Norfolk and Suffolk NHS Foundation Trust

Noted (AI summary) Norfolk and Suffolk NHS Foundation Trust states that the NHS 111 Mental Health Option telephone support line is not commissioned to provide medication prescriptions and refers to its Management of Medicines Policy; it also says it has implemented a new Standard Operating Procedure for mental health liaison teams within acute hospitals. DHSC states that the NHS England National Specialty Advisor for Mental Health Pharmacy will write to mental health Chief Pharmacist colleagues across England requesting that they ask local systems and prescribing committees to review their local mental health prescribing policies.

Noted (AI summary) NSFT has asked all clinicians that receive referrals into services to identify those where treatments have been recommended by non-NSFT clinicians in order to offer an assessment prior to signposting elsewhere. CYP staff will be reminded that a referral ought to be made, staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, Legal Services, when accepting a new case from CYP, shall be required to discuss with social workers any relevant vulnerabilities relating to the parent(s) and a referral has been sent to the Community Safety Partnership for consideration for a domestic homicide review of this case. Norfolk and Waveney ICB states that they have reviewed their Mental Health Individual Funding Request records and have not been able to identify any Individual Funding Request being made to them on behalf of Ms Madden, for Schema-based Cognitive Behavioral Therapy. Suffolk Constabulary notes the concerns raised but states that they conduct their own risk assessments when delivering Claire’s Law disclosures, which would include the wellbeing of the recipient of that disclosure and the delivery was conducted in accordance with policy and appropriate aftercare. The ICB will work with partners to ensure that learning and action is taken forward from this case, and the Trust has asked all its clinicians that receive referrals into mental health services to identify those where treatments have been recommended by clinicians from outside the Trust in order to offer an assessment prior to any decision being made on the most appropriate way forward. The Home Office acknowledges receipt of the report and restates commitment but describes no specific actions taken or planned.

Noted (AI summary) NHS England acknowledges the concerns and refers to actions taken by Norfolk and Suffolk NHS Foundation Trust, including a Quality Improvement Programme, re-evaluation of training, a new SOP, and changes to the Patient Safety Screening Form. They also describe the PSIRF and its aims. Following concerns raised, the Trust has added prompts to the patient safety screening form to consider retrieving patient calls for investigation and inquest purposes. Additionally, they have extended their current recording facility in one of their CRHTT areas which went live on 15th May 2024 and have enabled phone lines designated as requiring a recording facility.

Noted (AI summary) Hellesdon Hospital has implemented a complete ban on plastic bags, improved communication to families and carers, and put safeguards in place to disrupt the passage of restricted items. The Department of Health and Social Care acknowledges the concerns, mentions actions taken by the Norfolk and Suffolk NHS Foundation Trust, points to a safety alert published in 2011, and outlines progress in reducing suicides.

Noted (AI summary) NSFT expresses condolences and explains their limited involvement in Terrence Tuttle's care, stating they can only respond to one part of the coroner's concerns related to mental health liaison. They provide details of the mental health liaison team's involvement, assessments, and medication adjustments during his admission, highlighting communication and planned reviews.