Dear Ms Brown, Professor Stephen Powis National Medical Director 6t" Floor, Skipton House 80 London Road SE1 6LH 16t" April 2019 Re: Regulation 28 Report to Prevent Future Deaths —Amanda Briley 28th December 2016 Thank you for your Regulation 28 Report (hereinafter the `report') dated 11th January 2019 concerning the sad death of Amanda Briley on 28th December 2018. Firstly, would like to express my deep condolences to Amanda's family. Your report notes that Amanda had been diagnosed with Asperger's Syndrome and had previously made repeated serious attempts to self-harm. She had been detained under the Mental Health Act and was awaiting a specialist placement at the time of her death. I note that the inquest concluded that Amanda's death was as a result of hypoxic brain injury, Following the conclusion of the inquest, I note that you now raise concerns in your report regarding the fact that you have been advised that there is no central register of providers who offer specialist placements for individuals diagnosed with Asperger's Syndrome and other mental health issues, and you enquire as to whether such a register has been considered. Specifically, you noted the difficulties that had been encountered in trying to identify a suitable placement for Amanda, and question whether a register could eliminate this. In response to your report I can confirm that 'The Care Quality Commission' monitor, inspect and regulate services that provide health and social care; and a list of the services they regulate, including those that specialise in autistic spectrum conditions, can be found on their website (https://www.cc~c.orq,uk/what-we-do/services-we- re~ulate/services-we-re qu.late). must advise however that a central register does not exist within the NHS and the closest comparison is this CQC list. Ultimately a central register is not workable as there will always be 'a need for an individual assessment and dialogue with providers Health and high quality care for all, now and for future generations

on a case by case basis, to find the best match to meet a patient's specific needs, This dialogue with providers based on local intelligence and the working knowledge of the professionals involved is essential to place patients in the appropriate environment. As such for individuals with more specific needs, such as Amanda,'services need to be chosen based on an individual assessment of that person's individualistic needs. To this regard I can confirm that in October 2015 NHS England published its Care and Treatment Review (CTR) policy and guidelines which were developed as part of a commitment to improving the care of people with learning disabilities in England, and its aims to reduce inappropriate admissions, and unnecessarily lengthy. stays in learning disability and mental health hospitals. CTR meetings review whether a person is receiving the appropriate care and treatment and make recommendations for future care and treatment. CTRs are designed to ensure the voice of the person and their family are listened to, and they are chaired by the responsible commissioner with external input from appropriate clinical experts. CTRs can happen in the community when someone is at risk of admission to a learning disability or mental health hospital, or they happen once someone is admitted to a learning disability or mental health hospital. The CTR policy introduced key changes in March 2017, and one of these was an emphasis that CTRs and Care Education Treatment Reviews (CETRs) are for people of all ages with a learning disability, autism or both. This means that autistic people of all ages, with or without an additional learning disability, should now receive a CTR/CETR if they are either at risk of admission to or are living in a learning disability or mental health hospital; and should be included on the Assuring Transformation (AT) database and local dynamic support registers. Being on the AT database triggers the need for the CTR and CETR arrangements to be followed. The local dynamic support register should be used to alert when a person may be deteriorating or in crisis and therefore need additional care and support in an effort to avoid admission. CTRs or CETRs for autistic people contain autism specific key lines of enquiry, and the experts used within the meeting should be chosen based on them having appropriate knowledge and skills to understand the needs of the individual. Although these changes took place following Amanda's death, they will no doubt go a long way towards ensuring that the care and treatment needs of autistic people will be better understood and addressed in the future. The CTR and CETR processes mean that there is a multidisciplinary team approach to determining what is the best next step in a patient's care, possibly avoiding admission, or where admission is unavoidable, helping to ensure that the most appropriate placement is identified. In addition, in January 2019 NHS England published its `Long-Term Plan', which highlights autism as one of its key priorities for the next ten years, The Long-Term Plan identifies the following areas of focus for autistic people:
• A commitment to reduce waiting times for autism diagnosis.
• Children and young people in special and residential schools will be given better access to hearing, sight and dental checks.
• Children and young people with the most complex needs will have a keyworker to help coordinate the support they get. Health and high quality care for all, now and for future generations

• Investment in specialist community teams to help support children and young people with autism and their families.
• Piloting of annual health checks and flagging of reasonable adjustments on health records.
• The use of more Personal Health Budgets to give people more choice and control over how they are supported.
• The Care (Education) and Treatment Review programme will continue.
• The `STOMP': Stopping the over-medication of people with a learning disability, autism or both, and `STOMP-STAMP': Supporting Treatment and Appropriate Medication in Paediatrics programmes will continue.
• Local service providers will be given more control of budgets for people who are in inpatient care, or who are at risk of it to help them spend the money on support in the community, make stays in inpatient services shorter and stop out of area placements.
• More money will be given to crisis and forensic services for those at risk, of admission to inpatient services, or who have committed a crime.
• There will be work with the wider NHS to improve .understanding of autism. hope the information above addresses the concerns you have raised within your report and provides you with the assurances that within the NHS we are continuing to work towards improving access to mental health services, including the care and treatment of people with autism. If you .require any further information, please do not hesitate to contact me.

Dear Mrs Brown Re: A Briley Further to your report dated 11 January 2019, in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the coroners (Investigations) Regulations 2013, I offer the following response. We have investigated the matters of concern that have arisen during the course of the inquest of Amanda Briley. Leicestershire Partnership NHS Trust takes these matters very seriously and I hope that you and Ms Briley's family will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again. The matters of concern you have raised are as follows:
1. / am concerned that too many Leicestershire Partnership Trust employees do not have any or any sufficient training in autistic spectrum disorders. This Jack ofknowledge makes a difficult situation considerably worse for any presenting patient, with potentially dangerous consequences. I was not reassured that training is given at the earliest possible opportunity to reduce these risks, or that all appropriate staff are receiving or accessing training to a suitable standard. In this case even when it was acknowledged that Amanda would remain an in patient for some time, front line staffincluding her named nurse and the ward matron were ill-equipped to understand-her communication needs and care requirements. I ask for LPT to review and reconsider the current training planning in this area.

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Response , Head of Nµrsing and , Director for Adult Mental Health and Learning Disability Services have reviewed the Trust training provision. The Trust introduced an e-learning Autism Awareness module in November 2017 which is accessible to all staff. A recommendation went to the Trust Learning and Development Group in February 2018 that this training becomes role essential for clinical staff in AMH/LD Services; this was agreed and will be finalised at the Trust's Strategic Workforce Group in March 2019. In March 2018 a Recognising and Caring for People with Autistic Spectrum Disorders (ASD) practical workshop took place involving a range of professionals with experience of working with people with autism, a Speech and Language Therapists (SL T) Assistant, and Consultants from the Autism Diagnostic Service and Learning Disability Service. The Trust is currently looking at how to develop this training further for inpatient areas that will be working with patients with ASD in Mental Health Services. A training task and finish group has been set up with representatives from mental health wards, learning disability serv,ices, SLT and Occupational Therapy (OT) to develop a more in depth training product and this will be reporting back to the Directorate Management Team in April 2019. The group are considering how elements of Ms Briley's video interview with SLT can be used to enhance either the existing e-learning module or further training. and met with Ms Briley's mum who is keen to support the training review. They shared the e-learning module with her and Mrs Briley felt that whilst this was a good basic awareness resource, and that it was important to ensure ward staff in particular were equipped with the practical skills in how to apply the knowledge gained. She provided helpful insight and suggestions as to how the e-learning could be built on and is keen to support the development of the training. · In the interim the Directorate has identified some specialist mental health SL T resource. The individuals providing this support to the wards at the Bradgate Unit are skilled in .ASD diagnosis and management. All in-patients with a diagnosis of ASD· will be referred to the SL T service to ensure the care plans reflect a bespoke and differentiated approach. In addition the SL Ts are looking at the best ways to support ward staff and are working with the OTs to develop a decision making flowchart. Again the feedback from Ms Briley's mum will inform this tool.
2. The court was advised that it was "custom and practice" on bank holidays for the nursing staffto agree between themselves to ·have a shorter hand over and work an hour less. This removed an important part of the expected staff communication and left a significant gap in the safe transfer of information, on the days when senior staff are likely to be on leave and it was recognised that bank staffmay be covering. Furthermore, patients on an acute mental health ward are likely to struggle emotionally on these important social occasions when they are apart from family and familiarity. The handover on such days should be more, not less robust and I ask that the LPT conduct an urgent review and senior level scrutiny regarding this matter.

m=disabilit) Leicestershire Partnership NHS Trust is a smoke-free Trust. Please visit www.leicspart.nhs.uk/smokefree for details B!iconfiden1 EMPLOYER ­ NHS organisations are now using 100 per cent recycled paper as part of our sustainability

Response Ms Briley's inquest was just before the Christmas bank holiday period and immediate action was taken by the Heads of Nursing across the Trust to ensure the working arrangements and expectations of staff around the handover of patient care was clear during this period. On the wards at the Bradgate Unit there is a senior nurse on duty as the.'Clinical Duty Manager' (COM) at all times (24 hours, 7 days a week). The COM visited wards over the Christmas and New Year period to ensure handovers were taking place appropriately. In January 2019 the learning from Ms Briley's death and the inquest was discussed again at the Chief Nurse's meeting with all Heads of Nursing and as a result the Trust's Handover Policy and documentation will be reviewed and a further programme of checking the handover on wards will be developed. In April 2019 the Mental Health and Learning Disability Wards will commence introducing Nerve Centre which enables each staff member on duty to carry a hand-held device allowing them immediate access to a set of patient information including the latest handover for that patient. Staff members can directly add information about the patients care whilst with the patient, which then provides an automatic update to the central information for that patient held on Nerve Centre so all users can see any changes to care immediately. We hope this reassures you that we have taken appropriate action in response to your findings regarding training for staff around Autism, ensuring the handover at bank holidays periods is of the same standard as other times, and improved policies and support systems will provide safe and effective care in order to reduce the risk to our future patients. If I can be of any further assistance to you please do not hesitate to contact me.