Dear Mr Parsley,

Regulations 28 (Coroners Investigations Regulations 2013) notification made in response to the death of Owen Donal Gardner

I am writing in respect of the prevention of future deaths report you sent to the Trust following the inquest into the death of Mr Gardner, concluded on 3 July 2024.

You wrote to the Trust to raise matters of concern which you assessed the Trust could take action to reduce the risk of future deaths. I am grateful for you writing which supports our drive to provide safe services.

You identified concern that an individual with a short term memory difficulties and a cognitive deficit will miss an appointment which could prevent their death, if their next of kin (or chosen point of contact) are not also told of short notice changes to the timings of that appointment.

Your concern was based on the evidence that the Trust had agreed to inform Mr Gardner’s next of kin of his appointment with his clinical team. On occasions, short notice changes to dates resulted in Mr Gardner being informed but sometimes not his agreed next of kin. The impact of this was that Mr Gardner missed a number of appointments as he was unable to retain information of appointment changes. You heard evidence there was no robust system in place to facilitate this.

The Trust agrees it is critical that people are provided with the right support to enable them to access care at the right time. The practical role that families and carers play cannot be underestimated and the Trust’s goal is to work in collaboration with families to enable the best outcomes for people that access our services.

To this end, it is our policy, at the commencement of care, to identify who the family and/or carer is and how we may communicate with them, based on the consent and agreement from the service user. The policy and expectation is for staff to record service user consent to information sharing on the Trust ‘Your Data: Your Choices’ form. In addition, communication preferences should be noted in their care plan/combined assessment and those preferences used in accordance with the patient wishes, whether the communication takes place by telephone, email or text message.

It is most often the case that routine appointments are communicated by letter however urgent or cancellation appointment offers may be made via text, email or through telephone calls based on the agreed method and timeframe to the appointment. This means there is no one single technical solution that will fully mitigate the risk but a range of actions.

1. The Trust is in the process of procuring a new Electronic Patient Record (EPR) which includes ‘patient portal’ functionality that will enhance our capabilities for appointment scheduling, particularly in terms of visibility for patients. This new EPR is approximately two years from being NSFT Trust Management Norfolk & Suffolk Foundation Trust County Hall Martineau Lane Norwich NR1 2DBH Tel: 01603-421421

Date: 09 September 2024 Senior Coroner Nigel Parsley Suffolk Coroner’s Court Beacon House Whitehouse Road Ipswich IP1 5PB E mail: Coroners.service@suffolk.gov.uk By email only

available however, as we are following the nationally mandated procurement route for such purchases.

2. In the interim the trust has commenced work on enhancing the current EPR, Lorenzo. We have identified a potential enhancement that will allow staff to indicate, when generating correspondance (including appointments) that the correspondence should also be sent to the Next of Kin or Carer, according to stated patient preference

We have some concern that this feature could result in correspondance being sent to Next of Kin or Carers without appropriate permissions so the change would only be implemented once we have been reassured that it is clinically safe and compliant with our Information Governance policy.

Following this assessment, if the change goes ahead it will be completed as a priority as soon as possible, our current expectation is that it will be in place by the end of November 2024.

3. The Trust has also issued a patient safety alert to ensure the process remains a primary focus for our staff while this work is completed. This is attached for information.

4. In addition, our community services standard operating procedure will be updated to include the guidance on the enhanced changes to Lorenzo, along with confirmation of the expectation that communication preferences will be noted in the service user care plan/combined assessment for ease of reference when communicating with service users and those supporting them.

5. The Trust had also initiated a Listening into Action™ pioneer programme called Think Carer and Family. The Listening into Action™ programme approach is a comprehensive, systemic, outcome- oriented approach to empower staff at all levels to work through any challenges to ensure quality outcomes. In order to bring greater consistency to recording next of kin details to ensure that the technical improvement and system expectation mentioned in the above paragraphs can be meaningfully applied, the aim of the Think Carer and Family LiA programme which was launched on 10 June 2024 is to have 90% of carers and 100% of Next of Kin documented on service users’ records. Initially within Child and Adolescent Mental Health Team, West Suffolk, and Adult Crisis and Resolution Home Treatment Team, West Suffolk, rolling out to the rest of the trust from October 2025.

Finally, you are aware that the Trust undertook a safety incident review in order to identify any learning to improve practice and shared that report with the clinical team that provided care to Mr Gardner.

6. The clinical team involved in Mr Gardner’s care have undertaken further reflection and consideration of the Safety Incident Review investigation undertaken by the patient safety team alongside the findings made at inquest, and the Regulation 28 report. This has enabled the clinical team and its managers to reflect upon any human factors that contributed to the situation which arose in Mr Gardner’s case regarding family not being directly invited to the discharge appointment that had been brought forward by 90 minutes, by agreement directly with Mr Gardner. This further reflection took place on Thursday 5 September 2024 for this purpose.

The outcome from this meeting was that the EPR system enhancement noted at paragraph 2 will be helpful and the team, will robustly ensure that all future assessments will include consideration of possible short term memory difficulties and confirmation of communication preferences which will be recorded in the combined assessment/recovery plan and safety plans.

I hope the above-mentioned actions provide assurance to you and Mr Gardner’s family that NSFT is committed to improving practice for all our service users.