Dear Ms Mutch,

RE: Inquest touching on the death of David Power

I set out below the Trust’s response to your letter to Pennine Care NHS Foundation Trust (PCFT) and the issuing of a Prevention of Future Deaths Notice (Regulation
28), arising from the inquest into the death of David Power. May I take this opportunity to extend my own condolences to the family of David and apologise that you had to raise concerns relating to the services he accessed prior to her sad death. The Trust sets out its response to the points below raised by HMC’s as areas of concern:
1. I am concerned that the Home Treatment Team referred David to a service to receive psychological/ talking therapies. This was then called Healthy Minds. This referral took place when the HTT discharged David as they considered him to be sufficiently ‘stable’ under their HTT definitions.
2. However, David was not accepted for by Healthy Minds because they had a policy that they would not accept referrals for individuals who they did not consider to be sufficiently ‘stable’ under their Healthy Minds policies.
3. One of the criteria for stability was that the individual should not have attempted suicide or serious self-harm for 3 months. This was not known to the HTT at the time they made the referral. The effect of this policy meant that David was not accepted for this service, despite him making clear to services that talking therapies was what he needed most to support his mental health.
4. I heard evidence that this policy remains in place within NHS Talking Therapies (the successor to Healthy Minds) but is currently under review. I did not hear any evidence as to if or when it will change.

5. I am concerned that the lack of shared understanding and definition of ‘stability’ for patients along the talking therapies pathway creates a risk of future deaths. Taking the areas of concern relating to the issue of ‘stability’ across points 1-5, the Trust offers the following response for the attention of His Majesty’s Coroner. The Trust accepts that different services will work with patients who are classed as ‘stable’ within the remit of their services. For example, the Home Treatment Team or an acute in-patient ward will have a threshold for describing stability that is very different from a primary care service such as NHS Talking Therapies (TT). The Trust accepts that this variation in thresholds was not clearly understood by either service at the time of the referral for Mr Power. The NHS TT Step 2 & 3 is part of primary care, with a focus on needs-led care. The Standard Operating Procedure (SOP) will continue to outline the position that any current and significant self-harm will remain an obstacle to engaging in current therapy but will provide clarification that individuals will be assessed based on current stability, not past conditions, ensuring a streamlined process. Referrals will assess the patient's ability to engage and ensure their safety before admission onto the waiting list for therapy. NHS TT will refer individuals to the appropriate service if their service does not meet an individual’s needs and this will be monitored and checked by the NHS TT Leads and Service Manager via clear rationale that has been provided by the practitioner who has screened the referral. The draft SOP to outline the PCFT’s NHS TT Service and how they operate, is awaiting final review by the Trust’s Quality Group scheduled to take place on 22 November 2024. It will also be taken to the Psychotherapeutic Committee for discussion and then shared with relevant teams. In the SOP, changes have been made to the Risk Management Section (20) to reflect the NICE guidelines of risk formulation rather than risk rating.  The Trust has ensured that our lead for NHS TT has reviewed the SOP and the following clauses (‘Recent contact (less than 3 months) with other statutory mental health services’ and ‘Recent history of failed suicide attempt (less than 3 months)’) have been removed and will no longer be part of the screening as to whether a referral will be accepted or declined. Individuals will be offered an assessment if they meet the NHS Talking Therapies remit. Clinical judgment and supervision will be used to support decisions regarding the assessment process and may require discussion at the daily MDT, or individuals may be seen by a Navigator or a Senior Mental Health Practitioner (SMHP) if there are concerns. NHS TT Navigators are often the first point of contact and will not automatically reject patients, including those with drug and alcohol issues. Every case will be assessed individually, and support will be sought where necessary to handle complex situations.

The Trust’s NHS TT Teams will provide training to Living Well, HTT and our A&E Liaison colleagues to increase knowledge of how the TT services work in line with the new service SOP, this will foster and develop a much clearer shared understanding of the phrase ‘stable’. In relation to patient journeys that have a lack of clarity or diagnostic certainty, our clinical pathways between services (NHS TT and Living Well) have been strengthened. The Trust has now ensured that there is now a psychology representative from Step 3.5 at the daily NHS TT Team multi-disciplinary meeting to support the team with screening referrals. The Trust’s Living Well service also recognise that there is a lack of understanding, for both staff and service users and their carers, of the terms ‘stability’ and ‘stabilisation’. Both terms are used interchangeably when service users are referred into a service or to describe non eligibility for a service and a reason for referral rejection. The Trust recognises that these terms used do not reflect or align with person centred care approach, nor are these helpful to our service users, or their carers, particularly when understanding a service users’ care journey and why decisions were made. As a Trust we are taking action to support practitioners to change this aspect of describing a person’s current condition. The Living Well services, will be holding reflection and learning sessions for our staff in relation to language, with particular focus on these terms and what they mean and how there use impacts providing person-centred care. These will take place from end of January 2025 onwards. The Trust’s Living Well service will be offering service information sessions to other teams, both within PCFT, and to external providers and asking other services to attend our team meetings to present and allow discussion regarding their respective services on 27 November 2024. This session will be repeated over the coming months to ensure if reaches the widest audience. The service has also changed its approach to receiving and triaging new referrals. At the time of David’s death, all referrals into Living Well were recorded and managed by Big Life. All referrals for Living Well are now managed and processed through PARIS PCFT electronic record system and it was recognised at David’s inquest that improvements have been made in this area. However, it was evident at the inquest that more could be done in terms of referral management and transition/transfer between PCFT teams. In order to support the wider system and improve quality and mitigate risks in relation to referrals that transition between services there have, and will be, further changes as follows:
• New referrals coming to Living Well from external providers where the ask is NHS TT, individuals are screened for risk by a SMHP and forwarded to NHS TT as appropriate following screening. The referral remains open and is only closed when we have an outcome from NHS TT is agreed.

• Referrals from other PCFT services requesting another PCFT service – For service users with another PCFT service, where they no longer need this level of care however are still in need of mental health support from another team, the ask is that referrers attend the Living Well multi-disciplinary meeting to discuss the service user and their strengths and needs, this allows for both an internal service discussion and a person centred discussion providing an understanding of their strengths, what their current needs are, and how these can be met.
• The Trust acknowledges that there are situations where risk can escalate for those individuals who are under the Living Well services. Living Well have a daily escalation meeting where if there are any concerns regarding a service user’s safety or safety of others support can be explored and a plan formulated/agreed to support/manage any escalations; also, outside of this meeting a duty system can be utilised for those individuals who are in a process of waiting for an allocation of a senior mental health practitioner.

6. I heard evidence that since David’s death, the HTT has emailed all the staff at the Tameside HTT to re-iterate the importance of referring cases to SPOE meetings for MDT consideration, and that this has been discussed in two team meetings before February 2024. There was no evidence before me of whether this has been embedded or audited within the team to reduce the risk of future deaths. The Trust acknowledges that before discharge, a treatment/care pathway should have been discussed and agreed; page 13 of the HTT SOP which includes a paragraph relating to discharge process, specifically:

‘If the service user requires a referral to other community services such as Living well, and talking therapies, then the practitioner must complete a referral form online and send to appropriate service. This will then be discussed the week after, during their daily huddles, where they discuss each patient who has been referred and their suitability. Patients are not to be discharged from HTT until the outcome of the referral has been discussed and agreed. For service users where a longer term and/or complex care has been indicated, the practitioner can refer to the single point of entry meeting with the corresponding CMHT; this consists of various practitioners and the sector Consultant based on the patient’s GP location.’

The Trust HTT SOP explains the new processes for the HTT practice of referring to the Living Well and TT SPOE, plus other agencies. The HTT Service Manager and Team Manager have a responsible and accountable role for checking and auditing monthly (commenced 2024) that discharges and onward referrals are managed in accordance with the new SOP.

I hope that the information within this response has provided you with the assurance that you were seeking in relation to learning from these events. Should you require any further information or clarification on the details within this letter, please do not hesitate to get in touch with me again.