Dear Ms Lake

Regulations 28 and 29 (coroners investigations regulations 2013) notification made in response to the death of Christopher Sidle

I write to you in respect of Christopher Sidle who died on 4th July 2023. His inquest concluded on 22 March 2024; at the end of the inquest, you raised concerns outlined in this response within a prevention of future deaths notification.

I would like to reiterate to you and importantly to Christopher’s family our sincere regret and apologies for the death of Christopher whilst under our care.

1. Despite additional face to face training being made available to the CRHTT, witness evidence was heard which does not reflect the findings of the investigation and does not recognise the need for a full and proper assessment and the need not to accept a service user’s response to questions raised.

As a result of this concern the lead nurse from the care group has sought details from other mental health Trusts of any additional training that they require their own CRHT assessors to undertake, this was requested from the Mental Health Forum. This is a professional network of mental health leaders from other organisations. Only one Trust responded stating that they did not provide any additional training but recruited experienced Mental Health Clinicians. Therefore, we were unable to benchmark against other organisations.

Nevertheless, in response to this incident and as presented at inquest, the Trust has developed a core competency framework for CRHTT assessors which reflects fidelities outlined within the Core CRISIS Fidelity Scale. This was developed by 31.08.23 in response to an action arising from the Safety Incident Review (SIR) that was undertaken by the NSFT Patient Safety Team. Our action was to ensure that new assessing staff complete an induction and all assessors within the team complete core competency.

This commenced immediately following development of the core competency framework. All training around competencies was completed for all senior nurses (band 7 and 8) by 24.01.24. Competency assessment for all other assessors is scheduled and on track for completion by the end May 2024.

We have an additional and ongoing programme of work, delivering knowledge and understanding of the standards set out in NSFT core competency framework, applying this framework to assess each clinician within their individual line management supervision, offering additional support where this is identified. This will be completed by the end of June 2024.

NSFT Trust Management Norfolk & Suffolk Foundation Trust County Hall Martineau Lane Norwich NR1 2DBH

Date: 17 May 2024 Ms Jacqueline Lake Norfolk Coroner’s Service County Hall Martineau Lane Norwich

- 2 -

It is acknowledged that clinicians within CRHTT require a wide breadth of knowledge and understanding and as such in April 2024 a recruitment and retention project was launched for CRHTT. This project will attempt to recruit qualified and experienced clinicians, these will be qualified band 5 with post registration experience. They will undertake a 12-week preceptorship within CRHTT. New staff will be allocated to a named preceptor. Their preceptor will be an experienced member of staff who will act as their professional support during their induction to the CRHT Team. New team members will be expected to complete 80% of clinical time with their preceptor within that first 12 weeks. They will attend weekly supervision and monthly reflective practise, as well as complete a portfolio that will record evidence of their training and professional development.

Recruitment began 06.05.24 and four nurses are in the process of being recruited with expected start date 01.07.2024. Recruitment will continue until all posts have been filled.

Norfolk CRHTT is well established in utilising the 5P Formulation model in all interventions. This model refers to 5 factors (Presenting problem; Precipitating; Perpetuating; Predisposing; and Protective Factors) to support comprehensive understanding and formulation for care planning purposes.

The next phase in line with NICE Guidance around Clinical Risk, is to routinely evidence all risk using this same psychological approach. To support this approach the person in charge (a senior mental health professional, minimum band 6) is now co located with the clinical team, immediately available to support clinical discussion regarding patient care.

We will monitor the impact of these measures on patient care and assessment by undertaking a monthly audit. This will inform an evaluation report that will be presented to the Care Group Quality Assurance Group for monitoring purposes and to support improvement. For assurance purposes the report findings will be presented to the Trust Safety group and onward to the Trust Board Quality Committee.

The oversight of the CRHTT is further supported by an analysis of all Trust wide CRHTT’s which is being undertaken to support the Chief Transformation Officer in CRHTT transformation.

2. There remains a lack of understanding with regard to assessing a person’s mental capacity to make decisions and to fully and properly record the rationale for making decisions.

Bespoke training was designed in response to the difficulties identified in Mr Sidle’s care. This was delivered by the Mental Capacity Act Lead (MCA) to the CRHTT involved in his care. This was an interactive session delivered through “Teams” on 01.05.24 & 02.05.24. Staff awareness will be further supported through discussion of case studies as part of table discussion, at the forthcoming CRHTT training day on 21 August 2024.

To provide assurance that CRHTT apply their MCA knowledge consistently and appropriately, an audit programme has been developed. A monthly audit will go live in Norfolk CRHTT on 20.05.24. We will use our audit findings and other means (for example feedback from patient safety investigations), to identify ongoing training needs. We will provide bespoke training where this is identified as needed. This bespoke training offer is in addition to the Trust’s existing requirement for all clinical assessors to receive mandatory e learning training in mental capacity every three years.

From July 2024 the MCA audit will be implemented Trust wide to secure similar assurance regarding application of MCA across community and inpatient mental health teams. Audit results will be reported to the Care Group Quality Assurance Group for monitoring and to support further improvement. For broader assurance purposes the report findings will be presented to the Trust Safety group and onward to the Trust Board Quality Committee.

- 3 -

3. There remains a lack of understanding amongst the CRHTT with regard to the scope and limitations of other services available within the community team.

In May 2024 an updated Trust wide CRHTT Standard Operating Procedure (SOP) was ratified and implemented across the Trust.

The SOP addresses liaison between CMHT and CRHTT:

•
7.4 states ‘Assessments ideally are carried out with CRHTT staff and joint assessments with other community staff are actively encouraged. Response time for face-to-face assessments are key so if paired staff are not available for assessment, assessments may be carried out (taking into account risk and safety issues),..’

Through this the SOP highlights the importance of teams having clear discussions about the scope of services available from each team at the time of transferring care.

In addition, within the Norfolk CRHTT, experienced practitioners attend weekly interface meetings with community teams to increase their knowledge of each other's service.

4. Support provided by Flexible Assertive Community Treatment (FACT) is usually carried out by telephone and will in some circumstances not be sufficient to recognise ongoing concerns, for instance with regard to medication concordance.

An initial scoping exercise is being undertaken as part of Quality Improvement initiative led by the Deputy service director, to understand the existing arrangements and opportunities for improvement. in FACT delivery. This will report to the newly established (April 2024) Trust wide Safety Group to ensure there is consistency regarding the application of FACT. A review of existing FACT arrangements across the 5 Adult CMHTs in North Norfolk and Norwich inclusive of recommendations and a clear action plan, will be received by the Chief Nurse by 31st July 2024.

5. Important emails were not circulated to relevant personnel within the CRHTT. The evidence remains unclear what happened to the emails and why they did not reach the appropriate member of the team.

During the period under review at Inquest there were two separate (north and south) e mail boxes.

These have now been merged into one generic team email address. The process for receipt and management of emails to the CRHTT generic team e mail address has been reviewed.

A new process is in place that ensures that all emails are regularly checked and actioned by the qualified practitioner, as person in charge (PIC).

The PIC is the front door for all referrals and triages, responsible for the allocation and ‘flow’ of work through-out the shift.

To increase resilience, administrative support has now been allocated to assist the PIC with weekday administrative tasks which includes monitoring the inbox.

Outside normal office hours (on weekdays 17:00 - 20:00) oversight of the PIC email is now provided by a senior support worker (band 4) who refers to the PIC throughout the shift.

Support to the PIC from a designated senior support worker has also been introduced for weekend days.

- 4 -

Night shift is covered by 2 clinicians and 2 senior support workers with shared responsibility. All contacts are recorded on to the Night Handover Log. The embedding of this new process will be monitored through a six-month audit which will commence 20.05.24.

The audit findings will report to the Care Group Quality Assurance Group for monitoring purposes and to support further improvement. For assurance purposes the report will be presented to the Trust Safety group and onward to the Quality Committee.

6. A person can be identified at triage risk assessment as being in need of an “immediate response, within 4 hours” but an assessment is then arranged for within a 24-hour period.

This case highlighted the importance of professionals having the required skill and competency in risk assessment to inform their decision to re grade a referral, furthermore that the decision is made within a clear process.

The development and assurance of core staff competency (described under section 1 above) will support appropriate risk assessment decisions.

The requirement to discuss referral regrade with another clinician is clearly described within the Trust Clinical Harms SOP (updated February 2024) and included within the updated Trust wide CRHTT SOP (17.05.24). These documents prompt staff to follow the required approach.

We will evaluate compliance against this standard through local management monitoring with additional second level assurance provided through an audit that will be completed by the Patient Safety and Quality Team by mid-July 2024. This will enable us to provide assurance that all decisions to regrade a referral are being made by two clinicians in line with Trust standard.

This will be reported to the Care Group Quality Assurance Group for monitoring purposes and to support improvement. For further assurance purposes the report will be presented to the Trust Safety group and onward to the Quality Committee.

The tragic death of Mr Sidle has been a key learning point for the Trust. As described above, a number of actions have been undertaken that address the concerns set out within the Regulation 28 and 29 notice. Further to this, quality improvement in our CHRTT will remain a key focus.

Dear Ms Lake, Thank you for your Regulation 28 report to prevent future deaths dated 12 July 2023 about the death of Christopher Edward Sidle. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Christopher’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter. Your report raises concerns about a shortage of inpatient mental health beds. We recognise how important it is that people with mental ill health get the level of care that is appropriate for their needs, and we want to ensure that people have access to the right mental health support, in the right place, and at the right time. Through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, compared to 2018/19, expanding and transforming community mental health services. The long-term aim set out within the NHS Long-Term Plan is to improve community support for those with serious mental illness to avoid the need for an inpatient admission where possible. As part of this, major expansion in funding for community mental health services commenced in all areas in 2021/22 which also aim to reduce pressure on beds. However, we recognise that there are occasions where a mental health bed is not available locally. The 2024/25 NHS priorities and operations planning guidance has a commitment to improving patient flow and working towards eliminating inappropriate out of area placements.

Timely discharge of patients who are ready to be discharged is important to free up beds for those who need them. To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, reducing bed occupancy. The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk) For those in crisis, we are providing £150 million of capital investment for mental health urgent and emergency care infrastructure over 2023/24 and 2024/25. This includes investment into a range of wider local mental health infrastructure schemes, including new and improved crisis cafes, crisis houses, health-based places of safety and improvements to emergency departments and crisis lines. Over 160 schemes have been allocated funding by NHS England so far and 99 have been completed. The funding will also provide for specialised mental health ambulances which will be rolled out across the country – and be supported by practitioners trained to provide advice and treatments in cases of co- occurring physical and mental health issues. The care Quality Commission (CQC) continue to monitor the mental health sector and Norfolk and Suffolk NHS Foundation trust (NSFT) through their regulatory monitoring powers. The CQC will also continue to work with and monitor the trust on an ongoing basis and, if there are concerns about risk to patients, will not hesitate to take action. Access to mental health care and the quality of the care remain a key area of concern. The Department is also committed to ensuring that significant progress is being made in Norfolk and Suffolk to ensure that mental health services are of the high standard that patients and their families should rightly expect. This is why I met and will continue to meet with a range of campaigners, local stakeholders, the Trust and delivery partners to discuss progress on the Trust’s improvement plan, improvements in mortality recording, and how we can better understand the number of deaths, as set out in the 2023 Grant Thornton report into the reporting of deaths at the Trust. Whilst some improvements have been made, as set out in the most recent Care Quality Commission inspection report, it is clear that vital improvements are needed to be made and embedded to address the very significant challenges that remain. The Trust must be transparent and engage closely with families and local stakeholders as it aims to continue to make progress with its partners in improving mental health support in the area. The Trust is in the national Recovery Support Programme, which means it is subject to the highest degree of national oversight in segment 4 of the NHS Oversight Framework. NHS England is providing the Trust with focused and integrated support, with a full-time improvement director in place, and representation in the trust’s governance meetings so it has full visibility of the latest data on the improvements needed. It will work closely with the trust and stakeholders to ensure that the recent progress made continues and is built on.

I hope this response is helpful. Thank you for bringing these concerns to my attention.