Dear Mr Caller, Re: Regulation 28 Report Paul Robert Allan (Deceased) Thank you for your Regulation 28 report dated the 25th July 2018, and for bringing to my attention the concerns you had after hearing all the evidence. Your concerns relevant to Pennine Care have been reviewed, and the Trust's response is outlined below_ Concern 1: The Rochdale Community Mental Health Team discharged Paul Robert Allan from their care instead of transferring him to the Community Mental Health Team in Stoke where Paul Robert Allen was moving to. Response: The Trust takes seriously its duties around discharging clients from services in line with Trust approved policies and national guidance. Paul Robert Allen was under The Care Programme Approach (CPA) framework at the time of discharge. The CPA framework was introduced in 1990 as the approach for the care of people with mental health needs in England. Under the CPA policy section 7.11.2 states "All health and social care organisations have the duty to collaborate to ensure proper CO-ordinated care is delivered to people with mental health needs; Each district Local Authority Social Services Department and Health Trust will jointly operate a Care Programme Approach (CPA) Policy: Whilst the detail of local CPA policies may differ the core principles will be the same A objective of the CPA is to ensure individuals most in need of care do not slip through the net of service provision.' very key -

As a Trust we will circulate a reminder to all staff regarding the policy to include how to access the policy and its use in practice. It is a duty of all responsible clinicians and registered practitioners to take accountability for clinical decision making adhering to nation and local policy and guidance. The Trust have also ensured that CPA is included on clinical audit programme 2018/19 Concern 2: The Rochdale Community Mental Health Team failed to consult or work with the and Alcohol advisory services in relation to Paul Robert Allen as it is required to do sO. Response: The Trust has recognised the gap in services for dual diagnoses clients and the difficulties experienced in Rochdale as a result of the commissioning arrangements around Drug and Alcohol services being delivered by third sector organisations As such the Trust has recently been successful in their application for Greater Manchester funding from the transformation fund, to develop new posts to bridge this gap. The new posts will develop and establish pathways between Mental Health and Drug and alcohol services and work with the most complex clients and develop effective working practices. Further development meetings with the operational manager of the and alcohol services and Rochdale mental health services are supporting and enhancing this model: Our Rochdale services also form part of the Greater Manchester Strategic Transformation Partnership (groups of NHS and Local Authorities STP) who will be accessing improvement work in relation to suicide prevention across the Greater Manchester area_ Previous National Confidential Inquiry into Suicides and Homicides work has shown that the implementation of their recommendations was associated with reduced suicide rates in mental health trusts_ The NCISH '10 ways to improve safety' (below, and linked) summarises recommendations 20 years of research that could make a difference to suicide rates in our STP. Identifying which of the '10 ways' could be improved in your STP is the first step to an evidence- based quality improvement plan: The NCISH team would expect to see some of these recommendations incorporated into a locally co-produced suicide prevention driver diagram as part of the Ql plan: The Ql plans should focus on the main priority areas of (1) mental health services, (2) self-harm services, (3) suicide prevention in men: Drug drug from

Safci #ards Scrvicesfor Early follow- P dual diagnogis an dliscirge Loi stal? Nc put-ol-3ica (uover arlmissions 10 ways to improve safety 24-holr Qhutreacn) {@DmS Ellsis ieams Perstnalisedris: Fanly wolvrnient Managemeri "earning Iessons Cuidancen depression At a visit to our STP , the project team will provide bespoke data for our STP and Pennine Care NHS trust; benchmarked against national data. The team will discuss any concerns specific to our local area, and help us to incorporate these into our Ql plans: Services for dual diagnosis is an identified area by the NCISH and project" team that can reduce deaths by suicide Pennine Care NHS is a signatory to the Greater Manchester Strategic suicide prevention strategy and wil be working collaboratively and closely with partner agencies to bring the NCISH recommendations to practice Ihope this response assures you that the Trust takes seriously any concerns that you raised: