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In his evidence to you_ said that an appointment with himself would have been appropriate for Mr Hyde: You were understandably very concerned about this, as was, and our shared concerns have been thoroughly addressed within the Trust To reduce the likelihood of a similar occurrence in the future, the following improvements to the service have taken place in order to ensure all triage decisions are appropriate and clinically led: meeting with the CCG Clinical Lead, Sussex Partnership Clinical Lead for Community Services and Sussex Partnership Managers was held to review the ATS data to ensure all actions relating to referral management are clinically led and appropriate: In addition, Service Manager for the Assessment & Treatment Service for Brighton & Hove has agreed to undertake a quarterly audit of the triage outcome decisions with an independent senior clinician, to ensure our triage decisions are appropriate: We continue to discuss and review our performance against performance indicators with commissioners on a monthly basis and maintain an updated action plan to ensure this remains a continual focus for quality improvement_ We are always striving to improve the interface between primary care and secondary mental health services In order to improve relationships between GPs and Consultant Psychiatrists, GPs have been allocated named Consultant Psychiatrists_ Meetings between the psychiatrists and GPs have been arranged. js leading on this to ensure both GPs and psychiatrists are clear on their roles and the expectations of referrals Work is on- going to ensure there is a joined-up approach for our service users and their families and there is continual learning and improvement_ Mr Hyde's experience has been shared (anonymously) with staff to drivve home the lessons to be learned. In addition,to ensure widespread learning, feedback from the case has been given to Director of Nursing Standards and Safety _ This has guaranteed the issues are Iigh proille and education and understanding is widespread Furthermore, in order to educate all staff, lessons learned from Mr Hyde's experience have been included (anonymously) in the Trust's Quarterly Quality & Patient Safety Report. As you highlighted,we will never know if the outcome would have been different if Mr Hyde had been seen by prior to his sad death, however, we can reassure you that systems have been reviewed and improved and staff have carefully reflected on what happened_ Thank you once again for raising your concerns_ hope the actions outlined in this response demonstrate how important these issues are to the Trust, and how seriously we have taken the matters highlighted at Mr Hyde's inquest: feel sure that future service users will benefit from the lessons we have all learned following Mr Hyde's death and hope Mr Hyde's family can take some comfort in knowing this_