Dear Mr Williams, Thank you for sending Somerset Safeguarding Children Board a copy of your Regulation 28 report; dated 4th October 2017, in respect Of the death of Sofia Ann Legg, aged 14 years, who died on 26th September 2016. For your information, Somerset Safeguarding Children Board is proposing to commission a thematic learning review (additional to the CDOP process) to establish whether there are any specific issues that need to be addressed by organisations in Somerset with regard to preventing such tragic occurrences in the future. This is because of the Board's concern about this and a small number of similar incidents of young people taking their own life over recent months and years_

Dear Mr Williams Concluded Inquest in to the Death of Sofia Regulation 28 Report Thank you for your letter dated 6 October 2017. We were saddened to hear about the death of Sofia and the distress of her family: Within your Regulation 28 report; you have noted five areas of concern: We have responded to each area below: Access to CAMHS. Sofia was rejected for referral in April 2015. Might a lower threshold and earlier proactive interventionist policy have been of positive benefits to Sofia?
1.1 In line with NHS England requirements the NHS Somerset Clinical Commissioning Group (CCG) commissions CAMHS in Somerset for children and young people with severe andlor persistent mental health disorders. Within the available funding (as is the case nationally) it would not be possible at the present time to lower the CAMHS threshold. Since the original referral for Sofia in April 2015, there has been a significant change regarding CAMHS provision and referral process_ As was noted at the Inquest; there is now a single point of access (SPA) for CAMHS , outlining improved access for young people, families and health professionals with clear oversight and governance arrangements mandated. For referrals which do not reach the access threshold, the SPA service now aims to signpost to other services which can be accessed to provide appropriate and timely support, rather than the previous simple 'no' that referrers, patients and family previously received: This is an area of developing practice for the SPA team as we work towards greater integration between tiers of mental health service provision and health and care services more generally _
1.2 There is also a need to consider the provision of Tier 2 services. In recognition of this, as part of our Somerset Local Transformation Plan funding for Children and Young People's Mental Health and Emotional Wellbeing monies have been invested in the commissioning online counselling via Kooth (https:Ilkooth com/): In addition, the CCG has recently made a successful bid for national funding to Chair: Dr Ed Ford Chief Officer: Nick Robinson MINDFUL EMPLOYER Working Together to Improve Health and Wellbeing

Legg; very

support new counselling provision in Cheddar provided by the voluntary sector. This service is in process of being established.
1.3 Somerset CCG and NHS England Specialised Commissioning are jointly funding a CAMHS Enhanced Outreach Service which is now fully operational to support young people and families in similar situations. This service is available days a week from 8.OOam to 8.OOpm and is a Multi-disciplinary Team, which includes a Psychiatrist:
1.4 We recognises the importance of supporting children and young people at all tiers and to that end we are in the process of reviewing our current commissioning arrangements which includes, enhancing our joint commissioning with Somerset County Council Children and Family Services and Public Health. We would expect the outcome of this to lead to further improvements for our Somerset children and young people 2 Availability of CBT. Sofia was placed on a 6 month waiting list for CBT, This delay appears considerable:
2.1 It is highly regrettable that there was a considerable delay in the availability of CBT for Sofia: During October 2016, Somerset CCG invested additional funding in order to improve access to CBT The CCG has now changed the way it monitors the CAMHS contract; data is received for new 8 week referral to assessment and 18 week assessment to treatment standards which clearly show us if the Provider has children and young people waiting longer than 18 weeks for therapy: This enhanced surveillance will address a previous concern about the visibility of waits, for example, where Care Co-ordinators were 'holding' cases in lieu of evidence based therapy: There are also standards now in place to monitor referral to assessment time for urgent and emergency referrals Sofia's care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance.
3.1 The Care Co-ordinator identified the need of and sought the opinion and support of Psychiatrist, however, there was no-one immediately available: Regrettably, the on-call Psychiatrist was not contacted to offer advice for Sofia Support was sought from a Line Manager and the crisis plan was developed as an interim measure pending a psychiatric appointment.
3.2 Since the implementation of the Single Point of Access Programme (SPA) practitioners have open access to the Multi-disciplinary Team (including a Psychiatrist): The enhanced Outreach Team (out of hours CAMHS Team) is also now established and working 8.O0am- 8.OOpm Monday to Sunday and will take urgent referrals and offer intensive home support as needed. Additionally, the process around availability of the on-call psychiatrist has been strengthened by ensuring the rota is distributed electronically to the whole service. The recollections of Sofia's Care Co-ordinator and Sofia's mother as to the meeting of the 19 September were at odds with each other. Sofia's Care C- ordinator recollected in her evidence telling Sofia's mother that Sofia was not to be left alone. Sofia's mother deemed the impression Sofia's Care Co- ordinator's evidence was of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia's care plan which made no mention of her not being left alone and it was not reflected in the Care Co- from

ordinator's actions in not urgently contacting Sofia's school; where she would be during the following days to a psychiatrist: Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia.
4.1 Following receipt of your report the CCG has discussed the apparent dissonance between Sofia's care plan and the accounts of both Sofia's mother and the Care Co-ordinator with the Somerset Partnership NHS Foundation Trust's Head of Governance. It has been agreed that the Trust will undertake further lines of enquiry (within the investigation conducted by the Trust under the National NHS Serious Incident Framework, and overseen by Somerset CCG), to establish if the content and robustness of the care plan were adequately addressed within the investigation and subsequent action plan. Language used in the SIRI Report was felt to be inappropriate. The SIRI Report effectively said if the care plan had been followed the outcome might have been different and that no change in clinical practice would have resulted in any different outcome: do not believe either of these statements was true
5.1 We understand our discussions with the Somerset Partnership NHS Foundation Trust in our oversight of the investigation and action plan they have reflected and are making changes: to the manner in which shared the findings of their investigation with Sofia's mother , as part of their strategy for involving families, and the need to ensure there is a clear understanding between professionals and families when formulating safety plans The issue of sharing documented 'safety plans' with patients' and their families, where this is identified as something beyond sharing the agreed care plan with the patient; is an issue which the CCG is currently working with the Trust t0 ensure this becomes part of routine practice for people with identified immediate risks_ As a CCG we are committed to ensuring that the services we commission for children and young people's mental health are both responsive and of high quality and we are grateful to you for raising your concerns with us. that our response has fully addressed the concerns that you have raised, if not please do not hesitate to contact me. Yours sincereli Nick Robinsd Deputy Chief Officer and Director of Commissioning and Governance Acting Director of Quality and Patient Safety Clinical Lead Mental Health and Learning Disabilities from they hope Copy:

Dear Sir Concluded Inquest into the Death of Sofia Ann Legg D.O.D 26 September 2016 write with reference to your letter dated 5 October 2017 , in response to the Regulation 28 report in relation to Sofia Ann Legg: The multi-agency Child Death Overview Panel (CDOP) held on 16 November fully considered the circumstances of Sofia's death_ CDOP considered that there were a number of modifiable factors to reduce the risk of future child deaths. The following recommendations have been made:
1. Communication of crisis plans needs to be clearer for parents, with clear instructions about who to contact if there are further urgent concerns: 2 There needs to be earlier Iiaison with schools so that staff can be aware of issues in a school setting, particularly if a crisis plan has been in place. Urgent support can then be sought if required. 3_ CAMHS staff need to have easier access to senior medical staff so can discuss cases that cause concern more easily.
4. SUI reports need to be phrased in a sensitive manner bearing in mind will be made available to parents_ In discussion with the Chair of Somerset Safeguarding Children Board, the death of Sofia has been considered for a Serious Case Review (SCR): The decision of the Chair is that Sofia's death does not currently meet the threshold for an SCR can however confirm that the Chair of Somerset Safeguarding Children Board has decided that Sofia's death will be the subject of a Learning Review under Working Together 2015. The scope and overview report author are in the process on being determined: put they they

trust this response is helpful to You; should you require any further information, please do not hesitate to contact me in the future.

Dear Mr Williams CONCLUDED INQUEST INTO THE DEATH OF SOFIA LEGG am writing to respond to the Regulation 28 (Preventing Futures Deaths) Notice that you issued to Somerset Partnership NHS Foundation Trust on 5 October 2017 . My predecessor; Dr Nick Broughton, as Chief Executive, met with Mrs Legg in October of this year and offered our sincerest condolences and an unreserved apology for the areas of Sofia's care and the handling of the investigation that were not of the high standard expected. Whilst we cannot begin to imagine the pain Sofia's family have experienced, we would like to express the sadness that we, as an organisation, and our CAMHS staff in particular, have experienced as a result of Sofia's death. Somerset Partnership provides a Tier 3 community CAMH Service. Tier 3 services are frequently referred to as Specialist CAMHS. These are multi-disciplinary teams which work in the community with children and young people who present with the most complex mental health presentations and severe levels of risk This would include severe mood and anxiety disorders, eating disorders, the impact of complex trauma as well as serious self-harm and suicide risk. The treatments offered by a Tier 3 services include a range of specialist psychological interventions and medication which can only be delivered by staff who have a high degree of specialist training and experience. What is known as Tier 2 CAMHs is the level of service, based primarily in schools and the wider community, providing early detection of emotional and mental health difficulties and offering timely, preventative interventions_ You will be aware that there has been national publicity and Government recognition of the need to invest further in children's mental health services_ The organisation welcomed this national investment which has been translated locally into the CAMHS Transformation Plan for Somerset and has led to considerable service improvements over the last year. Somerset Partnership Chairman: Stephen Ladyman Chief Executive: Peter Lewis

However; Somerset continues to be in the lower quartile for investment and we believe that further service development will be needed if we are to address the increase in demand and the complexity of the mental health presentations we are seeing in young people. The Trust's response is intended to convey the range of actions that have already been taken since the tragic death of Sofia in September 2016 and to provide reassurance that the proposals for further action are to prevent future incidences of suicide for children and young people in our care
1. Access to CAMHS. Sofia was rejected for referral in April 2015. Might a lower threshold and earlier proactive interventionist policy have been of positive benefits to Sofia?
1.1 It is certainly true that a lower threshold might have allowed Sofia to access the service earlier_ However; for the reasons described above, capacity within the Tier 3 CAMH Service is limited:
1.2 Over the past year the Trust has introduced a Single Point of Access (SPA) for CAMHS and the remit has been to more consistently screen referrals, allow more time for advice and discussion with referrers and to maintain and monitor service thresholds: We believe this is making a difference by improving access as well as improving the quality of the advice and guidance that is given:
1.3 Whilst; the introduction of the SPA has been a significant step forward , it has highlighted the unmet need in what we refer to as the CAMHS Tier 2 resources. 1,.4 Our specialist CAMHS team has raised concerns that the 2 options in Somerset are not equitable with much of the rest of the country: An increase in the Tier 2 resource would be an important and effective investment decision to improve the long term mental health of children and young people.
1.5 The Trust has raised this concern with Somerset Clinical Commissioning Group and the Local Authority and is working closely with these colleagues on gap analysis, which is anticipated will assist in informing future funding priorities. The need for a Tier 2 early intervention service was also raised directly with the Secretary of State for Health when he visited the Trust on 24 November 2017 and he indicated that a new green paper will soon be published which sets out plans to transform services in schools, universities and for families The Trust welcomes this focus on children's and young people's mental health and the plans to address the current gap in 2 service provision.
1.6 As part of this review we are also currently undertaking work to benchmark our own internal threshold processes for CAMHS Tier 3 with the national definition of what a Tier 3 service is expected to provide, and with what is commissioned: to ensure that we have our threshold in the right place, and that if it is set too high that we can identify that; to ensure that we look to get the right level commissioned. Tier Tier

2 Availability of CBT. Sofia was placed on a six month waiting list for CBT. This delay appears considerable.
2.1 The Trust agrees that a six month waiting time for CBT is unacceptable and has been working hard to reduce this. Waiting times for all specialist therapies have been successfully reduced and CBT waiting times in the Trust are now measured in weeks, rather than months. However; CBT is not an emergency intervention and a review of Sofia's care has led us to conclude that she should have been offered a more generic, therapeutic intervention with more frequent appointments at an earlier stage. This would involve using psychoeducation and a range of therapeutic techniques to engage and build a trusting relationship with a focus on understanding and managing risk.
2.2 The way the CAMHS teams operate has been changing to ensure that there is much greater focus on generic interventions, relationship building and increased frequency of contact when suicidal thoughts are one of the main presenting problems.
2.3 During 2017 the way initial assessments are performed has also changed. This includes the re-structuring of clinics to better support all staff in their decision making and to include psychiatrists and senior clinicians at an earlier stage: Weekly multi-disciplinary meetings with psychiatrists in attendance have been implemented to guide staff through complex case discussions and identify those cases which may need their input: 3 Sofia's care co-ordinator at CAMHS did not obtain the urgent input of a psychiatrist in accordance with NICE guidance.
3.1 The guidance for urgent and emergency response times also involves making complex clinical judgments and these are made by staff on an individual patient basis. Within CAMHS the decisions are made not only by psychiatrists but by other experienced senior clinicians who are able to assess and intervene to manage suicidal presentations safely as part of the urgent care pathway: If a referral to a psychiatrist is considered as urgent the family are seen within 24 hours of the referral and if the assessment results in an emergency referral these are made within 7 days. The numbers of psychiatrists within the Trust is limited and they would be unable to see all cases where suicidal ideation is a feature.
3.2 The care coordinator did view Sofia's presentation as sufficiently concerning to take advice from senior staff, including her clinical supervisor on the day of the appointment; while Sofia and her mother waited in the building: The outcome of those discussions was that the situation was deemed as urgent and the care coordinator should complete a safety plan and seek an urgent psychiatric appointment_ The Trust has reviewed its escalation procedures and introduced new service provision since this tragic incident.
3.3 The last year has seen a transformation in the urgent care pathway for CAMHS. An Enhanced Outreach Team (EOT) is in place. This team can, where necessary, do daily home visits and seek to provide more frequent monitoring of young people's mental state. Sadly, this service did not exist in this form at the time of

Sofia's death but it is envisaged that young people will benefit from an increased crisis and home treatment provision in the future.
3.4 In addition the Trust now has a team of highly experienced psychiatric Iiaison nurses based at both acute hospitals in Somerset; these nurses assess young people who self-harm or experience suicidal thoughts on presentation to an emergency department; If the childlyoung person is discharged and require further CAMHS input this information is communicated to the relevant local team for follow up. This team can also admit to the paediatric ward if need to keep a young person safe and this would prevent a delay in care if the young person could only be seen by a psychiatrist to undertake these assessments. The recollections of Sofia's Care Co-ordinator and Sofia's mother as to the meeting of the 19 September were at odds with each other: Sofia's Care Coordinator recollected in her evidence Sofia's mother that Sofia was not to be left alone: Sofia's mother deemed the impression from Sofia's Care Co-ordinator's evidence was of Sofia being an extremely vulnerable and dangerous position but this was not reflected in Sofia's care plan which made no mention of her not left alone and it was not reflected in the Care Co-ordinator's actions in not urgently contacting Sofia's school, where she would be during the following days to psychiatrist Her care plan appears to be the critical written record of the outcomes of this meeting as it was not of sufficient detail to safeguard Sofia:
4.1 It has been recognised that the recollections of Mrs Legg and Sofia's care CO- ordinator are not in agreement with regards to the level of detailed safety advice given: Mrs Legg herself has told us that we, as service, may not understand how challenging this situation was for her as a parent: She was being asked to absorb new information about her daughter's mental state and her risk of ending her life which was new and shocking for her: extend again my own and the Trust's sincere apologies to Mrs Legg for this The Trust appreciates and fully understands this feedback given by Sofia's mother and realises that services need to work much harder to help families understand the impulsive and fluctuating nature of suicide risk in young people. CAMHS practitioners have been made aware of the importance of ensuring care plans are explicit and information is written clearly. This work will continue to be monitored through staff clinical supervision.
4.2 The information about suicide risk needs to be given in a number of different ways and the Trust is creating a range of information leaflets that give general advice about suicide risk, as well as continuing to develop the knowledge and skills of our CAMHS teams in assessing, managing and communicating around risk: The Trust is working with Public Health in Somerset County Council on Suicide Prevention and it is expected that these leaflets will be launched in 2018.
4.3 It has been fully recognised that family members need to be involved at the earliest stage when young people are expressing suicidal ideation and given time to absorb information and to process advice The CAMH service is continuing to work with staff through risk training and via local team business meetings to emphasise the importance of crisis plans which give advice to both the young they they telling being fully

person and parent as to the level of supervision needed; in clear language. These directions are reinforced in training and supervision for staff.
4.4 recently conducted review of Sofia's care has highlighted the issue of communication with the school as one of the most significant areas of learning for the service It has been concluded that the school might have been able to take different actions in their care of Sofia had been aware of the increased risk; It has not been standard for CAMHS staff to share risk assessments and crisis plans with schools and has been a matter for individual clinical judgement: We believe that in cases where young people are expressing suicidal ideation then this information should be shared with schools as standard practice_ This will involve cultural and practical changes and will have implications for our education colleagues_ We are starting a process of talking with the CCG, schools and our staff to work towards implementing this approach as standard. 5_ Language used in the SIRI Report was felt to be inappropriate. The SIRI Report effectively said if the care plan had been followed the outcome might have been different and that no change in clinical practice would have resulted in any different outcome: do not believe either of these statements was true.
5.1 The Trust wishes to apologise unreservedly for the poor and extremely distressing choice of words within the investigation report which it acknowledges has caused considerable anxiety for Sofia's family. A review of the investigation, which took place following the inquest; did not support the statements as described above made in the report: The Trust has identified several areas for improvement to ensure that this does not happen
5.2 The Trust has prioritised the need for all investigators to have the knowledge and ability to conduct a thorough, accurate and reliable investigation using national tools and techniques. Training of staff in the use of these national tools and techniques has already commenced and by the end of 2017 a cohort of trained investigators will be in place_
5.3 The scope and terms of reference for the investigation will be clearly defined to include the needs of families and there will be oversight throughout the process to ensure key questions are asked and answered, this will ensure that the Trust achieves credible investigations. This new process has already been implemented.
5.4 The investigation process will seek to review all aspects of care and treatment that may have had an impact on an event such as this: The Trust has recognised that the involvement of families is essential right from the beginning of the investigation until the eventual sharing of findings. Work to embed this process is underway with revised documentation and education.
5.5 Bereaved families are being asked to meet and contribute to the learning by sharing their own experiences, in order to inform current and future working to ensure that openness and support is in place_ Initial meetings with family representatives who wish to be part of this have taken place. they again, key

5.6 In addition the Trust will further review the investigation into the death of Sofia. This review will seek to challenge the statements made and provide a balanced and sensitive report: This is due to complete by the end of January 2018.