Dear Ma’am Regulation 28 Report Response – Denton Duhaney – 25th March 2021 and 30th March 2021 In response to the Regulation 28 report the Trust received on 21st July 2021, we wish to respond with the following information. As you will recall, you heard evidence regarding Regulation 28 matters in both written and oral evidence from Mr , General Manager for Gatekeeping and Liaison Services. Mr provided two statements to assist with the proceedings; these were dated 23rd and 29th March 2021. This response builds upon the evidence provided by Mr as part of the inquest proceedings.
1. Mr Duhaney was a patient at Pinderfield’s Hospital between 23rd and 25th June but at no time was he assessed or received treatment by the in house psychiatric team despite the fact that he had an underlying psychiatric presentation The statement of Mr dated 23rd March 2021, paragraphs 3.1 and 3.2, stated: I can confirm that any patients assessed by a Psychiatric Liaison Team in a hospital setting remain on the team’s caseload until the patient leaves the hospital site. Therefore, if the patients risk change prior to them leaving the hospital the team will be able to provide a review of the patient and offer support as needed. The Standard Operational Policy for the two teams [Wakefield/Dewsbury and Calderdale/Kirklees Psychiatric Liaison Team] has been reviewed and amended to ensure consistency of practice across the Trust’s Psychiatric Liaison Teams (e.g. there is no difference in the processes of the Wakefield/Dewsbury PLT, and the Calderdale/HRI PLT as a result).

At the time of the incident the Psychiatric Liaison Teams came under different management structures, however, in January 2020 this structure was amended, and these teams are now within the same Business Delivery Unit. It is envisaged that the change in structure will support the function of the services by ensuring a uniform management approach. In addition to the above information and changes, I can confirm that arrangements are made for there to be a handover of care between Psychiatric Liaison Teams where it is known an individual is being transferred between Acute hospitals in the Trust’s area of operation. The principle that the Psychiatric Liaison Teams maintain a patient on their caseload is an additional safeguard that was not present within Pinderfield’s and Dewsbury District Hospital due to the differing Standard Operational Procedures referred to in Mr statement of 23rd March 2021.
2. Pinderfields hospitals discharge protocol does not appear to have been adhered to when Mr Duhaney expressed a wish to self-discharge. The above relates to the discharge protocol implemented by Mid Yorkshire Hospitals NHS Trust. We do not propose responding to this concern.
3. No one from Pinderfield’s Hospital contacted Kirklees Intensive Home Based Treatment Team to notify them of Mr Duhaney’s self discharge.
4. Kirklees Home Based Treatment Team last had contact with Pinderfield’s Hospital on 24th June 2019. It was 6 days later that they made a further call to the hospital seeking an update upon Mr Duhaney. Points 3 and 4 above have elements that overlap, and we have therefore responded to both below. It is understood that Mid Yorkshire Hospital NHS Trust will also provide their own response to point 3 as this can be interpreted to apply to both Trusts. The statement of Mr dated 29th March 2021, paragraphs 3 through 6, stated: During the course of the inquest proceedings on 25th March 2021, evidence was heard that the Kirklees Intensive Home Based Treatment Team (IHBTT) did not have guidance on how and when to maintain contact with a service user whilst they were awaiting discharge from an acute hospital. It has historically been the case that an Acute Hospital would ensure that follow up arrangements are made, and the agreements are met at the point of discharge (i.e. to contact the relevant services on discharge). However, on hearing the evidence of

witnesses it was evident an additional safety netting approach would be required and during the course of my own evidence, I suggested that this was an area that required immediate action. This statement has been prepared to provide an update to HM Assistant Coroner, Ms Burke, on this particular point. I will today be producing and disseminating guidance to staff within the Trust community services (not just the Intensive Home Based Treatment Team) to provide clear instructions around maintaining contact with a service user awaiting discharge from an acute hospital, but equally to maintain contact with the Psychiatric Liaison Team and/or Acute Ward to ensure a seamless transition of care into the community. The above is intended to be an interim measure and going forward a more detailed review of this issue will be undertaken. Following further consideration of the interim guidance by Mr and the relevant team managers, the guidance disseminated on 29th March 2021 is a sufficient safety net to ensure a seamless transition of care from an Acute Hospital to Community Mental Health Services. Assurances have been provided by the relevant Services Managers that contact is being maintained with service users awaiting discharge from Acute Care Team and the Psychiatric Liaison Team (if involved in the service users care). As part of our ongoing partnership working with Mid Yorkshire Hospitals although we are responding to your concerns individually, we have had sight of each other’s response. I do hope the above information is of assistance and answers the concerns raised within your Regulation 28 report following the sad death of Denton Duhaney. We would like to offer our sincere condolences to Mr Duhaney’s family and friends.