Dear Ms Heaven,

RESPONSE BY SWANSEA BAY UNIVERSITY HEALTH BOARD TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS ISSUED IN THE INQUEST OF AMY PADLEY

This letter is written in response to the Report issued under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated notification dated 24th April 2024 wherein you identified the following concerns and stated that it was your opinion there is a risk that future deaths will occur unless action is taken.

The concerns you raised are set out below the concerns along with the actions taken by the Health Board.

CORONER’S CONCERNS Concern 1 When an individual is suffering from alcohol or drug addiction alongside a mental health diagnosis, which in this case was EUPD and depression, that the focus of SBUHB is normally to advise that individual to address their addiction before they can access mental health services. I heard that addiction services do not fall within the remit of SBUHB and are provided by third-sector agencies. I heard that individuals who have a mental health diagnosis may self -medicate to manage symptoms of a mental health deterioration and that increased use of alcohol/drugs can increase the risk of self-harm to such individuals which may prove fatal. Cadeirydd/Chairman: Prif Weithredwr/Chief Executive: gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Rydym yn croesawu gohebiaeth yn y Gymraeg ac yn y Saesneg. We welcome correspondence in Welsh or English.

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. Cadeirydd/Chair: Prif Weithredwr/Chief Executive:

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board

Swansea Bay University Health Board Response: The Mental Health (Wales) Measure (2010) (MH Measure) defines the provision of mental health services into Primary and Secondary care provision. This response will clarify the difference in service provision for individuals with co-occurring mental health and substance use between primary and secondary levels of care. Part 1 of the MH Measure relates to Local Primary Care and seeks to improve and expand the services available for GPs and similar to refer patients to for support.

These services essentially cover two groups, those who have “mild to moderate” mental health problems, for example anxiety or depression, and those who have more serious mental health problems but who are sufficiently recovered that their illness is stable. Part 2 of the MH Measure relates to Secondary Care. It provides people who receive secondary mental health services with two rights: the right to have a Care Coordinator appointed to work with them to coordinate their care and treatment, and the right to an individual and comprehensive Care and Treatment Plan to assist their recovery.

SBUHB Community Drug and Alcohol (SBUHB CDAT) Services do not fall under the MH Measure. Patients receive care in line with their assessed needs. Access to Substance misuse services is initially via a collective of specialist third-sector organisations (Barod, Newid, and Dyfodol) who have expertise and experience in meeting the needs of people experiencing substance misuse issues. Access to substance misuse services requires the patient to demonstrate motivation and a willingness to actively participate with the service provider, focusing on harm reduction and the provision of social support. SBUHB CDAT work collaboratively with these third-sector organisations, who play a crucial role in supporting individuals with addiction, offering relapse prevention work both pre and post detoxification, and providing ongoing support to individuals as they navigate recovery. These third-sector organisations work closely with the SBUHB CDAT to ensure a seamless and coordinated approach to care, enhancing the overall support system for individuals in need. As part of this, the SBUHB CDAT will work with individuals to reduce harm, maintain stability and work towards the longer-term goal of abstinence. This will include opiate substitute therapy (stabilising and maintaining individuals on treatments to stop opiate use) or detoxification programmes for individuals to safely cease dependent substance use.

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. Cadeirydd/Chair: Prif Weithredwr/Chief Executive: Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board The SBUHB CDAT service is staffed by qualified Mental Health Nurses and Consultant Psychiatrist who have specialist roles in the management of substance misuse patients. Since Spring 2024, SBUHB has employed two co-occurring (mental health and substance misuse) link workers, experienced mental health nurses covering the Swansea Bay footprint. They provide support to individuals with both mental health issues and substance use challenges. These link workers work specifically bridge the gap between the Community Mental Health Teams (CMHTs) and Community Drug and Alcohol Teams (CDATs) ensuring a more seamless, collaborative approach to care. They work as members of the multi-disciplinary team, with their role centred on promoting joined up working, actively participating in assessments, ongoing screening, care planning, and treatment delivery. Referrals to the link workers are accepted through attendance at multi- disciplinary team (MDT) meetings, case reviews, and clinical discussions. The co-occurring link workers apply a range of evidence-based approaches including harm minimisation, relapse prevention, motivational interviewing, and planning or supporting detoxification programmes. In addition, they provide tailored mental health care based on individuals’ clinical needs, reinforcing a recovery-focused model of support. The link workers carry a limited caseload of individuals who have been identified as having established substance misuse issues, allowing for more intensive and personalised intervention.

Between October 2024 and March 2025, SBUHB held co-occurring training for clinicians working in Liaison Psychiatry along with both mental health and substance use services in the community and in the wards, with the aim of building knowledge, skills and helping staff understand the complexities of dual diagnosis and equipping them to respond effectively. This two-day training focused on enhancing trauma-informed practice, promoting a deeper understanding of how mental health challenges and addiction are often rooted in past experiences and unmet needs. Through interactive sessions, reflective exercises, and real- life case examples, clinicians explored the impact of trauma, the evolving concepts of addiction and mental health, and the importance of relationship-based working. The training also highlighted strategies for self-care and team resilience, recognising the emotional demands of working with individuals facing complex co-occurring issues. Feedback from participants indicated the training was valuable in improving confidence, encouraging more holistic approaches to care, and fostering stronger collaboration across services.

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. Cadeirydd/Chair: Prif Weithredwr/Chief Executive:

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board This has improved the services ability to work with individuals with co-existing mental health and substance misuse challenges giving staff improved insight into the needs of the patients enabling them to provide a more inclusive and accessible service. Analysis of attendance and the effectiveness of the training (which includes a Microsoft forms review of the awareness and uptake of the role of the Co-occurring keyworkers) is currently underway with a report due in the June MHLD Quality and Safety Committee meeting with a view of deciding on any additional training and developmental needs being identified for action.

The SBUHB Local Primary Mental Health Support Service (LPMHSS) provide assessment and intervention for adults who are experiencing common mental health problems (such as Anxiety, Depression, Post Traumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder (OCD)), or stable severe and enduring mental health problems. This is described as a Primary Care Mental Health Service (under the MH Measure). Here, therapeutic interventions include a range of group work programmes (e.g., Emotional Regulation Skills) and/or individual therapy (as directed by the treating therapist) which are focused on reducing the psychological difficulties associated with mental health issues and is in line with NICE guidance. These services have been identified for patients where their assessment needs have identified they do not meet the secondary care criteria and this service is available to all patients in primary care.

There is a Community Personality Disorder Service (Dechrau Newydd) within Swansea Bay University Health Board (SBUHB), which offers a NICE Guidance recommended treatment, Dialectical Behaviour Therapy (DBT) for suicidal women and men with a diagnosis of EUPD, who are in receipt of Secondary Care Mental Health Services (MH Measure).

Concern 2 No guidance to staff within SBUHB on how to manage individuals with addiction and a mental health diagnosis and how SUBHB staff should liaise with and work alongside third- sector agencies in respect of an individual suffering from addiction.

Swansea Bay University Health Board Response: The SBUHB CDAT and third-sector organisations work together, ensuring a collaborative approach for individuals with both substance use and mental health concerns. This includes

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. Cadeirydd/Chair: Prif Weithredwr/Chief Executive:

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board regular coordination between clinical teams and third-sector agencies where necessary, to discuss specific cases and ensure that appropriate care plans are in place. While this collaboration is in place for Substance Use Services, we recognise the need for more formalised guidance and integration to ensure Community Mental Health staff are clear about how best to manage individuals with both addiction and mental health diagnoses. This has now been enhanced by the introduction (Spring 2024) of the co-occurring key worker role who are in place to help staff bridge the gap between mental health and addiction services.

In Liaison Psychiatry an additional Substance Misuse nurse was employed starting on 12th November 2023. This role has the additional responsibility in working with the mental health nurses in Liaison Psychiatry to highlight the mental health needs of patients with substance misuse issues. The additional Substance Misuse nurse has increased the opportunity for joint assessments with mental health nurses, aiming to provide a comprehensive care package for the individuals and improving awareness of the needs of this patient group within the service.

An Operational Co-occurring Group is currently being developed between Mental Health and CDAT services to implement clear working guidance on joint working processes. This group will commence in May 2025 and will be co-chaired by the Directorate Managers for both the Adult Mental Health Directorate and the CDAT Directorate. The objectives for this group are to develop a Standard Operating Procedure for managing individuals with both addiction and a mental health diagnosis, ways of strengthening this support, including developing further guidance for staff to help them navigate these complex cases and provide clear direction on how to liaise with third-sector organisations effectively. This will be completed by October 2025. The outcomes from the Operational Co-occurring Group will benefit both patients and staff by providing clearer guidance, monitor risks, improve understanding and secure closer collaboration and treatment between addiction and mental health teams.

There was previously a regional Co-occurring and Mental Health Steering Group meeting, which achieved some of its aims producing a regional Co-Occurring Mental Health and Substance Use Strategy for the West Glamorgan Region (2023-2026). The Strategy applies to all statutory and voluntary sector organisations delivering mental health and substance

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. Cadeirydd/Chair: Prif Weithredwr/Chief Executive: Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board use support to adults across the West Glamorgan Region, in both community and inpatient settings. Some of the work in relation to its implementation resulted in the development of the above link worker posts. The emergent Operational Co-occurring Group will use this Strategy as a basis for the development of a Standard Operating Procedure and Clinical pathway to take the work forwards.

The steering group will need to be re-established and supporting by the West Glamorgan Area Planning Board for Substance Use structures and further development work on the co-occurring issue will from part of the planned work the publishing of West Glamorgan Drug Commissioning Report which will be in the coming months.

Concern 3 Reluctance within SBUHB to offer mental health support alongside suggesting that an individual access addiction services. This may mean that individuals in mental health crisis and suffering from addiction may not be getting the mental health assessment and support that they require alongside seeking to overcome their addiction and as such there is continuing risk to life.

Swansea Bay University Health Board Response: For individuals who are experience a mental health crisis, and not currently under Mental Health, or Secondary Care Services, there is the Single Point of Access (SPOA) on NHS 111 option 2 for Mental Health Services. This is open to the general population of Wales on a 24/7 basis. This call line is managed by health professionals, who will triage calls and direct as appropriate to ensure the right level of response and intervention is arranged. This would be the first point of assessment and intervention for any individuals in crisis. This Service was launched across Wales in June 2023. SBUHB recognises the need to improve current pathways and the culture surrounding the delivery of mental health support alongside addiction services. While the existing approach aligns with established best practices, often prioritising the stabilisation of substance use before addressing mental health needs, we acknowledge that this model may not be suitable for everyone, particularly for individuals experiencing a mental health crisis. There is an increasing recognition of the importance of flexible, person-centred approaches that respond to the complexities of co-occurring conditions in a more integrated and timely way.

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. Cadeirydd/Chair: Prif Weithredwr/Chief Executive: Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board Following this inquest, associated learning and Regulation 28 concerns, further reflective and learning sessions will be facilitated throughout May 2025, to ensure the respective findings, appropriate NICE guidance and best practice is embedded and sustained across psychiatric liaison, mental health and CDAT.

For those patients with a diagnosis of EUPD who are eligible for secondary mental health care and therefore the SBUHB community personality disorder service (Dechrau Newydd), DBT is a comprehensive treatment approach whereby patients are allocated an individual therapist (e.g. weekly 1:1 sessions) and group skills session (e.g., weekly, lasting 2.5 hours) with telephone coaching being available weekdays (office hours) to patients in crisis between sessions as agreed with the therapist, or skills coach.

The primary care level of service, which is provided by the LPMHSS within SBUHB, offer a range of therapeutic group work programmes for adults, such as Emotional Regulation Skills, and/or individual therapies as directed by the treating therapist which are focused on reducing the psychological difficulties associated with common mental health issues such as Anxiety, Depression, PTSD and OCD. SBUHB (as across NHS Wales) provides free mental health and wellbeing programmes, via Silver Cloud, an online CBT programme which people can self-refer to. However, SBUHB acknowledges that the LPMHSS does not currently offer specific treatment approaches for EUPD, such as DBT as outlined by NICE guidance.

To progress the Co-occurring and Mental Health Strategy (2023–2026), SBUHB recognises the need to instigate local Operational Co-occurring Strategy meetings and re-engage with the Regional Area Planning Board for Substance Use and Partnership Board to explore further support following the receiving of the West Glamorgan Drug Commission Report. These meetings, starting in May 2025, will be critical in reviewing current practices, identifying gaps, and driving forward a more integrated and responsive approach to care. Key areas for action include reviewing and aligning mental health and substance use services to ensure individuals do not fall through the gaps while seeking treatment for either need, particularly during periods of crisis. The development of the SOP and Care pathway will achieve this. Strengthening partnerships between statutory Mental Health Services and Third-Sector organisations is also essential to improving support for individuals with co- occurring conditions. Additionally, there is a need to streamline access to mental health

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay. Cadeirydd/Chair: J Prif Weithredwr/Chief Executive: Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board care for individuals actively engaged in addiction treatment, enabling timelier, joined-up responses.

SBUHB would like to provide assurance that where patients are suffering a Serious Mental Illness, NICE guidance around managing coexisting Serious Mental Illness and Addiction will be followed by incorporating the additional developments (as detailed above) which will improve the service provided to any patients under a Primary or Secondary Care.