Dear David Regan,

Thank you for your letter and the accompanying Regulation 28 report following the investigation into the death of Isobel Lilian Stapleton. My immediate thoughts are with Ms Stapleton’s family and friends.

I am committed to ensuring that our services continue to learn from incidents like this, with the view to delivering safe and person-centred services, in line with the Health and Social Care (Quality and Engagement) (Wales) Act 2020 and our Health and Quality Care Standards.

In relation to the first three matters of concern in your report, I wish to highlight that a business case is being developed by Digital Health and Care Wales for the introduction and deployment of mental health systems across health boards in NHS Wales. Once a timetable for deployment has been agreed, this will be communicated. However, it is anticipated that this will be a phased approach over a number of years. This will align work to improve digital and data service provision in mental health. It will be based on the principle of parity with physical health and will deliver on key areas including electronic records, data sharing, use of digital across services, and improved mental health data. Officials are working with Cwm Taf Morgannwg University Health Board to accelerate the implementation of electronic patient records for mental health, ahead of the all-Wales system.

We have also provided dedicated support in the NHS Wales Executive to support health boards to improve the quality and safety of mental health services. This includes through a Strategic Mental Health Programme and a Mental Health Patient Safety Programme. A key focus of this work will be to improve discharge arrangements and to drive improvements in the quality of care and treatment planning. I am committed to ensuring a person-centred

approach to improve services – this includes with families and unpaid carers who play a crucial role in supporting people who are living with poor mental health. Care and treatment planning also enables us to capture this effectively, allowing us to be truly person-centred and to provide a focus on being “recovery-focused”. This approach, and our broader cross- Government work that we are taking, is out in our draft Mental Health and Well-being Strategy, which we consulted on recently.

Alongside this, the draft Suicide and Self-harm Prevention Strategy includes commitments to deliver rapid and impactful prevention, intervention, and support to those in society who are the most vulnerable to suicide and self-harm through the settings with which they are most engaged. This includes those in contact with mental health services. It also includes an objective to increase skills, awareness, knowledge and understanding of suicide and self-harm amongst the public, professionals and agencies who may come into contact with those at risk of suicide and self-harm.

In relation to matters of concern 4 and 5, I have written to Cwm Taf Morgannwg University Health Board to seek assurances in relation to in-patient access to clinical psychology, and support and treatment in the community.

I hope this provides you with the required assurances that we have carefully considered your report – and that I will continue to focus on delivering improvements to mental health services, and the approach we take to suicide prevention.

Dear Mr Regan

Regulation 28 Report to Prevent Future Deaths

I am writing in response to the Regulation 28 Report issued to Cwm Taf Morgannwg University Health Board (CTMUHB) on 28th June 2024 following the conclusion of the inquest into the death of Isobel Lilian Stapleton, whilst under the care of the Merthyr and Cynon (M+C) Crisis Resolution Home Treatment Team (CRHTT).

The Health Board values the opportunity to learn from the tragic events relating to Isobel’s death. The Regulation 28 report identified 5 key areas of concern listed below:

Cyfeiriad Dychwelyd/ Return Address: Bwrdd Iechyd Prifysgol Cwm Taf Morgannwg Pencadlys Parc Navigation, Abercynon CF45 4SN

Cwm Taf Morgannwg University Health Board Headquarters Navigation Park Abercynon CF45 4SN

Ffôn/Tel:

(1) Mental health practitioners are not easily able to access all of a patient's relevant clinical records pending the introduction of a "Once for Wales" solution, for which there is currently no timetable for implementation.

(2) Mental health practitioners may not be aware of the existence of all such records, some of which may be in paper.

(3) Mental health practitioners in Wales currently have no way easily to access NHS England clinical records.

(4) The inpatient hospital team at the Royal Glamorgan Hospital did and does not have access to a clinical psychologist to provide direct assessment and treatment of a patient.

(5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. The waiting list for any necessary psychotherapy is months in length.

This response is limited to the actions taken by CTMUHB in relation to the Coronial concerns, each of which will be responded to individually in order to provide assurance on the improvement actions implemented.

1. Mental health practitioners are not easily able to access all of a patient's relevant clinical records pending the introduction of a "Once for Wales" solution, for which there is currently no timetable for implementation

Firstly, I would like to provide assurance that the Health Board acknowledges the need to digitalise health records in order to improve patient safety, data accessibility, and clinical decision making at point of contact with the people who use our mental health services.

I can report that the Health Board had approved prioritisation of the implementation of the national Care Director solution under the Welsh Community Care Information System (WCCIS) programme. As a result, throughout Spring and Summer 2023 the Health Board commenced a series of workshops and planning exercises, supported by local authority colleagues and the national team within Digital Health Care Wales (DHCW). However, during this time, significant operational issues with the Care Director system identified by an early implementing neighbouring Health Board raised questions about future implementation. In addition, we noted that Care Director as a national solution will be withdrawn in January 2026, so all organisations are reviewing

their position on the best way forward and preferred solution and operating model.

The Health Board has continued to work with the National programme for Connecting Care, with an aim to deliver a fully integrated Mental Health solution as a priority. A Business Case was due to be submitted at the end of July 2024 for an alternative national solution but at the time of writing this response it has not been received by Welsh Government.

As a contingency measure we are also working with colleagues in another Health Board to accelerate the procurement and implementation of a Mental Health solution should the Connecting Care business case not be approved in the near future. CTMUHB are working on a business case for this which will include timescales and deployments plans, it is expected that we will be ready to procure in the Autumn of 2024.

2.Mental health practitioners may not be aware of the existence of all such records, some of which may be in paper.

Within the Health Board the multiple systems of documentation in mental health services has been highlighted as a high risk and as such is on the organisational risk register which is reported to Board.

As a mitigation for the multiple record system that are still in place across the Mental Health and Learning Disability (MHLD) Care Group the Health Board developed a Clinical Information Access and Recording Matrix (CIARM) in August 2023 for clinical team/staff access for all systems across the MHLD Care Group. This informs all clinical staff of how to access patient clinical risk and discharge planning information both in and out of hours and is the primary tool by which the MHLD Care Group mitigates the potential risks inherent with our present multiple systems.

The CIARM covers all clinical areas and teams and is accessible through the Health Board SharePoint (CTMUHB intranet) system for ease of access from every CTM desktop. A simple Standard Operational Procedure accompanies the matrix. Local copies have been copied, laminated and distributed to all inpatient units and unscheduled mental health assessment teams and strict version control is maintained by the MHLD Digital Transformation Project Lead with any updates shared with all staff.

With CIARM now in place practitioners report that patient information is shared more effectively between staff across multiple sites (in and outside of normal working hours) which allows more time to be spent on patient care, and that clinical staff now have the right information and the right time to inform Multidisciplinary decision making. The MHLD Care Group has finalised a range of routine audits of documentation, information sharing and communication

standards that have been digitalised through development of the Health Board Audit Management and Tracking (AMaT) platform.

4. The inpatient hospital team at the Royal Glamorgan Hospital did and does not have access to a clinical psychologist to provide direct assessment and treatment of a patient.

The acute mental health psychological team has been at full establishment since June 2024. This consists of a total 4.3 whole time equivalent staff (WTE) across CTMUHB acute adult mental health services:

 8c Consultant Clinical Psychologist 0.8wte: strategic and operational responsibility for psychological professions pan acute service  8b Practitioner Psychologist 0.8wte: Ward 14; Psychiatric Intensive Care Unit (PICU); Bridgend CRHTT  Band 7 Art psychotherapist 0.6wte ward 14 and PICU  Band 7 Psychological Practitioner: 1.0wte CRHTT Rhondda Taf Ely (RTE)  Band 6 Trainee Clinical Associate Applied Psychologist (CAAP) 0.6wte  Band 6 Psychological Practitioner: 0.5wte CRHTT M+C

There is no designated clinical psychology provision for the Royal Glamorgan Hospital Mental health Unit (RGH MHU). In an attempt to mitigate this, the following has been put in place:  Sessions are provided into RGH MHU from the 8c Consultant Psychologist and the RTE band 7 Psychological Practitioner.  Skills development/ emotional regulation and psychoeducation work is provided by undergraduate students on nine-month clinical placements from the University of Bath. This work is closely supervised by the Consultant Clinical Psychologist.  The trainee CAAP provides assessment, formulation and CBT-based interventions for individual patients on the ward. However, the Trainee CAAP has only recently started their training placement (January, 2024) so the level of complexity of input they are able to provide is therefore limited at this point.  As part of the broader improvement work to the inpatient service, workforce development is aimed at upskilling ward staff to be able to offer psychologically informed low-level interventions.

5. The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. The waiting list for any necessary psychotherapy is months in length

Since June 2024, there is a dedicated psychological professional available for direct assessment and treatment into all three of the CRHTTs. There is no

waiting list in these services, and the Psychologists and Psychological Therapists work closely with the team as soon as a need for input is identified. There has been significant investment of resource to address the backlog of people waiting for psychological therapies in both Primary and Secondary mental health services. This has reduced the number of people waiting over 52 weeks from 221 in May 2023 to 109 in May 2024.

In addition, people on the waiting list for psychological therapies in Local Primary Mental Health Support Services receive a contact phone call after two weeks and 6 months of waiting. The service uses CORE-10, a standardised assessment of common presentations of psychological distress to monitor and escalate any significant changes in clinical presentation or risk, at both of these contact points.

I hope that this response provides explanation and assurance that CTMUHB are committed to fully address the concerns in the Regulation 28 Report relating to Isobel Lilian Stapleton’s death.

Please do not hesitate to contact , Medical Director if you would like further assurances or if you require a meeting to discuss any arising areas