,.,,:f1 Dorset Integrated care Board Vespasian House Barrack Road Dorchester Dorset DT11TG

04 August 2022 PRIVATE AND CONFIDENTIAL Mrs RC Griffin Senior Coroner The Coroner's Office for the County of Dorset Town Hall Bournemouth BH26DY

Mrs R C Griffin RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS I am writing to you In response to your letter to , Chair of NHS Dorset, regarding your investigation into the circumstances surrounding the tragic and untimely death of Gaia Kima Pope-Sutherland. We take our responsibility to act on the learning from serious incidents seriously and I offer you this response to outline where NHS Dorset can use its role to support and influence some of the changes you seek.
1. As per Paragraph 2 (i) of your report outlining your concerns, a review will be undertaken of the nursing resources in epilepsy care locally within the Dorset Epilepsy Service. The review will: a) Encompass the full epilepsy health provision in Dorset including primary and secondary care for adults and children b) Cover interaction with other specialities where pertinent to patient care and service improvements c) Specifically, address the following health care service concerns raised: Concern Description Recommendation I. Lack of resourcing in epilepsy care services Review of the nursing resources:
• In the Dorset Epilepsy service Across England and Wales
• ii, Lack of communication between neurology and psychiatric teams Review of communication processes between neurology and psychiatry 32

The Epilepsy Service review will not include other health care concerns raised. These will be covered by other teams/workstreams. The expectation is for the review to take around eight weeks. I would be happy to share the progress of this review with you if that would be helpful.
2. The Regulation 28 Report will be shared and reviewed with NHS partners at the Pan Dorset Mortality Group. This will facilitate an overview of the Improvements suggested for NHS providers to take, as the ICB holds commissioning responsibility for these services. I hope the information I have offered provides some assurance that the findings of your investigation and the areas you have highlighted for the prevention of future deaths has prompted action and remains the focus of our continued commitment to supporting the safety and wellbeing of everyone who uses NHS services. As you may be aware NHS Dorset Integrated Care Board, is a newly formed organisation, which came into being on 1st July 2022, taking over the responsibilities from NHS Dorset CCG. I was appointed as Chief Executive for this new organisation and would therefore be the primary contact for any future communications. If it would be helpful to have a conversation to outline the changes that are taking place in the NHS in Dorset, I would be very happy to do so.

Dear Ms Griffin Re Regulation 28 Report to Prevent Future Deaths - Ref: 167554 Thank you for your letter dated 21 July 2022 and the attached report relating to the very sad circumstances surrounding Gaia Pope-Sutherland's death. I and my colleagues in Adult Social Care Services have followed the case as it was heard and appreciate having the opportunity to respond to your points. Having reviewed your Report, I note that one of the keys issues relates to the sharing of information, and in particular the outcome of a Mental Health Act assessment. I have referred to concerns 2x and 2xi in particular to inform this response. The BCP Council Approved Mental Health Professionals (AMHP) Service uses the Mental Health Act 1983 (amended 2007) and the Code of Practice to inform practice standard, which are monitored through an AMHP Quality Assurance Framework. The Code of Practice is very clear about the need to record and share information after an assessment has been completed, regardless of the outcome, and the BCP Quality Assurance Framework makes specific reference to this code. Regardless of whether an admission is facilitated, AMHP are expected to comply with the following:
• If an admission has been facilitated, the AMHP's must produce an outline report detailing the outcome of the assessment and other key pieces of Information at the point the person is admitted. The report must be given to the person receiving the application for detention or to the receiving ward. bcpcouncll.gov.u k 'BCP Council' is the operational name for Bournemouth, Christchurch and Poole Council. 36

Chief Executive BCP Council Civic Centre Bourne Avenue Bournemouth BH2 SOY
• The AMHP must then complete their full (or final) report within 2 hours of completing their assessment (or by the end of their shift If they are an out of hours worker) and again distribute this to the receiving Ward (if relevant), the Mental Health Legislation office, General Practitioner, Care Co-ordinator, the Medics involved in the assessment and the AMHP Lead within 72 hours. There may be rare occasions when the standard of 72 hours for distributing the Report cannot be met, for example when the AMHP cannot detennine which GP surgery the person is registered with. In such circumstances, AMHPs have dedicated business support assistance to expedite the matter. We are actively engaging with Dorset Healthcare Trust to agree the necessary amendments to the Pan-Dorset Standard Operating Procedure. We are of the view that the Standard Operating Procedure standard for distributing information is too slow and we will continue to apply the requirement of 72 hours. We are also in the process of discussing with AMHP's how they could succinctly share information with GP's, and in particular highlighting that information which is of most Immediate relevant to them. It is worth noting that the reason we required AMHP's to send the AMHP Lead a copy of their final report is to carry out a Quality Assurance check which provides assurance that standards, including timescales, are being met. I hope that this letter gives you reassurance about our procedures and would invite you to let me know if you have any further concerns regarding our policies and practices.

Dear Madam, Re: Gaia Kima Pope-Sutherland Thank you for your letter of 21'1 July 2022 enclosing the Regulation 28 Report to Prevent Future Deaths following the conclusion of the Gala Pope-Sutherland inquest. You may recall that , Head of Litigation and Inquests, attended all the Trust evidence and was present for many additional days of the evidence that you heard. I welcome your letter seeking to ensure that future deaths are prevented and that any risks to patients around epilepsy care are minimised. I understand that your concern arises from the evidence of Specialist Epilepsy Nurse who indicated (point 1 (iii)) that there are 10,000 patients in Dorset with epilepsy who are overseen by twCJ specialist epilepsy nurses, and felt that there were ) insufficient resources to treat the patients. I have asked my Senior Management Team to analyse the epilepsy data, and they discussed the matter further with Dr and Specialist Nurse in order to understand the figures outlined to you during evidence. The data itself comes from the Dorset Epilepsy Dashboard. The Dashboard draws in information from GPs and relates to clinical coding, capturing information such as the types and groups of patients, including socio-economic background, pregnancy and patients suffering with learning disabilities. As at 19th August 2022 the Dashboard showed there were 10,749 patients with epilepsy in Dorset (9,916 adults). Of these patients it is estimated that 50-60% are seizure free, giving figures of 3,966
-4,958 adults with active epilepsy. The Dashboard is a live programme and figures will change daily. The information•it captures continues to be developed with the next iteration planned for Autumn 2022. Nurse has confirmed that in terms of these active patients, contact with them can be via telephone, emails or seeing them in the nurse led clinic. Frequency of contact from a patient however can be very variable, and is difficult to capture accurately in statistics. Nurse has explained that for some patients, they may call just when they have a crisis, whereas others may call weekly or even more frequently, which means the nature of the demand for the service is unpredictable. Nurse estimated that in terms of nurse led

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clinics, each nurse would see approximately 1,300 patients each year in clinic (i.e. a total of 2,600 for the service) in addition to telephone and email contacts. We hope this is helpful clarification. Turning to your specific Preventing Future Death concerns: 2 (i) Lack of resourcing of epilepsy services I am pleased to inform you that since the Gaia Pope-Sutherland inquest concluded the Trust has appointed a new full time Band 4 epilepsy co-ordinator to the team, who directly supports the two epilepsy specialist nurses. It is anticipated that the successful candidate will commence in post on 1st October 2022. The main duties of this role include:
1. To work without direct supervision with individual patients as delegated by the qualified Nurse to ensure that treatment plans have been implemented and to monitor the impact of medication changes including looking at seizure recording. To also help implement lifestyle changes which may impact on seizure control.
2. To work using a holistic approach to identify patient's goals for care and agree a personalised care and support plan.
3. Emailing - as appropriate - referrals to other teams and agencies e.g. Steps to wellbeing, social services, Community Learning Disability Team and Homestart.
4. Monitoring patient attendance at appointments and following up vulnerable patients who do not attend as appropriate. Work closely with the frequent attender team based in the emergency department and the ambulance service.
5. Following up patients who present to the emergency department with seizures and ensuring that a pathway is in place for future nurse or consultant appointments as appropriate and signposting to advice for patients waiting to be seen.
6. Reviewing and typing updated protocols, policies, patient information leaflets and other documents as required. )
7. Setting up a webpage for the service and monitoring it's use and update as required. 8 . Assisting in running patient wellbeing groups, and training as required under the direction of the Qualified Nurse.
9. Helping patients to access self-management education courses, peer support or other interventions that support them in managing their long term condition and improving their health and wellbeing. The Band 4 epilepsy co-ordinator will report directly to the two epilepsy nurses and Dr

In addition, the Trust is currently in the process of recruiting to the epilepsy team a part time 1 day a week Band 7 specialist nurse. This is a temporary post with funding for 12 months. The successful candidate has a long track record of dealing with Children & Young Persons who suffer from epilepsy which will be of great assistance to young people transitioning to adult epilepsy care. Whilst this individual is employed through our bank, we will be reviewing the impact, with the aim of developing a substantive model and funding, as part of the system working through the Integrated Care Board's review.

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. In relation to your request for consideration of a review of the nursing resources in epilepsy care locally in the Dorset Epilepsy Service, I can confirm that the Integrated Care Board (ICB) are carrying out an 8 week review which started on 11 August 2022. The review team, informed by the Getting It Right First Time (GIRFT) reports for neurology and epilepsy, are looking at the entire Epilepsy and Neurology service. This will be specifically considering:
• Local GIRFT review of Dorset Neurology Services in 2019
• National GIRFT Review of Neurology Services 2021
• Relevant NICE Guidance
• MHRA Drug Safety Updates
• Neurology Clinics
• Paediatric to Adult Services Transition
• Neurology and Mental Health
• Workforce resources We have shared our GIRFT reviews of 2019 and 2021 and are currently working collaboratively with the ICB to assist the review. Those involved in the review include the UHD Chief Medical Officer, senior members of the Neurology team and our Productivity and Efficiency lead. We are awaiting the timescales to be confirmed for the ICB to share the findings of the review. However, it is envisaged that the review will be followed up by a longer term joint working group to take forward the recommendations. 2(ii) Communication between neurology and psychiatric teams I am grateful for the clarification received on 26 July 2022 that the concern in relation to communication does not relate to the Trust at a local level and is directed at the position nationally and the national body for neurology services. I plan to update you on progress in approximately 12 months to allow time for the recommendations of the ICB to be considered and actions identified. I hope this is acceptable and in the meantime if you have any further queries please do not hesitate to contact

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Dear Madam Regulation 28: Prevention of Future Deaths Report Response Deceased: Gala Klma Pope-Suthertand I write following the Inquest that concluded on 15th July 2022 into the death of Gaia Kima Pope- Sutherland and the Regulation 28 report issued to Dorset Council. I would firstly like to offer my condolences to the family and friends of Gala Pope-Sutherland for their loss. The Regulation 28 report raised the following concern about the Standard Operating Procedure, following a Mental Health Act assessment: ­
• " ... in respect of feeding back of information to the GP by the AMHP which is detailed at paragraph 2.1 Oof the Standard Operating Procedure for the flow of Information following a Mental Health Act assessment, I would recommend that consideration is given by Dorset County Council (now known as Dorset Council), BCP Council and OHUFT to reducing the timeframes from 7 days to 72 hours. Although this is the decision for Dorset County Council and BCP Council, the document Is a DHUFT document and so will require their consideration too.' Operational and strategic leads from Dorset Council have been communicating regularly since 21 July 2022 with colleagues from BCP Council and DHUFT, now referred to as Dorset Health Care, about the procedure. In addition to this Dorset Council have prioritised and completed an internal review of its pathways and what is recorded by the AMHP's on the social care management recording system, Mosaic. This Included ensuring that we adhere to the Mental Health Act Code of Practice, in particular, 14.100 which states: ­ "Having decided whether or not to make an application for admission, AMHPs should inform the patient, giving their reasons. Subject to the normal considerations of patient confidentiality, AMHPs should also give their decision and the reasons for it to:
• the patient's nearest relative
• the doctors involved in the assessment
• the patient's care co-ordinator (if they have one), and
• the patient's GP, if they were not one of the doctors involved In the assessment. Dorset Council has considered the recommendation to reduce the timeframe from 7 days to 72 hours to forward the completed AMHP report to the assessed persons GP. From the 191 of August 2022 Dorset Council put in place a new Internal data reporting system. This system now enables the AMHP duty manager and business support, for the AMHP's, to monitor that the initial AMHP report Is completed and emailed to the GP within 72 hours. This also ensures that there is tracking of the full AMHP report, which is then sent by secure e-mail to the GP within 7 days of a person having had a Mental Health Act 34

assessment. The e-mail to the GP will also confirm that a Mental Health assessment has been undertaken, the outcome of the assessment and provide the contact details for the AMHP service, should further information be required by the GP. A monthly performance report of this activity is then shared with senior managers. The initial AMHP report provides the following information:
• Referral details, including events leading up to referral
• Information about the persons Nearest Relative.
• Risks identified to the person's health, their own safety and the safety of others, environmental risks i.e., property, pets
• The Mental Health Act Assessment, date and time, location, professionals involved and contact details, legal grounds for decision making, outcome and follow up actions required. The full AMHP report includes information about:
• Relevant background information i.e., previous psychiatric admissions, substance misuse, MHA assessments, criminal justice contact. forensic history etc.
• The AMHP's recording of the interview with the person
• Alternative options considered e.g., referral to the Home Treatment Team
• Views of those involved in the assessment
• Person's responses
• Issue encountered i.e., ambulance/ transport delay, Police delay, lack of S.12 doctors etc The AMHP service in Dorset Council has a different operating model to that of BCP Council AMHP service. Dorset Council has a twenty-four-hour service over seven days, and BCP Council have a separate daytime (9 - 5 p.m. Monday to Friday) and out of hours service. Dorset Council has shift patterns of twelve hours with varying start times i.e., Bam-Bpm, 9am-9pm, 11 am-11 pm and 8pm to 8am. There is an 8-week rota so the AMHP's do not always work on consecutive days, hence the reason why full reports are not completed within 72 hours. From our internal review the managers within the AMHP service, through ongoing supervision, will also ensure that the AMHP's, before undertaking a Mental Health Act assessment, review any records held on the Dorset Council recording system, Mosaic. There is also now a mandatory field on Mosaic to notify the allocated adult social care practitioner that a Mental Health Act assessment has been undertaken. There is a Continuing Professional Development record which all AMHPs must complete to evidence their registration and approval as an AMHP. The Council also now requires AMHPS to have internal mandatory training about the sharing of confidential information in relation to the Mental Health Act assessment. I hope that the steps outlined to enhance the sharing and scrutiny of the AMHP statutory functions will provide assurance to the Chief Coroner of Dorset Council's commitment to mitigate the risks of future deaths of Dorset residents. Designated operational and strategic leads will continue to work closely with BCP Council and Dorset Health Care in all future reviews of key standard operating procedures where a person has a Mental Health Act assessment.

Dear Madam, Re: Regulation 28: Prevention of Future Deaths - Miss Gaia Kima Pope-Sutherland Inquest I write further to your Prevention of Future Deaths report dated 2i81 July 2022, issued in response to evidence heard during the inquest into the death of Miss Gaia Kima Pope ­ Sutherland (Gaia). The incredibly sad and distressing events surrounding Gaia's disappearance and untimely and tragic death have been the subject of a Trust Root Cause Analysis (RCA) investigation and a number of changes in practice have already been implemented, of which I understand you are aware. We, as a Trust, are committed to taking forward the further learning identified during the course of the inquest. I appreciate you bringing the six additional specific issues of concern to our attention, and I hope that this response provides assurance as to the action we have initiated to address those issues. I am also grateful to the court for providing clarification that the following specific concern relates to national bodies, as opposed to Dorset Healthcare University NHS Foundation Trust ("the Trust"), and therefore I will not comment further on this as part of my response: Further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is consideration as to how to ensure effective lines of communication between the 2 disciplines. Please find below our response to the six concerns raised in respect of the Trust
1) As per paragraph 1(ix) above, the occurrence of sexual harassment or assault whilst an inpatient at one of DHUFT's inpatient um1s could have a detrimental effect on a person's mental health which could have fatal consequences. I request that consideration is given to a policy being put in place to provide guidance to staff as to how to deal with this situation. 21

I note that in her letter to you dated 11 th July 2022, , Service Director, outlined the following Trust action being taken in response to the evidence she gave during the course of the inquest. I reproduce the relevant paragraph of letter below:
1. To introduce a Trust procedure that deals with victims of sexual violence when they come onto wards, in terms of safeguarding them from future incidents I deterioration on the ward. In addition ta consider specific guidance for staff as to how to support a patient following a sexual incident. I can confirm that I have written to , Deputy Chief Nursing Officer, on 8th July 2022 to ask that he identify a member of the Sexual Safety working group to lead on drafting a procedure that deals with how to best support victims of previous sexual violence when they are admitted to an inpatient unit. The procedure will also cover what staff need to do upon a patient reporting a sexual assault or incident to them (both within an inpatient and a community setting). I have asked to ensure that the procedure is finalised, approved and disseminated by 31 st October 2022. I would therefore suggest that I update you on this matter by Friday 11th November 2022, if that is acceptable to you. In addition to the above, the Trust also already works to the Bournemouth, Christchurch and Poole and Dorset Multi-Agency Safeguarding Adults Procedures, which detail definitions of sexual abuse and exploitation and how to raise a concern. That procedure includes an appendix on the roles and responsibilities of other agencies and includes details on the responsibilities of employees and managers in respect of harm, neglect and exploitation. We welcome your recommendation to strengthen these procedures with supplementary guidance specific to sexual harassment, assault and abuse, and believe the above forementioned actions, which are underway, address this point.
2) As per paragraph 1(x) above, there is no specific policy in place wllhin DHUFT around contact with the family or dealing with the Think Family approach. A lack of contact with family members, who know the patient best, could lead to information gaps, which could lead to future deaths. I request that consideration is given to a policy being created around contact both to, and from, a patient's family. In response to this concern, we will establish a working group led by , Interim Deputy Chief Nursing Officer, to develop a policy on Working with Families and Carers. The policy will cover expectations in respect of communication and engagement with and from families and carers that a patient wishes to involve in their care. The policy will also explain clear1y what the Think Family safeguarding approach is and how staff can work within this approach when there are safeguarding concerns. The development of the policy will be a co- produced piece of work between professionals working in services and people with lived experience of using mental health services and of supporting someone living with a mental health condition. The working group will also include the Trust's Carers Development Lead, the Lead for Recovery and Social Inclusion, and a member of the Trust's Safeguarding team. The working group will ensure the development, ratification and circulation of the policy to staff by 31st January 2023.
3) As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further
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request consideration is given to training staff on how to record information, so it is flagged on the record. In response to this concern, the Trust will develop a guidance document on viewing, adding and removing alerts on RiO and upload this to the Trust intranet by 30th September 2022. The existing RiO e-leaming and classroom-based learning courses, which are a mandatory requirement for new staff who will be using RiO as part of their role, will also be updated to orientate staff to the existence of the guidance and to demonstrate how and when to use the alerts system on RiO. This will be updated by 31 81 October 2022. This training will also be available as a standalone a-learning module, which will be available to all existing RiO users in the Trust. The a-learning module will be promoted to staff via email and via dissemination at the CMHT Team Leaders workshop. This will be available and disseminated by 31 at October
2022. This work will be led by our Clinical Systems Team and Patient Safety Team in partnership. Please note we have focused our action on the alerts system on RiO. As outlined in the evidence given to you by , there is also a separate function on RiO of flagging a progress note as a significant event so that it informs the risk assessment. We have not identified any further actions for this function, as this already forms part of our RiO training programme.
4) As perparagraph 1(xii) above, I would request that consideration is given to providing training to all staff on the access to Community Mental Health services which could also cover the processes regarding discharge planning from the care of the mental health teams. I and my team note your concerns that you considered there to be "some ambiguity and inconsistency during the evidence regarding the content of the Integrated Community Mental Health Teams (CMHT's) operational policy, and the understanding and application of it" The Trust team has considered carefully your recommendation that training be provided to all staff on access to Community Mental Health Services, including the process for discharge planning. It is our view that there is not a misunderstanding or ambiguity amongst staff with regards to accessing CMHT's or in respect of discharge from the service, but that clinical judgement is used by staff. It is our belief that the issues that arose during the evidence of Trust witnesses reflect a national problem that was described in the evidence provided by As you may know, CMHT's were commissioned some thirty years ago, to work with a population of people with what was previously clinically defined as userious Mental Illness". The service .was ) primarily set up, and resourced, as a specialist, secondary care mental health service for people with severe and enduring mental illnesses such as schizophrenia, bipolar, and treatment resistant severe depression. The threshold for the service was therefore set many years ago and was designed for people who had significant mental health needs. We fully recognise that in 2022, this model is not well placed to meet the wider mental health and wellbeing needs of our patient population. What is now needed is a mental health and wellbeing system that offers a range of support from varying organisations that can provide advice, guidance, information, signposting, education, support, care and treatment that meets a broader range of needs. Some of those needs fall into what we would recognise as a diagnosable mental illness, that will benefit from an evidenced based, clinical treatment, and many of those needs benefit from a non-medical or non-clinical model of support and care. Dorset is not alone in trying to transform its community mental health services. It is in this context that access to CMHT's has increasingly come under scrutiny, as our local population look for a service to meet the full range of needs that come under the broad umbrella of mental health. Not all of these services exist, and for those that do, they are currently not well coordinated as a system, but considerable effort is being made ta integrate and meet wider need.
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In respect of the care provided to Gala, the Trust remains of the view set out in the RCA report (and reiterated by Trust witnesses), that Gaia did not meet the eligibility criteria for CMHT care on the occasions she was discharged from CMHT care in December 2016 and March 2017, and also at the point she was assessed under the Mental Health Act ("MHA") in October 2017. That is not to diminish the difficulties Gaia faced, or her level of distress. We do not dispute that the failure to refer Gaia to Steps to Wellbeing ("STWB") for her Post Traumatic Stress Disorder in December 2016 was a missed opportunity. There were also missed opportunities in terms of the assessment and onward plan of care following the MHA assessment in October 2017, which are acknowledged by the Trust and formed part of the jury's conclusions. The Trust has taken action to address these issues as detailed in witness statement of 16 June 2022, and as set out in the evidence she gave to you, namely through: (i) the CMHT/STWB interface/screening meetings and updated SOP; and (ii} the updated SOP for Flow of Information following MHA Assessments For these reasons and the transformation work being carried out as described in this letter, the Trust does not consider that implementing an action to train Trust staff on the access to CMHT's would resolve the issues raised. It is our belief that the issues highlighted will be addressed through the transformation work ) that the Trust is closely engaged with, which was touched upon in the evidence of . The NHS Long Term Plan and the Commissioning Framework for Community Mental Health, sets out a new vision of mental health support provided by health, social care and voluntary, community and social enterprise (VCSE) organisations, beyond the model of CMHT care. In, Dorset, the multi-agency, coproduced project to deliver this vision is known as the Mental Health Integrated Community Care (MHICC) programme. The programme has reached the stage where it is co-designing a new operational model of care, to begin implementation in 2023 / 2024. One of the key areas the MHICC is working to address is providing better mental health support and care at a primary care level (beyond STWB, which offers psychological treatment for a specific range of conditions). The transformation programme is looking at how we can implement a new model of care, so that we can provide open access to mental health services at a primary care level to meet someone's needs, without eligibility criteria or thresholds. We have tested a virtual multi-disciplinary team in Poole between GP's, social care, STWB, the VCSE sector and CMHT's, and you may be pleased to note that we are working together to discuss the needs of patients and how best those are met in a coordinated way. We are also piloting a Peer Specialist (person with lived experience of mental health) working in a GP surgery in North Dorset, offering support to anyone who wishes to see a professional about mental health need, with support and supervision from the GP, STWB and CMHT. If successful, these are some of the ideas that may be rolled out across primary care, to meet patient mental health need. The Trust believes that the transformation programme will be the most effective approach to addressing the concerns raised in respect of CMHT care and the wider issues of access to mental health support, as opposed to implementing training on the existing CMHT model for staff. The Trust would be happy to keep you updated and provide information about the MHICC transformation programme if you would welcome that.
5) As per paragraph 1(xiii) above, when a Mental Health Act assessment is undertaken, there is a possibility that information may not be fed back to the GP in the best way or in a timely manner, if it is not fed back by those from the Mental Health team, and I therefore request that consideration is given to the DHUFT representatives forwarding information, directly to the GP, rather than through the discharging team at the acute hospital. This may include their RiO record notes, or their assessment notes. 24

This requirement has been considered by Deputy Chief Medical Officer. You heard during the course of the inquest (and as part of Dorset Council's evidence) that relevant information and a report following the assessment will be provided to the GP by the Approved Mental Health Professional (AMHP), who is part of and coordinates the assessing team. Dr has met with his clinical colleagues and it has been agreed that (in addition to this information provided by the AMHP): i) A RIO template will be designed to enable a section 12 Doctor to complete and set out key summary patient information following a MHA Assessment conducted in an acute hospital setting; ii) All doctors undertaking Section 12 work will be written to, to advise them of the template and provide them with guidance on how to use it. iii) The completed template will be sent to the patient's GP following a MHA assessment taking place in an acute hospital setting; and iv) A blank copy of the template, and details regarding the requirement for its use, will be added to the SOP for Flow of Information following a Mental Health Act Assessment. The Trust has agreed with your helpful recommendation and will formally amend the SOP to remove the paragraph previously inserted at section 3.2 during the course of the inquest, which outlined the following requirement:
3.2 In addition and specific to MHA assessments undertaken in an acute hospital setting (e.g. Poole Hospital, Royal Bournemouth Hospital, Dorset County Hospital), the Doctor(s) taking part in the MHA assessment must provide a written or electronic copy of the outcome of their assessment ta the acute hospital ward Doctor responsible for the person's care whilst in the acute hospital, so that this information can be reflected accurately in the acute hospital discharge summary. This will ensure a comprehensive discharge summary detailing the physical and mental health care and assessments a person received whilst in the acute hospital. This will be replaced with suitable wording to reflect the need to write to the GP directly using the new RiO template following a Mental Health Act assessment taking place in an acute hospital setting. This template will be developed and made live in the RiO system by 31 st January 2023, and the SOP updated by this date and issued to staff.
8) As perparagraph 1 (xiv) above, in respect ofthe feeding back of information to the GP by the AMHP which is detailed at paragraph 2. 10 ofthe Standard Operating Procedure for the flow of information following Mental Health Act assessments, I would request that consideration is given by Dorset County Council, BCP Council and DHUFT to reducing this timeframe from 7 days to 72 hours. Although this is a decision for Dorset County Council and BCP Council, the document is a DHUFT document and so will require their consideratt'on too. has written to Dorset Council and BCP Council on 27th August, 31 81 August and 9th September 2022 in respect of this matter. BCP have confirmed they are in agreement with the 72 hour timescale and tell us that they already work to this, and the Trust awaits Dorset Council's response. I can confirm that the Trust supports the recommendation to reduce the timeframe in question from 7 days to 72 hours and we will update the SOP accordingly, upon Dorset Council's agreement. I am grateful for your acknowledgement that this is a decision for the two councils in question, as opposed to the Trust. I hope that In respect of the concerns raised, the actions I have detailed above addresses those matters. I plan to provide a further written update to you regarding the progress of these 1111 25

action by 31 81 May 2023. Once again, I am again grateful for you bringing these Issues to my attention.

Dear Mrs Griffin Re: Regulation 28 Report to Prevent Future Deaths I write to provide a response on behalf of Dorset Police to the Regulation 28 Report, ("the Report") received on the 21 81 July 2022, followlng the conclusion of the Inquest touching the death of Gala Kima Pope-Sutherland. I have carefully considered the entirety of the Report and wish to reiterate that as an Organisation we continue to take seriously the need to reflect meaningfully on the evidence heard during Gala's inquest and are committed to ongoing service improvement that goes beyond the content of your Report. However, for the purpose of this response I will focus specially on the points at Section 5, paragraph 2(iii - v) of the Report and address them in tum below. Knowledge and training about life-threatening illnesses, such as epilepsy and mental health conditions This concern is directed to Chief Constable at the College of Policing. I wish to formally record my support for the learning from the inquest in relation to life-threatening illnesses to be shared with the College to inform National knowledge and understanding. I have personally written to CC Marsh to offer to support this work and to utilise the Organisation's teaming from Gala's inquest to inform and enhance any National training provision. I am aware that any updates to training and Information relating to medical issues would go through the College of Policing clinical governance group for appropriate oversight and to ensure guidance was implemented. I appreciate that this particular concern comes from the need for staff and officers, specifically including call handlers through to senior officers with oversight of an Investigation, to identify and appreciate the specific risk that a diagnosis of epilepsy and a dependency on medication can cause to an individual's welfare. To provide reassurance from a Dorset Police perspective the Organisation has delivered a series of training Inputs through bespoke Missing Persons Training and the Vulnerability continuous professional development programme since 2019. This training programme has targeted front line officers through to Commanders with a specific module focused on the 16

g 101 Non-emergency D Dorset Police DORSET II 999 in an emergency D @dorsetpollce IJ www.dorset.police.uk II dorset_pollce POLICE B 101@dorset.pollce.uk El DorsetPollceHQ Identification of vulnerability and heightened risk factors such as medical conditions. This programme remains a priority and provides a good foundation for the ongoing continued professional development and learning. Review of policies relating to concern for welfare reports, missing person reports and call handling, grading and deployment of resources The Missing Person Policy has been reviewed on two occasions since Gala's death in 2017. Firstly in 2018 and then more recently in 2021. This policy like other police guidance documents respond to updates following Or!~anisational and National learning through reviews, Inspections and inquiries that advance understanding and inform ongoing improvements to our policing response. The latest review of the missing person policy was In the process of being finalised during Gala's Inquest. I enclose a copy of the finalised policy, which is now adopted, and work Is ongoing to embed the changes in working practice. I highlight a few aspects of the updated policy that were relevant to the matters explored in the course of Gaia's inquest: a) A detailed flow chart for assessing the low, medium and high-risk categories has been re-Introduced, (p.36) this provides clear guidance on how to understand and afford a risk grading to a person who Is missing. b) The 'Absent' category Is no longer in use within Niche, (p.6); The Dorset Pollce policy clearly states that this category Is not to be used. c) Increased guidance for staff and officers on the use of PPNs, (para 3.9.2, p.27). The upgraded guidance focusses on the purpose of a PPN, requirements for staff and the importance of multi-agency engagement d) The existence and availability of specialist/additional resources is highlighted, (paragraphs 3.2.4 and 3.6 at p.19), to ensure that we utfllse officers and staff, both internally and externally to inform our investigations, with the ability to seek advice from experts. e) The roles and responsibilities of those involved in each stage of the handling of a missing person report Is clearly defined, (paragraphs 3.3-3.4, p.5-7). In addition, the Organisation commissioned a review with the independent charity Missing People UK which is now complete. This is enabling the Organisation to expand the work conducted so far and involves the implementation of a number of recommendations Including improvement areas such as: a} Continuing to ensure that missing people are an Organisation-wide priority. A plan will be overseen by senior leaders to implement and review progress within the Organisation and also from partner agencies such as Children's Services and education providers; b) Adopting a person-centred approach to service delivery, investigations and Incidents; c} Victim Service Assessments (VSA) are being conducted through Organisation Inspections in line with HMICFRS methodology 6 times a year, focusing on our Investigative approach and victim servlce; 17

D 101 Non-emergency 0 Dorset Police DORSET D 999 In an emergency D @dorsetpolice ID www.dorset.pollce.uk II dorset_pollce POLICE B 101@dor$et.police.uk l!I DorsetPollceHQ d) Continuing to embed and promote the Missing Person teams across the Organisation, to encourage awareness and understanding of how the teams work and to emphasise the Importance of an efficient frontline response to missing person reports; e) The missing person coordinator meeting daily with partners to discuss current missing persons and those missing from the previous 24 hours; f) Enhancing cross border information sharing, to better communicate and safeguard people travelling and reporting missing people in different police areas; g) Continuing to Improve the engagement and communication with families of missing people. The Dorset Police concern for welfare policy is designed, in consultation with partner agencies, to ensure that the public get the right service to meet their specific needs at the first point of contact. The current version is subject to a review led by the Prevention Department to capture the latest physical and mental ill health trends and guidance from key professionals. The initial draft of the policy is close to completion. The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes In March 2022. The Deployment Policy has been recently reviewed In llne with national guidance to ensure that each public contact Is risk assessed to inform the appropriate pollce response. The revised grading of Incidents Is now a key performance measure with regular reviews and evaluation to ensure compllance. As part of the Implementation process, we have now moved to the evaluation stage to understand how the changes In the pollcy have translated Into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report Is due this Autumn which wlll Inform ongoing developments. Training on each of these ooncies The next stage of the Vulnerablllty Programme is the 'Vulnerability 4' training package, scheduled for delivery between January and April 2023. The Vulnerability 4 training will include updates on the concern for welfare, missing people and the call handling, grading and deployment policies. It will be provided to police officers and staff, including control room call handlers, senior officers up to the rank of Chief Inspector and role-specific training to the ranks above Chief Inspector. In the meantime, the updated version of the missing person policy has been disseminated locally through Commanders and Inspectors, who are cascading the learning to frontllne officers and ensuring the policy has been read and understood. Force Contact Centre training on the new missing person policy begins from the 19th September on the current 10 week cycle for all staff. Every training cycle will Include refresher training on missing people and concern for welfare matters for the foreseeable future. The content of Vulnerability 4 will also be bullt into initial training for Police Officers, Call Handlers and PCSO's to ensure ongoing development of new staff into the Organisation. Furthermore, in 2023, there will be a similar opportunity to raise awareness further In relation to epilepsy, psychosis, medical conditions, medication and the effect of such on and individual and subsequent risks. The Organlstlon will work with the clinical lead to ensure such are covered in the First Aid Training which is rolled out to operational officers and staff. 18

II 101 Non-emergency D Dorset Police DORSET 1,1 999 In an emergency D @dorsetpollce D www.dorset.pollce.uk DI dorset_pollce POLICE 151 101@dorset.pollce.uk El DorsetPoliceHQ Contact Management staff have received vulnerability training since 2019 specifically tailored to meet call handling and dispatch requirements including enhanced risk assessments (Threat, Harm, Risk, Investigative opportunities, Vulnerability and Engagement), identifying the 'voice of the child' within incidents, and knowledge of support agencies for signposting. They also have continual professional development training as part of their shift pattern with additional opportunities through power hours to ensure refreshed guidance is cascaded. The Contact Management Quality Assurance team conduct live time dip sampling of calls and Incidents providing Immediate feedback ensuring a continual learning culture. The Make the Difference Team, a small team of officers who are commissioned wl1h scrutiny and review activity on behalf of the Organisation, regularly review and scrutinise a selection of our missing person investigations and have had bespoke 'masterclass' sessions with child protection specialists from HMICFRS. This has allowed the Organisation to Improve our standards and understand how to maintain good practice in these types of Investigation whilst also reflecting HMICFRS methodology in their review of investigations. Review of record keeping and training on record keepfng The Organisation has carefully considered a proportionate and targeted response to the concerns raised through Gaia's inquest In relation to record keeping, The Organisation holds millions of records and works across multiple systems and processes Organisation-wide, regionally and working with partner agencies. These processes are carefully mapped and overseen by business owners, with some areas inspected by HMICFRS and the Information Commissioner in relation to crime data integrity, record keeping and data protection. The Organisation has focused improvements on the key systems and processes that gave rise to a concern during Gala's inquest and the upgrade of the Niche system and developing IT solutions has also provided opportunities to design out risks of retrospective entries and updates to logs and documents. The Organisation has sought to reinforce standards and promote the Individual responsibility of staff, officers and volunteers to maintain clear and accurate records as part of their business and service delivery. Organisation-wide messaging on the Importance of accurate and transparent record keeping and the Integration of records management Inputs Into existing training will deliver the learning identified through the inquest and Preventing Future Deaths report. This will reinforce people's understanding and individual responsibility to keep accurate records. This approach is deemed a necessary and proportionate response to the recommendation, a wholesale review of record keeping across the entirety of systems In Dorset has not taken place. The Organisation's record management system, 'Niche' was upgraded In August 2022. The Niche training has been utilised to reinforce the expectations and Importance record management and data quality. POLSA and LPSM trained staff have been directed to use Niche to log their decisions and key Information. Niche can be accessed remotely via mobile technology and once an entry is made it cannot be amended retrospectively. If Information changes or details are recorded In error an additional chronological entry can be made highlighting any amendments and this can be cross referenced to the original entry. Once created, logs are also locked and cannot be amended. As previously noted Vulnerability 4 training will Include a session on log keeping and recording. The Organisation has reviewed Its approach to the management of training activity as several areas of Improvement were Identified in relation to the process, governance and systems. As a result, revised processes remain In place, to monitor the Identification of training need, the effectiveness of roll out, evaluation of training and officer and staff attendance. Rates of 19

D 101 Non-emergency D Dorset Police DORSET D 999 In an emergency D @dorsetpolice IJ www.dorset.poUce.uk II dorset_pollce POLICE B 101@dorset.pollce.uk II DorsetPollceHQ training completion and escalatlon procedures are in place with strategic oversight and recorded decision making through the Joint Workforce Supply Group. At the submission of the Organisation's response to the Preventing Future Deaths Report I propose to send out a further Organisation-wide message to all staff and officers providing a reminder along with guidance about the Importance of accurate and transparent record keeping. Whilst progress has been made on a number of the matters discussed above, I appreciate that there Is further work to be done. On behalf of Dorset Police I provide an assurance that improvement work continues as a priority to ensure the Organisation continues to keep people safe. This commitment will continue far beyond the conclusion of these Inquest proceedings.

Dear Ms Griffin, Re; Consideration of epilepsy and mental health illness training for all staff and officers in police forces and update to the new recruit curriculum. Firstly, on behalf of everyone at the College of Policing I wish to convey our deepest sympathy to Ms. Pope-Sutherland's family and friends for their loss and the tragedy of the circumstances of her death. I'd also like to thank you for your work to ensure learning results from this tragic incident. We recognise that policing must have some medical knowledge and this is provided through our first aid programme. This programme and medical knowledge makes explicit links to our vulnerability training. To ensure police responders are equipped to effectively respond to missing persons, our training focuses on managing the full spectrum of vulnerabilities through effective and proportionate risk management. In reality, this means that College standards require front line responders to ask good questions that enable an informed understanding of the range of risks affecting a missing person, on a case by case basis, to identify their severity and impact. Additionally, police responders should seek information from informed sources, such as family or doctor, to understand the impact and degree of any medical conditions potentially effecting a missing person. When this training is combined with the guidance we set as Authorised Professional Practice the standard is proportionate and appropriate. Additionally, the College is committed to providing the highest standards of training for those working in policing however, that training also must be accessible and practicable. Medical conditions can be very complex, those conditions in themselves can be variable and they do not exist in isolation. Different conditions have differing levels of severity that interact with the myriad of circumstances in which people go missing. The quantity of variables is simply too great to reasonably and effectively train.
• The number of medical conditions, the varying degrees of those medical conditions and and the complexity of the circumstances in which people go missing persons, are too great to be trained to non-medical personnel. ' I ' '.
t., I \ I ,· 38

We have recently considered this question in relation to other conditions, such as neuro diversity, and further concluded that seeking to give a higher level of expertise is unfortunately not practical. Policing deals with an almost limitless variety of incidents, some situations or medical issues may only being encountered by officers very rarely - their training would be almost irrelevant because of the time that had lapsed between the training and the time the knowledge was needed to deal with the incident.
• Additionally, such training would have to be subject to continuous professional development to ensure advancements are shared which would also be unrealistic. I do appreciate this is not the response you were hoping for but after very careful consideration we have concluded that that our current approach is correct for policing. We believe that by encouraging better investigation of vulnerability and identification of the risks of harm that may arise, policing can better respond and deal more effectively with the needs of the public.

Dear Ms Griffin, Thank you for your letter of 21 July 2022 to the Secretary of State for Health and Social Care, about the death of Gaia Pope-Sutherland. I am replying as Minister with responsibility for Mental Health and thank you for the additional time allowed. Firstly, I would like to say how deeply saddened I was to read of the circumstances of Ms Pope-Sutherland's death. I can appreciate how distressing her death must be for her parents and those who knew and loved her and I offer my heartfelt condolences. It Is vital that we take the learnings from what happened in this case in order to prevent future deaths. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, Departmental officials have made enquiries with Health Education England (HEE), NHS England (NHSE), as well as the relevant regulator, which in this instance is the Care Quality Commission. The Government is committed to supporting people with epilepsy and ensuring they receive the support that they need from statutory services and that that they are referred to specialist services as appropriate. Once diagnosed, and with a management strategy in place, most people with epilepsy can be cared for through routine access to primary and secondary care services commissioned locally by Integrated Care Boards (ICBs). Those whose epilepsy cannot be satisfactorily controlled, or whose condition cannot be appropriately diagnosed, should be referred to specialised neurological services, commissioned nationally by NHSE. NHSE has published1 adult and paediatric specifications setting out what providers must have in place to offer specialised care for patients with neurological problems, including epilepsy. You may wish to know that in order to support systems to understand the priorities In epilepsy care and improve service quality, NHSE have developed the RightCare Epilepsy Toolkit2. This toolkit, which was developed in partnership with stakeholders such as Epilepsy Action, provides expert practical advice and recommendations on several key areas. These include ensuring that all people living with epilepsy know how and where to 1 httos:/twww,eoa1and.nhs.uk/speciallsed-comm1ss;onlna-dooument-11brarv/seNice-specificat10ns/ 2 httos://WVMl.england.nhs.uk/riahtcare/toolklts/eplleosv-toolkit/ 9

access mental health and wellbeing support, and having policies in place to identify those most at risk of avoidable premature mortality and prevent epilepsy related deaths. The Toolkit makes clear the importance of ensuring that right systems are put in place to support the appropriate referrals for all patients3• You may also flnd it useful to know that there is a guidance available from the National Institute of Health and Care Excellence (NICE) regarding "Epilepsies in children, young people and adults'4, which sets out best practice in the diagnosis, treatment, care and support for people with all types of epilepsies. The NICE guidance sets out that all children, young people and adults should be referred urgently (for an appointment within 2 weeks) for an assessment after a first suspected seizure. The guidelines further describe the best practice that should be taken fully into account in the care and treatment of individual patients, however, this is not mandatory and therefore does not override the medical practitioner's clinical judgement. Moreover, the Government is taking action at a national level to improve services for those with neurological conditions, including epilepsy. NHSE has established the Neurosciences ) Service Transformation Programme, a multi-year, clinically led programme within NHSE, to develop a new model of integrated care for neurology services, including the care of people affected by epilepsy. The development of the optimal clinical pathway for epilepsy has been overseen by the Transformation Programme in conjunction with the National Neurosciences Advisory Group (NNAG) - a collaboration of professional bodies, patient groups, national and local policy and commissioning leads, that aim to improve treatment, care and support for people with neurological conditions. This work has been led by epilepsy specialists including representatives from the Association of British Neurologists. The pathway sets out what good treatment, care and support looks like. In addition, NNAG have developed a series of best practice optimal pathways for neurosurgery and neurology. These pathways are being used by NHSE's Neuroscience Transformation Programme to support neurosurgery networks with transformation and implementing high impact changes. This work is building on the optimal pathways that have been developed in partnership with stakeholders to support Integrated Care Systems and their neurology services to deliver the right service, at the right time for all neurology patients. With regard to your concerns related to the availability of training on access to community mental health services, including discharge planning - you may wish to note that NHSE provides funding and resources for continuous professional development for community mental health practice, together with supporting good care in all settings. HEE, working in partnership, also provides a range of quality training and resources for health care professionals, at all stages of their career, this Is intended to support good practice. The training and resources provided by HEE align with policy direction and legislative frameworks, together with national clinical guidance such as that published by NICE (Transition between Inpatient mental health settings and community or care home settings5), which acknowledges as its starting point. With regard to Ms Pope-Sutherland's discharge from hospital, my officials have informed me that the Trust has introduced a Standard Operating Procedure in May 2022, which covers the provision of information following Mental Health Act assessments. In addition, the 3 More information about the toolkit can be found here: https://www.england.ohs,uk/rightcare/wp- content/uploads/sites/40/2020/03/rightcare-epllepsy-toolkit-v2.pdf 4 https://www.nice.org .uk/guldance/ng217 6 https://www.nlce.orq.uk/gujdance/ng53 10

Mental Health Act 1983: Code of Practice6 covers communicating information following an assessment by the Approved Medial Health Professional (AMHP). Section 14.100 related to the commutating of the outcome of the patient's assessment specifically states that: "Having decided whether or not to make an application for admission, AMHPs should inform the patient, giving their reasons". The Code of Practice provides statutory guidance to registered medical practitioners, approved clinicians, managers and staff of providers, and approved mental health professionals on how they should carry out functions under the Mental Health Act in practice. It is statutory guidance for registered medical practitioners and other professionals in relation to the medical treatment of patients suffering from mental disorder. Finally, the Department takes the matters raised in this report seriously and will continue to engage with NHSE and local provider in order to improve the treatment of mental health patients. I hope this response is helpful. Thank you for bringing these concerns to my attention. ) Kinds regards, MARIA CAULFIELD MP ) 8hUos://assets.publlshina,servlce.aov.uk/qovernment1uotoads/system1ucloads/attachment datalfite/43 5512/MHA Coda of Practice.PDF 11

Dear Ms Griffin, Re: Caia Kima Pope-Sutherland (Regulation 28: Report to Prevent Future Deaths). On behalf of the Royal College of Psychiatrists, I am most grateful for the opportunity to comment upon this report in the context of the aspects you raised in your Regulation 28 Report regarding care for epilepsy. I would like to extend my deepest sympathies to Gaia Kima Pope-Sutherland's family. The Royal College of Psychiatrists {RCPsych) is the professional medical body responsible for supporting psychiatrists. The College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. The College does not work on the care of individuals and I am not able to comment on the specific circumstances surrounding the case of the death of Gaia Kima Pope-Sutherland. However, I have considered your findings, and have the following comments to make in relation the concerns that you raise. The College very much recognise the issues you raise in relation to the lack of effective and consistent communication between services for people with neurological conditions and mental illness. The particular brisk for this patient group that we believe needs to be addressed through resources, training, increased workforce is that Neurologists and neuroscience services commonly do not have the expertise or resource to manage the neuropsychiatric aspects of neurological disease and community mental health teams will consider that they do not have the expertise to manage people with organic mental illness or neurological comorbidity A recent paper that outlined the neuropsychiatric problems associated with epilepsy including the increased rate of suicide in people with epilepsy. It also showed a high incidence and prevalence of mood and anxiety disorders, psychosis and suicide in this group. Whilst neuropsychiatry services can provide assessment, treatment and rehabilitation for the most complex people with neurological and mental illness, there has been no resolution of the longstanding workforce issues for neuropsychiatry despite the hope that a GMC credential could allow for 12

neurologists and psychiatrists to develop expertise in this area. There is currently no funding for such a credential. Whilst neuropsychiatry services can provide assessment, treatment and rehabilitation for the most complex people with neurological and mental illness, there has been no resolution of the longstanding workforce issues for neuropsychiatry despite the hope that a GMC credential could allow for neurologists and psychiatrists to develop expertise in this area. There is no currently no funding for such a credential. As a College, we have been starting through our Neuropsychiatry Faculty to work on building the relationships in order to start a dialogue about the inequality of access to appropriate health services for people with neurological conditions. There are some solutions to the poor integration and communication between services that we have been supporting as a Faculty. The NHSE National Neurosciences Advisory Group will be publishing the Optimum Pathways for Neurological Conditions imminently (https://www.nnaq.orq.uk/optimum-clinical- pathways). These include exemplar pathways for epilepsy and also a Mental Health Crosscutting Theme that highlights where the interface between neuroscience and mental health services needs to be considered, what good looks like and some of the evidence for treatment and rehabilitation. It is hoped that these publications will provide support to commissioning of integrated services in neuroscience centres in ICSs. There is an opportunity as ICSs develop for primary and secondary mental health services to consider how they integrate with community neurorehabilitation and neurology provision so that there is joined up provision when this is required. Please do not hesitate to contact me if I can be of any assistance.

Dear

Ra: Regulation 28 Report to Prevent Future Deaths I am responding on behalf of the Association of British Neurologists (ABN) following your letter of 21 st July 2022 regarding the Coroner's report following the Inquest around the death of Gaia Kima Pope-Sutherland. The ABN is a professional organisation with the overarching aim to improve the health and well-being of people with neurological disorders by advancing the knowledge and practice of neurology in the British Isles. There were two specific concerns regarding the tragic circumstances of the death of Gaia Klma Pope-Sutherland listed: 2i: "there could be future deaths locally and across the country due to the lack of resourcing of epilepsy services. I request consideration is given to a review of nursing services in epilepsy care locally -in Dorset Epilepsy Service, and generally across England , and Wales." Neurology and epilepsy services across the country are stretched, and these workforce issues are no different from other medical specialist services across the UK. This includes neurologist and specialist nursing roles. For the latter the assessment of numbers is more complex as some are employed by acute medical NHS trusts and others by community NHS Trusts, but it is likely there are regional differences. The ABN does not have access to the numbers of epilepsy nurses but the ABN Epilepsy Advisory Group may be able to comment on numbers and the level of resourcing. To this end I have asked the Epilepsy AG for comment on this and how the system could work with more resource. 2ii: "further I am concerned that there could be future deaths as a result of the lack of communication between neurology and psychiatric teams and request that there is

consideration as to how to ensure effective lines of communication between the 2 disciplines." I would agree with Prof who gave evidence at the inquest regarding lack of communication between community psychiatric and neurology teams. He highlighted the role that GPs had previously played as "communication hubs" to have an overview of the specialists involved, but that they do not now have the time or resources to fulfil this role. The use of different IT systems between Primary care, NHS Hospital and Mental Health Trusts also does not help this situation. We have suggested the following actions that could be helpful:
- Ensuring all communication from psychiatry is copied to the treating neurologist (clinic letters and discharge summaries) and vice versa. The neurologist treating the epilepsy is informed if a patient is admitted to acutely to psychiatry. This will help inform care as some of the treatments used in psychiatry may have an impact on the seizures. Hospital neurologists include a line in their clinic letters to GP with a statement along these lines of "I would be grateful if you could forward copies of letters and discharge summaries from any psychiatric appointment, admission or other epilepsy-related admissions". I will also bring communicate these views with Prof President of the Royal College of Psychiatrists, to discuss how to improve these lines of communication. Any new outcomes from the actions above will be communicated to you. Please send any communication regarding this directly to myself rather than via my NHS secretary to avoid any unnecessary delay. My email is 11!!!!!111! 1!111111••• Please also copy to the ABN using the contact details on page 1.

Dear Madam, Re: Inquest touching upon the death of Miss Gaia Pope-Sutherland I write further to my letter dated 11th July 2022 to provide you with an update on the following action, which I committed to updating you on by 11 th November 2022. As you will recall, this area formed part of the agreed actions to be taken following my evidence during the inquest, and this action also forms part of Dorset HealthCare's formal Regulation 28 Preventing Future Deaths notice response dated 14 September
2022. A full update on the wider Regulation 28 notice response from the Trust will be provided as previously noted by , Acting Chief Executive Officer, by 31 81 May 2023. '- ) Please find my update on this matter below:
1. To introduce a Trust procedure that deals with victims of sexual violence when they come onto wards, in terms of safeguarding them from future incidents I deterioration on the ward. In addition to consider specific guidance for staff as to how to support a patient following a sexual incident. As outlined previously, I wrote to Mr Deputy Chief Nursing Officer, on 8th July 2022 to ask that he identify a member of the Sexual Safety working group to lead on drafting a procedure that deals with how to best support victims of previous sexual violence when they are admitted to an inpatient unit. The procedure was also required to cover what staff need to do upon a patient reporting a sexual assault or incident to them (both within an inpatient and a community setting). I asked to ensure that the procedure was finalised, approved and disseminated by 31st October 2022.
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has asked me to confirm to you that he is satisfied that he has met this action. The Trust's Safeguarding policy has been updated to highlight the response needed when an adult discloses they have experienced sexual abuse. This may be in a hospital or community setting. In addition, two appendix documents have been added to the policy setting out further details which I enclose for your reference.

has advised me that the 'guidance for staff in relation to historical sexual abuse fits in with the 'Making Safeguarding Persona/I agenda. It's important to determine what an individual wants to do, while encouraging them and supporting them to report it. £very situation is different so care for patients who disclose historical abuse will be planned on a case by case basis'. As per my previous letter, this is my final update on actions pertaining to my evidence. Should you have any queries in respect of this update, would be happy to assist you with these. I can confirm that I am happy for this letter to be shared with the family and other Interested Persons involved in the case should you wish to do so.