Dear Mr Farrow

RE: Mr Gordon Fenton

Thank you for your Regulation 28 Report dated 23rd April 2020 and for bringing to my attention the concerns you have after hearing evidence at the inquest of Mr Gordon Fenton. Your concerns have been reviewed jointly between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Foundation Trust. Pennine Care’s response is outlined below:

Concerns:
• The inquest heard that there was a particular tension in relation to shared care between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Trust for patients who are subject to psychiatric care, who have acute medical problems.
• There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts.
• There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient’s needs.

Response: We are very sorry if this was the impression projected to you, the jury and Mr Fenton’s family at inquest. We hope that you will accept from this response that both Tameside & Glossop Integrated Care NHS Foundation Trust (TGICFT) and Pennine Care Foundation Trust (PCFT) are committed to working together to improve the safety of all patients requiring psychiatric care who also have acute medical problems.

It is accepted that, at the time of time of Mr Fenton’s care, there were existing processes that required improvement in terms of shared physical and mental health care.

As part of our investigation into your concerns, extensive discussions have taken place between Tameside’s Associate Director and Mental Health Quality Lead at PCFT and the Head of Assurance and Governance and Lead Nurse for Mental Health and Learning Disabilities at TGICFT in relation to ongoing improvements in shared service, specifically in relation to creating a formal standard operating procedure and enhancing services offered by TGICFT.

It is understood that it was discussed in evidence that both organisations have been working towards creating a joint Standard Operating Procedure (SOP) for older people receiving in-patient mental health care and treatment on our older people’s wards who require medical input. It is recognised that these patients will often have the most complex comorbid physical and mental health needs and, therefore, it is extremely important that there must be a shared responsibility between mental health services and acute services to ensure all patients have timely access to specialist advice and are provided with safe and effective care.

This SOP will apply to all patients within PCFT’s Tameside older peoples’ mental health in-patient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers and Hague wards, of which Mr Fenton was a patient. The offering of Digital Health services will be conducted as a pilot, in the first instance for eight weeks, which will then be reviewed by both organisations to establish a more formal offer and outcomes. It is hoped that, if this procedure is successful, that similar processes will be developed for all of our patients requiring shared input.

A number of pathways have also been created with regards to mental health in- patient transfers of care and return in-patient transfers of care. In terms of transfers of care, the process will be split into three categories;

1. Patients with an acute deterioration of their physical health,
2. Patients with a chronic long-term condition who may be deteriorating or for ongoing management advice and;
3. Gathering of required information either at the point of admission or transfer back from TGICFT.

The process will include PCFT staff performing baseline physical observations and calculating the National Early Warning Score (NEWS), following which, if deemed necessary they will refer the patient to the medical team/on-call doctor and handover

the patient’s clinical presentation. At this time, PCFT will assess whether further assistance is required from the Digital Health Services to coordinate access to specialist services for review and to agree an appropriate management plan. If the patient does need immediate on-going physical health support, the nurse-in-charge will contact Digital Health to complete a full physical and mental health assessment to determine whether the patient requires admission to a medical ward. The Digital Health Team will be responsible for coordinating direct admission to a medical bed, however if an attendance to the Emergency Department (ED) is required, Digital Health will liaise directly with the ED Team Leader and complete a ‘Situation, Background, Analysis and Recommendation’ (SBAR) handover. PCFT will be responsible for informing the Mental Health Liaison Team of patient transfers to TGH.

Once a patient is deemed medically fit for discharge, TGICFT’s ward team will contact PCFT MH Liaison Team to provide a full handover of nursing care and agree patient outcomes, including on-going care and treatment. Included in this handover will be details of bloods completed within the preceding 24 hours. The appropriate PCFT junior doctor will then be asked to attend the medical ward as a matter of urgency to assess the patient’s suitability for transfer back to PCFT and arrangements made by PCFT MH Liaison Team to transfer the patient to Summers or Hague Ward.

Due to concerns raised as a result of Mr Fenton’s inquest, the SOP has reinforced that all patient’s with on-going care and treatment needs must be clearly defined and communicated to the receiving Mental Health Team to ensure safe transfer of care takes place. This will be accompanied by a discharge summary and prescription information that should already be provided under the current process. In the absence of any additional required information PCFT will liaise with the Digital Health Team who can access this information on their behalf.

We are confident that the new SOP will support our clinical teams in early identification of patients who may be experiencing an acute physical health deterioration and early intervention and prevent any unnecessary attendance for those patients at the Emergency Department (ED), or multiple moves for those older people currently an in-patient on Summers and Hague Wards. It is also anticipated that this will support signposting, including ongoing care and treatment of patients with chronic long-term conditions who require specialist services, as well as assisting with planned transfer of patients returning to our in-patient wards following a period of care and treatment within TGICFT in-patient services.

Please note that this SOP remains in its implementation stages as both Trusts are working to align their own pathways with the new arrangement. It is planned that his will go live at the end of August 2020. Once the new SOP is approved by both Trusts, self-directed training will be carried out by all staff to which the SOP is relevant and this training will be documented in their training record.

It should be noted that this new process will not replace current appropriate intervention that must be provided for all physical health needs as detailed in PCFT’s Physical Health Policy for Mental Health & Learning Disability Service Users (CL042). This policy was effective at the time of Mr Fenton’s admission and outlines expected standards to ensure that physical health care, appropriate to the needs of the individual, is delivered and identified appropriately prompting appropriate action.

Similar to the proposed SOP, PCFT perform baseline physical observations and calculate the national early warning score. Any abnormal results, concerns or potential problems highlighted will require either further assessment by ward staff to gather more information to define the problem and inform care, or immediate referral to a doctor or specialist practitioner. Where emergency admission or treatment is required, staff should utilise medical practitioners available throughout a 24 hour period through the on-call system, crash teams and/or 999 as appropriate.

It should be noted that, where possible, every PCFT patient is assessed using an in-patient physical health screening tool within 24 hours of their admission. Where it is not possible to complete the physical health screen within 24 hours, regular attempts to complete are made and documented. This assessment takes into consideration a number of clinical factors including BMI, wounds, infection, mobility including risk of falls, venous thromboembolism, pain, fluid intake etc. Any abnormal results, concerns or potential problems highlighted will require either further assessment by ward staff to gather more information to define the problem and inform care, or immediate referral to a doctor or specialist practitioner. This is also discussed by the multi-disciplinary team and reviewed during ward rounds or other MDT meetings. When transfers to a ward outside of the organisation takes place, physical health monitoring and examination information should be reviewed, this should also be incorporated into the transfer of care documentation.

The teams on Summers and Hague Wards are currently using Digital Health for advice and guidance with regards to mental health patients requiring medical input. It is planned that the updated process and outcome of Mr Fenton’s inquest will be presented at the Tameside & Glossop CCG Bi-Lateral PCFT Mental Health Contract Quality and Performance Group. One of the main purposes of the performance group is to provide education around improvements in patient care at the Trust and to ensure the implementation of the resulting action plans. This will be placed on the group agenda and discussed once pressures surrounding COVID-19 have eased. The outcome of the inquest and subsequent learning will also be presented at the Tameside Borough Quality Governance and Shared Learning Forum with any subsequent actions to be monitored.

PCFT are confident that, following communications and implementation of the new joint SOP and contingency measures in place, that there will be no reason as to why both Trust’s should deviate from recommended guidance or result in the same omissions that occurred in Mr Fenton’s journey.

I hope this response assures you that the Trust has taken your concerns seriously and is taking joint measures to address these.

Dear Mr Farrow, Regulation 28: Report to prevent future deaths, following the Inquest touching upon the death of Mr Gordon Fenton I am writing to you in respect of your letter dated 23rd April 2020, by way of a Regulation 28 Report issued following the Inquest touching upon the death of Mr. Gordon Fenton, which concluded on 6th March 2020. I hope to be able to address the concerns raised in your report and set out_ below my response which has been compiled further to joint working between Tameside and Glossop Integrated Care NHS Trust (TGICFT) and Pennine Care Foundation Trust (PCFT). Concern 1: The inquest heard that there was a particular tension in relation to shared care between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Trust for patients who are subject to psychiatric care, who have acute medical problems. I am very sorry if this was the impression projected to you, the jury and Mr Fenton's family at inquest. I hope that you will accept that both TGICFT and PCFT are committed to working together to improve the safety of all patients requiring psychiatric care, who also have acute medical problems. mm disability Chief Executive ­ Chair ffl~ rnnfinPnt

,~1:;.1 Tameside and Glossop Integrated Care NHS Foundation Trust As you may already be aware, TGICFT have obtained a copy of the court recording. This has been reviewed by the Trust and has identified areas of learning in terms of providing evidence at Coroner's Court and the importance of continuity, even where there may be a difference of opinion as to the expectations of each service. Please note that TGICFT are not commissioned by the Clinical Commissioning Group to provide in-reach services to Mental Health Wards, it is accepted that at the of time of Mr Fenton's care, there were existing processes that required improvement in terms of shared physical and mental health care, which have been detailed below. Concerns 2 and 3: There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts. There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient's needs. As part of our investigation into your concerns, extensive discussions have taken place between the Associate Director and Mental Health Quality Lead at PCFT, Head of Assurance & Governance for TGICFT and Lead Nurse for Mental Health & Learning Disabilities at TGICFT in relation to ongoing improvements in shared service, specifically in relation to creating a formal standard operating procedure and enhancing services we offer. I understand it was discussed in evidence that we have been working towards creating a joint Standard Operating Procedure (SOP) for older patients receiving mental health care and treatment from PCFT who require medical input. It is recognised that these patients will often have the most complex comorbid physical and mental health needs, therefore it is extremely important that there must be a shared responsibility between mental health services and acute services to ensure all patients have timely access to specialist advice and are provided with safe and effective care. The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT's older peoples' mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr Fenton was a patient. The offering of Digital Health services will be conducted as a pilot in the first instance for 8 weeks, which will then be reviewed to establish a more formal offer and outcomes. It is hoped that if this procedure is successful that similar processes will be developed for all of our patients requiring shared input. A number of joint pathways have also been created with regards to Mental Health Inpatient Transfers of Care and Return Inpatient Transfers of Care. In terms of transfers of care, the process will be split into three categories; Chief Executive I ­ ~= disability Chair- mr. rnnfirJpnt

r.!7:b1 Tameside and Glossop Integrated Care NHS Foundation Trust
1. Patients with an acute deterioration of their physical health,
2. Patients with a chronic long-term condition who may be deteriorating or for ongoing management advice and;
3. Gathering of required information either at the point of admission or transfer back from TGICFT. I understand that the process will include PCFT performing baseline physical observations and calculating the National Early Warning Score (NEWS), following which, if deemed necessary they will refer the patient to PCFT's medical team/on call Doctor and handover clinical presentation. At this time, PCFT will assess whether further assistance is required from the Digital Health Services to coordinate access to specialist services for review to agree an appropriate management plan. If the patient does need immediate on-going physical health support, the Nurse in Charge will contact Digital Health to complete a full physical and mental health assessment to determine whether the patient requires admission to a medical ward. The Digital Health Team will be responsible for coordinating direct admission to a medical bed, however if an attendance to the Emergency Department (ED) is required, Digital Health will liaise directly with the ED Team Leader and complete a 'Situation, Background, Analysis and Recommendation' (SBAR) handover. PCFT will be responsible for informing the Mental Health Liaison Team of patient transfer to TGH. Once a patient is deemed medically fit for discharge, our Ward Team will contact PCFT MH Liaison Team to provide a full handover of nursing care and agree patient outcomes, including on-going care and treatment. Included in this handover are bloods completed within the preceding 24 hours. The appropriate PCFT Junior Doctor will then be asked to attend the medical ward as a matter of urgency to assess the patient's suitability for transfer back to PCFT and arrangements made by PCFT MH Liaison Team to transfer the patient to Summers or Hague Ward. I am confident that the new joint SOP will support PCFT clinical teams in early identification of patients who may be experiencing an acute physical health deterioration and early intervention and prevent any unnecessary attendance for those patients at the Emergency Department (ED), or multiple moves for those older people currently an in-patient on Summers and Hague Ward. It is also anticipated that this will support signposting, including ongoing care and treatment of patients with chronic long-term conditions who require specialist services, as well as assisting with planned transfer of patients returning to PCFT following a period of care and treatment within our inpatient services. Once the new SOP is approved by both Trusts, self-directed training will be carried out by all staff to which the SOP is relevant and this training documented in their training record. I understand that in the meantime PCFT are using our Digital Health Team for advice and guidance with regards to mental health patients requiring medical input. It is planned that the updated process and outcome of Mr Fenton's inquest will be presented at our Divisional Governance Meetings and also reported to the Service Quality & Chief Executive ICJ= disability I Chair 8 [?ii rnnftrlPn;

Fi't:b1 Tameside and Glossop Integrated Care NHS Foundation Trust Operational Governance Group (SQOGG), with any subsequent actions to be closely monitored. Both Trusts are confident that following communications and implementation of the new joint SOP will address the concerns raised and minimise the likelihood of similar occurrences taking place and to enable both Trusts to provide safe and effective care to all our patients. I hope your concerns have been addressed, however should you have any queries arising from the content of this letter or require further information or clarification, please do not hesitate to contact me. Director of Nursing and Integrated Governance In the absence of the Chief Executive Chief Executive - IClrl disability I Chair - mr. rnnfirlpnt