Dear Ms Booth On behalf of Arts University Bournemouth, I acknowledge receipt of your letter dated 31 January 2025 relating to the Prevention of Future Deaths Report following the inquest touching the death of Alexander Channing. I note the concern raised by HM Coroner: There is no training provided to the wellbeing services at the Arts University Bournemouth in relation to students diagnosed with Emotionally Unstable Personality Disorder. I confirm to HM Coroner that a full day training session on EUPD and personality disorders was delivered to 17 members of Student Services staff, including Wellbeing Practitioners and Counsellors, on Monday 6 January 2025. Training was provided by , Senior Partner in Metal Health Training. is a psychologist and has also trained in postgraduate Psychiatry at Cardiff University School of Medicine. Full details of the training provided are available at https://mentalhealthtraining.co.uk/the- frontline-training-group/ I trust this action fully addresses the concerns noted in the Prevention of Future Deaths Report.

Dear Mr Middleton, Re. Mr Alexander Kieran Ari Channing – Regulation 28 report. I write in my capacity as Interim Chief Nursing Officer & Allied Professions Lead for Devon Partnership NHS Trust (DPT) in response to your regulation 28 report dated 31 January 2025. If I can first pass on my condolences to Mr Channing’s family and friends. In your report you highlighted areas of concern to The Vice Chancellor of Arts University Bournemouth, The Chief Executive of Dorset Healthcare NHS Foundation Trust, along with us Devon Partnership NHS Trust (DPT). In respect to the concerns pertinent to DPT I respond as below: There appears to be a failure amongst staff at the Exeter CMHT to appreciate that there can be a direct transfer of a patient’s care to another CMHT Trust without the need for a patient to have to first register with a GP surgery – Patient transfers to out of area services remain a challenge for all NHS providers. We have an agreed standard operating procedure that articulates the process to collaboratively transition a person between community mental health services from Devon Partnership Trust to another Trust. At times the referring team may still experience local challenges in relation to an out of area transfer, as the policy relates to DPT’s processes only. Details on referring a person to another Trust where they do not yet have a GP can be found on page 6 point 6.6, this is the specific detail,
1. Person without a known Address and/or Registered GP on Transfer
1.1. On occasion a person may not have a known address or registered GP in Devon or part of Devon that is covered by the team the person is transitioning too. This occurs where a person has been placed out of area or temporarily moves (home address) or is in unstable accommodation or is released from prison. The lack of address/changed address or registered GP, should not be the sole reasons for declining a transition or transferring to another team/service whilst in the first 3 - 6 months of the initial transition. If a service, even a monitoring service is offered by a Trust service it is incumbent on the service being transitioned to, to make reasonable adjustments (i.e. allocate to a practitioner/service

regardless of the eventual locality a person may be accommodated or where the GP will be registered) C16_Transitions_Ma r24 (2).docx Where this is the case, transfer will be planned and managed in a sensitive way taking into account an individual’s needs. The existing service keyworker/care coordinator or person identified in the Service Standard Operating Procedure [SOP], will be responsible for management of the transfer and ensuring all communication is clear to the user, referrer and receiving service to ensure that the person receives a seamless service. Until a person’s eligibility for services is determined, there should be no gap in service provision. The current services will continue until either the services the person is transitioning to are in place, or the assessment shows that there are no eligible needs. It should be noted that some services have long waiting lists. A person that is needing to transition to one of these services will have their referral reviewed with the local knowledge and prioritisation for their waiting list status in the service being transitioned to, this service will support the transition when agreed. The services covered by the Policy recognise that smooth transition planning may require collaborative involvement of a potential receiving service for a short period of time before the person becomes eligible for that service, initially in a consultation and liaison capacity. This will allow for adequate planning and hand over, without lengthy periods of uncertainty about what the onward service might look like. In general, this would not be expected to exceed between three to six months ahead, with the longer length for particularly complex cases. e.g. if a person is not eligible for a service until they are aged 18 or 65 or move to within the catchment area of a service, does not mean work on transition should not be undertaken prior to the cut- off point. It is not a case therefore of waiting for 3 months before a key worker is allocated, then a further 3 month wait until the new key worker starts to work with the referred person. The Trust aims to provide high quality, safe and effective services to all patients and recognises the importance of enabling effective continuity of care, particularly at times of transition when patients may be particularly vulnerable. It is important that any required transition process is managed sensitively and collaboratively to support continued engagement of the person and their support networks and safe and effective service delivery. There was a lack of involvement of a responsible clinician in the process of discharge planning from the district hospital in Exeter to the care of Bournemouth CMHT at Dorset Healthcare NHS Foundation Trust – In terms of discharge planning from Liaison Psychiatry, in relation to the planned discharge from the district hospital in Exeter, I can confirm that the following paragraph has been added to the Liaison Psychiatry Services Exeter, Torquay and Barnstaple Specialist Services Directorate Standard Operating Procedure. It gives detail on page 12 of the attached document.

For people who have been placed under Section 2 or Section 3 within the DGH and the plan is made for discharge to the community (not psychiatric hospital). The agreement is that the Consultant who rescinds the section will consider if 48 hour follow up by Home Treatment Team is required and make that referral prior to discharge. In those cases where this is not required then the rationale will be clearly documented in the patient electronic records. Individuals will be discharged from the service when the objectives and goals of the care and treatment have been met. This may be following an assessment in the Emergency Department or after a period of assessment. We will endeavour to signpost the person using our service to appropriate support in the community as required and liaise with our partner agencies. We do recognise and accept that an individual’s motivation to engage in treatment may vary according to their mental state. If an individual has made a choice not to engage in treatment, then we will aim to signpost them to other appropriate services, unless there is evidence to suggest that their capacity may be impaired, which would then require a capacity assessment to be undertaken. Upon discharge from Liaison Psychiatry a written assessment letter is provided for the patient, to the General Practitioner and, if applicable, the care team that is taking on the care and treatment of the individual. A copy is offered to the individual who is also given a service user satisfaction survey. The individual is also always asked whether they would like their carer or relative to receive a copy. Exeter Torbay and North Devon Liaison Our aim is to ensure good working practices and relationships between the Liaison Psychiatry team and across the Network functions within the Trust and with agencies/services outside the Trust. DPT endeavours to ensure that any transfer of care of patients from the Liaison Psychiatry Team to the appropriate Network function within or outside DPT is managed as rapidly and effectively as possible. There is no policy in place at Devon Partnership NHS Trust which encourages a repeated proactive approach in seeking consent from a patient to share information at relevant times. Devon Partnership NHS Trust has a policy in relation to confidentiality. In the attached policy it states that the person has a right to restrict disclosure to share information. DPT staff members would routinely review a person consent to share information. These reviews of confidentiality should take place when newly allocated to a new worker, identified new risks occur, or periods of transitions between teams. GV03_Confidentiali ty_Procedure_Feb19X

The person has the right to request restricted disclosure of all or some of their confidential personal information. If such a request is made there should be careful consideration of this and all reasonable attempts to respect their wishes and address their concerns should be made. Explanation of why the sharing is necessary in the particular circumstances should be given and the risks in relation to any restriction. Explicit consent must be received from the person and recorded on their electronic patient records for any sharing of information which is not directly related to their care. For example, someone may wish to have information shared with some family members but not others. It is important to ensure the consent is clearly recorded and understood. The person may change their mind about disclosure at any time before any disclosure is made and afterwards to prevent any further disclosures. If you feel that you need further detail, please do not hesitate to contact me again.

Dear Sir,

Re: Regulation 28 Report to Prevent Future Deaths following the inquest touching on the death of Alexander Kieran Ari Channing

I am writing following your letter dated 31st January 2025, following the inquest touching on the sad death of Alec.

Firstly, I wanted to acknowledge the incredibly sad circumstances of this case. I was so sorry to hear about Alec’s death, which I can only imagine must be a tragedy which his family and friends continue to live with. My thoughts are with everyone who knew Alec and with the staff who worked alongside him.

I acknowledge receipt of the Regulation 28 Report and the concerns you express as the Assistant Coroner overseeing the inquest, I note specifically the concern in relation to Dorset HealthCare NHS Foundation Trust ("Dorset Healthcare"):

There was a lack of involvement of a responsible clinician in the process of discharge planning from the district hospital in Exeter to the care of Bournemouth CMHT at Dorset Healthcare NHS Foundation Trust.

We would like to provide an assurance that Dorset HealthCare is fully committed to learning and taking any steps necessary to prevent future deaths and we understand the significance and importance of Regulation 28 Reports.

Having carefully considered the concern described, we have again reviewed the circumstances of Alec's discharge from Royal Devon and Exeter Hospital (whilst under the care of Devon Partnership Trust). In terms of what took place, Dorset HealthCare was unfortunately not involved with discharge planning on this occasion, apart from being contacted by Devon Partnership Trust to arrange a psychiatric outpatient appointment for Alec. The normal arrangement between NHS providers is for discharge arrangements to be led by the team seeking to transfer care. Learning from the circumstances of Alec’s death, we are seeking to strengthen our relationship with Devon Partnership Trust to ensure that there are effective and comprehensive discharge pathways between the two organisations.

Whilst we are confident that Dorset HealthCare does have relevant policies and procedures in place and our usual practice is to engage with discharge plans when patients are being transferred from areas outside of Dorset, this has been a tragic reminder of the need to

ensure this responsibility is understood by all of our clinicians and managers. We fully appreciate that we must take all steps possible across the NHS to facilitate the effective and well managed discharge of patients when they are transferring between services in different areas.

Following the conclusion of the inquest, feedback was provided at a local level at multi- disciplinary team meetings in the relevant area, this feedback included the concerns expressed by the Coroner and the experience of Alec's family.

Learning and Review Groups have been introduced in the Trust, in line with the Patient Safety Incident Response Framework, introduced in the NHS in 2023. They form part of Dorset Healthcare's organisational patient safety framework and are intended to share and disseminate learning across the directorates. Learning will be shared within the Learning and Review Groups at the next meeting which is scheduled for April 2025. The specific learning will be around the discharge of patients to and from services outside the Dorset Area.

I hope I have been able to provide reassurance that we have given proper consideration to your concerns and acted on the learning from this tragic case.