Dear Ma’am, Regulation 28 Response – Mark Ravensdale We write in response to the Regulation 28 report following the inquest touching the death of Mr Mark Ravensdale. We would like to start this response by offering Mr Ravensdale’s family our sincere condolences for their loss. As part of our response, the Trust does not intend to provide any information in respect of the clinical rationales in Mr Ravensdale’s care. We hope the information supplied in this response provides assurance that the Trust has carefully considered the concerns raised and will take appropriate action to address them. There were no attempts by mental health services to speak to Mark directly to properly and adequately assess his mental health condition The Trust’s Single Point of Access (SPA) teams triage approximately 2000 referrals per month. It is therefore essential that all referrals undergo an initial triage by a qualified mental health professional, with the support of the multi-disciplinary team as required, in order to establish an individual’s mental health needs, the most suitable plan for meeting any identified mental health needs and the urgency and priority of any assessment required. In addition to establishing the urgency and nature of the response, the SPA triage process will determine whether a full comprehensive assessment is required. The SPA triage process is aligned with national standards in the form of the UK Mental Health Triage (MHT) Scale Guidelines (Sands, Elsom & Colgate 2015). The triage process would commonly involve direct contact with the person referred unless there are circumstances where it is clinically appropriate to carry out triage using the clinical records,

alongside information from professionals and carers working with the individual. This is particularly appropriate when other agencies are directly involved in delivering care and where the person has had recent assessments. Following receipt of the Regulation 28 report the Trust undertook a review of the SPA triage process specific to your concern, led by the Associate Director of Operations, Adults and Older People Mental Health Care Group. It was identified that, although the outcome of any triage process is reached based upon an evidence-based approach in line with the UK Mental Health Triage (MHT) Scale Guidelines and a practitioner’s own clinical assessment, further guidance would support a practitioner to identify when direct contact with the person referred may be clinically indicated. The Trust will therefore develop and implement a triage checklist in respect of the review’s findings. A Plan, Do, Study, Act (PDSA) cycle process will be applied to the implementation of the triage checklist. PDSA cycles provide a model of improvement framework to support change to services and care delivery. PDSA stands for:
• Plan – what you are going to do
• Do – what you have planned
• Study – the results of your actions
• Act – on the results and make improvements An initial study of the triage checklist impact upon service and care delivery will be undertaken following 6 months of the checklist’s implementation, with appropriate actions taken as identified by the study. I do hope the above information is of assistance and answers the concerns raised within your Regulation 28 report following the sad death of Mr Mark Ravensdale.