Dear Ms Brown; Re: Barry Thraves Thank you for report made in accordance with paragraph 7, Schedule 5, of lhe Coroners and' Justice Act 2009 and Regulations 28 and 29 0f (he Coroners (Investigations) Regulations 2013. Following receipt of your letter, (he Head of Service for Adult Mental Heallh has met wlth colleagues within Adult Social Care here at Leicester City Council and has discussed (he case and concerns with (he Service Manager in Leicestershire Partnership Trust: am aware that Leicestershire Partnership Trust will be responding separately to and providing their own feedback t0 the concerns Officers within Adult Social Care have considered very carefully the concerns and what lessons there are t0 be learnt from this case Please be assured that we have taken this matter very seriously and please below our responses and action plan in relation to each of your matters of concern: Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months; on Barry not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at the time This concern relates to Leicestershire Partnership Trust's involvement with Mr Thraves and am aware that The Trust will be responding t0 you on this ii) Community support did not take place as planned; and the family were not even made aware that this was awaited and Barry was on the list. It was not clear what; if any, information Barry had received apart from very brief letter of discharge that specifically did mention the community support: Case records show that ward staff Beaumont Ward at the Bradgate Unit referred Mr Thraves to Adult Social Care on 11 November 2014 on his discharge from hospital: This referral was made to Adult Social Care's Single Point of Contact and duty worker within this team contacted Barry and his sister between 13 November 2014 as part of the process of gathering information about Mr Thraves'$ needs . Both Mr Thraves and his sister identified that he needed support to access 12 CETCESTER cTTY C 0 UNCIL Rutland Wing, 3" Floor City Hall, 115 Charles Street; Leicester, LET IFZ WWWI leicester gov uk Cicy Town your you ~find point; not and

2L the community and social inclusion options and s0 it was explained to him thal he would be transferred t0 a Mental Health Team for a full assessment: The case was transferred t0 the AMH (West) Team on 14 November: It is most unfortunate that from the date of transfer t0 a Mental Health Team Mr Thraves had to wait for an assessment, which subsequently resulted in his sister contacting his Social Work Team: In order to ensure an individual, and any relevant persons are aware of the process following a referral t0 Adult Social Care a new process has been developed which will be effeclive from January 2016. The process shall be triggered where Adult Mental Health identifies that someone will need to wait more (han 14 days for an assessment from the point that (he case is transferred to the team: Adult Mental Health Teams will write t0 them explaining that have been referred for an assessment; that they will be seen as soon as possible but that they should contact the team if anything changes. Any appropriate leaflets about other support services available will be sent out at this The Team Leaders will be responsible for this process and the fact that this letter has been sent out will be recorded within (he system: This will ensure Ihat individuals have the conlact details for the team who will be dealing with their assessment and so on and understand the process that will be taken. Having Ihe delails in writing will also make it easier for people t0 share Ihis information with family and carers_ Where there is an identified carer whom the person wants involved wilh their care the team leader will send a copy of that letter to the carer. In order t0 ensure all staff are aware and adopt this process and email was sent t0 the relevant teams, by the Head of Service on 15 December and Team Leaders will discuss this in team meelings s0 that all workers are aware of the process. iii) The expectation of the Local Authority is that appointments should take place within 28 days, but the unit is significantly under-resourced and delays are common and appear to be tolerated, and have been for some time Earlier timely appointments could assist in identifying and intervening with relapsing patients. This opportunity was lost: The Local Authority aims t0 assess people as soon as possible There is no longer a national indicator t0 assess people within 28 days of referral but Adult Social Care works towards (hese timescales Unfortunately at this time the team was under particular pressure due to term sickness and vacancies, subsequently resulting in individuals waiting a long period of time for assessments_ It is most unfortunate that this consequently impacted upon Mr Thraves and also other people awaiting assessment at that time Fortunately, the staffing situation has now improved, vacancies are filled , and waiting times for assessment have reduced. At times when Team Leaders are unable t0 allocate cases t0 workers immediately, Team Leaders are responsible for prioritising and repriorilising cases awaiting allocation. they point; long

31, This is done on a weekly basis, checking the cases requiring allocation and the caseloads of workers within the team to identify people who can pick Up new cases When Team Leader is off work this responsibility is picked up by the covering manager, and there will always be a covering manager: accordance with new processes; from January 2016, anyone awaiting allocalion will be contacted fortnightly by phone t0 check whether anything has changed and if the case needs re-prioritising: Team Support Workers within each team will undertake this task and report back to the Team Leader, who can Ihen reprioritise cases as required. This process has been implemented via email from the Head of Service to Team Leaders on 15 December 2015 and will be followed up by conversations in team meetings. Adult Social Care is currently restructuring and establishing an Enablement Service to work alongside the Adult Mental Health Social Work This service is des signed to be in place for April 2016 and will offer adults with mental heallh problems practical support from the of referral s0 that no one should have to wait for an assessment: iv) Communication between the community mental health team and other stakeholders was poor; with important information that had been identified (that Barry was depressed and not compliant with his medication) not being shared with the GP nor were the GP or psychiatric team aware that Barry was not receiving any community support: It is noted that the AMHP s report to the Coroner identifies that the psychiatrists and AMHP assessing Mr Thraves were aware that he was not compliant wilh his medication It is acknowledged that it should be standard practice for information to be shared with relevant professionals, such as the GP In order t0 ensure this takes place in practice the Head of Service has e-mailed all AMHPs on 15 December 2015 to remind Ihem of the importance of feeding back to GPs following an assessment under the Mental Health Act; where the GP was not part of that asst essment: In order t0 reinforce this practice a specific process to be followed has been implemented which requires the AMHP to provide information by telephone no later than the following working day after the assessment; and for such feedback t0 be subsequently provided in via letter , oullining any relevant information within two days Social workers across Adult Mental Health have been reminded of the importance feeding back to the whole mulli-disciplinary team and to carers, not solely the Registered Medical Officer. Information was not made readily available for either Barry, or the family who were trying to support him, of who was involved in his care, the extent of their role and who to contact to discuss this further or in the case of any deterioration or change in presentation. This made the task of the supportive sister considerably more onerous and difficult and introduced unnecessary further delays in obtaining support for Barry at a time when his mental health was deteriorating and he was in need of urgent review: ~14 Teams. point writing;

41 The process identified at point ii above, specifically the letters that will be sent to anyone who to wait for an assessment from an Adult Mental Health Team, will explain Adult Social Care's role and how to contact the team should the situation change: As detailed above, having this information in writing will enable individuals to share this with family and carers. Officers working within Leicester Council s Adult Mental Health Services were saddened t0 hear of Mr Thraves' s death and as a result of his death and Ihe circumstances surrounding it have considered extremely carefully (he support provided to him: This was done through conversations between the Head of Service, Locality General Manager, Team Leaders and the AMHP_ The processes identified and implemented, t0 be effective from 1st January 2016 are processes which aim t0 improve that service for people requiring their support, do hope that the above answers your concerns and identifies the ways in which Adult Social Care will be working to take action t0 prevent future deaths: However, you have any queries regarding this please do not hesilate to contact Sarah Morris, Head of Service for Adult Mental Heallh on 0116 454 5417 .

Dear Mrs Brown Re: Barry Max Thraves Further t0 your report dated 26 October 2015 ,in accordance with paragraph 7 , Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 , offer the following response. We have investigated the matters of concern that have arisen during the course of the inquest of Mr Barry Thraves. Please be assured that Leicestershire Partnership NHS Trust (LPT) has taken these matters very seriously and undertaken a review of the circumstances of the case in response t0 concerns raised trust that you and Mr Thraves' family will be satisfied that we have taken the appropriate measures t0 reduce the risk of a similar incident occurring: The Serious Incident investigation was conducted in the immediate period after Mr: Thraves' death: It was signed off by our commissioners in November 2015 and we met with Mr Thraves' sister on 10 December 2015. We offer specific detail to the responses to the Coroner's concerns below: Psychiatric follow up was planned for 2 months but an appointment was not offered for 4 months; on not attending no action was taken and there was no evidence before the court that any clinical consideration of his risks was undertaken at this time; Chair; Caihy EllIs Chief Executive: Dr Peter Miller City Barry

We agree with the inquest findings. The LPT Did Not Attend (DNA) Policy (attached as appendix 1) is clear that it should be a clinical decision about what action should be taken following a missed outpatient appointment This communication with the GP expected to be recorded by an entry in the medical notes No such record was found on the occasion of Barry's last appointment. There was no letter evident in the clinical records regarding Barry's non-attendance at his appointment and no letter was sent to the GP which would have indicated when the next appointment was due It was written in the clinical records by the doctor that the next appointment was to be arranged for 2 months' time. Actions takenlplanned: All community mental health team staff have been reminded of the requirements of the DNA policy and their duty to follow it. Regular spot checks will be carried out to ensure that compliance is maintained. The Trust DNA policy is in the process of reviewed and will be available in February 2016 and a clear flow chart of steps to take in case of a patient not attending their appointment is included in the new policy. The Service Manager Adult Mental Health Community Services has circulated an interim version of this flow chart to all Community Mental Health Teams to reinforce awareness of the procedure following missed appointment while awaiting the release of the new policy: The flow chart is attached as appendix 2. In the period between completion of the investigation and leading Up to the Coroners inquest LPT has been undertaking programme of specific work to ensure that the maximum use of clinical appointment slots are available in the Adult Mental Health Outpatients department thereby increasing the availability of appointments to our patients. This will reduce the numbers of people who are not attending appointments. Specifically our new patients are now being contacted a week before their scheduled appointment to remind them of the appointment date and time. If a patient is unable to attend then the appointment can be offered to someone else. Patients who missed their last appointment are also telephoned to remind them to attend and these patients are also bought to the attention of the clinician so that an assessment can be made as to whether or not any further action is required: A text reminder facility is available to patients who opt into the service and the publicity for this is being reviewed to encourage take up. LPT is also working towards a 'partial booking' system for outpatient appointments whereby appointments are booked much closer to the scheduled date to be seen allowing for more flexible use of available appointments and a reduction in cancelled clinics. Cancelling of clinics is sometimes unavoidable but it is subject to Clinical Director approval and an action plan to monitor compliance and improvement is scrutinized for assurance at the LPT Quality Assurance Committee Since the beginning of November 2015 what are known as 'open contacts' on the patient electronic record (RiO) are being monitored on a weekly basis. This is where patient has had an appointment date that has passed but the episode of care has not been closed on record, either by record of the appointment having taken place or evidence of a further appointment offered These will be drawn to the Chair: Cathy Ellis Chief Executive; Dr Peler Miller being the

attention of medical staff for a clinical decision: This will strengthen safeguards to ensure appropriate follow is offered to all patients_ Community support did not take place as planned, and the family were not even made aware that this was awaited and was on the list; It was not clear what; If any, information Barry had received apart from a very brief letter of discharge that specifically did not mention the community support. A referral for community support (community care contact form) was faxed from the Ward requesting support on 11 November 2014 and was noted in the ward notes but not in the discharge letter. This should have been recorded as part of the follow up arrangements in the discharge letter. No information about the delay in assessment by the Local Authority was received by LPT. Actions takenlplanned: We have written to all adult mental health clinical staff to inform them that must include all referrals to other agencies in the discharge letter and ensure that this is communicated clearly to patientslcarers. The LPT Discharge Policy is currently under review and the new policy Is due to be approved in February 2016. The current policy attached as appendix 3 states; Discharging Mental Health service users with severe mental illness inpatient Mental Health Services will be carefully considered in consultation with all professionals involved and undertaken in consultation with the service user and (where relevant) their carers or parents Any such decisions must be clearly communicated t0 the GP; the referer and all parties involved in the service users care and the service user themselves: The new policy will include: Within 24 hours of the service users discharge, the doctor must complete the detailed e-discharge letter which is stored within the electronic records system w Ithin RiO. This must be sent through t0 the GP via the ICE electronic system (for surgeries where ICE Is not available, the discharge letter must be sent via eithor secure email or fax). The service user / carer must be offered a copy: It should contain the following information as a minimum: Initial reason for admission Investigations canied out and all available results Clinical summary of treatment Clear statement of definitive primary diagnosis where confimed or reason for not being available Medication commenced and to be continued, including duration Medication changed or stopped, and reason Management Plan/Crisis Plan if problems (i.e. who to contact) Follow up arrangements and referral to other agencies Infommation provided to the service user Infection Prevention and Control status Chair Calhy Ellis Chief Execulive: Dr Peter Miller Barry they Afrom

Functional ability on discharge The expectation of the Local Authority is that appointments should take place within 28 but the unit is significantly under-resourced delays are common and appear to be tolerated, and have been for some time. Earlier; timely appointments could assist in identifying and intervening with relapsing patients This opportunity was lost. This is a question to be answered by our colleagues from the Local Authority as this regarding the Local Authority's Intensive Support Team, not an LPT service: The LPT Service Manager for Community Mental Health has raised the issue of long waiting times for assessments by the Local Authority Intensive Support team with the Head of Service in the Local Authority (City). Communication between the community mental health team and other stakeholders was poor, with important information that had been identified (that was depressed and not compliant with his medication) not shared with the GP , nor were the GP or psychiatric team aware that Barry was not receiving any community support: We agree with the inquest findings that communication between the Community Mental Health Team (CMHT) and wider stakeholders was poor: We agree that LPT did fail t0 communicate the fact that Barry did not attend his outpatient appointment to his GP and the steps regarding open contacts taken to prevent this happening in the future have been detailed are outlined above. We have informed our entire medical and nursing staff, in dated December 2015 that they MUST_write to GPs informing them about patients who Do Not Attend at our outpatient clinics as stated in the LPT DNA policy: In addition we will carry out an audit of the DNA policy to check compliance against the standards in the policy during quarter 2 of 2016/17. The record keeping audit, being scheduled for January 2016 will also include the recording of compliance with the standards within the revised discharge policy as described under point 2.
5. Information was not made readily available for either Barry, or the family who were trying to support him; of who was involved in his care, the extent of their role and who t0 contact t0 discuss this further or in case of any deterioration change In presentation. This made the task of the supportive sister considerably more onerous and difficult and introduced unnecessary further delays in obtaining support for at a when his mental health was deterioration and he was in need of urgent review: We agree with the inquest findings that information made available for ether Barry Or his family was unsatisfactory and that it is vital that relevant information is available for patients and their families, that this is provided, documented and made of individual's assessment and care planning: Actions takenlplanned: LPT is undertaking a 'Listening into Action' (LiA) programme around the involvement of patients and their carers in their care planning: LiA is a structured approach to Chair: Cathy Ellis Chief Executive: Dr Peter Miller days, and Barry being writing Barry time part each

assist service improvement: The first event in the programme is to be held in January 2016. Additionally a Trust Carers' Pack has been developed as of an established CQUIN (Commissioning for Quality and Innovation) provide information to carers about processes and services. The availability of the same will be widely publicized by the ward, outpatient staff, and service userand carer organisations. Team managers will be asked to cascade to all staff once itis completed and ready for distribution It is anticipated that this will be completed by March 2016. LPT's CMHTs are currently undergoing service redesign. An important part of this redesign is t0 remove internal barriers between our Outpatients Service and the wider CMHT. Included in this redesign work is a pathfinder project in the North West Leicestershire CMHT to look at a multi - disciplinary team held caseload model with the aim t0 roll this out across all CMHTs by April next year: We anticipate that this work will help to address the concern about Barry's sister's queries being passed between different parts of the team including the Consultant Psychiatrist and the referral management service In addition staff have been reminded that where family members are present during an assessment they must be offered the opportunity t0 give their views, observations and understanding in relation to the crisis and the support- may be able to provide. This infomation will be documented on the assessment fomm by the assessing professional and fomm part of the outcome of assessment; This has been communicated in writing to our CMHTs. The CMHTs have also been informed in that relevant information must be made available for patients and their families, where this is provided it must be documented and made part of each individual's assessment and care planning: All of the actions outlined in this response will be monitored through the service'$ clinical governance arrangements. We hope this reassures you that we have taken appropriate action in response to the issues you have raised under Regulation 28 and that we are committed to provide safe and effective care in order t0 reduce the risk to our future patients.