Dear Ms Brown Re: Louise TURNER Deceased D.O.D 27/06/2014 Inquest held on 16 May 2016 at County Hall, Topsham Road; Exeter Regulation 28 Report am writing to you in response to your letter dated 07 September 2016 to NHS Northern, Eastern and Western Devon Clinical Commissioning Group (the CCG): Please see below the CCG response to the matters of concern identified in the Regulation 28 report. Matters of concern 1 3 The CCG is responsible for the commissioning of care including monitoring the quality and safety of the services it commissions. As such the following outlines expected service response from Devon Partnership NHS Trust and the arrangements for monitoring: In accordance with the current service specification and contractual agreement for the provision of secondary mental health service, we would expect that Devon Partnership NHS Trust adhere to safe service delivery which includes timely, responsive and personalised interventions. We would expect that there are robust care planning processes in place in line with Care Program Approach principles, and that follow-up processes are in place to support seamless and safe discharge for every individual moving from an acute stay in hospital. Our expectation is that individuals will be offered regular review and timely follow-up including services for Assertive Outreach where appropriate. Information sharing is pivotal to this process and a multi-disciplinary approach is expected, including engagement with family, carers and significant others where appropriate. Chair: Chief Officer: Newcourt House , Old Rydon Lane, Exeter, EX2 7JU Tel. 01392 205205 wwwnewdevonccg nhs uk the

We expect that operational plans and protocols are subject to regular review to ensure that high standards of care and supervision remain in place and that there is robust workforce compliance_ With regard to serious incident investigations, specific actions are identified from the report recommendations in order to mitigate against a re-occurrence_ The CCG requires assurance that these actions are progressed and implemented and that learning is embedded within provider organisations. AIl actions identified by Devon Partnership NHS Trust in serious incident reports are recorded by the CCG safety systems team, and followed up by the patient safety and quality lead through routine meetings with the serious incident team at the Trust to review closed actions and the associated evidence of completion: Matters of concern 4 Following the publication of the Mental Health Crisis Care Concordat and the Care Quality Commission (CQC) inspection report into Devon Partnership NHS Trust in February 2014, it was identified that the lack of a Psychiatric Intensive Care Unit (PICU) in Devon was significant deficit to the mental health acute care system. This was further magnified by the publication of the Crisp Report (Crisp, N. Smith, G. and Nicholson; K (Eds.) Old Problems, New Solutions Improving Acute Psychiatric Care) which identified serious issues with the use of out of area placements for people experiencing acute mental ill health. The CCG led an option appraisal including all the Peninsula commissioners and providers, where it was identified that a PICU was required in Devon This proposal was considered by the CCG and it was concluded that the revenue funding to support the operation of a PICU was available within the Devon Partnership NHS Trust contract and that they should develop a plan for the design, construction and operation of a PICU within Devon to ensure provision across Devon; Plymouth and Torbay: A proposal to build a local PICU facility was reviewed and agreed by the CCG Executive Committee on 20 2016 with the Governing Body confirming their support for implementation for a local, 10 bedded PICU on the Wonford Hospital site, adjacent to the Cedars Mental Health Acute Unit by April 2018. Current PICU provision is sourced by Devon Partnership NHS Trust via a contractual arrangement with provider organisations in both London as well as Weston-Super- Mare_ The proximity of this provision informed recent commission decision and aligned to our commitment to deliver care closer where people live_ The CCG is committed to a jointly shared program of actions aligned to the Mental Health Crisis Care Concordat; along with other partner and stakeholder organisation including NHS providers and Devon and Cornwall Police. Through strong collaboration and robust local governance framework, a series of improvement measures are Chair: Chief Officer: Newcourt House, Old Rydon Lane, Exeter, EX2 7JU Tel. 01392 205205 wwnewdevonccgnhs uk July

being enacted to ensure multi-agency, safe responses for individuals experiencing mental health crisis_ hope that this letter answers your concerns, however should you have any further questions please do not hesitate to contact me_