Kirsty Taylor

Kirsty Clare Taylor

Regulation 28: Report to Prevent Future Deaths

28 July 2023

Hampshire and Isle of Wight Integrated Care Board (ICB) Response

Issue - The facts in this case have highlighted that progress on initiatives and connectivity between services is still too little and too slow. More needs to be done, and with greater integration.

1. Creation of all-age community and mental health Trust

In February 2022, was commissioned by the Hampshire and Isle of Wight Integrated Care System (HIOW ICS) to undertake an independent review of community and mental health services and to identify further opportunities for collaboration and integration. Evidenced by this review is the unwarranted variation in practice, and fragmented pathways, making services difficult to navigate and consequently people don’t consistently experience high- quality, person-centred care that meets their needs. The Trusts recognised this was a key challenge that could not be addressed by any one organisation.

The review was completed in April 2022 and one of the five key recommendations was that a new Trust should be established to oversee delivery of all community and mental health services across Hampshire and Isle of Wight (HIOW). The ICB formally endorsed the recommendations at a public meeting in October 2022. Subject to final ICB, NHS England and Secretary of State approvals, the new all-age Trust will go-live 1 April 2024. A move towards integrated all-age mental health service provision will:

Better meet the needs of our patients:

• Reducing unwarranted variation for patients.
• Overcoming the fragmentation across services and especially during transition from child to adult services.
• Establishing consistency of care regardless of age.
• Enabling a more joined up approach to physical health and mental health care.
• Embracing population health management and working closer with local system partners.

Improve safety:

• Ensuring no one falls between our services, particularly during transition from child to adult, building seamless all-age pathways of care.
• Ensuring responsive high-quality care is delivered by an appropriately skilled workforce.

Improve efficiency:

• The efficiencies of a larger single Trust will contribute towards addressing the unwarranted variations in access and outcomes for some of our population.
• Creating a more sustainable workforce by removing barriers around workforce mobility and creating a single, shared workforce plan and vision.
• Improving the ability to manage capacity according to need & respond to system pressures.
• Enabling at-scale or fragile services to operate at the appropriate scale, for example psychiatric liaison services within Acute Hospitals.

2. Autistic Spectrum Condition (ASC) and Attention Deficit Hyperactivity Disorder (ADHD) pathway developments

The existing assessment and prescribing pathways for Autism and ADHD are reflective of historical commissioning arrangements with a total of 11 organisations providing NHS assessment services under 25 contracts/agreements across HIOW. The ICB is currently in the process of re- commissioning these services to provide a more cohesive assessment and prescribing offer for the population of Hampshire and the Isle of Wight from 1 April 2024. This approach will enable the

secondary care provider of mental health services and future ASC/ADHD assessment and prescribing provider(s) to establish much stronger and collaborative working arrangements.

In addition to the re-commissioning of the assessment and prescribing pathways, a HIOW All Age ASC and ADHD Improvement Group is now operational and responsible for overseeing the transformation of the whole neurodiversity pathway, including:

a) The development of consistent early intervention offers for our Neuro-diverse population building on initiatives already in place such as the Neuro-developmental pilot launched in Portsmouth to re-focus support for children & young people with autism & other neurodevelopmental issues. The MDT is an innovative approach to supporting a new Neuro-developmental pathway and since its launch in Sept 2022 has demonstrated a decrease in the number of young people being added to the formal diagnosis waiting list (the approach allows individual action plans to be co-produced that results in a formal ASC/ADHD diagnosis lending little added value).

b) Co-designing and embedding a shared care arrangement which matches national policy and is locally agreed in partnership with Primary Care to ensure everyone can access prescribed medication safely and locally in a timely manner.

c) The development of a range of post diagnostic support options building on initiatives already in place such as the Neurodiversity Parenting Courses delivered by Re:minds and Southampton City Council. Qualitative feedback from this offer has found an improvement in understanding of Autism, adaptions, communication and that attending the programme has had a positive impact on family life reported by majority of attendees (comparing pre and post questionnaires).

Issue - Evidence before this inquest indicated that SHFT has recognised that the mental health provision for those with personality disorders must move towards an individual, therapeutic and trauma-informed approached.

The review and development of evidence-based pathway and provision for people with personality disorders is one of five key Mental Health System Transformation priorities in 2023/24 for the Hampshire and the Isle of Wight system. The review is in process and will consider:

 The benchmarking of current provision.  The views of our patients and stakeholders.  The current and future projected need.  Local & national best practice.

This review will lead to the development of improved provision for people with personality disorders to be mobilised in 2024/25.

Mental Wellbeing is a priority set out in the Hampshire and Isle of Wight Forward Plan including working in partnership with the system in developing trauma informed approaches across services to reduce health inequalities and improve emotional wellbeing. The ICB, alongside Southern Health Foundation NHS Trust, is a signatory of the Trauma Informed concordat for Hampshire, the Isle of Wight, Portsmouth and Southampton, committing to the delivery of the Trauma Informed Strategy, allocating resources, and providing support and commitment at a senior level.

Issue - Communication with the families of patients with mental health difficulties is still not being effectively achieved including that the family were never briefed on what EUPD and ADHD really meant or on the difficulties which could present because of their daughter’s joint diagnoses.

The ICB’s approach to quality oversight is based on three levels of assurance and support. This approach is aligned with the National Guidance on Quality Risk Response and Escalation in Integrated Care Systems (June 2022).

The trust remains under enhanced monitoring following publication of the Stage 2 Investigation from the Independent Investigation Panel, Chaired by . Within report,

recommendations were made under the heading: Communication, Liaison and ‘Care for the Carer’ and these have been a focus of the ICB’s Stage 2 monitoring.

To ensure that improvements in family and carer engagement are embedded and sustained, the trust is required to submit progress updates against its Stage 2 action plan to HIOW ICB and NHS England. At the last formal review in June 2023, the trust provided evidence of improvement across actions agreed to improve communication with families and carers. This included establishing Carers and Patients Support Hubs at various locations across Hampshire, improvements in the response to concerns and complaints, and improvement in the number of carers with a communication plan (30% to 80% in two years). This has been recognised externally through the Triangle of Care Star 2 award, which was received by the trust on 9 June 2023.

Whilst there is more to be done to ensure that feedback from families and carers is heard and acted on and informs the delivery of care and decision-making for those in receipt of services, the trust has demonstrated its commitment to deliver continuous improvements in this area.

Alongside the existing oversight of the trust, the learning identified in this case will inform the ICB’s ongoing focus on improving family and carer engagement.

In addition to improvements in engagement with families and carers, the HIOW All Age ASC and ADHD Improvement Group will be developing a greater range of resources for families to access post diagnosis.

Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Kirsty Clare Taylor who died on 25 June 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 28 July 2023 concerning the death of Kirsty Clare Taylor on 25 June 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Kirsty’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Kirsty’s care have been listened to and reflected upon.

Your Report raised concerns over the connectivity between mental health services and those services supporting neurodivergent patients, the mental health provision for those with personality disorders, communication with families of patients with mental health difficulties and support for families of patients with neurodiversity. You also raised that Southern Health Foundation Trust (SHFT) needed to further develop its Personality Disorder Pathway and that more needed to be done to increase connectivity between mental health services and those services supporting neurodivergent patients.

As part of the NHS Long Term Plan, all systems in England have been receiving significant funding from 2021/22 to develop and roll out new models of integrated primary and community mental health care in line with the Community Mental Health Framework for the improved support of adults with severe mental illness in their community and to integrate mental, physical and social care. A key requirement of the new model of care is the provision of a dedicated community mental health offer for those with diagnosis of ‘personality disorder’ or complex emotional needs. This offer should be co-produced and provide personalised, trauma-informed, and flexible care that is responsive to individuals changing needs. NHS England has shared key principles for the development of services for people with personality disorder and will continue to share guidance and positive practice with health systems. The Community Mental Health Framework also sets out the importance of engaging both service users and their families and carers, noting that assessments should be a collaborative process involving not only mental health team members but also the patient, their families, carers and support networks. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

16 October 2023

In September 2023, the Government also published its new Suicide Prevention Strategy for England: 2023 – 2028, a five year cross-sector strategy developed with the aim of reducing suicides in England. The strategy is underpinned by an action plan for organisations including the NHS, the Department of Health & Social Care (DHSC) and from across the voluntary, community and social enterprise (VCSE) sector. It is supported by a wide range of funding which includes £57million for suicide prevention and suicide bereavement services, as well as £150million capital investment into urgent and emergency care mental health pathways.

As part of the strategy, NHS England and DHSC will explore opportunities to improve the quality of care for patients with specific diagnoses of conditions associated with higher rates of suicide and ensure compliance with the National Institute for Health and Care Excellence (NICE) guidelines. This includes patients with personality disorders. It is also intended that by 2024/25 all parts of the country will have introduced crisis text lines to enable easier access to crisis care for people who are neurodiverse.

We also note your concern that more needs to be done within Southern Health Foundation Trust (SHFT) around development of their Personality Disorder Pathway, ADHD services and connectivity between mental health services and those supporting neurodivergent patients. NHS England is engaging with Hampshire & Isle of Wight Integrated Care Board (ICB) on the concerns raised and have been asked to be sighted on their response to your Report.

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.

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Kirsty Clare Taylor Regulation 28: Report to Prevent Future Deaths – Trust Response

Matter of concern (1): fragmentation of services Fusion

Southern Health NHS Foundation Trust, Solent NHS Trust, Isle of Wight NHS Trust and Sussex Partnership NHS Foundation Trust provide NHS community, mental health and learning disability services for the Hampshire and Isle of Wight population. We have been working together for a number of years to improve services for the people and communities we serve. Whilst in each Trust there are multiple examples of services providing excellent care, it has been recognised that further significant change is needed in order to deliver sustainable improvements in access, care and outcomes. Services are struggling to meet unprecedented increases in demand which means people are not always getting the care they need at the right time and in the right setting; we recognise there is unwarranted variation in practice and fragmentation in service delivery and want all people in Hampshire and the Isle of Wight to have equitable access to integrated, safe, consistent community and mental health care. There is consensus that we will be more likely to achieve this future by joining up the disparate, often inconsistent services and pathways delivered by four different community and mental health providers. It has therefore been concluded that the best way to enable our vision is by working together to establish a new, single community and mental health provider, while, at the same time, accelerating collaboration and transformation, led by our clinical experts, to reduce the significant pressures in our system. The creation of this new provider is progressing at pace (Project Fusion) with the new legal entity due to be in place by 1 April 2024.

Neurodiversity Clinical Delivery Group The clinically-led transformation of services is a key element of the Fusion work and one of the 10 Clinical Delivery Group areas is focussed solely on Neurodiversity. This is in recognition of both the inequity patients face across the county relating to access to neurodiversity services and also the impact of fragmented services on patient experience and outcomes. Our aspiration is to implement a single specification for all age neurodiversity services that spans assessment, diagnosis, treatment and support and works with system partners to ensure all aspects of a patient’s needs, not just the clinical factors, are attended to holistically. As we are not in control of the commissioning of these services and as commissioning changes may not be immediate, we are therefore focussing on what we are and will be responsible for in the new organisation and where we can lead by example. We know from

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the available evidence that it is not helpful to refer patients with neurodiversity on to multiple other services where reasonable adjustments could instead be made to support people in 'mainstream services'. We also know that wherever possible we should work jointly with other services to offer a joined up experience of care for patients and families making the best use of skills from within the wider organisation. Achieving this depends significantly on staff having the awareness, skills and knowledge of how neurodiversity can impact on a patient’s experience of services in order that they can adapt their care delivery accordingly. Robust training packages are being rolled out to support this. The Oliver McGowan Mandatory Training on Learning Disability and Autism is the standardised training that was developed for this purpose and is the government's preferred and recommended training for health and social care staff. The e-learning training was launched on 2 August 2023 and in just over 2 months, 75% of the workforce have completed this. We are delighted with the rapid uptake and the feedback from staff has demonstrated positive buy-in to the key learning the training seeks to deliver. We have also recently partnered with two voluntary care sector organisations who will help us to deliver the live elements of the training and are on track to have our first webinar launched at the beginning of November. Webinars and seminars are both mandatory as a second part of the training to the e-learning. Non-patient facing staff will complete e-learning and a webinar and patient facing staff complete e-Learning and a more comprehensive seminar, all of which is mandatory. In addition to the training, we intend to build a network across the county to share best practice and tackle issues collectively and we have a number of working groups in place, which include broad input across clinical and corporate services and the service user voice, with a remit is to ensure what we have designed is measurable, tested and sustainable for the future. These working groups are developing principles and Standard Operating Procedures for use across the new organisation when it comes into being. Whilst we do not have a policy that specifically addresses the treatment of patients with Learning Disability/ neurodiversity/mental health comorbidities, we feel the above work and development of Standard Operating Procedures will achieve the same outcome, hopefully in a way that is more visible than policies sometimes are. will be invited to be part of the work we have described above from a lived experience perspective.

Matter of concern (2): Personality Disorder Pathway should be developed at pace Pathway development By way of background, the Trust had already developed the Transform Pathway with involvement from experts by experience, clinicians and commissioners. This was for people with a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and the main focus was on embedding Dialectical Behaviour Therapy (DBT).

In 2021/22, as part of our community transformation programme development work for personality disorders, the Trust looked at the Transform model and identified some key gaps. The Trust also analysed themes from a number of national documents including the Royal College of Psychiatry position statement on people with personality disorder (2020),

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the Wessex Personality Disorders Pathway Review (2020) and the work from the National Confidential Inquiry into Suicide and Homicide on Safer care for patients with personality disorder (2018) among others.

The themes from these documents were then triangulated with a case note review of patients across the Trust and feedback from patient and family experience in order to accurately map out the Trust’s real-time position and its future aspirations.

Concurrently, in January 2022, ICD-11 came into effect. This version of what is the global standard for diagnostic health information contained a fundamentally different approach to classification of personality disorders. It did away with the numerous sub-types of personality disorder found in ICD-10 and replaced them with a single personality disorder diagnosis. In order to ensure that the Trust responded to this combination of local analysis and national and international developments, a new model has subsequently been developed over the past year for all services working with people who have Personality Disorder and Complex Trauma.

This model is based on a relational and trauma-informed therapeutic approach, incorporating evidence-based interventions for individuals, family interventions, psychological consultation to teams working with complexity, as well as training for staff. The absolute aim is that no door should be experienced as the wrong door, by individuals and their families. To change this involves building community awareness and training for all staff.

Since the inquest into Kirsty’s death, two half day workshops have taken place in August and September 2023 for staff from across the clinical services. These were an opportunity to summarise the model, review progress to date and start to develop an implementation plan for delivery. Outputs and updates were subsequently shared with the Quality and Safety Committee (Board Committee) at the end of September 2023 who gave their full backing to the proposals. A programme Steering board and 6 workstreams have formed to ensure a structured roll out and oversight of the implementation plans. One of the workstreams is the Families and Carers Support workstream and the Trust would again very much welcome Kirsty’s family to participate in this. will be in touch with them about this shortly as we recognise that their generous offer to give their time to support these changes will be invaluable. A further workstream which is focussed on the in-patient pathway has as one of its strands the development of tools to support patients with a Personality Disorder should they be admitted to hospital. This group includes among its membership experts by experience with neurodiversity and the Trust fully recognises the need for the whole pathway to be accessible for this patient group. As part of embedding the trauma-informed approach1 the Trust is involved in a whole system piece of work to ensure that wherever an individual or family touches our services they will experience a trauma-informed response. This is a large-scale piece of work involving training and cultural change across a range of organisations. Connected to this and as part of the NHS England Mental Health, Learning Disability and Autism Quality

1 Trauma-informed care acknowledges the need to understand a patient's life experiences in order to deliver effective care. It aims to increase clinicians' awareness of how trauma can negatively impact on individuals, and their ability to feel safe or develop trusting relationships with health and care services. It has the potential to improve patient engagement, treatment adherence and health outcomes.

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Transformation programme the Trust has been involved with development of core standards and commitments around changing the culture of our mental health inpatient wards. This work has informed and continues to inform the workstream focussed on the inpatient part of the Personality Disorder and Complex Trauma pathway and our wider services as to what it looks and feels like to be truly trauma-informed . The delivery of this new model will be in a phased approach to align with available funding from commissioners with the first phase of work focussed on reducing waiting times for psychological therapy in secondary care.

Recruitment As part of the new Personality Disorder and Complex Trauma model, the Trust is seeking to increase access for individuals to evidence-based interventions, aligning with the national agenda on increasing access for individuals with severe mental illness. Funding received for ‘recruit to train’ posts is enabling this to happen. The three ‘recruit to train’ posts developed in Southampton in October 2022 have already shown an impact with no patients currently on a waiting list for Dialectical Behavioural Therapy (one of the evidence-based interventions for people with Personality Disorders) and there is further training for current staff underway. The Trust has been vocal about the need for additional funding aligned to the development of the range of evidence-based interventions over the next 5 years, to continue to meet patient and family demand and reduce waiting times. We are in ongoing conversations with commissioners to seek to secure this. A separate measure taken to mitigate the national shortage of psychology staff has seen the Trust developing a new workforce and running an apprenticeship scheme with Plymouth University to develop Clinical Associates in Psychology (CAPS). Since 2022, the Trust has developed 48 CAPS across the organisation (3 cohorts of 16). These new roles have allowed for a more psychologically-minded approach in community mental health and crisis teams in both Adults and Older Persons Mental Health Services and these staff will be crucial in supporting the new Personality Disorder and Complex Trauma model to become embedded in these teams.

Matter of concern (3): Communication with families and listening to their concerns The Trust recognises the Coroner’s concern about repeatedly seeing evidence of poor engagement with families. This frustration, that we are still not getting this engagement right every time, is shared by Board members. It is an absolute priority for the Trust and whilst we in no way seek to underplay the amount of work left to do, we would like to provide assurance that there have been significant improvements made (and externally validated) which may not always be visible through what is, thankfully, the very small proportion of cases that come before the Coroner.

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Triangle of Care We are delivering a ‘Triangle of Care’ training package (launched by the Carers Trust) to frontline staff with more than 2000 staff having completed this training since 2019. Much of this training is co-delivered with Carers, Carers Leads and a former service user with their carer. Triangle of Care training is ongoing and available weekly for all staff. 17 Carers Leads and 14 nurses/practice development nurses have been trained to facilitate the training package. The face-to-face Healthcare Support Worker induction for new staff joining the organisation has included Triangle of Care training as an integral part of it since November 2022. This ensures buy-in from all delegates and provides them with the skills and knowledge going forward into their new careers. The aims of ‘triangle of care’ are clear:
• Carers and the essential role they play should be identified at first contact or as soon as possible thereafter
• Staff are “carer aware” and trained in carer engagement strategies
• Policy and practice protocols re confidentiality and sharing information are in place
• Defined post(s) responsible for carers are in place
• A carer introduction to the service and staff is available, with a relevant range of information across the care pathway. E.g. Trust Carers Booklet.
• A range of carer support services is available. In addition to the Triangle of Care training we have also provided training on carer awareness and carers rights, which was delivered by Hampshire Carers Together. We have held ‘Think Carer’ workshops for staff and recently launched an e-learning module of the Triangle of Care training to enable those staff who have difficulty attending training events to also access this. In June of this year we were delighted to be awarded Triangle of Care Star 2 accreditation and we are now working towards Star 3 to complete the process. In order for a mental health trust to achieve star 2 status, it must not only have completed the self-assessment for inpatient wards and crisis services, but also provision of support within community mental health services. In awarding Southern Health star 2 accreditation, , Triangle of Care Lead for the Carers Trust said “I am delighted to be working with Southern Health as they focus on giving carers greater recognition and support in their communities by delivering Carers Trust's Triangle of Care programme. The programme is promoting a set of standards that brings together unpaid carers, service users and staff as partners in care. This includes unpaid carers being identified and supported and Southern Health’s membership of the Triangle of Care promotes this work.” , Chief Executive of the Princess Royal Trust for Carers in Hampshire said “From reading the report, it is clear to see the commitment that Southern Health have towards partnership working with Carers and the six principles that sit at the core of the Triangle. The progress you have made alongside your future plans will ensure that Carers are embedded into all teams and services across the Trust.” The introduction of Esther coaching this year will further enhance and reinforce the Triangle of Care principles. Esther Improvement Coaches are specially trained dedicated members of staff who support the development of other staff to create a culture of continuous

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improvement to ensure person-centred care. User involvement is integral to the model, building a network around the patient including family, friends, and key staff.

Additional work programmes We have metrics which show that whilst there is a way yet to go, there has been significant improvement made. As an example, 77% of carers identified on our patient record now have a bespoke carer communication plan. This is in contrast to the position in 19/20 where carer communication plans were rarely in place. There are 152 carer leads in teams across the Trust with an additional 63 honorary Carers Leads – influencers and ambassadors. These are members of the team with a responsibility to champion family and carer engagement as part of their wider clinical role. We have also employed 22 staff in the roles of Carer Support Workers across the Trust. These are paid roles exclusively for working with carers. Carer information is now readily available through booklets and also via a dedicated section of our public facing website. A new Carers and Patient Support Hub was also set up in January 2022 and this is a listening service available to family members/carers who need additional advice, information or support. In order to ensure that this service is accessible to all we have set up hubs in community settings as well as our clinical areas. For example, we have hubs in areas such as Totton, Romsey, Lymington, Southampton and one in development in the North of Hampshire. During the last year, three of our carers have worked tirelessly on a project aimed at exploring carers experiences of hospital discharge from Adult Mental Health and Forensic services. The project was funded by NHS England and was co-produced and user-led throughout. The report produced a number of recommendations to improve the experience of carers and their families and with the support of our clinical staff an action plan has been implemented to address the issues.

Building on findings from the Mind the Gap scoping project which was completed last year, and in collaboration with Hampshire Young Carers Alliance, No Limits and other organisations, we are also currently undertaking a project to support and engage young carers. A key feature of this work will involve collaboration with schools, primary care and other health services. We are grateful to NHS England for funding this focussed work with young carers.

Information Sharing Policies and protocols with regards to information sharing (including the issue of capacity) are also in place. The Trust promotes the importance of both the 7th and 8th principles of the UK Caldicott Guardian Council in recognising the importance of the duty to share information being as important as the duty to protect patient confidentiality. They are included with our Triangle of Care work and information governance (IG) training. IG training is completed annually by every member of staff which will help to embed these principles further. Information sharing remains a real focus of ours and we take every opportunity to champion this work. Our Carers booklet, which was co-produced with carers and is handed out to family/carers whenever they come in to contact with services also has specific references to information sharing.

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Obtaining and providing feedback The Trust has increased the number of ways that people can give feedback and opportunities to share their experience. This includes Carers groups, storytelling events, carers forums, surveys etc. We have a number of carers groups across the Trust, as well as supporting external groups. Most recently, the Trust has funded and supported the setting up of a BAME carers group in Southampton. Feedback and issues highlighted from these different platforms is reported to the Carers, Family and Friends group and the Patient Experience and Caring group as part of our business-as-usual reporting. The Trust acknowledges the need to balance accountability and responsibility by ensuring that it meets the Duty of Candour and admits its mistakes. Our Investigating Officers and Family Liaison Officers openly engage with families when they are part of an investigation and check that service leads have shared information openly and honestly.

Strategy development Our People in Partnership Commitment details our commitment to working together with service users, patients, families and carers so that they have a say in their care and treatment and help us to improve. This Commitment was reviewed during 2022 with a series of task and finish groups established with representatives from our Working in Partnership Committee, Carers, Families and Friends Group, Governors, Voluntary Sector, Charitable Organisations and Partners. A consultation draft of the refreshed strategy was then produced for wider consultation and comment. The draft document was circulated to more than 1500 people, was shared widely on social media and a survey was also available for people to complete. Feedback was taken into account and the necessary amendments made to the strategy which was approved by the Quality & Safety Committee in January 2023 and subsequently Board in February 2023. Our strategy states that we will:
• Enable carers to access the support they need in their caring role through signposting and referrals to relevant carer support services, co-producing resources and developing carer groups
• Support carers by giving them timely information, respect and opportunities to share their stories and make their roles visible.
• Empower carers’ voices, by improving the way in which we listen and communicate with them, enabling them to continue in their caring role in good health and keeping safe.
• Increase opportunities for carer engagement We fully recognise that Kirsty’s family did not always find this to be their experience and we are desperately sorry this was not the case. Their feedback is a reminder to us that whilst we have made progress, there is more to do and the information provided above does not in any way diminish the responsibility we take for this.

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Matter of concern (4): More support to families particularly for patients with neurodiversity Family Connections is a programme that has been specifically developed for families of patients with a personality disorder. It aims to provide:
1. Education about personality disorder and family functioning
2. Individual and family skills, to help with managing their own negative reactions and building better and more satisfying relationships
3. Social support, from other group members who have lived through similar experiences and are living with similar situations Whilst we were initially only able to offer this in the Trust to a small sub-set of families whose relative was receiving a particular combination of interventions, we have sought to expand this. A new Family Connections model has been developed and has been run by Clinical Associates in Psychology (part of our new workforce expansion described in 2 above) for other family members with good outcomes. Whilst the original Family Connections programme was specifically for Personality Disorder and aligned to DBT, we are continuing to develop the programme to be accessible to a broader range of people with complex emotional needs including those with neurodiversity. Our ambition is ultimately for family interventions to be designed that are bespoke to the individual’s formulation. We would also refer the Coroner back to the information provided in section 1 above in respect of the work specifically underway to improve the experience that patients with neurodiversity and their families have when accessing our services.