Dear Ms Jones Rei Dean Rowland (deceased) Report to Prevent Future Deaths Thank you for your letter dated 28th June 2017, reporting concerns to us, in accordance with Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. Following discussions within the Mental Health Division, am now in a position to respond to your specific concern, which were as follows: In respect of
2. He was referred to a community mental health team having made two serious previous suicide attempts: He was discharged after only one consultation with no follow up plan other than for him t0 refer back to primary care. The family perceive he would have benefitted from a further appointment: He was willing to engage with services: Prior to his referral to South Staffordshire and Shropshire Foundation Trust (SSSFT) in July 2016 Mr Rowland was not known to mental health services, although as you report had taken two overdoses in the preceding four months due to difficulty in coming to terms with the end of his marriage: It was immediately following the second overdose that he was referred to mental health services, beginning with an assessment from the Crisis Resolution and Home Treatment Team (CRHTT) who felt more detailed assessment from the Community Mental Health Team (CMHT) would be of benefit; this assessment took place on 19"h August 2016, 18 days after the referral, with one episode of telephone contact in between in order to arrange the appointment: This is in keeping with expected point very

referral timeframes for a CMHT assessment. Notably, the appointment letter also invited Mr Rowland to hfriend or relative with him to the appointment; thereby considering the needs of carers, although Mr Rowland opted to attend alone_ When seen on 19" August 2016, Mr Rowland had moved to Birmingham in order to reside etirbis rotherd and described improvements in his mental health due t0 thisechange @ environment and a now amicable relationship with his ex-wife and access to his children. Mr Rowland described his wellbeing like have my life back and am my old self" and reported various self-help methods such as exercise and making time for himself Importantly he expressed no further ideas of suicide. A Patient Health Questionnaire (PHQ-9) was completed as part of the assessment; this is a 9-item questionnaire to explore current symptoms of depression, yielding score of between 0 and 27 Mr Rowland scored &, Which is indicative of mild depression that would not usually require ceatment; scores of 15 and above are usually seen in individuals requiring the inpucol CMHT. Mr Rowland"s recent suicidal ideation and behaviour was noted, but current wellbeing he was deemed at low risk for further self-harm or suicide. given his was discussed on 25"h August 2016 at a CMHT murttcesciplinaay tearn uicideng arodroating to the information gathered in the assessment; Mr Rowland and owing CMHT. was discharged from the Mr Rowland engaged fully in his assessment and coproduced the plan which was later communicated to him by letter. He felt that the difficulties in his mental health had limproved and that he did not require input the CMHT, but was aware that he could be Irereferred at any time should this situation change. The letter validated his efforts to be well and detailed online self-help resources to support these efforts, and also Irecommended that he register with a GP in Birmingham if he wished to continue to reside there; so that he could be referred quickly to his local mental health servicee {0 fetude Ishould the need arise. If the assessment had highlighted the need for he CMHT , this would have been transferred to the service in ongoing input Rowland's new residence, but as described it was not required Birmingham local to Mr am satisfied that the CMHT conducted sufficiently detailed assessment of Mr Rowland's needs, and with him arrived at the right decision at that time, to discharge him the service_ Following discharge ane Gatsfied' thaa alli commanieation with Mr Rowland detailed resources that he could access to support his offered appropriate advice to register with GP ocaceos hig nepporddressecoVeey iedred detailed points of contact with the CMHT should he move back to the The letter GP to rerefer him at any time should the need have arisen. area, and invited his family in the assessment The option to involve his was offered but declined by Mr Rowland: lhope this response to address your concerns. However if you require any further information please do not hesitate to contact me

Dear Ms Jones RE: Dean Rowland (Deceased) Thank you for your letter dated 28 June 2017 regarding this patient: The specific area of concern with regards to the practice-to improve access for patients to have an appointment or telephone call with a Doctor sooner than a routine appointment if So required: We have instituted a duty doctor and telephone triage system in the practice: If che patient attends or phones the practice requesting an appointment are told when the next routine appointment is available for the doctor of their choice and for any doctor If feel need tO be seen that or that their condition will not wait until the next available routine appointment they are offered a 'callback" will be called as soon as possible by one of the duty team who will either with the problem over the telephone or make them an appointment that to see a doctor or a nurse practitioner whichever is the most appropriate for the problem_ This means that everyone who needs to be seen will be seen on the same day hope this provides information you require and satisfies your concerns