Dear Mr Morris Re: Catherine Kennedx (Deceased) Thank You for your Regulation 28 report dated 13"h March 2018,and for bringing to my attention the concerns you had after hearing all the evidence. Your concerns have been reviewed and the Trust's response is outlined below: Matters of Concern "In the course of the inquest; evidence was heard about a telephone conversation between a nurse on Norbury Ward and the on-call junior doctor for the wards. Miscommunication in the course of that conversation in combination with other factors, played a part in the fact that over 14 hours elapsed between staff first being informed of the overdose and Mrs Kennedy being reviewed by a doctor: Whilst the Trust has taken a number of actions in response t0 its internal investigation into the circumstances of Mrs Kennedy's death, it is a matter of residual concer that sufficiently robust measures have not yet been taken to adequately reduce the risk of future deaths arising from miscommunication and assumptions occuring in the context of telephone conversations between ward staff and on-call doctors. In particular; it is a matter of concern that the Trust does not appear t0 consistently have used a communication paradigm (such as the SBAR paradigm introduced by the United States Navy and widely of application across the NHS) as to the content and documentation of communications, particularly arising in the context of seeking action from an on-call member of staff not based on the ward" Our key

Response: The Trust can confirm that the Situation, Background, Assessment;, Recommendation (Decision) tool is currently taught within the following courses within Pennine Care NHS Foundation Trust - SBAR(D) has been included within Intermediate Life Support training for approximately 18 months SBAR(D) has been taught as part of Clinical Risk Formulation Training for two years. It is taught as part of emergency management and how to verbally communicate the risk formulation when the risk is high and immediate SBAR(D) has been taught as part of STORM Suicide Prevention Training for the past 12 months SBAR(D) has been taught as part of the MVA 4 courses to summon assistance around post effects of restraint and or rapid tranquilisation_ We have done this for over 18 months to also support the Modified Early Warning Sores (MEWS) training, SBAR(D) is taught as part of the Modern Matron Clinical Skills Course for ward nursing staff. Organisational Leamning and Development have been supplying learners with a copy of the A5 SBAR(D) telephone pads, to write on as handing over: The pads are placed by the telephone to provide a prompt to anyone making the call to an on-call medic: However, to further support the use of this communication tool the context of ward staff seeking action an on-call doctor not based on the ward, the following recommendations made: 7 minute briefing to be developed to further support the use of this communication tool in the context of ward staff seeking action from an on-call doctor not based on ward. This is t0 be shared with mental health inpatient services across the Trust; Consideration to the SBAR(D) being added to the Trust Physical Health Policy: Wards to have a copy of the SBAR(D) poster displayed by the office telephone for staff reference_ SBAR(D) to be included within the Handover Guidelines being developed for ward staff by the Modern Matron: from have been the

SBAR(D) to be added to junior doctor induction pack hope this response assures you that the Trust takes seriously any concern that you raise .

Dear Mr Meadows, Catherine Anne KENNEDY (Deceased) Regulation 28 Report GMMH Response Further to The Regulation 28 Report issued to GMMH highlighting your concerns following Ms Kennedy's Inquest please see below the Trust's response to these concerns: To carry out thorough review of the issues raised and prepare a coherent and understandable action plan to deal with the serious failings. The action plan included within the SUI report does not indicate exactly when all the actions actually identified in the report should be completed by and to check that have been so completed: This is vital to ensure that improvements are made: GMMH apologise that an up to date action plan was not shared at the time of the inquest; to demonstrate the action taken to date by the service involved: The action plan has since been updated and attached with this response_ Based on the concerns raised within Regulation 28 Report; we have developed an action plan that specifically relates to the points raised by you during Ms Kennedys inquest: These actions are detailed within the attached action plan: It is well established psychiatric knowledge that when patients with chronic and relapsing mental health conditions who disengage with psychiatric andlor general health services, it is strong indicator of a deteriorating mental health state Lack of concordance of medication will the patient's mental and physical health at further risk of serious deterioration: As part of the re-design of Community Mental Health Services within Manchester; Standard Operating Procedures (SOP) that describe how our services should function have been revised and developed over the past 12 months_ The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment: Greater Manchester Mental Health NHS Foundation Trust; The Curve, Bury New Road, Prestwich, Manchester M25 3BL (Tel: 0161 773 9121) Improving Lives Bury put

In addition, a trust-wide procedure Is being developed by the Trust to support staff to work more effectively with service users who present at higher risk of disengagement from services There appears to be a serious lack of recognition about the importance of her disengagement with services, and particularly with GMMH: This was not escalated by anyone; including the deceased's consultant psychiatrist Since revision of our Standard Operational Procedures (SOP) across our Manchester Community Mental Health Teams In September 2018 the Trust continue to monitor how well the changes to practice are adopted In the teams Regular audits are carried out to monitor individual and team practice against standards out In the SOP Disengagement of service users has been highlighted within the revised CMHT SOP and has been Incorporated into the Zoning meeting guidance and CMHT Assertive Outreach pathway The Zoning meeting occurs daily where the care of service users presenting with more acute needs andlor risks IS reviewed and plans developed to manage these needs and monitor them on a basis until the situation resolves or that level of monitoring IS no longer Indicated. person's case IS brought to that meeting by their worker and the decision to step the level of intervention up to this meeting or indeed down is made through MDT discussion; which takes Into account person's specific needs and risks, as well as their personalised care plan informed by their needs and risk assessments Decisions made within the daily zoning meetings are recorded, therefore service users remain visIble until a situation IS resolved and the team are aware of plans In place as this IS also recorded within the clinical records system (PARIS) This IS a recognised change to practice since the development of the original RCA action plan (Action 7/ DATIX16310) which references meeting where 'CMHT allocations and concerns' were discussed and that checklst would be in place to ensure the service took the correct response to disengagement The Assertive Outreach pathway now operates 7 days a week, 365 days a year WIthin each of our CMHTs It provides a method of reaching and helping people With severe, often complex and long term mental health problems who do not easily engage or struggle to maintain contact with services It encourages clinicians to understand reasons why someone may not engage consistently and interventions on how to respond to this creatively and flexibly This pathway IS embedded into the Manchester CMHTs, after moving from a standalone city- wide service As of assurance that the changes In processes and practice described above are adopted, the content of zoning meetings and their records are to be audited against SOP practice standards Initially monthly and then at least quarterly. Action Will be taken by the CMHT Operational and Team Managers as required based on the outcome of the audits This Will include how well disengagement Is recognised and responded to In comparison to practice guidance within the SOP In addition to revisions to the CMHT SOP, guidance on how to respond to missed contacts or disengagement has been Incorporated Into the Day Follow Up Procedure, where teams ensure face to face contact IS made with a person during the 7 day period immediately following discharge This IS monitored weekly within each division at a service level and any

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occasions where this IS not done, this IS specifically Investigated to understand if the person IS safe and well and what further action IS required by the Trust Furthermore , a trust-wide task and finish group has been set up and IS In the process of developing procedural guidance applicable to all GMMH services on to respond to disengagement This IS with the aim of providing consistency in practice across all of our services and we anticipate this WIII be a standalone procedure, referenced within all service operational procedures There were missed opportunities to obtain information and liaise with the GP practice We recognise that as communication did not occur consistently or at necessary points In time, this resulted in missed opportunities to use any Information from Ms Kennedys GP to Inform how we should have responded to her disengagement Standards expected within practice are now described within the revised CMHT SOP , In relation to the need to communicate to GPs and referrers at points In person's care Specifically, when a referral is triaged, following assessment, sharing of care and treatment plans as needs changes; transfers between services and finally at discharge A referral tracker document IS now used within clinical meetings enables service users to remain visible to the Team Manager and IS a means of checking that the required steps in their care that should be completed are not missed, including communication The maintenance of the tracker IS reviewed daily at the team level by the Manager and monthly by the CMHT Operational Manager: Completion of any outstanding actions that arise from this review Will be overseen by the Operational Manager but are completed by the Team Manager Repeatedly sending her letters or offers of appointments without response was futile_ GMMH recognise and apologise for the breakdown of communication which led to a situation where either no correspondence or multiple letters were sent to Ms Kennedy and her GP It IS also recognised that no action was taken when no response was received, to understand the potential reasons for this Equally, at the point of initial assessment our workers are now prompted to consider the reason why a person does not engage In an Initial assessment appointment and whom should be contacted to Inform how this IS responded to, e g referrer, other agencies or individuals Involved The launching of the revised CMHT SOP Will further raise awareness within the team clinicians of the component parts of the service which relate to the timing of communication and disengagement The Community Service Manager will lead on promoting this This will be achieved through face-to-face communication within Individual supervision, team Business Meetings and team and leadership development sessions_ The teams WIII also repeat on monthly basis, the audit of GP communication completed within the original action plan However; this will be expanded to Include communication at

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points Specifically , at triage, assessment and discharge This will be led by the Team Manager In collaboration with Outpatient and CMHT administrators There was a serious failure to engage with other family members who may well have been able to contact her and encourage her to re-engage with services: GMMH recognise that due to the change In Ms Kennedy's consent not being communicated or updated,; that staff did not speak with Ms Kennedy's brother about her care and the difficulties they were experiencing In seeing Ms Kennedy In the CMHT or Outpatients clinic_ As acknowledged above, there IS a renewed emphasis on the role of communication to Inform how we plan the care we deliver to our service users , particularly In relation to disengagement. More specific Instruction IS made to regularly review any Information sharing agreements that are In place with service users This will ensure they are up to date and accurate This will be reviewed within Individual line management supervision with care coordinators and therefore monitored by Team Managers Staff wIll be directed to ensure that where a service user does not consent for carers to be Involved In their care and treatment that this Issue IS regularly revisited with service users and the outcome of these conversations are recorded on the clinical database There were repeated and serious failures of internal communication within GMMH, which are set out in more particulars in the SUI report; GMMH recognise and apologise for the Internal communication breakdowns Identified within the SUI report Actions were developed at the time of the report to Improve and change practices In relation to communication Specifically to ensure staff were aware of the SOP_ their responsibilities and the circumstances where clinicians should review who need to liaise with, particularly where engagement Is a recognise problem that requires action There were numerous opportunities missed in order to resolve the situation: GMMH recognise that In reviewing Ms Kennedy's care during the time described within the SUI report there were a number of occasions where staff should have acted differently GMMH apologise unreservedly for this This Included how GMMH should have communicated with others and also how GMMH should have responded to Ms Kennedy's lack of engagement; including the involvement of her brother Overall, the standard of her psychiatric care and management the end of August 2016 until her death fell below any reasonable standard of care which could be expected GMMH acknowledge that there were a number of care delivery concerns In relation to Ms Kennedy's care and recognise the further concerns expressed by her family and the court GMMH apologise for this would Iike to assure you that the reasons for the omissions and care delivery concerns, have been thoroughly Investigated and are understood at the service and Trust level This has been achieved through a Positive Learning Event where the final report; learning and action plan were reviewed wIth front line staff The report; learning and action plan were also reviewed corporately by the Trusts Internal Post Incident Review Panel

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The progress of actions being completed will also be monitored locally by services and at a Trust level, using the electronic incidents system (DATIX) All our Manchester CMHTs have undergone significant change WIthin the past 12 months Whilst this does not seek to excuse the concerns that have been highlighted here;, the service redesign and new structures aim to reduce the risk of such care delivery concerns arising again It seems that GMMH accept that there were failings and that her family should be offered an apology but that it was understood by the date of the inquest hearing this had still not been offered to them_ It IS With regret that Ms Kennedy's brother did not receive formal apology from the Trust in our letter to him would like to assure you that a written apology has now been provided to Ms Kennedy's brother by the Head of Operations for our South Manchester and Trafford, suggest that there are periodic reviews by the Medical Director of GMMH to ensure that appropriate standards are being met: The specific actions described within this letter are Incorporated in the enclosed action plan for ease will be entered Into the Trust DATIX system and will be monitored locally by the senior leadership team within South Manchester and Trafford . Division and by the corporate Governance Team Through ongoing audit; our services and the wider Trust WIll monitor adherence to practice standards within South Manchester CMHT and Outpatient services This WIll ensure we are consistently working In line with the revised SOP and that the learning following Ms Kennedys death Is sustained Mr Meadows , hope you and Ms Kennedy's family are satisfied with the response we have provided: If you have any further questions In relation to the contents of this letter; please don't hesitate to contact me