Dear Mr Haigh, RE: Lindsey Bailex Report _to_prevent future deaths Thank YoU for your letter, dated 11 July, reporting a matter to us in accordance with the Regulation 28 of the Coroner s (Investigations) Regulations 2013. Following discussions with the teams involved, am nOw in a position to respond to your concerns stated in your letter around a significant lack of information shared with Miss Bailey $ parents_ Following Lindsey s death, can / assure you we have undertaken a thorough investigation into the care delivered by the Trust: We have considered carefully the difference between confidentiality whilst patient has capacity versus the engagement of families or carers where the patient has declined for their information to be shared: We acknowledge that as a Trust we need to ensure all our staff are actively embedding family involvement within their daily practice whilst maintaining confidentiality: Whilst carer family involvement (including gaining informed consent to share information with families) is written into all of our Standard Operating Procedures for assessment, we have identified that clear guidance ad advice in engaging with families where the patient has declined for information to be shared is required: There is evidence from our electronic patient record system (RIO) that Lindsey had requested appointments away from the family home as she wanted some privacy and didn't want information shared. A review of the notes confirms that Lindsey wanted privacy and being

whilst there were appointments where she was happy for her family to be present ad involved, she had requested that she didn't want her family to know all the detail around what had been discussed_ At times, Lindsey disclosed some delicate information which she wanted kept in confidence, the notes state that this was troubling her ad she found it difficult talking to the team when the family were at home: From the notes, it is recorded that Lindsey did not want to worry her family: There is evidence that a carer's pack was given to the family to support them throughout Lindsev's treatment and that both her mother and father utilised support from the CRHT team via ur client support line and issues were discussed and resolved by the team. However there is no evidence in the notes to confirm that discharge plans and next steps were discussed with the family prior to discharge_ Below is an outline of the actions implemented from this investigation alongside updates on existing pieces of work related to improving the quality of interventions which families and carers receive across our Trust_
1) To develop a standard letter template which is sent out to families and carers whose family member have agreed for contact to be made: The letter will form part of our Standard Operating Procedures for assessment across our Mental Health Pathways and each letter will be modified to reflect the individual needs of the patient and their family member. The letter whilst respecting patient confidentiality will offer family members carers an opportunity to engage with services and receive support around their needs. This maybe by providing information to aid care plan development and /or offer education and reassurance to family members of the interventions that are planned where sharing of information has been agreed and offer a contact point should any concerns arise: This development is being supported by the Trust Involvement and Experience Team: Once agreed this letter will be included in all mental health pathways Standard Operating Procedures. This will be implemented by November 2019.
2) As part of the work to improve Carer Engagement the Trust is in the process of developing a Carer Engagement Standard Operating Procedure for Crisis Response Home Treatment Services which details the standards expected in respect of holding conversations with patients around family and carer involvement at first contact, and this then to be re-visited at every future appointment with the patient to ensure opportunities are not missed. Once developed this will be rolled out across all

Mental Health Pathways. This will be completed and implemented by December 2019
3) A bespoke training programme to be introduced to staff around engaging with families and carers The programme is currently be developed ad ked by our Involvement and Experience Team: Steering Group has been established , first meeting on 23" August 2019, with service users and carers to plan for workshops that will be held in October to design and develop the training package This will be delivered via face-to-face training for teams but also an e-leaming package We plan to involve carer leads in the organisation , extemal carers' organisations, Information Management ad Technology, Quality Improvement Team and the Infomation Governance Team: Once the workshops are complete, we plan to roll the training out from 1* January 2020 onwards organisation-wide:
4) All these actions will be monitored through the Performance Plus electronic action tracking system and will be discussed at local Goverance team meetings ad where appropriate escalated to the monthly Quality Governance Sub-committee hope this response helps address your concerns however if you require any further information please do not hesitate to contact me_