Leeds and Yorkshire Partnership Foundation Trust and Leeds Survivor Led Crisis Service
Action Taken
Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis Service have jointly developed a standardised daily handover template and implemented daily 'huddle' meetings for patients admitted to the respite facility. Additional measures include joint referral points, book-in meetings, joint reviews, weekly interface meetings, recommencement of operations meetings, and Clinical Improvement Forum meetings. (AI summary)
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Dear Ms Benyounes
RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Christian Barry Marsh, (Deceased)
Thank you for the correspondence regarding the outcome of the inquest touching upon the death of Mr Christian Barry Marsh. We would firstly like to take this opportunity to express our sincere condolences to Christian’s family and friends at the tragic death of Christian.
Following the Regulation 28 Report to Prevent Future Deaths issued on the 16th of September 2025 to Leeds and York Partnership NHS Foundation Trust (LYPFT) and Leeds Survivor-Led Crisis Service (Leeds Oasis), please find below the details of our joint response to address the concerns raised.
The Matter of Concern within the Regulation 28 report are below in bold text with our response following:
There remains no system for formal communication, sharing and handover of information about patients who are admitted to the respite facility operated by Leeds Survivor-Led Crisis Service, but remain under the clinical care of the Intensive Support Service at Leeds and York Partnership NHS Foundation Trust. It was candidly accepted in evidence that there needs to be an improvement in communication channels and information sharing for the partnership to run efficiently and effectively and to mitigate risk.
1. Standardised Daily Handover and implementation of daily ‘huddle’ meeting
• A standardised daily handover template has been developed to ensure key clinical information is captured in a standardised format. The handover document is completed daily for all patients by the Oasis team and includes
demographic information. It also records whether the person is a guest, meaning they are using overnight accommodation or a visitor, who attends during the day only. Additional fields include whether a 48-hour review is required, any LYPFT tasks that need to be actioned, incidents that have occurred in the past 24 hours, comments for the multi-disciplinary team (MDT), and whether a call back or joint review is needed.
Once completed, the handover sheet is emailed to the appropriate LYPFT Crisis Resolution Intensive Support Service (CRISS) team. There are three locality teams East, South, and West, and the handover is sent to the corresponding area in which the individual is currently receiving care. The shift coordinator within the CRISS team is responsible for accessing this information and ensuring this is taken for discussion in the daily ‘huddle’ meeting as described below.
• A daily ‘huddle’ has been established to provide dedicated time for the Oasis staff and registered staff member from CRISS team to come together and discuss the information contained within the handover document. This meeting is held via Microsoft Teams and takes place prior to the daily LYPFT Multi- Disciplinary Team (MDT) meetings, enabling immediate actions and queries to be addressed.
Through implementing this process, it has ensured timely and accurate information sharing between the two services, supporting continuity of care and effective clinical decision-making.
2. Multidisciplinary Review Meetings
• An MDT meeting (Multi-Disciplinary Team meeting) is a structured gathering of professionals from various disciplines who collaborate to discuss and plan care for individuals. These meetings are essential for ensuring holistic, coordinated, and person-centred care. LYPFT MDT meetings are held daily in each locality: East, South & West, and are attended by LYPFT staff including and not restricted to Consultant Psychiatrist, Psychologists, Mental Health Nurses, Occupational Therapists and Support Workers.
• To strengthen the sharing of information between the two services, the shift coordinator within CRISS is now responsible for ensuring the handover information from Oasis is brought into the MDT.
3. Documentation improvements
• Oasis records the handover details and any required actions on their own system.
• LYPFT adds Oasis handover notes to the patient’s LYPFT care record as well as a full record of the MDT discussion and any required action.
4. Real-Time Communication Channels
• “Real time” communication will continue with Oasis staff able to contact LYPFT staff by telephone to aid timely updates and queries.
5. Training and Governance
• Training on the use of the handover sheet will be provided to ensure all are aware of the roles and responsibilities in each organisation.
• We will monitor compliance and effectiveness through audits and feedback mechanisms.
In addition to the above, the CRISS team at LYPFT and Oasis staff are exploring the possibility of Oasis staff having access to LYPFT’s electronic patient record. This will be taken for further discussion through the operations meeting (described below).
We would also like to take this opportunity to describe the escalation processes and monitoring we currently have in place to ensure formal communication, risk management, and information sharing for patients admitted to the respite facility: Referral Point – jointly attended by LYPFT and Oasis staff to share, handover, and discuss issues of patient risk at the point of referral.
Book-in Meeting - jointly attended by LYPFT and Oasis staff to facilitate discussion and sharing of patient risk-related concerns at the point of admission.
Joint Reviews - conducted jointly by LYPFT and OASIS staff at 48 hours, 96 hours (if applicable), and 144 hours (if applicable) to ensure ongoing review and management of patient risk during their stay. Interface Meeting - held weekly between LYPFT and Leeds Oasis to discuss and share information and concerns around patient risk. Operations Meeting – previously held monthly and attended by members include staff from LYPFT, Leeds Oasis and Integrated Care Board (ICB). The meeting provided a forum to escalate risks impacting patient safety and service delivery. The meeting allowed strategic operational oversight and will recommence in November 2025.
Clinical Improvement Forum (CIF) Meetings – a monthly meeting that forms part of LYPFT clinical governance structures is attended by Leeds Oasis management to provide additional oversight and communication.
We would be pleased to provide any further information or clarification required. If you feel that a meeting with staff to discuss any of the above would be helpful, please do not hesitate to contact us.
I hope this response provides assurance of improvement, consistent with the concerns highlighted in the Regulation 28 and we thank you for the opportunity to further reflect on the learning following the sad death of Mr Marsh.
RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Christian Barry Marsh, (Deceased)
Thank you for the correspondence regarding the outcome of the inquest touching upon the death of Mr Christian Barry Marsh. We would firstly like to take this opportunity to express our sincere condolences to Christian’s family and friends at the tragic death of Christian.
Following the Regulation 28 Report to Prevent Future Deaths issued on the 16th of September 2025 to Leeds and York Partnership NHS Foundation Trust (LYPFT) and Leeds Survivor-Led Crisis Service (Leeds Oasis), please find below the details of our joint response to address the concerns raised.
The Matter of Concern within the Regulation 28 report are below in bold text with our response following:
There remains no system for formal communication, sharing and handover of information about patients who are admitted to the respite facility operated by Leeds Survivor-Led Crisis Service, but remain under the clinical care of the Intensive Support Service at Leeds and York Partnership NHS Foundation Trust. It was candidly accepted in evidence that there needs to be an improvement in communication channels and information sharing for the partnership to run efficiently and effectively and to mitigate risk.
1. Standardised Daily Handover and implementation of daily ‘huddle’ meeting
• A standardised daily handover template has been developed to ensure key clinical information is captured in a standardised format. The handover document is completed daily for all patients by the Oasis team and includes
demographic information. It also records whether the person is a guest, meaning they are using overnight accommodation or a visitor, who attends during the day only. Additional fields include whether a 48-hour review is required, any LYPFT tasks that need to be actioned, incidents that have occurred in the past 24 hours, comments for the multi-disciplinary team (MDT), and whether a call back or joint review is needed.
Once completed, the handover sheet is emailed to the appropriate LYPFT Crisis Resolution Intensive Support Service (CRISS) team. There are three locality teams East, South, and West, and the handover is sent to the corresponding area in which the individual is currently receiving care. The shift coordinator within the CRISS team is responsible for accessing this information and ensuring this is taken for discussion in the daily ‘huddle’ meeting as described below.
• A daily ‘huddle’ has been established to provide dedicated time for the Oasis staff and registered staff member from CRISS team to come together and discuss the information contained within the handover document. This meeting is held via Microsoft Teams and takes place prior to the daily LYPFT Multi- Disciplinary Team (MDT) meetings, enabling immediate actions and queries to be addressed.
Through implementing this process, it has ensured timely and accurate information sharing between the two services, supporting continuity of care and effective clinical decision-making.
2. Multidisciplinary Review Meetings
• An MDT meeting (Multi-Disciplinary Team meeting) is a structured gathering of professionals from various disciplines who collaborate to discuss and plan care for individuals. These meetings are essential for ensuring holistic, coordinated, and person-centred care. LYPFT MDT meetings are held daily in each locality: East, South & West, and are attended by LYPFT staff including and not restricted to Consultant Psychiatrist, Psychologists, Mental Health Nurses, Occupational Therapists and Support Workers.
• To strengthen the sharing of information between the two services, the shift coordinator within CRISS is now responsible for ensuring the handover information from Oasis is brought into the MDT.
3. Documentation improvements
• Oasis records the handover details and any required actions on their own system.
• LYPFT adds Oasis handover notes to the patient’s LYPFT care record as well as a full record of the MDT discussion and any required action.
4. Real-Time Communication Channels
• “Real time” communication will continue with Oasis staff able to contact LYPFT staff by telephone to aid timely updates and queries.
5. Training and Governance
• Training on the use of the handover sheet will be provided to ensure all are aware of the roles and responsibilities in each organisation.
• We will monitor compliance and effectiveness through audits and feedback mechanisms.
In addition to the above, the CRISS team at LYPFT and Oasis staff are exploring the possibility of Oasis staff having access to LYPFT’s electronic patient record. This will be taken for further discussion through the operations meeting (described below).
We would also like to take this opportunity to describe the escalation processes and monitoring we currently have in place to ensure formal communication, risk management, and information sharing for patients admitted to the respite facility: Referral Point – jointly attended by LYPFT and Oasis staff to share, handover, and discuss issues of patient risk at the point of referral.
Book-in Meeting - jointly attended by LYPFT and Oasis staff to facilitate discussion and sharing of patient risk-related concerns at the point of admission.
Joint Reviews - conducted jointly by LYPFT and OASIS staff at 48 hours, 96 hours (if applicable), and 144 hours (if applicable) to ensure ongoing review and management of patient risk during their stay. Interface Meeting - held weekly between LYPFT and Leeds Oasis to discuss and share information and concerns around patient risk. Operations Meeting – previously held monthly and attended by members include staff from LYPFT, Leeds Oasis and Integrated Care Board (ICB). The meeting provided a forum to escalate risks impacting patient safety and service delivery. The meeting allowed strategic operational oversight and will recommence in November 2025.
Clinical Improvement Forum (CIF) Meetings – a monthly meeting that forms part of LYPFT clinical governance structures is attended by Leeds Oasis management to provide additional oversight and communication.
We would be pleased to provide any further information or clarification required. If you feel that a meeting with staff to discuss any of the above would be helpful, please do not hesitate to contact us.
I hope this response provides assurance of improvement, consistent with the concerns highlighted in the Regulation 28 and we thank you for the opportunity to further reflect on the learning following the sad death of Mr Marsh.