Dear Mr Horstead,

Introduction

Thank you for the Regulation 28 Report dated 28 April 2021, regarding the inquest of Mr Sean Kay. We understand that the inquest was heard on 3 November 2020. The CCG was not invited to, nor involved in the inquest hearing. Although the Regulation report was not sent to the CCG directly, but we have since received it via Norfolk and Suffolk NHS Foundation Trust, and we understand that you require a response from the CCG. We have listened to the audio record of the inquest; thank you for providing a copy. We understand that you have concerns about commissioning, based on the oral evidence you heard from , Community Team Manager for the Early Intervention in Psychosis (EIP) Services at Norfolk and Suffolk NHS Foundation Trust. Sean Kay had been provided with mental health care by Norfolk and Suffolk NHS Foundation Trust. As a result of that evidence, we understand that you are concerned that there is a gap in the commissioned mental health services for patients who have been assessed to have an “At Risk Mental State” (ARM) before psychosis in the Norfolk area1. You were told that it was not clear which team within Norfolk and Suffolk NHS Foundation Trust would continue to offer care for Mr Kay, and that a planned meeting between a number of their teams to discuss and agree this (EIP, Wellbeing and CMHT) did not take place before his death. It seems that some of their teams felt that they would not be responsible for Mr Kay, because of the criteria that they have for each team. You were also told that in other geographical areas, an ARMS patient would be managed by their Wellbeing Team. It is unfortunate that you were given oral evidence about commissioning in our absence. The EIP service in Norfolk and Waveney Norfolk and Suffolk Foundation Trust (NSFT) provide an Early Intervention in Psychosis (EIP) service for Norfolk and Waveney. The service is commissioned to support patients from the age of 14. There has been significant investment between 2017 and 2021 to the value of about £1.2 million as per the Long Term Plan ambition.

1 Typically, before an episode of psychosis, many people will experience a relatively long period of symptoms, which is described as having an ‘at risk mental state’, often shortened to ARMS. This may include: a more extended period of less severe psychotic symptoms; or an episode of psychosis lasting less than seven days; or an extended period of very poor social and cognitive functioning (perhaps accompanied by unusual behaviour including withdrawal from school or friends and family) in the context of a family history of psychosis. When treating a person presenting with an at risk mental state, it is important both to support them with their current needs as well as to try to prevent transition to psychosis. Implementing the Early Intervention in Psychosis Access and Waiting Time Standard: Guidance, NICE,
2016.

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Mr S Horstead HM Coroner’s Office for Cambridgeshire and Peterborough

2

The EIP service delivers a NICE recommended package of care to patients within two weeks of referral to 77.2% of patients entering the service. This is significantly above the nationally mandated target of 50% at the time of the incident, to 60% currently. Norfolk and Waveney EIP service has recently been audited as part of the National Clinical Audit of Psychosis (NCAP) audit (2020/21 is Year 4). The audit explores the level of care provided to patients by EIP services resulting in a rating between 1 (low) and 4 (excellent/ comprehensive). The standards are based on the 2016 Early Intervention in Psychosis Access and Waiting Time Standard. The CCG is clear that Mr Kay should have been provided with mental health services by Norfolk and Suffolk NHS Foundation Trust, and that it is not the case that there is a gap in commissioning. The CCG commissions mental health services for the local population. There is no commissioning reason why ARMs patients cannot be cared for by either the EIP, or the Wellbeing team, or the CMHT. Which team deals with each patient is a matter for the Trust to determine, and ensure that their staff understand their chosen approach. It appears from the oral evidence of Ms Tingey that, in fact, Mr Kay could and should have been cared for by the EIP. As a commissioner, we are concerned that Mr Kay was not provided with the care that he needed. We have contacted Norfolk and Suffolk NHS Foundation Trust, which has confirmed to us that as a result of this sad case, they have made sure they have better communication channels and education between their teams, to ensure people do receive the help they need. Norfolk and Suffolk NHS Foundation Trust informed us as follows: “In respect of the management of patients currently transferring between teams, as you will be aware we have a Trust policy which covers this, and outlines the necessity for the original team to proactively ‘hold’ the patient until a firm handover is achieved. This is underpinned by improved regular interface meetings between teams, to ensure patients are known and receiving the right support delivered by the right team. A number of improvement initiatives, including a QI project on communication between teams, were undertaken in West Norfolk, as was a reflective learning session and individual capability actions completed; all as a result of the Trust review. Communication with carers of patients under EIS was also strengthened as a result of the review into Sean’s death, built on discussions with his family”.

Conclusion Where there is a concern about oral evidence given about commissioning in future; we would be grateful to be informed by letter, and given the opportunity to provide accurate information about our commissioning.