Dear Madam,

Response to Regulation 28 Report to Prevent Future Deaths

Thank you for your letter dated 2 May 2024, following the conclusion of the inquest into the death of Miss Evie Davies. I have reviewed your concerns fully and our responses and actions that we are undertaking to address these concerns are detailed within this letter.

The Concerns:

“During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The evidence I heard was that the café 71 service is run as a crisis line for those who are in ‘Lesser crisis’ than those who would call the mental health team crisis line or the crisis resolution home treatment team.

It appears that the cafe 71 team is operating in isolation/ separately to the mental health team, and for those patients who are under the mental health team, they will be unaware of the background and the risk factors for that person. They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team.

In addition, there does not appear to be any notification to the mental health team to say

200946337.1 that the person has been in contact such that this can be followed up. It is likely that there is notification to the GP but in this case, there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team, does not lend itself to the prompt action which may be required by the mental health team. I am concerned that the lack of information sharing between the organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and consider that your organisation has the power to take action, either as provider of the service or as commissioner.”

Response from Cheshire and Wirral Partnership NHS Foundation Trust (‘the Trust’ or CWP)

The Spider Project Café 71 Service and Trust Services

The Crisis Triage & Response Service (known as the crisis line) was established in 2020 it is a telephone service that is open to all ages and operates 24 hours a day, 7 days per week with no exclusion criteria. It provides support, advice and signposting for patients experiencing a self-defined crisis. There are a number of ongoing referral pathways to ensure people receive support in line with their presenting needs including the Café 71 which is delivered by The Spider project in Chester.

In order to assist, I wish to clarify the functionality and role of Café 71.

Café 71 is a community service which operates both open access direct for the population and through referrals from partners such as Primary care (GPs) and CWP. The service is commissioned by CWP to offer advice, guidance and crisis support to anyone aged 18 and over who are experiencing a self-defined crisis. Café 71 staff support individuals by helping them to de-escalate and resolve the crisis situations, the staff also work with the individual to recognise any underlying factors and supports onward referral and signposting to relevant services. By way of clarification, Café 71 operates between 10 am and 10 pm daily, it is not “run as a crisis line” as stated in the Regulation 28 report, to which this letter responds. Whilst Café 71 does provide telephone support to service users, where required, the majority of interventions and support provided by Café 71 are delivered “in person”, with service users being able to be referred into this service, or alternatively attend Café 71 (located in Chester) on any given day to receive support.

Café 71 is an appropriate referral for an individual who does not require immediate specialist or clinical support to keep themselves safe, but may nevertheless be presenting in a crisis and require support on an ongoing basis.

For clarity, should the Trust’s crisis line consider that a service user has immediate thoughts to self-harm or end their life, alternative signposting information and safety planning is considered in addition to – or as an alternative to – making a referral to Café 71. Café 71 is not considered to be an alternative to the Trust’s crisis line, but rather an additional resource for providing support to service users.

200946337.1 Café 71 staff also support people to identify and access appropriate services by referring or signposting, the aim is to improve an individual’s mental health and wellbeing, increase their independence and self-management of their mental health.

The Café also works to reduce social isolation, build resilience within people and communities through networking and peer support. The staff at Café 71 provide advice and signpost people away from clinical services when not required and provide support and a focus on recovery for individuals to develop self-management approaches to support their mental well-being.

If a person’s mental health needs and risks are not able to be met within Café 71’s environment, Café 71 staff will link in with CWP First Response clinical service and a clinician will offer mental health support and an assessment for the individual.

First Response service consists of the following crisis services:
• Crisis Triage & Response Service (includes Crisis Line)
• Home Treatment Teams
• Liaison Psychiatry
• Street Triage

As previously stated, Café 71 is not a clinical service; it does offer telephone support but is not operated as a ‘crisis line’. Any telephone contact by Café 71 would provide an opportunity to give support to a service user but would most often result in inviting them to attend Café 71 at the next available opportunity as a resource for further, ongoing support in relation to their self-defined crisis. It would not typically be for providing intensive support in response to an immediate crisis, for which the crisis line is the most appropriate resource. Should telephone contact be made by Café 71 to a service user who was presenting in immediate crisis, they should immediately be redirected and / or signposted to call the Trust’s crisis line, which is better equipped to provide immediate, crisis support to an individual. Should Café 71 staff have any concerns about a service user’s immediate safety, the Trust would expect this to be fed back immediately to the Trust, with advice to be provided to the service user as to keeping themselves safe in the interim period. If necessary, emergency services should be called by Café 71 staff should there be an immediate risk to life.

Miss Davies contacted the crisis line on 1 December 2021 at 13:05 and a referral was sent to Café 71, the reason for referral from crisis line to Café 71 was stated as below:

“Evie has been on a section under the MHA in October this year. She has lost her job as a care worker due to a conviction and is after some support in getting her CV updated and looking for a new job. There is a number of court cases on going also due to her losing her kids”.

Has been known to use drugs and alcohol and is pending an assault charge to an emergency worker”

At 20:27 on 1 December 2021 Café 71 staff emailed the crisis line as the referral did not contain a telephone number for Miss Davies. A telephone number was sent from the crisis line via email to Café 71 at 08:35 on 2 December 2021. A reminder has been issued to all

200946337.1 crisis line staff that all referrals between services need to contain contact information and where possible a warm transfer of the call should be completed where the call is directly transferred with patient consent. A warm call transfer refers to the caller being put on hold while the operative connects to the desired extension number or service and following a discussion with the receiving service the caller is transferred.

Following receipt of Miss Davies’ telephone number, Café 71 has confirmed their staff attempted to initiate contact with Miss Davies on 3 December 2021, 4 December 2021 and 5 December 2021. As no voicemail consent was provided alongside the referral, no voicemails were left on these failed attempts to contact.

On the 5 December 2021 Café 71 staff emailed the Trust’s crisis line to inform staff it had not been able to make contact on three occasions and advised if Miss Davies made contact with the Trust, the Trust should recontact Café 71. This is the standard process for Café 71 where contact cannot be made.

On 7 December 2021 the Operational Lead from the crisis line informed Café 71 staff that Miss Davies had sadly died on 2 December 2021.

The Trust can confirm there was no contact between Café 71 and Miss Davies from the referral being sent and her death.

Café 71 and how it collaborates with CWP Services CWP offers clinical support and guidance to Café 71, the location of the café and its geographical proximity to the crisis line has enabled close working relationships, shadowing opportunities and timely responses to any incidents or concerns the café raise. For context. the crisis line is in the same building as Café 71.

A frequent attender meeting is held monthly, in collaboration with professionals and services internal and external to CWP, including Community Mental Health Teams, High Intensity support staff, 3rd sector providers (including Café 71), Cheshire Police, Northwest Ambulance, Social Care, Crisis Line, Crisis Resolution Home Treatment Teams and Liaison Psychiatry. The aim of the meeting is to identify any people whose contact with any of the services mentioned above has increased due to their mental health issues with the purpose of offering a joined-up approach from all agencies to support the patient who maybe in crisis.

“They will take an assessment of that person at face value based on how they are in the call, as they don’t have access to the information held by the mental health team.” Café 71 do not have access to the Trust’s electronic Patient record system (SystmOne). However, the staff from Café 71 will contact crisis line staff to discuss any risk concerns, the teams work closely to ensure that the relevant information relating to a patient’s mental health is available to Café 71 staff. Café 71 staff can phone the crisis line to request further information, but more often the member of staff requiring the information will physically call into the office. Contacts between services are undertaken with patient knowledge and consent. The Trust would seek consent from the individual to refer them to Café 71.

Staff at the crisis line have access to the individual’s mental health records but will assess the person’s needs during the phone conversation based on the information they are providing. Not all callers to the crisis line are known to mental health services, so the call is based on the information discussed during the mental health triage assessment, with medical records

200946337.1 providing additional contextual information, if available. If a referral to Café 71 is deemed an appropriate action following the triage assessment, information pertaining to the person’s presentation, the reason for calling the crisis line, the rationale for the referral to Café 71 and any known risks will be provided, within Café 71 referral form that is emailed to the service.

The following learning has been undertaken by both the Trust and Café 71 to streamline how key information regarding individuals involved with mental health services can be shared with Café 71

Café 71 have confirmed they have updated their referral forms, the forms now include a prompt for the referrer to ask for consent on whether Café 71 staff can leave a voicemail and include information from the point of referral as to what support the individual requires, information relation to their mental health and any risks, the referral will also include information regarding other service and agencies the individual has been signposted to and what support has been put in place following the individual’s contact with the crisis line.

To provide assurances that this is embedded into practice, the Trust has included a review of referrals sent to Café 71 in an internal audit plan. This is being led by the Governance Lead for First Response, Ms Dreelan. The findings of the audit will be reported within the Acute Care and First Response Business and Governance meetings, for ongoing assurance. The audit will be completed 6 monthly. Where the findings of the audit do not meet the expected standard, remedial action will be taken to rectify this.

“There does not appear to be any notification to the mental health team to say that the person has been in contact such that this can be followed up.” If an individual is known to Community Mental Health Team, Café 71 will link in with the individuals’ key workers, this is via email or phone contact. This is set out in the current Community Mental Health Team Standard Operating Procedure. Café 71 staff are also invited to attend professionals’ meetings to provide feedback on the progress of the individual attending Café 71, including the level of engagement with the cafe, when an individual had completed their programme and offer recommendations for future support if appropriate.

Café 71 are also included during discharge meetings from in-patient mental health wards when attending the café as part of an individual’s recovery, if indicated.

As already stated, Café 71 also notify the Trust if they have failed to make contact with a service user on three occasions, following a referral having been made. This enables the Trust to monitor the progress of the referral and any additional support that the service user may – or may not – be accessing.

CWP acknowledge that there is open communication between Café 71 and mental health teams within the Trust and will reach out to teams for guidance and support whenever required, as mentioned previously there are formal meetings but the crisis line is accessible during operating hours of Café 71 to provide clinical guidance and support, communication is often face to face with crisis line staff, but information can also be provided via email.

“It is likely that there is notification to the GP but in this case, there was no detail provided which could have been passed on, and the timescales for review of correspondence by the GP, who again are operating somewhat in isolation to the mental health team.”

200946337.1 When an individual has contacted crisis line or has been referred into First Response services, the GP is informed of the contact, this is often via letter and as such there is an associated time delay. In relation to Miss Davies, I am aware that a report was submitted to the inquest by Dr Simants from The Elms Medical Practice, stating that Miss Davies had called the crisis line and was directed to Café 71 for support. This information has likely been obtained from Miss Davies’ medical records; for clarity, whilst GPs can refer into Café 71, in Miss Davies’ case the referral had been completed by the Trust, with the GP notified of this subsequently, and likely after Miss Davies’ death.

GPs can be contacted directly if concerns are raised during the crisis line triage assessment and from other services within the Trust, if it is appropriate to do so. Often, as the crisis line is a more intensive, immediate resource than an individual contacting their GP; it is sufficient to update the GP for their information following contacts.

GPs, along with other professionals, are also able to contact the crisis line directly and request mental health crisis support for individuals they are concerned about. To repeat; in Miss Davies’ case, the referral to Café 71 was made by the Trust’s crisis line, not by her GP. Café 71 can also link in with an individual’s GP, this is often via letter.

We hope that the clarification provided within this correspondence around Café 71’s function, as well as its ongoing liaison with the Trust provides a satisfactory response following the concerns highlighted in your Regulation 28 report. Further, that changes made by Café 71 to their referral form will also serve to improve and streamline mental health care for our patients.

Should you require any further information, please do not hesitate to contact me.

Dear Madam

Re: Regulation 28 Prevention of Future Deaths Notice - Evie Jane Davies

Thank you for your letter dated 2nd May 2024 sent following the conclusion of your inquest into the death of Evie Jane Davies.

I understand that you will share our response with Evie’s family, and I wish to pass on our sincere condolences for their loss.

Through the Regulation 28 letter you have raised a concern which involves the Crisis Line and Café 71; your concerns about the lack of information sharing between the organisations, and in particular in real time or as near as possible, gives rise to a risk of future deaths and you consider that we have the power to take action, either as provider of the service or as commissioner.

Cheshire and Merseyside Integrated Care Board hold a commissioning contract with Cheshire and Wirral Partnership NHS Foundation Trust (CWP) for a wide range of services, including the provision of community crisis services. In response to the contract requirements CWP have developed a service model for a community crisis service to meet a range of needs. The crisis service established by CWP consists of multiple components, including the Crisis Line and the provision of two crisis cafes. CWP have a contract in place with the Spider Project for these crisis cafes, one of which is Café 71, in Chester.

In line with the requirements of a NHS Standard Contract, CWP as the holder of the contract with the Spider Project, has agreements in place about how information is shared between services and organisations. We have liaised with CWP following receipt of your letter to confirm their contract arrangements with the Spider Project. CWP have advised us that they are responding to you regarding their information sharing processes and agreements on who has access to patient records across the crisis service.

CWP have provided assurance that staff at the Crisis Line do have access to people’s mental health records though not everyone who calls the Crisis Line is known to mental health services. Staff at the Crisis Line make decisions about any onwards referrals to services, one of which could be to Café 71. Evie contacted the Crisis Line on 1st December 2021 who then made a referral to Café 71.

GP’s, along with other professionals can contact the Crisis Line directly and request mental health crisis support for individuals they are concerned about. CWP have a system in place to inform the GP when an individual has contacted Crisis Line and in line with the concern you raised we will work with CWP and GP colleagues to improve the timeliness and content of that correspondence.

NHS Cheshire and Merseyside Integrated Care Board are deeply saddened by the death of Evie and hope this provides a satisfactory response to the request.

I am grateful to you for raising these issues with the NHS Cheshire and Merseyside ICB and I hope that this response has addressed the concerns raised. Should you require any further clarification or information, please do not hesitate to contact me.

Victoria Davies Area Coroner for Cheshire

NHS Cheshire and Merseyside No 1 Lakeside, 920 Centre Park Square Warrington, WA1 1QY Communications@cheshireandmerseyside.nhs.uk Cheshireandmerseyside.nhs.uk

Dear V. Davies.

I am writing in response to your recent Notification of Regulation 28 Report request regarding Evie Jane Davies.

Spider Project Cafe71 is a non-clinical provision commissioned to respond to anyone 18+ in self-defined crisis. The team will spend time with members, helping them to de- escalate crisis situations and to identify underlying factors. They will support people to identify and access appropriate services by referring or signposting them to relevant services.

Evie was referred to Café 71 by from the Crisis Line on 01/12/2021 at via referral form to our enquiries email.

The referral reason was stated as below:

“Evie has been on a section under the MHA in October this year. She has lost her job as a care worker due to a conviction and is after some support in getting her CV updated and looking for a new job. There is a number of court cases on going also due to her losing her kids”.

“Has been known to use drugs and alcohol and is pending an assault charge to an emergency worker”

Café 71 staff member emailed the Crisis Line on 01/12/2021 as the referral did not contain a telephone number for Evie.

A telephone number for Evie was sent via email on 02/12/2021.

Staff attempted to initiate contact, following the referral on 03/12/2021, 04/12/2021 and 05/12/2021. As no voicemail consent was provided, no voicemails were left on these failed attempts to contact.

Café 71 staff emailed the Crisis Line on 05/12/2021 outlining that we had not been able to initiate contact on three occasions and advised if Evie make contact with themselves again to contact us.

07/12/2021 Operational Lead of Crisis Line at the time, , notified Café 71 staff that Evie has sadly been found passed.

Our pathways and procedures involve attempting to initiate contact on three occasions for any individual being referred to Café 71 from any professional. If no contact can be made, we will always make an attempt to feed this back to the referrer.

Action taken:
- Referral forms for Café 71 are now more detailed, asking for consent to be obtained by the referrer whether staff can leave a voicemail from the point of referral. We also ask the referrer about what referrals/support have been put in place following their contact with the individual they are referring.
-

Kind regards,

Crisis Service Manager

Dear

FAO: Victoria Davies, Area Coroner

We are writing to raise our concerns regarding the recent Regulation 28: Report to Prevent Future Deaths. We have already submitted a response via email to but the recent press coverage has now led to us urgently needing to make contact again and we would politely request a response regarding the following points:

Firstly, we would like to understand the reasons why no one at Spider Project Cafe 71 was contacted prior to the Inquest or to the Regulation 28 report being written.

Secondly, we would like to raise the following questions regarding point 4 and point 5 of the report:

In point 4 it says that EJD called the Crisis Line and was directed to Cafe 71. We want to make it clear that EJD did not ever call Cafe 71, the only call that we are aware of was to the NHS Crisis Line. The notes in this section appear ambiguous and unfortunately the press have interpreted this as Cafe 71 receiving a call from EJD which is wholly incorrect. The report then goes on to say that there were no notes of this call and that the pro forma is blank. Again, this is the call to the Crisis Line and not to Cafe 71 but it could be misconstrued as being Cafe 71 and unfortunately the press have reported it as such. We reiterate that EJD never at any point contacted us. Cafe 71 did receive an email referral on Dec 1st from the Crisis Line regarding contacting EJD but no telephone number was provided. Cafe 71 then responded to the Crisis Line on the same day (Dec 1st) and then received EJD’s contact information the following day, December 2nd. In addition to this, as provided on our recent response to Christopher Birchall, the information provided in the referral notes we received from the NHS Crisis Line gave no indication of immediate risk and indeed the main crux of the referral stated EJD was seeking support with her CV.

In point 5, Cafe 71 is referred to as a crisis line whereas in fact it is a non-clinical safe cafe space for people in self-defined crisis in addition to there being a telephone number to call. It is not for lesser crisis but for those in self-defined crisis without a clinical need. Also in point 5, there is a sentence regarding a lack of notification to the mental health team about EJD being in contact, but again, this would be the Crisis Line who would notify the mental health team as it was them who received the phone call.

Our sympathies of course lie with all the family and friends of EJD and we think it is important that they know the truth. We do feel that we need to raise the above points and would appreciate a response.