Dear Miss Kearsley Rachal Marie Murphy am writing in response to the Regulation 28 Report dated 8 December 2016 and in particular to the concerns raised regarding the delay in the allocation of cases within Tameside Early Help Services. A thorough review has been undertaken of caseloads and allocation of work within the Early Help Service in part due to learning from cases such as this one and more recently our latest Ofsted inspection of children's services_ As a result; measures have been put in place which have led to a significant reduction of in the allocation of cases The table below provides quarterly data in relation to the number of families who have been entered onto a waiting list, having been identified as requiring a service Early Help. The data gives snapshot of the total number of families who were on the waiting list at the end of each quarter and gives clear evidence of the efforts that have been made to eradicate the use of waiting list. The three cases that were on the waiting list at the end of the most recent quarter were allocated as soon as the holiday period came to an end and normal staffing levels were in place. Number of Cases on Waiting Time Period List Sept 2015 60 Oct Dec 2015 Jan Mar 2016 33 Apr Jun 2016 15 Jul Sept 2016 15 Oct Dec 2016 3 Assurances can be given that in the past six months , any family entered onto waiting list was allocated a worker within a one month time frame and a manager from the Early Help Service kept in contact with the family during that period t0 monitor the situation. [G Raltt 4 THE WORKPLACE MINDFUL U CSE ATVRDSMENT 2lo 2016 WELLBEING CHARTER EMPLOYER WINNER King delay from July- About 1

Managers within the Early Help Service continue to monitor this and are now vigilant in ensuring Ihat the use of waiting lists is not common practice and that families receive a service at the point Ihat need is identified, The future monitoring of this performance will be undertaken at weekly Family Support Panel which will manage all allocations to Early Help ad other services in order to maximise the timely response to children's needs: In addition, a report will be submitted to the Tameside Safeguarding Children Board on a six monthly basis to keep the Board updated on the progress of the Early Help Services to ensure a strong multi agency ownership. trust that the measures that have been put into place will address the concerns raised within the Inquest in respect of the Early Help Service. Yours sincerely, Steven Pleasant MBE Chief Executive

WI~ 4! LlLLA NHS Foundation Trust 1s' February 2017 Corporate Governance Trust Headquarlers 225 Old Street Ashton-under-Lyne Lancashire OL6 7SR PRIVATE & CONFIDENTIAL RECEIVED Ms J Kearsley Telephone: 0161 716 3000 Acting Senior Coroner 0 2 FEB 2016 Coroner's Court Our Ref: Mount Tabor Street Department: Trust Headquarters Stockport SK1 3AG Dear Ms Kearsley, Re: Rachel Murphy (Deceased) Thank you for your Regulation 28 report dated the 13h December 2016,and for bringing to my attention the concerns you had after hearing all the evidence. Your concerns relevant to Pennine Care have been reviewed, and the Trust's response is outlined below, Concerns: There was a lack of understanding between medical professionals as to the means referral could be made to Psychological services and to whether there was an unclear message from Psychological services if were accepting referrals_ A Lack of understanding amongst medical professionals as to which cases may or may not be appropriate for referral to CAMHS services. Response: As part of the Trust's quality improvement work during 2016 the Trust implemented a new referral process for all aspects of Tameside and Glossop Healthy Young Minds Services (formally CAMHS). All referrals are now managed via one single point of entry and then allocated to a range of possible professionals dependant on the childlyoung person's needs eg: Psychologists, Nurse, Psychiatrist or 3rd sector services. This allows for greater clarity and understanding of where to direct requests for help to for all professionals: The Trust have also produced a service offer document which details, how to make a referral, how to contact the service for advice and importantly the document contains information of the types of problems that are appropriate to refer to Tameside and they . early ` Liqu}

Glossop Healthy Young Minds. This service offer document has been circulated widely to all partners and is also held on our website for easy access. The document has just recently been reviewed and will be expanded to provide a named contact for colleagues in the Paediatric medical services to contact for advice and consultation: The Trust believes that this addresses the confusion and lack of understanding that you have identified in relation to Rachel's care and treatment hope this response assures you that the Trust takes seriously any concerns that you raised Yours_sincerelv For and on behalf of Michael McCourt Chief Executive St8 1

NHS Tameside and Glossop Integrated Care NHS Foundatlon Trust Ms Joanne Kearsley Tameside General Hospital Fountair Street Acting Senior Coroner for Manchester South The Coroner's Court Ashton-Under Lyne Tameside Mount Tabor RECFmen OL6 9RW Stockport SK1 3AG 6 2 FEB "Zu15 Telephone: 0161 331 6000 27 January 2017 Dear Ms Kearsley Regulation 28: Report to Prevent Future Deaths following Inquest into the death of Rachal Murphy write further to your letter dated 8 December 2016 enclosing a Regulation 28 Report issued at the conclusion of the inquest touching upon the death of Rachal Murphy, which took place on 17 to 19 August 2016. We acknowledge that the Report has been issued to US some three months after the inquest was heard, but are, of course, very sorry that you had cause to issue this_ Further to a letter received by You from the Trust solicitors dated 30 August 2016, to be able to further address your concems, as set out in section 5 of your Report, to your satisfaction, in this letter. have addressed the areas of concern , adopting the same numbering in section 5 of your Report as follows: You stated: There was a lack of understanding between medical professionals as to the means by which someone could be referred to Psychological Services and whether there was an unclear message from Psychological Services as to whether were accepting referrals: As per the letter from our solicitors dated 30 August 2016, Paediatric Psychology Services within the Trust were at this time provided solely by Pennine Care NHS Foundation Trust The Trust were therefore very limited by the serviceslpolicies and practices adopted by Pennine Care. understand that it was heard in evidence that the clinical psychology services offered at the Trust through Pennine Care were undergoing a reconfiguration during 2015 and therefore the paediatric team were informed that referrals t0 the Paediatric Psychologist could not take place: am advised that this was confirmed by the Trust's Consultant Paediatrician in evidence, who stated that to the best of his knowledge the Paediatric Psychologist had been decommissioned and he therefore understood that referrals could not be made. understand that this contention was supported directly by the statement obtained from the Paediatric Psychologist who stated that ' had told ali paediatricians that could not take On any more referrals as the referral process was changing' Similarly when approached by the Trust's Specialist Epilepsy Nurse at the request of CAMHS, am advised that the evidence heard at the inquest supports the contention that & referral could not have been accepted and all referrals were to be sent back to CAMHS: understand that it was clear from the evidence of the Trust's Specialist Epilepsy Nurse that she felt that there was nothing further she could do as she was ultimately limited by the services provided by both CAMHS (who rejected the referral) and Pennine Care, who were not accepting referrals at that time. hope they

Vvniist Il seems arguapie Irom tne evidence summansed above that thera was a lack of understanding about Paediatric Psychology Services at this time, the system within the Trust has now changed. Please see the further explanation provided at point 2 below: 2 Lack of understanding amongst medical professionals as to cases which may or may not be suitable for referral t0 CAMHS. As indicated to you in a letter from our solicitors dated 30 August; it was the Trust's contention that during the course of the inquest there was in fact no evidence to suggest a lack of understanding in relation to CAMHS referrals and where evidence perhaps suggested that knowledge was limited, the Trust demonstrated that practices have now changed. understand that the Trust's Consultant Paediatrician gave clear evidence that CAMHS referral was not made by him in March 2015, not because he was unsure of the process, but because he knew how the process works and understood that without evidence of a more acute mental health problem, the referral would be refused (whict it ultimately was) and it was therefore important to look at other avenues of how to manage Rachal's behaviour: am advised that the Trust's Specialist Epilepsy Nurse spoke frankly about understanding of CAMHS at this time but provided reassurance in evidence that her knowledge of the service and the way in which she interacts with CAMHS has nOw changed, resulting in her undertaking a much more active role in terms of Iiaison with CAMHS, even in cases where a referral would not be accepted, and she confirmed in evidence that she will speak with CAMHS regardless of whether an ofiicial referral is in place_ The Trust have in response to this case, made changes to their practices to ensure that referrals to CAMHS are made in writing in any case where the Consultant Paediatrician has reasonable cause for concern in respect of a child's psychological wellbeing: The Consultants no longer filter referrals through Pennine Care staff nor do they consider the likely acceptance of referrals before making them: The referral is made and it Is for CAMHS to determine how to proceed: am informed that this change in approach has been successful to date with CAMHS appearing to be accepting more referrals in response. The Trust now have in place a number of safeguards to ensure that where a child being treated for epilepsy exhibits signs that may be consistent with mental health issues , that are managed and referred to the appropriate organisation. Consultant Paediatricians with epilepsy patients develop plan of care that is specifically tailored to each child and their family's needs. If a referral to CAMHS is required, no matter how small the concern, it is made. If a child exhibits signs that are consistent with them being high risk of self-harm/suicide, they will be admitted to hospital immediately for further assessment: All children treated for epilepsy are reviewed by the Trusts Specialist Epilepsy Nurse The Specialist Epilepsy Nurse reviews their progress, Iiaises with their family and school and if any concerns regarding mental health are identified, these are discussed with the Consultant Paediatrician and referral to CAMHS is made. The Specialist Epilepsy Nurse also liaises more informally with CAMHS by way of telephone advice, if a concern is identified. All children treated for epilepsy are given information regarding The Hope Group, a family support group for families with children suffering from epilepsy: The group is run independently the Trust but the Trusts Specialist Epilepsy Nurse is involved and often encourages families to attend weekly meetings as a further support network for patients and families who may be difficulties. The group provides a useful framework of support for children (and their families) to discuss and voice their concerns and worries outside of the hospital environment; The group is successfully attended and is assisting many families who find themselves in similar situations to Rachal and her family. Since this incident; the Trust have employed a Children and Young People's Mental Health Development Nurse who works closely with the Paediatric Team offering support and training to her likely they dealing from facing

develop mental health knowledge and skills to support safe, high quality and evidence based care for vulnerable children and young people: business case is currently being developed by the Trust to request funding for the introduction of a Psychologist for Paediatric Epilepsy patients. The introduction of such a role would provide another level of support to the team in dealing with patients who may be suffering with mental health issues. The appointment will be subject to the availability of NHS funding: 3 There was a significant delay in reporting Rachali$ EEG ad the Court heard that this remained the case in respect of reporting of EEG's at the time of the inquest. 24 hour, and in this case, 72 hour EEG's are very specialist tests that require specialist input and reporting: In order to interpret the outcome of these tests, analysis of an expanse of data collected over a 72 hour period has to be performed, the results of which may materially affect patient's diagnosis_ As indicated to you, in a letter from our solicitors dated 30 August 2016, 24 and 72 hour EEGs are performed and reported exclusively by Manchester Children's Hospital (operated by Central Manchester University Hospitals NHS Trust) Whilst the Trust can chase Up the results, (hey are not in control of the timeframes for reporting and delivery of EEG results, although given their specialist nature period of analysis is expected: A patient's care is also not affected whilst awaiting the EEG result The Trust therefore reiterate in line with para 7(1Jc), Schedule 5 of the CJA 2009, and also the Chief Coroner's Guidance No.5 on Regulation 28 Reports, that the Regulation 28 Report must be sent to "an organisation who the Coroner believes has the power t0 take such action". For the reasons stated above, the Trust respectfully submit that have no "power t0 take such action" and therefore should you still have concems in this respect, the Regulation 28 Report should be directed to the requisite organisation am somy that you had cause to issue this Regulation 28 and would like to take this opportunity to emphasise that do take your concerns very seriously: that have responded to your concers and reassured you of all the work that the Trust has already undertaken and is currently undertaking to reinforce the messages conveyed to you at the inquest regarding Paediatric Psychology Services Should you have any further questions arising from the contents of this letter, please do not hesitate to contact me.

Dear Miss Kearsley, Re: Miss Rachal Marie Murphy In response to the death of the above young lady and an internal review of her case, the Practice has into place measures to avoid the issues noted about the failure to check her liver function blood tests (LFTs) and how CAF documentation is handled, The British National Fommulary issue 72 advises that LFTs "should be checked before sodium valproate therapy is commenced and during the first 6 months of treatment, especially in patients most at risk" . Although the BNF does not advise checking LFTs annually for patients on sodium valproate, we all accept this would be good practice in view of the risk of hepatic dysfunction and have agreed to adopt this policy within the Practice have done a search of the Practice list for all patients currently prescribed sodium valproate and noted when their last LFTs were checked: If this has not been within the last year, they have been sent a letter inviting them in for a blood test, An alert has also been added to each set of notes detailing when their annual LFT is due and all administrative staff who issue prescriptions have been made aware RECEIVED put

to check the blood test is up to date before issuing a prescription: Should patients decline to have a blood test or not respond to the invitation, this will then be escalated by the member of administrative staff to the patient's usual GP to contact the patient and determine further action as appropriate. In the case of children under 18 years of age, all contact would be sent to the parentlguardian. Failure to respond to monitoring invitations would be escalated to the lead safeguarding GP to assess and consider whether the child is at risk and determine whether a referral to safeguarding is indicated: 2_ Since the CAF document from 2014 was received and scanned into Rachal's notes as file-only, a new member of staff has been employed by the Practice and trained to scan all paperwork received. She also attends annual training days on Docman, the software used to scan surgery letters. CAF documents received through the post will now be given to the duty doctor on the day arrive, to determine whether any action is required that such as responding to CAF meeting invitations, liaising with any other colleagues involved in the patient's care or arranging any follow up required at the Practice. Should no same-day response be needed, the document is then scanned and sent to all regular GP's at the practice to read, in order that are all made aware of the information contained We trust that these new procedures will help avoid a repeat of the circumstances involved in this tragic case