Dear Miss Dolan Inquest into the death of Matthew Christopher Roberts Thank you for your report written pursuant to the Coroners & Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and for bringing your concerns to my attention_ Firstly, may offer my sincere condolences to the parents of Mr Roberts and his extended family and friends: am aware that nothing can say will lessen their grief on the tragic loss of their son, however; can make assurances that lessons have been identified and we have agreed some changes to improve our systems and processes These are detailed below; under each of your concerns.
1. That there was no relevant procedure or practice requiring faxes to the Bognor El team be logged and scrutinised so that it might be noted if faxed pages were missing and potentially important information not received. AlI Sussex Partnership NHS Foundation Trust staff must complete Information Governance training annually to ensure that information received and sent is managed safely and effectively. The training includes clear ance on receiving and sending faxes. 88% of staff employed in our Early Intervention in Psychosis Services (EIPS) have completed this training within the last year: Following Mr Roberts' inquest; the Senior EIP Management Team identified the need to supplement this training to ensure the Information Governance Principles were being followed by their staff. Therefore, the team designed and produced posters setting out the guidance around the receipt of faxes. These are displayed above all fax equipment used by EIP staff. Each notice reminds our staff to pass all faxes promptly to the appropriate recipient; to verify all sent pages have been received, and that the sender has confirmed their fax has been received. have also asked the team to ensure compliance reaches 100% with regards to the Information Governance Training: 2 That there was no policy: procedure or practice, requiring a member of the El team to read written information provided by a referrer before the zoning Chair: Caroline Armitage 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 Re: guidz key

meeting and initial risk assessment Additionally it was practice, on occasions, for the information to be left unread until shortly before the first face to face appointment with the patient: Hence the determination of the patient's needs, the current level of risk and the urgency with which the first contact should be made with patient was not informed by all the available information being fully considered The EIP Team Leaders and Senior Clinicians within the EIP service have reflected on this and have developed a clear set of shared standards for accepting referrals. Key elements of the standards are: AII EIP teams to use an updated referral form to gather all relevant information. The EIP Practitioner is to confirm receipt of all referrals received by fax on the day of referral by telephone and to use this telephone call as an opportunity to gather any further relevant information_ The EIP Practitioner will take responsibility for ensuring that all referral information is promptly uploaded or recorded in the patient's electronic health records; our new electronic records systems is called 'Carenotes'_ The EIP Practitioner is to ensure that an up to date risk assessment is received from the referrer whenever the referral is from another mental health team within the Trust or externally, or an initial risk screen is completed in the case of a new patient; previously unknown to mental health services_ The EIP Practitioner is to consider all information provided by the referrer; including information around the presenting risks to help inform them of the clinically indicated response to the referral. The EIP Practitioner is to communicate clearly to the referrer, their provisional plans for making contact with the referred person and the expected timeframes for this The EIP Practitioner is to record the proposed plans for contacting the referred person clearly in the patient's electronic health records on 'Carenotes' . The Daily Zoning meetings will be used to consider all available information on new referrals and decide the clinically indicated responses_ These key elements have been developed by the Service Manager and the Clinical Lead of Sussex EIP into set of guidelines for staff on referrals. These guidelines will be reviewed and signed off by our Sussex Children and Young People's Mental Health Leadership Team by the end of
2017. Following formal sign off;, they will be shared with all EIP teams and practitioners and support will be provided to embed these expected standards 3_ That there was no relevant policy, procedure or practice whereby the Bognor El team would clearly confirm with the referrer the date on which contact with newly referred patient would be made_ EIP staff make robust attempts to engage effectively with their service users. Service users, including those newly referred to the service, are offered choice around 2 May

appointment times and venues for meetings: This helps the service to achieve higher rates of engagement with service users and better outcomes in relation to patient safety and service user recovery. Following a referral to the service, an EIP Practitioner will aim to make telephone contact with the referred client; based on their risk assessment the next working to agree a date and venue for their initial appointment. It is therefore not always possible to clarify at the point of referral, when the service user will be seen: am pleased to say we achieved 95% in February 2017 for the new target for EIP access and waiting times for assessment and treatment to be within 14 days. In cases where significant risks are identified, the EIP service recognises the need to make clear plans around contact and to communicate these clearly and effectively to the referrer and service user in order to reduce the risk; In cases where the service user does not engage with us, the EIP team will follow the Trusts Active Engagement Policy: These elements are also covered in the recently developed set of guidelines for staff on referrals. A transition proforma has been developed by the EIP service following your Regulation 28 report This is a best_practice tool for use by EIP Practitioners at the point of transitions into and out of EIP service. It requires members of the Multi-Disciplinary Team to consider risk issues which may present during the transition and formulate clear plans for responding to these, should occur.
4. That SPFT did not appear to undertaken any formal review of the death of someone known to the organisation and, although SPFT were aware a RCA was being conducted by Avon and Wiltshire NHS Trust; SPFT had not received nor sought that final RCA report from Wiltshire: An opportunity to learn relevant lessons from the above events had therefore been delayed until the inquest; almost a year after events. The Trust has developed new Serious Incident Policy: Justine Rosser, Director of Nursing Standards and Safety is the lead for this new policy which anticipate will be in use Trust wide from next week. This new policy will ensure investigations are carried out to identify learning without delay and follows NHS England guidelines and best practice. In future , when another Trust is leading on a Root Cause Analysis, SPFT will complete local review and feed into the other Trust's investigation to ensure maximum reflection and learning for both organisations is achieved. Thank you once again for raising your concerns with me; Although you confirmed it was not possible to say if the tragic outcome would have been prevented, take each and every death of a service user very seriously: To ensure lessons and improvements to practice are not isolated to one service, the learning from Mr Roberts' death will be shared, anonymously; in the Trust's Quarterly Quality and Safety Report which is circulated Trust wide and is shared externally with our commissioners (CCGs):