Dear Mr Moore write in response to your letter dated 20th August 2013 in regard of Miss Ann Margaret Spearing (DOB 21.04.49) and your request made under Regulation 28, Report to Prevent Future Deaths, that the Clinical Commissioning Group responds setting out action taken or proposed actions with associated timescales_ In this letter we respond to your concerns on the following issues_ That multiple organisations were unable to provide an intervention that successfully managed her eating disorder and self-neglect That each organisations access criteria were exclusive rather than flexible or person-centred That there should be a mechanism to provide either a bespoke intervention or transferrable funding to ensure that patients receive appropriate interventions or treatments and that resources are not wasted Miss Spearing moved to Bristol in March 2011, 4 months prior to her death: Prior to this she had lived and received services over a long period of time South Gloucestershire_ The handover to Bristol services was satisfactory, however it was clear at the time of her move to Bristol that her general health and wellbeing had significantly deteriorated and that there were underlying issues that required skilled intervention to resolve_ With respect to the issues you have raised note below that the following actions have been taken together with the outcomes expect these actions to achieve Bristol has recently reviewed, redesigned and is currently re-procuring its specialist mental health and learning disability services_ This process was undertaken following consultation with users, carers and relevant professionals_ It was initiated in response to concerns by all parties that Bristol's mental health services were neither flexible or If you need this letter in a different format, please telephone the number under the address from

2 responsive and that there should be a greater bias towards prevention and providing support closer to the patient's own home: This process has meant that a significantly expanded range of services will be available October 2014_ These will include interventions for patients with complex presentations or medically unexplained symptoms such as Miss Spearing: We already have in place significantly expanded primary care based psychological therapies service, directly accessible by self or professional referral. We anticipate that the revised services will be more flexible in their approach and easily accessible with both characteristics being elements of their specification. We also expect partnership between General Practice and mental health services to be more effective as services will be more accountable to General Practice both operationally; and now that GP's commission the services, via the Clinical Commissioning Group For your reference further details on the range and breadth of services is available via the following website http ILWw bristolccgnhs_uklyour-health-local-services/mental health-wellbeinglthe-story-so-far aspx Recognising that some of these changes are almost a year away, we have also undertaken or are about to undertake the following changes during the interim to minimise the risk of a similar situation occurring: These include: The development of Primary Care Liaison; this service was implemented in 2012 as Single Point of Access to secondary mental health services across Bristol and provides: An effective triage service for people accessing services, determining in a timely fashion the most appropriate service response and ensuring that this response is in place quickly: Advice and support for primary care staff to manage service users mental health needs and determine whether a formal assessment is necessary Determination of the nature severity of mental health needs with consequent sign posting and pathway facilitation. Rapid and accessible on-going support & advice to the non-specialist workforce such as GPs A Primary Care Eating Disorder Service, known as 'First Step' , was launched in
2013. First Step is a primary care eating disorders service and acts as gateway to Trust's disorders care pathway. It delivers evidence-based treatments such as enhanced Cognitive Behaviour Therapy in all GP surgeries across Bristol. A Primary Care Psychotherapy Service which, following a successful pilot, is being implemented in Bristol. Importantly this service will support people such as Miss Spearing who may present with medically unexplained symptoms, or have diagnosis or characteristics of a personality disorder; who are not suitable for existing secondary mental health services or those who find it difficult to engage with such services. It will also work with patients with mental health problems who have been discharged from services or do not meet the referral threshold for current primary or secondary services Ifyou need this letter in a different format, please telephone the number under the address from key the put July the eating

This should reduce the number of people who have a mental health problem but who do not meet the criteria for more traditional mental health services and thus bulk of their care remains with their GP's without always appropriate levels of specialist mental health support: To further support GP's and provide timely advice with complex patients such as Miss Spearing, we have piloted an enhanced advice and guidance support scheme to GPs This includes regular clinician fora and reissuing GPs with contact details for psychiatrists within their local catchment area mental health teams This has led to an increase in GPs contacting their psychiatrist colleagues directly by phone and email with clinical queries that require advice but not necessarily referral into the triage service for assessment. This has been felt to be a significant improvement to prior arrangements There is further work aimed at supporting on-going communication between GPs and Bristol psychiatrists, including further service change to ensure all GP practices have a nominated psychiatrist can link to do hope that these changes will minimise the likelihood of a similar situation as Miss Spearing's occurring again and that if there are difficulties in professionals and patients accessing the correct support we will have better systems in place to escalate and resolve this_ was saddened to learn of the circumstances of Miss Spearing's death and hope that our actions above assure you that the Clinical Commissioning Group takes the issue of self-neglect seriously: