Dear Miss Hamilton-Deeley Re: The Late Thomas Wall Thank you for letter enclosing your Regulation 28 Report of 2 August 2017, to the Clinical Commissioning Group, Sussex Partnership NHS Foundation Trust; and Pavilions_ My sincere condolences and sympathies go to Mr Wall's family and friends on the sad loss of Mr Wall: was struck by the text message sent to Mr Wall to his supportive ex-wife and can only begin imagine the pain felt: We as a Trust share your concerns that there is no local inpatient detox facility, patients family, friends and carers are having to travel to London, and are subject to long waiting lists_ It is important that there is a collaborative approach taken to dual diagnosis patients and we try to achieve this by working closely with our partner organisations such as Pavilions_ As the inquest heard Mr Wall had a joint assessment with Sussex Partnership NHS Foundation Trust and Pavilions and was open to both services for support and treatment. The commissioning of local substance misuse services is undertaken by Brighton and Hove City Council. The local substance misuse services in Brighton and were being provided by Sussex Partnership NHS Foundation Trust: In 2014 the service was out to tendering process by Brighton and Hove City Council_ Sussex Partnership in a full proposal and bid to keep the local substance misuse services as we recognise the value for patients and their families for services to be local to their homes, and the high number of service users who mental health needs and substance misuse needs Unfortunately , Sussex Partnership NHS Foundation Trust were not chosen by the commissioners of the service , Brighton and Hove Council, to continue to provide this service. Sadly, it is not within our gift to provide these services if we are not commissioned to provide them by the commissioners. We would welcome you to write to Brighton and Hove Council with your concerns_ Interim Chair: Richard Bayley Chief Executive: Samantha Allen Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP WWw sussexpartnership nhs_uk teaching trust of Brighton and Sussex Medical School your Hove put put have City City

Head of Legal Services, briefed me fully on the inquest of Mr Wall and was heartened that you praised the substantial input to Mr Wall's care from the Trust's Assessment and Treatment Service, the Mental Health Rapid Response Service, the General Practitioner and Pavilions and acknowledged the difficulties faced by these services as mental health and substance misuse services are not managed by one local provider such as the Trust Following the inquest; ensured that the informative Public Health England guidance shared at the inquest by] was provided to the Clinical and Service Director for Brighton and Hove, and the General Manager for Community Services for Brighton and Hove_ to ensure their teams are aware of the recent guidance to aid them in delivering services_ Thank you once again for your report and for highlighting your concerns, we welcome your input in assisting us to provide a more collaborative approach to dual diagnosis patients in Brighton and Hove_

Dear Ms Hamilton-Deeley Re: Thelate_Thomas Wall Regulation 28 report Brighton & Hove Council was not named in the Regulation 28 report for the late Mr Wall, but as Brighton & Hove City Council's Public Health department is the responsible commissioner for adult and substance misuse in-patient detoxification beds have been asked to respond as well to the report_ will address each statement in turn; No local inpatient bed detoxification service In December 2015 Sussex Partnership NHS Foundation Trust gave notice that would be terminating their substance misuse in-patient detoxification service from the 31st March
2016. The in-patient detoxification services at Mill View Hospital were no longer financially or clinically viable, following the withdrawal of London Boroughs their contract with Sussex Partnership NHS Foundation Trust. There was no alternative equivalent service in Brighton and Hove The public health department elected to work with Cranstoun, the lead provider in the Pavilions Community Substance Misuse Services partnership, and to refer patients to their inpatient detoxification unit in London. Cranstoun have been providing this service from the City Roads location in London for a significant period of time, and patients come from many areas of the country_ It is important to note that the inpatient detoxification beds were not included in the re-procurement of the community and alcohol service The change to the arrangements was presented to the Health and Wellbeing Board on 15th March 2016. An update was provided to the Overview and Scrutiny Committee on the 23rd March 2016 and an update provided to the Health Overview and Scrutiny Committee on 7th December 2016. A considerable amount of preparation work took place before the new service was Acting Director of Public Health Web: www.brighton-hove:gov.uk Telephone: (01273) 290000 Printed on recycled, chlorine-free paper City City the they from drug

Public Health Brighton & Hove City Council Brighton & Hove Second Floor, Hove Town Hall City Council Norton Road HOVE BN3 3BQ launched. This included service user consultation on the areas of concern, patient pathway planning and visits to the new service base. Although service users from Brighton and Hove now have to travel outside of the city to access inpatient detoxification services this is similar to what happens in other areas of the country, as local availability of this type of service is limited. The average length of stay is ten days. Contact with the outside world is usually restricted when a person is undergoing detoxification, and therefore being situated in an area that is not their home city may make detoxification more successful. After detoxification the individual returns to Brighton and Hove, and is supported to continue their recovery by linking to the existing local recovery community: Waiting times for inpatient detoxification In general patients are admitted to City Roads within ten days of having their assessment by the Pavilions doctor. All referrals to City Roads are reviewed at a multidisciplinary team meeting where a pre-admission checklist is completed: This includes service preparation work to ensure that an individual understands what will be required of them once they are in residence at the unit: This preparation work aims to ensure that people are referred at a point in their recovery journey where are most likely to be successful_ The aftercare support plan for once a person has successfully completed detoxification is also developed before the individual goes to City Road. This helps to ensure that the ongoing support a person will need to continue their recovery is in place If following the assessment it is felt that City Road is not suitable for the client an alternative provider is offered. Since the closure of the inpatient beds in Brighton and Hove, East Sussex refer their clients to a unit in Tunbridge Wells and West Sussex use a range of providers including Cranstoun The number of patients with Dual Diagnosis This is not straightforward: NICE guideline NG58 "Coexisting severe mental illness and substance misuse: community health and social care services" published in November 2016 states that "It is not clear how many people in the UK have a coexisting severe mental illness and misuse substances, partly because some people in this group do not use services or relevant care or treatment"_ The evidence review used to prepare the NICE guidance states "Dual diagnosis refers to people with a severe mental illness (including schizophrenia, schizotypal and delusional disorders , bipolar affective disorder and severe depressive episodes with or without psychotic episodes) combined with misuse of substances (the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage): Recent studies have estimated prevalence rates of 20-37% in secondary mental health services and 6-15% in substance misuse settings. However; methodological challenges including differing definitions of dual diagnosis, varying timescales for assessing comorbidity, key they get

Public Health Brighton & Hove City Council Second Floor; Hove Town Hall Brighton & Hove Norton Road City Council HOVE BN3 3BQ difficulties with diagnosis including diagnostic overshadowing, and the lack of a good theoretical model of the association between severe mental illness and substance misuse, mean that it is still unclear how many people in the UK have a severe mental illness and comorbid substance misuse problems_ To estimate the number of local people living with dual diagnosis, data for the period 01/09/2016 to 31/08/2017 from the local drug and alcohol treatment services is provided To complicate matters further the definition used in the data set changed on Ist April 2017 . Until the change the question asked was Does the client have a Dual Diagnosis? (Is the client currently receiving care from mental health services for reasons other than substance misuse): " From 01/04/2017 the question was 'Does the client have a mental health treatment need?" Using the former definition results in approximately one in five (340/1914) local service users having a dual diagnosis_ With the later definition this increases to two in every five (223/540) service users having a mental health treatment need_ Overall for the year 563 (23%) of the 2454 people assessed had a dual diagnosis or mental health treatment need_ Please let me know if you require any further information.

Dear Ms Hamilton-Deeley The late Thomas Wall Thank you for your recent Regulation 28 Report arising out of the sad death of the above As CCG we are very keen to reflect on the services we commission with a view to making improvements and avoiding future patient harm. Brighton & Hove City Council's Public Health department is the responsible commissioner for the adult and substance misuse in-patient detoxification beds. Interim Director of Public Health has therefore provided a reply although he and his team were not named in the report: A Joint Strategic Needs Assessment for Dual Diagnosis was completed in 2012 and made number of recommendations for improving service response to those with a Dual Diagnosis including greater recognition, identification and recording of Dual Diagnosis (DD) to understand the prevalence and need within the city and to ensure improved response to DD and the delivery of strengthened integrated care and service delivery across agencies_ multi-agency Steering Group with representation from service users, housing and hostel providers, commissioners and providers of primary and secondary care mental health and alcohol and substance misuse services has been meeting since the Joint: Strategic Needs Assessment publication to take forward these recommendations_ Progress has been made in number of areas including the implementation of Dual Diagnosis integrated model through the re-procurement of substance misuse services.
3.5 whole-time equivalent DD workers are now co-located with mental health services to increase joint working, engagement with support, and ensure smooth transition. Clinicians within substance misuse services can now access Sussex Partnership electronic patient records and vice versa. There are now agreed pathways between the services with regular meetings where complex cases are discussed to ensure that people receive appropriate support and care and do not fall between the gaps_ Better health for our city

Agreed referral and care pathway protocols are now in place for those with dual needs including increased awareness and training and increased access to primary care mental health support for those with dual needs which are no longer an automatic exclusion. The new service specification for primary mental health services supports a more proactive approach; Provision of accommodation with support has been increased for those with high support needs, including those with DD and inclusion of DD in medium support housing: The Fulfilling Lives project run by Brighton Housing Trust is focussed on patients with multiple and complex needs There has been a successful Department for Communities and Local Government bid for Rough Sleepers, which will enable an additional Homeless DD worker to be located within the Mental Health Homeless team Current Measures There has been an increase in the number of people in contact with both secondary Mental Health and Substance Misuse services measured using the Public Health England fingertips tool: Service user feedback is regularly reviewed with the most recent Service User report being produced in 2017 . Drug Related Death audits are being undertaken examination of cases to review if people still falling through gaps in services. The next meeting of the Dual Diagnosis Steering Group will review the latest Public Health England guidance for better care of people with co-occurring mental health and alcohol and use conditions and the local Service User report: Despite the above am aware the service needs ongoing review and development: Our mental health commissioning team are aware of this case and will ensure that your [and the CCGs] concerns fed back and discussed at the next Dual Diagnosis Steering Group meeting and will also ensure the CCG has direct discussions with the provider, hope this is helpful and please do not hesitate to contact me if any further information is of help.