Dear Mr Morris Ref: Regulation 28 report to prevent future deaths following the Inquest of Conor Crutchley who died on the 14th January 2018. am writing to respond to the concerns raised by your investigation on the guh January 2019 into the circumstances surrounding the tragic death of Conor Crutchley: The matters of concern raised and the actions we will take to address these concerns are as follows: - Concern The Early Intervention Team does not include specialist drug and alcohol workers and that access to the substance misuse service that is provided outside of Ihe trust is dependent on self-referral: Response 'Approximately 40% of people with psychosis misuse substances at some point in their lifetime , at least double the rate of the general population' (nice org uklguidancelcg120) In an audit that was completed with the Tameside Early Intervention Team (ElT) in 2016 it was identified that 44% of service users were both alcohol and substances and 22% using substances alone: (Audit of Substance Misuse Needs Input for Tameside Early Intervention Team 2016) This audit identified that out of the 63 people who were in need of alcohol andlor substance misuse intervention:
34.9% had their need met 32% of these interventions were successful 45% of these interventions had been commenced but the outcome was unknown 23% of these interventions had been unsuccessful due to the individual relapsing to alcohol andlor substance abuse or the individual stopped engaging:
57.1% of the individuals were offered intervention but refused to uptake the intervention. Visit us at wwwpenninecare nhsuk using IQur 91s41Lt9

8% of the needs were unmet The self-assessment completed by Tameside EIT in 2017/18, facilitated by the Early Intervention in Psychosis Network for all EIT's across England, identified that: 46% of people on the EIT caseload at the point of data collection used alcohol in the last 12 months and 26% of these individuals were assessed as engaging in harmful or hazardous use of alcohol: Of the total number of people on the caseload 2% received brief intervention and advice 2% received motivational interviewing 2% were referred to a specialist services 5% refused any interventions 85% did not need any interventions for alcohol use 24% of people on the EIT caseload al the point of data collection misused substances. Of the total number of people on the caseload_ 2% received brief intervenlion and advice 7% were referred t0 a specialist services 10% refused any interventions 80% did not need any interventions for substance misuse The Tameside Early Intervention Team does nol employ a specialist and alcohol worker; Specialist drug and alcohol services wilhin the Tameside & Glossop area are commissioned from an external provider, currently Change Grow Live (CGL) This service is accessed by referral; with the expectation that a Care Coordinator from the EIT would support a service user to self-refer to this service andlor, with consent, complete Ihe referral on their behali: This can be completed on-line, by letter or telephone. There is a further expectation that the Care Coordinator would offer any required support to attend the initial assessment with CGL: NICE guidance (nice org uklguidancelcg120) recommends consideration of seeking specialist advice and initiating joint working arrangements where individuals with psychosis are known to be; severely dependent on alcohol; dependent on both alcohol and benzodiazepines or dependent on opioids andlor cocaine or crack cocaine; where substance misuse is difficult to control andlor leads to significant impairment of functioning; family breakdown or significant social disruption such as homelessness EIT practitioners undertake joint working arrangements with CGL where substance andlor alcohol misuse is identified and individuals are willing to engage with support to address this Coordinators and other professionals within the ElT are expected to be competent in the recognition, treatment and care of those with psychosis and coexisting alcohol andlor substance use. Recognition includes an exploration of particular substance use , quantity_ frequency and pattern of use and the history of and route of administration. Supplementary information regarding alcohol and substance use is also gathered from family, carers and friends with the service user consent The assessment of alcohol and substance use is also undertaken during physical health assessments completed by the team, followed by the provision of brief interventions where appropriate. In order t0 enhance the assessment of 2 Visit Us at WwN penninecare nhs uk drug Care hoVI 1 @1sABLLQ

alcohol and substance use the team are in the process of scoping available validated measures to assess dependency, such as the Abuse Screening Test (DAST), for utilisation as part of the physical health assessment process. Training is provided to care coordinators and other professionals within the ElT in relation to co-morbid alcohol and substance use. Training includes dual diagnosis training, motivational interviewing (techniques to assess the person's readiness for change and movement forward on level of change) , updates on new and emerging substances and risk assessment, This has been provided in-house and by external providers. The majority of care coordinators within the team have previously undertaken dual diagnosis training and will attend refresher training as required. The EIT team manager will ensure that staff who have not completed training in this area will access appropriate training opportunities as soon as are available: This will be monitored through the management supervision process_ The Tameside EIT are in the process of developing roles for dual diagnosis champions within the team who will be supported to undertake additional training in relation to substance and alcohol use and cascade these skills within the team through a 'train the trainer' model: This will support the team to provide a comprehensive offer in relation to assessment of alcohollsubstance use, risk assessment including impact of use on illness and other risks including risk to self, other; neglect, vulnerabilities and exploitation, education, motivational work, harm minimisation and encouraging and supporting referral to and engagement with specialist drug and alcohol services: Where service users give incorrect or inconsistent information around suspected substance andlor alcohol use, for example denying use where there is suspicion of use, the relationship between the individual, their supporting network including their family and carers, and the care coordinator is utilised to work towards a point of reflection and acknowledgement of use in order to encourage engagement with appropriate interventions The EIT aims to offer evidence based interventions to individuals with needs pertaining to substance andlor alcohol misuse. A Cochrane review based on 25 Randomised Controlled Trials compared the effectiveness of psychosocial interventions offered (Psychosocial Interventions for People with both Severe Mental Illness and Substance Use; Cleary et al
2008) These included Cognitive Behavioural Therapy (CBT) motivational interviewing, 12 step recovery, skills training and psycho-education: The review found no compelling evidence to support any one psychological treatment over treatment as usual A further study explored a model of integrating carelintervention which found that compared with standard care, integrated treatment for co-occurring disorders led to significant improvements in psychiatric symptoms and levels of met need but not in substance use or quality of life. (Integrated care for Co-occurring Disorders; Psychiatric Symptoms; Social Functioning and Service Costs at 18 months; Craig et al 2008) suggestion from this study was t0 create a single role on each team dedicated to the delivery of psychological therapy, with time set aside to deliver therapy and supervise a broadly trained workforce_ The EIT currently has a dedicated psychological therapy resource to support individuals through provision of a range of psychological interventions 3 "92 Visit Us at WWW penninecare nhs uk Drug they 1 01sa1lt9

Concern At times there can be a significant wait for individuals to access talking therapies and that this is associated with difficulties in recruiling and relaining suitably qualified therapists Response The waiting list for (alking therapies that was in place at the time that Conor was being supporled by the ElT was as a result of not having sufficient capacity within the team to provide the ievel of psychological therapies required rather than difficulties in recruiting and retaining qualified staff. Tameside Early Intervention Team is working towards achieving the NICE Early Intervention in Psychosis Access and Walting time standards This includes the offer of Cognitive Behavioural Therapy for Psychosis (CBTp) and family Iherapies. Nationally there are different levels of attainment of these standards, linked to a planned incremental improvement by providers and commissioners over a period of time to work towards the standards set for achievement by 2020/2021. The standards for provision of NICE recommended interventions for people experiencing a first episode psychosis include the following: more than 24% of EIT service users will take up individual CBTp. more than 16% of families will take up family intervention_ These standards take into account Ihat il may nol be appropriate lo offer interventions to all service users , for example Ihose that joined the service recently, and that not all service users offered interventions will take them up. All service users and families who are supported by an ElT will be offered access to psychological therapy: The self-assessment compleled by Tameside EIT in 2017/18 facilitated by the Early Intervention in Psychosis Network for all EIT's across England identified that: 68% of individuals with a First Episode Psychosis of people on the EIT caseload at the point of data collection started a course of CBTp. This was a 16% improvement from 2016/17 The national average for this standard was 34%. Tameside ElT was rated as one of the (op performing teams in the country against this slandard. 2% of individuals with a First Episode Psychosis of people on the EIT caseload at the of data collection started family intervention: This was a 4% reduclion from 2016/17 The national average for this slandard was 18%. Tameside ElT was rated a5 one of the teams requiring greatest improvement against this standard. The Tameside ElT actively promote uptake of psychological interventions as there is a good evidence base for their effectiveness. This is a popular intervention with service users supported by the team and & high percentage of the service users supported by the team accept the offer of this intervention which can lead to a wait for the appropriate therapy to commence_ In order to support the reduction in the wait for psychological interventions for individuals supported by the EIT, Tameside and Glossop CCG provided funding for an additional psychological therapist post within the team. This post was successfully recruited to and the practitioner commenced in post in December 2018. The practitioner is trained to Visit us at WWI: penninecare nhs uk point hovt 1 O15A8LL9

provide both individual and family interventions This has resulted in a reduction in the waiting times for therapy within the team. The current wait for CBTp for individuals with first episode psychosis is approximately 10 weeks and there is only 1 person waiting for CBTp who is managed on the 'At Risk Mental State' (ARMS) pathway In addition to this a practitioner within the team has also undertaken 'train the trainer' training in Family Intervention and has completed a 5 programme within the team to equip practitioners with the skills to offer this intervention in order t0 improve capacity to respond to requests for Ihis intervention in a timely manner: There is currently no wait for family intervention: The management of the wa) list for psychological interventions in the team has also been reviewed and nOw includes a process of making monthly contact with individuals on the waiting list to ensure they still wish to access therapy and to provide an update on current waiting times hope that the information provided offers assurances that the findings of your investigations and the areas highlighted for the prevention of future deaths have been considered and prompted action Please do not hesitate to contact me should you require any further information.