Kaye McCoy

25 August 2023 

PRIVATE AND CONFIDENTIAL 
Caroline Saunders 
Senior Coroner (Gwent) 

Dear Ms Saunders 

Regulation 28 Report received by Aneurin Bevan University Health Board further to 
the inquest touching on the death of Kaye McCoy which concluded on 27 June 2023  

Thank you for your letter of 30 June 2023 and accompanying report, which the Health Board 
received on 06 July 2023.  

I am writing to provide you with the Health Board’s response to the Regulation 28 Report to 
Prevent  Future  Deaths,  which  was  issued  following  the  inquest  into  the  death  of  Mrs  Kaye 
McCoy.  

As requested, the information presented below is intended to describe the actions which have 
been taken/are being taken by Aneurin Bevan University Health Board to mitigate the risk of 
future deaths. You require the Health Board to provide you with the following information: 

1.  Confirm the processes that are in place to ensure that all patients who are in receipt of 
care  by  the mental  health  teams  have  a  strategy  for  the  engagement  with  the  family 
and  how  this  will  be  audited.  You  note  that  Mrs  McCoy  had  been  under  the  care  of 
Older Adult Mental Health Services since 2017, and 

2.  Confirm  the  plans  for  ensuring  that  all  patients  in  crisis  can  be  followed  up,  out  of 

hours and at weekends by a crisis team or similar.   

With  regard  to  the  first  point,  the  Division  of  Mental  Health  and  Learning  Disabilities  has  a 
number of processes currently in place to  support family engagement, for example, training 
in both Care and Treatment Planning and in Wales Applied Risk Research Network (WARRN) 
risk  formulation,  which  emphasises  the  importance  of  family  involvement  and  engagement, 
particularly  in  the  recognition  and  management  of  relapse  indicators  and  contingency 

Bwrdd Iechyd Prifysgol Aneurin Bevan  
Pencadlys, 
Ysbyty Sant Cadog 
Ffordd Y Lodj 
Caerllion 
Casnewydd 
De Cymru     NP18 3XQ 

Aneurin Bevan University Health Board 

Headquarters 
St Cadoc’s Hospital 
Lodge Road 
Caerleon 
Newport 
South Wales     NP18 3XQ 

Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan 
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board 

 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 planning (with the person’s consent). Trainers have been asked to strengthen this element of 
training. 
This  year’s  National  Confidential  Inquiry  into  Suicide  and  Safety  in  Mental  Health  (NCISH) 
Annual Report also provides data and evidence relating to family and supporter involvement 
in  patient  care.  This  is  discussed  during  the  Division’s  awareness-raising  training  to 
registrants about NCISH findings which highlights and promotes helpful and inclusive dialogue 
with  patients  and  their  families/  supporters.  The  Division  will  be  producing  a  guidance 
document – ‘Principles for family/ supporter involvement in care and care planning’ for staff 
which  will  also  include  advice  and  principles  in  relation  to  confidentiality  and  inclusion.  This 
will be drafted by the end of October 2023. 

With  regard  to  the  second  point,  the  Health  Board  does  not  have  a  stand-alone  Crisis 
Resolution Home Treatment Team (CRHTT) for older adults. The implementation of CRHTTs in 
mental  health  in  Wales  was  a  policy  directive  of  the  then  Welsh  Assembly  Government  in 
2010  as  part  of  the  Adult  Mental  Health  National  Service  Framework  for  Wales,  and  Health 
Boards  received  funding  to  develop  these  teams  to  meet  the  needs  of  working  age  adults. 
Psychiatry  in  older  adult  mental  health  is  a  sub-specialty  in  its  own  right  with  a  distinct 
clinical  skillset  and  knowledge  base.      The  following  are  existing  pathways  for  older  adults 
needing support, advice, assessment or intervention in a crisis: 

a.  The  out  of  hours  GP  service  can  make  referrals  directly  to  the  Older  Adult  Mental 
Health  service  via  the  junior  doctor  on  call.  Following  assessment,  a  plan  will  be 
devised  with  the  patient  and  their  family  which  might  include  a  plan  for  admission  to 
hospital. 

b.  Older  people  experiencing  crisis  who  present  to  the  Emergency  Department  will  be 
referred to the Older Adult Psychiatric Liaison team for assessment and a plan will be 
devised  with  the  patient  and  their  family  which  might  include  a  plan  for  admission  to 
hospital. 

c.  The  ‘111  press  2’  service  is  a  24  hour  a  day,  seven  day  a  week,  phone  line  open  to 
people of any age. Callers can be patients of the service, relatives, friends or people in 
need.  The  service  is  staffed  by  employees  of  the  Health  Board  who  are  trained  to 
support  people  in  crisis,  offer  advice  to  people  calling  on  behalf  of  themselves  or 
others,  and  to  link  people  with  crisis  teams  for  assessment  where  this  has  been 
assessed as a need. 

d.  The  ‘Shared  Lives’  project,  previously  available  to  younger  adults,  has  recently  been 
extended  to  include  older  people  in  crisis.  The  schemes  match  someone  who  needs 
care with  an  approved  carer.  The carer  shares  their  family  and  community  life,  and 
gives care and support to the person with care needs. (This service was not available 
at the time that Mrs McCoy was experiencing crisis). 

e.  Tŷ  Cynnal  is  a  house  provided  in  partnership  with  ‘Platfform’,  a  third  sector 
organisation that supports people with mental health issues with housing. The house is 
available  to  support  people  experiencing  mental  health  crisis  who  do  not  require 
medical/hospital  support  but  require  a  safe  sanctuary  for  support  to  manage  their 
distress. People are referred to Tŷ Cynnal by the mental health service. This option has 
only  recently  become  available  to  older  people  experiencing  crisis  who  are  already 
known to the mental health service.  

2 

 
 
 
 
 Additionally, the Older Adult Mental Health service has completed a 6-month pilot extending 
the  hours  of  the  Community  Mental  Health  Team  in  Caerphilly,  to  include  evenings  and 
weekends.  The  pilot  funded  extra  clinical  staff  to  support  this  function  and  Caerphilly  was 
chosen as the pilot area as the highest populated borough within Gwent to establish need and 
demand. One of the terms of reference of the Health Board’s incident review into Mrs McCoy’s 
death  was  whether  her  needs  would  have  met  the  criteria  for  inclusion  in  this  pilot.  The 
Investigating  Officer  found  that  she  would  have  been  offered  this  service  if  she  lived  in 
Caerphilly at that time. 

The  pilot  has  now  ended  and  the  Health  Board  is  considering  its  findings  and 
recommendations.  

In addition to the pathways described above, the Health Board is exploring other alternatives 
including understanding the offers of other Health Boards in Wales to inform a future review 
of crisis provision for this group, with associated standards for ongoing audit. In the interim, 
the  Health  Board  will  continue  to  audit  use  of  the  current  pathway  by  the  older  adult 
population to continue to inform service development. 

I  trust  that  this  information  reassures  you  about  the  Health  Board’s  plans  to  improve  the 
accessibility  of  crisis  services  for  older  people,  as  well  as  family/supporter  engagement  in 
care and care planning. However, if you require any further information or assurance, please 
do not hesitate to contact me. 

Yours sincerely 

Prif Weithredwr | Chief Executive 

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