Dear Coroner

Re: Andrew Gibbins Deceased – Regulation 28 (Prevention of Future Deaths)

Thank you for your letter regarding the investigation into the death of Mr Andrew Gibbins.

I have asked our Head of Patient Safety, Head of Deteriorating Patient and Head of Mental Health to address the matters of concern that you have over the actions in the joint action plan with the Norfolk and Suffolk Foundation Trust - the response is as follows;

Recommendation Two - Cohesive working between both Trusts with particular regards to joint working and inter Trust protocols;

The Trusts have commenced monthly meetings between the head of mental health and the lead nurse for NSFT’s West Suffolk Care Group to ensure cohesive working/trouble shooting and good communication. These meetings are minuted for action planning, service improvement and assurance purposes.

The handover process has been reviewed and when a patient is transferred from NSFT to WSFT for a physical health intervention the SBAR documentation will be handed over to WSFT staff. This information will be incorporated into the WSFT risk assessment. This will be incorporated into the acute hospital mental health policy by 31 May 2021.

Recommendation Three – Acute hospital to review the missing person’s policy;

The acute hospital missing person’s policy has been reviewed in January 2021 and deemed fit for purpose - attached.

Jacqueline Devonish H M Coroner Coroners Service Beacon House White House Road Ipswich Suffolk IP1 5PB

Chief Executive’s Office West Suffolk NHS Foundation Trust Hardwick Lane Bury St Edmunds Suffolk IP33 2QZ

Recommendation Four – Acute hospital and ambulance Trusts to review communication processes.

We have reviewed our communication process with the Ambulance Trust who have informed us that they did pass the information to us (as would be normal process for them), but on this occasion it appears there was some miscommunication. It has been reinforced with the staff involved the importance of ensuring all information has been received and documented correctly.

I hope that the above information and evidence provides you with a level of assurance in making your final decision and thank you for your consideration in this sad inquest.

Dear Ms Devonish, The inquest of Andrew Gibbins Following the inquest of Mr Andrew Gibbins on 1st December 2020 you issued a Prevention of Future Deaths Regulation 28 Notice to NSFT and the West Suffolk Hospital. We were surprised to receive this due to confirmation at the inquest that no such notice would be issued to any of the parties involved however; we understand that on reflection you felt communication needed to be improved between the two hospitals. To this end would like to reassure you that we have taken your concern seriously and have in place regular interface meeting with the West Suffolk Hospital to date we have held five such meetings. These previously were informal however we have moved these to a formal footing with agreed actions and minutes for governance purposes_ This meeting is attended by senior staff who are authorised to make decisions: and implement improvements, actions are tracked, and communication pathways have been strengthen as a result hope this provides you with the information you need to assure you that communication has improved between the two providers_