Dear Coroner for Birmingham and Solihull,

Re: Response to Regulation 28 Report to Prevent Future Deaths

We are writing in response to the Regulation 28 Report to Prevent Future Deaths report following the inquest into the tragic death of Spencer Barr. We would like to express our condolences to the family and friends of Spencer, who have clearly lost a very special person.

The Regulation 28 report highlighted a number of concerns and was sent to other key mental health partners. Colleagues from Birmingham Women's and Children's NHS Foundation Trust (responsible for Forward Thinking Birmingham, FTB) and Change Grow Live - CGL (Birmingham city council public health commissioned service) recognised the need for close collaboration, and we have met to discuss the raised concerns and work on a joint response and plan of action.

We hope that it fully addresses the concerns raised in the report and emphasises the important developments taking place across Birmingham.

Your matters of concern were

Birmingham Children’s Hospital Steelhouse Lane Birmingham B4 6NH Tel:

1) In the months prior to his death, Spencer had been under the care of multiple agencies, including Referral Management Team (RMC) (part of Birmingham Women's and Children's NHS Foundation Trust), as well as the addiction service Change Grow Live (CGL); the Young Adults Central Team of the Probation Service; and Birmingham and Solihull Mental Health NHS Foundation Trust.
2) I heard evidence that full circumstances surrounding Spencer's deterioration and drug relapse in November 2021 - namely that he had received a significant back payment of benefits totalling over £5,000 from the DWP resulting in him purchasing drugs and overdosing - were not adequately conveyed between agencies, and as such agencies were unaware of the heightened risk of potential self-harm and death that was posed by these circumstances. Inter-agency co-operation therefore appears to be inadequate, and consideration should be given to ensuring clinicians receive better training when it comes to the sharing of relevant information between agencies.

Response to 1 & 2 above It is important to clarify that no current process exists nationally or in policy that would have enabled or required the DWP to seek out information about a person’s mental health or substance misuse risk from healthcare providers.

If such a process is to be developed this must be in the context of the DWP policy as it would not be legal for healthcare providers to proactively offer confidential Health information to the DWP. As you will appreciate there are also a number of issues of confidentiality that would need to be addressed in order to allow such a process to function, such as patient consent to share information.

As stated, once the services were made aware by the family of the payment to Spencer, this information relating to the potential for an increase in risk was shared between FTB and CLG and the risk assessments and multi-disciplinary team revised Spencer’s risk assessment quickly. There was no mechanism for services to have oversight of benefits or monies provided to Spencer.

3) I heard evidence that Birmingham Women's and Children's NHS Foundation Trust are now taking steps to improve intra-agency co-operation in an attempt to mitigate against the risk of further deaths in the future. However, I heard evidence that other agencies may not be aware of their own limitations when it comes to inter-agency co-operation. For instance,

CGL gave evidence that they had no concerns regarding their co-operation with other services, but Birmingham Women's and Children's NHS Foundation Trust indicated that the connections between their respective agencies was poor. I am therefore concerned that there is no universal approach being taken by all agencies to improve inter-agency cooperation, and consideration should be given to the formation of a working group being set up between all agencies to ensure a coordinated approach is taken.

Response to matter of concern 3 Forward Thinking Birmingham have set up a multi-agency working party to ensure the dual diagnosis pathways between organisations providing mental health services and substance misuse services are reviewed and strengthened. The task group includes representatives invited from CGL, FTB, BSOL CCG, BCC and BSMHFT.

CGL have direct access to referring into FTB and can directly refer young people where there are mental health concerns and substance misuse concerns this has been strengthened further with the agreement of the development of a fast-track pathway and expediting referrals for mental health assessment from CGL via a trusted assessment model. We believe this will support patients at the earliest opportunity addressing risk. The oversight of the task group and progress will be monitored through the Birmingham Joint Strategic Operational forum where all system partners are represented.

4) Additionally, I am concerned that there appear to be no central points of contact for agencies to facilitate that co-operation. I heard evidence that CGL has no central point of contact for referrals being made/to allow sharing of information - instead relying on information being conveyed via specific individuals. I am therefore concerned that where there is no central point of contact, there is a risk of information not being passed on in a timely manner when a specified person is absent from work for whatever reason. Consideration should be given to central points of contact being created within each agency and ensuring that those points of contact are shared between agencies to ensure information can flow freely between them.
5) Furthermore, I heard evidence that certain organisations do not accept direct referrals or share information between agencies. For instance, I heard that CGL solely depend on referrals from GP practices and do not allow referrals direct from other agencies.

Consideration therefore should be given as to whether there a better system of interagency referral is possible and feasible.

Response to matters of concern 4 & 5 In FTB both the service user’s named Core Worker and Lead Professional act as central point of contact. Additionally, each clinical team has a Duty Worker who is allocated at each shift and acts as a point of contact if the service user’s named Core Worker or lead professional is not available this ensures that there is always a specific allocated point of contact in the working day to share essential information. FTB is committed to ensuring information is shared across agencies to support patient safety and we have agreed to grant licences to CGL that will enable them to access important clinical patient details.

When the Core Worker or lead professional is not available the out of office message will include the telephone number for colleagues who can redirect queries and make arrangements to make contact with patients in a crisis.

We would like to reassure you that CGL have an established central point of contact and have accepted referrals from any individual and agency since March 2015 when the service was commissioned in Birmingham. Referrals can be made via the telephone or the CGL website at the following link https://www.changegrowlive.org/drug-alcohol-service-birmingham/referrals.

In the last 12 months CGL have received referrals from various sources including self-referrals individuals wanting to access support for themselves, family and friends, GPs, mental health services, housing, probation, the police, hospitals, and children services. We hope this provides you with assurance that interagency referral systems are in place and operating.

We hope that you can see that FTB/CGL have taken their roles very seriously and that learning has taken place. As well as addressing the points of concern outlined in the Regulation 28 report, the system is looking at recently announced funding opportunities for substance misuse services and investment into a 16-25 youth substance misuse and mental health pathway, this would further improve care for young adult patients with substance and mental health issues and align with the 0-25 services in Forward Thinking Birmingham.

Finally, if helpful we would very much welcome the opportunity to talk further with you about the mental health system in Birmingham both in terms of the challenges and the improvements being made for the patients and families we serve.

Dear Sir, I am writing on behalf of the Probation Young Adults Central Team Birmingham in response to the Regulation 28 Report issued following the Inquest into the very sad death of Spencer Barr. I know that you will share a copy of this response with the family and I would first like to express my sincere condolences for their loss. Every death in such circumstances is a tragedy and the implementation of learning from this is therefore very important. I respond to the areas of concern you raised as follows:­ Matter of concern – inter agency co operation appears to be inadequate regarding the sharing of relevant information between agencies Response – Probation is committed to having in place relevant and up to date Information Sharing Agreements to cover all areas of its work which provide a legal framework within which information can be passed to and from partner agencies. Probation is reviewing the position in this regard with the other IP organisations to ensure there are no barriers to sound and effective inter agency co-operation and sharing of information. Matter of concern – that there is no universal approach being taken by all agencies to improve inter-agency cooperation and consideration should be given to the formation of a working group being set up between all agencies to ensure a coordinated approach is taken Response – It is noted that Forward Thinking Birmingham has set up a multi-agency working group in response to this recommendation and Probation is very willing to be a party to this working group and contribute to improvements in inter-agency cooperation and sharing of information. Matter of concern – that there appear to be no central points of contact for agencies to facilitate that co-operation. Consideration should be given to central points of contact being Open Letter (Other - Not to SU) 07/2018

created within each agency and ensuring that those points of contact are shared between agencies to ensure information can flow freely between them. Response – Probation now has a central point of contact e-mail wmps.birminghamsctransfers@justice.gov.uk . Probation is taking steps to raise awareness of this SPOC with partner agencies to ensure this central point of contact facilitates information to be shared at all times. Matter of concern – Consideration should be given as to whether a better system of inter agency referral is possible and feasible. Response – insofar as this relates to Probation, the commissioning of rehabilitative services and the making of referrals is subject to regular review as part of the commissioning processes and Probation is committed to continuous improvement and will continue to work with partner agencies to refine and improve referral processes. Thank you for bringing these matters of concern to our attention. Please be assured that learning from the circumstances of this untimely death will also be shared more widely with colleagues across the Probation Service.