Dear Ms Riley,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Twm Bryn

I am writing further to the Regulation 28 Report to Prevent Future Deaths, following the inquest which touched upon the death of Mr Twm Bryn, and which was issued to the Health Board on 17 February 2023.

I would like to begin by offering my deepest condolences to the family and friends of Mr Bryn for their loss.

In the Notice, you raised two concerns:

 Continued staffing pressures within Primary Mental Health Services resulting in assessment delays and waiting lists for support e.g. the waiting list for LPMHSS counselling remains at 4 – 6 months.

 Whilst awaiting counselling, the only interim support available to patients that are assessed as mild or low risk, are services that come with a requirement to self- refer, despite lack of motivation being a common symptom. The LPMHSS does not have a standardised process for referring low risk patients for interim support and no interim contact or monitoring is offered or arranged (unless patients have self-referred to an organisation providing such services).

In response to the Notice, I requested our Mental Health and Learning Disability Division to carefully consider your concerns and provide details of their plans to make our services as safe as possible taking into account the learning from the inquest.

I can advise that, as part of our response to the ministerial priorities for 2024/2025, we are looking at service change and redesign of our Local Primary Mental Health Support Services (LPMHSS). A workshop has taken place with key leads across the Division including team managers, our Deputy Medical Director and team members from our partnerships, planning and strategy teams to look at short term interim solutions along with the longer term service redesign options/models. When a shortlist of options is

Dyddiad / Date: 14 April 2023 Sarah Riley Assistant Coroner for North West Wales Coroner's Office Shirehall Street CAERNARFON Gwynedd LL55 1SH Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG

agreed we will work with our partners to refine options and will be working to ensure we have a robust Equality Impact Assessment (EqIA) in place to drive engagement and direction. This will closely align with existing workstreams for the delivery of crisis care services including 111/2 to ensure we have a whole-system approach.

Work has begun to rationalise existing administrative processes across the Community Mental Health Teams to ensure we have removed where possible any variation in practice, and Standard Operating Procedures are being agreed for the Division as a whole.

We will, alongside our internal service redesign, be reviewing our commissioned services to ensure we have robust contractual agreements that complement and enhance mental health services for the population of North Wales.

Staffing remains our biggest risk for the delivery of effective and timely care to our service users. Whilst there is risk across our teams, the level of risk varies and at present Denbighshire, Anglesey and Conwy are experiencing the greater pressures. We continue to pursue the vacancies within our current establishment, but as noted above the work being undertaken to look at service redesign will impact on how our current staffing is used and utilised. Alongside our internal service redesign we will be reviewing our commissioned services to ensure that we have robust contractual agreements that complement and enhance our core services, and work with our partners to ensure they form part of our whole system approach.

Any patients currently on waiting lists are supported by the duty teams whilst awaiting allocation. The waiting lists are due to currently unfilled vacancies that have been placed into recruitment but unfortunately not all have attracted candidates and have remained unfilled despite being advertised a number of times.

Assessment clinics are planned utilising overtime staff to take into account any shortfall in staffing due to sickness absence and vacancies. There is a backlog of assessments despite this with the additional work only providing a short term maintenance position that is not sustainable in the longer term. We are exploring block booking of agency staff as a short term staffing solution to bring the service back into alignment with the Mental Health Measure performance standards.

Face to face groups are being scoped in terms of demand, third party venue availability and costs (in light of Covid-19 restrictions and the potential risk to individual clients and their communities through prolonged exposure in small environments). 1:1 interventions are undertaken on a patient choice basis. Virtual groups are consistently being provided and are well received by a proportion of service users - the intention is to provide virtual groups for the majority (in terms of accessibility and logistics) with face to face provided for those that have logistical issues or whose needs are better met in a face to face environment.

Staff have been individually contacted with the names of their patients who currently have an expired Care and Treatment Plan (CTP), and have plans in place to make improvements to their compliance by undertaking CTP reviews with their patients. CTP compliance is routinely discussed in both monthly managerial supervision and on a case by case basis. Staff also receive a weekly update specific to their caseload and in addition also receive a list of those patient CTPs that will expire within the next 3 months to assist and inform them to bring their compliance back into alignment with the Mental Health Measure compliance standard required.

Due to the variation in practice across the teams in terms of managing patients on a waiting list, an Unallocated Patient Waiting List Protocol has been developed. This draft protocol ensures that service users referred to the Health Board Community Mental Health Teams and Local Primary Mental Health Support Services are managed efficiently, equitably and consistently. The draft protocol will now progress through consultation, approval and distribution.

The Community Mental Health Teams (CMHT) and Local Primary Mental Health Support Services (LPMHSS) will on occasion operate a post-assessment/referral allocation waiting list. This will be governed by the capacity of the team to manage caseloads safely and effectively. In addition the protocol describes a set of interventions which enables the service to understand the steps required to ensure adequate management of an allocation waiting list. The Head of Operations for the Central Locality and the Head of Planning and Performance for the Division have been identified to lead on a standard process for support and review of patients waiting for intervention. As a result, a protocol has been submitted for consultation, which will then follow due process of approval and subsequent launch in teams.

A scoping review is underway regarding scheduling of appointments for assessment, which has been found to take up a portion of time for clinical staff. Consideration is being given to administrative or non-registered staff performing this task, which would release more clinical time for assessments and interventions.

Discussions are in progress regarding expanding additional counselling options made available in the West. This will create more capacity for counselling and reduce waiting times.

The Service Managers for Community Mental Health Services have been directed to offer additional shifts to staff working in other mental health services in West and Central to complete assessments.

Recognising the difficulty in recruiting to vacancies, as outlined earlier, a recruitment drive has been launched Divisionally using an external specialist firm, Just R Recruitment, to attract staff to the area. A review of job descriptions for LPMHSS is under way to consider what amendments would be required in order to recruit non-nursing care professionals such as Social Workers and Occupational Therapists, which would provide a wider scope of recruitment.

An Annual Mental Health Measure Caseload Audit is currently being undertaken across the Division.

We recognise many of these improvements will take some time to develop and embed, and in many cases are reliant on the recruitment of staff. In the short term, 111+2 staff will contact patients on a fortnightly basis to review needs and offer any support as required.

We will also continue to strengthen our working with patients, referrers, carers and families to develop public awareness to include information sessions held in local ICAN Hubs, GP Surgeries, Emergency Departments, Carer Groups and Third Party Organisations. Our helpline services will also continue to be a source of support.

As this response describes a wide array of actions, we will closely monitor the actions we are taking in response to the Notice.

Local area monthly performance reports include waiting list activity and progress of reduction, these are presented at the monthly MHLD Service Finance Performance Delivery Group. This group monitors and reviews performance trajectories and the mitigations to ensure progress is maintained and considers barriers to improvement with waiting list reduction. Further escalation is undertaken if required through the divisional and organisational governance framework until resolved.

In addition to the above monitoring, the division also produces monthly reports on referrals to community mental health services including the iCan hubs, Call Helpline and the 111+2 service which are accessible to patients in the community.

I will also be requiring the MHLD Division to report to the Health Board Leadership Team, chaired by the CEO, on the progress of these improvement actions in 3 months’ time.

I hope this letter sets out for you the significant improvement plans underway within the Mental Health and Learning Disability Division; however, I acknowledge that it also sets out the significant challenges that exist including the difficulty in recruiting to vacant positions which has a notable impact on our ability to reduce caseloads, waiting lists and improve access overall.

Our Mental Health and Learning Disability Division would be happy to meet and discuss the challenges and our plans in more details, or provide further information should that be helpful.

Once again, I offer my deepest condolences to the family and friends of Mr Bryn for their loss. I hope my letter offers you assurance on the concerns you raise.