Dear Mr McNamara 12th February 2018 This matter is being dealt with by:

Reference: T 0115 977 4876 E

W nottinghamshire.gov.uk Private and Confidential To be opened by addressee only Mr McNamara Assistant Coroner HM Coroner for Nottinghamshire The Council House Old Market Square Nottingham NG1 2DT ##MAILMERGE - Do not delete this text or change the colour from white

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As EMAS response times have been taking longer, the general issue of how to improve conveyance and ambulance provision for Mental Health Act work has been escalated to the Crisis Concordat Task and Finish Group and has also been discussed with health commissioners via the East Midlands Local Authority Mental Health Leads Networks.

The Crisis Concordat work is exploring whether the Trust could provide a separate dedicated conveyance service for people detained under the Mental Health Act. This would allow the AMHPs to pre-book an ambulance for the purposes of s135 (1). Discussions are underway about how this could be commissioned and funded.

Due to further recent significant demand for EMAS services over the winter period, the lead Clinical Commissioning Group (CCG) Commissioners for the EMAS contract are currently exploring, (with advise from the Nottinghamshire County Council AMHP team), an interim solution utilising short term winter pressures money. The aim is to identify a rapid solution that avoid delays for all organisations and protects the patient, until the above work is completed.

(3) The lack of formality to the ‘briefing’ or risk assessment exercise before officers enter premises with a view to exercising a s.135 (1) MHA Act 1983 warrant.

The Council’s response

A more robust process for communicating demographics and essential risk information in relation to the s135 (1) warrant between AMHPs and the Police has been developed jointly.

This will include a typewritten document that is completed initially for the magistrate and then sent electronically by the AMHP when requesting police assistance under s.135 (1). This will ensure that clear communication to all agencies including recent risk assessments and environmental factors are taken in to account with regard to the specifics of the situation. Should you require any further information or clarification regarding the above, please come back to us.

Dear Mr McNamara Re: Report to Prevent Future Deaths: Mr Ryan James Vout (deceased) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 6 November 2017 (received on 18 December 2017) , bringing to my attention HM Coroner'$ concerns arising from the Inquest into the death of Mr Ryan James Vout: would like to assure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously: In particular, matters arising from Coroners' Inquests from which lessons can be learnt; including Prevention of Future Death Reports, are discussed within the Incident Review Group and Lessons Learned Group. This process has been applied to the Prevention of Future Death Report pertaining to the Inquest into the death of Mr Ryan James Vout. Emergency care Urgent care We care Way

The MATTER OF CONCERN specific to EMAS is as follows: The inability to pre-arrange attendance of an ambulance when police officers exercise a 5.135 (1) MHA Act 1983 warrant AIl interested parties, especially the police, expressed frustration that within Nottinghamshire there is no alternative, dedicated, fully equipped ambulance, capable of pre-booked for attendances such as the one in this case for the execution of 5135 MHA 1983 warrants (or detention under 5136 MHA 1983). set out below the actions that EMAS proposes to take and our response to HM Coroner's concerns as detailed in the PFD notice_ EMAS acknowledges its responsibility to enact a duty of care to all patients. The ability to pre-book an ambulance to attend an incident with police officer or approved mental health practitioner (AMHP) to exercise a Section 135 or Section 136 warrant under the 1983 Mental Health Act has always been available: The conflicting priorities of operational demand often require EMAS to prioritise patients according to the presenting complaint: Therefore clinical presentations often take precedence and need a more urgent response_ As there are conflicting challenges around response times, EMAS recognises the importance of ensuring that patients presenting with acute psychotic disorders also an urgent response: The Trust plan is to adapt its operating model with an urgent care tier, which will enable patients with a more urgent care requirement; to be responded to appropriately and safely in a timely manner. This will go live across all five counties on 2 April 2018 and should allow us to better meet the needs of our patients with mental health disorders We continue to work collaboratively with our mental health providers and stakeholders to improve our services for patients with mental health problems hope that the measures set out in this letter provides you with the appropriate level of assurance in relation to EMAS' commitment to continuous improvement in the management of mental health issues: Please do not hesitate to contact me should you require any additional information, or any clarification, in connection with the above:

Jackie Doyle-Price MP Department Parliamentary Under Secretary of State far Mental Health and Inequalities of Health 39 Victoria Street London SW1H OEU 020 7210 4850 Our reference: PFD-1112047 2 3 FEB 2313 Mr Andrew McNamara HM Assistant Coroner; Nottinghamshire Office and Main Court The Council House Old Market Square Nottingham NGL 2DT Jea M c kc danca Thank you for your letter of 18 December to the Secretary of State about the death of Mr Ryan James Vout. Iam responding as minister with responsibility for mental health: I was very saddened to read of the circumstances surrounding Mr Vout's death: Please pass my condolences to his family and loved ones: 1 appreciate this must be a very difficult time for them. Your report raises three areas of concern Firstly, around discharge planning; secondly, the ability to pre-book appropriate transport for conveyance of a patient sectioned under the Mental Health Act; and thirdly, the risk assessment conducted by the police to the exercise of a section 135 warrant: The latter area of concern is one for the and I will not address this in my response. The other two areas of concern fall to health services. The matters raised are operational and relate to the Nottinghamshire Healthcare NHS Foundation Trust and the ambulance service and I trust the responses you will receive from those organisations will be helpful. My response will focus on the national policy expectations in relation to the issues you have raised. With regard to discharge planning from inpatient to community care, I have noted your concerns around the lack of co-ordinated discharge planning in Mr Vout's case. This is clearly regrettable. From being prior police

Learning lessons where things have gone wrong is essential to ensuring the NHS provides safe, high quality care. I am advised that the Nottinghamshire Healthcare NHS Foundation Trust conducted a serious incident investigation that identified a number of recommendations for learning from this case. Iunderstand the report of the investigation has been shared with you, and I am assured that Nottingham Clinical Commissioning Group (CCG) is liaising with the Trust through its quality assurance processes: In terms of national policy, I would like to assure you that we recognise that robust discharge planning and follow-up support are crucial to ensuring that people have a experience of acute mental health care and can be stepped down to the most appropriate and least restrictive setting for their needs, safely and at the earliest opportunity: The Mental Health Act 1983 Code of Practice, whilst being statutory guidance for providers of services under the should be observed as best practice by all commissioners and providers of services to people who may become subject to the Act. We revised the Code of Practice in 2015 and set out guiding principles to improve the care for patients The principles include mental health providers involving patients' carers and families in decisions about their care. The Code of Practice also makes it clear that we expect multi-disciplinary teams involved in care planning and discharge to include all relevant professionals and agencies which may be involved in a person '$ care. Additionally, over the last 12 months, NHS England has been working closely with the National Collaborating Centre for Mental Health and a number of local areas to identify and share best practice in relation to the acute mental health care pathway, which includes well-managed discharge. The following principles have been identified and are now communicated as components of robust discharge processes: if the person agrees, and in accordance with the Mental Capacity Act 2005, Mental Health Act 1983 (amended 2007) and Care Act 2014,their family, carers and significant others should be engaged throughout their care. should be involved in care decisions from the very start of the pathway through to the end of care and given information about the care plan; discharge decisions and changes to treatment: Families and carers should be supported throughout; City good Act, being key They

Department of Health the discharge destination should be considered early on in admission to acute care, particularly for people with housing needs, and everyone should have a clear discharge plan in place, including an estimated date; all inpatient wards should have an effective interface with other services, particularly community-based acute mental health services; to facilitate access, transfer of care and discharge back into the community; and crisis resolution and home treatment teams operating in line with the evidence- base should have the means to facilitate safe discharge from inpatient settings and support people to go home on leave from wards With regard to the second area of concern; that of the conveyance of patients sectioned under the Mental Health Act, I should point out that the Mental Health Code of Practice is clear that local policies should be agreed between services:
16.30 Local authorities, NHS commissioners, hospitals, police forces and ambulance services should have local partnerships in place to deal with people experiencing mental health crises: The objective of local partnership arrangements is to ensure the people experiencing mental health crises receive the right medical carefrom the most appropriate health agencies as soon as possible. The police will often, due to the nature of their role, be the first _ of contact for individuals in crisis but it is crucial that people experiencing mental health crises access appropriate health services at the earliest opportunity:
16.31 It is also important to ensure that a jointly agreed local policy is in place governing all aspects of the use of section 135 and section 136. Good practice depends on a number of factors: For example: local authorities, hospitals, NHS commissioners, police forces and ambulance services should ensure that they have a clear and jointly agreed policy for use of the powers under sections 135 and 136, aS well aS the operation of agreed places of safety within their localities; all professionals involved in implementation of the powers should understand them and their purpose, the roles and responsibilities of other agencies involved and follow the local policy; professionals involved in implementation of the powers should receive the necessary training to be able to carry out fully the role ascribed to their agency; and being point

the parties to the local policy should meet regularly to discuss its effectiveness in the light of experience and review the policy where necessary, and partner agencies should decide when relevant information about specific cases can be shared between them for the purposes of safeguarding the person and the protection of others, if there is thought to be a risk of harm. The Code of Practice is available at: WWWgOV uklgovernment/uploads-system /uploadslattachment_data/file/281242/3635 3_Mental_Health_Crisis_accessible pdf: You may also be aware that we launched the Mental Health Crisis Care Concordat in 2014 which has been signed by all services, including the police service and the NHS, involved in providing care for people who may experience a mental health crisis The Crisis Care Concordat is clear that every local area should have agreed clear protocols for local services responding to a mental health crisis which clearly identify roles and responsibilities Every local area has a Mental Health Crisis Care Concordat Action Plan in place and we continue to work with these areas to embed and improve their plans. You will appreciate that arrangements within Nottinghamshire are a matter for local NHS commissioners and providers and the police service to determine. Finally, as YOu may be aware, the Government has commissioned an independent review of mental health legislation and practice to tackle the issue of mental health detention: Professor Sir Simon Wessely, former President of the Royal College of Psychiatrists, will lead the review which will deliver recommendations for change to the Government. Sir Simon will look at the evidence, review practice, and above all consider the needs of service users and their families, and how best the system can help and support them. He will identify improvements in how the Act is used in practice, as well as how we might need to change the Act itself: Vice Chairs will be appointed to work with Sir Simon and ensure the leadership of the review has comprehensive professional expertise whilst also representative of service users and others affected by the Mental Health Act: The review is currently gathering evidence with a view to producing an interim report on its priorities by the spring, and a full report by the autumn; with recommendations to Government and other relevant organisations. being -

Department of Health Further detail on the independent review, including its Terms of Reference; are available at Www_gov uklgovernmentInewslprime-minister-announces-review-to_ tackle-detention-of-those-with-mental-ill-health [ hope this information is helpful. Thank you for bringing the circumstances of Mr Vout's death to our attention. ~Jkus JACKIE DOYLE-PRICE