Dear Miss Cartwright LQUISE SHARONHENRY DATE OFDEATH: 2 APRIL 2013 DATE QFEJJNQUEST: 2 5 DECEMBER 2014 This response has been prepared by Derbyshire County Council and Derbyshire Healthcare NHS Foundation Trust as a result of HM Coroner issuing report under para 7 schedule 5 of the Coroners' and Justice Act 2009 and regulations 28 and 29 of the Coroners' (Investigations) Regulations 2013. During the course of the inquest the evidence revealed matters giving rise for concern to the Assistant Coroner In her opinion, there is a risk of future deaths occurring unless action is taken The matters of concern identified by the Assistant Coroner for both Derbyshire County Council "the Council") and Derbyshire Healthcare NHS Foundation Trust (DCHFT) to address can be summarised as follows: Lack of understanding amongst professionals regarding roles and responsibilities Failures within the discharge process Misunderstanding regarding the responsibility of the "Recovery Team" 1P a g e c Re

The Council and DCHFT have carefully considered the contents of the Regulation 28 report together with the evidence heard at the inquest and reviewed the matters referred to with senior managers within DCHFT. Whilst the Council and the DCHFT are keen to address the areas of concern identified by the Assistant Coroner; it is of the opinion that some knowledge of the historical context of the service is useful in terms of identifying corrective actions_ Background Mental Health Service Provision in Derbyshire The service has undergone extensive development since 2013. Historically, adult health and social care mental health services were organised and managed as an almost fully integrated programme in Derbyshire. Social workers employed by the Council were based in the same buildings as the nurses and health care professionals employed by the Trust. Over time this resulted in the social workers taking on responsibility for monitoring mental health, medication regimes and medical care planning: The national policy focus on the personalisation of adult social care services had the effect of returning the integrated organisation and management of mental health services to two separate organisations that had the capacity to collaborate and co-work cases: This meant that social workers could return to focusing on social care needs and the mental health professionals could more directly focus upon specific mental health interventions: This organisational adjustment started in 2011 and involved great deal of upheaval. It was difficult time for the personnel involved and it is acknowledged by the Council that there was, for time, some uncertainty about the division of roles and responsibilities Senior management at the Council and DCHFT addressed this by reviewing expectations and planning for the future_ However, it is often the case that it can take some time to embed new organisational arrangements, and policies and procedures into practice, especially after an extensive alteration to the service_ team of managers from both the Council and DCHFT negotiated the new roles for each element of the service_ Attached herewith is copy of document titled "Referrals from Derbyshire Healthcare NHS Foundation Trust to Derbyshire County Council (Appendix
1). This document sets out in section 1 the agreed division of responsibilities where the case is social care led: 2 |P a g e

In January 2012, the overall caseload dealt with by the Mental Health Service (both health and social care) was divided by service user primary needs_ Those who were deemed to have primary social care needs were allocated social worker as their lead professional_ Those with primary mental health needs were allocated a healthcare lead professional (referred to by healthcare as a Care Coordinator): Miss Henry was deemed to have a greater need for social care support at the time and that is why MN, employed by the Council as social worker and Approved Mental Health Professional was allocated as her lead professional: continued in the role of Miss Henry's Consultant Psychiatrist to monitor her mental health with annual Care Programme Approach ("CPA") reviews and amend medication as required_ Taking into account this historical context and following discussions with the Trust; the Council's proposed actions for addressing the 3 areas of concern identified by the Assistant Coroner are set out below: MATTER OF CONCERN 1 ROLES AND RESPONSIBILITIES The evidence presented to the Assistant Coroner indicated the following areas of concern: The Community Mental Health Team, including the Psychiatrist, did not understand the roles and responsibilities (including the correct procedure) undertaken by the Council's "Recovery Team' There was lack of clarity as to whether the social worker was following the Care Programme Approach or Self Directed Support ("SDS") framework There may be an ambiguity as to who acts as "Care Co-ordinator. In order to address these concerns the Council and DCHFT intend to review:- ACTIONS 1_ The case of Miss Henry demonstrated that there was misunderstanding amongst professions as to roles and responsibilities of mental health services workers_ The Council and DCHFT intend to review this matter at the forthcoming "Service Manager Interface Meeting" to be held on 27 March 2015. This is a joint meeting between the Council and DCHFT. The clarification of respective roles and responsibilities of mental health and social care workers will be the focus of these discussions_ 3 | P a g e her

2 Preliminary discussions have already taken place between Health and Social Care senior managers about the interface between CPA and SDS. Both organisations are clear that the two policies are intended to be complementary. It is acknowledged there may be cases where the individual is subject to CPA but where social worker is the lead practitioner: The Council is clear that in following SDS, this will also fulfil the requirements of CPA. A plan involving senior managers from both organisations has been agreed to update the DCHFT Care Programme Approach Policy to provide clearer updated guidance upon this issue 3 Within the Council it has been acknowledged that there needs to be sound understanding of what our services do and how do work together to support those people in need of skilled care and_support. The Council therefore plans to place feature about the Fieldwork (Mental Health) (formerly known as the Recovery Team in the next Practice Bulletin which we shall distribute to all teams including the Children and Younger Adults Department and the Trust This will also serve to publicise the rebranding of the team described below. This information will also be shared with DCHFT colleagues. The Council has also established that there is still some work to be done in terms of education for health and social care workers on the expectations of each service pathway: The outcomes of the Service Manager Interface Meeting described above will be cascaded down to staff via line management supervision: MATTER OF CONCERN 2 DISCHARGE PROCESS The evidence presented to the Assistant Coroner indicated the following areas of concern: Discharge letter to the GP did not identify risk relapse triggers This could impact on the potential for reassessment in the case of subsequent deterioration in mental health In order to address these concerns, the Council has in place the following actions: ACTIONS COUNCIL 1 The Council is clear that the discharge arrangements set out in its Self- Directed Support ("SDS") policy must be properly applied in every case This is the policy relevant to social workers, NOL the Care Programme Approach ("CPA") although are intended to be complementary Adherence to this policy ensures that following the decision to discharge someone social care support they are properly informed as to the reasons for this decision and any alternative sources of support: 2 The Council is satisfied that since Miss Henry's death_ the SDS framework has been further embedded into social work practice and all discharges are more structured and robust.
3. The service user will have a review to discuss whether they feel that continue to require support If they are discharged, receive 4|P a g e they put they from they they

written discharge plan explaining that have been discharged from the service_ The letter also contains the contact numbers for those agencies continuing to provide care and also information on what to do if feel that require support in the future: This letter is shared with all of the agencies involved s0 that there is a clear and agreed plan of discharge. A copy is also sent to the GP. Enquiries are made of the service users as to what plans have in place to manage to crisis This will be included in the discharge plan. The Council has initiated a review of how Adult Care Mental Health workers manage risk within service_ A Task and Finish Group was set up in January 2015 to ensure social workers work consistently and robustly in managing risk to include compliance with SDS procedures including where person is discharged This Group will also work collaboratively with the Trust and other Health colleagues where appropriate: In addition, the Council intends to email all relevant fieldwork staff with a reminder of the SDS processes, particularly the arrangements to be followed on discharge. 5_ The Council is satisfied that; if applied correctly, the existing policy would ensure that upon discharge a letter would be written to the client's GP setting out the reasons for the discharge decision and would identify any risk triggers and indicators to ensure that there would be re- assessment and possible reinstatement of support if there are signs of a deterioration in mental health: 6 To ensure there is consistency across all cases, an audit will be undertaken in respect of a sample of recently closed cases to confirm adherence to the SDS discharge procedure. This will better infom Adult Care senior management as to whether further staff training is required. ACTIONS DCHFT 7 staff briefing has been circulated raising awareness relating to this issue across DCHFT . 8 A plan has been agreed to update the Care Programme Approach and Discharge, TransfersMTransition Policy to provide clearer updated guidance upon discharge planning particularly in relation to communications with GPs. 9 The issue will be raised at the Trust Medical Advisory Committee to raise awareness with all DCHFT psychiatrists 5 |P a g e they they - they they the Policy

10_ A benchmarking_audit_and follow up audit of discharge letters is to be conducted by
11. On completion of the audit; review of the discharge letter format available within the PARIS system will take place and it will be amended accordingly. templates will be configured which will alert GPs to information should enter onto the 'special patient notes' facility: MATTER OF CONCERN 3 USE OF TERM "RECOVERY TEAM" The evidence presented to the Assistant Coroner indicated the following area of concern: 2 services using the term "recovery team" namely the Council and the Trust's Community Mental Health Team (often referred to as the "CMHT") could lead to confusion amongst both professionals and service users_ In order to address this concern the Council intends to do the following: ACTIONS 1_ The Council accepts that 2 teams from different agencies being called the same name could lead to confusion: The Council therefore intends to "rebrand its recovery team as "Fieldwork (Mental Health)" . This reflects the description given to the other, generic social care teams which are known as Fieldwork teams_ 2 This renaming of the team will be launched by the Council at the next scheduled Social Care Forum on 24 March 2015. It will be on the next Practice Bulletin which be distributed to all Adult Care and Children and Younger Adults staff within the Council as well as health colleagues It will also be put before the forthcoming Health and Social Care Interface meeting on 27 March 2015. ACTIONS DCHFT DCHFT is currently undergoing a transformation and is in the process of developing Neighborhood community provision. It is likely that within this process the term Recovery Team no longer be used. New terminology ,will be in place by November 2015 and DCHFT will be mindful of the need for clarity between organisations_ 6 | P a g e New they put will will

The Council and DCHFT recognise the issues that were raised. during the Inquest and your subsequent Regulation 28 notice and we hope this response and subsequent work we have jointly planned will satisfy you that we have taken these issues seriously and will do our utmost to further develop and strengthen our policies and procedures for the future

Dear Colleague Re: Special Patient Notes and Right Care Plans have been asked to remind you about the use of Special Patient Notes and, where available_ Right Care Plans particularly in relation to patients with mental health conditions following a Regulation 28 report to prevent future deaths from the Coroner's Office. At a recent inquest the Derbyshire Assistant Coroner heard that the Out of Hours service did not have access to any information relating to a patient with a serious mental health condition In particular, there was no information regarding relapse triggers or a clear plan of action in the event of a significant relapse Had this information been available to the Out of Hours service it would have meant that the clinicians involved would have been better placed to risk assess the patient and it is possible that a tragic death may have been avoided. Following receipt of this report a review of information sharing with one Out Of Hours provider showed that of 444 new plans only 29 related solely to mental health conditions. The vast majority of plans were for complex medical conditions_ This suggests that Special Patient Notes and Right Care Plans are less frequently completed for patients suffering from significant mental health problems and that this situation could be improved recommend that practices review their Serious Mental Illness registers to ensure that appropriate patients are identified that should have information shared with Out of Hours providers. Clearly patients such as the one in this case who have clear relapse triggers or indicators that their condition is deteriorating putting them at risk of harm should have this information shared. understand that the Medical Interoperability Gateway has been introduced in parts of Nottinghamshire and will be rolled out to the rest of the county and also across Derbyshire_ This allows access, with patient consent; to read coded information in the patient's medical record: This in time should improve record sharing_

would be grateful if you would review your patients with serious mental health conditions to ensure appropriate information is available to Out of Hours services to allow them to effectively manage such patients_