Dear Mr Tomalin Re: Jessica BIRKHEAD Deceased DOB. 28/07/2015 Inquest held on 20 2016 at Devon County Hall, Topsham Road; Exeter Regulation 28 Report am writing to you in response to your letter dated 02 June 2016 to NHS Northern, Eastern and Western Devon Clinical Commissioning Group (CCG) Please see below the CCG response to the matters of concern identified in the Regulation 28 report_ In terms of context; the CCG's approach to commissioning access to mainstream healthcare services for people with learning disability is in accordance with national policy: People who have a learning disability should have access to the same specialisms as the general population, whilst recognising that reasonable adjustments may need to be made in services to enable this access It is not practical or indeed clinically desirable to run a host of parallel health services for people who have a learning disability as should always be able to access the expert input need as patients, for example in primary care , physical acute medical and surgical services or mental health services. This in turn will enable people with learning disability to use evidence based services supplied by members of staff with the appropriate skills who are supervised and trained according to their specialist function. This is a widely supported position intrinsic in government policy and research such as;- Improvement; expansion and reform ensuring that 'all' means 'all' DH 2002 Mary May ` they they

Equal treatment closing the gap (DRC 2009) Improving the Health and Wellbeing of People with Learning Disabilities: An Evidence-Based Commissioning Guide for Clinical Commissioning Groups (CCGs) Valuing People Now (DH 2001) Valuing People Now (DH 2009) The CCG recognises that people in our community who have different needs may need different approaches to care and the duty under the Public Sector Equality duty (2011) for public sector organisations to ensure that services are reasonable adjusted_ (1) Details of measures the CCG has implemented to assist people with learning disabilities to access appropriate main stream adult services and to support both the service user and the main stream adult services to ensure that appropriate care is provided The CCG has specifically commissioned services with Devon Partnership NHS Trust (DPT) to support the access of people who have a learning disability to mainstream services_ In primary care there are approximately 20 nurses operating across Devon to ensure that individuals have good support in primary care services This is a significantly higher level of service than other CCG's. The Extended Service provision of Annual Health Checks in Primary Care for people with learning disabilities has been maintained. In addition work has taken place with the locality screening teams (Cervical cancer , Bowel Cancer; Abdominal Aortic Aneurysm, Breast cancer and Diabetic Retinopathy) and immunisation teams (influenza) to increase uptake of these services by people with learning disabilities. In secondary care there is an Acute Care Liaison nurse in all of the large general hospitals in Devon and additional Iiaison learning disability nurses offering support The specification for this service is explicit stating it is there 'to provide a Iink between social carelcommunity learning disability teamslprimary care and facilitate health promotion supporting people to access other health services i.e. chiropody; dentistry, mental health services district nurses etc ' In addition the specification states that this service will "support good mental health outcomes and access to all universal mental health services" The intensive assessment and treatment team (IATT) in learning disabilities also offered support in this case and is there to support direct input to the person if they are experiencing behavioural problems. The current service specification states that therefore a key function of the team is to enable advice and support to those agencies to make sure those reasonable adjustments happen in those other services. and 'IATT is not a crisis intervention service' Mental health, physical or social care crisis should be dealt with through the normal services. fully

However IATT staff will support and advise those services offering guidance where appropriate_ Mental health services such as the Depression and Anxiety Service (DAS) are able to identify vulnerability and make reasonable adjustments where required to enable people with learning disabilities to access services From the root-cause analysis report completed by DPT it is noted that regular conversations had taken place between mental health services and learning disability services. Services appeared responsive and caring with a wide range of input in place. (2) Details of further measures the CCG plans to take in the future to assist those with learning difficulties to access appropriate main stream adult services or to support both the service user and main stream adult services to ensure that appropriate care is provided. The " Green Light" audit tool (NDTi;, 2013) has previously been deployed to review and benchmark inpatient services response to people who have mental health needs and also a learning disability andlor autism: The CCG clinical and quality leads will assess with the leads of relevant provider organisations whether this tool could appropriately be applied to other community services to provide review of access of mental health services to individuals and to identify what further reasonable adjustments are needed in services to enable service improvement: Assessment and agreement as to how this tool can be appropriately deployed will be completed in 2016/17 in order to inform any quality improvement initiatives to be undertaken in 2017/18_ trust that this response addresses the matters that you have raised in your report; however should you have any further questions please do not hesitate to contact me.

Dear Mr Tomalin Re: Mrs Jessica Mary BIRKHEAD (D.O.B. 07.06.1985) deceased 28 July 2015 am writing in response to your letter addressed tot Idated 02 June 2016. wrote to you on 08 June 2016 and note your letter dated 07 July 2016 in which you state that you are happy for my response to the Regulation 28 Report made into the death of Jessica Birkhead, which have prepared on behalf of who has retired, and the current partners at the Practice_ take note of the contents of the Regulation 28 Report and in particular your concerns as stated in note five of the report_ Jessica first moved into the East Devon area in August 2006 when she was registered at the Honiton Surgery: At the time she had moved specialist unit in Minehead to in a specialist care home in Honiton_ She had a case manager and care worker. In addition, she was referred to a clinical psychologist who worked with her over the following year She saw her GP regularly and following completion of the work with the clinical psychologist was referred to the East Devon Learning Disability Team in November 2007_ She continued to have regular health checks with her GP while she lived in supported accommodation _ In December 2012 she was registered at the Devon Square Surgery in Newton Abbott: She was referred to a consultant psychiatrist in March 2013 by her GP. She then moved to Colyford to live with her husband, baby and mother-in-law Atthis time she registered with the Seaton & Colyton Medical Practice_ She was reviewed byl Consultant Psychiatrist with the Learning Disability Partnership on 05 April 2013 who set out a clear plan for her care_ This was shared with her social worker and clinical psychologist. She was reviewed again by _ in
2013. Following this she had a further clinical psychology assessment between June and September 2013_ She was reviewed again by Consultant Psychiatrist with the Learning Disability Partnership, in October 2013 with plan to keep her under regular review: There followed further assessments in March 2014 and June 2014 from live July the

2 20 July 2016 Re: Mrs Jessica BIRKHEAD (D.O.B. 07.06.1985) deceased 28 July 2015 NHS No. 474 405 1022 Subsequent to this and Isuggested that Jessica might be referred for cognitive behavioural therapy and reierred her to the Depression and Anxiety Service She was reviewed again by in October 2014. She continued to have regular contact with her GP and had a full learning disability health assessment in November 2014 coordinated by her_social worker: She also had further appointments with the Depression and Anxiety Service: Isaw her again on 18 March 2015 when she was accompanied by her occupational therapist from the Community Learning Disability Team_ She remained under the care of the Learning Disability Team and consultant psychiatrist She also remained under the care of the Depression and Anxiety Service having been rereferred to them in April 2015. Jessica sadly died on 28 July 2015 having taken an overdose_ There is no reference in her primary care records that she expressed to her GP any thoughts of deliberate self-harm: take note with regards to the 'Matters of Concern" raised under Regulation 28. However, it is my opinion that Jessica was under the care of a consultant psychiatrist specialising in learning disabilities, the Devon Learning Disability Team and also the Depression and Anxiety Service, as had previously been arranged by two consultant psychiatrists. It is not; therefore my view that the support services were not equipped to deal with someone of Jessica's intellectual disabilities_ The Seaton & Colyton Medical Practice held an informal Significant Event Audit Meeting following Jessica's death; following which provided a report to the Coroner as requested Following receipt of the Record 0f iInquest and taking particular regard to the Regulation 28: Report to Prevent Future Deaths, the practice will hold a formal Significant Event Audit Meeting in which we will discuss Jessica's case and consider appropriate pathways for others in the future in a similar situation to Jessica to take into account any learning difficulties and associated medical problems_ trust that this reply is satisfactory and we will forward the results of our Significant Event Audit when it has taken place_