Dear Mrs Brown, REGULATION 28: REPORT TO PREVENT FUTURE DEATHS write in response to the Prevention of Future Deaths report that was issued following the inquest into the death of Luke Ayres with assurance of the action that we are taking in relation to your concerns. Luke Ayres sadly died when he was an inpatient on Severn Ward, Reaside Clinic on 27 September 2015. Luke was found kneeling on the floor with ligature around his neck at approximately 7pm that evening and despite attempts by staff and paramedics, he was unable to be resuscitated. There are a range of improvement measures that we have in place as a result of the death of Luke as part of our serious incident investigation_ These include:- Implementation of a single anti barricade system on Severn Ward Funding allocation to enable the whole of Reaside Clinic to operate a single anti barricade system 'the Kingsway system'. Works have already commenced in this regard and will complete at the end of September 2016. The Kingsway system will also be operating on Severn Ward at this stage Replacement of 70 observation panels at Reaside Clinic Piloting of a new clinical handover tool the WHAT tool on Severn Ward. Initial evaluation has proved positive and we are now seeking to roll out this approach to documented longitudinal and cross sectional risk within clinical handover across the Trust A review of our observation policy amendments to the policy and associated training requirements are scheduled to be approved in July 2016 Implementation of a more robust approach to Environmental and ligature risk assessments with input from subject matter experts from the Health and Safety Team, Estates and Facilities Team working alongside Ward Managers Chair: Sue Davis, CBE Chief Executive: John Short Customer Relations Mon Fri; 8am 8pm Tel: 0800 953 0045 Text: 07985 883 509 Email: customerrelations@bsmhft nhs.uk Website: www bsmhft nhsuk Abol; Stonewall DIVERSITY CHAMPION Impro mental health wellbeing 'O15ABL46 put Mtive 1 ving

During the inquest; evidence gave rise to concern about the procedures associated with the handling of medical emergency calls at Reaside Clinic, together with a lack of assurance that Paramedics would always be greeted in reception by a member of ward staff who could immediately escort them to the scene of the incident_ As a result of these concerns we have reviewed all of the technical telephony reports associated with the medical emergency call and can see that the call to the ambulance service was cut off during or immediately following transfer from reception to Severn Ward. We believe that this was user error on this occasion, however we are aware that the telephony system at Reaside Clinic is very aged and cannot therefore rule out a technical fault: We have therefore approved funding to replace the telephony system at the clinic so that it is in line with systems in place across our other Trust sites. We anticipate that this work will commence in Quarter 3 of this year (circa October 2016). We would like to thank you for bringing this matter to our attention. During the inquest you raised concern that the individual handling the medical emergency call was not at the side of the patient and questioned whether it would be appropriate to therefore have a cordless telephone on the ward for use in medical emergency situations. We have explored this matter with our information technology colleagues. Sadly due to the age and construct of the building at Reaside Clinic, there are a range of points where wi-fi connection cannot be assured. We therefore believe that a cordless telephone result in greater risk of delay in gaining medical emergency response. We have therefore decided to extend the simulation of medical emergencies on our wards at Reaside to include the connection of the call to the ambulance service and to also ensure that the individual nominated to make the call has all of the relevant medical information and observations of the patient to hand: We currently deliver quarterly medical emergency simulation exercises at Reaside Clinic (the most recent being just 2 weeks ago) and will explore the possibility of increasing the frequency: On the matter of receiving the Paramedics at the Clinic, we have amended our local protocol to ensure that the nurse in charge nominates an individual to await arrival of the Paramedics. This individual will also wear a high visibility vest so that they are immediately identifiable upon arrival of the paramedic team: We believe that the improvements identified above will enhance our current arrangements for medical emergencies at Reaside Clinic and would Iike to thank you once again for bringing these matters to our attention: You may find it helpful if write to you again in six months to update you on our progress and will diarise this accordingly: