Dear Mr Clow Please find below the organisational response to the recently received Preventing Future Deaths Report following the unfortunate death of Mr. Paul Barton, the inquest of which was concluded on 15 September 2021 We offer our sincere condolences to Mr. Barton's family- Concerns raised within the Report: (1) The approach of the Crisis Resolution Home Treatment Team of considering their role to be limited to avoiding the need for patients to receive inpatient treatment: The primary role of any medical professional ought to be the protection of life, but within the written and oral evidence from the CRHTT the focus was on prevention of hospital admission alone. CRHT teams were originally up to provide urgent intensive support for individuals who had serious mental health problems and who would otherwise be likely t0 require inpatient hospital admission. This remains a core function of tne service . The aims of the service as outlined in the service specification are: Act as a 'gatekeeper' to mental health services for functional all age mental health admissions Provide immediate multi-disciplinary, community-based treatment 24 hours days a week, including a face-to-face assessment wthin 4 hours_ Ensure tat individuals experiencing acute , severe mental health difficulties are treated in the least restrictive environment as close to home as clinically possible_ Remain involved with the patient until the crsis has resolved, the patient is well enough to be linked inldischarged to the appropriate care pathway: Dur-an Va-Tman House Making Pothesle-Ro3o Difference Nccinghamic}644 Trust Honesty Respect Compassion Teamwark set e and key day;

hospitalisation is necessary, be actively involved in discharge planning and provide intensive care at home t0 enable early discharge_ A detailed assessment should be underaken as belov: The aim is to help t0 reduce service users' vulnerability t0 crisis and maximise their resilience: In line with the Royal College of Psychiatnists (RC PSYCH) best practice guidance and core fidelity standards, tne initial assessment gathered from multiple sources includes: An investigation into the nature of the crisis and the presented problems The identification of immediate social stressors and social networks. Psychiatric history including past records and family history. A comprehensive evidence-based assessment which includes: Mental health and medication; Psychosocial needs; Strengths and areas for development The identification of the clinical signs and symptoms, including ability t0 self-care , mental health problems are found: A physical health review takes place as part of tne initial assessment, or as soon as is practically possible . The review includes but is not limited Details of past medical history; Current physical health medication;, including side effects and compliance with medication regime; Lifestyle factors
e.g , sleeping pattems, diet smoking, exercise, sexual activity, drug and alcohol use An assessment of practical problems of daily living- A documented risk assessment and management plan which is co-produced and shared where necessary with relevant agencies (with consideration of confidentiality) . The assessment considers: rsk to self; rsk t0 others; nsk from others_ The identification of the person for whom it is 3 crisis, other people affected by the crisis and associated risk t0 tnem Identification of dependents and their needs, including childcare issues, and young or adolescent carers_ A social assessment including education and employment A multidisciplinary assessment of the service users needs: A multidisciplinary assessment of the service users level of risk_ Planning for supported transition t0 other services AlI service users have a documented diagnosis and a clinical fomulation: The service user and te team can obtain a second opinion if there is doubt,uncertainty or disagreement about the diagnosis, fomulation or treatment. Written information about the service, its role and contact details are provided to all service users and carers present at initial assessment Based on the detailed assessment a decision will be made aS t0 whether the individual will benefit from CRHTT input or if an altemative service is required, which may include inpatient admission, onward referral, and discharge_ The service specification describes the process as below The team begins discharge planning at the point of assessment and this communicated t0 relevant parties: Duncan Macnila Hcuse Making a PonchesierRcad Ncenonamke) Difference VSt Honesty Respect Compassion Teamwork t0: any E44

Involvement is time limited, people are promptly discharged when acute care is no longer needed. At least 90% of service users stay less than 6 weeks (length of stay active treatment not phone support prelpost discharge) and service users and involved family are given at least 48 hours' notice before discharge from the CRHTT (excluding hospital admissions) Prior to discharge the team should ensure that: There is good understanding (service users, family, carers, relevant others) of why the crsis occured and how ii could be avoided in future_ Coping strategies have been explored with the service user and familylcarers. A Relapse prevention plan is in place Service userifamilylcarer have had an opportunity to express their views about the service and contrbute t0 service improvement The team must facilitate discharge and transfer of care t0 an approprate service , dependent on clinical situation local provision. This could include Primary Care , Assertive Outreach Team; Early Intervention in Psychosis, Continuing Health Care, other mental health services A clear discharge plan is given t0 the service user on discharge, and sent t0 all other relevant parties within 48 hours and must include details of: On-going care in tne communitylaftercare arrangements. Crisis and contingency arrangements including details of who t0 contact. Medication, including monitoring arrangements When, where and who will follow Up with the service user as appropriate Clinical outcome data is collected at assessment and discharge as 3 minimum. Post discharge service users or families may contact the CRHTT directly for support or advice for at least 2 weeks following discharge. As demonstrated, the expectations of a CRHTT assessment and plan are clear and require detailed infommation gathering consideration of a wide variety of factors on which t0 base care planning and decision making: This should include whether a hospital admission is required but tnis cannot be tne sole determining factor. To ensure that all staff are aware of these parameters, the CRHTT operating procedure will be updated by 31 December 2021 t0 include more detailed explanation as above_ The updated procedure will be shared with all staff via email and discussed with all staff via team meetings_ This will highlight the broader considerations for CRHTT support as of a safety plan, and individual discussions as part of ongoing supervision will also support a broader understanding: (2) This inquest was one of a number of inquests | have conducted where staff members from Nottinghamshire Healthcare NHS Foundation Trust have placed great reliance upon their interpretation of a patient $ intention and / Or a patient'$ denial of ongoing Duncan Maciat Acuse Potchesie-Rcaoi Making Nccnghamna)644 Difference Honesty Respect Compassion Teamwork and and and and pan

suicidal intention. This is SO even where, as was the case for Mr Barton; there is a clear and established pattern of fluctuating and contradictory intentions and desires towards suicide. There are a range of measures in place and planned t0 address practice in this area including training and reflective practice opportunities AlI clinicians must complete mandatory annual training in suicide awareness and prevention. This training outlines the many factors tnat should be considered when undertaking 3 risk assessment in 3 potentially suicidal patient Tnis includes not only the immediate presentation, but corroborating evidence from family members, recent events, and pattems of behaviour; thinking and underlying factors such as established mental health conditions, compliance with medications and substance misuse. From tnis comprehensive gathering of infommation, a fomulation should be developed based on this range of evidence on which t0 base the care planning and safety planning: This plan should never be based solely on an individual denying suicidal intentions atthe time of the assessment Rather, it should weigh tis in the context of recent events and known facts. This current training is only available online for Adult Mental Health staff_ priority of the Trust $ Towards Zero Suicide Strategy (2020-2023) was t0 review the Trust's suicide prevention training offer and implement a new training model to bring this into line with the Trust's Towards Zero Suicide approach (2020) and Health Education England $ Suicide Prevention Competencies A paper to agree the proposed training method of delivery and resource requirement was presented t0 the Trust's Senior Leadership Team on 26 November 2021 for approval. This paper proposes three levels of training: Level 1 _ Suicide Awareness Training for non-clinical staff, online 3-yearly- Level 2 Suicide Awareness Training for all clinical staff, online 3-yearly Level 3 Suicide Response Training for clinical staff required t0 provide a clinical response to suicidality, 3-yeary, either face t0 face or via Microsoft Teams is however recognised that training alone does not achieve embedding of leaming into practice or operational and quality improvements_ Therefore , the Trust is proposing that tne required resources not only deliver training but also support embedding training into practice: This would include: Clinically based engagement and support: Bespoke tailored training and facilitated team leaming (including discussion and reiiection) to further adapt the training t0 clinical areas and embed leaming and the use of approprate clinical tools: Additional bitesize training based on leaming themes (including those from patient safety processes such as investigations and Coroner Inquests), clinical tools and safety planning Prioritisation for teams who experience greater exposure to suicide and self-hamm (as identified through Trust data) and be based on related leaming t0 promote safe and responsive services which can also be evidenced Reviewing and further development of related resources Duncan Matlla Hcuse Pothesle-Rcad Making a NctnghamKCJe44 Difference Fust Honesty Respect Compassion Teamwork

Involvement in evaluation and improvement relating t0 risk assessment safety planning: Following approval of the proposals, an implementation plan will now be developed, which will be shared with the COC and Coroner on completion. The CRHTT operating procedure will be updated by 31 December 2021 t0 include more detailed guidance about risk assessments and the clear expectation that the presenting infomation at the time of the assessment is evaluated, considerng recent events. Further training is needed for all staff working in CRHTT as this forms 3 core part of their role_ The training offer includes some team training sessions facilitated by the Trust wide Clinical Lead for Suicide Prevention . Three of these sessions have already been delivered these will continue as a regular space for teams t0 reflect on cases and access senior supervision: In addition t0 this, there is a four-day training programme facilitated by one of Adult Mental Health's Clinical Nurse Specialists, which all CRHTT staff will be offered Three sessions have already been completed and there will be three sessions running each year: This covers attachment and trauma, stabilisation skills, overview of Mentalization- Based Therapy (MBT) Structured Clinical Management (SCM), Dialectical Behavioural Therapy (DBT) and crisis role in these interventions, managing crisis telephone calls and working with young people in crisis The Leaming and Develpment Department have also been providing sessions relating t0 culture and values (Appendix 4). This begins with a diagnostic tool (Appendix 5) completed confidentially by team members to elicit the strengtns of the team and areas that need t0 be worked on. There will then be sessions facilitated by the Leaming and Development team t0 assist in achieving the identfied improvements Staring in January 2022 bespoke training workshops will be provided for each CRHTT by ffrom the Leaming and Development Deparment and will be used as continuous learing and refective practice spaces t0 augment and embed this leaming: There are monthly interface meetings between CRHTT and the LMHTs During these meetings, case examples are presented in order t0 jointly share leaming and discuss practice issues,as well as developing and maintaining good working relationships Carer peer workers are recruited into each team: The Job Description is enclosed as Appendix 6 . These roles will ensure there is & specific focus on the needs of carers, including discussion of expectations and inclusion in discussions about assessments and care plans Leaflets and information sources will also be reviewed and regularly updated for carers: addition, peers will link t0 wider carer networks in the Trust The teams are working on the core fidelity principles (Appendix 7) and part of this activity is an annual feedback process that includes patients, carers, staff and key stakeholders These retums measure progress and enable adaption of actions needed. A dashboard is in development s0 that the Key Performance Indicators (KPIs) can be reviewed routinely on a monthly basis . This is currently operational but is updated with a final version expected by 31 December 2021. Drncan Macmila7 Hcuse Making a Potchaste-Roao Nccngnam N63644 Difference Trust Honesty Respect Compassion Teamwork and and being being

(3) The quality of the Trust's own investigation into the circumstances of Mr Barton'$ death: It failed to identify themes of concern: It included many false and inaccurate statements, failed to challenge false assumptions made at the time and introduced new false information which was not taken from any available records. It caused distress to the family and did not reassure me that the Trust had taken an appropriate response t0 the concerning facts of this case: We unreservedly apologise for the distress and disruption caused because of our mistakes: The Operational Manager has reviewed this report and the relevant themes have been identified_ The Quality Improvement Plan is being updated t0 ensure these are captured and acted upon We will share this with you on completion A final version of the report is encbsed (Appendix 1), along with the attachments (Appendix 2 and 3)- Following on from correspondence with your office in October 2021, we have not yet shared this amended report with te family, or a copy of this response. We understand from an email dated 20ih October 2021 that the family preferred not t0 hear directly from the Trust at this time_ We are very willing t0 share the cocuments directly with them should they wish to receive information in this way and remain open t0 meeting with any of Mr Barton'$ relatives in the future to discuss his care, investigation content Or processes; or t0 try and answer any outstanding questions they may have, should this be something they would find helpful. This has been shared with the investigator for their leaming and reflection. In the short-term; this will also be raised as 3 more general lessons leamed t0 remind all staff of the importance of factual accuracy. These actions set out will be monitored uithin the Trust through a specific Quality Improvement Plan with General Manager las the nominated lead In addition_ it has been identified that key themes regarding the quality of our Serious Incident Reports have required a more robust and Trustwide review action plan. The Trust's Govemance arrangements t0 oversee the management of serious incidents (Sls) is outlined belove Serous Incident Review GIOUp Chaired Dyte Associre Kcccunaable Cuality The @Moup mae s wWeekly t0 discuss all new Sls, #Msur? Direc or0i Cuality Cpanzional Group 3enenj e inmediate jeton has Eaen taken and agre? level oiinvestigation required Tnere is Exectjive Direco atendance and rcently atendance irom Our main comnissioned Folloiing thj: maaring te Becutve Director 0r Nurs ng AFP { Quality wIl ecalze signifc: Sls p te Bxecujve Team Weekly- DiisionalCECLEmeetings Mental Health and Forensics MFS Chaired the Kcccnable Dvisiona The dmvisinz Clin cal Inciden: Revie Creatinga Leaming Associate Medica Diector Cuahy an Rsk Grolps Environment Goup (CIRCLE) ecem ana revet Icidents which are idenjied 35 snous 3no in need 0 FS_ Chaired bythe Deputy more focused scrjiny "hich is orside tne remit 0i any Direcor 10 Forens € cher cument group Vchin e avisien; #Msur? Sevics 3encena e *cjon tken andind apereenje essons 0 eamt ojer t0 [eoucePsodes 0t recmtenc Duncan Mactmat Hcuse Potcheste-Rcad Notngnam N3J644 Difference J5t Honesty Respect Compassion Teamwork and Making

Denjty any need sevi0 meviev & Developmant and pudncnacmyuichquirsnumade Quality; Operational Group Chaired Executve Kcconaable Cujy group Meet Montuy; responsibilites include Direcor ofNugsing; 4 HPs & Menb Aejn Legis aton COC cempliace 3na quality standards Pajent say Qualy Commite? clinica efecveness; ano Patent experene C06 recemves Cuarteny Pajent Safety Reponts; "nch ncludes detals 0f al SIs progress cn investiaions outcomes eaning and Were #anoetate M1y #eaic thenes 'Tends Qualis & Menta Health Legislation Commitee Chaired Non- Kccun ble to the Board This Board Conmitee provides assurance On asects Execriive Direcor Direc;ons 0 Qu3y and mantal health legislajon. 0l the Jgend) tney receive six mently Paten: Safety Repors ting % Senous Incdtnt Raming ano cutcone5 0 nezopatons As a Trust over the past two years, we have looked to further strengthen the govemance and assurance in relation t0 the management of Serous Incidents through the overall review of team structures, systems and process and policy revision_ This includes: Establishment of a Centralised Patient Safety Team: As a result of an organisational wide review of govemance, durng 2019/2020 we created a Trustwide Patient Safety team (Previously there were teams in each division which led to inconsistent approaches) . There is now a Trustwide Head of Patient Safety (also the Trusts nominated Patient Safety Specialist) . The Head of Patient Safety reports t0 the Associate Director of Quality and has open access to the Director of Nursing, AHPs and Quality- The Patient Safety Team has responsibility for the overall co-ordination of incidents and investigations across the Trust_ By undertaking this review, it has enabled us t0 eliminate varation in the management of incidentsIsenous incident investigations between directoratesidivisions. It also enables a consistent approach in the appointment of investigators, preparation of terms of reference and ensuring investigators have points of contact t0 discuss investigations and concems We have also taken tne opportunity to develop a centralised Investigation Team, at present this is a small team of 2 Sl Investigation Leads who will primarily be apportioned tne most significant and time critical cases. However; we are looking to support this centralised team with the employment of a limited number of experienced bank Sl invesigators, again these individuals are independent of tne divisions/services and will have significant experience of being involved in investigations: Establishment of Eamily Liaison Team: As a Trust we looked at the opporunity t0 significantly improve the communication and interaction we have with families and patients when an incident occurs, and more particularly a serious incident_ With tis in mind our investment group has approved the funding of a Family Liaison Service. The team will comprise of 3 full time posts The family Iiaison team will work across all Trust services to support patientsifamiliesicarers through the difficult process of Duncan Vasmiat Hcuse Potchesie-Rcao NcEnghamac)EAA Difference Trust Honesty Respect Compassion Teamwork This and and Pan Making

serous incidents, inquests and investigations into serious incidents_ The purpose of this role is t0 provide explanation and support through what can be a difiicult process for families. The three posts are currently out t0 advertisement we would envisage making an appointment in November; to commence in post eary 2022_ As a Trust we see this as an impontant and pivotal team t0 ensuring a consistent support mechanism for families through what is a stressful and difficult time for them and t0 also ensure their voice and questions is represented in the investigation itself Medico-Leqal Tean: Although our Medico-Legal team is well established, the Trustwide govemance review gave US the opportunity to centralise some of the provisions still available within some services. The Medico-Legal team and in particular the Inquest function nOw covers all Trust services. The inquest team provides a strong link between the coroner's office and the trusts operational services They provide support in the preparation of court papersIstatements and also supporting staff through what can often be a difiicult process_ They also provide a link t0 the families involved, and of course with the development of the Family Liaison service, it will be imperative that these two teams work closely and seamlessly together: Review of Trust Policy: With the appointment of our Director of Nursing, AHP and Quality (Executive Lead for Patient Safety) in January 2020,there was also the opportunity t0 review and refresh existing practices in relation t0 the process for the management of serious incidents Some of the immediate changes made were: All Comprehensive (Level 2) investigations would be approved by an Executive Director Terms of reference for a comprehensive investigation would be approved by an Executive Director All Concise (Level 1) investigations would be approved by an Associate Director of Nursing: We also took the opportunity to work with our intemal auditors, to reviely our processes and polices related to incident reporting and serious incident management and as a result changes t0 the Managing Serious Incidents (SI) and Reporting Leaming from Deaths policy (15.02), were made which formally reflected the changes made by the Director of Nursing; AHPs and Quality shortly after her appointment Review of Staff training Incident Investigation We have worked with extemal partners t0 ensure that staff undertaking serious incident investigations are trained and knowedgeable in investigation techniques_We are now providing a new 2-day training event for investigators based on a "Systems Based Approach" This approach is advocated by the Patient Safety Incident Response Framework (PSIRF) which will be implemented within NHS Organisations from April 2022. The role of SBA is to identify the Duncan Mactmat Hcuse Potheste-Rcao Notngham N3J644 Difference Trust Honesty Respect Compassion Teamwork and and Making

systems-based problems when an incident occurs, ratner than focusing on tne indivduals involved_ Our aim is t0 train 100 investigators year on year: We have recognised that whilst the centralised investigation team gives uS a consistent approach t0 investigations, the volume of investigations means we must utilise operational staff as part of the overallinvestigation process,hence the provision of incident investigation training- However, in training these people we also need to ensure we continue t0 eliminate variation; so to assist with this we have put in place support and mentoring which will be provided through the dedicated centralised investigation team: Quality Assurance of Investigation Reports We also recognised that we also needed t0 strengthen our overall review of our investigation reports and ensure those individuals who are approvinglauthorising the final report have the skills t0 cntically appraise the report and ensure it is fit for puppose_ With this in mind, aS part of our training offer; we have also worked with our providers t0 establish Quality Assurance training course for people who approve Or sign of Concise/Comprehensive reports_ The course provides the attendees with skills to cntically access the investigation report and ensure in concentrates on Systems Based outcomes and SMART actions. Our aim is to train at least 50 people each year The purpose of this training is t0 provide senior individuals who have responsibility for approving reports t0 with the skills t0 analysis the report , ensure fairness, that systems-based leaming has been applied and that the report and findings reflect the agreed terms of reference and any questions raised by the patient or family- Implementation of Just and Restorative Culture Asa Trust we had significant progress in embedding a Just and Restorative Culture by ensuring we act with compassion, treating people fairy justly embracing a leaming culture; where if something goes wrong; we seek first t0 understand. When things do g0 wrong in all cases we should: Seek first to understand before taking action Focus on restoration, not retribution and consider what was responsible rather than just who was responsible Consider the psycholgical impact on all individuals involved In Notts Healthcare there are many ways we are already working together t0 create a Just and Restorative Culture (JRC), and we can demonstrate that it is the overall Culture linked to Compassionate Leadership that will ultimately enable colleagues to feel safe enough t0 speak up without fear of reprisal or blame, to feel heard and supported. Overview There is recognition that this overall review, restructure and development of both teams and training has been necessary t0 strengthen the goverance in relation t0 serious incident investigations. Whist sone of these changes have been established for a little while others have either come online in the last few months Or will do in the very near future. We believe that through the govemance review and significant investment for centralised investigators and family liaison service we will be able t0 ensure: Duncan Mactlla7 Hcuse Ponchesie-Rcao Making a NcCngham NeJ E44 Difference Trust Honesty Respect Compassion Teamwork and and

Strong governance in relation t0 serious incidents Oversight through our meeting structure Approval of Terms of reference Final approval and sign-off of Concise and Comprehensive investigations Elimination of variation Development of expertise through training in the use of Systems Based Approach (SBA) to Sl investigations Providing Sl approving managers the skills and techniques to critically appraise investigations Support and guidance for all our staff attending and involved within the coronial process Through the implementation of the Family Liaison service, we will be able t0 ensure families have: An identified point of contact Their voice and questions are represented within the investigation process Clear lines t0 ensure the outcome of the investigation is fed back t0 them and they have the opporunity to comment The appropriate level of support throughout the Sl process and inquest hope the infomation above provides the assurance tnat we nave considered your recommendations seriously and are actively seeking t0 improve the services we provide by implementing the actions outlined: