Evie Davies

Victoria Davies 
Area Coroner for Cheshire 

20th June 2024 

Dear Madam  

Re: Regulation 28 Prevention of Future Deaths Notice - Evie Jane Davies 

Thank you for your letter dated 2nd May 2024 sent following the conclusion of your inquest into 
the death of Evie Jane Davies. 

I understand that you will share our response with Evie’s family, and I wish to pass on our sincere 
condolences for their loss.   

Through the Regulation 28 letter you have raised a concern which involves the Crisis Line and 
Café 71; your concerns about the lack of information sharing between the organisations, and in 
particular in real time or as near as possible, gives rise to a risk of future deaths and you consider 
that we have the power to take action, either as provider of the service or as commissioner. 

Cheshire and Merseyside Integrated Care Board hold a commissioning contract with Cheshire 
and Wirral Partnership NHS Foundation Trust (CWP) for a wide range of services, including the 
provision  of  community  crisis  services.  In  response  to  the  contract  requirements  CWP  have 
developed a service model for a community crisis service to meet a range of needs. The crisis 
service established by CWP consists of multiple components, including the Crisis Line and the 
provision of two crisis cafes. CWP have a contract in place with the Spider Project for these crisis 
cafes, one of which is Café 71, in Chester.  

In line with the requirements of a NHS Standard Contract, CWP as the holder of the contract with 
the Spider Project, has agreements in place about how information is shared between services 
and  organisations.  We  have  liaised  with  CWP  following  receipt  of  your  letter  to  confirm  their 
contract arrangements with the Spider Project. CWP have advised us that they are responding 
to  you  regarding  their  information  sharing  processes  and  agreements  on  who  has  access  to 
patient records across the crisis service.  

CWP have provided assurance that staff at the Crisis Line do have access to people’s mental 
health records though not everyone who calls the Crisis Line is known to mental health services. 
Staff  at  the  Crisis  Line  make  decisions  about  any  onwards  referrals  to  services,  one  of  which 
could be to Café 71.  Evie contacted the Crisis Line on 1st December 2021 who then made a 
referral to Café 71.  

GP’s, along with other professionals can contact the Crisis Line directly and request mental health 
crisis support for individuals they are concerned about. CWP have a system in place to inform 
the GP when an individual has contacted Crisis Line and in line with the concern you raised we 
will  work  with  CWP  and  GP  colleagues  to  improve  the  timeliness  and  content  of  that 
correspondence.  

NHS Cheshire and Merseyside Integrated Care Board are deeply saddened by the death of Evie 
and hope this provides a satisfactory response to the request. 

I am grateful to you for raising these issues with the NHS Cheshire and Merseyside ICB and I 
hope  that  this  response  has  addressed  the  concerns  raised.  Should  you  require  any  further 
clarification or information, please do not hesitate to contact me. 

NHS Cheshire and Merseyside 
No 1 Lakeside, 920 Centre Park Square 
Warrington, WA1 1QY 

Communications@cheshireandmerseyside.nhs.uk 

Cheshireandmerseyside.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 Yours sincerely 

Executive Director of Nursing & Care 

NHS Cheshire and Merseyside 
No 1 Lakeside, 920 Centre Park Square 
Warrington, WA1 1QY 

Communications@cheshireandmerseyside.nhs.uk 

Cheshireandmerseyside.nhs.uk

Chief Executive  
Trust Headquarters Redesmere 
Countess of Chester Health Park 
Liverpool Road 
Chester 
CH2 1BQ 
Ref D131545 

Victoria Davies   
Area Coroner for Cheshire 

Cheshire Coroner’s Service, 
Museum Street,  
Warrington, 
Cheshire 
WA1 1XJ 

27June 2024 

Dear Madam,  

Response to Regulation 28 Report to Prevent Future Deaths 

Thank you for your letter dated 2 May 2024, following the conclusion of the inquest into the 
death of Miss Evie Davies. I have reviewed your concerns fully and our responses and actions 
that we are undertaking to address these concerns are detailed within this letter.  

The Concerns: 

“During the course of the investigation my inquiries revealed matters giving rise to concern. 
In my opinion there is a risk that future deaths could occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. The evidence I heard was that the café 
71 service is run as a crisis line for those who are in ‘Lesser crisis’ than those who would call 
the mental health team crisis line or the crisis resolution home treatment team.  

It appears that the cafe 71 team is operating in isolation/ separately to the mental health team, 
and  for  those  patients  who  are  under  the  mental  health  team,  they  will  be  unaware  of  the 
background and the risk factors for that person. They will take an assessment of that person 
at face value based on how they are in the call, as they don’t have access to the information 
held by the mental health team. 

In addition, there does not appear to be any notification to the mental health team to say 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 that the person has been in contact such that this can be followed up. It is likely that there 
is notification to the GP but in this case, there was no detail provided which could have been 
passed on, and the timescales for review of correspondence by the GP, who again are 
operating somewhat in isolation to the mental health team, does not lend itself to the 
prompt action which may be required by the mental health team. I am concerned that the 
lack of information sharing between the organisations, and in particular in real time or as 
near as possible, gives rise to a risk of future deaths and consider that your organisation 
has the power to take action, either as provider of the service or as commissioner.” 

Response from Cheshire and Wirral Partnership NHS Foundation Trust (‘the Trust’ or 
CWP) 

The Spider Project Café 71 Service and Trust Services 

The Crisis Triage & Response Service (known as the crisis line) was established in 2020 it is 
a telephone service that is open to all ages and operates 24 hours a day, 7 days per week 
with no exclusion criteria. It provides support, advice and signposting for patients experiencing 
a  self-defined  crisis.  There  are  a  number  of  ongoing  referral  pathways  to  ensure  people 
receive support in line with their presenting needs including the Café 71 which is delivered by 
The Spider project in Chester.   

In order to assist, I wish to clarify the functionality and role of Café 71. 

Café 71 is a community service which operates both open access direct for the population 
and  through  referrals  from  partners  such  as  Primary  care  (GPs)  and  CWP.  The  service  is 
commissioned by CWP to offer advice, guidance and crisis support to anyone aged 18 and 
over who are experiencing a self-defined crisis. Café 71 staff support individuals by helping 
them to de-escalate and resolve the crisis situations, the staff also work with the individual to 
recognise  any  underlying  factors  and  supports  onward  referral  and  signposting  to  relevant 
services.  By way of clarification, Café 71 operates between 10 am and 10 pm daily, it is not 
“run as a crisis line” as stated in the Regulation 28 report, to which this letter responds. Whilst 
Café  71  does  provide  telephone  support  to  service  users,  where  required,  the  majority  of 
interventions and support provided by Café 71 are delivered “in person”, with service users 
being able to be referred into this service, or alternatively attend Café 71 (located in Chester) 
on any given day to receive support.  

Café 71 is an appropriate referral for an individual who does not require immediate specialist 
or clinical support to keep themselves safe, but may nevertheless be presenting in a crisis and 
require support on an ongoing basis.  

For clarity, should the Trust’s crisis line consider that a service user has immediate thoughts 
to  self-harm  or  end  their  life,  alternative  signposting  information  and  safety  planning  is  
considered in addition to – or as an alternative to – making a referral to Café 71. Café 71 is 
not considered to be an alternative to the Trust’s crisis line, but rather an additional resource 
for providing support to service users. 

200946337.1 

 
 
 
 
 
 
 
 
 
 Café 71 staff also support people to identify and access appropriate services by referring or 
signposting, the aim is to improve an individual’s mental health and wellbeing, increase their 
independence and self-management of their mental health.  

The Café also works to reduce social isolation, build resilience within people and communities 
through networking and peer support. The staff at Café 71 provide advice and signpost people 
away from clinical services when not required and provide support and a focus on recovery 
for individuals to develop self-management approaches to support their mental well-being.  

If  a  person’s  mental  health  needs  and  risks  are  not  able  to  be  met  within  Café  71’s 
environment, Café 71 staff will link in with CWP First Response clinical service and a clinician 
will offer mental health support and an assessment for the individual. 

First Response service consists of the following crisis services: 
Crisis Triage & Response Service (includes Crisis Line) 
• 
Home Treatment Teams 
• 
Liaison Psychiatry 
• 
Street Triage  
• 

As previously stated, Café 71 is not a clinical service; it does offer telephone support but is 
not operated as a ‘crisis line’. Any telephone contact by Café 71 would provide an opportunity 
to give support to a service user but would most often result in inviting them to attend Café 71 
at the next available opportunity as a resource for further, ongoing support in relation to their 
self-defined crisis. It would not typically be for providing intensive support in response to an 
immediate crisis, for which the crisis line is the most appropriate resource. Should telephone 
contact be made by Café 71 to a service user who was presenting in immediate crisis, they 
should immediately be redirected and / or signposted to call the Trust’s crisis line, which is 
better  equipped  to  provide  immediate,  crisis  support  to  an  individual.  Should  Café  71  staff 
have any concerns about a service user’s immediate safety, the Trust would expect this to be 
fed back immediately to the Trust, with advice to be provided to the service user as to keeping 
themselves safe in the interim period. If necessary, emergency services should be called by 
Café 71 staff should there be an immediate risk to life.  

Miss Davies contacted the crisis line on 1 December 2021 at 13:05 and a referral was sent to 
Café 71, the reason for referral from crisis line to Café 71 was stated as below:  

“Evie has been on a section under the MHA in October this year. She has lost her job as a 
care  worker  due  to  a  conviction  and  is  after  some  support  in  getting  her  CV  updated  and 
looking for a new job. There is a number of court cases on going also due to her losing her 
kids”. 

Has been known to use drugs and alcohol and is pending an assault charge to an emergency 
worker” 

At  20:27  on  1 December  2021  Café  71  staff  emailed  the  crisis  line  as  the  referral  did  not 
contain a telephone number for Miss Davies.  A telephone number was sent from the crisis 
line via email to Café 71 at 08:35 on 2 December 2021. A reminder has been issued to all 
200946337.1 

 
 
 
 
 
 
 
 
 crisis  line  staff  that  all  referrals  between  services  need  to  contain  contact  information  and 
where  possible  a  warm  transfer  of  the  call  should  be  completed  where  the  call  is  directly 
transferred  with  patient consent.  A  warm  call  transfer  refers  to  the  caller  being  put  on  hold 
while  the  operative  connects  to  the  desired  extension  number  or  service  and  following  a 
discussion with the receiving service the caller is transferred.  

Following  receipt  of  Miss  Davies’  telephone  number,  Café  71  has  confirmed  their  staff 
attempted to initiate contact with Miss Davies on 3 December 2021, 4 December 2021 and 5 
December 2021. As no voicemail consent was provided alongside the referral, no voicemails 
were left on these failed attempts to contact.  

On the 5 December 2021 Café 71 staff emailed the Trust’s crisis line to inform staff it had not 
been able to make contact on three occasions and advised if Miss Davies made contact with 
the Trust, the Trust should recontact Café 71. This is the standard process for Café 71 where 
contact cannot be made.  

On 7 December 2021 the Operational Lead from the crisis line informed Café 71 staff that Miss 
Davies had sadly died on 2 December 2021.  

The Trust can confirm there was no contact between Café 71 and Miss Davies from the referral 
being sent and her death. 

Café 71 and how it collaborates with CWP Services 

CWP  offers  clinical  support  and  guidance  to  Café  71,  the  location  of  the  café  and  its 
geographical proximity to the crisis line has enabled close working relationships, shadowing 
opportunities and timely responses to any incidents or concerns the café raise. For context. 
the crisis line is in the same building as Café 71. 

A frequent attender meeting is held monthly, in collaboration with professionals and services 
internal  and  external  to  CWP,  including  Community  Mental  Health  Teams,  High  Intensity 
support staff, 3rd sector providers (including Café 71), Cheshire Police, Northwest Ambulance, 
Social Care, Crisis Line, Crisis Resolution Home Treatment Teams and Liaison Psychiatry. 
The  aim  of  the  meeting  is  to  identify  any  people  whose  contact  with  any  of  the  services 
mentioned above has increased due to their mental health issues with the purpose of offering 
a joined-up approach from all agencies to support the patient who maybe in crisis. 

“They will take an assessment of that person at face value based on how they are in 
the call, as they don’t have access to the information held by the mental health team.” 

Café  71  do  not  have  access  to  the  Trust’s  electronic  Patient  record  system  (SystmOne). 
However, the staff from Café 71 will contact crisis line staff to discuss any risk concerns, the 
teams work closely to ensure that the relevant information relating to a patient’s mental health 
is  available  to  Café  71  staff.  Café  71  staff  can  phone  the  crisis  line  to  request  further 
information, but more often the member of staff requiring the information will physically call 
into  the  office.  Contacts  between  services  are  undertaken  with  patient  knowledge  and 
consent. The Trust would seek consent from the individual to refer them to Café 71. 

Staff at the crisis line have access to the individual’s mental health records but will assess the 
person’s needs during the phone conversation based on the information they are providing. 
Not all callers to the crisis line are known to mental health services, so the call is based on the 
information  discussed  during  the  mental  health  triage  assessment,  with  medical  records 

200946337.1 

 
 
 
 
 
 
 
 
 providing additional contextual information, if available. If a referral to Café 71 is deemed an 
appropriate  action  following  the  triage  assessment,  information  pertaining  to  the  person’s 
presentation, the reason for calling the crisis line, the rationale for the referral to Café 71 and 
any known risks will be provided, within Café 71 referral form that is emailed to the service. 

The following learning has been undertaken by both the Trust and Café 71 to streamline how 
key information regarding individuals involved with mental health services can be shared with 
Café 71 

Café  71  have  confirmed  they  have  updated  their  referral  forms,  the  forms  now  include  a 
prompt for the referrer to ask for consent on whether Café 71 staff can leave a voicemail and 
include  information  from  the  point  of  referral  as  to  what  support  the  individual  requires, 
information  relation  to  their  mental  health  and  any  risks,  the  referral  will  also  include 
information regarding other service and agencies the individual has been signposted to and 
what support has been put in place following the individual’s contact with the crisis line. 

To provide assurances that this is embedded into practice, the Trust has included a review of 
referrals sent to Café 71 in an internal audit plan. This is being led by the Governance Lead 
for  First  Response, Ms Dreelan.  The  findings  of  the  audit  will  be  reported  within  the  Acute 
Care and First Response Business and Governance meetings, for ongoing assurance. The 
audit will be completed 6 monthly. Where the findings of the audit do not meet the expected 
standard, remedial action will be taken to rectify this. 

“There does not appear to be any notification to the mental health team to say that the 
person has been in contact such that this can be followed up.” 

If  an  individual  is  known  to  Community  Mental  Health  Team,  Café  71  will  link  in  with  the 
individuals’  key  workers,  this  is  via  email  or  phone  contact.  This  is  set  out  in  the  current 
Community Mental Health Team Standard Operating Procedure. Café 71 staff are also invited 
to  attend  professionals’  meetings  to  provide  feedback  on  the  progress  of  the  individual 
attending Café 71, including the level of engagement with the cafe, when an individual had 
completed their programme and offer recommendations for future support if appropriate.   

Café  71  are  also  included  during  discharge  meetings  from  in-patient  mental  health  wards 
when attending the café as part of an individual’s recovery, if indicated.  

As  already  stated,  Café  71  also  notify  the  Trust  if  they  have  failed  to  make  contact  with  a 
service user on three occasions, following a referral having been made. This enables the Trust 
to monitor the progress of the referral and any additional support that the service user may – 
or may not – be accessing. 

CWP  acknowledge  that  there  is  open  communication  between  Café  71  and  mental  health 
teams  within  the  Trust  and  will  reach  out  to  teams  for  guidance  and  support  whenever 
required, as mentioned previously there are formal meetings but the crisis line is accessible 
during operating hours of Café 71 to provide clinical guidance and support, communication is 
often face to face with crisis line staff, but information can also be provided via email.   

“It  is  likely  that  there  is  notification  to  the  GP  but  in  this  case,  there  was  no  detail 
provided  which  could  have  been  passed  on,  and  the  timescales  for  review  of 
correspondence  by  the  GP,  who  again  are  operating  somewhat  in  isolation  to  the 
mental health team.” 

200946337.1 

 
 
 
 
 
 
 
 
 When an individual has contacted crisis line or has been referred into First Response services, 
the GP is informed of the contact, this is often via letter and as such there is an associated 
time delay. In relation to Miss Davies, I am aware that a report was submitted to the inquest 
by Dr Simants from The Elms Medical Practice, stating that Miss Davies had called the crisis 
line and was directed to Café 71 for support. This information has likely been obtained from 
Miss Davies’ medical records; for clarity, whilst GPs can refer into Café 71, in Miss Davies’ 
case the referral had been completed by the Trust, with the GP notified of this subsequently, 
and likely after Miss Davies’ death.  

GPs can be contacted directly if concerns are raised during the crisis line triage assessment 
and from other services within the Trust, if it is appropriate to do so. Often, as the crisis line is 
a more intensive, immediate resource than an individual contacting their GP; it is sufficient to 
update the GP for their information following contacts. 

GPs, along with other professionals, are also able to contact the crisis line directly and request 
mental  health  crisis  support  for  individuals  they  are  concerned  about.  To  repeat;  in  Miss 
Davies’ case, the referral to Café 71 was made by the Trust’s crisis line, not by her GP.  
Café 71 can also link in with an individual’s GP, this is often via letter. 

We hope that the clarification provided within this correspondence around Café 71’s function, 
as  well  as  its  ongoing  liaison  with  the  Trust  provides  a  satisfactory  response  following  the 
concerns highlighted in your Regulation 28 report. Further, that changes made by Café 71 to 
their referral form will also serve to improve and streamline mental health care for our patients.  

Should you require any further information, please do not hesitate to contact me. 

Yours sincerely,  

Director of Operations/Deputy Chief Executive 

200946337.1

Dear  

FAO: Victoria Davies, Area Coroner 

We are writing to raise our concerns regarding the recent Regulation 28: Report to Prevent 
Future Deaths. 
We have already submitted a response via email to 
coverage has now led to us urgently needing to make contact again and we would politely 
request a response regarding the following points: 

 but the recent press 

Firstly, we would like to understand the reasons why no one at Spider Project Cafe 71 was 
contacted prior to the Inquest or to the Regulation 28 report being written. 

Secondly, we would like to raise the following questions regarding point 4 and point 5 of the 
report: 

In point 4 it says that EJD called the Crisis Line and was directed to Cafe 71. We want to 
make it clear that EJD did not ever call Cafe 71, the only call that we are aware of was to the 
NHS Crisis Line. 
The notes in this section appear ambiguous and unfortunately the press have interpreted 
this as Cafe 71 receiving a call from EJD which is wholly incorrect. 
The report then goes on to say that there were no notes of this call and that the pro forma is 
blank. Again, this is the call to the Crisis Line and not to Cafe 71 but it could be misconstrued 
as being Cafe 71 and unfortunately the press have reported it as such. We reiterate that EJD 
never at any point contacted us. 
Cafe 71 did receive an email referral on Dec 1st from the Crisis Line regarding contacting EJD 
but no telephone number was provided. Cafe 71 then responded to the Crisis Line on the 
same day (Dec 1st) and then received EJD’s contact information the following day, December 
2nd.  In addition to this, as provided on our recent response to Christopher Birchall, the 
information provided in the referral notes we received from the NHS Crisis Line gave no 
indication of immediate risk and indeed the main crux of the referral stated EJD was seeking 
support with her CV.  

In point 5, Cafe 71 is referred to as a crisis line whereas in fact it is a non-clinical safe cafe 
space for people in self-defined crisis in addition to there being a telephone number to call.  
It is not for lesser crisis but for those in self-defined crisis without a clinical need. 
Also in point 5, there is a sentence regarding a lack of notification to the mental health team 
about EJD being in contact, but again, this would be the Crisis Line who would notify the 
mental health team as it was them who received the phone call.  

Our sympathies of course lie with all the family and friends of EJD and we think it is 
important that they know the truth.  We do feel that we need to raise the above points and 
would appreciate a response.  

Yours sincerely 

 
 
 
 
 
 
 
 
 
 
 Additional formal response to Regulation 28 re – EJD.  
We request that this is published alongside our initial response.  

We have already submitted a first response via email but we are now submitting this as an 
additional response and we are still within the 56 days given to respond to the Regulation 
28.  

Firstly, no-one at Spider Project Cafe 71 was contacted prior to the Inquest or to the 
Regulation 28 report being written and we would like this to be known.  

Secondly, we would like to respond to the following points:  

In point 4 of the report it says that EJD called the Crisis Line and was directed to Cafe 71. We 
want to make it clear that EJD did not ever call Cafe 71, the only call that we are aware of 
was to the NHS Crisis Line. 

The report then goes on to say that there were no notes of this call and that the pro forma is 
blank. Again, this is the call to the Crisis Line and not to Cafe 71. We reiterate that EJD did 
not ever contact Café 71. 

Cafe 71 did receive an email referral on Dec 1st from the Crisis Line regarding contacting EJD 
but no telephone number was provided. Cafe 71 then responded to the Crisis Line on the 
same day (Dec 1st) and then received EJD’s contact information the following day, December 
2nd. This was the day that EJD was sadly found deceased.  

In addition to this, the information provided in the referral notes we received from the NHS 
Crisis Line gave no indication of immediate risk and indeed the main crux of the referral 
stated EJD was seeking support with her CV.  

In point 5, Cafe 71 is referred to as a crisis line whereas in fact it is a non-clinical safe cafe 
space for people in self-defined crisis in addition to there being a telephone number to call.  
It is not for lesser crisis but for those in self-defined crisis without a clinical need. 

Also in point 5, there is a sentence regarding a lack of notification to the mental health team 
about EJD being in contact, but again, this would be the Crisis Line who would notify the 
mental health team as it was them who received the phone call.  

Our sympathies of course lie with all the family and friends of EJD and we think it is 
important that they know the truth.

Spider Project Café 71 
                                                                                      71-77 St Anne Street,  
                                                                                     Chester   
                                                                                     CH1 3HT 

Dear V. Davies.  

I am writing in response to your recent Notification of Regulation 28 Report request 
regarding Evie Jane Davies.  

Spider Project Cafe71 is a non-clinical provision commissioned to respond to anyone 
18+ in self-defined crisis. The team will spend time with members, helping them to de-
escalate crisis situations and to identify underlying factors. They will support people to 
identify and access appropriate services by referring or signposting them to relevant 
services. 

Evie was referred to Café 71 by 
via referral form to our enquiries email.  

The referral reason was stated as below:  

 from the Crisis Line on 01/12/2021 at  

“Evie has been on a section under the MHA in October this year. She has lost 
her job as a care worker due to a conviction and is after some support in getting 
her CV updated and looking for a new job. There is a number of court cases on 
going also due to her losing her kids”. 

“Has been known to use drugs and alcohol and is pending an assault charge to 
an emergency worker” 

Café 71 staff member 
referral did not contain a telephone number for Evie.  

 emailed the Crisis Line on 01/12/2021 as the 

A telephone number for Evie was sent via email on 02/12/2021.  

Staff  attempted  to  initiate  contact,  following  the  referral  on  03/12/2021,  04/12/2021 
and 05/12/2021. As no voicemail consent was provided, no voicemails were left on 
these failed attempts to contact.  

Café 71 staff 
 emailed the Crisis Line on 05/12/2021 outlining that we 
had  not  been  able  to  initiate  contact  on  three  occasions  and  advised  if  Evie  make 
contact with themselves again to contact us.  

07/12/2021  Operational  Lead  of  Crisis  Line  at  the  time, 
 that Evie has sadly been found passed.  

,  notified  Café  71  staff 

 
 
 
 
 
 
                                                                                         
 
                                                                          
                
 
 
 
 
 
 
 
 
 
 
 
 
 
 Our pathways and procedures involve attempting to initiate contact on three occasions 
for any individual being referred to Café 71 from any professional. If no contact can be 
made, we will always make an attempt to feed this back to the referrer.   

Action taken:  

-  Referral forms for Café 71 are now more detailed, asking for consent to 
be obtained by the referrer whether staff can leave a voicemail from the 
point  of  referral.  We  also  ask  the  referrer  about  what  referrals/support 
have been put in place following their contact with the individual they are 
referring. 

- 

Kind regards,  

Crisis Service Manager