Dear Miss Hamilton-Deeley Re: The Late Alice Mead Thank you for your report of 24 June 2015, written pursuant to the Coroners & Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, and for highlighting the matters giving rise to concern_ Our thoughts are with Ms Mead's family and friends and we would like to reiterate our condolences on their tragic loss. Following Ms Mead's death, a serious incident investigation was conducted and following the inquest, John Child, Service Director Brighton & Hove, convened a meeting with both managerial and clinical colleagues in his service who were directly involved in Ms Mead's care, to discuss the learning and actions arising: This letter summarises the learning and hope it provides assurance that the matters you have raised have been taken seriously and improvements in Sussex Partnership have been made to continually improve the care we provide to our service users and their families_ As you say, a care coordinator was not allocated to Ms Mead when her previous care coordinator left the Trust. At that time, Ms Mead's case was reviewed, and the decision was made not to allocate a new care coordinator. General Manager, Community Services Brighton & Hove, has confirmed the introduction of an improved system; where, all care coordinators caseloads are reviewed with Consultant Psychiatrist and Team Leader. Particular focus is applied to caseload reviews when a care coordinator is and the decisions and outcomes are documented by the reviewing team on the electronic health record clinical information system: Service users will-be allocated a lead practitioner or care coordinator; based on their clinical need and are not reliant on calling the duty team. There is rolling programme of case load reviews for all clinical community staff and the review team consists of a Consultant Psychiatrist, the team leader and clinical supervisor as a minimum. The Care Programme Agproach (CPA) is in the process of being reviewed across the This work is led byL Director of Occupational Therapy and Recovery Practice. have newly constituted CPA steering group, with cross care group representation and we are agreeing the new processes in preparation for the roll out of Carenotes (the new electronic records system) A new CPA policy has been drafted and we hope to launch it in September 2015_ When the new CPA policy is launched there will be full staff training in place_ Information leaflets and short films will be available and all information will be available on the Trust's intranet. The training will be co-produced with service users and peer trainers to ensure a holistic approach. are also developing practice guidance to help staff to think about how to plan care more sensitively in consultation with the service user. This work is quality focussed and will provide greater clarity for staff and their roles within CPA Chair: Caroline Armitage Chief Executive: Colm Donaghy Trust Headquarters: Sussex Partnership NHS Foundation Trust; Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP wwwsussexpartnership nhsuk Teaching Trust of Brighton and Sussex Medical School leaving Trust: being We We

In relation to the calls Mead made and communication with staff, Brighton Urgent Response Service, now Mental Health Rapid Response Service (MHRRS), and the Assessment and Treatment Service (ATS) Duty Team are now co-located in the same working space. They have agreed protocol for information sharing: This allows for improved communication between the teams and for vital information on service users to be shared with staff and fed back to service users There is a communication book in place and a whiteboard to keep pieces of information and service user contacts prominent within the team. In addition, to aid improved communication, there is now Duty Lead working every day: The Lead working that day prioritises the incoming work and supports the decisions made by the call takers. They review and update the communication book and whiteboard. The Team Leaders go in to provide extra support and they have reiterated to their staff the importance of good communication and documentation. Within the local leadership team it has been agreed to form three clusters that will cover a set group of GP surgeries_ Once fully established this will allow the team to work more closely together and provide each with greater support. Staff in the East ATS and MHRRS, responsible for assessing service users' risk, have undergone bespoke Applied Suicide Intervention Skills Training (ASIST)_ This internationally renowned training was delivered in June 2015 by Grassroots, Suicide Prevention charity. To ensure risk assessments are up to date we have developed a new East ATS caseload spread sheet to capture risk assessment dates; supervisors will monitor this frequently, audit compliance, and escalate to the Team Leaders if action is required. Following Ms Mead's inquest, a new approach to calls is underway in East ATS. If a service user calls 3 times in a 2 week period in need of mental health input, they will be seen face to face. The only exceptions will be in circumstances when the case is reviewed by senior member of the team and a face to face appointment is not deemed in the best interests of the service user or appropriate; in these cases a detailed record will be kept documenting the decision rationale There are local monthly leadership meetings, chaired by Fiona Blair, ATS Service Manager, Brighton & Hove Locality. Fiona has shared the learning from Ms Mead's inquest (anonymously) at the Leadership Meeting: As a Trust we are committed to learning and improving patient safety - Lessons Ms Mead's experience were shared through the Trust's Report and Learn Bulletin and via the Trust's Quality and Safety Report; distributed throughout the Trust and with the CCGs_ Thank you again for your report The Trust has no objections to this letter being shared or published by the Chief Coroner_