Dear Mrs Hunt Re: Regulation 28 Report to Prevent Future Deaths Cleghorn Thank you for your letter of 26th July 2016 and the enclosed Regulation 28 Report to Prevent Future Deaths following the tragic death of Patricia Ann Cleghorn: was very sorry to read of the circumstances around her death, and would like to express my deep condolences to her family. It is important that every death by suicide of.a patient under the care of NHS services is fully investigated and learnt from to prevent similar occurrences in the future; note that this report has also been sent to Birmingham and Solihull Mental Health Trust to support this learning locally: In terms of national policy, want to highlight some key developments which believe are relevant to the issues you have identified regarding the lack of available acute inpatient beds and inadequate care provided by the Home Treatment Team, which your report concludes were both contributory factors in Ms Cleghorn's death: understand that VOU recently received letter dated g"h August from my colleague_ in response to a Regulation 28 report where raised similar concerns following a another case involving a death by suicide. want to acknowledge that much of the national work outlined in his response is also relevant here and therefore worthy of reiteration_ NHS England recently established an adult mental health programme which is taking a whole system approach comprising crisis, acute, and communitylprimary care work streams: The acute care work stream has been developed in response to number of recommendations set out by the Commission On Acute Adult Psychiatric Care and The Five Year Forward View for Mental Health, and is particularly relevant to the concerns outlined in your report. As noted in recent letter; we are aware that Crisis Resolution Home Treatment Teams are not always resourced to fully meet their core functions in High quality care for all, now and for future generations AEC you

line with the known evidence base. This includes providing intensive home treatment as a safe, genuine alternative to inpatient admission and appropriately gatekeeping acute mental health beds . Gatekeeping is the responsibility for deciding if a person should be admitted as an in-patient; and should include an assessment of whether the person is suitable for home' treatment Where the clinical judgement is that person's acuity is such that require an inpatient admission, then should be able to access a bed. As set out in the Five Year Forward View for Mental Health we are committed to ensuring that all areas have Crisis Resolution Home Treatment Teams providing high-quality, 24/7 , community-based crisis response and intensive home treatment in line with clinically based evidence by 2020/21. This commitment is supported by over E4OOa million; of investment following the Governments Autumn 2015 Spending Review, which will be made available to local areas over four years from 2017/18, and is intended to address the considerable pressure and high, bed occupancy in the acute mental health pathway: Further;_we are working with the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists to develop series of evidence-based treatment pathways for mental health care with accompanying commissioning support tools This includes the development of an acute care pathway comprising comprehensive set of quality standards, which is planned for completion within 2016/17 . The work involves range of multi-agency experts, including clinicians, social workers, service managers, service users and carers, and will focus on access to care, patient safety, patient experience and clinical outcomes_ The scope of the pathway comprises both inpatient and community settings, reflecting the need to ensure services are commissioned and delivered in the context of whole system approach based on clinical need and the safe management of patients. As such, there will be significant focus on the safe provision of alternatives to admission, including 24/7 intensive home treatment, and system-wide demand and capacity management; which promotes the provision of care close to home and in the least restrictive appropriate setting; increasing the availability of in-patient beds for those that need them: This work will draw on learning from identified areas of best practice such as North East London, Bradford and Sheffield, with the aim of spreading innovation across the country_ In addition to the work currently being progressed by the acute care work stream,_ The Five Year Forward for Mental Health set national ambition of significantly reducing the number of people taking their own lives To this aim, all Clinical Commissioning Groups will be expected to contribute to the development and delivery of local multi-agency suicide prevention plans, together with their local partners by 2017 . This expectation has been underlined in guidance for local areas regarding the development of their Sustainability & Transformation Plans and will be supported by further national investment of E25 million from 2018/19_ which is_additional to the E400 million identified for expanding Crisis Resolution Home Treatment Teams. In line with recommendation 57 of The Five Year Forward View for Mental Health, NHS England is working with NHS Improvement and the Care Quality Commission to ensure that learning from all deaths by suicide of people in the care of NHS services is used to try to prevent repeat events. Moreover, NHS High quality care for all, now and for future generations they they View the

England will continue to play its part in wider national partnership work as member of the Department of Health's National Suicide Prevention Strategy Advisory Group. For further detail on how the transformation of mental health services will be delivered over the next five years, please see Implementing the Five Year Forward View for Mental Health (htips LwWengland nhs uklwp conteniuploads/2016/Zlfviv-mbpdf) published by NHS England on 19" July. Thank you for bringing this matter to my attention.

Philip Dunne MP Minister of State for Health Department of Health Richmond House 79 Whitehall London SWIA 2NS 020 7210 4850 Mrs Louise Hunt HM Senior Coroner Birmingham & Solihull Areas 50 Newton Street Birmingham B4 6NE 2 2 SEP 2016 ar Ns ILk Thank you for your letter of26 July 2016,following the inquest into the death of Patricia Ann Cleghorn. I was very sorry to hear of Mrs Cleghorn's death in December 2015 and wish to extend my sincere condolences to her family. In your letter you refer to two matters of concern, the first of which is a matter for the Department of Health and others: Mrs Cleghorn could not be admitted to hospital as there were no inpatient beds available. Iheard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care. The second issue is One for the Trust to answer: Mrs Cleghorn had repeatedly stated that she would end her life by taking an overdose. Despite this she was allowed to self-medicate with amitriptyline, MST and Oramorph. No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her; The Government has made it clear that beds must always be available for those who need them In its 2015-16 Mandate to NHS England, the Government stated that it expects NHS England to make rapid progress, working with CCGs and other commissioners, to

help deliver our shared to have crisis services that; for an individual, are at all times as accessible, responsive and high quality a8 other health emergency services. The mental health Crisis Care Concordat (http://www.crisiscareconcordat org:uk)) published in February 2014 describes the roles and responsibilities of public services for improving outcomes for people experiencing a crisis. The Crisis Care Concordat makes it clear that local commissioners should commission a range of mental health services that allow beds to be available for a person in urgent need. Each local area in England has produced its own `Mental Health Crisis Declaration" The availability of mental health beds is a matter for local commissioners and I understand that the response from Professor Sir Bruce Keogh, National Medical Director; NHS England, has addressed both this issue and the question of inadequate care provided by Crisis Resolution Home Treatment Teams Tunderstand NHS England's reply also includes a description of developments in national policy in relation to adult mental health: 1 hope this response is helpful and I am grateful to you for bringing the circumstances of Mrs Cleghorn's death to my attention. 6y5 ~5 A PHILIP DUNNE goal key -

Dear Mrs Hunt; REPORT TO PREVENT FUTURE DEATHS: PATRICIA ANN CLEGHORN write in response to the Prevention of Future Deaths report that was issued following the inquest into the death of Patricia Ann Cleghorn with assurance of the action that we are taking in relation to your concerns Patricia Ann Cleghorn sadly died from an intentional overdose whilst being cared for in community by one of our Home Treatment Teams. She was awaiting voluntary admission to an in-patient bed, but as none were immediately available she received twice daily visits from the Home Treatment Team: She had stated her intention to take her own life and was self- medicating: At 17.00 on 14 December 2015 Patricia was seen at home in her bedroom by the Home Treatment Team and given a 5 mg diazepam tablet: This had & dramatic effect on her which was not appreciated by the healthcare assistant despite questioning by Patricia's husband and soon after this Patricia was found collapsed, an ambulance was called but she was declared dead by the Paramedics_ The conclusion by the Coroner was that her death had been contributed to by neglect The MATTERS OF CONCERN raised were as follows: (1) The deceased could not be admilted to hospital as there were no inpatient beds available_ heard evidence at Ihe inquest that had she been admilted it is unlikely she would have died when she did_ The availabillly of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care, Chief Executive: John Short PALS Patlent Advice and Llaison Servlce Customer Care Mon Fri, 8am ~ 8pm Tel: 0800 953 0045 Text; 07985 883 509 Emall: pals@bsmhft nhs uk Website: www bsmhft nhsuk Impreving mental health wellbeing O1sa8ls9 the Atout 1

(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oramorph No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her, AVAILABILITY OF INPATIENT BEDS In respect of issues raised in relation to the lack of availability of an inpatient bed (1_ we are very sorry thaf this was the experience for Mrs Cleghorn and that she took her life during this period. We extend our apologies to her family and have undertaken significant work with the aim of preventing any future deaths of this nature. can confirm that the availability of acute mental health beds is sadly a national challenge and we are working collaboratively with Trusts across the region and nationally t0 try to accommodate demand, wherever possible. We recognise that at times this means that some vulnerable people are cared for in the community. As a result of the unfortunate death of Mrs Cleghorn we have taken immediate action to review our bed management processes and community processes, so that we can ensure that any palient awaiting access to an inpatient bed receives enhanced care from our communily staff: Some of the immediate actions include: Creation of an urgent care assessment team to concentrate specifically on Ihe assessment of patients who are in crisis. This approach has been piloted and has demonstrated that having an urgent care assessment team improves outcomes for patients at this vulnerable time. The substantive team will be in place by the end of September 2016 One consultant psychiatrist will form part of each home treatment team to ensure that all patients who are presenting high levels of risk have daily access to medical review or medical opinion: This will be in place across all of our home treatment teams by the end of October 2016 At the time of Cleghorn's death we had an average of 30 people awailing admission to an inpatient bed, and a further 15 patients placed in out of area beds At the time of writing this response am pleased to report that we have just 2 patients walting for access to a bed and only 1 patient placed in an out of area bed This improvement is reflective of a range of work that has taken place within the Trust over the last few months to improve the flow of patlents through our inpatient beds and enhanced skill and care provision within our community services and home treatment teams. All of these patients have received: An updated risk assessment An updated mental health slate assessment Proposed plan of inpatient care An agreed plan of care in the communily whilst awaiting a bed being Mrs

An agreed review timetable for the patient (all patients must have at least a daily review but this may be increased as per needlrisk A crisis plan agreed with palients and carers where possible, to include all relevant support contact details for service users in crisis and also highlights protective factors and relapse management (updated plan from August 2016 and compliance daily audit introduction) This is now part of our standard policy approach to managing patients who are awaiting access to a bed within the organisation: All patients waiting are reviewed on a daily basis by the bed management team and a clinical director to decide the level of urgency for access to the bed: Those requiring urgent access will be prioritised and if there is no bed capacity within the Trust all other local providers will be contacted to see If have capacity, and if not private providers will be contacted More strategically we are working with our MERIT partners_ who include; Dudley and Walsall Mental Heallh Partnership NHS Trust, Coventry and Warwickshire Partnership Trust and Black Country Partnership NHS Foundation Trust; across region to develop consistent and unified pathways of care for patients in crisis. MEDICATION In respect of the concerns raised concerning a lack of formal risk assessment and failure to appreciate the drugs available to Patricia (2) we have liaised with colleagues including the Senior Nurse for Professional Standards, Head of Pharmacy Services, the lead for invesligations, Clinical Service Managers for Home Treatment Teams and Home Treatment managers, and the following are our findings and proposed action plan: Findings: We do not consider it appropriate for a non-registered professional to have administered the first dose of the newly instituted benzodiazepine medication. Indeed this was a breach of our current Medicines Code which stipulates following "3.5.12 Staff who are not registered nurses may deliver medication for self-administration by the service user. However where medication is to be administered, via any route, the person supervising the administration of the medication must be a nurse whose registration is recorded on the NMC professional register" and
3.9.4 Schedule 2 and 3. Controlled Drugs, benzodiazepines and hypnotics The administration of all Controlled Drugs including benzodiazepines and hypnotics must be witnessed by a second practitioner".
2. This has highlighted the need for Us to clarify the role of non-registered staff in our community crisis teams, with particular emphasis on the scope of their role and to ensure that tasks delegated to them are within their sphere of competence
3. Medicines supply and assessment of the stock of medication that the service user has access to should form part of the clinical risk assessment for service users in crisis In the community. they the the

Where risks are identified then medicines supply should be tightly controlled and overall medicines possession checked regularly as far as possible. If indicated, following appropriate risk assessment we will work with service users and carers to remove excessive medication in the interests of safely. It has to be recognised that we have (o work within reasonable limits which are determined by the services user's capacity and preparedness to fully disclose informalion and allow checkslsearches. If our staff are in any way unsure that it is safe to supply medication, the team will need to consider whether to withhold supply and explain why Proposed Action Plan - All of the actions are in place with the exception of item 4 which will be delivered by the end of November 2016 We will take action with regards to managing the breach of policy 2 The Senior Nurse for Professional Standards issued a formal practice alert on 12th September 2016 to registered and unregistered clinicians in our crisis and community teams to reinforce the requirements for: Clinical Risk Assessments regarding risk of self-harm andlor suicide; Risk Assessments with regard to medicines management and self-medication; Safe administration of medication as per current Medicines Code and NMC Code We required staff to sign returns to say that they had read and understood the directive
3. We have established a Clinical Risk Management Group which is addressing: Clinical Risk Management approaches and training; Suicide Prevention; Improved implementalion of crisis care plans: The Head of Pharmacy will undertake an immediate review of the Medicines Code to ensure that these issues highlighted above are properly considered and addressed in the revised Code and supporting direction for staff. This will be reported through our internal governance arrangements by (he end of November 2016_ We believe that the improvements identified above will enhance our current arrangements and would like to thank you once again for bringing these matters t0 our attention: You may find it helpful if was to write to you again in six months to update you on our progress and will diarise this accordingly:

Dear Mrs Hunt

Regulation 28 Report in relation to the Inquest touching on the death of Patricia Ann Cleghorn Ref: 112029 - Patricia Ann Cleghorn - (LH/AS)

I write in response to the Report to Prevent Future Deaths that was issued following the Inquest into the death of Patricia Ann Cleghorn, with assurance of the action the Care Quality Commission (CQC) is taking in relation to your concerns.

Birmingham and Solihull Mental Health NHS Foundation Trust (‘the Trust’) is the CQC Registered Provider of services received by Mrs Cleghorn. In May 2014 we carried out a comprehensive inspection of the Trust and it was rated ‘Good’ overall. We will be carrying out a fully comprehensive re-inspection in 2017 and intend to use the issues highlighted in your Report as a ‘key line of enquiry’.

The CQC became aware of Mrs Cleghorn’s death upon receipt of the Regulation 28 Report. As a result of the Report we made a request to the Trust for a copy of their investigation into the death and received a copy of the Trust’s Root Cause Analysis report (RCA). Based on the RCA we required the Trust to provide us with the following information:

 What training do qualified and unqualified staff receive in the home treatment team with regards to medication management and administration?

 What is the Trust policy/guidance for staff on monitoring medication reconciliation?

 Did the records detail whether the nurse who administered the diazepam to the Mrs Cleghorn at 5pm had a case discussion with the prescriber afterwards and if so what was the nature of the discussion?

The Trust responded to the questions and supplied us with their checklist to support the process of medicine reconciliation. We were concerned that the information received specified that the nurse who had visited was unqualified but that the RCA did not. We contacted the Trust to confirm that the nurse was unqualified.

A quarterly meeting between CQC and the Trust took place 15th September 2016 where we discussed what actions they had taken. We will be meeting with the Trust again in December 2016 to review the impact of their action plans.

Matters of Concern raised in your Report:

1. The deceased could not be admitted to hospital as there were no inpatient beds available. I heard evidence at the Inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care.

There remains a shortage of acute beds in this Trust and in other Mental Health Trusts in the region. This shortage will continue to impact on vulnerable people in the community. The provision of acute mental health beds rests with the Trust and with the clinical commissioning groups (CCGs), The role of the CCGs is to get the best possible health outcomes for the local population, by assessing local needs, deciding priorities and strategies, and then buying services (including mental health services) on behalf of the population from providers such as this Trust. The CCGs also check on the quality and safety of such services.

Whilst this shortage continues, the risk that another person will take his or her life remains high.

This Trust has taken action to reduce that risk by the creation of an urgent care assessment team and the availability of consultant psychiatrists to provide medical review. CQC will continue to meet with the Trust’s nominated individual to monitor their action plan in December 2016 to ensure they (the Trust) continue to take action to minimise the risk to vulnerable people in the community.

2. The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oramorph. No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.

The likelihood of other people being exposed to the same risks remains. However, the Trust found that it was wrong for non-registered professionals to administer the first dose of a new medication and was a breach of the current medicines code. As a result, they will be reviewing and clarifying the role of non-registered staff in the crisis team. The crisis teams, as part of the clinical risk assessment, review medicine they provide and medication that people have access to in their home. CQC is currently considering whether enforcement action is required at this stage.

With the actions identified by the Trust implemented, the risk to vulnerable people on home treatment will be low.

The CQC local Inspection team continue to meet with ‘local services’ and in addition we will formally review the actions put in place by the Trust and their impact of those actions on patients at our quarterly meeting with the Trust in December 2016.

Should you require any further information, please do not hesitate to contact me.