Kirsty Taylor

Kirsty Clare Taylor 

Regulation 28: Report to Prevent Future Deaths 

28 July 2023 

Hampshire and Isle of Wight Integrated Care Board (ICB) Response 

Issue - The facts in this case have highlighted that progress on initiatives and 
connectivity between services is still too little and too slow. More needs to be done, and 
with greater integration. 

1.  Creation of all-age community and mental health Trust 

 was commissioned by the Hampshire and Isle of Wight 
In February 2022, 
Integrated Care System (HIOW ICS) to undertake an independent review of community and 
mental health services and to identify further opportunities for collaboration and integration. 
Evidenced by this review is the unwarranted variation in practice, and fragmented pathways, 
making services difficult to navigate and consequently people don’t consistently experience high-
quality, person-centred care that meets their needs. The Trusts recognised this was a key 
challenge that could not be addressed by any one organisation. 

The review was completed in April 2022 and one of the five key recommendations was that a new 
Trust should be established to oversee delivery of all community and mental health services across 
Hampshire and Isle of Wight (HIOW). The ICB formally endorsed the recommendations at a public 
meeting in October 2022. Subject to final ICB, NHS England and Secretary of State approvals, the 
new all-age Trust will go-live 1 April 2024. A move towards integrated all-age mental health 
service provision will: 

Better meet the needs of our patients: 

•  Reducing unwarranted variation for patients. 
•  Overcoming the fragmentation across services and especially during transition from child to 

adult services. 

•  Establishing consistency of care regardless of age. 
•  Enabling a more joined up approach to physical health and mental health care. 
•  Embracing population health management and working closer with local system partners. 

Improve safety: 

•  Ensuring no one falls between our services, particularly during transition from child to adult, 

building seamless all-age pathways of care. 

•  Ensuring responsive high-quality care is delivered by an appropriately skilled workforce.  

Improve efficiency: 

•  The efficiencies of a larger single Trust will contribute towards addressing the unwarranted 

variations in access and outcomes for some of our population.   

•  Creating a more sustainable workforce by removing barriers around workforce mobility and 

creating a single, shared workforce plan and vision. 

•  Improving the ability to manage capacity according to need & respond to system pressures. 
•  Enabling at-scale or fragile services to operate at the appropriate scale, for example psychiatric 

liaison services within Acute Hospitals. 

2.  Autistic Spectrum Condition (ASC) and Attention Deficit Hyperactivity Disorder (ADHD) 

pathway developments 

The existing assessment and prescribing pathways for Autism and ADHD are reflective of historical 
commissioning arrangements with a total of 11 organisations providing NHS assessment services 
under 25 contracts/agreements across HIOW. The ICB is currently in the process of re-
commissioning these services to provide a more cohesive assessment and prescribing offer for the 
population of Hampshire and the Isle of Wight from 1 April 2024. This approach will enable the 

Page 1 of 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 secondary care provider of mental health services and future ASC/ADHD assessment and 
prescribing provider(s) to establish much stronger and collaborative working arrangements.  

In addition to the re-commissioning of the assessment and prescribing pathways, a HIOW All Age 
ASC and ADHD Improvement Group is now operational and responsible for overseeing the 
transformation of the whole neurodiversity pathway, including: 

a)  The development of consistent early intervention offers for our Neuro-diverse population 
building on initiatives already in place such as the Neuro-developmental pilot launched in 
Portsmouth to re-focus support for children & young people with autism & other 
neurodevelopmental issues. The MDT is an innovative approach to supporting a new 
Neuro-developmental pathway and since its launch in Sept 2022 has demonstrated a 
decrease in the number of young people being added to the formal diagnosis waiting list 
(the approach allows individual action plans to be co-produced that results in a formal 
ASC/ADHD diagnosis lending little added value). 

b)  Co-designing and embedding a shared care arrangement which matches national policy 
and is locally agreed in partnership with Primary Care to ensure everyone can access 
prescribed medication safely and locally in a timely manner. 

c)  The development of a range of post diagnostic support options building on initiatives 

already in place such as the Neurodiversity Parenting Courses delivered by Re:minds and 
Southampton City Council. Qualitative feedback from this offer has found an improvement 
in understanding of Autism, adaptions, communication and that attending the programme 
has had a positive impact on family life reported by majority of attendees (comparing pre 
and post questionnaires). 

Issue - Evidence before this inquest indicated that SHFT has recognised that the mental 
health provision for those with personality disorders must move towards an individual, 
therapeutic and trauma-informed approached. 

The review and development of evidence-based pathway and provision for people 
with personality disorders is one of five key Mental Health System Transformation priorities in 
2023/24 for the Hampshire and the Isle of Wight system. The review is in process and will 
consider: 

• 
• 
• 
• 

The benchmarking of current provision. 
The views of our patients and stakeholders. 
The current and future projected need. 
Local & national best practice. 

This review will lead to the development of improved provision for people with personality 
disorders to be mobilised in 2024/25. 

Mental Wellbeing is a priority set out in the Hampshire and Isle of Wight Forward Plan including 
working in partnership with the system in developing trauma informed approaches across services 
to reduce health inequalities and improve emotional wellbeing. The ICB, alongside Southern Health 
Foundation NHS Trust, is a signatory of the Trauma Informed concordat for Hampshire, the Isle of 
Wight, Portsmouth and Southampton, committing to the delivery of the Trauma Informed 
Strategy, allocating resources, and providing support and commitment at a senior level. 

Issue - Communication with the families of patients with mental health difficulties is still 
not being effectively achieved including that the family were never briefed on what 
EUPD and ADHD really meant or on the difficulties which could present because of their 
daughter’s joint diagnoses. 

The ICB’s approach to quality oversight is based on three levels of assurance and support. This 
approach is aligned with the National Guidance on Quality Risk Response and Escalation in 
Integrated Care Systems (June 2022). 

The trust remains under enhanced monitoring following publication of the Stage 2 Investigation 
 report, 
from the Independent Investigation Panel, Chaired by 

. Within 

Page 2 of 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 recommendations were made under the heading: Communication, Liaison and ‘Care for the Carer’ 
and these have been a focus of the ICB’s Stage 2 monitoring. 

To ensure that improvements in family and carer engagement are embedded and sustained, the 
trust is required to submit progress updates against its Stage 2 action plan to HIOW ICB and NHS 
England. At the last formal review in June 2023, the trust provided evidence of improvement 
across actions agreed to improve communication with families and carers. This included 
establishing Carers and Patients Support Hubs at various locations across Hampshire, 
improvements in the response to concerns and complaints, and improvement in the number of 
carers with a communication plan (30% to 80% in two years). This has been recognised externally 
through the Triangle of Care Star 2 award, which was received by the trust on 9 June 2023.  

Whilst there is more to be done to ensure that feedback from families and carers is heard and 
acted on and informs the delivery of care and decision-making for those in receipt of services, the 
trust has demonstrated its commitment to deliver continuous improvements in this area. 

Alongside the existing oversight of the trust, the learning identified in this case will inform the 
ICB’s ongoing focus on improving family and carer engagement. 

In addition to improvements in engagement with families and carers, the HIOW All Age ASC and 
ADHD Improvement Group will be developing a greater range of resources for families to access 
post diagnosis.  

Page 3 of 3

Christopher Campbell Wilkinson 
Senior Coroner 
Hampshire, Portsmouth & Southampton  
Senior Corner 
The Castle  
Winchester  
SO32 8UL 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

16 October 2023  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Kirsty Clare Taylor who 
died on 25 June 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 28 July 
2023  concerning  the  death  of  Kirsty  Clare  Taylor  on  25  June  2022.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Kirsty’s family and loved ones. NHS England are keen to assure 
the  family  and  the  coroner  that  the  concerns  raised  about  Kirsty’s  care  have  been 
listened to and reflected upon.  

Your  Report  raised  concerns  over  the  connectivity  between  mental  health  services 
and those services supporting neurodivergent patients, the mental health provision for 
those with personality disorders, communication with families of patients with mental 
health  difficulties  and  support  for  families  of  patients  with  neurodiversity.  You  also 
raised  that  Southern Health  Foundation  Trust  (SHFT)  needed  to  further  develop its 
Personality  Disorder  Pathway  and  that  more  needed  to  be  done  to  increase 
connectivity  between  mental  health  services  and 
those  services  supporting 
neurodivergent patients.  

As  part  of  the  NHS  Long  Term  Plan,  all  systems  in  England  have  been  receiving 
significant  funding  from  2021/22  to  develop  and  roll  out  new  models  of  integrated 
primary and community mental health care in line with the Community Mental Health 
Framework  for  the  improved  support  of  adults  with  severe  mental  illness  in  their 
community and to integrate mental, physical and social care. A key requirement of the 
new model of care is the provision of a dedicated community mental health offer for 
those with diagnosis of ‘personality disorder’ or complex emotional needs. This offer 
should be co-produced and provide personalised, trauma-informed, and flexible care 
that  is  responsive  to  individuals  changing  needs.  NHS  England  has  shared  key 
principles for the development of services for people with personality disorder and will 
continue to share guidance and positive practice with health systems.  

The Community Mental Health Framework also sets out the importance of engaging 
both service users and their families and carers, noting that assessments should be a 
collaborative  process  involving  not  only  mental  health  team  members  but  also  the 
patient, their families, carers and support networks.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
  
 In  September  2023,  the  Government  also  published  its  new  Suicide  Prevention 
Strategy for England: 2023 – 2028, a five year cross-sector strategy developed with 
the aim of reducing suicides in England. The strategy is underpinned by an action plan 
for organisations including the NHS, the Department of Health & Social Care (DHSC) 
and from across the voluntary, community and social enterprise (VCSE) sector. It is 
supported by a wide range of funding which includes £57million for suicide prevention 
and  suicide  bereavement  services,  as  well  as  £150million  capital  investment  into 
urgent and emergency care mental health pathways.  

As part of the strategy, NHS England and DHSC will explore opportunities to improve 
the quality of care for patients with specific diagnoses of conditions associated with 
higher rates of suicide and ensure compliance with  the National Institute for Health 
and  Care  Excellence  (NICE)  guidelines.  This  includes  patients  with  personality 
disorders.  It  is  also  intended  that  by  2024/25  all  parts  of  the  country  will  have 
introduced crisis text lines to enable easier access to crisis care for people who are 
neurodiverse.  

We  also  note  your  concern  that  more  needs  to  be  done  within  Southern  Health 
Foundation Trust (SHFT) around development of their Personality Disorder Pathway, 
ADHD services and connectivity between mental health services and those supporting 
neurodivergent  patients.  NHS  England  is  engaging  with  Hampshire  &  Isle  of  Wight 
Integrated  Care  Board  (ICB)  on  the  concerns  raised  and  have  been  asked  to  be 
sighted on their response to your Report.  

I would also like to provide further assurances on national NHS England work taking 
place around the Reports to Prevent Future Deaths. All reports received are discussed 
by  the  Regulation  28  Working  Group,  comprising  Regional  Medical  Directors,  and 
other clinical and quality colleagues from across the regions. This ensures that key 
learnings and insights around preventable deaths are shared across the NHS at both 
a national and regional level and helps us pay close attention to any emerging trends 
that may require further review and action.  

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

Kirsty Clare Taylor 

Regulation 28: Report to Prevent Future Deaths – Trust Response 

Matter of concern (1): fragmentation of services 

Fusion 

Southern Health NHS Foundation Trust, Solent NHS Trust, Isle of Wight NHS Trust and 
Sussex Partnership NHS Foundation Trust provide NHS community, mental health and 
learning disability services for the Hampshire and Isle of Wight population.  

We have been working together for a number of years to improve services for the people 
and communities we serve. Whilst in each Trust there are multiple examples of services 
providing excellent care, it has been recognised that further significant change is needed in 
order to deliver sustainable improvements in access, care and outcomes.  

Services are struggling to meet unprecedented increases in demand which means people 
are not always getting the care they need at the right time and in the right setting; we 
recognise there is unwarranted variation in practice and fragmentation in service delivery 
and want all people in Hampshire and the Isle of Wight to have equitable access to 
integrated, safe, consistent community and mental health care.  

There is consensus that we will be more likely to achieve this future by joining up the 
disparate, often inconsistent services and pathways delivered by four different community 
and mental health providers. It has therefore been concluded that the best way to enable our 
vision is by working together to establish a new, single community and mental health 
provider, while, at the same time, accelerating collaboration and transformation, led by our 
clinical experts, to reduce the significant pressures in our system. The creation of this new 
provider is progressing at pace (Project Fusion) with the new legal entity due to be in place 
by 1 April 2024.  

Neurodiversity Clinical Delivery Group 

The clinically-led transformation of services is a key element of the Fusion work and one of 
the 10 Clinical Delivery Group areas is focussed solely on Neurodiversity. This is in 
recognition of both the inequity patients face across the county relating to access to 
neurodiversity services and also the impact of fragmented services on patient experience 
and outcomes. 

Our aspiration is to implement a single specification for all age neurodiversity services that 
spans assessment, diagnosis, treatment and support and works with system partners to 
ensure all aspects of a patient’s needs, not just the clinical factors, are attended to 
holistically.  

As we are not in control of the commissioning of these services and as commissioning 
changes may not be immediate, we are therefore focussing on what we are and will be 
responsible for in the new organisation and where we can lead by example. We know from 

1 

 
 
 
 
 
 
 
 the available evidence that it is not helpful to refer patients with neurodiversity on to multiple 
other services where reasonable adjustments could instead be made to support people in 
'mainstream services'. We also know that wherever possible we should work jointly with 
other services to offer a joined up experience of care for patients and families making the 
best use of skills from within the wider organisation. 

Achieving this depends significantly on staff having the awareness, skills and knowledge of 
how neurodiversity can impact on a patient’s experience of services in order that they can 
adapt their care delivery accordingly. Robust training packages are being rolled out to 
support this. The Oliver McGowan Mandatory Training on Learning Disability and Autism is 
the standardised training that was developed for this purpose and is the government's 
preferred and recommended training for health and social care staff. The e-learning training 
was launched on 2 August 2023 and in just over 2 months, 75% of the workforce have 
completed this. We are delighted with the rapid uptake and the feedback from staff has 
demonstrated positive buy-in to the key learning the training seeks to deliver. 

We have also recently partnered with two voluntary care sector organisations who will help 
us to deliver the live elements of the training and are on track to have our first webinar 
launched at the beginning of November. Webinars and seminars are both mandatory as a 
second part of the training to the e-learning. Non-patient facing staff will complete e-learning 
and a webinar and patient facing staff complete e-Learning and a more comprehensive 
seminar, all of which is mandatory. 

In addition to the training, we intend to build a network across the county to share best 
practice and tackle issues collectively and we have a number of working groups in place, 
which include broad input across clinical and corporate services and the service user voice, 
with a remit is to ensure what we have designed is measurable, tested and sustainable for 
the future.  

These working groups are developing principles and Standard Operating Procedures for use 
across the new organisation when it comes into being.  

Whilst we do not have a policy that specifically addresses the treatment of patients with 
Learning Disability/ neurodiversity/mental health comorbidities, we feel the above work and 
development of Standard Operating Procedures will achieve the same outcome, hopefully in 
a way that is more visible than policies sometimes are.  

lived experience perspective.  

 will be invited to be part of the work we have described above from a 

Matter of concern (2): Personality Disorder Pathway should be developed at pace 

Pathway development 

By way of background, the Trust had already developed the Transform Pathway with 
involvement from experts by experience, clinicians and commissioners. This was for people 
with a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and the main focus 
was on embedding Dialectical Behaviour Therapy (DBT).  

In 2021/22, as part of our community transformation programme development work for 
personality disorders, the Trust looked at the Transform model and identified some key 
gaps. The Trust also analysed themes from a number of national documents including the 
Royal College of Psychiatry position statement on people with personality disorder (2020), 

2 

 
 
 
 the Wessex Personality Disorders Pathway Review (2020) and the work from the National 
Confidential Inquiry into Suicide and Homicide on Safer care for patients with personality 
disorder (2018) among others. 

The themes from these documents were then triangulated with a case note review of 
patients across the Trust and feedback from patient and family experience in order to 
accurately map out the Trust’s real-time position and its future aspirations.  

Concurrently, in January 2022, ICD-11 came into effect. This version of what is the global 
standard for diagnostic health information contained a fundamentally different approach to 
classification of personality disorders. It did away with the numerous sub-types of personality 
disorder found in ICD-10 and replaced them with a single personality disorder diagnosis.  

In order to ensure that the Trust responded to this combination of local analysis and national 
and international developments, a new model has subsequently been developed over the 
past year for all services working with people who have Personality Disorder and Complex 
Trauma.  

This model is based on a relational and trauma-informed therapeutic approach, incorporating 
evidence-based interventions for individuals, family interventions, psychological consultation 
to teams working with complexity, as well as training for staff. The absolute aim is that no 
door should be experienced as the wrong door, by individuals and their families. To change 
this involves building community awareness and training for all staff.  

Since the inquest into Kirsty’s death, two half day workshops have taken place in August and 
September 2023 for staff from across the clinical services. These were an opportunity to 
summarise the model, review progress to date and start to develop an implementation plan 
for delivery. Outputs and updates were subsequently shared with the Quality and Safety 
Committee (Board Committee) at the end of September 2023 who gave their full backing to 
the proposals.  

A programme Steering board and 6 workstreams have formed to ensure a structured roll out 
and oversight of the implementation plans. One of the workstreams is the Families and 
Carers Support workstream and the Trust would again very much welcome Kirsty’s family to 
participate in this. 
 will be in touch with them about this shortly as we recognise 
that their generous offer to give their time to support these changes will be invaluable.  

A further workstream which is focussed on the in-patient pathway has as one of its strands 
the development of tools to support patients with a Personality Disorder should they be 
admitted to hospital. This group includes among its membership experts by experience with 
neurodiversity and the Trust fully recognises the need for the whole pathway to be 
accessible for this patient group. 

As part of embedding the trauma-informed approach1 the Trust is involved in a whole 
system piece of work to ensure that wherever an individual or family touches our services 
they will experience a trauma-informed response. This is a large-scale piece of work 
involving training and cultural change across a range of organisations. Connected to this and 
as part of the NHS England Mental Health, Learning Disability and Autism Quality 

1 Trauma-informed care acknowledges the need to understand a patient's life experiences in order to 
deliver effective care. It aims to increase clinicians' awareness of how trauma can negatively impact 
on individuals, and their ability to feel safe or develop trusting relationships with health and care 
services. It has the potential to improve patient engagement, treatment adherence and health 
outcomes. 

3 

 
 
 
 
 
 
 Transformation programme the Trust has been involved with development of core standards 
and commitments around changing the culture of our mental health inpatient wards. This 
work has informed and continues to inform the workstream focussed on the inpatient part of 
the Personality Disorder and Complex Trauma pathway and our wider services as to what it 
looks and feels like to be truly trauma-informed . 

The delivery of this new model will be in a phased approach to align with available funding 
from commissioners with the first phase of work focussed on reducing waiting times for 
psychological therapy in secondary care. 

Recruitment  

As part of the new Personality Disorder and Complex Trauma model, the Trust is seeking to 
increase access for individuals to evidence-based interventions, aligning with the national 
agenda on increasing access for individuals with severe mental illness. Funding received for 
‘recruit to train’ posts is enabling this to happen.   

The three ‘recruit to train’ posts developed in Southampton in October 2022 have already 
shown an impact with no patients currently on a waiting list for Dialectical Behavioural 
Therapy (one of the evidence-based interventions for people with Personality Disorders) and 
there is further training for current staff underway.  

The Trust has been vocal about the need for additional funding aligned to the development 
of the range of evidence-based interventions over the next 5 years, to continue to meet 
patient and family demand and reduce waiting times. We are in ongoing conversations with 
commissioners to seek to secure this.   

A separate measure taken to mitigate the national shortage of psychology staff has seen the 
Trust developing a new workforce and running an apprenticeship scheme with Plymouth 
University to develop Clinical Associates in Psychology (CAPS). Since 2022, the Trust has 
developed 48 CAPS across the organisation (3 cohorts of 16).  

These new roles have allowed for a more psychologically-minded approach in community 
mental health and crisis teams in both Adults and Older Persons Mental Health Services and 
these staff will be crucial in supporting the new Personality Disorder and Complex Trauma 
model to become embedded in these teams. 

Matter of concern (3): Communication with families and listening to their concerns 

The Trust recognises the Coroner’s concern about repeatedly seeing evidence of poor 
engagement with families. This frustration, that we are still not getting this engagement right 
every time, is shared by Board members. It is an absolute priority for the Trust and whilst we 
in no way seek to underplay the amount of work left to do, we would like to provide 
assurance that there have been significant improvements made (and externally validated) 
which may not always be visible through what is, thankfully, the very small proportion of 
cases that come before the Coroner. 

4 

 
 
 
 
 
 
 Triangle of Care 

We are delivering a ‘Triangle of Care’ training package (launched by the Carers Trust) to 
frontline staff with more than 2000 staff having completed this training since 2019. Much of 
this training is co-delivered with Carers, Carers Leads and a former service user with their 
carer.  Triangle of Care training is ongoing and available weekly for all staff. 17 Carers Leads 
and 14 nurses/practice development nurses have been trained to facilitate the training 
package.  

The face-to-face Healthcare Support Worker induction for new staff joining the organisation 
has included Triangle of Care training as an integral part of it since November 2022. This 
ensures buy-in from all delegates and provides them with the skills and knowledge going 
forward into their new careers.  

The aims of ‘triangle of care’ are clear:  

•  Carers and the essential role they play should be identified at first contact or as soon 

as possible thereafter  

•  Staff are “carer aware” and trained in carer engagement strategies  
•  Policy and practice protocols re confidentiality and sharing information are in place 
•  Defined post(s) responsible for carers are in place  
•  A carer introduction to the service and staff is available, with a relevant range of 

information across the care pathway. E.g. Trust Carers Booklet. 

•  A range of carer support services is available.  

In addition to the Triangle of Care training we have also provided training on carer 
awareness and carers rights, which was delivered by Hampshire Carers Together. We have 
held  ‘Think Carer’ workshops for staff and recently launched an e-learning module of the 
Triangle of Care training to enable those staff who have difficulty attending training events to 
also access this. 

In June of this year we were delighted to be awarded Triangle of Care Star 2 accreditation 
and we are now working towards Star 3 to complete the process. In order for a mental health 
trust to achieve star 2 status, it must not only have completed the self-assessment for 
inpatient wards and crisis services, but also provision of support within community mental 
health services. 

In awarding Southern Health star 2 accreditation, 
the Carers Trust said “I am delighted to be working with Southern Health as they focus on 
giving carers greater recognition and support in their communities by delivering Carers 
Trust's Triangle of Care programme. The programme is promoting a set of standards that 
brings together unpaid carers, service users and staff as partners in care.  This includes 
unpaid carers being identified and supported and Southern Health’s membership of the 
Triangle of Care promotes this work.” 

, Triangle of Care Lead for 

, Chief Executive of the Princess Royal Trust for Carers in Hampshire said 

“From reading the report, it is clear to see the commitment that Southern Health have 
towards partnership working with Carers and the six principles that sit at the core of the 
Triangle.  The progress you have made alongside your future plans will ensure that Carers 
are embedded into all teams and services across the Trust.” 

The introduction of Esther coaching this year will further enhance and reinforce the Triangle 
of Care principles. Esther Improvement Coaches are specially trained dedicated members of 
staff who support the development of other staff to create a culture of continuous 

5 

 
 improvement to ensure person-centred care. User involvement is integral to the model, 
building a network around the patient including family, friends, and key staff. 

Additional work programmes 

We have metrics which show that whilst there is a way yet to go, there has been significant 
improvement made. As an example, 77% of carers identified on our patient record now have 
a bespoke carer communication plan. This is in contrast to the position in 19/20 where carer 
communication plans were rarely in place.  

There are 152 carer leads in teams across the Trust with an additional 63 honorary Carers 
Leads – influencers and ambassadors. These are members of the team with a responsibility 
to champion family and carer engagement as part of their wider clinical role. We have also 
employed 22 staff in the roles of Carer Support Workers across the Trust. These are paid 
roles exclusively for working with carers.  

Carer information is now readily available through booklets and also via a dedicated section 
of our public facing website. A new Carers and Patient Support Hub was also set up in 
January 2022 and this is a listening service available to family members/carers who need 
additional advice, information or support. In order to ensure that this service is accessible to 
all we have set up hubs in community settings as well as our clinical areas.  For example, we 
have hubs in areas such as Totton, Romsey, Lymington, Southampton and one in 
development in the North of Hampshire. 

During the last year, three of our carers have worked tirelessly on a project aimed at 
exploring carers experiences of hospital discharge from Adult Mental Health and Forensic 
services.  The project was funded by NHS England and was co-produced and user-led 
throughout.  The report produced a number of recommendations to improve the experience 
of carers and their families and with the support of our clinical staff an action plan has been 
implemented to address the issues.   

Building on findings from the Mind the Gap scoping project which was completed last year,  
and in collaboration with Hampshire Young Carers Alliance, No Limits and other 
organisations, we are also currently undertaking a project to support and engage young 
carers.  A key feature of this work will involve collaboration with schools, primary care and 
other health services.  We are grateful to NHS England for funding this focussed work with 
young carers. 

Information Sharing  

Policies and protocols with regards to information sharing (including the issue of capacity) 
are also in place. The Trust promotes the importance of both the 7th and 8th principles of the 
UK Caldicott Guardian Council in recognising the importance of the duty to share information 
being as important as the duty to protect patient confidentiality. They are included with our 
Triangle of Care work and information governance (IG) training. IG training is completed 
annually by every member of staff which will help to embed these principles further. 

Information sharing remains a real focus of ours and we take every opportunity to champion 
this work.  Our Carers booklet, which was co-produced with carers and is handed out to 
family/carers whenever they come in to contact with services also has specific references to 
information sharing.  

6 

 
 
 
 
 Obtaining and providing feedback 

The Trust has increased the number of ways that people can give feedback and 
opportunities to share their experience. This includes Carers groups, storytelling events, 
carers forums, surveys etc. We have a number of carers groups across the Trust, as well as 
supporting external groups. Most recently, the Trust has funded and supported the setting up 
of a BAME carers group in Southampton.  Feedback and issues highlighted from these 
different platforms is reported to the Carers, Family and Friends group and the Patient 
Experience and Caring group as part of our business-as-usual reporting. 

The Trust acknowledges the need to balance accountability and responsibility by ensuring 
that it meets the Duty of Candour and admits its mistakes. Our Investigating Officers and 
Family Liaison Officers openly engage with families when they are part of an investigation 
and check that service leads have shared information openly and honestly. 

Strategy development 

Our People in Partnership Commitment details our commitment to working together with 
service users, patients, families and carers so that they have a say in their care and 
treatment and help us to improve.  

This Commitment was reviewed during 2022 with a series of task and finish groups 
established with representatives from our Working in Partnership Committee, Carers, 
Families and Friends Group, Governors, Voluntary Sector, Charitable Organisations and 
Partners. A consultation draft of the refreshed strategy was then produced for wider 
consultation and comment. 

The draft document was circulated to more than 1500 people, was shared widely on social 
media and a survey was also available for people to complete.  

Feedback was taken into account and the necessary amendments made to the strategy 
which was approved by the Quality & Safety Committee in January 2023 and subsequently 
Board in February 2023. 

Our strategy states that we will: 

•  Enable carers to access the support they need in their caring role through 

signposting and referrals to relevant carer support services, co-producing resources 
and developing carer groups 

•  Support carers by giving them timely information, respect and opportunities to share 

their stories and make their roles visible. 

•  Empower carers’ voices, by improving the way in which we listen and communicate 
with them, enabling them to continue in their caring role in good health and keeping 
safe. 
Increase opportunities for carer engagement 

• 

We fully recognise that Kirsty’s family did not always find this to be their experience and we 
are desperately sorry this was not the case. Their feedback is a reminder to us that whilst we 
have made progress, there is more to do and the information provided above does not in any 
way diminish the responsibility we take for this.  

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 Matter of concern (4): More support to families particularly for patients with 
neurodiversity 

Family Connections is a programme that has been specifically developed for families of 
patients with a personality disorder. It aims to provide: 

1.  Education about personality disorder and family functioning  
2.  Individual and family skills, to help with managing their own negative reactions and 

building better and more satisfying relationships 

3.  Social support, from other group members who have lived through similar 

experiences and are living with similar situations 

Whilst we were initially only able to offer this in the Trust to a small sub-set of families whose 
relative was receiving a particular combination of interventions, we have sought to expand 
this.  A new Family Connections model has been developed and has been run by Clinical 
Associates in Psychology (part of our new workforce expansion described in 2 above) for 
other family members with good outcomes.   

Whilst the original Family Connections programme was specifically for Personality Disorder  
and aligned to DBT, we are continuing to develop the programme to be accessible to a 
broader range of people with complex emotional needs including those with neurodiversity. 
Our ambition is ultimately for family interventions to be designed that are bespoke to the 
individual’s formulation. 

We would also refer the Coroner back to the information provided in section 1 above in 
respect of the work specifically underway to improve the experience that patients with 
neurodiversity and their families have when accessing our services.  

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