFCS) and several are dual trained for cases which span both schemes. As a requirement for the post of DBS Medical Advisor (MA), all employed must hold a full, unrestricted licence to practise with the General Medical Council and continue to undertake annual appraisals to maintain their revalidation certificates. This includes a requirement to undertake a minimum of 50 hours continuing professional development (CPD) activity per year relevant to the scope of the doctor’s role. The MAs undertake regular in-house CPD which may be general or informed by particular case types or issues raised, both medical and legal. Individual staff members hold various specialist qualifications, but the key factor in their recruitment is their experience and breadth of knowledge within the field of patient care and medicine. Medical Advisors usually join the department following a successful career in some branch of clinical medicine relevant to the Armed Forces. This includes, but is not limited to, General Practice, Orthopaedics, Occupational Health, Mental Health, and Public Health. On joining they are trained in medico-legal determinations and evidence- based medicine, as they relate to the legislation covering the Armed Forces Compensation Scheme or War Pension Scheme administered by DBS. Medical Advisors give case-specific, evidence-based advice and certificates on causation and assessment and provide reasons for decisions. DBS Medical Advisors are not involved in the clinical diagnosis, care or treatment of War Pension or Armed Forces Compensation Scheme claimants. A Medical Advisor’s role is limited to providing advice and guidance based upon pre-existing medical evidence which is used to determine the level of disablement in accordance with the relevant scheme rules. The Medical Advisor in question started in DBS on 24 Oct 2013 and provided medical advice in respect of Mr Cole’s AFCS mental health claim on 10 Dec 2013. Given that the MA was ~6 weeks into the role, in terms of prevention, this response should focus on initial MA training and mentoring. After reviewing the case specific facts, DBS is confident that the approach to this case was not indicative of its current approach. Since the appointment of a Senior Medical Advisor in Dec 2022, a structured training programme has been implemented for all new AFCS Medical Advisors. This involves initial legislative training with the Policy Medical Advisor, followed by an intensive period of 3-4 weeks face to face case-based training with the Senior Medical Advisor or equivalently experienced MA. Subsequently several months of close mentorship occurs by an experienced MA, including reviewing each decision made to ensure correct decision making and a consistent approach, whilst continuing to provide ongoing guidance and training. Following careful assessment of their training progress made to date, if deemed appropriate, the newly trained MA is then allocated a dedicated mentor for the scheme on which they trained, and as such is able to easily access advice, guidance and further training as required. Considering that this medical advice was provided in Dec 2013, in addition to a more structured and supportive initial training programme for new MAs, the following measures have also been implemented more generally since that time: • Monthly peer AFCS case-based discussion groups which allow the MAs to ensure consistency via benchmarking and identify issues that may require further policy guidance. • In house CPD sessions. For example bringing in specialists from Defence Medical Services to upskill MAs in relevant medical conditions, such as non- freezing cold injury or PTSD. The MAs are also encouraged to join the Civilian Medical Practitioner CPD sessions which are also relevant to the MA role. • Having a single point of contact for complex case queries/case discussion, providing less of a barrier for MAs to seeking advice/reassurance in respect of queries. • Improved identification of overall MA training needs; utilising various methods including quality monitoring outcomes, tribunal outcomes, opportunistically, via complaints and through customer/colleague feedback. This feeds into the in- house MA training discussed above. • Making sure all MAs have access to necessary medical resources, for example DMICP and ensuring Athens accounts15 are maintained to ensure access to up- to-date medical evidence. • Since early 2023 DBS is now performing an increased number of validation checks on completed MA quality monitoring files and performing improved analysis of the quality monitoring outcomes. This is being fed back into the in- house MA CPD programme. It is acknowledged in the case of Mr. Cole that the MA was new to the role and required more support and guidance, and that this was a shortcoming which DBS has recognised and worked hard to address. As detailed above, there have been significant improvements in MA training and support since this decision was made in 2013 and it is hoped that this response provides reassurance in this regard to HM Coroner and the family and friends of Mr Cole. Matter of Concern 3b - I have a Concern about the rejection of claims for PTSD under the Armed Forces Compensation Scheme if there is not a formal diagnosis 15 An authentication system that acts as a key to unlock access to resources for eligible health and care staff. An account gives access to NHS-funded online books, journals, databases, evidence sources and e- learning by a consultant psychiatrist or psychologist but evidence of PTSD within medical records from other medical professionals. The Armed Forces Compensation Scheme legislation (available at: The Armed Forces and Reserve Forces (Compensation Scheme) Order 2011 (legislation.gov.uk)) specifies that mental disorders must be diagnosed by a clinical psychologist or psychiatrist at consultant grade; this is the case for all mental disorders, not only PTSD. The requirement for a consultant level diagnosis has been considered multiple times by the Independent Medical Expert Group (IMEG) as part of their reports on mental health, and on each occasion found to be appropriate. IMEG is an advisory non- departmental public body sponsored by the Ministry of Defence that advises the Minister for Defence People, Veterans and Service Families on medical and scientific aspects of the Armed Forces Compensation Scheme and related matters. Their responsibilities include: • • investigating the issues on which advice is requested; reaching conclusions and making recommendations based on evidence; • providing evidence comprising independent, published, peer-reviewed scientific and medical literature; and • consulting other experts and inviting interested parties to submit relevant research (but IMEG does not commission research) A summary of IMEG considerations is outlined below. In 2013 IMEG considered the need for a formal diagnosis at this level as part of their second report, in the section entitled “Who should make the diagnosis?”. This report concluded that diagnosis should be by consultant level psychiatrist or clinical psychologist. The report is available here: IMEG Report 2 Mental Health (publishing.service.gov.uk). In early 2016 a quinquennial review, or QQR, was conducted of the Armed Forces Compensation Scheme to make sure that the scheme remained fit for purpose and displayed the flexibility to adapt to changing conditions and environments. This was an independent review. Overall the QQR concluded that the AFCS remained on track and fit for purpose, with some areas needing improvement. IMEG considered issues raised in the QQR as part of their fourth report, including mental health, and concluded that “Diagnosis remains very important and should continue to be made by a psychiatrist or clinical psychologist at consultant level.” The report is available here: IMEG report 4 AFCS QQR issues (publishing.service.gov.uk). IMEG further considered mental health in their fifth report, published in 2020. This reviewed the conclusions reached in 2013 as part of their second report. IMEG concluded that: “Because of the classification complexities and uncertainties discussed above and the need for rigour and consistency in diagnosis, both in clinical and compensation terms, we continue to recommend clinical diagnosis at consultant level.” The report is available here: IMEG Report 5 Review of 2013 IMEG Second Report on Mental Health (publishing.service.gov.uk). There is ongoing work to keep the requirement for a consultant level psychiatrist or clinical psychologist under review and ensure it remains an appropriate requirement for mental health claims. A further quinquennial review of the Armed Forces Compensation Scheme has been conducted which will comment on this matter when published; a copy will be made available on gov.uk and provided to HM Assistant Coroner for Derby and Derbyshire. Additionally, IMEG are again reviewing mental health as part of their seventh report, expected in early 2024. Once complete, a copy of their report will be published on gov.uk and provided to HM Assistant Coroner for Derby and Derbyshire.
Chief Executive’s Office The Resource Duncan Macmillan House Porchester Road Nottingham NG3 6AA 14 August 2023 Private and Confidential Ms S Cartwright HM Assistant Coroner for Derby and Derbyshire Saint Katherines House Saint Mary’s Wharf Mansfield Road Derby DE1 3TQ Dear Ms Cartwright, Please find below the organisational response to the recently received Preventing Future Deaths Report, following the sad death of Mr Cole. The Matters of Concern raised within the report that relate to Nottinghamshire Healthcare NHS Foundation Trust (thereafter referred to as the Trust): Concern that the Trust is doing too little to identify and address the risk of suicide for Veterans is a Trustwide role which Nottinghamshire Healthcare Trust is committed to working collaboratively with patients and staff to prevent suicide and reduce harm. This includes how we work with patients to meet their needs and also equip our workforce to have the right knowledge and skill to respond effectively to suicidality and promote safety. As such, we have a Trustwide Lead for Suicide Prevention, Rachel Lees. This role implementing is responsible Nottinghamshire Healthcare’s suicide prevention strategy, and working with other partners across the wider system. This role works strategically and clinically to reduce harm and promote safety in relation to suicidality, particularly focusing on training delivery, clinical practice and sharing of learning and key messages. This role provides expert professional advice, guidance and support, working closely with colleagues at all levels of the organisation to develop and improve practice. for developing and Through triangulation of our mortality surveillance data within Nottinghamshire Healthcare Trust, we recognise that the Veteran group do present with factors that impact on their ability to access and The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA receive support. Subsequently, they can present with an increased risk of harm. We are committed as an organisation to supporting this patient group and plan to do the following – 1. 2. 3. 4. The three yearly review of the Suicide Strategy is underway and will include a focus on staff awareness of factors which may be affecting different sub-groups of patients and clinical considerations and implications for practice. Specifically, this will reflect the enhanced risk for the veteran patient group from what we have learnt in the Trust and nationally. Our Trust essential training for Suicide Awareness and response will also reflect this. The Trust holds an annual Suicide Prevention conference where this learning will be reflected. Our colleagues in OpCourage and Trust Armed Forces Community Network will also be in attendance and hosting an information stall. The topic for July’s Trustwide Suicide Prevention Champions Network meeting was Veterans and Suicide Prevention with the Operation Lead for OpCourage Midlands attending as the guest speaker to present and share information about the Armed Forces Covenant and OpCourage with colleagues. This meeting was recorded and is being shared Trustwide through various Communications, including being made available on the Trust’s intranet. Rachel Lees will undertake a thematic review over the next 9 months of patients that are veterans and open to services to understand care and treatment and identify any learning. This will be reported through the Quality Operational Group for learning. Nottinghamshire Healthcare is also a Gold Member of the Armed Forces Covenant and has recently been re-accredited by Veterans Covenant Healthcare Alliance and are "Veteran Aware." (Appendix 1) Concern that there is a lack of understanding as to the appropriate services to make referrals to for Veterans by the Trust mental health practitioners. The Trust has taken action to gain knowledge of appropriate Veteran services which are available, and we are able to make referrals to. As a result of this, we have looked to update our mental health practitioners with regards to this information. All this information has been collated from Nottinghamshire Healthcare culture and staff engagement facilitators, who are part of the Veterans’ Network. Leaflets and posters have been provided and are being distributed throughout the Mental Health Care Group and shared with the wider Trust for review and distribution. As part of the information provided is a card that has a QR code on it, practitioners can scan this code and it takes them to the Veteran information pages on the Nottinghamshire Healthcare Trust intranet site ‘Connect.’ Concern that there is a lack of understanding as to the services available for Veterans. All inpatient sites now display posters that state that ‘We are Proud to be Veteran Aware’ and include the contact details for the Veterans and families service Champions. Posters are being distributed to all community team bases and will be displayed by the end of August; follow up checks are planned. The Trustwide Lessons Learned Bulletin (Appendix 2) contained information relating to Veterans, and this is shared Trustwide and available on the staff intranet site. Specifically in the Adult Mental Health Care Group the monthly communication the ‘Governance Gazette’ in July (Appendix 3), features an article on Veteran services, this communication is distributed to all teams and is discussed in the team meetings which are attended by all levels of staff. The article also has links to The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Op Courage and Army and You. The Nottinghamshire Healthcare culture and staff engagement facilitators are presenting to the members of the Adult Mental Health Quality and Risk Group, which is attended by senior operational managers, service managers team leaders and trainers on 07 September 2023. This information has been shared with the Trust for wider learning and Care Group relevant business managers and governance leads are review plans to disseminate this information with the emphasis being focused for the specific areas to include training. The Patient Medical records (RiO) now request that a section to be completed which seeks to ask if they are a veteran. We are in the process of scoping if this can be a mandated question and to also add a hyperlink which will guide the practitioner to the services available. We also plan to add a prompt about ensuring that the patient is supported with the referral if required. This functionality will be audited in 6 months’ time to review accessibility and whether this can be used more widely. For our Forensic Care Group we have specific pathways and support available for Liaison and Diversion we provide a veterans pathway in custody which includes a mandatory referral to the service – Liaison and Diversion also work closely with and direct individuals to Op Nova in the community. For Offender Health Services, Clinical Specialists provide all the specialist therapeutic input for individuals and groups. They supervise healthcare teams and provide Veteran Awareness training for healthcare teams and all prison staff. This work is supported by Care after Combat who provide support and individual mentorship for veterans making all necessary practical preparations for release. These preparations start as early as a year pre-release to take into account the often lack of or limited civilian living prior to incarceration. This and the through the gate mentorship are significant in the reduction/minimisation/prevention of Adjustment Disorder which many of the men experienced on leaving the Armed Forces and which is often a contributing factor to offending behaviour. The Care after Combat team also co-facilitate the regular groups. They also take on full responsibility and cost for the production, printing and delivery of the Wellbeing/Action packs. Concern that there is too much emphasis on Veterans being solely responsible for self- referral, with no assistance to assist in accessing appropriate services. The Trust has reflected upon the self-referral pathway for Veteran related services that require a self-referral and recognise that this can present with difficulties in accessing further appropriate services. For example, the impact having to tell a personal and sensitive story repeatedly can be distressing and result in a barrier to such services being accessed. We recognise that OpCourage remains a self-referral service for Veterans however, as a Trust, we have made the decision to always support this process. This process will be monitored through the audit of veteran patients. We recognise that a cultural change is required in practice to ensure that where a self-referral is required, that we undertake this in collaboration with the patient to ensure access is not restricted and will be kept under review and oversight. The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA In addition, guidance has been written for staff to demonstrate professional curiosity in relation to a service users’ motivation or ability to complete self-referrals. This identifies those who need support to self-refer and clinicians will complete this with the individual or for them if appropriate. This guidance will be included in the updated version of the Local Mental Health Team (LMHT) Standard Operating Procedure (SOP), which will be provided for reference once completed by the end of August 2023. This SOP will incorporate the need to refer Veterans to OpCourage rather than rely on self-referral due to the known difficulty our Veterans have in seeking support. All LMHT staff will be provided with a copy via email and this section will be highlighted in the business meetings. The Trust will need to have assurance that this practice is embedded, therefore an audit will take place over a period of three-month period to identify that staff are exploring if a service user requires support to access self-referral services and for the specific needs of Veterans these referrals are being made on their behalf. A Veteran folder (Appendix 4) has been developed to help and support referrals for Veterans, this has been shared throughout the Adult Mental Health services And is currently being reviewed by our Mental Health Services for Older Peoples leads and Specialist Services leads to check suitability for patient group and will be shared across Mental Health Services by 18 August 2023. There was a presentation of Mr Cole’s findings from the inquest at the Mid Notts and Bassetlaw Local Quality and Risk Meeting on Monday 24 July 2023. The learning from this continues to be shared via the business meetings with the teams across the Mental Health and Forensic Care group and Quality & Risk Meetings for wider learning. The emphasis being that support with self-referral will be considered for those who require this. Concern of a lack of understanding (or effort) as to how to request and obtain military DCMH medical records. Support has been sought from the Head of Information Governance (IG) to identify the process in which to have any military records released. The Trust was informed by the MoD that the records needed to be formally requested and written consent sought from the individual prior to the application being made. IG colleagues then worked to produce a procedure that would clarify this process for staff with the appropriate contact numbers included for each armed forces and the necessary consent forms enclosed as an appendix. This procedure (Appendix 5) was approved on 1 August 2023, by the Information Security Forum (ISF) which is the Trust’s IG and IT Security meeting. The procedure has now been published on the Trust’s Intranet Policies Page and it is being explored how this can be added to the veteran demographic section to support staff in reminding them of this new process. As a result of the development of this, it will be circulated via the Executive Weekly Briefing, the Line Managers’ Bulletin and a link will be added to the Veteran information page on Connect, as well as being included in the next Trustwide Lessons Learned Bulletin. Each Care Group and Care Unit within the Trust has developed their own sharing mechanisms which include discussion in the Care Unit Quality Oversight Group/Quality and Risk Meetings, Service Business Meetings and Team/Ward Meetings with Governance leads ensuring this is included in the relevant agendas. The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Concern as to the quality of the Trust’s Investigation Report and the process of review is not sufficiently robust. As an organisation we understand the importance of the investigation of Serious Incidents and ensuring that the investigation undertaken is both detailed and robust and provides every opportunity to establish learning to prevent recurrence. In this case our investigation fell below the standard we would have expected and for that we unreservedly apologise for the distress and disruption caused as part of your coronial process. We recognize that there are cases where the standard of report writing and investigating has not been to the level required and have undertaken a number of measures to improve this. The Mental Health Care Group introduced a panel sign off process which collectively reviews the investigation to provide a higher level of quality assurance and triangulation of information. We envisage our reviewed and strengthened governance will mitigate this risk moving forward. The learning from the outcome of this preventing future deaths report will be shared as part of on- going training provided to staff undertaking serious incident investigations and those involved within the approval process of investigations. Incident Investigation Training: We continue to work with external partners to ensure that staff undertaking serious incident investigations are trained and knowledgeable in investigation techniques. We will continue in our commitment to providing a two-day training event for investigators based on a “Systems Based Approach” (SBA). This approach is advocated by the Patient Safety Incident Response Framework (PSIRF) which will be implemented within NHS Organisations during the Autumn of 2023. The role of SBA is to identify the systems-based problems when an incident occurs, rather than focusing on the individuals involved. Our aim is to provide five two-day Serious Incident Investigation training sessions each year, which enables the opportunity for 125 attendees across those sessions. Investigation Terms of Reference: For each serious incident investigation, clear and specific terms of reference are drafted and shared with the Operational Care Groups for comment at draft level before final sign off. They assist with the scope of the investigation and carefully balance ensuring that investigators are clear of the investigation requirements and expectations, and that they are directed to any specific areas to be considered, without being too prescriptive which could risk restricting the panel / investigator in their review. When completed, terms of reference are signed off as follows: ▪ ▪ Concise level terms of reference are signed off within the Operational Care Groups concerned by either Head of Nursing or Associate Director of Nursing Comprehensive level terms of reference are signed off at Executive Director level. Quality Assurance of Investigation Reports: The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA We also recognised that we needed to strengthen our overall review of our investigation reports and ensure those individuals who are reviewing/approving/authorising the final report have the skills to critically appraise the report and ensure it is fit for purpose. Whilst historically we have facilitated a one-off session to assist managers with the quality assurance process, we have now looked to extend our training offer. Therefore, working with our external training providers, we have commissioned a series of Serious Incident Quality Assurance training events during 2023/2024. Between September 2023 and December 2023, we will facilitate six one- day training events. The course will provide the attendees with skills to critically assess the investigation report and ensure it concentrates on Systems Based outcomes and SMART actions. Our aim is that within the six sessions we can train approximately 150 individuals. The purpose of this training is to provide senior leaders who have responsibility for approving reports with the skills to analyse the report, ensure fairness, that systems-based learning has been applied and that the report and findings reflect the agreed terms of reference and any questions raised by the patient or family. The Trust recognises the need to consider neurodiversity when undertaking investigations. Guidance has now been developed to support investigators to consider individual need, reasonable adjustments, access to learning development and consultation forums. Review of active Investigations & Inquests: Whilst we appreciate the need for the work outlined above in terms of the development of our staff in terms of expertise to both undertake investigations, and critically analysis the resulting investing reports. We are also mindful that we have a significant number of completed investigations and upcoming inquests, where we believe we need to undertake a pro-active and objective review of active inquests in the Trust to identify cases where lessons should be learnt and responded to. This will include but not be limited to: ▪ ▪ ▪ Consideration of learning for the Trust, what lessons have been learnt or need to be learned from this matter. Ensuring family engagement and compliance with Duty of Candour A summary of key themes from both current and historical cases which may support improvement work. I hope the information above provides the assurance that we have and continue to consider your recommendations seriously, and that we are actively seeking to improve the services we provide by implementing the actions outlined. Yours sincerely The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA Chief Executive Nottinghamshire Healthcare NHS Foundation Trust Reference: Kapur N, While D, Blatchley N, Bray I, Harrison K (2009) Suicide after Leaving the UK Armed Forces —A Cohort Study. PLoS Med 6(3): e1000026. https://doi.org/10.1371/journal.pmed.1000026 Encs: Appendix 1: CEO email dated 24th July 2023 Appendix 2: Trust Lessons Learned Bulletin Appendix 3: Excerpt from AMH Governance Gazette for July 2023 Appendix 4: Veteran Pack Appendix 5: Procedure for obtaining military DCMH medical records The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
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