Dear Madam, Response of Adferiad Recovery Ltd to the Regulation 28 Report to Prevent Future Deaths Inquest touching on the death of Emily Anne Corfield We write with reference to your Regulation 28 Report to Prevent Future Deaths ("the Regulation 28 Report") dated 14 July 2023 concerning the inquest touching on the death of Ms Emily Anne Corfield. On behalf of Adferiad Recovery Ltd ("Adferiad"), may J express our deepest condolences to Ms Corfield's family and friends. May we assure you and the family that the matters set out herein have been carefully and thoroughly considered by Adferiad's senior management team which, we trust, reflects our commitment to place the health and wellbeing of our patients at the heart of everything we do. Adferiad is a charity and we are funded through various projects by Betsi Cadwallader University Health Board ("the Health Board") and the Welsh Government. We are a therapeutic support service and the service in question provides non clinical help and support for people with mental health, substance use, addiction and other complex needs. We are not a crisis service. Our Counselling and Motivation for Addiction Service provides free therapy for those requiring specialist substance misuse psychological M..ltJ Adftr~1d R~co"cry yn Adfor,Jd Pe-:o· ..cry 1s ).(cf:,dliad corlfott-diy f.!lu~nno• o ch,mt,:,bl~ inccrpor'l)t?'Q ac ,•,edy ccfre,i ru yng or43.,n1-;uttcn ,~ 1-.tcrcd •r, Nt3hymru n Llocgr E.l"lglar,ct :-., d W.1lcs

interventions including: counselling; cognitive behaviour therapy; and access to recovery groups. Our therapists are qualified counsellors with additional training in substance misuse and recovery. Individuals can be referred to us by other health and care providers/professionals and/or they can self- refer. We set out below our Response to the Matters of Concern insofar as they relate to Adferiad. For ease of reference, the relevant Matters of Concern appear below in blue type and Adferiad's Response is in black type.
1. Matter of Concern 1: Firstly, evidence was heard during the Inquest that Emily had self-referred on a number of occasions for support to Adferiad (formerly Cais). It could not be established whether or not Emily had received written correspondence from them relating to appointments and/or offer of support as correspondence was not retained by Adferiad. Emily was on occasion closed to the service for not having responded to correspondence. The system at the time was that communicating with service users was in writing only. It appears that more recently, policies and procedures have been established to ensure that correspondence relating to those who require support and I or contact the service is now retained though these were not provided at the Inquest. Without clear and thorough policies and procedures relating to all contact with service users or those who seek support, the organisation will not be able to adequately monitor the support processes.
2. Response to Matter of Concern 1: Following a referral to Adferiad, a patient will be placed on our waiting list for an assessment. Thereafter, at the material time:
2. 1 Ourpractice was to send hard copy letters to our patients to confirm:
2. 1. 1 They had been placing on the service's waiting list for an appointment; or
2.1.2 They remained on the service's waiting list but an appointment was not as yet available (letter sent 6 weeks post referral). This letter would M.1~ Adfor.tiU Ra-covery yn Adfod,td RtC:::).\l~.:ry ,,s ,-cfyd i:,,d c:orfforcd ig ~lu~onnot .J ~h.JritJb!,:, incc•,::::o,,..t.,.U .sc wcdy coft(l'!.tftJ yng c rg:.mis,1t1on re;wstcrc-:1 fr, Nghymru J Uoegr EJ"lgla,.d and

also ask the patient to confirm within 10 days ifthey wished to remain on the service's waiting list; or
2.1.3 The time and date oftheir appointment.
2.2 A hard copy ofthese letters was not retained on the patient's file, but the date on which they were posted to the patient was recorded electronically on the relevant electronic patient file. At the inquest, Adferiad's gave evidence that a new, better system and procedure is now in place, whereby all correspondence is kept electronically on a database, and all calls are logged. The system is the Adferiad Information Management System andis accompaniedbythe Aims User Guide. All staff have received training on this new system and are aware of Adferiad's requirements. Accordingly, Adferiad's current practice is that: every letter sent to a patient is scanned and stored electronically on our IT system; and every call made to/received from a patient is recorded electronically. In addition, concerning the monitoring ofsupport, the new system, amongst other things, allows a "red flag" to be displayed for those patients who are considered to be a risk to themselves or others, has the option to add viewable risk management plans, records signposting that has taken place and has an internal referral system to refer patients directly to another service. Further, if a patient leaves the service, staff need to input the exit date, reason and other relevant information. Adferiad is updating its service specification to incorporate these requirements. The updated service specification will be implemented and rolled out to all staff by the end ofSeptember 2023. Adferiad had understood from correspondence received from the Coroner's Office on 23 March 2023 that no further documentation was required, and Adferiad was not an Interested Person. Nevertheless, Adferiad understands that matter can arise during the course ofthe inquest, and it is regrettable that the documentary evidence was not before the court. Adferiad is committed to extending full co-operation to coronial investigations and inquests.
3. Matter ofConcern 2: Secondly, it was indicated that due to resource restrictions that communication cannot be by telephone with those requiring support I service users (in writing only) and the waiting time for M.10- Adfcr.:,1d Uf-<;.ov..:ry ~n A.dforiJd ~;JCO\IN~ 1~ scfydlind ,o:crfforcdig. clu~..,:nnc! J c.h:,rh.:,bl(- inc:orpor,>U•d ,1c ·.r.-cd',I cofrc~tru. 't"Y ')f9'Jnis..itu:.,n r'C9 1•~ter'Cd •f\ Nghymn,.1., LI n 1 Eng!anr:i ;Jnd h

support sessions I counselling is long. This will have a detrimental impact and deaths may occur if the treatment and support is not afforded in a timely manner.
4. Response to Matter of Concern 2: At the material time, our administrators were responsible for sending out the abovementioned letters to patients. They did not, however, make routine calls to patients as this would require a different skill set given that in our experience, when patients are spoken to on the telephone, they often seek therapeutic engagement. Our administrators are not therapists and using our therapists to make routine telephone calls would add pressure to the service in the context of current resources and consequently, add to service waiting times. Adferiad is, however, currently in the process of seeking a range of updated automated communication routes for the service (such as a text reminder service) and as we proceed with this initiative, we will, of course, continue to have regard to your concern. However, we are unable to guarantee that patients will act on appointments; and/or respond to our telephone calls, messages, visits, or other forms of communication. We acknowledge your concerns regarding our service's waiting times but , funding decisions concerning the service are matters for the Health Board and/or Welsh Government. We trust that this Response provides assurance that action is being taken by Adferiad to address the matters raised by HM Coroner.

Dear Ms Robertson,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Emily Corfield

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 16 July 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Emily Corfield.

I would like to begin by offering my deepest condolences to the family and friends of Ms Corfield for their loss, and to apologise to them for the failures that were identified during the inquest which led to your notice.

In the notice, you highlighted your concerns that Ms Corfield had not received input from the alcohol liaison service when an inpatient nor in the community and that you were not assured of the Health Board processes to ensure that referrals to the service are acted upon.

In response to the notice, I requested our Mental Health and Learning Disabilities Division (MHLD) consider your concerns and provide details of their plans to make our services as effective as possible, taking into account the learning from the inquest.

Firstly, I can confirm there is a Mental Health and Learning Disabilities Liaison Psychiatry Services in Acute Hospitals Delivery Framework (MHLD AC001) that is within date and available on the Intranet for all Health Board staff to access. This document outlines the services provided by Liaison from a multidisciplinary group of staff and includes alcohol liaison staff. The referral process to liaison services is detailed within the framework.

During consideration of your concerns, it was identified that the liaison service did not receive a referral from the treating team located in our Integrated Health Community (East). In response to this, a communication has been produced that outlines the referral process to liaison services that will be shared with clinical teams across the Health Board to ensure there is clarity and consistency across all areas. This communication has now been issued.

Dyddiad / Date: 12th September 2023 Kate Robertson Assistant Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN

Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG

Although in date and operational, the MHLD Liaison Psychiatry Services in Acute Hospitals Delivery Framework will be reviewed by a working group of stakeholders, to include liaison team managers and key clinicians, led by a senior manager to ensure the referral process is clear and unambiguous.

Once the review is complete, the revised framework will be subject to a period of consultation and will then proceed through the ratification process. Progress on the review and ratification process will be monitored by the Divisional Policy and Procedure Development Subgroup and any potential delays will be escalated to the Divisional Senior Leadership Team.

I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed.

We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful.

Once again, I offer my deepest condolences to the family and friends of Ms Corfield for their loss and I reiterate my sincere apologies to them for the concerns identified at the inquest.