Dear Ms Brown Re: Wendy Louise TELFER Deceased D.O.D. 20/03/2016 Inquest held on 11-12 January 2017 at Devon County Hall, Topsham Road, Exeter Regulation 28 Report write with reference to your letter dated 15 January 2017, in which you ask health commissioners to consider the untenable situation of delayed discharges from acute mental health wards. Devon Partnership NHS Trust (DPT) had indicated to you as of the inquest that delays in discharge were due to difficulty in ensuring sufficient acute mental health bed capacity. NHS Northern, Eastern ad Western Devon Clinical Commissioning Group (NEW Devon CCG) is aware that the rate of delayed discharges from all DPT acute mental health wards is higher than should be expected: This is influenced by a range of factors including for example, discharge planning from other Provider organisations funding approval -processes and the availability of suitable accommodation and onward care_ In order to address the issue of delayed discharges, the following approach has been taken by health commissioners: Monitoring of timely discharge performance data 1_ The local Northern and Eastern Devon A&E Delivery Board monitors delayed discharge data for all Trusts in the area including DPT; 2 The DPT contract review meeting also monitors the rates of delayed discharges from mental health wards through data reported to NEW Devon CCG by DPT; Chief Officer: Janet Fitzgerald Newcourt House, Old Rydon Lane, Exeter, EX2 7JU Tel, 01392 205205 mnewdevonccg nhs 4k part

Board also has oversight of
3. The Northern and Eastern Devon A&EdDelivelel discharges: DPT has improvement plans which aim to reduce delayed discharges from atplalano this Board for the reduction in delavedc adults is submitted health wards and plan for working older people's mental expected. been agreed with the aim of reducing delayed discharges: number of actions have capacity within its rehabilitation unit to 4_ DPT has temporarily diverted unused utilise as short term step down bed capacity; Council representatives have
5. NEW Devon CCG, with Devon County DPT aimed at mapping participated in series 0 workshops acitabeoVby pocessee NEW Devon current and future discharge and panel approval for improvement in Cucents awaitingrehe Sinal report and recommendations these processes from DPT; working in partnership with 6_ NEW Devon is already leading cupreresproceske1g for Dae approvai % Devon County Council to streamline currenti towards simplified s117 funding of s117 aftercare and are working joint aftercare funding agreement; additional step down beds to be made 7 DPT have indicated need for CCG is working with DPT to available in the Exeter area and NEW Devon identify solutions for this need; management and consultative 8_ New DevonCCCG has offered DPT additionaz and who have had success support from its urgent careacoroviceroningecce delaysh0 discharge; supvoking with acute hospital providers to County Council with 9_ NEV Devon CCG is working closely with Decien_ for older people: {Ecare eone commissioning and market sufficiency Devon County Council and DPT's Individual Further work is also required with who commission range of care Patient Placement and Adult Social Care teaos in need of accommodation or Pndehousiage options for individuals leaving sheeidaland match local supply to that apeclaissagsupport; in order to ellce assconseeti Mental Health recovery to commence consultation on need_ DPT is shortly Gurther intelligence about this need. pathways which should also provide matters that you have raised in your report; trust that this response addresses the do hesitate to contact me_ howeverashould you have any further queries please

Dear Ms Brown am writing further to your letter dated 15 February 2017, enclosing your Regulation 28 Report to Prevent Future Deaths_ In my response, will address your first matter of concern: understand that Devon Partnership Trust (DPT is responding to you separately on the issues raised. It might be helpful to summarise some of the mental health training that is currently delivered at the RD&E, both with the assistance of staff from DPT and from other sources_ Part of the role of the DPT Liaison Psychiatry team is to offer training to colleagues in the acute hospital. This is done both formally and informally. In 2016, the Liaison Psychiatry Team has formally trained at least 496 staff; having taught 175 teaching sessions. The regular formal training delivered by the Liaison Psychiatry team includes: A weekly training programme to the multi-professional team in the Emergency Department on various topics, including the Mental Health Act 1983 ("MHA") Regular training to the Site Management Team focussed on the MHA as have oversight of this and its application in the acute trust; Both of these training programmes are specific, targeted training sessions to areas where there is the highest volume of contact of patients with mental health issues One of the DPT Consultant Psychiatrists , delivers training on the Mental Capacity Act 2005 ("MCA") & the MHA at IelalyttWce} yerrly to Foundation doctors Core Trainees doctors and Consultants Mental Health Champion Training (x5 full days) to RD&E clinicians who have volunteered themselves as Mental Health Champions for the RD&E. This helps support staff with patients in practice. Other regular training sessions are delivered to the Emergency Department and to the foundation doctors in training on the role of the Liaison Psychiatry Team in the RD&E: This training includes use of the Mental Health Act Chairman: James Brent Chief Executive: Suzanne Tracey WZK856 11/16 being they

A whole day's package has just been built and is due to start being delivered later this month called "Management of Challenging Behaviour Using Rapid Tranquilisation as a last resort" this refers to use of the MHA in its content: This is being delivered to the medical wards and targeted at registered and non-registered staff where patients with mental health needs alongside physical needs are being nursed:. A full days training on Dementia & Delirium once monthly for registered and non-registered staff Other mental health training undertaken by RD&E staff from other providers includes: The Cavendish Care Certificate for unregistered staff has module on Mental Health is delivered by the Trusts Learning and Development Team and covers application of the MHA The Trusts Learning and Development team deliver the Level 3 Health Care Diploma which has a unit on Mental Health AlI medical staff have MCA training on their programme which can overlap and lead to discussion on the MHA University accredited Mental Health related modules which is usually undertaken by ED staff at the University of Plymouth Further , the RD&E is training specialist pool of nursing staff for specific mental health input: This will lessen the need to use agency staff. This will allow the Trust to have better control over the training and expertise of the specialist mental health staff. It will also improve communication between the physical and mental health care professionals_ You will see from the list above that there is a lot of training already being provided across the RD&E on the Mental Health Act. Most of this is specifically targeted at the groups of staff who have the most contact with vulnerable patients such as EDIAMU staff and Site Management With regards to future development; there is general consensus that greater awareness and understanding of the MHA would be beneficial to all staff. Ensuring that this training is of a suitable level, proportionate and appropriate to staff grading is essential. We are looking at the best ways to target resources most effectively and efficiently_ Training Needs Analysis is being done to ascertain what further training is necessary and where and how it should be targeted. Specific consideration is being given as to whether the module of training delivered to the high intensity areas such as the Emergency Department and Site Management_staff could also be helpfully delivered to the medical overflow wards, which includes Culm Ward: The relative volume of queries made to the Liaison Psychiatry team from these overflow areas is looked at, to ascertain the need in these areas. If such a need is found, the level of training, to which levels of staff, can then be determined. Consideration is also being given to the viability a 'leaflet drop' with payslips. This has recently been done by the Child Protection/Safeguarding Team to good effect: This would ensure that all staff in all grades and positions have some basic training and an information resource on the MHA Further 'catch all' training may also include information being added the RDRE intranet as must-read document It is hoped that the new 'Mental Health Champions trained could assist with any new training: An Action Plan setting out what steps will be taken to assess the training need is enclosed. being being being being

Royal Devon and Exeter NHS NHS Foundation Trust All of the current MHA training requests that if staff have any concerns about a patient's mental health; then should contact the specialist Psychiatric Liaison Team for advice on how to manage that patient in normal working hours and the psychiatric on call Crisis Team out of hours_ The escalation process also includes contacting the Devon Partnership Trust on call team both in and out of hours if an issue is unresolved. The next stage of the process includes contacting the Devon Partnership Trust on-call Director if required This is what is practiced throughout the RD&E at the moment This would also be our first line of advice in future training_ With respect to Wendy Telfer's case, she had been formally assessed on two occasions by specialist practitioners from the DPT and they did not consider she should have been under formal MHA section. On the of her discharge, there was some uncertainty about her MHA status and her current presenting symptoms Therefore , RD&E staff sought specialist advice from the Psychiatry Liaison Team on two separate occasions_ They were not advised to use the MHA to detain the patient if she tried to leave. It was on the basis of this specialist advice that she was allowed to leave_ Whilst we are always keen to improve practice, in this case RD&E staff had been clearly guided with professional, specialist advice about the use of the MHA in these circumstances, We would be circumspect about any training which meant staff , who used the powers under MHA very infrequently, acted in direct contravention of the expert advice. hope that the above satisfies you that we are looking at ways to improve MHA training within the Trust; We are aware of the need to improve the knowledge and understanding of staff around the MHA while still expecting staff to rely on the specialist service for advice

Dear Ms Brown Re: Wendy Louise Telfer (deceased) DOD 20/03/16 - Inquest 11 to 12 January 2017 Regulation 28 Report to Prevent Future Deaths Thank you for your letter of 15 February 2017 which we received on the 17 February 2017 following the inquest into the death of Wendy Louise Telfer As an organisation we are committed to learning these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust: The Trust has in collaboration with the Royal Devon and Exeter NHS Foundation Trust (RD&E) undertaken a Root Cause Analysis Investigation following the death of Wendy; the report was shared at the inquest and can confirm that the action for Devon Partnership Trust resulting from the report has been completed and is now part of regular management supervision What shouid havethoppaned? Happened? Rectliostion- (Inaluding Person Completion ~ccG Sign oH dato Iinks to exlsting watk Responsible Date streams and Initlatives) (Job Role) (Link to numbered recommandatlons) Accurate onid delailed records Stondards of Monitored by the CTL via line Clinical Manager 31/01/17 should be maintained at all times in documentation parlicularly management supervision Liaison Psychialry accordance to DPT policy; & MNC relating to recording of systems and documenlalion Team; responsibilities ond regulations. telephone conversations audits_ and multidisciplinary discussions were not recorded robustly within the clinical records The Liaison Psychiatry teams in Exeter have recently completed the self-review within the Psychiatric Liaison Accreditation (PLAN) process: PLAN is an initiative of the Centre for Quality Improvement: PLAN works with services to assure and improve the quality of psychiatric Iiaison in hospital settings. PLAN engages staff and patients in comprehensive process of review, through which good practice and high-quality care are recognised and services are supported to identify and address areas for improvement. Accreditation assures staff, patients and carers, commissioners and regulators of the quality of the service provided, PLAN includes core areas common for all teams, such as assessment and care planning: Record keeping is an essential part of this process and is scrutinized by completion of a case note audit; The final review of the three liaison psychiatry Chair: Julie Dent CBE Chief Executlve: Melanie Walker from What College being

services by PLAN is in May 2017. The Liaison services are continuously reviewing processes and adapting to make service quality improvements. This is also supported by managerial supervision and all clinicians are actively encouraged to seek personal clinical supervision It is clear following review of your report and consideration of your recommendations that there are continued improvements that can be made to prevent future deaths of this nature The actions we have taken or plan to take are described below, Availability of in-patient beds and Crisis Resolution and Home Treatment teams The Trust is acutely aware of pressure upon our available bed stock and has raised the issue with our commissioners through both our contract monitoring meetings and via a formal letter from our Board level clinicians highlighting the very real risk to patient safety: We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and have now extended their operational times to midnight days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards_ We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital. We have also used spare capacity in one of our recoverylrehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital: We now have in place a central trust wide bed management team to proactively manage and secure beds for those in need as quickly as we possibly can_ We temporarily secured additional contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than rely on ad hoc arrangements as we are in competition with other NHS providers for private beds. think it is important to note that securing additional capacity is compounded by both the ever tightening financial position of our commissioners , ourselves and the reducing availability of staff across the country would much like to assure you that we as a Trust are everything we can to use our available resources in the most efficient way we can to meet the increasing demand we are facing: would also like to assure you that we will always the safety of our patients first and will continue to do our level best to ensure someone needing a bed is provided with one as soon as we are able to source either internally or externally via the private sector, Training of physical healthcare staff There has been great deal of work in recent years with the site management team at the RD&E regarding the use and application of the Mental Capacity Act (MHA) This work has developed having recognised through our joint working that there had been a need to increase the awareness of the MHA and the importance it has in a hospital which is registered to take detained patients under the Act. We agreed that wider training across the hospital for nurses and medical staff was unrealistic given that the majority of staff would only come into contact with the Act infrequently, we agreed that all the training and expertise would be held by the site management team and our MHA office and Iiaison team regularly meet the site manager to discuss incidents, share learning, update in relation to any amendments to the Act and deliver rolling training to the site managers who run a 24 hour; 7 day a week rota across the whole hospital: All of the RD&E wards are instructed to contact the site manager with any MHA related issue. The site manager's office has all of the paperwork and guides and contact details for further support if needed. This has been successful in that most wardslstaff know to ring site management for MHA advice. This system is now well embedded and generally works well: Due to the high turnover of staff and medical Chair: Julie Dent CBE Chief Executive: Melanie Walker the they have doing very put

staff in training it has been the best way we have been able to disseminate learning and develop degree of expertise into the hospital. As described by our Liaison Psychiatry Clinical Team Leader during the inquest we have continued to support the training of the staff within the RD&E; have described below the general role of the Liaison Psychiatry Team in training and the specific work undertaken during the last year_ Part of Liaison Psychiatry's role is to offer training to staff in the general hospital, this is undertaken both formally and informally: During 2016 the team have formally trained at least 496 staff, having delivered 175 teaching sessions. The regular formal training delivered includes: weekly slot in the Emergency Department (various topics, including Mental Health Act) Regular slots to the Site Management Team focussed on the Mental Health Act One of our consultant Psychiatrists_ delivers training regarding the Capacity Act & MHA at least twice yearly to foundation doctors, Core Trainees and Consultants Mental Health Champion Training (5 full days to RD&E clinicians who have volunteered themselves as Mental Health Champions: Other regular slots to the Emergency Department and as part of the foundation doctors training on the role of Liaison Psychiatry in the hospital, this includes use of the Mental Health Act. A full day package has just been developed called 'Management of Challenging Behaviour Rapid Tranquilisation a last resortl' and this began monthly roll-out in March 2017 this refers to use of the MHA and Mental Capacity Act in its content; Dementia & Delirium full days training once a month that the actions described demonstrate our commitment to the learning we have undertaken and that the Trust is committed to this continued positive work with within our services and with the Royal Devon and Exeter NHS Foundation Trust If you require any further information please do not hesitate to contact me.