Dear Ms Loxton Stephen lan William Tidey (deceased) Regulation 28 Report to Prevent Future Deaths (PFD) Iam writing further to the PFD report that you sent to Surrey and Borders Partnership NHS Foundation Trust (the Trust) in relation to Mr Stephen Tidey, who sadly died on 22nd December
2016. Thank you for taking the time to investigate his death so thoroughly and for bringing the matters of concern you have to our attention: In response to your concerns, the Trust has actioned the following: We have met with our Multi-Agency Safeguarding Hub (MASH) colleagues from Surrey County Council to discuss this case and the learning that can be taken from it:
2. Since Mr Tidey's death; we have already implemented a standardised log across all of our Community Mental Health Recovery Service (CMHRS) teams, which must be used to record all of the 39/24 forms (now referred to as Single Combined Assessment of Risk Form (SCARF)) that are received by the CMHRS_ The log must record the date the SCARF is received, the name to whom the SCARF relates and what action has been taken in response. have received assurances that these logs are now being completed by the CMHRS teams
3. However, we have also devised a new checking system between the MASH and the CMHRS teams In the future, when the Trust's practitioner within the MASH receives a SCARF form which indicates a high risk to an individual and which the practitioner considers requires urgent action by the CMHRS team, a phone call will be made by the MASH practitioner to the relevant CMHRS to check that the SCARF has been recelved and to notify the CMHRS that action is required urgently. We discussed whether a phone call could be made by the Trust's MASH practitioner to the 'CMHRS time a SCARF form is sent from the MASH to the CMHRS, however due to the volume of SCARF forms received and processed this was considered to be a workable solution. It should be borne in mind that the MASH was originally designed as an initial point of contact for reporting concerns about the safety of children, young people and adults. It is not a crisis response service, and that is reflected in the MASH's operational hours (Monday Friday, 9am 5pm): We have therefore written to Surrey Police, who complete the SCARF forms, to remind them of the purpose of the MASH and to reiterate its operational hours. We have advised Surrey Police that; should they become aware of an urgent concern about the safety of a every not

child, young person or adult outside of, or near to the closing of, the MASH's operational hours; it would not likely be appropriate for the police to document these concerns on a SCARF form and send it to the MASH: This is because the SCARF form will not be looked atby the SABP MASH practitioners until the following working day, and therefore no urgent action will be taken: In the case of urgent concerns that arise either outside of, or near to the closing of, the MASH's operational hours, we have advised Surrey Police to contact either: Surrey County Council's Emergency Duty Team (EDT); which provides an emergency social work service for urgent situations which arise out of normal office hours and which cannot be left with an appropriate degree of safety until the next normal working day: The EDT operates Monday to Friday from Spm to 9am, 24 hours at weekends and over all bank holiday periods The Trust's Crisis Mental Health Helpline, which provides advice and assistance in relation to persons who are in a mental health crisis_ The Crisis Line operates Monday to Friday from Spm to 9am, 24 hours at weekends and over all bank holiday periods. The Trust's Safe Havens; which provide out of hours help and support to people and their carers who are experiencing a mental health crisis or emotional distress_ There are five Safe Havens open in town centre locations across Surrey and north east Hampshire, and we have provided the police with the details of all of these. 5 'We have set up an automated email reply, which is sent from the Mental Health/Drug & Alcohol inbox within the MASH, This automated email details the MASH's operational hours and advises of the out of hours services that are available: The automated email is sent in response to any email that is received outside of the MASHs operational hours, so that anybody sending a SCARF form to the MASH Mental Health/Drug & Alcohol inbox will be aware that the SCARF form will not be processed until the next working day, and will know where to seek urgent advice or assistance if required. 6, The Trust will soon be introducing Single Point of Access (SPA), which will be phased in from October 2018. The SPA will operate 24 hours a days per week and will be contactable for advice or to discuss concerns about a person who has a mental health need, We have advised Surrey Police that they will, in due course, be able to contact the SPA if they need to obtain any urgent; out of hours advice_ On behalf of the Trust; would like to offer our sincere condolences to Mr Tidey's relatives for their loss and hope that our actions outlined above assures you and them that we have learnt and continue to learn from his death. Please do not hesitate t0 contact me or Chief Medical Officer , should you require any further information_

Dear Ms Loxton, write in response to your letter dated the gth of May 2018 regarding the Inquest touching the death of Stephen Ian William TIDEY and the Regulation 28 Report Action to Prevent Future Deaths. In this report you posed 3 questions which will respond to in turn; Q1. How Multi Agency Safeguarding Hub (MASH) reports are processed by the MASH team upon receipt? Police Officers submit a risk assessment form called Single Combined Assessment of Risk Form (SCARF) to the Police MASH where it is triaged A triage will include: Checking the content of the referral itself to ensure it reflects factual information rather than opinions or assumptions_ Review the content of the referral to assess whether there are any unidentified risks or vulnerabilities. Staff are trained to assess risk and will consider primary, secondary and tertiary risks. If identified, these are referred immediately back to the original officer for appropriate action: Checking for hidden crimels. If crimes are identified, the officer will be notified and requested to record and further investigate: This will not delay the sharing of the SCARF which will be shared in the usual way If the referral is related to Domestic Abuse (DA); the DASH (Domestic Abuse, Stalking and Harassment assessment) section of the SCARF is completed by the officer This will be reviewed as part of the SCARF as described above: The DASH section is however removed from the SCARF before sharing as this remains confidential but significant information which may impact on risk will be written into the main section of the SCARF for partners to be aware. The outcome of DA related referrals will also be shared Checking whether there are any warnings on our Surrey Police records management system for those involved: Checking for previous SCARF referrals. An escalation process exists whereby, if a 4th referral is received into MASH within a 90 period, the risk of the 4th referral is automatically increased by one level and shared, highlighting the frequency of referrals. This will prompt partners to consider underlying concerns and appropriate support or intervention: Suuav CRIMESTOPPERS 0800 555 111 Surrey Police, PO Box 101, Guildford, GUI 9PE 4t day

Noting of officers initial risk assessment level and consideration throughout the triage process as to its appropriateness MASH staff have the ability to increase or decrease the risk rating as a result of their triage but, if changed, a rationale must be included as to why: Check Early Help Management (Surrey County Council Children's Services system) to confirm if child subject of referral is known/open to them: If are currently working with the child, then the referral is shared directly with the team involved. This process is not in place for Adults so all adult referrals are sent to the MASH Adult Social Care. Review and assign one of four Police MASH Risk level/Level of Need.These are defined Red (level 4) High Risk requiring Specialist intervention these are dealt with within 4 working hours Amber (level 3) Medium Risk requiring Targeted and Timely Intervention dealt with within 24 working hours_ Green (level 2) Standard Risk requiring Early Help ~ dealt with within 72 hours Blue (level 1) No/Minimal risk Not shared no set target as not requiring Local Authority intervention or support: Bring to the attention of MASH Detective Sergeant anything that may need escalating or requires fast time action, for example where a MASH officer considers a child or adult to still be at risk of harm Once triaged, the SCARF referral is shared electronically via secure email. This process is the same irrelevant of risk as the mail boxes are monitored throughout the working All adult referrals are shared directly with MASH Adult Social Care Childrens referrals are shared either directly with Social Care teams already working with the children (as above) and the remainder to MASH Childrens Social Care Referrals relating to Missing Children or those who's parents/carers are involved in a domestic dispute where police have been called are also shared with Education and Health The Niche report is updated with a record of and sharing and an individual staff 'tracker' is completed with action taken for future audit trail and statistical requirements.
02. Whether there is an effective system in place to ensure that MASH reports are followed up by appropriate Community Mental Health Team (where necessary) Once a referral is made from Surrey Police to a partner agency via the MASH there is no current means for Surrey Police to ensure it is acted upon and this would be outside of the existing agreement between Surrey Police and Surrey County Council. A partners response to a referral is not monitored by Surrey Police and unfortunately we are unable to respond in detail to this question Surrey Police therefore respectfully request that this question is passed onto the SABP and Adult Social Care for their response:
03. Whether there is an effective system in place to deal appropriately with MASH referrals received outside normal weekday office hours, and that those completing the MASH referral forms (e-g. Police officers) know where these should be sent outside normal working hours when a high risk is identified The Police MASH is in operation seven days a week (08.00
17.00 Monday to Friday and 08.00
16.00 Saturday and Sunday): There is only ever approximately one day'$ worth of backlog and this is risk assessed at the start of each working day: they as; day. triage being

Red risk graded SCARFS (refer to risk grading and timescales in submitted after the end of business on any given day are prioritised at the start of the next working and the timescales outlined above are adhered to. Procedures are in place that allows Police Officers, outside of normal working hours, to refer directly to the Emergency Duty Team (EDT) when high risk situation is identified. This can include, for example; where a child needs urgent accommodation or coordination for contact with an Approved Mental Health Practitioner (AMPH) in the case of a vulnerable adult with urgent mental health needs. These out of office referrals are made by the officer directly by telephone but will always be followed up with a detailed SCARF referral Please let me know if | can be ofany further assistance.