Dear Miss Kearsley Ret Mr Jake Bobinson [Deceased) DOBi (03-Mar-19921 Dod (78/08//301L1 Thank vou for your Regulation 28 Report regarding this young man's death. note Se
50), which appeared particularly to be related to our practice_ your concerns in which was sent from) In response | enclose the letter at Trafford Services on the 30th of June 2015 confirming that it was medically acceptable for Jake to be started on a detox _ that the has been recorded a5 going programme: You will note letter through: would also point out that your comment about the not provided in evidence is in my opinion erroreous It was in fact included documentation sent to your office by on the 24th of August 2015 in 25 pages of request for information. It a5 part of your offices initial was therefore not deemed necessary to duplicate the information in letter to you on the 9th of September_ hope this clarifies our practices my would like further information role in this matter but if you please do not hesitate to contact me: As a general point; understand your concerns re the disconnection and bounda Zommunity Mental Health Services, Phoenix Futures, Trafford AIM and ries between Trafford. My personal concern for a number of Care Services in vears been for patients like Jake with what is oosely termed a "dual diagnosis" which effectively means a person with mental health Iddition to, or secondary to, alcohol or substance misuse. It is think widely issues in Lare ctitioners that Community Mental Health Services recognised by Primary nanage this type of patient; The are extremely reluctant both to see and result is that are, in my opinion, often suboptimally vhichever and alcohol services which happened to have been commissioned managed by at the time. 'ont'd. 1 of 2 Drug fax being fax fully Primary has Pra they drug Page

Re: Mr Jake Robinson (Deceased) DOB: (03-Mar-1992) DOD (28/08/2015)

As a practice we have obviously recorded Jake'$ death as a Significant Eventand have discussed the situation fully. We found that a request to discuss Jake'$ situation with his mother in June of 2015 was overlooked due to emails from her being received whilst was On holiday, a written apology has already been sent to Jake'$ mother regarding this. The only other action that the practice in our opinion should perhaps have taken was to arrange a visit or consultation with Jake after his second admission to A&E on the of July 2015 In conclusion, the RAID Team stated that in their opinion there was no evidence of acute mental illness that his primary concern currently was illicit drug use. At that time their plan included leaving under the care of Phoenix Futures as he had a good rapport with his keyworker, he was discharged from RAID with it being stated that he was aware f crisis pathways In retrospect however we were not aware of when his next appointments were and who they were going to be with am not sure whether availing ourselves of this information would have made a major difference but it is certainly something we will reflect on further_ {Yours sincerely Enc copy letter to Trafford Drugs Service 17th, and him 'un

Dear Mrs Kearsley Re Regulation 28: Jake Robinson (deceased) am responding to the Regulation 28 you issued to the Trust on 17/12/15. Following the outcome of the Trust's Serious Incident Review into the death of Jake and the subsequent inquest; a number of actions have been taken: You note a concern that there was no indication in the review by Greater Manchester West as to whether a letter had been received by Services and if not; why not? (GMW) can confirm that the Serious Incident Review Team and Trafford Aim were unaware that a letter bad heen sent to Trafford Aim until the issue was highlighted in a meeting with the reviewer lead and after the conclusion of the review. Trafford Aim have carried out a robust search of bboth ifs Office base and the electronic database and have found no evidence to indicate the faxed letter from the GP had been received. A fax is usually sent when information is required quickly it is good practice in accordance with Information Governance processes in an attempt to maintain confidentiality for the sender to alert the recipient of the fax to it being sent and subsequently for the sender to confirm with the service that it has been received. As the GP practice did not do this the service were unaware that a faxed letter had been sent. Trafiord Aim however have taken the opportunity to review their administration process regarding receipt of letters and faxes sent to the service. A more streamlined process has been put in place which has reduced the points at which a letter or may get lost: The Trust encourages reviewer leads to give all parties, who maybe involved in the serious incident; the opportunity to be involved in Serious Incident Review process, including GPs. If the reviewers had invited the GP to contribute to the process and the GP took this opportunity, it is the issue of the missing letter would have come to light and have been included in the review. The Trust will continue to highlight to review leads through training events and local guidance the importance of ensuring all agencies and professionals such as GPs are invited to contribute to the GMW review process where appropriate. The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment Greater Manchester West Mental Health NHS Foundation Trust; Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121. Triangie of Care Chief Executive: Bev Humphrey M E M 8 € R Drug fax likely key

Greater Manchester West [NHS] Mental Health NHS Foundation Trust At the start of the review process the reviewers met with Jake's mother; who did not raise the issue of the letter_with the reviewers. Hokevernotheterrogation of thevteviewelly email has shown that sent several emails to the reviewers and the missing letter was mentioned in one of them amongst other subjects. The reviewers missed the particular emailand sincerely apologise for this error. The missing letter was subsequently raised by in meeting with the reviewers following the completion of the report; and the reviewers took steps to establish its whereabouts, and were able to conclude that Trafford Aim did not have possession of it, A further concern is raised in that Phoenix Futures have no ability to prescribe medication to their service users and have to access Trafford Aim for this, leading to disconnected approach to dealing with Jake's difficulties Trafford Aim is an advice, recovery and treatment service for adults over 25 with dependent or alcohol use_ Phoenix Futures is a service that is commissioned by Trafford Local Authority to provide psycho social interventions to individuals with alcohol problems and those under 25 with substance misuse problems. Both Phoenix Futures and Trafford are commissioned to meet the needs of different groups of service users however work closely together: The number of service users under the age of 25 who require medical intervention and treatment for drug problem is small: However, the Trust recognises that on occasion this can occur and has an established protocol between both services that allows those service users under the age of 25, who require a medicines review, to quickly assess the service. All efforts to reduce duplication and streamline the pathway for the service user are made As part of the review Trafford Aim identified that Jake should have been booked straight in for medical review. Instead however;, he was booked in for an assessment with a non medical member of staff: This was inappropriate as the assessment provided by Phoenix Futures had been carried out and clear need for medical review established. All staff have been reminded of the established protocol. The Trust acknowledge that whilst this process and close working relationship between Trafford Aim and Phoenix Futures exist, the disjointed nature of the commissioned services is not ideal. The Trust had developed a Dual Diagnoses Steering Group to review how these services and mental health services work together. There has already been two planning, meetings. The aim is to ensure effective partnership working by collocating services, effective joint assessment and joint working of cases with dual diagnosis. Trafford alcohol and services will be retendered in April 2017 . The are hopeful that this will provide an opportunity to develop lead provider model which will mitigate against the difficulties you describe. The Trafford Commissioner is aware of these concerns and is also organising a multiagency review. Finally you note that an explanation is needed in the review as to why the appointment clash between Trafford Aim and the CMHT led to the appointment with CMHT being rearranged. The Trust is committed to safeguarding children, young people and vulnerable adults and requires all staff and volunteers to share this commitment Greater Manchester West Mental Health NHS Foundation Trust; Trust Headquarters, New Road; Prestwich, Manchester M25 3BL Tel: 0161 773 9121. Triangle of Care Chair: Alan Maden Chief Executive: Bev Humphrey M € M B E R drug they very drug Trust Bury

Greater Manchester West NHS Mental Health NHS Foundation Trust The appointment at the CMHT was for an assessment by a qualified mental health practitioner and not an appointment with a psychiatrist. Due to the specialised area and knowledge required to treat drug problems,; general adult psychiatrist would not have the knowledge and expertise to prescribe for Jake's problem: Given this context and the fact that Jake had previously informed the CMHT he wished to prioritise appointments with Phoenix Futures and Trafford the CMHT cancelled their appointment: The CMHT however did not consider the fact that they could have also attended the appointment at Trafford Aim in order to facilitate an assessment and engage Jake in the service. also did not discuss the clash of appointments with Jake or Trafford Aim. The CMHT now have dedicated workers whose role it is to solely provide an assessment and duty worker role function; The workers have been reminded of the need to consider alternative ways to carry out an assessment and it is hoped that the consistency of workers means that when a dual diagnosis referral is received there will be a more consistent response to engaging service users in the assessment process hope this response provides assurance to Jake's family ad yourself that GMW have taken the learning from Jake's death seriously and have in place measures to ensure safe and effective services

Dear Miss Kearsley Re: Jake Robinson (Deceased) have now had the opportunity to review and to consider the responses received from Bodmin Road Health Centre , Greater Manchester West Mental Health Foundation Trust (GMW), Salford Clinical Commissioning Group (CCG) ; and Trafford Clinical Commissioning Group (TCCG): These set out the detail of the relationships between the providers, the commissioners and the patient: Greater Manchester West Mental Health Foundation Trust have verified that - do not have any record of the faxed letter sent by the Bodmin Road Health Centre Practice, relating to the clinical advice that would have allowed Jake to maintain his treatment benzodiazepine addiction: To remedy this, Greater Manchester West Mental Health Foundation Trust have undertaken a serious incident review and have implemented systems to capture and act upon letters or faxes received: The Bodmin Road Health Centre has similarly noted risks and taken steps to manage urgent correspondence and to confirm actions_ Greater Manchester West Mental Health Foundation Trust have identified that their initial review of the case did not identify the missing letter; despite Jake's mother raising this specifically: Greater Manchester West Mental Health Foundation Trust has noted this within their internal review: Salford CCG, as the lead Commissioner with Greater Manchester West Mental Health Foundation Trust have identified that the two services, namely Phoenix Futures and Trafford AIM provide different services to different client groups and that the relationship between the two can be improved note that a Dual Diagnosis Steering Group has been set up by local commissioners to review this: Greater Manchester West Mental Health Foundation Trust acknowledges that the Community Mental Health Team could have attended an appointment jointly with Trafford AIM to improve engagement and assessment for Jake. they' for

In order to reduce the risks of recurrence of a similar incident at these and other organisations across Greater Manchester so that referrals are managed and monitored by the responsible commissioning and provider organisations intend to undertake the following actions by 29 April 2016. will send a reminder letter to all GPs outlining best practice when sending urgent correspondence That is, the practice should make contact by telephone, or otherwise; to obtain timely verification that the urgent letter or fax has been received and to note this within records, and not to rely solely on the sender's fax confirming transmission This letter will also include guidance on suicide prevention and the need to note the risk, irrespective of any previous understanding by the recipient; so as that risk persists will also ensure that a letter is sent to all mental health service commissioners outlining NHS England expectations that commissioned services must establish arrangements for the following: a How urgent correspondence is handled and acted upon. This is also a contractual obligation which will be monitored by the commissioner. b To provide assurance to the commissioner on the robustness of clinical risk assessment tools, particularly in relation to risk to self and historical events_ Where different services service providers interface, to ensure that the structured management for shared care is clear and unambiguous: Undertake a review of systems that are in place to track and establish lessons learned from any incidents and near misses. To review policies and procedures for vulnerable patients who have a propensity to miss appointments. If you have any queries in respect of the above please do not hesitate to contact me.