Dear Mr Rebello Re: Regulation 28 Report_Barry Marshall Fullarton acknowledge receipt of your Regulation 28, dated 17 2019, which was sent following the conclusion of the inquest into the death of Mr Fullarton: You have asked for the Trust' s response to the areas of concern raised within this report, to detail the proposed actions to be taken by the Trust along with the timetable for these actions. The area of concern highlighted in your report is as follows: Those carrying out mental health assessments should have regard to how a mental disorder manifests in a patient In this case, the diurnal nature of the reactive depressive illness was evident from the medial records such that an assessor could have documented that the assessment at a particular time when mood was good may not be a valid when in low mood. Diurnal mood variation (DMV) is considered prominent symptom of depression, as such, this is part of the training that our clinicians receive_ This training includes the importance of diagnosing depression and gaining an understanding about a person s sleep patterns and changes in mood over the course of the This training helps to assess for and differentiate between the different symptoms of depression. It may not always be possible to offer appointments at different times of the day, however, given the concerns you have shared, we plan to use your helpful feedback as learning: As such, the Trust will provide further guidance to our staff regarding ways that can consider facilitating appointments at different times of the through the following actions: We will develop share learning bulletin to outline the importance of responding to assessments for DMV, and include the consideration as to whether people should and could be seen at different times This will be circulated to all our clinical teams by the end of July 2019. This will be sent directly to all staff, and will also be included in governance and team meetings. There is a Trustwide Grand Round for all clinicians in September 2019, where this learning and feedback will be shared Helping people to be the best can be May day: they day, they

We produce a Trustwide Learning from Experience report three times a year; in which we plan to summarise this learning as part of that report; confirm the above actions, and follow-up their completion. The next edition, which covers the time period April July 2019, will be presented at our Trustwide Quality Committee in September 2019. This will ensure oversight of the delivery of the actions we have stated above. The Suicide Prevention Training will also be adapted to include DMV when teaching around depression and Mental State Examination. would like to assure you that as a Trust, we have taken the matters outlined within your report extremely seriously, and that we remain committed to ensuring that we continuously review and learn to help us to improve the care that we provide to people accessing our services.