Dear Mr Haigh, RE: Susan Janet ADAMS Regulation 28 Report to Prevent Future Deaths Thank you for your letter dated 21 st April March 2021, reporting a matter to us, in accordance with Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. May I take this opportunity to reassure you that following Mrs Adams death, we undertook a thorough investigation into the care delivered by the Midlands Partnership Foundation Trust. MATTER OF CONCERN: Mrs Adams and her family lived in Dosthi/1, Tamworth, Staffordshire. I was told that this was approximately 50 feet from the border with Warwickshire (and not far from West Midlands as well) and that her GP Practice was in Kingsbury Warwickshire. She needed regular psychiatric assistances from secondary mental health services and I was advised there were significant commissioning difficulties with this because of the home address and GP Practice being in different counties. Mrs Adams could access the crisis team in Staffordshire but long term treatment was supposedly to be provided in Warwickshire. This may have impacted on the care that Mrs Adams received and could be relevant for others who

r~t:bj Midlands Partnership NHS Foundation Trust A Keele University Teaching Trust live close to county boundaries. I wonder if anything can be done to facilitate arrangements for secondary psychiatric care in these circumstances. Following discussions within the mental health seNices in the Staffordshire and Stoke on Trent Care Group and with corporate seNices, I am now in a position to respond to the specific concern raised during the course of the inquest. In 2020, the period covered in the serious incident investigation report, Mrs Adams had contact with a number of mental health providers during periods of crisis, according to the geography you describe in the matter of concern. Mrs Adams lived in Dosthill, Tamworth, and it would not be uncommon for individuals in Tamworth to touch on services delivered by the three NHS providers described here:
• Midlands Partnership Foundation Trust (MPFT): Mrs Adams' husband contacted the Access pathway in MPFT - pathway staff would offer advice, and forward any calls to the MPFT crisis resolution team when Mrs Adams was in crisis; these assessments would always be offered when required. They would also offer details for Coventry and Warwickshire services as Mrs Adams' commissioned provider, should she require future interventions.
• Birmingham and Solihull Mental Health Foundation trust (BSMHFT): Mrs Adams frequently attended Good Hope Hospital where she was seen by the mental health liaison team, a seNice delivered by BSMHFT. The BSMHFT liaison team communicated with the Access team at MPFT and identified no mental health needs that necessitated care from secondary seNices.
• Coventry and Warwickshire Partnership NHS Trust (CWPT): As Mrs Adams' GP commissioned services from CWPT, advice would be for their services to be accessed where needed. However, when she was in a period of crisis the assessment would be undertaken by the team who were geographically closer to where she was. For example, on 19th July 2020 CWPT crisis team communicated with MPFT, MPFT provided the response to Mrs Adams with no delay. Throughout this period Mrs Adams' difficulties were deemed to be related to alcohol misuse with no acute mental health problems that would require secondary mental health services. In earlier years when Mrs Adams did require a secondary mental health services (1999 ­ 2005, 2014-2015, 2018, 2019) this was offered by MPFT (or the predecessor organisation South Staffordshire and Shropshire Foundation Trust). Throughout all of Mrs Adams' episodes of care, including that in 2020, MPFT has worked well with partners to ensure people living on the county border are not disadvantaged in terms of seNices offered and in delivering patient-centred collaborative working between organisations. However, given your concerns, we believe the matter is one for commissioners to consider and have therefore forwarded this case to them for their consideration and are happy to support the outcome of those conversations, as appropriate.

r~L:kj Midlands Partnership NHS Foundation Trust A Keele University Teaching Trust I hope this response helps to address your concerns. However, if you require any further information please do not hesitate to contact me.