Dear Madam

I write in relation to the above inquest which concluded on 16th June 2023.

On 22nd June 2023 you made a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was sent to Reading Borough Council and Berkshire Healthcare NHS Foundation Trust. I am writing to provide you with the Berkshire Healthcare response to your concerns.

1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference?

NHS Trusts are changing and improving the way mental health services are provided in the community to support people with mental illness. In Berkshire Health Care we are calling this programme of work “One Team”. This transformation of services is happening across the country following the publication of the Community Mental PRIVATE AND CONFIDENTIAL

Heidi J Connor Senior Coroner for Berkshire for Berkshire Coronor’s Office Reading Town Hall Blagrave Street Reading RG1 1QH

London House London Road Bracknell Berkshire RG12 2UT

Health Framework for adults and older adults by NHSE. The new ways of working will improve mental health services so that GPs, mental health teams, local authority and other support organisations in the community work better together so that patients can receive the care they need in a timely way without having to navigate confusing systems. This programme of work is ongoing and is expected to be implemented by September 2024. This work will make a difference by providing:

 Clear care and safety plans to address target problems and safety concerns.  A named worker which provides an opportunity to build trust and a meaningful connection as well as clarity and oversight on plans.  Connection with meaningful activities.  An opportunity to create or fulfil personal hopes and aspirations.
• Feedback opportunities so that outcomes can be measured.
• Better support in the community through the availability of a wider system of support to reduce reliance on crisis services. Instead of teams of mental health professionals, teams will be multi-agency teams, consisting of colleagues from social care and health working alongside the Voluntary, Community and Social Enterprise (VSCE) sector,. They will also include people with lived experience. This approach broadens the support available for people with any level of mental health need. Multi-agency and multi-disciplinary forums will ensure information is not lost or misunderstood and holistic, trauma informed care plans are collaboratively created. This mechanism will also ensure needs are being met by the most appropriate service and expectations are realistic and clear.

Specifically: a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February? b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February?

At the time Lucy was discharged from CRHTT on the 2nd of February 2022, she had a 16 hours per week of community support in place provided by Adult Social Care (ASC) with a planned move to accommodation with support available 24/7. Lucy also had access to the Service User Network (SUN) which provides group support, and Shout (which provides support with stress, anxiety, suicidal thoughts, and links to many other sources of support for example autism and mental health, bullying, relationships). A Pharmacist review of medication was planned for 17th February
2022. In the new model the following additional support could also be offered in

combination with the package from adult social care and this would avoid the need for a crisis team referral on 15th Feb 2022:

 Mental Health Integrated Community Service (MHICS) This team is now in place and provides specialised mental health support within the community, focussing on recovery and resilience. This is a multidisciplinary team set up to support people with significant mental illness via direct from services including referral from primary care (Additional Role Reimbursement Scheme (ARRS) worker could refer, ARRS workers are mental health practitioners working in the GP surgery). The aim is to provide early intervention to prevent escalation to services for serious mental illness.

 Elmore complex needs floating support service. This is a charity we have commissioned to provide support to people with a wide range of complex needs, who are at risk of falling between the gaps of existing services. Alongside the Trust’s existing offer Elmore provides innovative ways to build trust, increase patients’ engagement with relevant agencies and deliver support tailored to the people who need it. The target group is those who have multiple support needs and complexity. For example, homelessness and rough sleeping, substance misuse, offending, physical disability, self-harm, learning difficulties, domestic abuse, sex working, or experience of abuse and neglect. A motivated team, with wide ranging expertise has been identified to work as part of our personality disorder pathway to provide this individual support. Patients may have very chaotic lives and be distrustful of statutory agencies. Elmore is essential in building the trust required to engage, and maintain that engagement, with other agencies that can provide much needed support. Elmore are now able to accept referrals.

 Managing Emotions Programme (MEP) This is part of the personality disorder pathway. The Managing Emotions Programme is a range of courses designed to equip people with the tools and skills needed to manage overwhelming emotions more effectively. This programme is running.

 Outreach workers These workers are able to offer short term support and safety planning to those who do not meet threshold or who are unable to access community mental health teams and/or psychological therapy. Will be fully operational by December 2023

 Integrated Multi-Disciplinary Team Complex cases can be discussed to enable a clear formulation of risk and needs. This forum will ensure the person gets the most suitable pathway and care plan to enable the patient to achieve their personal and treatment goals. It is also a place where important information can be shared across agencies pathways, for example,the ARRs worker could present a case here to ensure the correct pathway is in place, adult social care staff can attend to share any concerns. This function will be operational by December 2023.

2) Do they consider that resourcing of these services is adequate and safe? Resourcing remains an issue for all Mental Health Trusts due to the national shortage of qualified mental health practitioners, particularly nurses and psychiatrists. Fewer people want to work in mental health services, and this poses a problem in terms of recruitment and retention. In addition, demand for mental health services is greater than it was previously. The trust has a number of initiatives in place to address these issues:

 The reconfiguration of community mental health services as part of the One Team project seeks to ensure the resources we have are being utilised in the right place. Significant changes have already been made to bring the East and West services together to improve resilience and make best use of staff resources and expertise. The leadership of these services is currently under review with the aim of ensuring the right level of operational support is in place, and that staff can be mobilised across the whole of Berkshire, reducing unwanted variation and moving resource around as required making services safer.  Case load reviews - Historically in all mental health services, patients would remain on CMHT caseloads for many years, which can impact significantly on safety as thresholds for acceptance and waits for CMHT due to capacity are directly linked to this. The review will increase resources available by ensuring people are on the correct pathway and receiving the correct evidence based treatment and support.  A Nurse consultant network is also now in place; these are senior specialist roles that attract mental health nurses by providing an opportunity to practice in a senior clinical role, as well as having protected time to focus on education and research and a clear development pathway. The Nurse Consultants can also intervene when there is complexity, which helps with resourcing as staff are supported with caseload capacity and complexity. Nurse Consultants also have a role to play in monitoring workforce capacity to ensure safety.

 Increasing the support, skills and knowledge by offering training and supervision to the primary care workforce so they can care for people with mental health problems.  Utilising professional nurse advocates to provide staff with restorative supervision through dedicated staff trained as professional nurse advocates on a monthly basis, to reduce staff turnover as a result of burnout.  Human Resource initiatives to focus on recruitment include targeted recruitment, apprenticeship schemes, linking with universities, using social media and recruitment campaigns.

The resourcing of mental health care remains a challenge. However, patient safety is at the heart of everything that we as a Trust do, and we feel that the initiatives we have implemented, and which are ongoing will optimise the deployment of available resources to ensure we support and safeguard our patients as best we can. We are aware that further learning may arise from the ongoing Safeguarding Adults Review (‘SAR’), we are working closely with the panel and will respond to the recommendations.

Dear Madam, Re: Regulation 28 Response regarding Ms Lucy Anne Walles I write in relation to the matter raised in your Regulation 28 letter to Reading Borough Council in respect of the above inquest which concluded on the 16th of June. I am writing to provide you with Reading Borough Council’s response to your concerns, listed below under each query.
1. Timescales for review and the triage of safeguarding referrals The Safeguarding team at Reading Borough Council manages most of the safeguarding referrals (around 80%) which come into the Council through the Council’s Customer Contact Centre. If the individual referred has care and support needs and is already known to Adult Social Care Services, the referral is passed directly to the team involved and this accounts for the remaining 20% of referrals that come through this route. For those referrals coming into the Safeguarding team, they are screened, and a named Safeguarding worker is assigned if the referral requires consideration under safeguarding procedures. When a Safeguarding contact is received which is the responsibility of a neighbouring authority, as in Ms Lucy Anne Walles’ situation, the safeguarding team will contact them to inform them and pass on the details. The timescales for the management of the contact and referral process are set out as guidance on the Berkshire Safeguarding Policy and Procedures and Reading Borough Council, along with all the other Local Authorities covered by the West of Berkshire Safeguarding Adults Board, follow these procedures. Following the death of Ms Lucy Anne Walles and the lack of timeliness of an appropriate safeguarding response to safeguarding contacts in this case, improvements have been made to the safeguarding service in Reading. Those relating to the resourcing of the service, are referred to below. In relation to improvements in processes, where a safeguarding contact contains information which may indicate the individual has suicidal ideation or is at risk of significant self-harm, a priority flag is added at the point of contact on the client recording system for the Safeguarding Team’s attention, or the responsible adult social care team reading.gov.uk | facebook.com/ReadingCouncil | twitter.com/ReadingCouncil

who are dealing with the case. This priority flag highlights the urgency of the case for those allocating work and can be removed or added during further assessment of the individual. This change in process has been required to strengthen the management of high-risk safeguarding referrals, particularly given the volume of safeguarding contacts received, and the resource limitations on the safeguarding team referred to below. The other improvement in process in the management of safeguarding contacts through the Customer Contact Centre and the Safeguarding Team is that, since the creation of a dedicated senior Safeguarding Lead role for Reading in June this year, there are daily consultations between the Safeguarding Team and the Customer Contact Centre to ensure appropriate referral processes are followed and there is priority flagging of high-risk safeguarding referrals. The indicative timescale for a member of the safeguarding adults team to triage the referral of a safeguarding concern is within one working day as indicated in the guidelines.1
2. Requirements to speak to the individual about whom Safeguarding concerns have been raised. The practice standards for safeguarding in this area are supported by the Making Safeguarding Personal (MSP) initiative led by the Local Government Association and Reading staff are required to follow these standards. Individuals who are the subject of safeguarding concerns should always be made aware about the nature of any safeguarding concern, so they are fully appraised of what information is being shared about them and any actions which are likely to be pursued on their behalf. They should also be given opportunities to express their wishes and feelings. Only in exceptional circumstances where dialogue would increase the risks to them or to others, or where the individual lacks mental capacity, should this not be a requirement and in the latter circumstance, those with power of attorney, who are able to act in the best interests of the individual, should be fully consulted. In the circumstances surrounding Ms Lucy Anne Walles death, Lucy was not made aware by the Council when safeguarding concerns were raised on her behalf and this did not follow the requirements of best practice required in MSP. There has been significant tightening up of practice by the safeguarding team to ensure that individuals are personally contacted about safeguarding referrals and these improvements are the subject of greater monitoring and audit in safeguarding cases. The Safeguarding Lead and two senior social workers in the safeguarding team ensure that no safeguarding concern is closed without the individual being contacted.
3. Training around section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a section 42 enquiry. Reading Borough Council adopts a comprehensive approach to safeguarding training as outlined below: All staff in Adult Social Care undertake Level 1 training which focusses on safeguarding awareness and the identification and reporting of abuse and neglect. This includes the 1 https://berkshiresafeguardingadults.co.uk/p/4-adult-safeguarding-procedures/43-responsibilities reading.gov.uk | facebook.com/ReadingCouncil | twitter.com/ReadingCouncil

requirements for Section 42 enquiries. This is mandatory training and compliance is monitored by the Council. This training is delivered throughout the year. Level 2 training is aimed at all Adult Social Care front-line staff and external partners such as care home managers and familiarises attendees with the Berkshire West Safeguarding Procedures including use of the procedures, the requirements of “Making Safeguarding Personal”, conducting safeguarding investigations as part of an enquiry, and the legal frameworks including deprivation of liberty and the Mental Capacity Act. Level 2 is mandatory for all staff who undertake any role in safeguarding enquiries and is delivered throughout the year. Level 3 training is aimed at staff who manage safeguarding enquiries, for example Senior Social Workers and Managers, and those who work in specialised roles which involve safeguarding. It is mandatory for such staff and must be refreshed within 3 years. Attendance is monitored departmentally and is reported to the West Berkshire Safeguarding Adults Board. All three levels of training are run at regular intervals throughout each year and all three levels of training cover what options should be considered if a concern does not meet the section 42 enquiry threshold. There is also a “Safeguarding for Managers” Course which is run twice a year for relevant managers which looks in more depth at best practice in supervising safeguarding cases, managing risks and lessons from research and from Safeguarding Adult Reviews. In addition to the core training offer outlined above Assistant Directors in Adult Social Care and the Safeguarding Lead are now providing tailored safeguarding training for Managers to ensure that all senior staff have a consistent approach to safeguarding contacts, referrals and enquiries and are appraised of best practice guidance. All Social Care practitioners have access to the training materials and briefing notes produced by the Safeguarding Adults Board following Safeguarding Adult Reviews (SAR) reports and are given opportunities to attend learning events for SAR recommendations. The SAR findings for Ms Lucy Anne Walles (under the title “Bree” SAR) and the recommendations therein will be the subject of learning events.
4. Systems for making other agencies aware of safeguarding referrals and concerns. The West of Berkshire Safeguarding Adults Board require Pan Berkshire policies and procedures to be followed in respect of all safeguarding cases which are either related to Reading residents, or to individuals receiving services in Reading. These policies and procedures set the expectation that the outcome of a Safeguarding Concern is required to be communicated to the referrer, with the persons consent wherever possible. Other appropriate action may also be considered for example if the individual is presenting with care and support needs this information would be passed to the appropriate team to assess. Where the Concern is progressed to a Safeguarding Enquiry the Agencies involved are consulted as part of that Enquiry and over any care and protection plan which is then developed. In the case of Ms Lucy Anne Walles, there had been multi agency discussions led by Wokingham as the responsible Local Authority for the case, but the safeguarding referrals reading.gov.uk | facebook.com/ReadingCouncil | twitter.com/ReadingCouncil

were received by Reading which did not trigger a multi -agency meeting to consider the collective risks. The West of Berkshire Safeguarding Adults Board is currently working on strengthening and standardising of the guidance in the procedures, particularly the multi-agency processes being used across the local authorities. The SAR author has identified this as a gap and has already begun to discuss with representatives from the Safeguarding Adults Board the lack of an agreed and shared multi- agency risk assessment in respect of Ms Lucy Anne Walles and Reading Adult Social Care is fully involved in the consideration of recommendations and on improving transparency and clarity in this regard.
5. In relation to the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. All policy changes in respect of processes and policies relating to safeguarding in Reading are subject to approval by the West of Berkshire Safeguarding Adults Board, in which Reading is a key statutory agency partner and follow the Pan- Berkshire policies and procedures used by all agencies. The tri- borough arrangements for safeguarding agreed by the Board require consistency of processes and procedures across the Board footprint and therefore Reading only changes formal policy, when agreed through the Safeguarding Adults Board. Revisions and associated amendments of the pan Berkshire procedures are instigated for several reasons including the recommendations of Safeguarding Adults Reviews, best practice guidance, and changes in national safeguarding policies. Training on Adult safeguarding for Council staff (content outlined above) is delivered locally through the Organisational Development Team, coordinated by a dedicated Workforce Development Officer for Adult Social Care, the Principal Social Worker and Principal Occupational therapist and other senior staff in the Adult Social Care service. In addition, the Safeguarding Adults Board delivers training and learning events on a range of matters relevant to safeguarding practice and the learning from Safeguarding Adults Reviews and thematic safeguarding reviews. The Board also has a responsibility to monitor the delivery of multi-agency learning on matters related to adult safeguarding. As part of the improvement work being undertaken this year to improve the performance of safeguarding in Reading, Senior Managers in Adult Social Care in Reading have undertaken workshops with all the managers engaged in safeguarding, to strengthen their understanding of the safeguarding processes and the requirements of best practice which we are seeking to deliver as outlined in point 3.
6. Improving the interaction between agencies involved and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is being actively encouraged. Should there be written guidance about this somewhat subjective issue? Multi agency meetings occur as part of the safeguarding processes. However, multi-agency meetings are arranged to discuss many forms of risk and the care and support needs of reading.gov.uk | facebook.com/ReadingCouncil | twitter.com/ReadingCouncil

individuals, not only those who meet the section 42 threshold. When the threshold for Section 42 enquiry is not judged to have been met, any agency can refer for a Multi-Agency Risk Meeting (MARM) or the lead authority can call a MARM meeting, and this is outlined in the procedural documentation for the West of Berkshire Adult Safeguarding Board.
7. Whether the resourcing of the service is adequate and safe? Safeguarding services in Reading, in line with all other parts of the UK have been experiencing and continue to experience increases in the number of reported safeguarding concerns, which have resulted in significant service pressures over the last three years. In 20/21 for example there were 1598 concerns reported to Reading, whereas in 21/22 this had risen to 2969. There have been difficulties in recruiting and retaining permanent staff to work in safeguarding, in part because of national workforce shortages, but also because of the high-level demands in skills and experience needed to work with very vulnerable individuals in crisis situations. The Council continues to review the required organisational structure to see which is best able to meet the increased demand in order to deliver adequate and safe resourcing of adult safeguarding in Reading and has made changes as a result. Following the appointment in June 2023 of a Senior Safeguarding lead, 3 additional full time safeguarding staff were appointed, and this has provided a 30% increase in dedicated staff resource for managing safeguarding referrals. The Senior Safeguarding Lead is accountable to, and works with, the Assistant Director for Safeguarding, Quality and Practice. This has strengthened the managerial oversight of the delivery of the safeguarding service and continues to report performance of safeguarding to the Departmental Management Team, led by the Executive Director. These increases in safeguarding resources described above have been delivered despite resource pressures effecting the Council, in recognition of the importance of safeguarding for the residents of Reading. However, workforce challenges in social care are being felt by all Local Authorities in the UK at the current time particular in respect of shortages of skilled and experienced staff throughout the adult care service which continue to challenge the resourcing of safeguarding systems across health and social care.
8. What are the systems for auditing and what happens if auditing reveals on going issues? As noted earlier the West of Berkshire Safeguarding Adults Board provides the framework policies and procedures for all safeguarding in Reading and staff must adhere to those and operate to those, with due regard to the requirements for safeguarding set out in the Care Act (2014) and other legislation and guidance. Any issues identified with the procedures and policies are picked up through the SAB as described in 5 (above) and any individual skills deficits with individual workers are addressed through managerial oversight and guidance as work is subject to auditing of cases and worker supervision which has been strengthened in Reading in the last 6 months. Themes from audits and the learning from them are shared with staff in “Learning Together” sessions which are led by the Principal Social Worker and Principal Occupational Therapist. Learning from SARs and other reviews of Safeguarding are overseen by the Safeguarding Review Panel of the SAB and recommendations from that panel to commission external reading.gov.uk | facebook.com/ReadingCouncil | twitter.com/ReadingCouncil

reviews, thematic learning reviews, appreciative enquiry, training and other forms of learning from practice, are made to the Board and supported by senior representatives from the 3 Councils and partner agencies. The “Bree” SAR will form the basis of learning events and other opportunities for dissemination of recommendations for improvements in safeguarding and support of vulnerable individuals at risk of suicide. In June this year the creation of a senior management post to lead safeguarding practice in Reading, is enabling challenges in the delivery and resourcing of effective safeguarding to be brought to the attention of senior managers in Adult Social Care and in the wider Council. The postholder also oversees the work of the Safeguarding Team, undertakes auditing and reviewing of safeguarding cases and provides expertise in management of complex Section 42 enquiries. In July 2023 Adult Social Care in Reading introduced a Quality Assurance Framework for the service which includes an audit programme which supports auditing of safeguarding referrals, not just at team level but also incorporating wider auditing by managers and some external commissioned audits undertaken by specialists. The individual learning from these audits is fed back to workers and their managers and any themes for learning which emerge, form the subject of workshops with appropriate staff. This Quality Assurance Framework systematises case audit in a more thorough form from previous auditing activity and allows for more rigorous consideration of any gaps in processes, policies or practice skills. The Departmental quality assurance process is led by the Executive Director under the title “Striving for Excellence” which is following the framework provided for inspection of adult social services by the Care Quality Commission (CQC), who are in the process of inspecting all local authority adult social care services. This includes the performance, delivery and outcomes of safeguarding services as a key part of their inspection. The explanation outlined above under each point aims to provide reassurance around progress in relation to the specific actions that were for the Council to address. In overall conclusion the Council will continue to work to improve its response to safeguarding concerns drawing on support from agency partners represented on the Safeguarding Adults Board and will give full consideration of recommendations from the Safeguarding Adults Review concerning the tragic death of Ms Lucy Anne Walles. The findings of the Safeguarding Adults Review will contribute to the improvement work particularly in respect of how we respond across health and social care services to vulnerable people at risk of abuse, neglect and harm and those at risk of suicide.