Dear Dr Morris RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: JAMIE PASHLEY (DECEASED) We write further to the above Report dated 28 2017 and detail the Trust's formal response below_ We note that you have raised concerns about the level of reliance placed on those with alcohol dependence to proactively manage their rehabilitation in light of the Inquest touching the death of Jamie Pashley which concluded on November 2016_ We further note this Report has also been sent to South London and Maudsley NHS Foundation Trust as well as to the Secretary of State for Health, who are Iikely to be in a position to provide additional information from a wider viewpoint to address your concerns_ Concern Upon discharge after detoxification; should individuals, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to drop-In clinic, be provided with fixed appointment? Trust response: Alcohol dependency patients have notoriously high DNA rates. As a result; providing fixed follow-up appointments for this category of patients after detoxification a8 an in-patient and signposting would likely generate high level of wasted appointments_ This is why it is common practice within the NHS to instead use motivational models and to ensure patients a8 far a8 practicable are linked in with appropriate third-sector services prior to discharge rather than providing further hospital appointments_ In Mr Pashley's case, he had been making good progress with his alcohol- withdrawal therapy and at his review with the Substance Misuse Liaison Nurscono7 August 2015, she noted Mr Pashley had himself already made contact with the Community Psychological Services and was booked in for an assessment on 27 Ie' shvi /4 KING'S HEALTH PARTNERS An Academic Health Sciences Centre for London Pioneering better health for all Your ' College Dr May Qne very

August 2015. The Nurse also encouraged him to access support available at Lorraine Hewitt Housein the interim, prior to the IAPT assessment;, which Mr Pashley agreed to do. Post-discharge; Mr Pashley saw his GP on 14 August 2015 and had telephone contact with Lambeth Talking Therapies on 20 August 2015. The Trust recognises that providing a fixed repeat appointment may be beneficial for some alcohol dependency patients but it is unclear how effective this would be in ensuring patients access other specialist third-sector services subsequently- In Mr Pashley's case, he saw his GP in the interim period but this was sadly unable to change the outcome_ The Trust's view is that more assertive follow-up approach prior to discharge in addition to arranging an appointment with the patient's GP may be a more effective approach_ There is currently a trial underway in which King's College Hospital is taking part around this new approach, which we hope will be beneficial to such patients going forwards. Concern Should telephone contact also be made with an individual between discharge and first appointment review? Trust response: As is the case with the the provision of fixed appointments, the Trust recognises that making telephone contact in this interim period may be beneficial for some alcohol dependency patients. However, it is again unclear how effective this would be in ensuring patients access other specialist third-sector services subsequently. Additional funding would be required to expand the alcohol dependency service within the Trust; which would then allow for more contact with the patient: Concern Three Is there a need to increase the availability of an alcohol Iiaison nurse currently provided between the hours of 0900-1700 , Monday to Friday; at the hospital tor an individual to access, given they have met that person whilst an in-patient? Trust response: The Trust currently employs one Alcohol Liaison Nurse who deals with the alcohol dependency patients on wards. She performs checks on the quality of their detoxification, and links them in with Lifeline (an organisation involved with various abuses and addictions, which has since ceased operation and been replaced with CGL (Change, Grow, Live)): The Trust acknowledges that there is demand for an increased team s0 that patients can access staff that they worked with whilst an in-patient Various approaches have been made to local CCGs and charities without success to date, and s0 the Trust is considering a business case t0 increase the Alcohol Liaison team. The benefits to Iwe

the Trust would likely be the reduction of ED attendances and reduction of admissions in particular. The Trust is committed to continually improving its services s0 that patient safety remains the priority. On behalf of the Trust, we would like to express our deep condolences to Mr Pashley's family, and wish them well for the future Please do not hesitate to contact us should you require any clarification or further information_ Kind regards