Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Mr Samuel Thomas Howes who died on 02 September 2020

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 April 2023 concerning the death of Mr Samuel Thomas Howes on 02 September 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Samuel’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Samuel’s care have been listened to and reflected upon.

This response focuses on the national NHS policy and programmes relevant to the matters of concern you have identified in your Report. Most of the matters of concern raised in your Report are in respect of the provision of local support and the actions taken in providing that support to Mr. Howes and his family. These local concerns would need to be addressed by the relevant local commissioners and providers.

Your Report however does raise a matter of concern that is relevant to national policy and service delivery, which we would like the opportunity to address:

1) Samuel’s case should be a stimulus for some level of Child and Adolescent Mental Health Service reflection of how different Child and Adolescent Mental Health Services (CAMHS) are organised and work together.

Improving mental health support for children and young people is a priority for NHS England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access will increase, with 345,000 more children aged 0-25 accessing support in 2023/24 compared to 2019. We have made significant progress towards this commitment with a record of 720,817 children and young people receiving support from the NHS in the 12 months to February 2023. This has been achieved through investment in the children and young people’s mental health workforce, which has increased by 46% since the start of the LTP, and by 70% since 2016. However, the prevalence of mental health need has also increased following the pandemic in 6-16 year olds from 1 in 9 National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

26 June 2023

to 1 in 6, and in 17-19 year olds from 1 in 10 to 1 in 6. Many services face significant demand and, therefore, increasing access to support continues to be a priority.

We also accept that alongside increasing capacity across services, there is a need to ensure Children and Young People’s services are integrated with support across the whole system – including mental health support as part of the transition from child to adult services for adults, physical health needs, social care, education and health and justice. This includes integration with drug and alcohol services, which are largely commissioned by Local Authorities. Oversight of drug and alcohol service policy rests with the Office for Health Improvement and Disparities within the Department for Health and Social Care, who are copied into the Report.

While local commissioners are responsible for ensuring services are integrated, NHS England has a role to support this at national and regional levels. We have established Clinical Networks and regional delivery groups for mental health across NHS regions to support commissioning of effective services. We have ensured the leadership in these networks and groups are aware of the findings of this Report. NHS England commissioned the National Collaborating Centre for Mental Health to review models of care for young adults aged16 - 25. Their report published in 2022 highlighted examples of positive practice in terms of integration including and set out principles and considerations to inform the development of support, care and treatment for young people. This includes considerations where young people have co-existing mental health and substance abuse needs.

In terms of care for the most complex needs:

The Framework for Integrated Care (Community) (“Framework”) is the evidence- based response to the NHS LTP commitment to invest in additional support for the most vulnerable children who have complex needs. These are young people who could be described as presenting with high-risk, high-harm behaviours and high vulnerability.

The Framework is now well established, and following expressions of interest, 12 vanguard sites have been selected with one in each of the seven NHS England regions, plus additional vanguard sites in the Midlands and in London.

The vanguards are required to demonstrate partnership working across multiple agencies including health, local authority, education, and youth justice agencies demonstrating how they will deliver the Framework and the outcomes within it. All vanguards have been brought together at shared learning events to collaborate and update on progress as well as highlighting areas of good practice and overcome any challenges together.

Vanguards started to submit quarterly data to the national dataset from October
2022. The dataset aims to collect information on the needs of and outcomes for children in the community, evidence that key objectives of the Framework are being met and enable national and regional commissioners to identify and target improvements in health inequalities.

In addition to the Framework, NHS England is working with partners across Government including the Department for Education, Department for Health and Social Care and key stakeholders, such as the Association of Directors of Children’s Services and the Local Government Association to consider how we can better work together to deliver children’s social care and health services for children with the most complex needs, including those with significant mental health challenges.

A Task and Finish Group is in the process of being set up and will examine the barriers to commissioning and providing joint care and health provision, and how to support the sector to better this deliver in future. It has been confirmed to the House of Commons by the Department for Education Minister. Link here. This will be achieved through implementing the recommendations in ‘Stable Homes Built on Love’, the government’s strategy for transforming children’s social care, and building on other ongoing programmes, such as the NHS LTP.

Finally, whilst this is not listed in the matters of concern, your Report also refers to issues relating to information sharing between agencies. The NHS Shared Care Records (SHCR) programme is working to enable the safe and secure sharing of an individual’s health and care information as they move between different parts of the NHS and social care. Information on this programme is published in the NHS England website:

NHS England » Joining up and sharing health and care data

We have also liaised with South London and Maudsley NHS Foundation Trust who have advised us that the following actions have been completed since the death of Samuel.

• Dual diagnosis leads have been identified in each borough across the directorate and they have all either attended or booked dual diagnosis training appropriate to their role.
• Dual diagnosis has their own CAMHS Dual Diagnosis forum and a representative then which then feeds into the physical heath forum as well as the trust wide Dual diagnosis forum.
• Learning from Serious Incident (SI) and policy are standing agenda items at the team’s business meetings, CAMHS SI panel and the monthly Dual Diagnosis forum.
• AUDIT appears on the “My Ward” dashboard; please note is it is only expected to be completed for 16 years and above and therefore does not appear as 100% on the “My ward tool” this is sent out weekly to highlight any gaps.
• CAMHS Data Managers have been holding briefing sessions across our services and part of the session includes AUDIT completion requirements.
• Key Performance Indicators (KPI`s) are standing agenda items teams monthly P&Q meetings and CAG wide monthly P&Q meetings.

I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mr Taylor,

Thank you for your Regulation 28 report to prevent future deaths dated 24 April 2023 about the death of Samuel Thomas Howes. I am replying as Minister with responsibility for mental health and patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Samuel’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter.

Your report raises concerns over the provision of care for children and young people with complex needs.

In preparing this response, Departmental officials have made enquiries with NHS England as the matters of concern you have raised are mainly for NHS England to address. I understand that NHS England has already provided you with a comprehensive response, setting out what progress is being made to improve children and young people’s mental health services, and how the Framework for Integrated Care (Community) Framework is helping young people with the most complex needs.

From a national perspective, I would add that under the NHS Long Term Plan, the NHS forecasts that, between 2018/19 and 2023/24, spending on mental health services has increased by £4.7 billion in cash terms, compared to the target of £3.4 billion set out at the time of the NHS Long Term Plan in 2019. This includes expanding and transforming children and young people’s mental health services. As part of this, the aim is for an extra 345,000 more children and young people to get the NHS-funded mental health support they need by March 2025 compared to 2019.

With regard to the concerns around the response from mental health services to Samuel’s alcohol and/or drug dependency, we recognise that we need to do more to tackle this issue. As highlighted in the independent review of drugs, individuals with co-occurring mental

health and drug and/or alcohol conditions are often passed from one service to the other, excluded from mental health services until they resolve their substance misuse needs, and excluded from drug services until their mental health needs have been addressed.

This is why the Department and NHS England are working together on a joint action plan to improve the mental health treatment offer for people who use drugs and alcohol. This includes improving access to mental health services for people using drugs and alcohol as people are currently too often excluded from, and/or fall between the thresholds of, services. It will also promote better links between mental health services and drug and alcohol treatment services to ensure people receive joined-up care. The first phase of the programme targets adult mental health services, and a second plan for children and young people will follow.

In addition, the Government has committed to investing an additional £532 million to improve drug and alcohol treatment and recovery services from 2022/23 to 2024/25, building on an £80 million investment in 2021/22. This includes improving the capacity and quality of children and young people's treatment, with an ambition to get an extra 5,000 children and young people in treatment by 2024/25.

The Department has also published a commissioning quality standard providing guidance for local authorities to support them in commissioning effective alcohol and drug treatment and recovery services in their area. This is available at: Commissioning quality standard: alcohol and drug services - GOV.UK (www.gov.uk). This encourages a partnership approach to commissioning that includes the local NHS and other health providers in the planning and delivery of these services.

In addition, the Office for Health Improvement and Disparities (formerly Public Health England) has published guidance to support the commissioning and provision of joined up services for people with co-occurring mental health and substance misuse problems. The guidance sets out the principles which should underpin the way substance misuse and mental health services work together, including that each person should have access to a care co-ordinator to help ensure all their needs are addressed. This is available at: Better care for people with co-occurring mental health, and alcohol and drug use conditions (publishing.service.gov.uk)

I hope this response is helpful. Thank you for bringing these concerns to my attention.