From Nicola Blackwood Parliamentary Under Secretary of State for Public Health and Innovation Department of Health Richmond House 79 Whitehall London SWIA 2NS Ms P A Schofield Senior Coroner West Sussex Record Office Orchard Street Chichester West Sussex PO19 IDD ') Ms Schkzu Thank you for your letter dated 5 October 2016,following the inquest into the death of Rose El-Keria: Iwas very sorry to hear of Miss El-Keria's death: Please extend my sincere condolences to her family. You have raised the following matters of concern: The staffing levels at Ticehurst House Hospital and availability of national guidance on staffing levels for inpatient Child and Adolescent Mental Health Services (CAMHS) An on-going shortage of acute mental health beds for young people close to the community where live. NHS England and Health Education England (HEE) are working to improve the capacity and capability of workforce delivering mental health care for children and young people, so that by 2020 an additional 70,000 receive effective treatment per This work extends to supporting training programmes for staff working in inpatient CAMHS to improve team functioning and delivery of evidence-based care: Ihave been advised that in 2016,NHS England commissioned the Royal College of Psychiatrists and National Collaborating Centre for Mental Health (NCCMH) to develop guidance on the implementation of the staffing required to deliver safe, effective and compassionate care in inpatient and community mental health care for children, young people and adults The guidance will be relevant to commissioners, providers, young people and parents, and will contain: MP Amy they year:

A methodology for delivering safe, effective; compassionate and sustainable staffing; Guidance on staffing to support delivery of the evidence-based treatment pathways (these include pathways for children and young people); Recommendations on minimum staffing numbers and competences required across different mental healthcare settings; Positive Practice Examples and Helpful Resources pack This programme is expected to be completed by December 2017 and will inform future revisions of the service standards for the Quality Network for Inpatient CAMHS (QNIC), which are reviewed every two You have also raised concerns about the quality of care provided to Miss El-Keria whilst she was in Ticehurst House Hospital and in particular the ability of staff to mitigate risks of suicide and self-harm: The Government revised the Mental Health Act 183 Code of Practice in 2015,which we expect all mental health providers to implement: The Code of Practice is clear that patients should have in place a robust care plan developed by a multi-disciplinary team and that this should include effective risk assessment: The Department of Health published good practice guidance on assessing and managing risk in mental health in 2009. This can be accessed through the GOV.UK website at the following address: https:ILwww_gQv_uklgovernment publications/assessing-and-managing-risk-in- mental-health-services You have also raised concerns about access to CAMHS inpatient beds close to where live: [am aware of instances where children have had to travel too far away from home to access care The Prime Minister announced in January 2017 that by 2020/21 no child will be sent out of their local area for non-specialist care. You may also be aware that NHS England has reviewed CAMHS inpatient services nationally which has resulted in an additional 56 CAMHS inpatient beds commissioned across the country to meet demand. However; we should also be seeking to avoid unnecessary admissions to hospital wherever possible That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home: We have also invested €400 million to improve crisis care services in the community s0 that people receive the right care years: they being

Department of Health in the right place when experience a mental health crisis. Every local area now has a mental health crisis care action plan in This Government is committed to achieving parity of esteem for mental and physical health: We have invested El.4bn over the course of this Parliament in children and young people's mental health and we remain committed to delivering the vision set out in the Five Year Forward View for Mental Health and Future in Mind to transform mental health services Every area in the country now has a children and young people's transformation plan in place to achieve this and every area has developed a sustainability and transformation plan to deliver long-term improvements to health services. Every death of a person in a mental health setting is a tragedy and every patient has the right to expect high quality and safe care. This is why we commissioned the Care Quality Commission (CQC) to review the in which deaths of people in NHS settings are investigated and learned from to avoid further tragedies. On 13 December 2016,the CQC published the findings ofits review in a report titled Learning, candour and accountability: A review of the way NHS trusts review and investigate deaths of patients in England. It concluded that learning from deaths is not currently being given sufficient priority within the NHS and that bereaved families and carers have pOor experiences with providers. The Secretary of State accepted the CQC's recommendations for improvement and a programme to deliver his commitments is underway: The first stage will be the delivery this year of a National Framework on Learning from Deaths for NHS providers. The aim is to standardise and improve practice across providers by providing clear expectations in relation to identifying, reporting, reviewing, investigating and learning from deaths, and significantly, engaging with bereaved families and carers. From April 2017, Trusts will be required to publish specified information on deaths each quarter; including estimates ofhow many deaths were judged more likely than not to have been associated with problems in care. Trusts will also be required to publish evidence of leaming and action as a result of the information. This increased transparency, through improved data collection and reporting; is about supporting a systemic, NHS-wide approach to learning from deaths. The CQC will also strengthen its assessment of providers by covering learning from deaths they place. way

In addition, as a result of cases such as that of Miss El-Keria '$, earlier this year [ set out measures for how we will improve the recording and monitoring of deaths of patients under the care of inpatient child and adolescent mental health services, with every death now directly reported to Ministers. I hope that this response is helpful and [ am grateful to You for bringing the circumstances of Miss El-Keria's death to my attention: Ans Nso NICOLA BLACKWOOD hncezQ1

From Nicola Blackwood MP Parliamentary Under Secretary of State for Public Health and Innovation Department Richmond House of Health 79 Whitehall London SW1A 2NS Ms P A Schofield I© Senior Coroner West Sussex Record Office Orchard Street 02 MAR 2017 Chichester West Sussex P019 1DD Thank you for your letter dated 5 October 2016, following the inquest into the death of Amy Rose El-Keria. I was very sorry to hear of Miss El-Keria’s death. Please extend my sincere condolences to her family. You have raised the following matters of concern:
• The staffing levels at Ticehurst House Hospital and availability of national guidance on staffing levels for inpatient Child and Adolescent Mental Health Services (CAMHS)
• An on-going shortage of acute mental health beds for young people close to the community where they live. NHS England and Health Education England (HEE) are working to improve the capacity and capability of workforce delivering mental health care for children and young people, so that by 2020 an additional 70,000 receive effective treatment per year. This work extends to supporting training programmes for staff working in inpatient CAMHS to improve team functioning and delivery of evidence-based care. I have been advised that in 2016, NHS England commissioned the Royal College of Psychiatrists and National Collaborating Centre for Mental Health (NCCMH) to develop guidance on the implementation of the staffing required to deliver safe, effective and compassionate care in inpatient and community mental health care for children, young people and adults. The guidance will be relevant to commissioners, providers, young people and parents, and will contain:

• A methodology for delivering safe, effective, compassionate and sustainable staffing;
• Guidance on staffing to support delivery of the evidence-based treatment pathways (these include pathways for children and young people);
• Recommendations on minimum staffing numbers and competences required across different mental healthcare settings;
• Positive Practice Examples and Helpful Resources pack This programme is expected to be completed by December 2017 and will inform future revisions of the service standards for the Quality Network for Inpatient CAMHS (QNIC), which are reviewed every two years. You have also raised concerns about the quality of care provided to Miss El-Keria whilst she was in Ticehurst House Hospital and in particular the ability of staff to mitigate risks of suicide and self-harm. The Government revised the Mental Health Act 183 Code of Practice in 2015, which we expect all mental health providers to implement. The Code of Practice is clear that patients should have in place a robust care plan developed by a multi-disciplinary team and that this should include effective risk assessment. The Department of Health published good practice guidance on assessing and managing risk in mental health in 2009. This can be accessed through the GOV.UK website at the following address:

mental-health-services You have also raised concerns about access to CAMHS inpatient beds close to where they live. I am aware of instances where children have had to travel too far away from home to access care. The Prime Minister announced in January 2017 that by 2020/21 no child will be sent out of their local area for non-specialist care. You may also be aware that NHS England has reviewed CAMHS inpatient services nationally which has resulted in an additional 56 CAMHS inpatient beds being commissioned across the country to meet demand. However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care

Department of Health in the right place when they experience a mental health crisis. Every local area now has a mental health crisis care action plan in place. This Government is committed to achieving parity of esteem for mental and physical health. We have invested £1.4bn over the course ofthis Parliament in children and young people’s mental health and we remain committed to delivering the vision set out in the Five Year Forward Viewfor Mental Health and Future in Mind to transform mental health services. Every area in the country now has a children and young people’s transformation plan in place to achieve this and every area has developed a sustainability and transformation plan to deliver long-term improvements to health services. Every death of a person in a mental health setting is a tragedy and every patient has the right to expect high quality and safe care. This is why we commissioned the Care Quality Commission (CQC) to review the way in which deaths of people in NHS settings are investigated and learned from to avoid further tragedies. On 13 December 2016, the CQC published the findings of its review in a report titled Learning, candour and accountability: A review ofthe way NHS trusts review and investigate deaths ofpatients in England. It concluded that learning from deaths is not currently being given sufficient priority within the NHS and that bereaved families and carers have poor experiences with providers. The Secretary of State accepted the CQC’s recommendations for improvement and a programme to deliver his commitments is underway. The first stage will be the delivery this year of a National Framework on Learning from Deaths for NHS providers. The aim is to standardise and improve practice across providers by providing clear expectations in relation to identifying, reporting, reviewing, investigating and learning from deaths, and significantly, engaging with bereaved families and carers. From April 2017, Trusts will be required to publish specified information on deaths each quarter, including estimates of how many deaths were judged more likely than not to have been associated with problems in care. Trusts will also be required to publish evidence of learning and action as a result of the information. This increased transparency, through improved data collection and reporting, is about supporting a systemic, NHS-wide approach to learning from deaths. The CQC will also strengthen its assessment ofproviders by covering learning from deaths.

In addition, as a result of cases such as that of Miss El-Keria’s, earlier this year I set out measures for how we will improve the recording and monitoring of deaths of patients under the care of inpatient child and adolescent mental health services, with every death now directly reported to Ministers. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Miss El-Keria’s death to my attention. NICOLA BLACKWOOD

Dear Senior Coroner Schofield, I write to respond on behalf of the Chief Executive, Mary Harpley, to whom you wrote on 05/10/2016. On 03/10/2016, and following the Inquest hearing touching upon the death of Amy Rose El- Keria, you issued a Preventing Future Death Report request from the London Borough of Hounslow, to deal with three particular issues, as follows:
1) The evidence given at the Inquest showed that there was a clear misapprehension by Hounslow Social Services as to their role in supporting Amy whilst at Ticehurst. It appears that Social Services did not appreciate their important ongoing role to ensure Amy’s welfare whilst placed at Ticehurst. , the Court expert, gave evidence that Hounslow may have seen this health funded placement as a stand-alone intervention that did not require their input.
2) Social Services clearly have a vital role to play in ensuring family contact where a child is placed far from their family home where difficulties arise. There was no assessment carried out to assess whether there was any need to provide support to a child in need under Section 17 of the Children Act 1989, even when Amy’s mother had specifically raised the difficulties she was having with contact with Amy, including the cost of travel, with her support worker.
3) The family gave evidence to the extent that having better contact with Amy and more input into her care may have brought about a different outcome particularly when she was distressed. The London Borough of Hounslow has re-drafted and updated its Thresholds Guidance & Assessment Protocols to ensure specific reference is made to these matters. Advice was sought from Mental Health professionals as part of this process. The London Borough of Hounslow will ensure that this information is disseminated across Children’s Social Care, and that refresher and update briefings will be delivered to all relevant social workers and staff. The information will be disseminated across Children’s Social Care teams the week of 28/11/2016 and Heads of Service and Team Managers will ensure that all managers and practitioners are fully briefed. Information will be shared by Heads of Service at their next Management Meetings and with social work staff at their next Team Meetings. An additional development session for refreshing knowledge will be delivered to Managers, Independent Reviewing Officers, and Advanced Practitioners at the next Managers’ Forum in the New Year.

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These staff briefings and development sessions will specifically cover the local authority’s duties to children placed in hospital and other settings away from home under S85 and S86 of the Children Act 1989 and assistance in those circumstances under S17 Children Act 1989. They will additionally highlight to all social care staff that when notified of a Tier 4 mental health inpatient, the expectation is that the local authority shall undertake a S17 or S47 assessment as commensurate with its duties under the Children Act 1989. In both instances, the social worker assessment should consider issues of contact, including promotion and support of contact between those children and their families as appropriate. The threshold document is available to the public on the council’s website and specifically on its Local Safeguarding Children’s Board site. The document is public facing but is primarily aimed at assisting those professionals working with children to understand how thresholds are applied and how child protection professionals make decisions in respect of appropriate action. Assistance to children in need under S17 of the Children Act 1989 for children placed in a hospital or other setting is referenced at section 3.9 (pages 12-14) under the headings ‘Children Receiving Tier 4 Inpatient Provision’ and ‘Children Act 1989 Section 85 & 86 Duties’. The threshold document assists professionals to take appropriate action in relation to children in need and now has a specific section on children with mental health disorders to ensure that the specific needs of the vulnerable are highlighted and referrals are made to children’s social care as required. The threshold document is also published on Hounslow’s internet, which is publicly accessible and contained within the Children’s Social Care’s procedure manual. Specific reference is made to promotion and maintenance of contact between children and their families, following an assessment of needs. The awareness of social workers of their duties to children placed in health settings away from their homes and the importance to those children of regular contact with their families will be reinforced by the staff briefing sessions referenced above, as well as the express references in the threshold document. The London Borough of Hounslow is confident that the concerns expressed by you are and will be addressed by these actions, and will ensure that there is clarity and consistency in social work practice where children are placed in health and other settings away from home. Please don’t hesitate to contact me should you require further clarification or information.

Dear Ms Schofield Re: Regulation 28 Report to Prevent Future Deaths following the Inquest concerning the death of Ms El Keria Thank you for your Regulation 28 report dated 18 November 2016 addressed to of the Group. Please note that hhas now stepped down as Chief Executive Officer of the Group and I have been appointed to that position with effect from December 2016. I am therefore responding to your report on behalf of the Group as Chief Executive Officer . Addressing your concerns Adequacy of staffing levels We note your comments in relation to the QNIC guidance published by the Royal College of Psvchiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels. More generally,_staffing levels at the Child and Adolescent High Dependency Unit (HDU) at Hospital Ticehurst (and indeed on all our wards) are kept under constant review to ensure are appropriate to the ever-changing needs and numbers of patients: Reviews of patient behaviours and their needs (as set out in care plans ad risk assessments) are carried out at the beginning of each shift as part of the formal handover and adjustments made to staffing levels and mix as appropriate: In assessing adequacy, the following factors also need to be taken into account: nursing staff on a ward should not be considered in isolation from the support and input provided by other professionals on the ward (for example, one to one sessions are provided by a number of clinical professionals including therapists and doctors); CAMHs patients attend school and therapy in the day (this therefore increases the stafflpatients ratios remaining on the wards); iii , ward managers and other supernumerary staff are not taken into account in determining appropriate staff/patient ratios (but do of course interact with patients throughout their shift);
iv. staff can be called in from other wards at any time but particularly in an emergency; Pro~ Grntnl scnaccraro arocdic Group, Fifth Floor; 80 Hammersmith Road, London, W14 8UD Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup com WWW priorygroup.com 1 Prlory Group No_ Limitcd trading as the Prlory Group Registered Olfice: Filth Foor; 80 Hammersmith Roxd, London; WI4 BUD CHKS 4 Reglstercd In England No: 07480152. Part of the Priory Group of Companies OF Amy Priory Priory Priory Priory they they Prlory

there are robust on-call arrangements which all senior managers must participate in; and vi we encourage a culture of openness and team working and if employees have concerns around staffing can raise those with the ward manager, clinical services manager or hospital director_ 2 Risk assessment and management including the Risk Assessment Tool I am pleased to advise you that an enhanced Risk Assessment Tool was launched on 28 November 2016 and that staff briefings in relation to using the tool are underway: The new tool enables a better assessment of behavioural risk prior to admission and encourages patients to become more involved in understanding their risks and how to manage them. Feedback from our staff about the tool has been very positive
3. Observations and information sharing In common with all healthcare providers and as part of its commitment to continuous improvement; Priory Group keeps all of its operational policies and procedures under constant review including in relation to observation and engagement: Observation recording forms have been enhanced and are now more user friendly with clear instructions on what should be recorded. We have also endeavoured to make the policy clearer in relation to information sharing: Local site compliance with observation procedures is monitored: via out-of-hours unannounced internal audits.
4. Emergency procedures Please note that in relation to BLS and ILS, monthly simulation drills are undertaken and these involve all staff and involve a variety of different emergency life support scenarios: Feedback from the drills has been positive and indicates that staff are continually putting into practise the skills that have been taught: reviewed your comments in relation to ALS training carefully, we consider there is greater overall benefit for the hospital if we retain an expert in ALS/resuscitation who will deliver training and coaching to our staff. The expert is to be retained under appropriate contractual arrangements and will provide face-to-face training for nursing and medical staff and work with the hospital management team on developing and' implementing the emergency scenarios and provide objective feedback: I do hope that these actions will provide you with the reassurance that you require. If I can be of further assistance then please do not hesitate to contact me.

Dear Ms Schofield Re. Regulation 28 Report to Prevent Future Deaths following the Inquest concerning the death of Ms Amy El Keria Thank you for your Regulation 28 report dated 18 November 2016 addressed to Mr Tom Riall of the Priory Group. Please note that has now stepped down as Chief Executive Officer of the Priory Group and I have been appointed to that position with effect from 1 December 2016. I am therefore responding to your report on behalf of the Priory Group as Chief Executive Officer. Addressing your concerns
1. Adequacy of staffing levels We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels. More generally, staffing levels at the Child and Adolescent High Dependency Unit (HDU) at Priory Hospital Ticehurst (and indeed on all our wards) are kept under constant review to ensure they are appropriate to the ever-changing needs and numbers of patients. Reviews of patient behaviours and their needs (as set out in care plans and risk assessments) are carried out at the beginning of each shift as part of the formal handover and adjustments made to staffing levels and mix as appropriate. In assessing adequacy, the following factors also need to be taken into account:
i. nursing staff on a ward should not be considered in isolation from the support and input provided by other professionals on the ward (for example, one to one sessions are provided by a number of clinical professionals including therapists and doctors);
ii. CAMHs patients attend school and therapy in the day (this therefore increases the staff/patients ratios remaining on the wards);
iii. ward managers and other supernumerary staff are not taken into account in determining appropriate staff/patient ratios (but they do of course interact with patients throughout their shift);
iv. staff can be called in from other wards at any time but particularly in an emergency; Priory Central Services are accredited by Priory Group, Fifth Floor, 80 Hammersmith Road, London, W14 8UD Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup.com www.priorygroup.com Priory Group No. 1 Limited trading as the Priory Group, Registered Office: Fifth Floor, 80 Hammersmith Road, London, W14 8UD. Registered in England No. 07480152. Part of the Priory Group of Companies. CHKS PG01381/Octl3

v. there are robust on-call arrangements which all senior managers must participate in; and
vi. we encourage a culture of openness and team working and if employees have concerns around staffing they can raise those with the ward manager, clinical services manager or hospital director.
2. Risk assessment and management including the Risk Assessment Tool I am pleased to advise you that an enhanced Risk Assessment Tool was launched on 28 November 2016 and that staff briefings in relation to using the tool are underway. The new tool enables a better assessment of behavioural risk prior to admission and encourages patients to become more involved in understanding their risks and how to manage them. Feedback from our staff about the tool has been very positive.
3. Observations and information sharing In common with all healthcare providers and as part of its commitment to continuous improvement, Priory Group keeps all of its operational policies and procedures under constant review including in relation to observation and engagement. Observation recording forms have been enhanced and are now more user friendly with clear instructions on what should be recorded. We have also endeavoured to make the policy clearer in relation to information sharing. Local site compliance with observation procedures is monitored via out-of-hours unannounced internal audits.
4. Emergency procedures Please note that in relation to BLS and ILS, monthly simulation drills are undertaken and these involve all staff and involve a variety of different emergency life support scenarios. Feedback from the drills has been very positive and indicates that staff are continually putting into practise the skills that they have been taught. Flaving reviewed your comments in relation to ALS training carefully, we consider there is greater overall benefit for the hospital if we retain an expert in ALS/resuscitation who will deliver training and coaching to our staff. The expert is to be retained under appropriate contractual arrangements and will provide face-to-face training for nursing and medical staff and will work with the hospital management team on developing and implementing the emergency scenarios and provide objective feedback. I do hope that these actions will provide you with the reassurance that you require. If I can be of further assistance then please do not hesitate to contact me.

Chief Executive Officer Priory Group