Dear Mr Healy-Pratt Mr Rodney Dixon I write in response to your Regulation 28, Report to Prevent Future Deaths, dated 21 June 2021, following the Inquest into the death of Mr Rodney Dixon. I was very sad to learn of Mr Dixon's death and I personally convey my sincere condolences to his family. I understand that Mr Dixon took his own life, at home in Eastbourne, on 15 July 2019 during the course of a Mental Health Act (MHA) Assessment. I also understand that you were satisfied that those carrying out that Assessment (the 'Assessors') collectively had sufficient information to make the decision they did and that Mr Dixon's decision to take his own life was reasonably unforeseeable. However, I recognise and understand that you are concerned about potential future risks that may present themselves to other patients; specifically, by sub-optimal MHA Assessment training and the accessibility to the MHA Assessors of relevant patient information prior to completing MHA Assessments. Your office has helpfully shared the Response provided to you by East Sussex County Council (ESCC) and I note that they have explained their responsibility for the recruitment, training, warranting and management of the Approved Mental Health Practitioners (AMHPS) and provided details of changes that they have initiated. It is regrettable that a direct discussion, between Sussex Partnership NHS Foundation

Trust (the 'Trust') and ESCC, about your concerns, has not occurred as yet. However, I am pleased to be able to assure you that the Trust's Deputy Chief Nurse has contacted at ESCC to obtain details of the changes they have made to enable the Trust to gain a full understanding. The Trust will then facilitate the sharing of that information with the Trust's doctors to ensure that those who also work as independent s.12 doctors, at the behest of ESCC, do so in the knowledge of ESCC's changes in practice. Regarding accessibility of relevant patient clinical information, I would like to assure you that it has long been the case that ESCC have had access to the Trust's electronic record system, Carenotes, to enable patient information to be accessible to them. The expectation is that the ESCC AMHP would access the necessary information and appropriately share it with any independent s.12 doctor who does not have access. In addition, it has been the working practice for many years that the Trust also shares information verbally and/or by providing hard copies of relevant patient records to AMHPs and to independent s.12 doctors, as needed. This further communication route facilitates the sharing of information if, for any reason, electronic access to Carenotes is not achievable. The Crisis Resolution Home Treatment Team are the Trust team that are available to support the MHA Assessors with access to relevant patient information and are available 24 hrs a day. However, I recognise your concerns and, therefore, have asked the Deputy Chief Nurse, when she discusses matters with ESSC, to identify if there are any difficulties with these established access processes that need to be addressed. I hope that this Response is of reassurance, to both you and Mr Dixon's family, that the Trust has looked seriously at how it can support the MHA Assessment process, to learn from Mr Dixon's death and to keep patients safe. Your sincerely

Chief Executive

1 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

James Healy-Pratt, HM Assistant Coroner for the area of East Sussex in response to a Regulation 28 Report to Prevent Future Deaths following an inquest hearing into the death of Rodney Dixon on the 17th to the 19th of May 2021

1 EAST SUSSEX COUNTY COUNCIL

I am Mark Stainton, Director of Adult Social Care, East Sussex County Council, St Anne’s Crescent, Lewes, BN7 1UE

2 CORONER’S MATTERS OF CONCERN

The MATTERS OF CONCERN were identified as follows: –

Mental Health Act assessments are conducted in East Sussex deploying clinicians from both from both ESCC and SPFT (Sussex Partnership NHS Foundation Trust) and independent clinicians such as psychiatrists.

The training around Mental Health Act assessments, patient risk management, and their Assessors is sub-optimal. Reasonable access to patient data by independent clinicians for MHA assessments need to be ensured prior to assessments. 3 BACKGROUND Rodney Dixon took his life on the 15th of July 2019 at his home in Eastbourne, during the course of a Mental Health Act assessment. The Assistant Coroner commenced an investigation into his death on the 23rd of July 2019 which concluded following a three day Inquest on the 19th of May 2021. The Assistant Coroner reached a narrative conclusion that the cause of death was Hanging and that Mr. Dixon took his own life, following a deterioration in his mental and physical health. The Assistant Coroner requested that East Sussex County Council review its’ training in relation to Mental Health Acts assessments and “ensure there is clarity of understanding amongst all stakeholders that are involved in risk assessment”. Written submissions were welcomed in relation to this issue, and ESCC submitted its’ submissions on the 11th of June 2021. The Regulation 28 follows on from that.

4 DETAILS OF ACTION UNDERTAKEN. As a local authority, the Council is responsible for the recruitment, training, warranting and management of Approved Mental Health Practitioners (AMHPS). The Council has no input into the recruitment or training of Doctors and other medical staff who practise in this area. That is the responsibility of the Sussex Partnership Foundation Trust (SPFT) who have also been issued with a Regulation 28 notice.

2 The Council has reviewed its’ training and documentation in respect of AMHPs Since the conclusion of the Inquest, the following actions have been undertaken:

(1) Leon Gooding (Head of Adult Social Care) hosted a meeting with all the Council’s Approved Mental Health Practitioners (AMHPs) to discuss the issues arising from this case. During the meeting, It was agreed that the client in cases similar to that of Mr. Dixon should not be left unsupervised unless assessed to be of low risk. The Council’s Mental Health Act referral and Risk Assessment Forms have been updated. They include a new section entitled “dynamic risk assessment”. A copy of this new assessment is attached hereto. It is published on the Council’s internal website. It says as follows “All individuals must be risk assessed with the aim to ensure their safety for the entirety of the assessment process, up to and including admission. At no point throughout the assessment is the client to be left unsupervised unless assessed by the assessing team to be presenting with low current risk to self of others. It is the AMHP’s responsibility to ensure the assessing team has access to the most recent risk assessment and relevant client clinical history.” (2) Yearly risk management training with Brighton University for existing AMHP’s has been arranged. This is part of the annual training that AMHPs undergo anyway but it will now include specific training on risk management. (3) The AMHP warranting and re-warranting process has been updated. A dynamic risk assessment has to be completed and presented to the assessing team. It is now part of the process that AMHPs undergo as part of the warrant and re- warranting process.
5. DETAILS OF FURTHER ACTION PROPOSED

The actions the Council has undertaken above will be regularly reviewed and updated/amended if appropriate
6. SAFETY OF THOSE ASSESSED UNDER THE MENTAL HEALTH ACT

Every death by hanging is a tragic loss of life. The Council is committed to improving training for its AMHPs and in the way they conduct and implement Mental Health Act assessments

The death of Rodney Dixon is a tragedy and the Council offers its’ sincerest condolences to the family.

7.

Signed

, Director of Adult Social Care