Dear Mr Williams Re: the late Eve Cullen Regulation 28: Report to Prevent Future Deaths write further to your letter dated 8 January 2015 in accordance with Regulation 28 of the Coroner's Rules in respect of the late Eve Cullen. confirm that the Trust conducted a serious review of this incident and acknowledge that there have been differences in how urgent referrals have been dealt with by the Trust in different parts of the county: The Trust is commissioned to provide mental health services in Worcestershire by three difference clinical commissioning groups; namely Redditch & Bromsgrove CCG Wyre Forest CCG and South Worcestershire CCG_ In terms of South Worcestershire , there are very clear protocols agreed with the Clinical Commissioning Group identifying the timescales for referrals made by general practitioners and other. professionals and having a standardised system for processing such referrals Unfortunately, it has not to date been the case that the same process applies in respect of the other areas in which the Trust provides services in Worcestershire however we are working with the North CCG's to address this, as it is our ambition to introduce standardised system across the County: The Trust is working towards performance measures for all categories of referrals and will incorporate into policy, which will distinguish between urgent and routine referrals with defined timescales for contact: Whilst there had been discussions in respect of this issue for some time, as a result of you bringing this matter to my attention; confirm that have taken action to improve processes in Redditch and Bromsgrove in respect of the timescales in which urgent referrals are dealt with. confirm that since receiving your correspondence the Trust has written to all general practitioners in Redditch & Bromsgrove on February 2015 identifying protocol for the referral of mental health patients and the timescales in which can be seen: This clarifies that referrals marked urgent should be triaged within 24 hours. The triage process may involve discussion with the referrer, a discussion with the individual andlor a face to face assessment 43 HANOZOJ "WN"H ~4i#' (34 `Za they

The referral will be received by the CMHT worker; who will agree with the referrer a timescale for response All referrals agreed as requiring an urgent response will be seen for a face to face assessment within 24 hours_ The CMHT duty worker will agree with the referrer what actions the CMHT will take and how any outcomes will be reported. The CMHT will contact the patient to discuss the referral and make arrangements for the assessment to be completed Whilst this process has recently been implemented, data is gathered to enable a review to assess effectiveness and to identify any issues. A similar process is being implemented in Wyre Forest. When the assessments of 14 and 15 were referred to the CMHT these were noted as requiring assessment within a week; unfortunately this did not happen within that timescale due to a lack of clarity about timescales_ Whilst I recognise that tragically, these changes have come too late for Mrs Cullen, confirm that will be writing to to outline the information provided to yourself and to offer my apology for the confusion in respect of the referral to the community mental health team in respect of his wife's care_ One issue that do need to raise with you is in respect of the referral from the Queen Elizabeth Hospital dated July 2014 which you did not believe had been actioned by the community mental health team. Having reviewed this matter; it was clarified that the referral dated 4 July 2014 was received by the community mental health team on 11 July 2014. Discussions with the Queen Elizabeth RAID (rapid assessment interface, discharge) confirmed that at the point of the referral urgent follow-up was not indicated, as a result the referral was due to be reviewed by the weekly multidisciplinary team meeting: Clearly, by 14 July 2014 the situation had changed and Mrs Cullen's presentation appeared to be more worrying and this was where there was further opportunity for a fuller assessment, it was due to a lack of clarification about timescales that the assessment unfortunately did not occur prior to Mrs Cullen leaving home on 17 recognise that the Trust did not ensure that you had all the appropriate evidence available at the inquest in respect of the initial involvement of the CMHT. As you are aware the Trust has recently recruited a new Company Secretary who will be leading on inquests, and will be seeking to ensure that you are provided with appropriate information to enable you to conduct a full inquiry into the circumstances of deaths_ am confident that the new system adopted in Redditch and Bromsgrove will bring into line the processes that currently operate in the south of the county and appear to operate in smooth manner. would like to thank you for drawing this matter to my attention and hope that you feel the Trust has addressed the issue appropriately. confirm that will write personally to explaining what action has been taken: