Nicholas Stout

Tarncroft 
Lanchester Road Hospital 
Lanchester Road 
Durham 
DH1 5RD 

10 August 2023 

Private & Confidential 
Mr James E Thompson 
HM Assistant Coroner for  
County Durham and Darlington 
H M Coroners Office 
PO Box 282 
Bishop Auckland 
Co Durham  
DL14 4FY 

Dear Mr Thompson 

Inquest into the death of Nicholas Stout 
Regulation 28 Report to Prevent Future Deaths Response 

We write in response to your Regulation 28 Report dated 15 June 2023 following your 
investigation into the death of Nicholas Stout.  

We have taken Nicholas’s death very seriously and our investigation has sought to establish 
where lessons can be learned and/or services improved. 

The details of the actions implemented and embedded by us following this incident were 
, Modern Matron. We do not intend to repeat the 
detailed within the statement of 
detail in this response other than to reference the specific paragraphs that are relevant to the 
concerns raised in the Regulation 28 report.  

For the purposes of responding to your specific concerns raised in the Regulation 28 Report, 
I shall address each of them in turn: 

1.  The nationally set time from initial contact with the crisis team to some form of 

assessment is 4 hours. I heard evidence that achievement of this target in every 
case is not realised. It is of concern that timely assessment and treatment of 
persons undergoing mental health crisis should be assessed as speedily as 
possible and within the set time period. 

1.1.  Trust Response 

Ensuring timely assessment and treatment for people experiencing a mental health 
crisis is crucial and we endeavour to meet all expected timescales for the assessment of 
people in crisis. 

The national standard for very urgent assessments to be completed is within 4 hours. 
Urgent assessments should be carried out within 24 hours.  

For all new patients and those individuals not open to other secondary mental health 
services, the UK national triage tool is undertaken to initially triage and assess the  

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 patient and to agree the priority of assessment. This is in line with national standards set 
out by NHS England. The clinician carrying out the triage assessment will develop a 
safety plan, in discussion with the patient and their family/carer, to ensure the patient is 
safely supported until the crisis assessment takes place.  If an immediate response is 
required due to an imminent safety or wellbeing concern this would be requested 
through 999 emergency services in line with national guidance. As per the evidence of 
Ms Price, the crisis service is not commissioned or resourced to provide an emergency 
response and clinicians do not have the appropriate skills, and in many cases, a suitable 
legal framework to provide such a response.  

, speaking to 

In evidence, 
periods of high demand, additional staffing is provided to ensure that targets are 
achieved. However, we acknowledge that crisis service acuity can be unpredictable, and 
may change from day to day. 

 statement, confirmed that during known 

To support maintaining safe staffing levels, the crisis service management team review 
staff resource daily in line with the Trust's safe staffing levels escalation procedure and 
attend the daily safe staffing meeting, this meeting is Care Group-wide. This allows for 
alternative options of support to be identified at times of increased acuity and to ensure 
that assessments are not delayed and are carried out in a timely manner.  

Additionally, the Crisis Team have introduced an escalation procedure to ensure that if 
there is a concern that an assessment would not be undertaken within the given 
timescales, that this is discussed with senior management. Arrangements will then be 
made to ensure that assessments are not delayed which can include deploying staff 
resource from other teams, and management stepping into clinical roles.  

There are examples where response times are breached due to patient preference for 
appointment times or venues and this is supported by the risk assessment and safety 
planning approach detailed above. Breaches are also recorded when teams are unable 
to locate service users post-triage and/or they do not attend their appointment. There 
are weekly reporting processes in place to monitor responses to very urgent referrals 
which allows for clinical oversight of decision making, target compliance and support 
allocation of any additional resource or intervention if required. Any breaches and 
compliance with the standards are monitored through our governance structures, 
reported monthly within Specialty Governance meetings and escalated through to the 
Care Group.  

Table 1 - Durham and Tees Valley 4 hour response target (very urgent) 

2.  The triage tool was explained in evidence to be essential in ensuring the patient 
received the correct treatment/service and is to be undertaken every time a 
patient contacts the Crisis Team. I was informed there was an aspiration to 
achieve completion of the Triage Tool every time, but it is not being completed on 
every occasion. It is of concern that such a key document which identifies risk,  

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 care and other matters is not completed on every occasion as it is mandated to be 
done. 

2.1.  Trust Response  

In evidence, HMC heard evidence from 
undertaken in the Durham and Darlington area in relation to the triage tool assessment 
process and staff development. 

 that development work had been 

Development work was undertaken in June 2022 to embed the use of the national triage 
tool. The service has ensured that all current registered practitioners have received an 
induction regarding the crisis team processes, and all new members of the team are 
fully inducted. The induction includes education regarding the triage tool, guidance as to 
the use of the triage tool and the rationale that underpins its use. This enables staff 
working within the Crisis Team to be clear on team processes and to ensure that triages 
are undertaken by trained senior registered practitioners.  

 confirmed that a monthly audit was undertaken to monitor the use of the triage 

tool, as well as case management supervision with clinicians, reviewing that this had 
been completed. Supervision is carried out on a quarterly basis in line with the Trust 
Supervision Policy. As part of the development work, discussions were held with all staff 
within supervision regarding the use of the tool and triage documentation. 

Audits of compliance with the triage tool sit within the Trust's quality assurance 
schedule. Specifically, the monthly “QA5 audits”, which encompass triage and 
assessment standards. The Trust has a well-established Quality Assurance and 
Improvement Programme which was first initiated in April 2021. This is focused partly on 
patient care documentation, recognising that high quality documentation is an enabler of 
high-quality patient care, as well as observation of practice and talking to teams in 
clinical areas. The programme comprises of a range of quality assurance tools that are 
used to gain a holistic assessment of the quality of patient care. These tools are subject 
to review to ensure they are informed by current areas of risks where further assurance 
is required. The Quality Assurance and Improvement Programme has proven to be an 
effective method of monitoring compliance against key standards of care related to 
patient safety, clinical effectiveness and patient experience. It has facilitated significant 
sustained practice improvements and provides the organisation with both quantitative 
and qualitative assurance evidence. 

The QA5 tool includes questions about the triage process including use of the tool, the 
quality of completions as well as the outcomes. Audits continue to show sustained 
improvement in the use of the triage tool and documentation. The most recent three 
months of audit data showed a 100% compliance with the completion of the triage tool 
where the tool was identified as being required. 

3. 

In relation to making safeguarding referrals for children, the evidence I heard was 
in this particular case a referral should have been made and was not. I was told 
training had been undertaken to make all staff aware of what action to take. 
However, I was told in the majority of occasions it was believed a referral would 
be made. It is of concern in terms of protecting children that I was not satisfied 
that a referral was made in all situations that warranted such a referral. 

3.1.  Trust Response  

As an organisation, safeguarding is recognised as an integral part of our care delivery. 
All staff are required to undertake mandatory training for safeguarding children and  

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 adults, this training is updated at regular intervals to ensure staff remain updated with 
relevant policies and procedures, ensuring that staff understand the importance of 
safeguarding referrals and that referrals are made promptly whenever there is a concern 
for a child or vulnerable persons welfare. 

 confirmed that since this incident, staff have received additional 

In evidence, 
training in relation to the Parental mental ill health on children tool (PAMIC). 
confirmed that the tool considers how a parent’s mental health may impact on a child 
and supports the clinician completing the tool to consider whether a referral to the local 
authority for safeguarding teams should be completed and actions that should be 
considered to safeguard the child/children.  

As a Trust we are committed to learning from this incident and have implemented the 
necessary improvements to prevent such incidents from happening in the future.  
Safeguarding concerns are now a standard agenda item discussed daily within 
community and crisis huddles, attended by all members of the multi-disciplinary team. 
Any identified actions are promptly acted upon, with individual clinicians taking 
responsibility for allocated tasks. The learning in relation to this incident has been 
discussed within team meetings, and the review from the incident has been shared with 
the team to ensure widespread awareness.  

To strengthen safeguarding practices across the organisation, the Trust safeguarding 
team allocate members of the team to link in with different clinical areas across the 
Trust. This provides increased support and guidance within the teams, enabling timely 
and effective handling of safeguarding concerns. The organisation has also issued a 
Patient Safety Briefing following this incident, this briefing has been shared throughout 
the wider organisation to ensure that the learning from the incident has been 
communicated and lessons learnt across the Trust.  

To provide assurance and to maintain consistent monitoring across the organisation, the 
Trust has enhanced its quality assurance schedule and has introduced the QA5 audit 
detailed earlier in this response. A recent addition to the audit tool includes reviewing 
compliance against PAMIC tool completion, whether a safeguarding concern has been 
identified in the past month, and whether appropriate actions have been undertaken 
when a safeguarding concern has been identified. This audit helps us to ensure agreed 
policies and procedures are being followed and to take corrective action where 
necessary to ensure safeguarding procedures are being followed.  

Additionally, to provide immediate support and advice during core working hours, the Trust have 
allocated safeguarding duty workers. This professional lead is available to discuss any 
safeguarding concerns and to offer guidance on how to address concerns safely, 
ensuring a child’s welfare remains a central priority. Outside of regular working hours, 
the Trust safeguarding policy directs staff to contact the local authority safeguarding 
team to ensure that concerns are promptly discussed and addressed as required.   

We were recently inspected by our regulators, the Care Quality Commission (CQC), 
who pay close attention to the application of mandated safeguarding standards in 
practice. The CQC have not raised any concerns about our safeguarding practices.  

4. 

I was told in evidence that a Safety Plan which is compiled with input from the 
patient, their families and practitioners did not exist in Mr Stout's case. I was told 
it is crucial document for identifying risks and ways to mitigate them. I was also 
told work was commenced by your organisation in December 2020 to ensure full  

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 and complete compliance with this requirement, but I was not reassured there 
was such compliance with the completion of Safety Plans in all cases at this time. 

4.1.  Trust Response  

In evidence, 
that safety plans were completed. 
to check compliance with completion of safety plans and summaries.  

 confirmed that work had been undertaken by the Trust to ensure 
 indicated that a monthly audit was in place 

 confirmed that additional training in relation to the importance of completing 

safety summaries and plans had been completed with crisis staff and all staff had now 
completed this.  

As part of the Crisis Team’s daily huddle, every patient’s care is discussed. As part of 
the huddle safety summaries and safety plans are checked and discussed as a multi-
disciplinary team. Any changes or updates that are required are identified and staff are 
tasked to complete these. 

Within the Early Intervention in Psychosis (EIP) Team, staff have regular caseload 
supervision which looks at patient care and safety management documents such as the 
safety summary and safety plan. Results from QA5 audits are fed back to staff in 
monthly team meetings. Audit outcomes are reviewed through service and specialty 
governance meetings and escalated through to Care Group Boards. A function of these 
groups is also to develop and monitor improvement plans and actions for areas where 
audit compliance falls below the expected standard.  

In both teams, bespoke safety summary and safety plan training, that is supplementary 
to mandatory harm minimisation training, is delivered and allows for exploration of 
specific risks and scenarios related to their service provision. This training is a regular 
offer within the teams and is completed as part of the induction of new staff into the 
team.  

All staff complete the Trust mandatory Harm Minimisation training. This training supports 
clinicians to develop skills and competence in the completion of person-centred safety 
plans that look at a range of risk factors when safety planning. Additionally, the crisis 
service is arranging for crisis clinicians to attend the non-mandatory “Connecting with 
People” suicide awareness training.  

Monthly QA5 audits are conducted in accordance with the Trust Quality Assurance 
schedule. The tool asks questions about the quality of the safety summary and if it 
reflects the patient’s current level of risk. The tool also reviews if it is documented 
appropriately as to how these risks will be mitigated and managed within the safety plan. 
Audits continue to show sustained improvement in the completion of safety summaries 
and safety plans including the quality of these documents. They allow an opportunity for 
timely corrective actions where required and live supervision for clinicians.  

As a Trust we recognise that staff need support in managing their caseload and an 
integral part of this is effective caseload management supervision.  In addition, caseload 
oversight follows the patient pathway so that our response remains central to a patient’s 
need, whilst also ensuring the right staff have the right skills to offer at the right time to 
promote recovery. For these reasons the Trust implemented a new Caseload 
Management Supervision Policy in January 2023 following a successful pilot in the last 
quarter of 2022. This policy ensures that monthly caseload supervision is completed, the 
use of an electronic caseload dashboard to facilitate and highlight areas of supervision 
and time to consider the quality of essential care documents. 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We believe we have taken all reasonable steps to make clear our standards and to train 
and support our staff to reach the expected standards.  We proactively monitor and 
quality assure compliance through a robust governance process. 

We trust that this response provides the necessary assurances that action has been taken to 
address matters of concern. 

Yours sincerely 

Chief Nurse 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS

Office of the Chief Executive 
West Park Hospital 
Edward Pease Way 
Darlington 
Co Durham 
DL2 2TS 

20 October 2023 

Private & Confidential 
Mr James E Thompson 
HM Assistant Coroner for  
County Durham and Darlington 
H M Coroners Office 
PO Box 282 
Bishop Auckland 
Co Durham  
DL14 4FY 

Dear Mr Thompson 

Inquest into the death of Nicholas Stout 
Regulation 28 Report to Prevent Future Deaths Response 

I am writing to you in response to your direction in the prevention of future deaths notice 
served to Tees, Esk and Wear Valleys NHS FT on 15 June 2023 regarding the death of Mr 
Nicholas Stout. 

Just a short note at this stage to 
acknowledge receipt of your 
letter dated XXXX  2017 bringing 
to my attention concerns raised 
I am responding in the same format and with similar information to that in the response letter 
by your above named constituent 
sent August 2023, I hope this consistency will be helpful.  
in respect of XXXXXXX 
We have taken Nicholas’s death very seriously and our investigation has sought to establish 
where lessons can be learned and/or services improved. 
I have asked for an investigation 
to be carried out into the 
The details of the actions implemented and embedded by us following this incident were 
concerns raised by XXXXX 
, Modern Matron. We do not intend to repeat the 
detailed within the statement of 
following which I will send a 
detail in this response other than to reference the specific paragraphs that are relevant to the 
detailed reply to you. 
concerns raised in the Regulation 28 report.  

With kind regards 
For the purposes of responding to your specific concerns raised in the Regulation 28 Report, 
I shall address each of them in turn: 

Yours sincerely 

1.  The nationally set time from initial contact with the crisis team to some form of 

assessment is 4 hours. I heard evidence that achievement of this target in every 
case is not realised. It is of concern that timely assessment and treatment of 
persons undergoing mental health crisis should be assessed as speedily as 
possible and within the set time period. 

1.1.  Trust Response 

Colin Martin 
Chief Executive 
Ensuring timely assessment and treatment for people experiencing a mental health 
crisis is crucial and we endeavour to meet all expected timescales for the assessment of 
Date 
people in crisis. 

The national standard for very urgent assessments to be completed is within 4 hours. 
Urgent assessments should be carried out within 24 hours.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 For all new patients and those individuals not open to other secondary mental health 
services, the UK national triage tool is undertaken to initially triage and assess the 
patient and to agree the priority of assessment. This is in line with national standards set 
out by NHS England. The clinician carrying out the triage assessment will develop a 
safety plan, in discussion with the patient and their family/carer, to ensure the patient is 
safely supported until the crisis assessment takes place.  If an immediate response is 
required due to an imminent safety or wellbeing concern this would be requested 
through 999 emergency services in line with national guidance. As per the evidence of 
, the crisis service is not commissioned or resourced to provide an emergency 

response and clinicians do not have the appropriate skills, and in many cases, a suitable 
legal framework to provide such a response.  

, speaking to 

In evidence, 
periods of high demand, additional staffing is provided to ensure that targets are 
achieved. However, we acknowledge that crisis service acuity can be unpredictable, and 
may change from day to day. 

 statement, confirmed that during known 

To support maintaining safe staffing levels, the crisis service management team review 
staff resource daily in line with the Trust's safe staffing levels escalation procedure and 
attend the daily safe staffing meeting, this meeting is Care Group-wide. This allows for 
alternative options of support to be identified at times of increased acuity and to ensure 
that assessments are not delayed and are carried out in a timely manner.  

Additionally, the Crisis Team have introduced an escalation procedure to ensure that if 
there is a concern that an assessment would not be undertaken within the given 
timescales, that this is discussed with senior management. Arrangements will then be 
made to ensure that assessments are not delayed which can include deploying staff 
resource from other teams, and management stepping into clinical roles.  

There are examples where response times are breached due to patient preference for 
appointment times or venues and this is supported by the risk assessment and safety 
planning approach detailed above. Breaches are also recorded when teams are unable 
to locate service users post-triage and/or they do not attend their appointment. There 
are weekly reporting processes in place to monitor responses to very urgent referrals 
which allows for clinical oversight of decision making, target compliance and support 
allocation of any additional resource or intervention if required. Any breaches and 
compliance with the standards are monitored through our governance structures, 
reported monthly within Specialty Governance meetings and escalated through to the 
Care Group.  

Table 1 - Durham and Tees Valley 4 hour response target (very urgent) 

2.  The triage tool was explained in evidence to be essential in ensuring the patient 
received the correct treatment/service and is to be undertaken every time a 
patient contacts the Crisis Team. I was informed there was an aspiration to 

 
 
 
 
 
 
 
 
 achieve completion of the Triage Tool every time, but it is not being completed on 
every occasion. It is of concern that such a key document which identifies risk,  

care and other matters is not completed on every occasion as it is mandated to be 
done. 

2.1.  Trust Response  

In evidence, HMC heard evidence from 
undertaken in the Durham and Darlington area in relation to the triage tool assessment 
process and staff development. 

 that development work had been 

Development work was undertaken in June 2022 to embed the use of the national triage 
tool. The service has ensured that all current registered practitioners have received an 
induction regarding the crisis team processes, and all new members of the team are 
fully inducted. The induction includes education regarding the triage tool, guidance as to 
the use of the triage tool and the rationale that underpins its use. This enables staff 
working within the Crisis Team to be clear on team processes and to ensure that triages 
are undertaken by trained senior registered practitioners.  

 confirmed that a monthly audit was undertaken to monitor the use of the triage 

tool, as well as case management supervision with clinicians, reviewing that this had 
been completed. Supervision is carried out on a quarterly basis in line with the Trust 
Supervision Policy. As part of the development work, discussions were held with all staff 
within supervision regarding the use of the tool and triage documentation. 

Audits of compliance with the triage tool sit within the Trust's quality assurance 
schedule. Specifically, the monthly “QA5 audits”, which encompass triage and 
assessment standards. The Trust has a well-established Quality Assurance and 
Improvement Programme which was first initiated in April 2021. This is focused partly on 
patient care documentation, recognising that high quality documentation is an enabler of 
high-quality patient care, as well as observation of practice and talking to teams in 
clinical areas. The programme comprises of a range of quality assurance tools that are 
used to gain a holistic assessment of the quality of patient care. These tools are subject 
to review to ensure they are informed by current areas of risks where further assurance 
is required. The Quality Assurance and Improvement Programme has proven to be an 
effective method of monitoring compliance against key standards of care related to 
patient safety, clinical effectiveness and patient experience. It has facilitated significant 
sustained practice improvements and provides the organisation with both quantitative 
and qualitative assurance evidence. 

The QA5 tool includes questions about the triage process including use of the tool, the 
quality of completions as well as the outcomes. Audits continue to show sustained 
improvement in the use of the triage tool and documentation. The most recent three 
months of audit data showed a 100% compliance with the completion of the triage tool 
where the tool was identified as being required. 

3. 

In relation to making safeguarding referrals for children, the evidence I heard was 
in this particular case a referral should have been made and was not. I was told 
training had been undertaken to make all staff aware of what action to take. 
However, I was told in the majority of occasions it was believed a referral would 
be made. It is of concern in terms of protecting children that I was not satisfied 
that a referral was made in all situations that warranted such a referral. 

3.1.  Trust Response  

 
 
 
 
 
 
 
 
 As an organisation, safeguarding is recognised as an integral part of our care delivery. 
All staff are required to undertake mandatory training for safeguarding children and  
adults, this training is updated at regular intervals to ensure staff remain updated with 
relevant policies and procedures, ensuring that staff understand the importance of 
safeguarding referrals and that referrals are made promptly whenever there is a concern 
for a child or vulnerable persons welfare. 

 confirmed that since this incident, staff have received additional 

In evidence, 
training in relation to the Parental mental ill health on children tool (PAMIC). 
confirmed that the tool considers how a parent’s mental health may impact on a child 
and supports the clinician completing the tool to consider whether a referral to the local 
authority for safeguarding teams should be completed and actions that should be 
considered to safeguard the child/children.  

As a Trust we are committed to learning from this incident and have implemented the 
necessary improvements to prevent such incidents from happening in the future.  
Safeguarding concerns are now a standard agenda item discussed daily within 
community and crisis huddles, attended by all members of the multi-disciplinary team. 
Any identified actions are promptly acted upon, with individual clinicians taking 
responsibility for allocated tasks. The learning in relation to this incident has been 
discussed within team meetings, and the review from the incident has been shared with 
the team to ensure widespread awareness.  

To strengthen safeguarding practices across the organisation, the Trust safeguarding 
team allocate members of the team to link in with different clinical areas across the 
Trust. This provides increased support and guidance within the teams, enabling timely 
and effective handling of safeguarding concerns. The organisation has also issued a 
Patient Safety Briefing following this incident, this briefing has been shared throughout 
the wider organisation to ensure that the learning from the incident has been 
communicated and lessons learnt across the Trust.  

To provide assurance and to maintain consistent monitoring across the organisation, the 
Trust has enhanced its quality assurance schedule and has introduced the QA5 audit 
detailed earlier in this response. A recent addition to the audit tool includes reviewing 
compliance against PAMIC tool completion, whether a safeguarding concern has been 
identified in the past month, and whether appropriate actions have been undertaken 
when a safeguarding concern has been identified. This audit helps us to ensure agreed 
policies and procedures are being followed and to take corrective action where 
necessary to ensure safeguarding procedures are being followed.  

Additionally, to provide immediate support and advice during core working hours, the Trust have 
allocated safeguarding duty workers. This professional lead is available to discuss any 
safeguarding concerns and to offer guidance on how to address concerns safely, 
ensuring a child’s welfare remains a central priority. Outside of regular working hours, 
the Trust safeguarding policy directs staff to contact the local authority safeguarding 
team to ensure that concerns are promptly discussed and addressed as required.   

We were recently inspected by our regulators, the Care Quality Commission (CQC), 
who pay close attention to the application of mandated safeguarding standards in 
practice. The CQC have not raised any concerns about our safeguarding practices.  

4. 

I was told in evidence that a Safety Plan which is compiled with input from the 
patient, their families and practitioners did not exist in Mr Stout's case. I was told 

 
 
 
 
 
 
 
 it is crucial document for identifying risks and ways to mitigate them. I was also 
told work was commenced by your organisation in December 2020 to ensure full  

and complete compliance with this requirement, but I was not reassured there 
was such compliance with the completion of Safety Plans in all cases at this time. 

4.1.  Trust Response  

In evidence, 
that safety plans were completed. 
to check compliance with completion of safety plans and summaries.  

 confirmed that work had been undertaken by the Trust to ensure 
 indicated that a monthly audit was in place 

 confirmed that additional training in relation to the importance of completing 

safety summaries and plans had been completed with crisis staff and all staff had now 
completed this.  

As part of the Crisis Team’s daily huddle, every patient’s care is discussed. As part of 
the huddle safety summaries and safety plans are checked and discussed as a multi-
disciplinary team. Any changes or updates that are required are identified and staff are 
tasked to complete these. 

Within the Early Intervention in Psychosis (EIP) Team, staff have regular caseload 
supervision which looks at patient care and safety management documents such as the 
safety summary and safety plan. Results from QA5 audits are fed back to staff in 
monthly team meetings. Audit outcomes are reviewed through service and specialty 
governance meetings and escalated through to Care Group Boards. A function of these 
groups is also to develop and monitor improvement plans and actions for areas where 
audit compliance falls below the expected standard.  

In both teams, bespoke safety summary and safety plan training, that is supplementary 
to mandatory harm minimisation training, is delivered and allows for exploration of 
specific risks and scenarios related to their service provision. This training is a regular 
offer within the teams and is completed as part of the induction of new staff into the 
team.  

All staff complete the Trust mandatory Harm Minimisation training. This training supports 
clinicians to develop skills and competence in the completion of person-centred safety 
plans that look at a range of risk factors when safety planning. Additionally, the crisis 
service is arranging for crisis clinicians to attend the non-mandatory “Connecting with 
People” suicide awareness training.  

Monthly QA5 audits are conducted in accordance with the Trust Quality Assurance 
schedule. The tool asks questions about the quality of the safety summary and if it 
reflects the patient’s current level of risk. The tool also reviews if it is documented 
appropriately as to how these risks will be mitigated and managed within the safety plan. 
Audits continue to show sustained improvement in the completion of safety summaries 
and safety plans including the quality of these documents. They allow an opportunity for 
timely corrective actions where required and live supervision for clinicians.  

As a Trust we recognise that staff need support in managing their caseload and an 
integral part of this is effective caseload management supervision.  In addition, caseload 
oversight follows the patient pathway so that our response remains central to a patient’s 
need, whilst also ensuring the right staff have the right skills to offer at the right time to 
promote recovery. For these reasons the Trust implemented a new Caseload 
Management Supervision Policy in January 2023 following a successful pilot in the last 

 
 
 
 
 
 
 
 
 
 
 quarter of 2022. This policy ensures that monthly caseload supervision is completed, the 
use of an electronic caseload dashboard to facilitate and highlight areas of supervision 
and time to consider the quality of essential care documents. 

We believe we have taken all reasonable steps to make clear our standards and to train and 
support our staff to reach the expected standards.  We proactively monitor and quality 
assure compliance through a robust governance process. 

We trust that this response provides the necessary assurances that action has been taken to 
address matters of concern. 

Yours Sincerely  

Chief Executive