Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Emily Rose Collishaw who died on Wednesday 6 September 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 27 June 2024 concerning the death of Emily Rose Collishaw on 6 September 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Emily’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Emily’s care have been listened to and reflected upon.

Your Report raised the concern that the organisations working with Emily took time to agree their different roles, that the level of support provided was insufficient and that the referral for residential care should have been made earlier. You also raised that the delay in accessing residential care has progressively been getting longer over the past 10 years, which poses risks such as sudden death to patients.

NHS England has been engaging with South East London Integrated Care Board (SEL ICB), who we note you have also sent your Report to. We are advised by SEL ICB that Mental Health colleagues have reviewed Emily’s care and consider that there is evidence of coordination between the Home Treatment Team and the Pier Road Project (PRP) interface, to include joint visits and information sharing, as well as consultation with the family. I would refer you to SEL ICB’s full response to your Report for further information.

The PRP is commissioned locally by the Local Authority, London Borough of Bexley, as is usual for drug and alcohol rehabilitation services for which responsibility sits with local government, overseen by the Department of Health and Social Care (DHSC). I note that you have also addressed your Report to the DHSC, as well as the Department of Levelling Up, Housing and Communities, and it would be more appropriate for the government to comment on your concerns about wait times for residential rehabilitation placements.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

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Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Emily, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mr Harris, Thank you for the Regulation 28 report of 27th June 2024 sent to the Minister for Public Health, Department of Health and Social Care about the death of Emily Collishaw. I am replying as the Minister with responsibility for Public Health and Prevention. Firstly, I would like to say how saddened I was to read of the circumstances of Emily Collishaw’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises the following concerns:
1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse.
2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients. In preparing this response, my officials have made enquiries with the Care Quality Commission to ensure we adequately address your concerns.

My department recognises the need to improve specialist drug and alcohol treatment services. Additional funding has been available since 2022/23 for local authorities to improve the quality and capacity of drug and alcohol treatment, including inpatient detoxification and residential rehabilitation services, and an additional £266.7 million was made available to them this year. I am aware of variability across the country in access to inpatient detoxification and/or residential rehabilitation. To address this (as part of the increased funding provided since 2022/2023), combinations of ring-fenced funding, targets, additional guidance and targeted support have been used to improve capacity and quality of inpatient detoxification and residential rehabilitation. We also plan to publish further guidance for local areas on improving access to residential rehabilitation later this year. In London in 2021, following the steady closure of the city’s inpatient detoxification units due to increasing costs and an unsustainable spot purchase funding model, the PanLondon Inpatient Detoxification Programme was established to address the issue and an 11-bed unit in St Thomas’ hospital was opened. The unit provides a high level of care for a small cohort of people with complex needs. Work is currently underway, led by the London Regional Team of the Office for Health Improvement and Disparities (OHID) to further develop sustainable inpatient detoxification provision in London. At a local level we would expect alcohol and drug treatment services to do what they can to minimise delays in accessing inpatient detoxification and residential rehabilitation, provide individual support to anyone waiting for it, and to regularly review their needs. The UK Clinical guidelines on alcohol treatment (to be published later this year) will include recommendations to promote this good practice. Guidance has been issued on the importance of integrated and co-ordinated care for people with co-occurring mental health and alcohol or drug conditions including NICE Guidance 58 and Better Care for people with co-occurring mental health and alcohol/ drug use conditions. OHID’s Commissioning Quality Standard provides guidance for service commissioners on improving services for people with co-occurring mental health and alcohol or drug conditions. Local services should work together so that people can access the help they need for both their mental health and their alcohol or drug use. We do, though, recognise that improvement is still needed across England, and OHID and NHSE will continue to work closely together to improve integrated and co-ordinated care for people with comorbidities, including co-occurring mental health conditions and alcohol and drug use conditions. I hope this response is helpful. Thank you for bringing these concerns to my attention.

Dear Diane, thanks for sharing a copy of this coroner's report into the death of Ms Emily Rose Collishaw. After reviewing the report, MHCLG officials do not consider that there is a specific policy angle here for Us to respond to, so am writing to confirm that there will not be a response from this Department_ have informed the Department for Health and Social Care who will be the lead Department responding to this report Thank you again, and please let me know ifyou have any questions Best wishes, Ministry of Housing; Correspondence Unit Ministry of Housing, Communities & Local Government Communities & gov uk/mhclg @mhclg Local Government Reg: From: Many -