Dear Ms Serrano, Re: Regulation 28 Report to Prevent Future Deaths – Rebecca Claire Pykett (25 February 2019) Thank you for your Regulation 28 Report dated 17 July 2021 concerning the death of Rebecca Claire Pykett on 25 February 2019. Firstly, I would like to express my deep condolences to Rebecca’s family. I note the recent inquest concluded Rebecca Pykett’s death was a result of

Following the inquest, you raised concerns in your Regulation 28 Report to NHS England regarding the allocation of a care coordinator to support Rebecca with her care.
1. During the course of the inquest evidence was heard in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co- Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive.
2. The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role. What was taking place was that a clinician was being chosen, in Rebecca Pyketts case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator.
3. An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pyketts’ case. National Medical Director & Interim Chief Executive, NHSI Skipton House 80 London Road London SE1 6LH 13th December 2021

4. It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co-ordinator. The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the care Co-Ordinator was being dealt with as a “box ticking” exercise, to satisfy the record keeping system.

5. Once allocated, in this way, it was clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator.

Care coordination is an important function needed to support people with complex mental health needs and the Community Mental Health Framework sets out a clear ambition for services to ensure all people requiring support, care and treatment in the community have a co-produced, personalised care plan in place which takes into account all of their needs. The level of planning and coordination of care will vary, depending on the complexity of their needs and for people with more complex problems, who may require interventions from multiple professionals, one person should have responsibility for coordinating care and treatment and this coordination role can be provided by workers from different professional backgrounds.

This is also described in the recently published Care Programme Approach – Position Statement which sets out how community mental health services should be working towards a minimum standard of high quality care for everyone in need of community mental health support, including ensuring everyone has a named key worker with a multi-disciplinary team approach to both assess and meet the needs of patients.

I note that the Trust was also sent a copy of the Regulation 28 Report and they have responded to the specific concerns about their Electronic Patient Record system and care coordinator allocation processes.

We are working with NHSX to support improvements in the use of digital systems, including Electronic Patient Records in mental health services. In 2020/21 £30million was invested to support the digitisation of mental health providers. A significant portion of this funding was to improve digital infrastructure and provide hardware for services to improve their digital and remote care offer.  In 2021/22 a further £50million is being allocated to improve digital capability mental health providers including improving Electronic Patient Records.

NHS England and NHS Improvement (NHSEI) recognise the considerable improvements needed to advance community mental health services to ensure everyone who needs high quality care and support can access it in a timely way.

The work described above is underpinned by commitments set out in the Long Term Plan to improve community mental health, so people receive the support that they need to help them stay well.

All local areas have received funding to develop and begin delivering new models of care that integrate primary care and community mental health services for adults with severe mental health problems. By the end of 2023/24, all areas will have one of

these models in place, with care provided to at least 370,000 adults per year nationally.

These models of care will give people greater choice and control over their care. They will also improve access to a range of interventions and support, including psychological therapies, physical health care, employment support, medicines management and support for self-harm and coexisting substance use, with care increasingly personalised and trauma-informed. The new models should also ensure appropriate links are made with other mental health services, for example inpatient and crisis services, to ensure patients have a seamless experience of care and that their needs can be met in the most appropriate setting.

We acknowledge the historic treatment gaps for people with severe mental health problems and are committed to addressing this through the work set out above, as well as through the Clinical Review of Access Standards. Accessing care in a timely way is an important factor in improving outcomes for patients and NHSEI is developing a 4 week waiting time standard for community mental health. A consultation on this standard has just closed and pending a review of the responses, NHSEI will provide a formal response and next steps.

While there is still work to be done to address the issues set out above, we hope the information provided offers some reassurance that we at NHSEI are committed to improving community mental health services.

Thank you for bringing this important patient safety issue to my attention.

Dear Mrs Serrano Regulation 28 Report – Prevent Future Deaths During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (1) During the course of the inquest evidence was hear in regard to the fact that each patient who is under the care of the CMHT should be allocated a Care Co-Ordinator. This Care Co-Ordinator will be responsible for co-ordinating the care that each CMHT patient will receive. (2) The allocation of the Care Co-Ordinator was of concern as there was no system to ensure that a Care Co-Ordinator was actually being allocated into this role. What was taking place was that a clinician was being chosen, in Rebecca Pykett’s case, her Consultant Psychiatrist who was no, in fact carrying out the role, and tasks expected as a care co-ordinator. (3) An example would be that the allocated Care Co-Ordinator should be allocated within 5 days, see their patient within 5 days, and complete a care plan. This did not happen in Rebecca Pykett’s case. (4) It appears that there was routine allocation of the allocated Consultant Psychiatrists as care co- ordinator. The reason behind this routine allocation was that Lorenzo (the patient record keeping system employed by the north Staffordshire Combined Healthcare NHS Foundation Trust), required this box to be filled in. Therefore the allocation of the care Co-Ordinator was being dealt with as a “box ticking” exercise, to satisfy the record keeping system. (5) Once allocated, in this way, it was clear from the evidence that was produced at inquest that no such role was carried out by the Care Co-Ordinator. Dr

Consultant Psychiatrist/Medical Director Trust Headquarters Lawton House Bellringer Road Trentham ST4 8HH

Trust responses to Matters of Concern Above

(1) The revised Trust Care Management Policy provides details on the role of the Care Co-ordinator being responsible for co-ordinating patient care. On receipt of this notice, we reviewed our practice to provide assurance that there were no gaps in Care Co-ordinator provision. I can confirm that procedures have been implemented since the incident to ensure that the Trust policy is adhered to. This is monitored and reviewed on a monthly basis at internal performance meetings.

(2) Since this incident, we have reviewed our processes and procedures and have clarified the expectations associated with the role of Care Co-ordinator through additional training. Weekly reports are reviewed by the Team Leaders to monitor the performance of all staff allocated as Care Co-ordinators. Individual staff members are provided with the information pertaining to their individual case load with the expectation that they will address any outstanding issues, the following week’s report provide assurance that this has been done.

(3) The revised Trust Care Management Policy provides expectation in terms of the timeframes required for allocation, assessment, care planning and review (see appendix 1). Training for all Care Co-ordinators has taken place to ensure that staff are aware of the full requirements of their role. Assurance that this process is followed is monitored through the weekly review of compliance reports, overseen by Team Leaders. This data is further reviewed at Service Manager and Associate Director Level with accountability being provided through Monthly Performance Review sessions with the Executive team.

(4) Care Co-ordinators are allocated according to the patients assessed clinical needs. For many patients, it is appropriate that a consultant psychiatrist fulfils the role of a Care Co-ordinator should the patient remain on standard care. This is recorded in the Electronic Patient Record (EPR) using the Care Programme Approach (CPA) determination tool or the individual’s core assessment. The allocated Care Co-ordinator may change should the individual needs of the patient change. Therefore, the Trust can confirm that this is not treated as a “box ticking” exercise. This process is aligned to the Trust Policy.

(5) The Trust recognises from this inquest process that the role of the Care Co-ordinator did not meet the standards expected. Since this was highlighted we have addressed these gaps, as previously stated the weekly reports provide feedback on key aspects of the care coordinators role. While there is still work to be done as set out in the action plan below (see appendix 2), I hope that the information provided above provides assurance that we at North Staffordshire Combined Healthcare NHS Trust are committed to improving practice and implementation of the Care Management Policy.

Please do not hesitate to contact me should you need any further information.