Dear Mr Short; Regulation 28 Report to Prevent Future Deaths: Grant David Burns After a full assessment; it has been found that in this incident there was a lack of cO-operative working between Southern Health mental health services (Early Intervention in Psychosis Team) and Substance Misuse Services. After some discussion, the action now required is to compile spread- sheet of those clients identified as being worked with by Adult Mental Health and Substance Misuse Services_ This spread-sheet needs to be updated at the Southampton and Alcohol Recovery Service Management meeting with regular communication with Southern Health Foundation Trust. This action was in place on the 27th of March 2017 and is due to end on the 1th of April 2017. The desired outcome of this action is to improve clients' experience of services, working cohesively and consistently to support risks and the individuals' recovery. There is evidence that the spread-sheet was completed on Wednesday 20"h March 2017 and has been added to the weekly Joint Clinical Meeting Agenda for Monday the 10th April 2017. It has also been added to the Solent morning meeting agenda as a standing item twice weekly. The second action concerns referrals which are screened in Substance Misuse Services_ The Change Grow Live Manager with the Solent NHS Trust Clinical Manager will identify if there is any involvement from mental health services. If Adult Mental Health is involved, contact is to be made via telephone calllletter or email with the mental health treating team to make them aware that the Substance Misuse Services are also involved in the patients care meeting will then be arranged to start the joint working process_ A named staff member will be identified to take responsibility for this action, which will usually be the Change Grow Live Care Co-Ordinator. Should there be no response from the mental health team following the substance misuse workers making contact; they will escalate this to their line manager to raise with the Area Manager Southampton Mental Health Team Manager. This action was in place on the 3rd of April 2017 and will end on the 10th of April 2017. The third action is to review the Dual Diagnosis Policy within Southern Health Foundation Trust and Solent NHS Trust to ensure that the action above is included within it as best practice for staff to follow. This action commenced on the 3rd of April 2017 and is due to end on the 1st of 2017 . 3 INVTSTORR IN PFOFTF Solent NHS Trust Headquarters, Highpoint Venue, Bursledon Road, Southampton S019 8BR Telephone: 023 8060 8900 Fax: 023 8053 8740 Website: Wsolentnhs uk Drug put put May O15ABLC9

The fourth action is to undertake an annual audit of compliance against the standards set within the policy. This is due to be in place in September 2017 and will end in April 2018 In relation to issue 2, namely the report being incomplete because there was no input from the worker at New Road, a number of actions have been put in place_ In this particular instance , the incomplete reports were due to lack of input from both Substance Misuse Services and Adult Mental Health in relation to Serious Incident Requiring Investigation reports_ In order to avoid this from happening again an action has been put in place to review the current Serious Incident Requiring Investigation policies for Southern Health Foundation Trust and Solent NHS to ensure the explicit requirement of Serious Incident requiring investigation investigators to engage with all stakeholderslservices who werelare involved in persons' care, and offer them input into the investigation process_ This action was in place on the 3rd of April 2017 and is due to end on the 1st of May 2017 . The desired outcome of this action is to ensure that policy mandates the requirement for Serious Incident Requiring Investigation Investigators to ensure that all known stakeholders and services are involved in the completion of the report: Action 6 is to undertake an annual audit of compliance against the standards set within the policies This action will be in place in September 2017 and will end in April 2018_ Finally the seventh action is with regard to the third issue of the lack of communication between partner agencies_ The action is to create bespoke Joint Working Practice document to outline the standards expected of staff in Substance Misuse Services and Adult Mental Health with regard to communication between organisations where patients are supported by both: These standards should cover, though are not limited to: Frequency of contact; Joint visitslmeetings and escalation process_ This action commenced on the 3rd of April and is due to end on the 18th of April 2017. The outcome of the action is to maintain consistent shared knowledge of patients' risks and needs, and how these can be addressed. It is anticipated that there will then be a clear understanding by patients and carers regarding the involvement of different services, including their roles and functions_ Finally the eighth action is to undertake an annual audit of compliance against the standards set within the policies This action is due to be in place in September 2017 and will end in April 2018_