Barbara Woodman

Dear Mr Stewart

Barbara Woodman (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) and Surrey County Council

Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 22nd December 2023, in relation to the inquest touching the death of Barbara Woodman. We have considered the report carefully, together with senior officers within both organisations.

In the PFD report, you highlighted a concern relating to the use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.

The purpose of a Single Combined Assessment of Risk Form (SCARF) is to enable Surrey Police to inform services where they have had contact with an adult who is considered to be vulnerable and/or at risk. It provides information to partner agencies and will often add to the information that the Trust already holds about a person. This could inform further actions that might be taken by the Trust which may include revisions to assessments or care plans.

A SCARF is not designed to be used to access crisis support or as an out of hours referral tool. The Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s may use. This operates 365 days a year, 24 hours a day. In addition, there is a dedicated Professionals Line phone number, which also operates 365 days a year, 24 hours a day, which can be accessed by Surrey Police and South East Coast Ambulance Service where an urgent discussion is required. This allows emergency services to request critical information in an immediate timeframe to help inform decisions about people they have come into contact with.

Within Surrey County Council the Emergency Duty Team (EDT) operates out of normal office hours 7 days a week, 365 days a year, this includes cover for all bank holidays including Christmas and New SABP NHS Foundation Trust 18 Mole Business Park Randall’s Road Leatherhead KT22 7AD

Woodhatch Place 11 Cockshot Hill Reigate RH2 8EF

15 February 2024

Private and Confidential

Year. Any referrals or concerns from the police that require an immediate response there is a clear, well known and well used process for officers, in that they must make contact with either the Emergency Duty Team or nominated social worker, outside of PSPA hours. There should be no need to use a SCARF and a SCARF should only be used where the situation has been left in a way that it is suitable for the sharing to be delayed until the next day or over the weekend. In 2023 the EDT recorded 140 contacts from the Police directly to them.

We work collaboratively with partner agencies to review and improve our joint working processes. In relation to SCARF procedures, representatives from the Trust most recently met with Surrey County Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review of our cross agency SCARF process. As part of this consideration will be given as to how information is shared between agencies and family/carers alongside issues of confidentiality and consent.

The Community Mental Health Recovery Services, which operate Monday to Friday, 9am to 5:00pm, carry out a screening process in respect of SCARF forms received. Appropriate action will then be taken based on the information provided and the risk profile of the person this relates to.

In relation to your concern relating to the lack of a unified record keeping system allowing sharing of patient information between different components of the NHS, including primary and secondary care providers, you have also addressed the report to the Chief Executive of NHS England who will be best placed to respond to this concern.

On behalf of the Trust and Surrey County Council, we would like to offer our sincere condolences to Ms Woodman’s family for their loss. We hope that our actions outlined above assures you and Ms Woodman’s family that we have reflected on your concerns and provided reassurance as to our processes.

Dear Coroner

Re: Regulation 28 Report to Prevent Future Deaths – Barbara Ann Woodman who died on 31 March 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 22 December 2023 concerning the death of Barbara Ann Woodman on 31 March 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Barbara’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Barbara’s care have been listened to and reflected upon. 

In your Report you raised the concern that there is a lack of unified record keeping which allows for the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes across Integrated Care Services (ICS) boundaries. The NCRS provide access to the Summary Care Record (SCR) which is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines. It is created from GP medical records - whenever a GP record is updated, the changes are synchronised to the SCR. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient's direct care but do not need access to the patient's full record, provided that the patient has given their permission. The approved care settings to view SCRs include mental health care settings. The SCR Team are also currently undertaking trials with other care settings, including within private hospitals and privately funded healthcare services, with a view to working towards seeking national full roll out approval. Details of long-term conditions, significant medical history, or specific communications needs are now included by default for patients within an SCR, unless they have previously told the NHS that they did not want this information to be shared. For more information, and to illustrate the type of content included in an SCR, an example SCR is available here: Additional Information in the SCR National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

4th March 2024

Additional Information in the SCR could include mental health conditions (e.g. bipolar disorder) or previous psychotic or self-harm episodes where these have been recorded in the patient’s GP record. The SCR does not contain any documents (e.g. a mental health care plan or mental health crisis plan) but the SCR can act as a signpost to clinicians to seek further information from other teams involved in a patient’s care. The Direct Care APIs programme (formally GP Connect) also supports care co- ordination both through their send document / update record capability and through their access record HTML and structured capabilities. Each of the services providing care to this patient would be expected to provide updates to the patient’s registered GP. Thus, the correspondence back to the patient’s registered GP and current and future mechanisms to share documents / correspondence / updates from the GP record would also act to support care co-ordination for similarly vulnerable patients. Another record system which should aid the sharing of health information between different organisations is the Shared Care Record. This joins up information based on an individual rather than an organisation and is a safe and secure way of bringing an individual’s separate records from different health and care organisations together.  As of 2021, all primary and secondary care organisations have been able to share a subset of the patient information they hold – the core information standard – between providers within their own Integrated Care Board (ICB) footprint. There is now a target to achieve national interoperability (read only) between all Shared Care Records in England by March 2025. This project will ensure that any authorised health and care professional can have safe, secure and ready access to the person-based information they need to deliver high quality individual (direct) care. NHS England would refer you to Surrey Police, County Council and Surrey & Borders Partnership Trust (SABP) on your second concern relating to the use of the SCARF process during out of hours. NHS England has been sighted on and notes the response sent to the coroner by SABP and the County Council, detailing their mental health crisis support services. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.