Dear Mr Rheinberg Inquest into the death of Lewis Charles FRANCIS Regulation 28 Report ­ Ref PCS/NR/VTVL File ref: 3935 This letter is in response to Regulation 28 Report dated 16 April 2020.
-It has been identified there is an issue with the pathways within Mental Health Services and not within in the Police Service. There are limited options using criminal justice powers and the Police are reliant on the NHS to divert from those. In line with Recommendation 6 (2) of the Coroner's Regulation 28 report, Wiltshire Police is working1with other force areas and the South West Provider Collaborative to develop the proposed Memorandum of Understanding.

Dear Mr Rheinberg,

I am responding on behalf of the Chief Constable of Avon & Somerset Police further to the Report to Prevention Future Deaths under paragraph 7, Schedule 5 Coroners and Justice Act 2009 and Regulation 28 Coroners (Investigations) Regulations 2013, issued by you on 16th April
2020.

Specifically in respect of the ‘Actions Should be Taken’, the Chief Constable can confirm:

Action 1: Evidence at the inquest suggested that steps were already being taken by the members of the South West Provider Collective to develop a Memorandum of Understanding between relevant organisations and agencies so as to provide for the transfer of mentally ill prisoners direct from police custody. Confirmation of the action be taken in this regard together with a time frame for implementation is required.

Response:

The actions taken to date include:

1. Review and communication within the Provider Collaborative:
• Communication has been undertaken setting out the process for out of hours admissions to all secure inpatient unit across the region. This has clarified that admissions can occur out of hours if an urgent admission is clinically indicated – 5 March 2020;
• A review of the national specifications and contracts with our Providers across the region has been undertaken, with confirmation made to Providers that services are commissioned to admit out of hours if there is a clinical indication of urgency.

2. Development and implementation of South West Provider Collaborative 24/7 Support to the secure inpatient service providers, enabling these services to progress admissions which are considered to be clinically appropriate. Consultation was undertaken through March 2020 and implementation commenced on the week commencing 13 April 2020.

3. Work has been undertaken for the mapping of key organisations, individuals, and relevant organisations and agencies to ensure the right people are involved in the final production of the Memorandum of Understanding. This work was undertaken between 22 April 2020 and 15 May
2020.

4. There has been engagement with those directly involved in the drafting of the Memorandum of Understanding (those considered ‘relevant organisations and agencies’):
• Key clinical leads within the Provider Collaborative co-opted as a clinical advisory group – 20 and 27 May 2020;
• Police (Inspector Avon and Somerset Police) – 19 May and planned on 11 June 2020;
• Her Majesty’s Court and Tribunal Service Legal Team Manager (Business) Devon, Cornwall & Dorset South West Region) – 19 May and planned on 11 June 2020;
• Crown Prosecution Service Senior District Crown Prosecutor, CPS South West) – 19 May and planned on 11 June 2020.

Agreement was reached that the above mentioned individuals will represent their organisation or agency across the South West footprint.

5. Further engagement has also occurred in relation to wider stakeholders as follows:

• Head of Mental Health Section at the Ministry of Justice on 1 May 2020;
• South West Division of the Care Quality Commission on 5 May 2020;
• NHSE/I South West Specialised Commissioning Project Director on 6 May 2020;
• Clinical Director for Secure Services, Birmingham and Solihull Mental Health NHS Foundation Trust (Mental Health trust enacting the Memorandum of Understanding taken in expert evidence) on 28 April and 15 May 2020;
• on 27 May 2020 (expert evidence to the Coroner’s Court).

Communication with both and has assisted considerably in enabling a first- hand understanding as to to the development, clinical application, and service impact of the Memorandum of Understanding.

Progress

We have met with our multi-agency partners, and agreed a high level set of principles (Appendix 1), which will guide our final Memorandum of Understanding

As a result of this meeting, the partners have developed a suitable process, which is currently in final draft within the South West Provider Collaborative. Similarly, our multi-agency partners have also drafted a proposal. We are meeting again on 11 June 2020 to review how these dovetail, to ensure that we can implement the recommendations and introduce a region-wide Memorandum of Understanding.

Next Steps

1. Agree, in the multi-agency forum, a final Memorandum of Understanding based on our agreed set of principles;
2. Final Memorandum of Understanding to be reviewed and approved by our respective organisations or agencies;
3. Agree an implementation plan to include communications within our organisations, agencies, and with key stakeholders.

Implementation Plan and timescales

1. Trialling the draft clinical process within Devon Partnership NHS Trust on 2 cases as a test of change (May 2020);
2. Final agreement of Memorandum of Understanding by the end of August 2020;
3. Relevant organisation/agency approval – by the end of October 2020;
4. Communication to other key stakeholders – by the end of November 2020.

It is acknowledged local areas will then develop operational procedures to support the practical implementation of the memorandum of understanding including provision of services run by local authorities and the adult MH services we work alongside in our organisations. On behalf of the South West Provider Collaborative we trust this provides you with the further assurance to the evidence provided to you during the inquest that you were seeking.

Action 2: Further evidence at the inquest suggested that an initiative was underway through the good officers at Avon and Somerset Police to cooperate with the South West Provider Collaborative in the development of the Memorandum of Understanding detailed above. Confirmation on behalf of the named police forces is required that they are willing to work towards the development of such a Memorandum of Understanding.

Response:

I can confirm that Inspector has been liaising with partner organisations within the South West Provider Collaborative on behalf of Avon & Somerset Police, and will continue to engage with the important work that is needed on the issues raised in your report.

Action 3: It appeared desirable that training with regards to the special needs and susceptibilities of those prisoners within the autistic spectrum be provided for prison officers, support staff and newly appointed prison officers undergoing training both in the form of face to face training and the provision of information through prison intranet systems.

Response:

We believe that this action is directed towards the Prison Service alone and therefore we understand that a response from the Chief Constable is not required on this particular issue.