Dear Ms Lake Re: Regulation 28: Report to Prevent Future Deaths (17/09/2019) Tyla Katherine Joan Cook In response to the concerns raised in the above report in relation to Norfolk and Suffolk NHS Foundation Trust have provided details below of actions taken or proposed to be taken to address these issues Concern 1: It was agreed at the CETR meeting on gth August 2017 that Tyla was to be seen by the Eating Disorder Service. He was not seen until 25th October 2017 . The evidence was the 11 week delay in seeing Tyla was due to a heavy caseload and the practitioner having to remove other cases from his caseload before he was able to work with Tyla Trust response to concern 1: In order to prevent delays accessing care when a service user presents with complex co-morbid mental health conditions the following process has been developed The care coordinator will ask other teams to joint work andlor provide consultation to ensure all relevant expertise is promptly accessed. Input from another team will be prioritised according to risk and not held on a waiting list if there is an urgent need. Any concerns regarding capacity and access to care will be escalated to the locality operational manager. A service user may have a care co-ordinator from one team, such as Youth, and a CO-worker from another team, such as Eating Disorders_ The teams will work closely together to ensure that relevant interventions and treatments are offered in line with the service user's care plan: Reviews and meetings will include professionals from all the care teams involved. The service user and familylcarer will be kept informed throughout: Concern 2: There were no written up-to-date care and crisis plans in place_ The most recent written care plan related to Tyla being an inpatient at the Dragonfly Unit; from where he was discharged on 9 August 2017. The written plans were therefore several months out of date. This is against Trust Policy. Evidence was heard that at a CETR meeting on 6 November 2017 period of a further 3 months was requested to prepare an up-to-date written care plan. In the event; and despite the family'$ repeated requests for plans in it was decided that the care plan could be commenced by 30 November 2017 on the basis Tyla's input into the care plan was important and it would take time to his meaningful input. The evidence was that there were oral plans in place which were relayed to Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren Working together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE for better mental health Tel: 01603 421421 Fax: 01603 421341 WWWnsft nhs.uk writing; gain

the parents (including at times of distress) , who continued to request plans in The high level of distress and anxiety within Tyla's home was recognised. An interim written plan was not considered nor that a written plan may have helped the family in providing support to Tyla. Steps have been taken by the Trust to recognise when up-to-date written care plans are not in place and it is understood that staff have undergone some work in improving the quality of care plans. However, in this case an active decision was made not to update the written plan for some time_ Further evidence did not reveal any insight into the support a written plan could have given the family to support Tyla. Trust response to concern 2: NSFT recognises the importance of care plans for all service users and that these need to be done in collaboration with the service user and their families carers if possible. However; in some circumstances this can take time in which case an interim care plan will be put in place whilst a more comprehensive and collaborative plan is developed. In addition Tyla's discharge from Dragonfly was not planned and s0 there was not an opportunity at that point to adjust the care plan or crisis plan in preparation for his return to community services We have recognised that we did not have a robust process in place to ensure this does not happen in the future. We have developed the attached process whereby in future, for any service user who is discharged from an inpatient unit without the normal discharge planning process happening, we will ensure that on leaving the ward the service user and their family carers are provided with written emergency contact information and an interim safety plan. The care co-ordinator must arrange to review the service user within 7 days as per national standards At this meeting will review the care and crisis plan and update accordingly: will provide written copies to the service user and their family carers as appropriate There will be a CPA meeting arranged within 28 days to further review the care and crisis plan with the whole team working with the service user In some circumstances service users do not wish to share confidential information with their families or carers. However; we recognise the importance of still emergency contact information and safety plan with families and carers_ A programme of training being rolled out offers training in care planning and crisis or safety planning with all staff which will ensure the above changes are embedded within teams. Concern 3: The review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust; Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be developed and implemented to train staff on how to apply good non-technical skills (teamwork,; leadership, task prioritisation and communication) when responding to an emergency: At the inquest it became clear that no steps have been taken to organise this event and there is confusion as to who is responsible for arranging this learning event. The care providers indicated it was for the West Norfolk Clinical Commissioning Group: The West Norfolk Clinical Commissioning Group do not appear to accept responsibility for organisation of the event: Tyla died on 15 November 2017. The West Norfolk Clinical Commissioning Group review was published 8
2019. No steps have been taken with regard to this learning event; save East of England Ambulance Service Trust who has been in contact with the West Norfolk Clinical Commissioning Group. There is concern that a multi-disciplinary learning event will not be organised and will not take place Trust response to concern 3: There is a multi-agency meeting fixed for the Ath November which our Head of Patient Safety, Saranna Burgess, will attend with representatives from all the other organisations involved to plan this_ Working together Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 5BE for better mental health Tel: 01603 421421 Fax: 01603 421341 Wnsft nhs.uk writing: being the they They sharing May

trust that the above responses address your concerns:

Dear Mrs Lake Inquest Tyla Katherine Joan Cook Regulation 28 Reply am writing in response to your report made under Regulation 28 of the Coroners (Investigations) Regulations 2013 where at paragraph 5(3) you refer to recommendation contained in the West Norfolk CCG's Review in May 2019 that there should be multi- disciplinary learning event arranged between the participants. Your concern was that no clear steps had been taken to organise the event by the time of the inquest in September_ am pleased to be able to advise you that on 4th November meeting was held at Chatterton House in King's Lynn and present were senior staff all of the participants, namely the Director of Nursing and Quality Assurance West Norfolk CCG (Chair), the Deputy Director for Patient Safety and Quality Norfolk & Suffolk NHS Foundation Trust, the Interim General Manager East of England Ambulance NHS Trust; the Approved Mental Health Professional (AMHP) Team Manager Norfolk County Council, and the Deputy Director of Patient Safety from this Trust. Other support staff were in attendance. One of the main agenda items was for the learning event to be arranged and it was decided that a date would be selected in February 2020 and that the West Norfolk CCG would take the lead in organising the venue and facilitating the event with support and contribution from the other participants hope very much that the event will be a success and will play its part in reducing clinical risk in future. Please let me know if you require any further information.

Dear Ms Lake Thank you for your Regulation 28 report of 17 September 2019 and your considered recommendations This letter provides an overview of the actions we have taken following Tyla's death and responds to specific points in your report: Following Tyla's death the Norfolk Safeguarding Children Board (now Norfolk Safeguarding Partnership) commissioned a Serious Case Review to ensure that all learning from the circumstances of Tyla's death has been captured and that all agencies take the necessary steps to put this learning into practice. The decision to undertake a serious case review was agreed at the Serious Case Review Group of 12 February 2018 Following the appointment of an independent lead reviewer the first scoping meeting took place on May 2018 and the multi ~agency panel have provided single-agency chronologies and undertaken interviews with all of the professionals involved with Tyla: The final draft report, with findings and recommendations will be signed off 11 November 2019 at the Safeguarding Practice Review Group. Children's Services have a Service Director and a Senior Officer as members of this group and ensure the governance arrangements are robustly upheld and implemented. Once the final report is published we will ensure that a copy is also sent to your office_ There are five overarching learning themes from the review relate to better adolescent care pathways, to embed an environment where the fundamental issues in relation to contextual safeguarding are better understood, for a holistic family approach to be better understood and for courageous conversations to take place throughout and across organisations. In essence a whole system approach to working with children, young people and their families. Although these are recommendations from this particular review, are all areas of work that are currently underway and being adopted in our approach to working with children and families.

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The majority of the specific points made in your report relate to actions to be taken by our health partners. We have been in Iiaison with health colleagues on these matters and the various health partnerships will be providing you with their joint response to the recommendations pertinent to them: The specific recommendations for Children's Services was in relation to attending a learning review in relation to the case_ A task and finish group has been established, coordinated by West Norfolk CCG to oversee the learning review with your recommendations in mind. can confirm that a formal learning event took place on 7 November 2019 whereby all professionals and their managers who worked with Tyla were invited. In addition, a further event will take place in early February 2020. Invites will go out to NCC Social Care; NSFT staff, East of England Ambulance and QEH: hope have been able to assure you that we are taking all recommendations seriously and continue to work collaboratively with our partners to learn the lessons highlighted in this case_

Dear Mrs Lake Re: The late Tyla Katherine Joan Cook Regulation 28 Report to Prevent Future Deaths dated 17 September 2019: West Norfolk CCG's response refer to the Report to Prevent Future Deaths (PFD) dated 17 September 2019 issued following the Inquest into the death of the late Tyla Katherine Joan Cook The PFD Report was sent to West Norfolk Clinical Commissioning Group (CCG) together with the Chief Executives of Norfolk and Suffolk NHS Foundation Trust (NSFT); The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust (QEH) and Norfolk County Council (NCC): It was also copied to East of England Ambulance Service NHS Trust (EEAST) as an Interested Person for the Inquest Point 3 of section 5: Coroner's matters of concern in the PFD Report relates to a multi-disciplinary learning event involving participants from NSFT , QEH, NCC and EEAST. This matter of concern is jointly addressed to West Norfolk CCG, NSFT, QEH and NCC (joint addressees') who are under a duty to respond by 12 November 2019. This letter comprises West Norfolk CCG's response to the Point 3 of section 5 of the PFD Report Copies of this letter wil_be sent to the Chief Executives of the joint addressees and also, for information, to the Chief Executive of EEAST. Commissioning NHS Services for West Norfolk Chair: Dr Paul Williams Accountable Officer: Melanie Craig King

Point 3 of Section 5: Coroner'$ concerns For ease of reference, Point 3 of Section 5 is set out below (using the above abbreviations for the stakeholders): "3. The Review carried out by the West Norfolk CCG in May 2019 recommended a multi- disciplinary learning event involving participants from NSFT, QEH, NCC and EEAST be developed and implemented to train staff on how to apply good non-technical skills (teamwork; leadership, task prioritisation and communication) when responding to an emergency. At the inquest it became clear no steps have been taken to organise this event and there is confusion as to who is responsible for arranging this learning event: The Care providers indicated it was for West Norfolk CCG. The West Norfolk CCG do not appear to accept responsibility for organisation of the event Tyla Cook died on 15 November 2017. The West Norfolk CCG Review was published
2019. No steps have been taken with regard to this learning event; save EEAST who has been in contact with the West Norfolk CCG. There is concern that a multi-disciplinary learning event will not be organised and will not take place. West Norfolk CCG response Background and context The Review referred to at point 3 of Section 5 comprises Recommendation 2 of the Action Plan to the independent Investigation Report dated 08 May 2019 (the 'Action Plan' and 'Investigation Report') compiled by an independent reviewer commissioned by West Norfolk CCG. The key points of Recommendation 2 are summarised as follows:
1. multi-disciplinary learning event ("the learning event') involving participants from NSFT, NCC; EEAST and QEH must be developed and implemented to train staff on how to apply good non-technical skills when responding to an emergency: 2 QEH to set up pan-Trust and West Norfolk CCG task and finish group (the task and finish group') to develop the learning event designed for NSFT, QEH, NCC, West Norfolk CCG and EEAST. 3 The task and finish group to be led by QEH's named Deputy Director of Patient Safety with the group's members from each organisation to include NSFT, EEAST and NCC with their representatives also named_ The task ad finish group led by QEHs Deputy Director of Patient Safety to deliver the learning event
5. The target dates for implementation of the task and finish group and delivery of the learning event were 30 June.2019 and 31 October 2019 respectively.
6. West Norfolk CCG has associated monitoring responsibilities for Recommendation 2 (via our Serious Incident Review Panel) to include that the learning event has taken place. The Investigation Report was issued in the week before the initial date for the Inquest to commence in May 2019 and provided to the Coroner at that time_ The proximity of the dates of the issue of the Investigation Report and Inquest aside, the plan was that the learning event would take place after conclusion of the Inquest This was in order for any learning or other issues from the Inquest to be captured in one event May

In the event; as the Inquest was deferred from the initial date of May 2019 to September 2019, the date of delivery of the learning event was in turn deferred. However this did not preclude and undertaking the action required to set up the task and finish group and preliminary arrangements for the learning event: Issues The issues in point 3 of section 5 comprise: Issue 1: Clarification and confirmation of the lead organisation with responsibility for organising the learning event Issue 2: The organisation and delivery of the learning event to ensure and assure that it takes place Issue 1: Lead organisation for lhe learning event Recommendation 2 clearly states that firstly, the task and finish group is responsible for the implementation of the recommendation (i.e: is the 'action owner') Secondly, that QEH and its Deputy Director of Patient Safety are the organisational and individual leads respectively for this recommendation The CCG was not aware that there was any issue about the lead for Recommendation 2 until we received QEH's submissions dated 15 September 2019 made to the Coroner in respect of prevention of future deaths via our solicitors on 16 September 2019. This was despite requesting each of the 3 NHS trusts to provide an update to us on the relevant actions for their organisation by Friday 30 August 2019. This was both to monitor progress but also in anticipation that the Coroner may require and request this information: Neither NSFT nor QEH responded to us specifically as regards Recommendation 2. On 30 August 2019, EEAST advised us that it was taking part in workshop with all involved' and was awaiting dates to be shared and further information. Paragraph 25 of the QEH submissions states that a meeting took place on 24 June 2019 between QEH's Medical Director fand Deputy Director of Patient Safety and the CCG's Director of Nursing and Quallty Assurance (QA) and Deputy Director of Nursing and QA to discuss the taking forward of a 'joint training event' . Further inforation regarding this meeting was provided in the statement of QEH's Deputy Director of Patient Safety dated 16 September 2019 which we received after the conclusion of the Inquest and receipt of the PFD Report In the statement;, the Deputy Director of Patient Safety refers to Recommendation 2 Action 1 of the Action Plan and that he had been given an action t0 set up a task and finish group and arrange learning event He references meeting on 24 June 2019 which QEH's Medical Director and he attended with the CCG's Director of Nursing and QA and Deputy Director of Nursing and QA. He states that this action was discussed and the CCG agreed to facilitate and lead on it; Having reviewed this statement;, the CCG's Director of Nursing and QA has confirmed that the meeting on 24 June 2019 was set up in response to her letter of 10 May 2019 sent to QEH's then Medical Directon Chief Nurse Advisor and Acting Chief Nurse The letter referenced the Investigation Report and assurance on the learning and associated actions and requested meeting with all QEH addressees to discuss the care and service issues identified for QEH in the Investigation Report: initiating

The CCG' s Director of Nursing and QA has confirmed that: Whilst_she attended the meeting on 24 June 2019 with QEH's Medical Director land Deputy Director of Patient Safety, the CCG's Deputy Director of Nursing and QA was not present in relation to the discussion regarding the Investigation Report also confirmed by the Deputy Director of and QA. Her recollection of the meeting is that the CCG and QEH agreed that QEH would commence or complete their actions on the Action Plan. Also that the CCG would defer its action on Recommendation after-action review (i.e. until after Inquest): There was no discussion regarding 'joint training event' andlor Recommendation 2. Given the nature of the meeting, there was no requirement (or request) for formal minutes to be taken, approved and circulated. She did not receive any written follow up from QEH as to the outcome and actions from the meeting_ Accordingly there was no agreement by the CCG at that time or subsequently that the CCG would take the lead on any training event or Recommendation 2. In summary on this point relating to Recommendation 2: West Norfolk CCG has always understood and proceeded on the basis that QEH and its Deputy Director of Patient Safety were the leads for Recommendation 2 and, prior to the contact from the Coroner's officer the Inquest; was not aware that there was any issue to this. At no point did the CCG agree to take over from QEH as the lead on Recommendation 2 andlor any training event referred to in the Action Plan_ Given the specific and frontline nature of the action under Recommendation 2 which relates to providers, the CCG would not have been an appropriate lead on this action and, for this reason, would not have agreed to this. Our participation and involvement in the action and task and finish group relates to advising the providers on the commissioning of any services necessary to complete the action: Had QEH provided a written update of the outcome and actions to the CCG following the meeting on 24 June 2019, any issues about the lead for Recommendation 2 could been identified and resolved at that point. Similarly, this would have been identified and resolved if QEH had responded within the deadline to the CCG's request in mid-August 2019 for an update on its actions under the recommendations in the Action Plan and specifically Recommendation 2_ In the event, the Deputy Director of Patient Safety responded on 16 September 2019 solely in relation Recommendation 9 Duty of Candour: Neither NSFT nor EEAST have indicated to the CCG at ay point their understanding is that the lead for Recommendation 2 was transferred QEH to the CCG. In relation to the reference (in point 3 of Section 5) to EEAST's contact with the CCG, EEAST has confirmed that the only contact it has received centrally throughout the process is from the CCG and the independent reviewer commissioned by the CCG. This is in relation to the investigation or progress on the Action Plan: On reflection, West Norfolk acknowledges that: Nursing during relating have from

The CCG having initiated the meeting with QEH on 24 June 2019, arrangements should have been in place for the outcome and actions from the meeting to be documented and circulated within a reasonable timeframe for agreement by the attendees; and As QEH's response for an update on its actions on the Action Plan was not received by the deadline of 30 August 2019, the CCG should have sent a further request soon after this date and then escalated within QEH: Actions In relation to the lessons learned on this aspect and with the aim of preventing similar events occurring: The CCG will contact QEH as regards the implementation of agreed governance arrangements for the management of less formal meetings_ Specifically that the outcome and actions from meetings will be documented and circulated by a named person within a reasonable timeframe for agreement by the attendees (also within a reasonable timeframe)_ Action date: The CCG has identified a proposed CCG lead and potential QEH lead for this action. The CCG will contact QEH by Monday 25 November 2019 (i.e. after QEH has received a copy of this letter): 2 The CCG will implement more robust governance arrangements for tracking QEH's responses to prescribed deadlines and action where these have not been met. Action date: This action was commenced by the CCG on 06 November 2019 _ a proposed CCG lead and options for taking this forward have been identified. Issue 2: Delivery of the learning event In order to progress Recommendation 2 to completion, the action taken and proposed by West Norfolk CCG comprises the following: The CCG has: Arranged for the task and finish group (with attending representatives from NSFT, EEAST, QEH, NCC and West Norfolk CCG) to meet on 04 November 2019 to discuss the development of the learning event Action completed 04 November 2019. Requested QEH (Risk and Safety team) to draw together the learning from the Investigation Report for consideration by the task and finish group (in line with Action of Recommendation 2): Action completed 01 November 2019. The task and finish group meeting on 04 November 2019 was attended by representatives (the 'group members') from NSFT , EEAST, QEH; NCC and the CCG and chaired by the CCG. The actions (with provisional timescales to be confirmed by the group members) agreed at the task and finish group meeting are ongoing and include: Tyla's parents are to be updated by the CCG as to the action that has been taken and is proposed in relation to Recommendation 2. The learning event is to be arranged to take place for mid-February 2020 (this broadly equates to the same period for implementation of the learning event in the Action Plan in relation to the Inquest date) put

An External facilitator for the learning event has been identified by West Norfolk CCG and is available for the proposed date of the learning event: The materials to be developed for the learning event are to include a pen portrait of Tyla (his parents are to be invited to share wishes on changes made by NSFT and QEH in light of the incident and messages from the staff involved in the incident: Information regarding the relevant Lessons Learnt will also be included eg: Lesson Learnt 12 Monitoring of acute physical health deterioration. As part of the sharing and dissemination of the outcomes of this incident and the Investigation report; the invitees to the learning event are to include senior operational staff from the Emergency Department at Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) and James Paget University Hospitals NHS Foundation Trust. hope that this response addresses the issues raised in the PFD Report as these relate to West Norfolk CCG and is of assistance to you: Should you require any further information or wish to discuss with me, please may request that you contact my PA, in the first instance, who will make the necessary arrangements_ can be contacted on Or by email: In the meantime, propose to update you about the outcome of the learning event when it has taken place early next year.