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IN THE MATTER OF THE INQUEST IN TO THE DEATH OF REECE WILLIAM NELSON RESPONSE OF NAVIGO TO THE PDF REPORT DATED 5.12.23 FROM MARIANNE JOHNSON, HM ASSISTANT CORONER FOR NORTH LINCOLNSHIRE AND GRIMSBY Introduction 1 This is the response of Navigo to the Regulation 28: Report to Prevent Future Deaths (the Report) raised by Marianne Johnson, HM Assistant Coroner for North Lincolnshire and Grimsby, dated 5 December 2023, following the conclusion of an inquest on 5 December 2023 into the death of Reece William Nelson, who died on 28 February 2022 when he was found hanging from his wardrobe door at his home address. 2 Navigo Health and Social Care CIC (Community Interest Company) provides NHS commissioned adult, child and adolescent mental health services in North East Lincolnshire. Issue raised by the Coroner 3 The concern as set out in the Report is: On the morning of Reece Nelson's death his family attempted to contact his Care Coordinator due to concerns regarding his mental state. The Care Coordinator was on sick leave, however this information was not reported to the family and therefore no return call was made to them. Had the family been made aware that the Care Coordinator was on sick leave they would have tried alternative routes to contact the mental health services to seek assistance. Response to the Concern 4 The response is as follows:
4.1 Navigo would like to convey its sincere condolences concerning the death of Reece William Nelson.
4.2 Navigo became aware that (Reece William Nelson’s Grandmother) dialled the mobile phone of (Reece Wilson Nelson’s Care- Coordinator) on the morning of his death, following a conversation on 20 October 2022 between , (Reece William Nelson’s Grandfather) and (Navigo’s Head of Operational Governance and Quality).

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4.2 Navigo informed and that it would review staff cover arrangements in its Community Mental Health and Wellbeing Services Operational Policy (‘the Policy’).
4.3 Upon reviewing the Policy, the paragraphs below were drafted for inclusion: In the event a Care Coordinator rings in sick or any other sickness absence period, the Team Leader will go through staff diaries and task admin to phone each patient to let them know their worker is off sick, the Team Leader will also determine whether alternate support is required in the absence of their Care Coordinator. In the event other support is required the Team Leader is to liaise with the duty person to arrange this. The team are to be made aware and relevant duties allocated in the morning huddle by the Team Leader. All patients will be made aware that they can contact our duty worker for support at any time during office hours Monday to Friday 9am to 5pm. The duty worker is able to conduct a home visit where needed. Duty person to explain the crisis/out of hour’s process and reiterate to the patient that all relevant crisis contact details are found on the patient’s care plan. If the Care Coordinator is a nurse and off sick, priority allocation of depots to be covered by other qualified nurses. If a patient has a planned home visit, Team Leader to ensure this is completed by duty person, Support Worker and or another Care Coordinator.

For prolonged periods of sickness absence, Team Leader will allocate caseload to other Care Coordinators.
4.4 The amendments to the Policy as contained in 4.3 above were approved at the Policy Group meeting on 18 January 2023 and the amended version of the Policy was uploaded to Navigo’s rainmeter on 27 January 2023.
4.5 The Policy has since been re-written following the Community Mental Health transformation and alignment with Primary Care Teams and is now entitled Primary Care Networks and Community Mental Health Teams Operational Policy (‘the Revised Policy’) and the paragraphs read as follows: In the event a Community Mental Health Team member of staff telephoning sick or any other sickness absence period, the Team Leader will go through staff diaries and task admin to phone each patient to let them know their worker is off sick. The Team Leader will also determine whether alternate support is required in the absence of their identified Key Worker. In the event other support is required the Team Leader is to liaise with the Duty Worker to arrange this. The team are to be made aware and relevant duties allocated in the

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morning huddle by the Team Leader. All patients will be made aware that they can contact our Duty Worker for support at any time during office hours Monday to Friday 9am to 5pm. The Duty Worker is able to conduct a home visit where needed. Duty Worker to explain the crisis/out of hours process and reiterate to the patient that all relevant crisis contact details are found on the patients care plan. If the Care Co-ordinator is a Nurse and off sick, priority allocation of depots to be covered by other qualified Nurses. If a patient has a planned home visit, Team Leader to ensure this is completed by Duty Worker, Support Worker and/or another worker. For prolonged periods of sickness absence Team Leader will allocate caseload to other workers. For periods of annual leave, workers are responsible for ensuring robust planning takes place to ensure service users and their families receive the correct level of support as per the agreed care plan.
4.6 The Revised Policy was approved by the Clinical Governance Committee on 22 March 2023 and uploaded to Navigo’s rainmeter on 20 June 2023.
4.7 The Coroner’s Office sought confirmation, in its e-mail of 18 October 2023, that the policy change (concerning cover arrangements) identified in Navigo’s Serious Incident Report had been implemented and this was duly provided by Navigo in an e-mail of the same date. Action proposed by Navigo in response to the concern 5 Navigo will continue to operate in accordance with the Revised Policy and will ensure processes to inform both new and existing staff members of the cover arrangements remain in place and are audited. 6 Voicemail messages on Navigo work phones will include contact details for urgent assistance. A communications plan will be developed for its implementation and an assurance plan to monitor compliance. 7 If the family have any further questions Navigo would be happy to receive them from the family and will respond directly to the family. Any further questions can be raised by contacting: Patient Advice and Liaison Service Navigo House 3-7 Brighowgate Grimsby North East Lincolnshire DN32 0QE

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Email: Phone: (Office hours 9am-5pm Monday to Friday or voicemail) Signed

Position Chief Executive Dated 30th January 2024