Dear Sir

Inquest into the death of Richard Burgess

This letter is written in response to the Regulation 28 Report which you issued against the Trust following the inquest into the death of Mr Richard Burgess. As you are aware, the Trust takes all patient deaths very seriously and investigates them very thoroughly to establish if lessons can be learned or services improved and this case was no exception. Following the inquest, the findings of the Trust’s Serious Incident Report have been shared again at the Trust’s Locality Quality Standards and Safety Meetings, in addition to the findings of the inquest and the reports of the independent expert. On 27 July 2021, the Central Business Unit will also feedback to the Locality Quality Standards Meeting the outcome of their discussions on the findings of the inquest and the independent expert reports to see if any additional learning can be identified.

For the purpose of responding to your specific concerns raised in the Regulation 28 Report, I shall address each of them in turn.

1. The provision of a multi-disciplinary team and professionals with suitable skills, qualifications and competencies commensurate with their role and the speciality of dementia care.

1.1. As presented at the inquest, all staff employed by the Trust have the relevant skills, qualifications and competencies for their role. All staff working with dementia patients have received appropriate dementia care training, with relevant staff receiving care planning formulation training, in addition to observation and engagement training.

Executive Medical Director Executive Suite St Nicholas Hospital Jubilee Road NEWCASTLE UPON TYNE NE3 4RT

1.2. As part of the multi-disciplinary team (MDT), Mr Airey explained that the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are all actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.

2. A prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need of medication.

2.1. As presented at the inquest, the Trust does adopt a preventative approach to person centred care. Tools such as the Newcastle Model, life stories, dementia mapping etc., are used to help formulate care plans, which include activities linked to these assessments and ways to engage patients in therapeutic interventions that are tailored to their specific needs. Staged behavioural support plans also, by their very nature, set out proactive steps to try and prevent behaviour from escalating from one stage to another, with medication prescribed only if required.

2.2. As presented at the inquest, changes have been made to the way in which reviews of patient care takes place, with an emphasis now on regularly reviewing all of the information available, which includes, but is not limited to, the environment, medication, physical health, engagement by staff, incidents, observation levels, risks, patterns in challenging behaviour and analysing how these are all impacting the patient so care plans can be adapted accordingly.

2.3. As explained by , due to the nature and degree of presentations with dementia that require admission and detention in hospital, patients sometimes require regular medication to assist with their behaviour. With the new review process there is more detailed analysis at MDT meetings, with the input of a Pharmacist, as to how often medication is being used, its effectiveness and whether a regular prescription is required, in addition to any changes in such medication. There are also safeguards within the Mental Health Act that monitor and review these treatments.

3. The evidence of assessments or the application of assessments of the impact of the persons’ difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practises, emotions, beliefs and thoughts of a person.

3.1. As described above, all of these factors are regularly reviewed and analysed, with the relevant information translated into care plans.

4. A continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories.

4.1. As presented at the inquest, triangulation of care is an important aspect of care and the Trust regularly engages with families to help formulate care plans. As per

evidence, care planning is an ongoing process, which evolves with the patient. Whilst the Trust uses life stories in the first instance to inform care plans, other information

which is acquired over time, from ongoing assessments of the patients and communication with friends and families are used to inform care plans, which are reviewed regularly.

5. A focus on the person, asserting absolute value of the person and individualised approach, whilst understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs.

5.1. As presented by at the inquest, the Trust adopts a person centred focus for each individual and uses models such the Newcastle Model and Kitwood’s flower, which focuses on the key principles of personhood (love, comfort, attachment, inclusion, occupation and identity) to inform care plans. Life stories, ‘this is me’ boards and flashcards, were some of the examples given to show how individual information is used to tailor care plans and activities to individuals.

6. Converting policy into practice.

6.1. All Policies and guidelines which are implemented by the Trust are put into practice, with staff receiving information and/or training on the implementation of them. As explained at the inquest, audits are put in place to monitor compliance, with some policies, such as the observation and engagement policy, requiring staff to complete yearly competency based training.

6.2. Compliance with training is also monitored to ensure that all staff are fully up to date with relevant policies and practices, with additional training provided if a need is identified.

6.3. In addition to formal training, the Trust also sends out regular bulletins and emails to staff to keep them updated about any relevant news and/or changes in polices or guidance, as well as relaying key information via team meetings and individual supervision.

6.4. The Trust also has champions for some of its policies/initiatives so that extra support is provided to assist in embedding practices, especially when they are new.

I hope that the information provided offers you the assurance that the Trust have invested significant time, effort and resource into investigating this incident and looked again at the findings of the inquest and independent expert with a view to improving patient care and safety.

Dear Mr Winter, Thank you for your letter of 19 May 2021 about the death of Richard Burgess. I am replying as Minister with responsibility for mental health and I am grateful for the additional time in which to do so. Firstly, I would like to say how saddened I was to read of the circumstances of Richard Burgess’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, enquiries have been made with NHS England and NHS Improvement and their regional and local partners, and the Care Quality Commission (CQC). You raise a number of concerns in your report that I will address in turn. Ensuring that we have a workforce that has the right values, skills and knowledge, is essential to providing a high-quality service for all those who have need of care services, including those living with dementia. This is why the Department continues to commission and fund a range of training opportunities and other programmes to help recruit people into the sector and develop career pathways, and to support staff to progress to more senior management and leadership roles. In addition, we want all relevant staff to have received appropriate dementia training. The requisite training needs are set out in the Dementia Training Standards Framework (Framework) , which includes the competencies expected of staff across three tiers of training. There is particular focus on person-centred care within the Framework and in relation to training, the existing knowledge and competencies required are covered at Tier 1 (Care Certificate), and Tier 2 of the Framework, and in a number of places, for example:
• Section 3.4 Care Certificate - makes reference to staff needing to be able to “Deal with Incidents, errors and near misses”, and

• Section 4 - refers to “understanding the importance of clear documentation to communicate the care needs of the person with dementia”.

Awareness of the different types of dementia and associated symptoms are covered in Section 1 the Framework, such as - dementia awareness; know what is meant by the term dementia; and understand the importance of recognising a person with dementia as a unique individual.

Since 1 April 2015, newly appointed health care assistants and social care support workers, including those providing care to people with dementia and their carers, have been undergoing training as part of the national implementation of the Care Certificate.

Good progress has been made to date in training the social care workforce, with around half of those estimated to require Tier 2 level training, having undertaken training to a level equivalent to it. The Department is currently exploring options for increasing uptake of Tier 2 training by everyone who needs it, and in March 2019, the Minister for Care co-signed a letter with the Chief Executive Officers of Skills for Care and Health Education England which was circulated to health and care organisations highlighting the importance of training.

In relation to the provision of person-centred dementia care, that takes account of individual needs and risks, and uses detailed assessment and dynamic, proactive approaches to care, you may wish to note that the Care Act 2014 promotes a personalised approach to safeguarding which should be person-centred and outcome-focused. Care providers should carry out appropriate assessments, and work with the individual to safeguard them in a way that promotes choice and improves quality of life, whist also keeping them safe from abuse and neglect.

In relation to the assessment of patients specifically, the Care Act 2014, sets out statutory guidance on how individuals should be involved in assessments. It makes it clear that from their very first contact with the local authority, people must be given as much information as possible about the assessment process, as early as possible, to ensure a personalised approach. The process must be person-centred throughout, involving the person and supporting them to have choice and control. This might range from offering guidance and information to arranging for services to meet those needs.

Where a person may have difficulty engaging with care and support or safeguarding processes, advocacy services are available to assist a person to understand how their needs can be met by the local authority or otherwise. This includes understanding how a care and support plan can be personalised and tailored to meet specific needs.

The Care Act 2014 also requires each local authority to set up a Safeguarding Adults Board (SAB) in order to provide assurance that local safeguarding arrangements and partners are acting to help and protect adults who they suspect are at risk of abuse or neglect. Adult Safeguarding Boards have the authority to carry out a Safeguarding Adult Review (SAR), which should be undertaken in instances when serious abuse, neglect or a fatality has occurred and there is concern that providers could have worked more effectively to have better protected the vulnerable adult.

If it has not done so already, the relevant SAB should consider if it is appropriate to undertake a SAR in relation to Mr Burgess’ death. The aim of the SAR should be to identify the lessons to be learnt from Mr Burgess’s death and apply those lessons to future cases. This is essential in promoting effective learning and preventing future deaths or serious harm occurring again.

As the independent regulator of social care, the CQC monitors, inspects and regulates services to make sure they meet fundamental standards of quality and safety. Person- centred care is a fundamental standard, and personalised care plans are a key element in ratings of provider responsiveness. The CQC considers how comprehensive plans are, staff awareness of plans and how the needs, goals and preferences of users are considered.

The CQC also monitors how well registered providers are protecting people from harm. As part of its regulatory approach to registering, monitoring, inspection and enforcement, the CQC checks that care providers have effective systems and process in place to keep people safe from abuse and neglect. The CQC will respond as appropriate to identified risks within a registered provider and act promptly on safeguarding concerns identified through its monitoring or inspection functions. The CQC will raise concerns with the provider, seek assurance that people are protected from further harm and, where necessary, raise safeguarding concerns with the local authority, clinical commissioning groups and the police.

In addition, Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, details the actions that providers must take to ensure that each person receives appropriate person-centred care and treatment that is based on an assessment of their needs and preferences. Providers must work in partnership with users, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves.

Providers must also work within the requirements of the Mental Capacity Act 2005, which includes the duty to consult others such as carers, families and/or advocates where appropriate.

In summary, we recognise that personalised care is vital to those people that need care and support. It has demonstrated the ability to improve outcomes and enhance quality of life, enabling people to take control and responsibility for the things that are important to them as well as the care they need. Work is underway to deliver more person-centred, co- ordinated social care, that is responsive to individual needs, promotes choice, and maintains independence.

Promoting integrated care is a priority for this Government and our aim is to join-up care around a person’s needs so that, from their perspective, the experience of care is seamless. The proposals in the Health and Care Bill, such as “Integrated Care Systems”, will help to address the barriers which prevent effective join-up between health and social care services and support local systems to implement solutions that work best for them and the individuals they support.

Finally, I expect the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust to reflect on the findings of your investigation, and take appropriate action to strengthen and improve services. I am aware that the Trust has provided a response explaining the action it has taken following Mr Burgess’s death, particularly in relation to the way patient care is reviewed and monitored. I understand that the Trust’s strengthened review process now provides a more detailed analysis on each patient, which will assist multi-disciplinary teams to effectively plan care for dementia patients.

I hope the above response is helpful and provides the necessary information to address your concerns.

NADINE DORRIES

MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH