NoRWicH PRACTICES LIMITED npl Norwich Practices Health Centre Response to the report written by Jacqueline Lake Senior Coroner NORFOLK Report Prepared by Board of Directors at Norwich Practices Health Centre Introduction We are collectively the Board of Directors of Norwich Practices Health Centre comprising both senior management personnel and clinicians_ The aim of this report is to respond t0 the concerns raised by Jacqueline Long, Senior Coroner, Norfolk, regarding Ihe events that lead to the death, by suicide, of Solomon James Bealey: Learning Outcomes and Action Plan The practice has regarded (his tragic death as significant event and reviewed its policies and procedures For the purpose of this report we will concentrate on what happened within this organisation, the lessons learnt and what we have done to prevent this type of incident happening again. The GP , when seeing Soloman for the first time in December 2010, fell slightly uncomfortable that there was a in presentation but felt that there were no immediate safeguarding issues. Learning Outcome It is likely that a discussion with a member of the Safeguarding team at this time would have triggered their involvement: Action Reflective discussion with the Designated Nurse for Safeguarding Children: It may have been helpful for the GP to have discussed his concerns with member of the designated team who could have supported him in securing an earlier appointment with CAMHS: They would have also been able to provide him with professional peer support. 2 On receipt of the letter from CAMHS team, following Soloman's appointment, there was nothing documented on his record by the GP who filed the letter 80 subsequent clinicians, unless they looked at the scanned document; would have been unaware of the care plan_ Learning outcome The letter clearly stated several action points although it is unclear where Ihe responsibility for these lie. We accept that we could have explored this further and agreed clear lines of responsibility with the CAMHS leam Action The clinical team are in the process of developing a template for a Mental Health Care Plan to be integrated onto SystmOne, our hosted clinical IT system: As a result of this review, Mental Health Care Plans already in place have been read-coded, This triggers a patient status alert which is visible under the patient demographic box and on the patients home screen: Patients that we have identified will have a review of their care plan before
30.11.15 and any concerns will be discussed at our weekly clinical meeting: delay

3 A further letter a CAMHS Practitioner was received on 12th April 2011 in which it is stated that he saw Soloman on 1ghh January 2011 and his mood had greatly improved Unfortunately; due to illness in his family, Soloman had been unable to attend further appointments after this_ The practitioner spoke to Soloman's mother on 220d March 2011 and she informed him that Soloman's mood had greatly improved and that neither he nor his family felt lhey needed any further support from CAMHS. We were unaware that Soloman had not attended any appointments after January until we received this letter on 12th April 2011. Learning outcome This letter was filed, no action (aken Although this was seemingly a discharge letter citing positive outcome we did not instigate any follow up to ensure ongoing support to Solomon or his family: This was possibly a missed opportunity to engage with Solomon and his family and to remind lhem of the ongoing support and advice available to Ihem from the practice, although this is not routine practice on receipt of discharge letter_ Action For patients identified as a significant concern, discharge notices from the Mental Health team will trigger contact, via telephone, from the practice to the patient to offer an appointment for GP review to discuss ongoing need for support; The nurse who saw Soloman on 1st October 2014 prompted discussion of Soloman as Patient of Concern at the clinical meeting on 7ih October 2014. Following the meeting the GP tried to contact Soloman's molher by telephone but it was the wrong number Subsequently, a letter was sent by the GP outlining her worries to Soloman's parents. This was not responded to and neither was the subsequent letter of 21 October 2014_ Unfortunately, there was no further follow up or discussion Learning outcome We accept that we should have investigated Ihe wrong telephone number and pursued the lack of response to our letters. Action have standing agenda item 'Patients of Concern' at our weekly clinical meeting: With immediate effect;, we have agreed to have a 'Patients of Significant Concern' register. Patients will be added as agreed at the clinical meeting and the register will be reviewed weekly. Patients will only be removed from the Iist if the level of concern has lessened or resolved , Your report and our subsequent review has been discussed with the whole team at our clinical meeting on 3r November 2015. The above learning outcomes and action plan has been shared and agreed. Recommendations to reduce risk of future deaths Improvement in communications between Mental Health teams and practices: Any suicide attempt made by a child under 16years will trigger an automatic referral to the Safeguarding Team Multi-agency involvement at the earliest opportunity, in this case, the GP, Designated Safeguarding team, CAMHS, Sprowston High School, Parents _ Clear lines of responsibility where an action plan is in place, with time frames where indicated. Indication on patient records Ihat a Mental Health Care Plan is in place. Offer of continuing support to patients of significant concern who have been discharged from the Menlal Health Care team. This process will be reviewed in 6 months' time (May 2016) from We

It would be useful if the responses from the other agencies involved could be shared with Norwich Practices Health Centre. In addition, if there are any further recommendations as consequence of this tragic case then we would be very happy to implement them: Should you have any queries relating to this case or my response to your report, please do not hesitate to contact US _