Dear Mr Parsley

Re: Ms Kerry Hunter

I write in response to your prevention of future deaths report dated 25 April 2019 following the conclusion of the inquest into the death of Ms Kerry Hunter. I know you will share a copy of this response with Kerry’s family and I would like to express my condolences for their loss. Kerry’s death is a tragedy and it is essential the Trust takes all opportunity to learn.

The report referenced the work the Trust is doing to develop the treatment provided to those who suffer from a personality disorder. It noted the evidence provided at the inquest that people eligible for this treatment would be required to transfer to the Trust’s Integrated Delivery Team in order to be referred to this service.

Currently care for people with personality disorder is provided by the Trust’s community mental health teams and integrated delivery teams, where clinical psychologists either carry out therapy directly or supervise care coordinators. Some psychologists are trained in Dialectical Behaviour Therapy (DBT) methods but there are no teams that operate as a full DBT model. When a full DBT package of treatment is required, service users are referred to independent or external NHS services funded by Clinical Commissioning Groups. There is an independent sector unit in Norfolk and others around the country. There are no specific outpatient external/private DBT providers.

The plan for the new Personality Disorder Service involves eight elements:

1. Clinically-led personality disorder leadership team supporting a change in culture and clinical practice at a senior level modelling consistency, accountability and leadership.

2. Improved access and assessment that involves a needs-based screening process which works alongside diagnostic criteria to ensure people access the part of the pathway which will deliver the most benefit and prevent unnecessary admissions to hospital.

3. Specialist personality disorder therapy teams comprising nurses, psychologists, psychiatrists, occupational therapists and social workers within local teams, delivering targeted interventions to those with the most complex needs and providing advice & consultation to their colleagues and the wider system.

4. A breadth of training ranging from Knowledge and Understanding Framework (KUF) training for all staff, through to full Dialectical Behaviour Therapy training for the specialist teams.

5. 72 hour inpatient protocol providing purposeful, formulation-driven, recovery-focused care packages concentrated on self-regulation and discharge. Linked to the screening process in order to ensure only those with a need access this level of intervention.

6. Needs-based interventions involving a framework of delivery that works with diagnosis to enable better management of people with personality disorder in standard community and inpatient pathways.

7. Crisis support through integrated working with local crisis teams and crisis cafes/hubs to deliver the needs-based model including personality disorder-specific training. Supporting teams with positive care planning to better support people in the community and improve their health outcomes.

8. Peer Support Workers to model hope and recovery, providing a vital link between statutory and third sector services and supporting the individual throughout the pathway with a focus on life beyond service engagement.

The strategy has started with the recruitment into the post of personality disorder strategy lead, who will be supported by an implementation team covering the next twelve months.

Where someone with a complex presentation is seeking recovery, they will be encouraged to engage with the specialist personality disorder therapy teams because of their enhanced skills and knowledge. However, it is recognised that people will have contact with other services that the Trust provides. This includes our acute hospital liaison services and Wellbeing service. We are clear, in line with national guidance and best practice, that the presentation or diagnosis of a personality disorder is not a diagnosis of exclusion which is why training will be aimed at all staff and access available to specialist advice. These services will continue to be available based upon the presenting needs of the service user.

As we implement the service we will have regular review points to assess the impact both in terms of outcomes but also in respect of areas such as the access route. This will help inform adjustments in order to provide an effective service.

Thank you for providing this report to the Trust.

Dear Mr Parsley,

I write to update in respect of the Prevention of Future Deaths (PFD) report made in the case of Kerry Hunter in April 2019.

I have discussed this with our Trust lead for personality disorder and complex needs who has provided the updates below.

In response to the initial PFD questions:

“Details of new policies and procedures of clarity of information given to people with BPD” Through service user involvement, we are co-producing as much of our patient-facing information about our pathways and interventions as possible. We have “Working Together Groups” and other avenues for gaining service user feedback and ideas around unmet needs, service improvement, information and policies. We are currently reviewing our personality disorders and complex emotional need (PD/CEN) strategy for release in April 2024 after service user and carer consultation. There is also a system-wide “Pathway Integration Meeting” in place which any provider can attend which improves system knowledge about what support and intervention is available in different provider organisations.

“Training and development of staff in NSFT in relation to BPD” The trust continues to roll out a comprehensive training programme for NSFT staff in relation to PD/CEN. The main training for staff is our Knowledge and Understanding Framework, which is entirely co-produced and co-delivered. We also have a two-day dialectical behaviour therapy (DBT) skills course which any member of staff can attend.

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Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH Web: www.nsft.nhs.uk

Course Numbers trained to date Crisis Plus 22 DBT Practitioner level 145 MBT Practitioner 13 DBT skills level 999 ADDRESS 471 MBT skills 195 SCM basic 9 KUF 345 Carers for PD Awareness 18

In addition, staff in CFYP, Adult and Older Adult services have been able to train in evidence-based therapies like Mentalisation-Based Therapy (MBT) and Dialectical Behaviour Therapy (DBT). This has been supported by CCG funding and latterly by NHSE funding. As a result, most clinical areas for working age adults and youth have a full programme of at least one evidence-based therapy, and a tiered approach depending on severity and complexity. We are currently developing a specific offer for older adults with complex emotional need, supported by specific training.

“Formal risk assessment and completion of requisite documentation in cases of people with BPD” We deliver STORM skills training (self harm and suicide prevention training) as our main training on risk and safety planning for clinical staff. This was piloted in Suffolk CFYP and is now being rolled out trust wide. Like other trusts, in response to national guidance, we are moving away from actuarial approaches to risk and instead focus on collaborative risk formulation and safety planning. STORM training includes specific training on safety planning, and our Dialog+ care planning tool is used to collaboratively create a safety plan for every adult and working age adult under our care. Our Youth teams have formed their own safety planning documentation which is co-produced with our young service users. Every service user will receive a co-produced safety plan.

Concern around stepping up and down: In the PFD in relation to Kerry Hunter, it was stated that “those with BPD would have to agree to be transferred for treatment from the Integrated Delivery Team to the new service and it was noted by the expert witness, that many service users will have had significant previous contact with mental health services”. We have upskilled and increased the staffing resource within community teams so that service users now have improved to access evidence-based treatment. This means that service users do not have to be referred on to a specialist service or face transitions of care in order to access specialist treatment. Where teams have not been able to support a full programme of an evidence-based therapy (like DBT), there are partial programmes in place. Within primary care, we are supporting our Mental Health Practitioners (MHPs) to offer evidence-informed approaches, and we are working to expand the availability of psychological therapy to close the gap between primary and secondary care. We recognise that transitions of care can be difficult for our service users, and seek to have a “no wrong door” approach across the system, so that service users can access the right care, wherever they initially present.

Modifications for ASD/ neurodevelopmental presentations with respect to therapies like CBT : Service users with comorbid ASD and Personality Disorder need adjustments of the standard intervention protocols we use. We are recruiting to one specialist post to provide for people with these comorbidities in South and West Norfolk, and we have set up a working group in psychology to guide us as to evidence and

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Trust HQ: County Hall, Martineau Lane, Norwich, NR1 2DH Web: www.nsft.nhs.uk

best practice in relation to modifying our therapeutic offer. This comorbidity will be recognised as an area of increased focus within our revised PD/CEN strategy.

I hope that this information offers you reassurance on the areas raised.