Dear Mr Cohen,

Re Regulation 28 Report to Prevent Future Deaths - Mr Lindsay

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1st August 2024 concerning the death of Mr Lindsay on 28th February 2024. In advance of responding to the action raised in your Report, I would like to express my deep condolences to Mr Lindsay's family. The response from the North East and North Cumbria Integrated Care Board (NENC ICB) to the concern in your Report is as follows.

Concern: I am concerned that providing treatment for Mr Lindsay's mental health was passed between several teams, with none of them being willing to accept that it fell within the ambit of services they had been commissioned to provide. I am concerned that there is a risk that in future cases mental health support will not be provided to those suffering from terminal illness and that this may lead to other patients experiencing crisis and attempting to end their lives. I consider that the lack of clarity as to the responsibility for providing such care may cause further deaths.

The ICB have undertaken a review of Mr Lindsay's patient journey from the months prior to his diagnosis with metastatic Oesophageal Cancer up until his date of death.

Working with the organisations involved each team has completed a review of their care and treatment and reflected on the patient's pathway. As a result, a few immediate actions were identified and are currently being implemented. These are as follows:

• Cumbria, Northumberland, Tyne and Wear NHS FT (CNTWFT) are raising awareness with their teams of the Marie Curie helpline for people living with terminal illness as well as educating teams on the Macmillan service offer.

• North Cumbria Integrated Care NHS Trust (NCIC) have provided further training to the palliative care team to help better support conversations with patients, who may have risk issues, how to assess them and to secure the right level of care. The Trust are also reviewing their draft Mental Health Strategy, this is to ensure it reflects and highlights that those patients

presenting with a long-term condition are likely to have a higher risk of death by suicide. The strategy will also clearly outline the role and responsibilities of the CNTWFT mental health teams and the necessity to share assessments and safety plans with relevant parties.

To further address your concern, the ICB will also be holding a reflective learning event with those involved in Mr Lindsay's care and treatment. This will enable the teams to reflect, identify and explore further opportunities to improve patients experience of care and to ensure that there are no unforeseen barriers in ensuring that any patient suffering a terminal illness receives seamless, responsive and supportive care. We would be happy to share the outcome of this event with Mr Lindsay's family and yourself.

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