Dear Mr. Singleton, Jacqueline Williams (deceased) ~ Regulation 28 report to prevent future deaths The Trust acknowledges receipt of your letter dated 2 November 2015 In the regulation 28 report you raise the following concerns: The process of referral to the Mental Health Liaison Team is subject to human error 2 The referral process does provide opportunity for staff in the emergency department to see conformation that a referral has been accepted and when can expect an assessment to take place 3 The Mental Health Liaison Team do not have a process to identify patients that the staff in the emergency department believe they have referred for assessment: Following this incident we undertook joint investigation with East Lancashire Hospitals NHS Trust: This resulted in the development of an action plan t0 implement measures to improve safety and prevent such tragic event from recurring: We continue to implement this action plan and work closely with East Lancashire Hospitals NHS Trust and the commissioning groups for East Lancashire and Blackburn with Darwen; Below are details of the actions that have been taken to date and those that are planned that address the concerns of your regulation 28 report: In the immediate term, we have briefed all staff on the referral process to ensure fully understand that process and shared the learning from our joint investigation_ We have also met with East Lancashire Teaching Hospitals NHS Trust to explore in detail how we can improve the referral process upporting Health and Wellbeing 01548449 ch )r Mdckim: MINDFUL EMPLOYER Way they they Lou, 0 JFl( 8

Lancashire Care [NHS] NHS Foundation Trust Within the Emergency Department they use the CRISP board to record the referrals made to specialists teams and we are looking to utilise this technology: A further option we are exploring is the development of a system whereby East Lancashire Hospital NHS Trust staff email the Mental Health Liaison Team wilh the patient's details and a brief reason for referral: The Mental Health Liaison Team would then acknowledge receipt of the email and also give approximate time of assessment: The referral information is already recorded within the Mental Health Liaison referral log book, however this approach we are looking to implement will ensure that positive confirmation is provided to Emergency Department staff. hope this addresses your concems and wish to assure you that we are keen to implement systems to prevent similar incidents in the future_ Should you require any further information the Trust will be more than to assist: