Dear Mr Bennett Re: Regulation 28 Report to Prevent Future Deaths Anthony John William Watson; deceased 22.10.2018 Thank you for your Regulation 28 Report (hereinafter the 'report') dated 12th February 2019 concerning the death of Mr Anthony John William Watson on October 2018. Firstly would to express my deep condolences to Mr Watson's family: Your report concludes that Mr Watson's death was as a result of significant head trauma following a fall height. The incident occurred whilst Mr Watson was waiting to be admitted to a local inpatient mental health bed based on the advice from the mental health services that immediate admission was necessary_ Following the inquest and noting the report's similar themes to the reports issued by the Birmingham and Solihull Coroners on 4th October 2018, you highlighted the ongoing issue that not all patients who require immediate admission for inpatient mental health treatment in Birmingham and Solihull are found an appropriate bed in the area_ As such, you expressed your concerns that there are an insufficient number of beds in Birmingham and Solihull; and that out-of-area beds are too far away: Further; in this particular case, you also noted the impact of Mr Watson's age on: the inability of Birmingham and Solihull Mental Health NHS Foundation Trust ("Trust") to find him an appropriate bed for a timely hospital admission- note that a copy of your report has been sent to the Trust, however; you may wish to seek a formal response from the Birmingham and Solihull Mental Health NHS Foundation Trust regarding the concerns raised in your report for a response on the specific circumstances relating to Mr Watson's death. At the same time, [wanted to highlight some national policies and priorities which | believe are relevant to the issues you have identified in your report as both having bearing on Mr Watson's death and continuing to pose ongoing concerns for patient safety _ Concern the lack of beds and that Mr Watson was not offered_ a bed out-of-area NHS England and NHS Improvement 22nd like from key

In recognition of the importance of continuity of care and the proximity to existing support networks; NHS England has committed to eliminating the practice of sending people out of area for non-specialist acute inpatient care due to local bed pressures by 2021 This applies to older adult beds_ as well as general adult and psychiatric intensive care units (PICUs) and is underpinned by the expectation that there is always local capacity to meet the needs of individuals requiring this type of support: Concern 2 similar themes to the Jinked PEDs issued on 04/10/2018 have enclosed a copy of the letter sent to Mrs Louise Hunt; senior coroner of Birmingham and: Solihull; in December 2018 in response to the concerns she raised about the 7 linked deaths identified by Birmingham and Solihull coroners. It includes a summary of relevant outcomes a 'deep dive' meeting in November 2018 which brought together all stakeholders involved in the commissioning provision and regulatory oversight of mental health services in Birmingham and Solihull in response to the concerns raised_ More recently, members of the national: NHS England Mental Health Team attended further ` follow-up deep dive meeting: in March 2019 focused on Birmingham's Suicide Strategy and Mental Health Improvement Plan; which included senior representation : from the CCG, Trust; local authority public health team and regional NHS England and NHS Improvement teams Concern 3 Mr Watson's age Under the Equality Act 2010,it is unlawful to deny an older person treatment on the basis of their: age. NHS England's national policy position is that the decision whether to admit a person to a general adult or older adult mental health service should not be based on a person's age but on their needs. This decision should not be made at the expense of the person's immediate safety: As this decision is the provider's responsibility, You may wish to seek a formal response on this specific issue from Birmingham and Solihull Mental Health NHS Foundation Trust: Concern 4a Availability of_beds_on_young_adult_units_on 18-22 October 2018' Concern 4b Offer of.an out of_area bed due to contractual issues; _Concern 4c at least_one_patient_every_day_in Birmingham_and Solihull is advised no bed is available and Concern 5 _ Jack of inpatient beds insufficient numbers of beds in Birmingham and_ Solihulland out of area beds The reduction of out of area placements (OAPs) is high priority both nationally and locally and ! can confirm as part of the 2019/20 NHS Operational Planning and Contracting Guidance all Sustainability and Transformation Partnerships (STPs) are reviewing their plans and trajectories for reducing these placements_ Over the last year we have been working jointly with NHS : Improvement to provide clinically-led support offer to assist areas in their work to reduce OAPs This has involved Iocal workshops run by clinical experts with the necessary experience of leading complex system change, which is required to enable the safe and sustainable reduction of OAPs_ Birmingham and Solihull STP are engaged with this support offer and participated in a bespoke clinically-led workshop in March 2019_ This provided an opportunity for system stakeholders to discuss current approaches and to have their local plans reviewed and informed by the national team's clinical experts_ NHS England and NHS Improvement from very:

However; further to this issue it is important to note that ending OAPs by 2021 is a stretching ambition as OAPs are an indicator of broader system pressures and underlying capacity challenges, and therefore_ long-term system-wide transformation is required if OAPs are to be sustainably eliminated . Bearing this in mind, NHS England and NHS Improvement have clearly communicated that patient safety should be prioritised above all else; no one in need of an acute inpatient admission should be turned away to avoid using an OAP. Trying to end OAPs too quickly, without making the appropriate system changes, be unsustainable in the long-term and has the potential to risk patient safety if the quality and timeliness of care are compromised to reduce QAP usage. While your report states that Mr Watson would very likely have declined an out-of-area bed had one been offered due to the significant distance involved it is still concerning that this offer was not made_ and that there was ' nothing else available: in closer neighbouring areas because of 'contractual issues Your report mentions that you are already aware of Iocal remedial action underway to address issues raised in the linked reports of October 2018. From a national perspective, NHS England and NHS Improvement will continue to follow up through our regional colleagues in the West Midlands and existing governance structures to ensure ; that: all of_ the actions described and committed to in response to these reports have been taken, and that lessons have been learned with this learning applied to improve safety and quality This will follow on from discussions that took place in March 2019 referred to above NHS England's ambition NHS England is committed to ensuring that by 2020/21 all areas have properly resourced Crisis Resolution and Home Treatment Teams (CRHTTs); providing high-quality, 24/7 community-based crisis response and intensive home treatment; as genuine alternative to hospital admission for: adults_ of all ages This commitment is supported by central investment and is intended to: ensure people can be effectively supported in the least restrictive setting where it is safe and appropriate for the individual; and in doing so help address avoidable pressures and high bed occupancy in the acute mental health pathway, to ensure beds are always available for those that need them_ can confirm that evidence from those areas which maintain local bed availability suggests that this is not simply down to the number of locally commissioned beds but iargely related to the effective management of the whole system pathway and investment in local services_ in particular community alternatives As such_ also wanted to reassure you about the specific steps we are taking to improve access and quality of, crisis and community mental health care as of the NHS Long Term Plan, which includes a specific focus on provision for older adults: By 2023/24, anyone experiencing mental health crisis will be able to call NHS 111 and access 24/7 age-appropriate mental health community support: By 2020/21 no acute hospital will be without a mental health Iiaison service for all ages in A&E departments and inpatient wards, and at least 50% of these services will meet the 'core 24' service standard as NHS England and NHS Improvement will part to,

a minimum Increasing to 70% by 2023/24, working towards 100% coverage thereafter Finally, the NHS Long Term Plan also details how new and integrated models of primary and community health services will support adults and older adults with severe mental illnesses A new community based offer will include access to psychological therapies, improved physical health care employment support; personalised and trauma- informed care medicines management and support for self-harm and coexisting substance use By 2023/24, new models of care underpinned by improved information sharing, give 370,000 adults and- older adults greater choice and control over , their: care and support them to live well in their communities_ the information above addresses the concerns you have raised within your report and provides you with the assurances that you requested. If you require any further information, please do not hesitate to contact me_

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NHS Birmingham and Solihull CCG: Response to the Birmingham and Solihull Coroner’s Regulation 28 report to prevent future deaths
1. Introduction

1.1 This report provides a response to the Birmingham and Solihull Coroner, in respect of the Regulation 28 report to prevent future deaths issued to NHS Birmingham and Solihull Clinical Commissioning Group (the CCG), relating to the death of Anthony John William Watson.

1.2 The Regulation 28 report raises concerns about the fact that no elderly care bed was available for Mr Watson between 18th October 2018 and his death on 22nd October 2018.
1.3 The CCG has recently provided a comprehensive report to the Senior Coroner for Birmingham and Solihull on mental health services in the area, in response to a previous Regulation 28 report to prevent future deaths. Much of the information contained in that report is pertinent to the circumstances of this particular case and, therefore, we will not seek to repeat those details in this response.
2. Background and context

2.1 On 12th February 2019, the CCG received a Regulation 28 Report to Prevent Future Deaths from the Birmingham and Solihull Coroner relating to the death, and subsequent inquest, of Anthony John William Watson who sadly passed away on 22nd October 2018.

2.2 The CCG commissions mental health services for over 25s from Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) through an NHS standard contract. The standard contract sets out the required operational standards, as well as national and local quality requirements.

2.3 Statements submitted to the inquest confirm that Mr Watson had been receiving care from BSMHFT since 2017. By 18th October 2018 Mr Watson’s condition had deteriorated such that he required admission to hospital. The CCG has no direct knowledge of these events and has ascertained this information through documents provided by HM Coroner.

2.4 On 18th October 2018, Mr Watson was referred to the Community Enablement and Recovery Team (CERT), which forms part of Mental Health Services for Older People (MHSOP). The referral was made by the Community Mental

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Health Team for Older People, under which Mr Watson had been receiving treatment.

2.5 Mr Watson was visited at home by the CERTS Team on 18th, 19th and 20th October. He was visited on the 21st October, however, Mr Watson was in hospital at that point. A referral to the Home Treatment Team had been made on 19th October by the CERTS Team, but that referral was not actioned with the result that the Home Treatment Team did not make any visits to Mr Watson over that weekend. Both Mr Watson and his wife had been provided with crisis access numbers for further support.

2.6 The CCG has been provided with a draft root cause analysis report by BSMHFT. It is understood from the report that, although enquiries were made as to availability of an inpatient bed and no local beds were available, there was no attempt to locate an out of area bed. Other beds may have been available out of area but still within a reasonable travelling distance of Mr Watson’s home and these would not necessarily be 70 miles away as mentioned in the inquest statements.

2.7 The CCG has reciprocal arrangements in place for patients to access out of area beds when there are no local beds available. This arrangement is delivered through the MERIT Vanguard, which arose out of the Department of Health New Models of Care Programme and is a partnership between four NHS mental health providers in the Midlands (Birmingham and Solihull Mental Health NHS Foundation Trust, Black Country Partnership NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust and Coventry and Warwickshire Partnership NHS Trust. The Vanguard has sought to improve crisis care through more flexible use of bed stock across the region and by seeking to embed ‘recovery principles’ in practice. In addition, the CCG can authorise the use of ‘overspill’ arrangements if asked, and would have done so on this occasion based on the clinical decision that an inpatient bed was needed. BSMHFT’s root cause analysis investigation identified a lack of understanding within the BSMHFT service as to the process for requesting an out of area bed and who could authorise one, along with the overall belief that they could not be requested. The CCG’s reciprocal arrangement on beds was not utilised appropriately and therefore resulted in Mr Watson potentially being prevented from accessing a bed in the West Midlands.

2.8 On this occasion, although there was no local bed available for Mr Watson, no attempt was made by BSMHFT to locate an out of area bed within the MERIT Vanguard, or elsewhere. Whilst it is recognised that it is not ideal for a patient to be admitted to a unit outside of their local area, pressure for inpatient beds sometimes dictates that beds may not be available close to the patient’s home and that the nearest available bed may be outside of the immediate area.

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3. Understanding and responding to capacity and demand

3.1 Since 2016, the CCG (both in the current form and as three former CCGs, prior to the Birmingham and Solihull CCG merger on 01 April 2018) has taken a number of steps, with partner organisations, to understand and respond to concerns about capacity and demand within the local mental health system.

3.2 The CCG recognises that there has been increased demand for mental health services since 2016, and has responded to this additional pressure with increased funding and through working with Forward Thinking Birmingham (providers of mental health services across Birmingham and Solihull for those aged up to 25), BSMHFT and the local Sustainability and Transformation Partnership (the STP) to look at different ways of working throughout the system. The CCG will continue to monitor the situation to ensure that all partnership working across Birmingham and Solihull is focussed on improving access and the quality of care.
3.3 The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment. Part of this approach involves the CCG being an active partner in the STP and the Mental Health Programme Delivery Board. The ambition of the STP is to achieve sustainability, through a strong focus on prevention and recovery.
3.3 The CCG has a Mental Health Programme Delivery Board with a plan of action which includes a range of initiatives to deliver measurable changes for mental health services. This includes reducing the number of patients being placed in inpatient units that are out of the local area to zero by 2021. The plan is jointly owned by the CCG, Birmingham Women’s and Children’s NHS Foundation Trust, BSMHFT, Solihull Metropolitan Borough Council and Birmingham City Council. A ‘zero suicide’ ambition has been committed to, which is led by the local authorities’ respective public health teams. This ambition will be supported by evidence based, preventative action and high-quality crisis support, as well as reducing stigma around mental health and improving access through early intervention services.

4 Conclusion
4.1 The CCG aspires to there being no avoidable deaths in Birmingham and Solihull and takes every reported unexplained death very seriously. The CCG is continuously working with providers to improve the quality and safety of

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services, as well as looking at new and innovative ways to improve all mental health services.

4.2 The CCG has previously provided HM Coroner with an overview of the steps being taken in response to the increased demand for mental health services in the region.

4.3 The CCG recognises the need to take a multiagency approach to the prevention of deaths, including creating robust partnerships with mental health support services e.g. substance abuse services, community intervention and crisis management. The CCG must also ensure that inpatient beds are maximised and available for those who need them.

4.4 The CCG further recognises that these measures will not provide an immediate solution which ensures there is always sufficient bed capacity, as there are other considerations that impact on the system. Achieving improved capacity and flow cannot be realised solely through investment and must be supported by optimised models of care and practice such as those described above.

4.5 The CCG will continue to keep under review the pressures on mental health services and the need to develop new initiatives to manage patient flow and improve services.

4.6 Notwithstanding the above, there appears, in this instance, to have been failings in care delivery which impacted on the ability for a bed to be located for Mr Watson. BSMHFT have identified these failings and have taken actions to rectify them.

4.7 The CCG will continue to monitor and review mental health services in Birmingham and Solihull, and is happy to have an ongoing dialogue with HM Coroner in relation to any concerns.