Dear Mrs Mason Re. Michael Anthony Tarratt Thank you for your letter dated 14" March 2014, with the enclosed Regulation 28: Report to Prevent Future Deaths; would reassure you that Leicestershire Partnership NHS Trust has carefully considered the concerns you have raised, and put actions in place to respond to them Your concerns am aware that you are concerned that: Despite evidence from the Drug & Alcohol team that it was appropriate to update the relevant GP every 3 months or at least every 6 months was accepted on this occasion that no contact had been made for 18 months Consideration should be given to more regular contact between the services providing treatment. Despite evidence that the GP prescription of Tramodol (for knee pain) was inappropriate for an opiate dependant patient, no contact was made with the GP surgery and it was left to the patient to tell his GP, There was no evidence to suggest thatMr Tarralt dia Inis; Consideration shouia be given rouline excilange information regarding prescriptions between services, to avoid one agency counter- acting the treatment another; Consideration should be given Uhe appropriateness of asking the patient to be responsible for this communication; Action Taken notification by way of urgent memo by email has been sent to all members of the Drug & Alcohol team that the agreed standard for communication and correspondence with patients GPs is that contact must be made with the GP After the initial assessment; this will be a summary of the structured treatment plan: Chair; Professor David Chiddick CIE Chiel Executive: [Jr Peter Miller Alou 4 81548149 Iike 0

Every three months as a minimum, or more often, if there has been a change to the treatment plan or a risk needs t0 be communicated At the end of contact when the patient is discharged from treatment: The Leicester Recovery Partnership's working draft Standard Operating Protocol (SOP) is under review and due for publication within the next few weeks relation to GP communication the SOP will state: GP letters Structured Treatment For GPs that refer their patients to LRP who are in drug or alcohol structured treatment we must send an assessment summary letter written by the assessor, the exception being when the comprehensive assessment has been completed in open accesslduty the assessment summary should then be completed by the RN or EP the case on after the first face t0 face appointment. If the service user does not attend this appointment we must still send summary and advise that we will be offering further appointments We must send GP review update letters every 3 month as a minimum or before if there is a change or risk and then at completion of treatment Open Access[Tier 2 We will not routinely send GP assessment summaries or updates for these service users but if we feel WE need to liaiselinvolve their GP at any other in treatment we need t0 discuss with the service user, obtain consent and send an assessment summary or update letter. enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent; These are due to be uploaded as of the configuration with SystmOne within the next 14 days. The subsequent phase of work that be completed by June 30" 2014 at the latest will include prompts reminders t0 practitioners when GP updates are due A case note audit is due t0 take place within the next 14 days and will include a review of GP correspondence. Audits will be completed every 6 months thereafter. This matter has also been discussed at the Operational Managers meeting to highlight the need to include in staff supervision any training requirements or ongoing monitoring Itwill also be included on the agenda of the next Neighbourhood Team meeting Please be reassured that Leicester Recovery Partnership takes ownership for ensuring exchange of information with GPs and the service user not responsible for this communication;