Dear Mr Murray Reference – Regulation 28 Report to Prevent Future Deaths
1. Further to your Regulation 28 Report sent on 15th October 2019 to the Trust, in relation to the inquest into the death of Matthew George Williamson, who died on 24th October 2018, please find our response set out below.
2. The matter of concern which you raised was as follows: “There appears to be a lack of opportunity for carers and family members to provide more pertinent information to clinical mental health teams and the interplay between mental health providers isn’t clear. This makes it very difficult to navigate as there is no patient road map which would assist with access to and type of treatment”.
3. Mr Williamson had been under the care of West London NHS Trust, specifically the Ealing Primary Care Mental Health (EPCMH) Team, when he was found dead, hanging in the family home on 24th October 2018. He had been discharged from the EPCMH service twenty days prior to his death. The Trust conducted a Level 2 Investigation into the incident, and published a report of the findings. We understand that you have already seen this; however, this is attached for your convenience.
4. In relation to the concern you raised in your Regulation 28 Report, and noted above, the Trust investigation included a specific Term of Reference for the panel to review: “To establish whether there was effective and appropriate communication and liaison between the patient’s family and all agencies involved in the patient’s care to meet his needs”.
5. The Trust investigation concluded that the “communication between the patient’s family and all agencies involved in the patient’s care was inadequate”. It was also noted in the investigation report that the family of Mr Williamson also highlighted what, in their view, were “multiple issues with regards to communication between services”.

CONFIDENTIAL

6. The investigation noted that the family also made it clear that they were keen to ensure that those family members and carers close to and supporting a patient with mental health problems, would be more involved in the clinical assessment processes in future. These are concerns that we are absolutely committed to addressing.
7. The key issues identified in the Trust investigation, which are related to the above Regulation 28 Report included:  Disjointed commissioning and national reporting requirements has led to 3 different clinical record systems being used by teams, which are not interoperable with each other.  Trust operational policy makes no provision for family involvement during the assessment and/or treatment phase.  There is a lack of local guidance for managing instances where consent to involve the family is denied by the patient.  Further staff training in Carer Awareness is necessary.  ‘Triangle of Care’ principles were inconsistently implemented within the teams.
8. We are pleased to report that we are making good progress to address all the issues identified above and that are within our control.
9. Specifically, as it is often GPs who will see patients with a range of mental health difficulties and who will then refer patients needing mental health services, we have established the Trust Single Point of Access (SPA) to support both GP referrals, and to help signpost people in need who have chosen not to see a GP, or who are unable to see a GP.
10. The SPA is also known as the 24/7 Helpline, and is a telephone based service which manages all adult mental health referrals as well as providing telephone support to patients and carers. The SPA helps to provide the right out-of-hours care for people in crisis 24 hours a day, 7 days a week, 365 days a year. When someone feels unsafe, at risk or unable to cope without professional advice, trained mental health advisors and clinicians will work with people to enable them to manage their difficulties without having to access other services. In an emergency, the SPA aims to respond within four hours, and within 24 hours in urgent cases, any time of day or night – these are the same response times for acute NHS services.
11. The SPA ensures that all referrals from GPs, carers and other statutory and third sector referrals are processed and responded to in a timely way, following a robust clinical triage process.
12. The service manages all adult referrals, except those for cognitive impairment or dementia services. The SPA also provides the out of hours service for child and adolescent mental health services.

CONFIDENTIAL

13. GPs can also refer patients who they consider to have mild or moderate mental health difficulties directly to the Trust Primary Care Mental Health teams. These teams offer a specialist mental health service for those people who do not need an intensive multi-disciplinary package of care, but would benefit from medical, psychological, occupational or nursing support to help them maintain their wellbeing or recover from a period of mental health difficulties.
14. For those people needing more intensive care, West London Secondary Community Mental Health Care is provided by specialist mental health teams and involves a case management approach, with the possibility of more intensive input.
15. While successive national mental health policies and strategies have left Community Mental Health Teams (CMHTs) unchanged, the new community framework calls for “transformation and modernisation”. Existing CMHTs in most areas of the country are based entirely in secondary (specialist) care and they operate with thresholds that require someone to have a level of severity of mental health need to qualify for support. The national framework anticipates that this should be replaced by a new “core” community mental health service, which will incorporate existing CMHTs with primary care mental health services, in a place based offer aligned to the Primary Care Networks.
16. Importantly, the framework refers to a ‘no wrong door’ policy to make meaningful support far more accessible, whilst addressing the current assessment system by outlining a bigger role for local government and the voluntary sector. The use of ‘alliance contracting’ is promoted to bring a wider range of providers together to meet people’s needs
17. As a result of this new framework, West London NHS Trust services are in the process of transforming to a series of integrated primary and secondary mental health teams, wrapped around the Primary Care Networks. Our new service will offset the need for criteria to be met to access a more intensive input at times of increased mental health need, and will ensure that boundaries between services are removed.
18. This means that once a person is referred, the ‘system’ will respond to the needs of the patient – rather than to an increased clinical acuity, leading to a referral and gateway assessment. This will enable a time-limited period of specialist intervention and intensive input to be delivered. These changes are already underway and will be fully implemented during 2020 / 2021.
19. We are addressing the involvement of carers and families through the ‘Triangle of Care’. The Triangle of Care was launched in July 2010 by the Carers Trust and the National Mental Health Development Unit, emphasising the need for better local and strategic involvement of carers and families in the care planning and treatment of people with mental ill-health.

CONFIDENTIAL

20. The ‘Triangle of Care’ sets out how carers, service users and professionals should work together to support recovery and to sustain patient wellbeing by including and supporting carers.
21. The Trust is a formal member of the ‘Triangle of Care’ membership scheme, and we have committed to implementing the standards set out in the ‘Triangle of Care’. Part of this includes submitting regular progress reports to the Carers Trust. Progress reports for each stage of implementing the ‘Triangle of Care’ (Stage 1 and Stage 2) are expected. At West London NHS Trust, ‘Stage 1’ is the roll out of self- assessments throughout our inpatient services and crisis teams, and ‘Stage 2’ is the roll out of self-assessments throughout community services. We are currently considering whether a further stage is required for our community physical health services.
22. To support implementation of the ‘Triangle of Care’ across the Trust, an overarching project delivery plan and risk log has been developed. This has been presented to the Trust Board. Regular project delivery updates are reported to the Trust Service User and Carer Experience meeting, and from there, to the Trust Board.

23. In August 2019, the Trust was given its first Carers Trust Triangle of Care star. The first star is for completing Stage One (self-assessing all inpatient and crisis teams) and then committing to improve. We are committed to achieving further progress, and this star an encouraging start, and is the first of three required before we are given full recognition by the Carers Trust.

24. In order to continue towards Stage 2 and beyond, the Trust has identified the following areas for development:

• To continue to strengthen managerial, clinical, and carer support in implementing the Triangle of Care whilst embedding it into day-to-day practice
• To focus on the expectation that all staff attend Carer Awareness Training
• To take steps to establish a Carers Council
• To strengthen how we measure the impact of the work we do
25. Further details about the work we are doing is available on our ‘Triangle of Care’ webpage, which can be found by following the link:

someone/triangle-of-care/
26. Finally, although much of the work underway across West London NHS Trust is part of a wider regional and national strategy to address the issues outlined in the Regulation 28 Report, our Trust investigation report clearly identified some local actions that the Trust must take to address the issues highlighted above. These included:

CONFIDENTIAL

 Amendment of operational policies to include sections on strengthening family involvement; managing cases where consent is not given; and the adoption of the Triangle of Care.  Ealing PCMHS staff must attend Carer Awareness and Triangle of Care training sessions.
27. We are pleased to report that the above two actions have been completed.
28. The challenges involved in improving opportunities for carers and family members to provide more pertinent information to clinical mental health teams, as well as improving and elucidating the interplay between mental health providers need to be addressed both locally, and strategically. We believe we are making good progress in both areas, as outlined in the narrative above. We also acknowledge that further work is required, but believe that we have a clear strategy and aim identified to address this during the coming year.
29. We are more than happy to provide you with further information should the above not suffice. Please do not hesitate to contact either myself or , Head of Patient Safety and Clinical Effectiveness, should this be the case.