Dear Dr Fiona J. Wilcox, INQUEST RE GEORGIA SYLVIA NELSON (GN) RESPONSE TO REPORT, PARAGRAPH 7, SCHEDULE 5 CORONERS AND JUSTICE ACT 2009 AND REGULATIONS 28 AND 29 CORONER'S (INVESTIGATIONS) REGULATIONS 2013 refer to the regulation 28 report (Report to prevent future deaths) in relation to the above matter. am Principal Lawyer in the Bi-Borough legal team and am sending the response on behalf of the Council: response to the Regulation 28 report has been prepared by senior officers in both the housing team and adult social care teams at the Royal Borough of Kensington and Chelsea (hereinafter referred to as RBKC): The Council would like to offer its sympathy to the relatives of GN and our deep regret that GN felt that she had to take own life. The Council strives to ensure our most vulnerable people are supported and we welcome every opportunity to learn how we can best achieve this_ The Council was not an Interested Person in the Inquest and therefore do not know what information the Coroner took into account; other than referred to in the Coroner's Regulation 28 report: Email: DX: 84015 Kensington High Street 2 Address: Bi-borough Legal Services, G29, Town Hall; Hornton Street; London W8 7NX City = her

The Coroner listed the following concerns: That there is no suitable housing specifically for young patients with severe and enduring mental illness in RBKC.
2) There are no long-term placements, potentially life long, for any patients requiring supported housing in RBKC with such mental illness.
3) There is severe shortage of rehabilitation housing placements in RBKC for patients who require them:
4) That there should be a system to ensure that there is a proper discharge planning and referral for all patients discharged after admission with mental illness.
5) That whilst mental health patients are in hospital, all opportunities are used to improve their care and treatment and that; where possible, they are not discharged before these been appropriately addressed, rather than discharging them as soon as are deemed no longer at active risk to themselves or others
6) That rehabilitation should be more actively considered as discharge option for patients , especially where there are pre-admission concerns about their housing: Concerns 1 to 3 relate to housing and this letter provides a detailed response to points to 3 That there is no suitable housing specifically for young patients with severe and enduring mental illness in RBKC. The Council and the West London Clinical Commissioning Group (WLCCG) , recognise that continuous improvement is vital in delivering safe and effective services for young people with support needs, including mental health issues. Although Adult Social Care and Housing, in partnership with WLCCG, commission a range of housing and support options Email: DX: 84015 Kensington High Street 2 Address: Bi-borough Legal Services, G29, Town Hall; Hornton Street; London W8 7NX have they

for clients with mental health needs, including those with severe and enduring mental health, all agencies need to identify how we will build on and strengthen existing processes in order to learn from the review of all serious or significant incidents. Young adults (aged 18-25) make up around one tenth of the resident population in the three Boroughs (12.2% in Hammersmith and Fulham; 9.6% in Kensington and Chelsea and 10.7% in Westminster) and a slightly smaller proportion of GP registered patients in Hammersmith and Fulham Clinical Commissioning Group (9.3%) and West London CCG (8.1%). In Central London CCG this age group constitutes 16% of GP registered patients_ Despite this, very little evidence has been gathered about their health and wellbeing needs_ In RBKC , children with mental health needs place demands on personal social services , education, health , youth justice services and families About 7000 to 8000 children and young people will benefit from mental health support at any one time in this area. Of these_ approximately 1900 children 5-16 are likely to experience some type of mental disorder, with less than 100 having a severe mental health problem. This is in line with inner London Out of this number of young people with severe mental health issues, there may be a few who can be referred to supported housing services through the Single Homeless Team: The Housing Department agrees with and will continue to work with Adult Social Care, WL CCG and colleagues in the Central North West London NHS Foundation (CNWL) in any decision-making process in regard to the type of support and accommodation needed, ensuring decisions are made through an assessed process and agreed through a multi- disciplinary approach and monthly panel meeting: The Mental Health Placement Panel consists of Adult Social Care representatives and the Clinical Commissioning Group commissioners and care cO-ordinator: Where services are not available within the borough, specialist placements outside of the borough can be purchased to best meet the individual's needs. It is acknowledged that within the relatively small borough that is RBKC, it is not possible to have services that provide for all presentations of need_ Through Adult Social Care and Housing and in partnership with WLCCG, there is range of housing and support options that are commissioned in the borough, supporting those from 18 plus with a range of mental health needs, including those with severe and enduring Email: DX: 84015 Kensington High Street 2 Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street; London W8 7NX aged

mental health: This offer includes residential care, complex and high support supported accommodation, step down supported accommodation and floating support services. Currently there are 62 units of mental health high support services, and 645 units of high to low supported housing services The services supporting people with the most complex needs are staffed 24 hours a day and all include key-working and one to one support; with additional support from care coordinators from the Community Mental Health Teams (CMHT). AlI service users have reviews and support plans ensuring links with other additional support services, such as and Alcohol Well-Being Service. Access to these services is also through an assessment of need carried out by the CMHT and agreement at the Mental Health Placement Panel. There is no single dedicated housing service specifically for young patients with severe and enduring mental illness in RBKC. However, as is noted in the report; GN was placed in supported housing which is commissioned by the Housing Department and provided by an independent specialist housing provider The service is at the higher level of intensive supported housing, is staffed 24 hours and on average 11 support hours a week are provided to each young person in that service. All service specifications have a recovery focus with personalised plans to support each individual's needs_ The service GN was placed in has a strong focus on assertively supporting this vulnerable and challenging client group to engage in meaningful daytime activities and to access education, vocational training and volunteering and employment opportunities. offer alternatives to previous lifestyles, which have often included anti-social behaviour and social exclusion. As of the support provided; the staff will conduct the following: Needs and risk assessment staff will assess the needs of the clients, such as housing, mental health, well-being, finance , etc. Support Planning staff will then draw up a support plan, such as supporting clients with their independent skills, in accessing mental health services, in attending appointments, etc_ Email: DX: 84015 Kensington High Street 2 Address: Bi-borough Legal Services, G29, Town Hall, Hornton Street; London W8 7NX Drug day They part living

Review staff will review the support plan, risk assessment at regular intervals in order to monitor progress and check they are meeting their agreed goals. The clients who are care managed will be assigned to care co-ordinators from the Community Mental Health Team The staff work in partnership with other external agencies, such as the Community Mental Health Team, Home Treatment Team and Community Safety Team: GN was being supported to develop such skills and, as you note in the report; was being fully supported by the service in which she had remained: She was also awaiting placement review following leaving hospital to ensure the ongoing accommodation and support which would meet her needs. The Coroner has commented in her report that GN's care was provided by staff operating above and beyond their professional responsibility and that the placement would have been untenable without this dedication: At the time of the placement the Council was content that the provider was able to meet GN's needs. We would like to offer you this joint response, to outline where the Housing Department Adult Social Care and West London Commissioning Group colleagues, in partnership with Central North West London Trust; can work together to influence some of the changes you seek your concerns_ As of the broader commissioning of services, we would like to strengthen the following regular partnerships meetings to look at need and demand to support what services are jointly or singularly commissioned within the borough along with development of specifications to ensure key outcomes such as tenancy sustainment and the performance of the providers in enabling resident to be independent where possible is managed and monitored in each of the services. This is done through formal contract monitoring arrangements and placement review processes which are set out below: Monthly Placement Project Group meetings consider overall data as to the movement of borough residents through all the types of provision offered, changes in the general pattern of need, and steps which may be taken at a strategic level to ensure new needs are met Monthly Placement Project Board meetings will follow the findings the placement project group regarding any specific gaps or improve the throughput of the supported housing services in the borough. This may also examine specific services necessary to meet the needs of the clients_ Email: DX: 84015 Kensington High Street 2 Address: Bi-borough Legal Services, G29, Town Hall;, Hornton Street; London W8 7NX from part from

Quarterly Providers' Strategy Group meetings will be organised to bring together the support providers and other stakeholders to discuss issues surrounding and any strategic development of support housing services. This information feeds into needs assessment work and commissioning strategies. 2 There are no long-term placements; potentially life for any patients requiring supported housing in RBKC with such mental illness. The Housing Department and Adults Social Care has an aspiration for any clients, where possible, to work on their recovery and enable them to move towards more independent lifestyles_ However, we also acknowledge that for some clients, this may not be possible and may continue to struggle with their daily living_ In such cases, we understand that short-term recovery focussed supported housing may not be the service that particular client needs. Instead_ we need to review the support needs of that client and find a longer- term placement solution: The Council acknowledges that there are no long-term placements, potentially life long, for any patients requiring supported housing in RBKC with such mental illness as the focus is on recovery and improving wellbeing and independence. Adult Social Care commissions residential care and supported accommodations which are provided with focus on delivering a flexible and personalised approach to support each individual's needs and their recovery. Any move on is determined by a personalised approach to recovery and for some this may be short stays in services and for others longer with many years based on needs and their recovery journey and capacity. These services are flexible and support each person by working with them and their goals and aspirations, involving a range of agencies and support to best achieve outcomes for the individual: This is managed through support plans and working ensuring partners across health, social care, housing and support services are engaged to support at best the broader needs of the individual: We would Iike to take the following action when addressing the prevention of future deaths. If the client may need long term or life long supported housing, the case will be brought to the funding and placement panel to decide what kind of long term or life-long support and accommodation will be commissioned through an evidence-based assessment by the Email: DX: 84015 Kensington High Street 2 Address: Bi-borough Legal Services, G29, Town Hall; Hornton Street; London W8 7NX long, key

multi-disciplinary team: Most likely, the purchasing specialist placements outside of borough will best meet the individual's needs as it is acknowledged that within RBKC, at present; it is not possible to have services that meet all needs_
3. There is severe shortage of rehabilitation housing placements in RBKC for patients. In RBKC we currently have 707 units providing supported accommodation to people with range of mental health needs, each with an individualised support plan which would include rehabilitation to enable people to develop greater independence. This would include, for example, developing daily living skills, managing medication, accessing specialist services, budgeting, managing own tenancies, developing peer relationships and accessing universal services including training and getting back into employment: This is supported by the key workers along with Community Mental Health Teams, through process of reviews and assessments. Within our offer, we do not consider there is a severe shortage, but we recognise the need to continually assess demand and capacity, which we do through the various placement boards and project groups_ Rehabilitation can be defined as to prepare someone to resume normal life after an illness_ Traditionally it can be service provided by health: However, supported accommodation also undertakes a similar function, supporting people with mental health needs to stabilise their lives, recover and live more independently. The Royal College of Psychiatry believe rehabilitation services help people recover from the difficulties of longer-term mental health problems_ It will help and support people who still find it difficult to cope with everyday life or get on with other people. It will aim to help you deal with problems, to get your confidence back, and to help you to live as independently as possible: Many NHS regions in the UK have mental health rehabilitation units . Just over half are based in the community and the rest are based in hospital sites. Around half of NHS Trusts in England also have community rehabilitation teams who work with people after have left hospital and moved to supported accommodation. These services support people who have made the move from a rehabilitation unit to some form of supported accommodation, but who require ongoing support with their day-to-day lives, both social and personal: Email: DX: 84015 Kensington High Street 2 Address: Bi-borough Legal Services, G29, Town Hall; Hornton Street; London W8 7NX they

The community rehabilitation team can give more specialised support than the more general community mental health teams The team will continue the work of the rehabilitation unit. will work with you to update your care plan and make sure that it progresses. will support residents with managing medication, looking after the home and social and leisure activities. It is this type of model that may be considered as part of the review described below: West London and Central London CCGs have been commissioning inpatient 'open' rehabilitation beds for Kensington & Chelsea and Westminster residents, at Horton Hospital, which is a site providing a range of different rehabilitation services on the outskirts of Epsom in Surrey: This has been a historical arrangement and these beds have provided a safe and rehabilitative environment in which to develop people's independent L skills, normally after an acute episode, for those with complex and enduring mental health needs The goal is to prepare people to move towards more independent It is important to bear in mind, however; that one size will not fit all; there are a number of different categories of mental illness, and differing numbers of service users within each group, each requiring specialised rehabilitation services and input and it is not possible to meet the needs of all of these groups within one service or indeed within the local area: Where possible, the Inner London CCG's will work together to commission rehabilitation as close to home as possible, but at present; there will always be situations where some service users require specialist rehabilitation in setting which it is not possible to provide for locally_ The CCG, with partners, is also looking at the wider rehabilitation pathway, demand across the pathway and potential solutions for longer term commissioning of additional capacity to help manage demand, including some specialist out of area placements_ The CCG continuously reviews all of the services commissioned to ensure are responsive to changing population needs; the current service is quality and provides value; however it is provided in a hospital setting, with all of the limitations in terms of lack of independence that this entails_ It is also provided at some geographical distance from the originating boroughs_ Wherever possible it is preferable for patients to be treated within the community, preferably close to or within their own community and support networks: Community based services can deliver improved outcomes and are in line with how Email: DX: 84015 Kensington High Street 2 Address: Bi-borough Legal Services, G29, Town Hall; Hornton Street; London W8 7NX They They living living: will they good

patients tell us would like to be supported: The aspiration is, where people are well enough, we support their recovery and enable them to move towards more independent accommodation, closer to family and support networks_ The CCG are working with Central & North West London (CNWL) NHS Trust to arrange move on for residents currently in the rehabilitation inpatient beds at Horton. This work includes ensuring that the residents themselves are at the centre of any move-on decision making and there has been on-going engagement with the service users and their families to date. The clinical view is that this will take until the end of this calendar year to complete As of the review, the two CCG's, RBKC, Westminster City Council and CNWL are all working together to identify and explore any on-going needs and service developments within the local areas which may arise from this. We all recognise the need to move service users closer to their homes for mental health rehabilitation placements, to ensure better connections are maintained with family, friends, and local mental health services that can support service users on discharge. This is in line with best practice guidance, working collaboratively to align with GP practices, health and support services, and existing accommodation pathways across both boroughs, to create smoother step-down and step- up transitions for people and contributing to a better experience and outcomes for service users The focus will be on improved quality and best value across the partnership. One of the options being considered is the development of a local 'wrap around community rehab offer' with support and rehabilitation services provided in supported accommodation setting: It is hoped that; if this is the preferred option, a service would be up and running within 18 months_ Should the Coroner have any queries arising from this report or require any information to be clarified they should not hesitate to contact me.

Dear Professor Wilcox Re: CNWLCOM59279 Dear Professor Wilcox, Re: Georgia Sylvia Nelson; Prevention of Future Deaths Notice am writing in response to your correspondence to Robyn Doran, Chief Operating Officer CNWL NHS Foundation Trust, dated April 2019_ As Trust; we are saddened by Miss Nelson's death and take an incident of this severity very seriously. Through our investigative and learning lessons process we will ensure that changes are embedded at both a local and Trust wide level, providing the level of reassurance that is expected of the Trust In your Report; you set out the following concerns: That there is no suitable housing specifically for young patients with severe and enduring mental illness in RBKC 2 There are no long term placements, potentially life for any patients requiring supported housing in RBKC with such mental illness
3. There is a severe shortage of rehabilitation housing placements in RBKC for patients who require them That there should be system to ensure that there is proper discharge planning and referral on for all patients discharged after admission with mental illness 5 That whilst mental health patients are in hospital all opportunities are used to improve their care and treatment and that where possible, they are not discharged before these have been appropriately addressed, rather than discharging them as soon as they are deemed no longer at active risk to themselves or others 6 . That rehabilitation should be more actively considered as discharge option for patients especially where there are pre-admission concerns about their housing: Central and North West London NHS Foundation Trust; Trust Headquarters, 350 Euston Road, Regent'$ Place, London NW1 3AX Telephone: 020 3214 5700 WWWcnwLnhs uk 291 very long;

Concerns 1, 2 and 3 are within the domain of the Royal Borough of Kensington & Chelsea, who develop and commission housing provision; including range of supported accommodation: Whilst the Trust does not commission these services, as the major provider of NHS mental health care within the Borough, we do work closely with the local authority to inform and assist them in developing new services_ We think however , they will want to respond to these 3 points separately as the responsible organisation, and we are aware they are currently in the process of responding to you in this respect. Points 4, 5 and 6 are areas over which we have responsibility, and address these points below: 4: That there should be system to ensure that there is proper discharge planning and referral on for all patients discharged after admission with mental illness. The Trust has specific policies (CPA Policy 2015 and the Discharge and Transfer of Patients,
2015) in place that out the expectations and requirements of discharge planning and referral for patients leaving hospital are completed. These policies underpin the important principle of the need for community teams work to closely with inpatient teams to ensure that planning is carried out to ensure as seamless a transition as possible from our inpatient services to the community in recognition of well-known vulnerability of this period. Practice currently in place at level to ensure these policies actually impact on practice includes the following: At the point of admission immediately plan for discharge through daily use of discharge tool to anticipate needs post discharge: Rapid notification of the care coordinator and family members of the admission and invite to attend the ward for pre-discharge meetings To further support this critical point in the pathway we will: The Crisis and Home Treatment Teams now attend the daily handover meeting on each ward t0 ensure aware of any planned discharges and contribute to discharge planning for all patients on the wards_ Ensure we deliver on the National CQUIN that people leaving hospital have face to face contact within 72 hours of discharge by an identified worker That all patients leave hospital with a clear plan of who to contact in crisis and where to help if need it as well as details of the above appointment This will help this critical period of adjustment and support longer term ongoing care and communication, Ensure the learning from this case is shared across all in-patient; crisis and community teams
5. That whilst mental health patients are in hospital all opportunities are used to improve their care and treatment and that where possible, are not discharged before these have been appropriately addressed, rather than discharging them as soon as are deemed no longer at active risk to themselves or others We agree that patients should not be discharged simply by virtue of presenting no risk to self or others. The emphasis from mental health legislation and policy is that the aim of inpatient treatment is to optimise their recovery time and allow patients to return to their life and engage in treatment outside of hospital as soon as possible. However we recognise that this must be supported through a holistic assessment during the admission to inform the ongoing will set the ward they are the get they they they

care needs after discharge effective and that robust discharge processes are in place to deliver this safely To ensure that this is the case we will: We have successfully piloted a new trauma-informed approach to in-patient care delivery in one of our units and this is implemented across all sites_ This will support the development of a more personalised approach to in-patient care The Crisis and Home Treatment Teams attending the handover meeting on each ward daily will ensure they are aware of any planned discharges and contribute to discharge planning for all patients on the wards community team has daily 'zoning' meeting and we will ensure that all inpatients are discussed in the relevant team so community teams are aware of all current in-patients and their progress can contribute meaningfully to the intended aim of the admission Community team leads will attend the daily bed management meeting huddles where forthcoming discharges are discussed to ensure are sighted on these and can support better communication We have a range of support and interventions for patients outside hospital settings which we will ensure are maximised in the discharge planning process_ For example the Recovery College offers a range of person-centred interventions and the Trust has well-developed Vocational service , offering Employment Support using the Individual Placement and Support Model, a User Employment Programme and a strong programme of Peer Support:
6. That rehabilitation should be more actively considered as discharge option for patients especially where there are pre-admission concerns about their housing: We acknowledge your concern about rehabilitation needing to be actively considered as discharge option. Rehabilitation can take place in a wide range of settings and modalities, such as that described in Point 5 above NICE are due to produce guidelines on Rehabilitation in adults with complex psychosis and related severe mental health conditions that we know are likely to propose a wider range of options to provide patients with rehabilitation not just in an inpatient setting: This is the national direction of travel, with patients brought back from out of area placements to their local community and rehabilitation being provided in high supported accommodation or even in patients' independent accommodation: We are working with our commissioner and local authority to ensure that services are commissioned for our patients that give the widest choice of rehabilitation options and keep up to date with modern ways of working: This will mean that as discharge planning starts at admission, we will follow the new NICE guidance on considering rehabilitation as appropriate: Ido hope have been able to address the areas of clarification that you have asked for and that have given you sufficient assurance that our services do thrive to provide the best possible care, taking into consideration the legal framework in which we work, local and national policy and the views of our service users when planning care and aftercare from hospital.