Dear Mrs Mutch,

Re: Barry Preston

Re: Regulation 28 Report to Prevent Future Deaths

I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest touching the death of Barry Preston on 19th and 20th February 2020 dated 4th May
2020.

On behalf of Bolton NHS Foundation Trust, it is clear that there was lack of coordination in Mr Preston’s care and for that I would like to offer my sincere apologies.

Following receipt of the Regulation 28 Report, I requested that that the Deputy Medical Director, Deputy Chief Operating Officer, Divisional Governance Lead for the Integrated Community Services Division and the Service Manager for the Integrated Discharge & Therapy Service review the concerns that related to Bolton NHS Foundation Trust.

I would like to assure you that Bolton NHS Foundation Trust (BFT) has liaised closely with relevant colleagues at Bolton Council and Greater Manchester Mental Health Foundation Trust (GMMHFT) in order to fully ensure that a collaborative approach was taken to respond to the concerns raised. I am now in a position to respond to the points as outlined in Section 5 that are relevant to Bolton NHS Foundation Trust. Where relevant, I have noted that Bolton Council and/or the GMMHFT will also provide a response for services that are integrated.

Section 5 (1): The quality of documentation was not always of a good standard and part of the reason why his catheter was incorrectly believed to be a long-term catheter.

Since the death of Mr Preston, Bolton NHS Foundation Trust has introduced an Electronic Patient Record (EPR). This is the single electronic record on which all patient details, notes and actions are recorded. All staff within Royal Bolton Hospital have access to view and record patient details on the system. The Integrated Discharge Team and the Intermediate Tier Services can also view and input into the electronic patient record which has improved the standard and consistency of documentation in real time.

2 Section 5 (2): The inquest heard that he was kept on wards that were not suitable for him or his needs. The inquest was told that this was due to capacity and flow issues within the Royal Bolton Hospital.

With regards to Mr Preston’s first admission on 28th October 2018 until 10th November 2018, a review of the hospital’s bed flow has indicated that speciality beds on the complex care wards were low in number. Mr Preston’s clinical predicament required him to have an observable bay and there were a high number of patients on the complex care wards requiring an observable bay and an enhanced level of care at that time. This led to Mr Preston’s extended stay on the Medical Admissions Unit when the usual planned length of stay on a Medical Admission Unit is 48 hours. It was deemed safer for Mr Preston to remain on the Medical Admission Unit in an observable bay.

When Mr Preston was readmitted to hospital on 11th November 2018, he was admitted under the care of the Emergency Department’s Medical Team and transferred to ward F3, this is the admitting ward for the Emergency Department as well as the Surgical Assessment Unit. Mr Preston was moved when a bed became available on the complex discharge Ward (A4).

The Trust seeks to make every effort to minimise the number of patients who are placed on an outlying ward and recognises that at times, when bed capacity within the hospital is compromised, decisions to outlie a patient may be necessary. With hindsight, more effort should have been made to ensure he was on the right ward to support the provision of the best possible care.

Currently, a review of the Patient Outlier Policy is being undertaken to ensure there is clear guidance in order to minimise the risks associated with patients being cared for on all wards irrespective of the speciality nature of the ward. This review is being undertaken throughout June and July 2020, engaging relevant stakeholders and led by a senior manager in consultation with the Deputy Director of Operations, Director of Quality Governance and senior Nursing and Clinical staff. The new Patient Outlier Policy will be rolled out across the Trust on 1st August 2020 provided the current COVID-19 pandemic circumstances do not delay its introduction.

Action being taken:

 BFT is currently undertaking a review of the Patient Outlier Policy

Section 5 (3) The inquest heard that he had a care coordinator in the community. However, the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interest meetings were taking place. There was a lack of understanding between agencies of role and responsibilities under the integrated care model.

The Bolton Council Local Authority and GMMHFT will provide a full response to this concern, this has been with the benefit of input from the Integrated Discharge Team (IDT).

Section 5 (4): The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement.

During the period of time that Mr Preston was an inpatient he was seen by multiple teams including the Home First Team, inpatient therapy services and the Integrated Discharge Team (IDT). Since this incident it has been recognised that there were multiple handovers between teams and these teams have now been brought together under a single management structure in order to provide improved communication between staff groups and lead to better patient experience.

3 At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in-reach model which was reliant on other professionals to identify those patients who had existing social care needs prior to admission to hospital . The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards, as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge.

As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.

The IDT has identified that the role of a seconded mental health post within the team was a key omission in the management of Mr Preston’s journey. The use of different organisation’s case recording systems also resulted in the failure to identify that the patient already had a care coordinator in the community and the needs to identify an IMCA to represent the patient’s best interest. Since this incident the IDT has in conjunction with GMMHFT, removed this role from the service in order to provide a single care coordinator (this will either be a social worker or discharge nurse) for each patient who is hospital based and will liaise with other organisations where needed. All input will be recorded in the patient’s electronic patient record and social services case recording systems.

Action being taken:

 Development of a competency framework to address the skills gap in assessing patients with complex needs by 31st August 2020.  Training of all staff to be completed by 30th September 2020.

I am advised that Bolton Council Local Authority will also be providing you with a detailed response to Section 5 (4).

Section 5 (5): The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care. Acquiescence by him was seen as him understanding and having capacity.

In response to the concern raised of poor appreciation of the gentleman’s lack of capacity to make decisions about his care, BFT has completed a review of the ‘Mental Capacity Act 2005’ policy. The narrative in the policy has been strengthened in respect of defining roles and responsibilities in the completion of mental capacity assessments , and there is clarity as to whom should be ‘The Decision Maker’ and the legal requirement for referral and involvement of Independent Mental Capacity Advocates in the absence of a relevant representative. The revised policy has been ratified by the Safeguarding Committee on 16th June 2020.

In conjunction with the review, Bolton NHS Foundation Trust is revising mandatory and non- mandatory training provision in respect of the Mental Capacity Act which Medical Staff, Nurses and Allied Health Care Professionals undertake, ensuring clarification of roles and responsibilities.

Action taken:

 Review of BFT’s Mental Capacity Act Policy.

4  There has been a review of training provision in respect of the Mental Capacity Act (MCA). Bespoke training is now provided to designated cohorts and will be completed by 30th September 2020.  MCA forms are now available for completion by all designations of staff on the Electronic Patient Record.

I am advised that GMMHFT will also be providing you with a response to Section 5(5).

Section 5 (7): His placement at Laburnum Lodge was made without clear understanding of his needs. He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.

The Home First team is a therapy based team which aims to support those patients in the ED and assessment wards to return home without a longer period of hospital admission. It has been identified that there is a skills gap within this team and a competency framework has been developed to support staff in making the appropriate recommendation for placement at intermediate care units. In order to ensure all transfers are safe these will be reviewed on a daily basis by a member of the nursing team within the IDT.

Actions being taken:

 All wards have been advised that the decision to reduce the level of enhanced care should not be undertaken by ward staff without a full multi-disciplinary meeting  Ward Managers have been instructed that any patient with complex needs should be escalated to the IDT for a full MDT meeting where any transfer of care is being considered.  Development of a skills and competency framework.

The IDT have liaised closely with the Local Authority and a response detailing actions taken by the Local Authority in relation to Section 5 (7) will be provided.

I hope that the response of Bolton NHS Foundation Trust has provided you with the assurance that the Trust has taken appropriate action to mitigate the risk of future deaths.

Please do not hesitate to contact me in the event you require any further assistance.

Dear Ms Mutch Re: Barry Preston (deceased) Regulation 28 Preventing Future Deaths Response Thank you for highlighting your concerns during Barry Preston's Inquest. The report was sent to the Chief Executives of Greater Manchester Mental Health NHS Foundation Trust (GMMH), Bolton Council, Royal Bolton Hospital (RBH) and the Secretary of State for Health. GMMH, Bolton Council and RBH have met to review the concerns you have raised and agree who would be in the best position to respond to each ofyour concerns. Please see below GMMH Trust's response to the concerns you have raised and the actions taken by the Trust:
3. The inquest heard that he had a care coordinator in the community. However, the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interest meetings were taking place. There was a lack of understanding between agencies of role and responsibilities under the integrated care model. The point regarding care coordinator responsibilities is addressed fully in point 4, The Integrated Discharge Team (IDT) is a multidisciplinary team consisting of health and social care professionals from Bolton NHS Foundation Trust and Bolton Council. The team is responsible for the coordination of the discharge planning process for those inpatients within the acute trust with an identified health and/or social care need that will need meeting on discharge. At the time of this incident, the IDT also had a mental health social worker seconded into the service from Greater Manchester Mental Health NHS Trust It became clear throughout the inquest that the role of the mental health practitioner within the Integrated Discharge Team was fragmented, and that only certain wards within the acute trust made referrals to the Integrated Discharge Team which resulted in a lack of communication Tho Trust is commlttod to safeguarding children, young poople and vulnerable adults and requirvs all staff and volunteers to share this commibncmL Gtealer Manchester Mcn1al Health NHS Foundillion Trusl The Curve, Bury New Rood, Prestwich, Manchester M25 3BL (Tel 0161 TT3 9121)

during Mr Preston's various transitions between Royal Bolton Hospital wards, Laburnum Lodge and Trafford General Hospital. A review of the mental health practitioner role within the Integrated Discharge Team had commenced prior to the death of Mr Preston, however following a subsequent review with the Local Authority and Bolton Foundation Trust, taking into consideration the concerns noted within the inquest, the decision has been taken to end the secondment of the mental health social worker and return the practitioner to their substantive post within Greater Manchester Mental Health. Going forward there is now one point of contact with mental health services, the care coordinator, who will in-reach into the hospital when any service user they are involved with is admitted, to provide consistency and ensure hospital staff are aware of any input from mental health services.
4. The Inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement. It was clear from the inquest that the coordination of Mr Preston's care was lacking, and for that GMMH would like to offer our sincere apologies. There are a very clear expectations that the care coordinator is the conduit when an individual is admitted to an alternative care setting. The care coordinator is expected to link in with all care providers to ensure individuals are appropriately supported / advocated by family and/or advocacy/Independent Mental Capacity Advocate (IMCA), and where capacity is not clear or is lacking, that a formal capacity assessment is undertaken and Best Interest meetings occur. Whilst the role of assessing the capacity for clinical interventions should be undertaken by a professional who has full understanding of the procedures to be undertaken, the care coordinator had a pivotal role in ensuring this occurs. Whilst the transfer of Mr Preston's care was between acute care settings (and not secondary mental health settings), the care coordinator should have considered that there had been a significant change to Mr Preston's usual presentation and this should have triggered a more formal review of his care, and as such, GMMH would like to offer our apologies that this did not happen, as this is below the standard that we would expect. In addition to the care coordinator remaining involved, the acute trust wards also have access to the mental health liaison team who in reach into the wards to provide assessment, advice and support to the medical wards in respect of managing patient's mental health. We would like to assure the coroner that the following actions have been taken:
• Care coordinators have been advised that as part of their role, they are expected to proactively in-reach into acute trusts, to ensure effective communication is facilitated, to mitigate risks of individuals being moved between wards I hospitals / other care settings without the care coordinator being informed; this will enable to care coordinator to appropriately coordinate care, taking into account an individual's holistic needs. (This is outlined with the Older Adult Service Operational Procedure and the Policy for the Transfer of Service Users to Acute Care). The Trust Is commllted to safoguarding childmn, young people and vulnerable adulls and requlms all staff and volunteel'!I to share this commitment. Gremer Manchester Mcnlal Heallh NHS Founda1ion Trusl The Curve Bury New Rood, Prcslw1ch Manchester M25 3BL (Tel 0161 773 9120 ~lngUve,

• Team Managers have discussed the expectations with all staff, that every time there is a significant change in an individual's circumstance, that capacity assessments & Best Interest Meetings are considered and clearly recorded, and that care coordinators ensure they proactively liaise with other care providers to ensure any changes to the care plan can be reviewed and updated appropriately, and this is being monitored via supervision.
• The learning from this event was reflected upon within supervision with the individual care coordinator
5. The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care. Acquiescence by him was seen as him understanding and having capacity. Dr from GMMH, noted that Mr Preston's capacity was unclear. This should have led to the care coordinator liaising with the acute trust and ensuring a formal capacity assessment was completed with specific aspects to his care, and where this was lacking a Best Interest meeting should have been completed. Unfortunately, this did not occur and decisions were made by the acute trust, without the appropriate clinician undertaking appropriate decision specific capacity assessments. Learning form the inquest has been shared with the Senior Management Teams, over both Adult and Older Adult Services and with the Senior Leadership Teams, which has overarching responsibility within Bolton Mental Health Services and an action plan put in place to ensure that all staff are up to date with Best Interest & Capacity Training and Care Programme Approach (CPA) training, which is monitored by team managers. Learning from the inquest will be shared trust wide, via the trust wide Care Programme Approach (CPA) meeting. Through supervision and team meetings, all staff have been informed of the expectations of a care coordinator when patients are admitted to alternative care settings, such as acute trusts, and informed that they must consider support from advocacy / IMCA. Team Managers will proactively review cases where individuals have been admitted to other care settings in supervision to ensure that care coordinator are proactively coordinating the individuals care, and consideration has been given to Capacity and Best Interest meetings, where appropriate. I hope this response demonstrates that GMMH have taken the concerns you have raised seriously. If you have any further questions in relation to the Trust's response please do let me know.

Dear Mrs Mutch Barry Preston Regulation 28 Report to Prevent Future Deaths 1am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the Inquest touching the death of Barry Preston on 19 and 20 February 2020. Following receipt of the Regulation 28 Report, I requested that that the statutory Director for Adult Services review the concerns that related to Bolton Council and I am now in a position to provide a response. Bolton Council has liaised closely with Bolton Foundation Trust (BNFT) and Greater Manchester Mental Health Foundation Trust (GMMHFT) in order to fully ensure that a collaborative approach was taken to respond to the concerns and I am now in a position to respond to the points as outlined in Section 5. On behalf of Bolton Council, BNFT and GMMHFT it is clear that there was lack of coordination in Mr Preston's care and for that please accept our sincere apologies. Section 5 (3) The inquest heard that he had a care coordinator in the community. However, the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interest meetings were taking place. There was a lack ofunderstanding between agencies ofrole and responsibilities under the integrated care model. The point regarding care coordinator responsibilities is addressed in point (4) by GMMH. However, with regard to the lack ofunderstanding of roles and responsibilities under the integrated care model, we have made some changes following the inquest which should provide assurance. The Integrated Discharge Team (IDT) is a multidisciplinary team consisting of health and social care professionals from BNFT and Bolton Council. The team is responsible for the coordination of the discharge planning process for those inpatients with an identified health and/or social care need that

will need meeting on discharge. At the time of this incident, the IDT also had a social worker seconded into the service from GMMHFT. It became clear throughout the inquest that the role of the mental health practitioner within the Integrated Discharge Team was fragmented, and that only certain wards within the acute trust made referrals to the IDT which resulted in a lack of communication during Mr Preston's various transitions between Royal Bolton Hospital wards, Laburnum Lodge and Trafford General Hospital. A review of the mental health practitioner role within the IDT had commenced prior to the death of Mr Preston, however following a subsequent review with the Local Authority and BNFT, taking into consideration the concerns noted within the inquest, the decision has been taken to end the secondment of the mental health social worker and return the postholder to Greater Manchester Mental Health. There is now one point of contact, which is the care coordinator, who will in-reach into the hospital when any service user they are involved with is admitted. Section 5 (4) The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership ofhis care. It was unclearas to who was making decisions and assessing suitability ofplacement During the period of time that Mr Preston was an inpatient he was seen by multiple teams including the Home First Team, inpatient therapy services and the IDT. Since this incident it has been recognised that there were multiple handovers between teams and these teams have now been brought together under a single management structure in order to provide improved communication between staff groups and lead to better patient experience. At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in reach model which was reliant on other professionals identify those patients who had existing social care needs prior to admission to hospital . The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge. As a combined service it has been identified that there are a number of skills and competencies which all members of the team wiff need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 Response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020. The IDT has identified that the role of a seconded mental health role within the team was a key omission in the management of Mr Preston's Journey. The use of different organisation's case recording systems also resulted in the failure to identify that the patient already had a care coordinator in the community and the needs to identify an IMCA to represent the patient's best interest. Since this incident the IDT has in conjunction with GMMHFT, removed this role from the service in order to provide a single care coordinator (this will either be a social worker or discharge nurse) for each patient who is hospital based and will liaise with other organisations where needed. All input will be recorded in the patient's electronic patient record and social services case recording systems. Section 5 (6) The inquest heard that whilst an inpatient he was served a pudding that was hot that, while eating it unsupervised, he dropped it on himselfand suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort.

Mr Preston sustained a first degree burn to his chest whilst in the care of Trafford General Hospital after he was served a pudding that was too hot. This incident was investigated by Manchester Foundation Trust and steps have been taken to improve safety measures in relation to the temperature of food and how this is served to patients including supervisory arrangements. Whilst the Manchester Foundation Trust completed its own internal root cause analysis it is not clear whether they referred this incident to Trafford Council for a section 42 Safeguarding Investigation under the Care Act 2014 .As the host authority, Trafford Council would have been responsible for undertaking the investigation had it been referred to them by the hospital but they would have notified Bolton Council if this was the case as Bolton was the authority where Mr Preston was ordinarily resident. This has been checked with Bolton Safeguarding Adults Team and there is no evidence that Trafford contacted to advise of a safeguarding investigation under the multi - agency safeguarding procedures. Section 5 (7) His placement at Laburnum Lodge was made without clear understanding of his needs. He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital. It was clear from the evidence heard at the inquest that Mr Preston's needs were very different to those prior to admission to hospital. Mr Preston required the assistance oftwo carers for all transfers and needed assistance with personal care and eating and drinking. The decision to transfer Mr Preston to Laburnum Lodge was made by the occupational therapist in the Home First Team which is managed by the community division of Bolton Foundation Trust. The occupational therapist deemed Mr Preston suitable for transfer to this intermediate care facility primarily related to his mobility needs and recommended occupational therapy and physiotherapy input. The occupational therapist sent the referral to Laburnum Lodge and the registered manager made the judgement that they could meet Mr Preston's needs in the unit, based on the documentation provided. It was highlighted that Mr Preston was at risk of falls therefore a falls assessment was completed by care staff on admission to the unit and he scored 13 which is high risk. A bed sensor was put in place and he was nursed in bed to try and mitigate the risk of further falls. It became evident at the inquest that Mr Preston was receiving enhanced care at level 3 which is 1 :1 supervision whilst on the ward but he was downgraded to level 2 by ward staff just prior to transfer. With hindsight, he should not have been downgraded to level 2. The level of supervision required was a crucial factor in minimising the risk of further falls and Laburnum Lodge agreeing that they could meet his needs. Had he remained at level 3 enhanced care then Laburnum Lodge would not have deemed him suitable as they are not staffed or equipped to provide 1 :1 supervision Actions taken by Bolton Council and BNFT
• All wards have been advised by Bolton Foundation Trust that the decision to reduce the level of enhanced care should not be undertaken by ward staff without a full multi - disciplinary meeting
• Ward Managers have been instructed that any patient with complex needs should be escalated to the integrated discharge team by the ward for a full MDT meeting where any transfer of care is being considered.
• Development of a skills and competency framework.

I hope that the coordinated responses of Bolton NHS Foundation Trust, Bolton Council and Greater Manchester Mental Health Trust have provided you with the assurance that all organisations have taken appropriate action to mitigate the risk of future deaths. Please do not hesitate to contact me In the event you require any further assistance.

From Nadine Dorries MP Minister of State for Patient Safety, Suicide Prevention and Mental Health

39 Victoria Street London SW1H 0EU

020 7210 4850

Your Ref: 312214 Our Ref: PFD-1222239

Ms Alison Patricia Mutch HM Senior Coroner, Manchester South HM Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG

7 July 2020

Ms Mutch,

Thank you for your letter of 4 May 2020 about the death of Barry Wayne Preston. I am replying as Minister with responsibility for mental health.

Firstly, I would like to say how saddened I was to read the circumstances of Mr Preston’s death. It is important that we take the learnings from his death so that people continue to receive the highest quality, safe care from the NHS.

I have noted your concerns about the care Mr Preston received while in hospital, including the co-ordination of that care and that it failed to meet his needs. It is deeply concerning to read from your report that Mr Preston’s placement at Laburnum Lodge was made without a clear understanding of his needs and that he fell twice within 24 hours.

I expect the Bolton NHS Foundation Trust, the Greater Manchester Mental Health NHS Foundation Trust and Bolton Council to carefully consider and respond to the specific concerns highlighted by your report. I am advised that Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust have apologised for the lack of co-ordination in Mr Preston’s care while he was in hospital and the failure to conduct a formal assessment of Mr Preston’s mental capacity. You will know from the responses of the NHS trusts and Bolton Council to your report that they have worked together to resolve the matters of concern highlighted, with several actions taken to improve the co-ordination and quality of care for people with physical and mental health problems. I am pleased to see that learnings are being taken from the circumstances around Mr Preston’s care. My response will focus on the national level aspects of the concerns you have raised.

The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.

The Care Programme Approach1 has been key guidance for health and social care agencies working in partnership within community mental health services since 1992. It is designed to ensure that a lead mental health professional coordinates the care and support of people with mental health needs and this should include support across health, social care and housing services. This includes meeting the rights of adults with eligible needs under the Care Act. Under this model, it should have been clear who was leading on the coordination of care for Mr Preston, particularly as he had both physical and mental health needs.

I am advised that local authorities within Greater Manchester, including Bolton, are working with Greater Manchester Mental Health NHS Foundation Trust to assess, develop and improve their integrated care arrangements and the role of social work in line with the Social work for better mental health programme2, published by the Department of Health and Social Care in 2016.

Last year, the Greater Manchester Mental Health NHS Foundation Trust finalised a 2019- 2022 Social Work Strategy, agreed with local authorities in Salford, Trafford and Bolton3, to support improvements in integrated arrangements, including the need to develop access to the Care Act, and greater collaborative working.

In light of your report, the Chief Social Workers for Adults office will make contact with the Principal Social Worker for Bolton and the Director of Nursing and Governance at the Greater Manchester Mental Health NHS Foundation Trust to discuss the progress that both organisations have made in developing and implementing changes to their integrated care model and protocols for people with physical and mental health issues.

You may also wish to note that NHS England and NHS Improvement (NHSEI) has recommended a review of the effectiveness of the Care Programme Approach and its links to the Care Act as part of the community mental health review in the NHS Long Term Plan4. Twelve areas of the country are piloting new models of care based on the principles outlined in the Community Mental Health Framework for adults and older adults5, designed to improve how health and social care agencies work together to deliver joined-up, multi-agency care for community mental health services.

1 https://www.nhs.uk/conditions/social-care-and-support-guide/help-from-social-services-and-charities/care-for-people- with-mental-health-problems-care-programme-approach/

2 https://www.gov.uk/government/publications/social-work-improving-adult-mental-health

3

al%20work%20as%20a%20profession.&text=This%20Social%20Work%20Strategy%20hopes,in%20mental%20health% 20service%20practice.

4 https://www.longtermplan.nhs.uk/

5 https://www.england.nhs.uk/wp-content/uploads/2019/09/community-mental-health-framework-for-adults-and-older- adults.pdf

Officials have shared the concerns in your report with NHSEI so that they can be considered as work to deliver improved, co-ordinated community mental health services progresses, in particular, guidance to mental health trusts on partnership working and use of the Care Programme Approach, especially when the person has mental and physical health issues.

I have noted your concern that no new assessment on capacity and no best interests meetings were held to consider Mr Preston’s care in hospital. As set out in the Mental Capacity Act (2005)6 (MCA), every person must be assumed to have capacity unless it is established that they lack capacity in relation to the specific decision. This recognises the need to respect personal autonomy but equally, where there are good reasons for concern, the presumption cannot be used to avoid taking responsibility and determining capacity. Moreover, if it is established that the person lacks the relevant capacity, then the person will receive important safeguards.

While a formal best interests meeting is not a statutory duty, under section 4 of the MCA the decision maker must take into account, if it is practicable and appropriate to consult them, the views of anyone named by the person as someone to be consulted, anyone engaged in caring for the person or interested in their welfare, any person with lasting power of attorney or a deputy appointed by a court. The MCA Code of practice also recognises that there will be times when a joint decision must be made. Best interests’ meetings are particularly useful when the decisions are complex or involve serious consequences for the person.

The person should also be consulted, and the Code of Practice7 recommends that all possible and appropriate means of communication should be tried. A best interests meeting may be required if there is a dispute or a decision is required concerning a long- term move or serious medical treatment. Section 4 (9) of the MCA confirms that if someone makes a decision, having complied with all the relevant subsections, that they reasonably believe is in the best interests of the person who lacks capacity they will have complied with the best interests’ principle set out in the Act.

If anyone is unhappy with a service provided by their local authority, they have the right to make a complaint using the statutory local authority complaints procedure, and to refer that complaint to the Local Government Ombudsman if they remain unhappy with the local authority’s response.

In some situations, a person whose needs are being assessed or met under the Care Act has the right to an advocate to support them to ensure that their voice is heard within the care planning process. Equally, for certain best interest decisions under the MCA, an advocate must represent and support the person who lacks capacity.

6 http://www.legislation.gov.uk/ukpga/2005/9/section/4

7 https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice

I hope this response is helpful. Thank you for bringing these concerns to my attention.

NADINE DORRIES