RECEIVED MINISTRY OF DEFENCE FLOOR 5 ZONE B MAIN BUILDING 13 APR 2015 WHITEHALL LONDON SWIA 2HB Ministry Telephone: 020 7218 9000 (Switchboard) of Defence ANNA Soubry MinisteR OF STATE For DEFENCE PERSONNEL, WELFARE AND VETERANS April 2015 De W ny fin la to Thank you for your letter of 20 February 2015 in which you enclose a copy of the Regulation 28 Report following the Inquest into the death of Lance Bombardier Richard Jeffrey Jones: was very sorry to hear of Lance Bombardier Jones' death and would like to offer condolences to his family: As you will be aware, my Department takes its relationship with HM Coroners extremely seriously and we fully recognise how important it is that we learn all possible lessons to ensure that deaths in similar circumstances in the future are prevented. You are concerned about the current provision of mental health care for members of the armed forces, in particular: The way in which information obtained from such a patient is recorded, with special reference to the perceived level of risk and the degree of urgency in carrying out an assessment; How that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency; and Who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is transfer of care_ With regards to the above, you asked for a review to be undertaken of the policy and procedures in place to deal with referral to another agency of a member of the armed forces who appears to be suffering from mental health issues understand that Health Minister Dr Dan Poulter will be writing to you separately with his Department's response to your concerns: would therefore like to set-out what my Department is doing: Mr lan Singleton Wiltshire & Swindon Coroner's Court 26 Endless Street Salisbury Wiltshire SP1 IDP my

Medical Information (as defined at Annex A) is collected directly from the individual who is presenting to clinician within the Defence Medical Facility, the Department of Community Mental Health (DCMH) or other clinical setting: If it is deemed pertinent by the individual concerned or the clinician the individuals significant other will also be invited to take part in the assessmentlreview as well as all other relevant information (referral letter; discharge letter; medical reports): The Chain of Command are also included in the gathering of information either by them providing information to the GPIMedical Officer or the Commanding Officer being requested to provide an official occupational report to the mental health specialist: At each assessmentlreview the safeguarding of the individual and others are assessed, considered and reported upon in reports and clinical notes: The findings of which are consolidated into the individual's Defence Health Record. When information needs to be shared internally or externally; the mode of transfer is dependent upon the urgency and associated risk The following modes of transfer are used to convey information between agencies in descending levels of risk: in Person b_ telephone followed by an electronic report to the identified clinician E-mail ensuring Caldicott Principles are observed d_ Letter can confirm that we are now updating leaflet 2-7-2 of the Department's medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services: This will include new guidance and policy on the principles of transfer; which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies The updated leaflet will also set-out clearly who has the primary responsibility of an individual; To summarise , this will state that the responsibility of the patient remains with their current clinician until the care of that individual is officially transferred to the care of another clinician who will be taking over their care In general, this will mean that the responsibility for a patient will be retained by any referring clinician until the receiving clinician has seen the patient; or has specifically communicated their acceptance of responsibility to the referrer: This addition to JSP 950 Leaflet 2-7-2 will also include guidance on: Entitlement of Service Personnel to NHS services The need for DCMHs to liaise with local NHS services to promote good working relationships

Information NHS services ideally require in order to provide care for Service Personnel The need for DMS facilities to be informed about NHS care provided to Service Personnel How NHS care providers can access advice from DMS about occupational or other military specific issues Annex A to JSP 950 leaflet 2-7-2 also outlines the provision of out of hours Defence mental health services by an on-call Service Liaison Officer The Service Liaison Officer offers out of hours telephone advice 365 days a year and is to provide:
a. administrativelprocedural advice to clinical staff wanting to admit a patient into an in-patient service (e.g. at an NHS hospital):
b. alternative case-management options, including arranging urgent appointments at the individuals local DCMH the next working an accurate log of actions taken during the out of hours period and to pass this information to the patient's unit; local DCMH, Medical OfficerIGP andlor in-patient service the next working day: It should be noted that the Service Liaison Officer Service is not a clinical one_ The on duty SLO is not expected to carry out an assessment or take responsibility for someone in crisis or discharged from hospital: The Ministry of Defence has recently become a signatory to the Mental Healthcare Crisis Concordat: This means the Defence Medical Services will engage with the aims of the Concordat to improve care for those in mental health crisis, and in particular the MOD will seek to improve joint working with NHS providers hope that my response adequately explains the steps my Department has taken to address your concerns: ~inle~ ANNA SOUBRY day

Dear Mr Singleton Thank you for sending me a Prevent Future Deaths report regarding Richard Jones deceased following his recent inquest Your report was considered byour Critical Incident Review Group, which is chaired by my Medical Director_ on 2 March 2015, It was decided that to best explore the issues you have raised we should conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces. This will enable staff from the different agencies to collaborate and identify the best solutions to the problems you have raised concerns about; to include a review of any relevant policies and procedures. will happily update you on the outcome of that joint work in due course_ Thank you much for bringing your concerns to my attention:

From Dr Dan Poulter MP Parliamentary Under Secretary of State for Health Department Richmond House 79 Whitehall of Health London SWIA 2NS POCS 922067 Tel: 020 7210 4850 Mr [ Singleton Assistant Coroner 2 4 MAR 2015 Wiltshire and Swindon Coroner' s Office 26 Endless Street Salisbury Wiltshire SPL IDP Qea( Sxxldr( Thank you for your letter following the inquest into the death of Richard Jones. [ was very sorry to hear of Mr Jones' death and wish to extend my sincere condolences to his family. You are clearly concerned about the current provision of mental health care for members of the armed forces. In addition, the circumstances of this specific case have prompted you to raise the following matters for our attention: the way in which information obtained from such patient is recorded, with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment; how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed 0n, particularly as to the level of risk and degree of urgency; and who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care. You ask for review of the policy and procedures in place to deal with referral to another agency ofa member of the armed forces who appears to be suffering from mental health issues, having to the above concerns Firstly, I would expect the mental health providers named in your report to provide comment on the detail of this particular case and to address your concerns from their local perspective. regard

The Ministry of Defence (MoD) has responsibility for the provision of primary care services for serving personnel. The MoD also provides additional mental health care for serving personnel delivered through fifteen military Departments of Community Mental Health (DCMHs) located in military centres in the UK, as well as centres overseas. DCMHs are staffed by psychiatrists, mental health nurses, clinical psychologists ad mental health social workers. The aim is to treat personnel with mental health needs at the unit medical centre and, with the patient's permission, involve the GP and senior officers in managing the condition. A wide range of psychiatric and psychological treatments is available; including medication, psychological therapies and change of environment where appropriate. Inpatient care; when necessary, is provided by the NHS in contract with the MoD. Service patients receive treatment much closer to their units than previously, when the armed forces operated their own psychiatric hospitals. A close relationship is maintained between local DCMHs and the NHS to make sure inpatient care is the best it can be. Where MoD services are unavailable serving personnel are able to use NHS services on an emergency basis in the same way as other NHS patients. Armed Forces veterans access NHS mental health services in exactly the same way as the wider population. In order to help and encourage Armed Forces veterans with mental health problems to seek care, NHS England has put in place 10 veteran mental health teams across England one of which is based in the South West. At a national level, the Department of Health (DH) works closely with the MoD and with NHS England to ensure that service personnel receive the right health services. Medical notes relating to an individual patient must pass readily from the MoD to the NHS and back again as appropriate. This will become increasingly important as the number of Armed Forces reservists is increased, as these personnel will access health services from the MoD when mobilised, and from the NHS at other times. Discussions are already in place between DH, MoD and NHS England on this issue and these will address the specific concerns you have raised in your report: In addition; the DH is in discussion with the MoD to secure MoD'$ commitment to the Mental Health Crisis Care Concordat: This is a national agreement between services and agencies involved in the care and support of people in crisis. It sets out how organisations will work together better to make sure that people get the help needed in mental health crisis. In February 2014,22 national bodies involved in health;

policing, social care, housing, local government and the third sector signed the Concordat: It focuses on four main areas: Access to support before crisis making sure people with mental health problems can get help 24 hours a and that when ask for help, are taken seriously: Urgent and emergency access to crisis care making sure that a mental health crisis is treated with the same urgency as a physical health emergency: Quality of treatment and care when in crisis making sure that people are treated with dignity and respect; in a therapeutic environment Recovery and staying well preventing future crises by making sure people are referred to appropriate services. Although the Crisis Care Concordat focuses on the responses to acute mental health crises, it also includes a section on prevention and intervention: The Concordat builds on and does not replace existing guidance. It is expected that the MoD commitment to the Concordat will be in place by the end of April 2015. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Mr Jones' death to my attention. G} h) DR DAN POULTER point day they they

Salisbury NHG NHS Foundation Trust Salisbury NHS Foundation_Trust Reponse_to_Regulation 28 Report Touching the death of Richard JeffreyJONES RECEIVED 2 0 APR 2015 Respondents Name & Position My name is Peter Hill and am the Chief Executive Officer at Salisbury NHS Foundation Trust (SFT) Purpose of the report have received the Regulation 28 report prepared by lan Singleton, Assistant Coroner for Wiltshire and Swindon, following the investigation into the death of Richard Jeffrey Jones who received treatment at Salisbury NHS Foundation Trust in October 2012 This response is required by 2oth April 2015, Introduction The inquest touching the death of Richard Jeffrey Jones concluded on the 27th January 2015. The Regulation 28 report, arising from the inquest expresses three concerns summarised as: a) As to the way in which information such patient is recorded, with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care_ Additionally, Mr Singleton asked us to review the policy and procedures that we have in place to deal with the referral to another agency of a member of the armed forces who appears to be suffering from mental health issues having regard to the above concerns_ Response_to Coroner' s Concern The_way_in_which information _from such patient is_recorded_with_especial reference_to the perceived level ofriskand the degree of_urgencyin carrying out an assessment Since the death of Mr Jones, and following review of the case in collaboration with AWP, an immediate action taken by SFT Emergency Department was to implement a new mental health risk assessment tool as recommended by the College of Emergency Medicine. This tool provides a more accurate assessment of the risk of suicide or self harm than the SADPERSON score we were previously using: It enables clinical staff to risk assess patients and document their prior to referring the patient to the mental health team with an indication of the appropriate urgency for their response. (Mr Jones fell within the low risk category using the old and new tools): The tool is from findings

Salisbury NNHS] NHS Foundation Trust contained in the 'ED Handbook' which contains clinical guidelines and is provided to all new clinical staff at their induction. The service for mental health patients is provided by Avon & Wiltshire Mental Health Partnership (AWP) on terms agreed with the Wiltshire Clinical Commissioning Group (CCG): A liaison psychiatry team is available 9am to Spm seven days week, and operates within standard operating procedures agreed by the Trust and AWP. All patients for assessment are discussed with the Iiaison team and a response timeframe agreed. During the operating hours of the service, emergency or high risk patients are seen within 60 minutes of referral: Outside the hours of operation of the liaison team the referral for high risk and medium/high risk patients is made to the on-call team who have a response time of 4 hours. Advice can also be sought from the on-call team for medium/low risk patients where there are persisting concerns about mental health issues preventing discharge. These services and the response that AWP the Iiaison service provide are detailed in the department Action Card' which has been agreed in collaboration with AWP . The mental health 'Action Card' will be included in the next edition of ED Handbook later this year. Action Summary _ Implementation of mental health risk assessment completed following review of case. Standard Operating Procedure amended in collaboration with AWP How _information is shared with other agencies involved in the_care of that patient to_ensure_that itis accurately passed on_particularly as tothe level of risk and degree of_urgency: The sad death of Mr Jones led to considerable reflection as to the way in which information is shared with other agencies: Within the hours of 9am and Spm assessment of mental health patients is made by the Iiaison psychiatry team: This team attends the ED on arrival in the morning to obtain referrals, review patient records and agree a timeframe for assessment: Telephone contact is made to the liaison team to make them aware of additional patients who attend the ED during the day and require assessment The liaison team have access to the patient's ED records including risk assessments completed: Outside of these hours telephone contact is made with the on-call team and agreed actions documented in the patient's ED record. To ensure robust recording of information to the out-of-hours AWP service proforma will be generated for clinician use: This will include information such as the assessed level of risk as per the mental health risk assessment tool, the agreed timeframe for assessment, the name of the accepting mental health practitioner, and other agreed actions from the telephone referral conversation The proforma will safeguard against any misunderstandings between an ED clinician to an AWP any

Salisbury NHS] NHS Foundation Trust mental health worker and vice versa_ Once completed, the information will then be faxed or emailed to an agreed secure number or address for AWP to place with the AWP patient record, and the original will be held within the ED patient record at SFT. This will be incorporated within the ED upgraded electronic system by the end of the vear SO that it can be transferred and stored electronically. Action Summary _ To implement the use of a 'Mental Health referral proforma' in collaboration with AWP. To include the proforma within the ED electronic system by the end of 2015. Who_has primary_responsibility for the care of that patient and_how that_is recorded bYallthose involved_particularly where there_is a transfer of care Whilst a patient is cared for within the ED the Duty ED Consultant has primary responsibility for them. Transfer of care occurs when the patient has been referred to and accepted by another speciality. The relevant consultant within that specialty then has primary responsibility for the patient: In the same way, the transfer of care from the ED to a mental health practitioner is made when a referral is accepted by the mental health liaison team or the on-call team Should the patient leave the ED before assessment by the mental health liaison team or on-call team, immediate steps are taken by staff in ED to safeguard the patient: An assessment is completed by the most senior clinician on duty at the time: Where a patient is assessed as high risk, action then might include calling security the police, and attempting to engage with the patient and/or next of kin. For both high and low risk patients SFT ED would make contact with the mental health team to inform them that the patient was no longer in the department on site and to them with the information available_ The follow up ofa mental health assessment for a patient who had absconded would be led by, and be the responsibility of, the specialist mental health team which had accepted the referral. The GP would also be informed ofthe patient' s failure to wait for assessment; As an additional safeguard, all patients who do not wait to be seen in ED are recorded as 'absconders' and reviewed the following day by the duty ED Consultant_ The assessment made and actions taken at the time are reviewed by this senior clinician who decides whether any further action is required_ Review the policy and procedures that are_in place_to dealwith the_referral toanother agency ofa member of the armed forces who appears to be suffering_from mentalhealth _issues_having regard to the above concerns SFT treats patients presenting with mental health needs in the same way, regardless of their employer background. Therefore referral occurs in line with the Standard Operating Procedure of referring all patients to mental health services at AWP as commissioned for US With regard to update

Salisbury NNHS] NHS Foundation Trust onward referral for a member of the armed forces we understand that this would be undertaken by AWP if required, as they have an established working relationship with the armed forces: discharge letter is sent by the ED clinicians to the relevant GP, whether civilian or military by background. Conclusion It is hoped that the measures detailed above will offer reassurance that Salisbury NHS Foundation Trust has addressed the matters of concern raised by Mr Singleton. We strive to continue to improve the service that we offer patients with mental health needs. The case of Mr Jones saddened the staff involved and those who attended the inquest: have all directly contributed to the improvements we have made since the incident in 2012, the inquest in 2015,and the Regulation 28 report: Peter Hil Chief Executive Officer Salisbury District NHS Foundation Trust They

Dear Mr Singleton , RE: Regulation 28 report to prevent future deaths Richard Jones Thank you for your letter of 20 February to Iregarding the unfortunate circumstances of Mr Jones' death: have been asked to reply on his behalf: Public Health England (PHE)s role in mental health is to help the public health system achieve 'public health parity' for mental health: An example of how we assist local authorities is the National Mental Health Dementia and Neurology Intelligence Network (NMHDNIN); help commissioners, policy makers and clinicians collate information and data on three pathways through health services that affect millions of people in England. This information is also available to the public, service users and their families_ am aware you have also written to the Department of Health (DH), and understand that DH, the Ministry of Defence (MoD) and NHS England (NHSE) work closely together to ensure that service personnel receive the right health services. These organisations are also aware of the need for effective patient note transfer between the MoD and the NHS: also understand that DH is in discussion with MoD to secure commitment to the Mental Health Crisis Care Concordat; and it is expected that MoD commitment to the Concordat will be in place by the end of April 2015. DH will continue their discussions with MoD and NHSE on this issue and these discussions will address the specific concerns you have raised in your report. Unfortunately, PHE are not in a position to advise on this matter further: Engl they

Finally, have been advised that the mental health providers named in your report are expected to provide comment on the detail of this particular case and to address your concerns from their local perspective.