Lucy Jones

Dear Ms Saunders Re: Regulation 28 Report received by Aneurin Bevan University Health Board further to the inquest touching on the death of Lucy Amanda Jones which concluded on 20.12.2022 I am writing to provide you with the Health Board’s response to the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Lucy Amanda Jones. As requested, the information presented below is intended to describe the action taken / being taken to mitigate the risk of future deaths. You require the Health Board to provide you with the following information:
1. The steps that are being taken to ensure that patients who are so unwell to be detained under the Mental Health Act, do not have to wait for more than 2 years for psychological therapies.
2. The policy that determines what steps should be taken to ensure that mental health practitioners can be properly reassured about the health of their patients who are refusing or reluctant to engage. The discharge summary of 27 November 2019 following Miss Jones’ discharge from Talygarn acute mental health ward indicated that she was on a waiting list with the psychology service for Cognitive Behavioural Therapy for psychosis (CBTp). Each ward is allocated 1.5 days of a Senior Psychologist – this was ringfenced funding provided by Welsh Government to support the provision of psychological therapies in inpatient environments in Bwrdd Iechyd Prifysgol Aneurin Bevan Aneurin Bevan University Health Board Pencadlys, Headquarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP18 3XQ South Wales NP18 3XQ Ffôn: 01633 436700 Tel No: 01633 436700 E-bost: abhb.enquiries@wales.nhs.uk Email: abhb.enquiries@wales.nhs.uk Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board

mental health services. If someone were able to engage in psychological therapy at that point it would commence with no waiting time. It is the case that many people are not able to respond to or engage in psychological therapies either within the acute phase of their illness or in an acute environment. Psychologists in these roles therefore work with others in the multi-disciplinary team to facilitate and advise on pathways to psychological care in the community. With regard to management of the waiting list, decisions regarding clinical need and likelihood of clinical gain, as well as the needs of others on the waiting list are made by the Principal Psychologist in each area who has oversight of the waiting list and is a full member of the multi-disciplinary team (MDT). This allows the service to expedite where appropriate. The clinical notes indicate that Miss Jones was offered an appointment on 12 May 2021 with the psychology service, which she did not attend. This was some 18 months after her discharge from Talygarn ward, though it is acknowledged that there was a significant delay in offering appointments due to the Covid pandemic, associated lockdowns and staffing issues including redeployment and absences at this time. During this time, Miss Jones was in touch with her Care Co-ordinator, a Social Worker within the Community Mental Health Team (CMHT) who would have been able to liaise with psychology colleagues in the team as required. In regard to this particular case, since this time the Health Board has invested further in psychological input to acute treatment areas and is piloting a model of embedded psychological care which gives some provision for outpatient follow-up. This allows for smoother transitions, increased relational consistency (rather than needing to develop a new therapeutic relationship with a different clinician), and more effective care pathways. There is, of course, also the growth in the ‘Open Dialogue’ model of care (a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system/network meeting, which always include the patient) and this is being provided by multi-disciplinary staff embedded in both acute care environments and community provision. In terms of future provision, the nursing strategy for the Adult Mental Health and Specialist Services Directorate outlines the longer-term plan for a consultant nurse post for psychological therapies and advocates nurses training in the provision of evidence based psychological interventions. This should also improve access along with the Health Education and Improvement Wales (HEIW) commitment to training multiple disciplines in quality assured psychological interventions by providing paid places on the PGDip in CBT. With regard to the policy that determines what steps should be taken to ensure that mental health practitioners can be properly reassured about the health of their patients who are refusing or reluctant to engage, the Adult Mental Health and Specialist Services Directorate has developed a policy to guide clinicians in their next steps when a person does not attend 2

appointments and/or further disengages with the team/service – the Disengagement and Did Not Attend policy. The policy seeks to explore and balance the clinician and team’s duty of care to that patient along with the person’s right to refuse/decline treatment and intervention - where the person has the mental capacity to make this decision and there is no statutory power to compel this. The policy supports clinical decision making based on the person’s needs, identified/known risks and any information from others. It supports communication required with the patient and others (where indicated) and the views of the multi­ disciplinary team, and advice for the patient i.e., routes back to the mental health service should their mental health deteriorate. The policy remains in draft at the moment with consultation due to end on 10 March 2023, and will then be ratified by the Division’s Quality & Patient Safety meeting scheduled for 29 March 2023, with a view to this then being considered and adopted by other Directorates in the Division which offer secondary care services. I trust that this information offers you reassurance of the actions taken by the Health Board in respect of the issues raised. If any further information or assurance is required, please do not hesitate to contact me.

Dear , In our practice we have yesterday discussed the Prevention of Future Death Report regarding Sarah Mitchell in a Clinical Governance meeting. Present in the meeting were myself and 8 other doctors as well as 3 of our Health Care Practitioners. Two decisions were made:
1. The hospital does not easily have access to our clinical system, but they do have access to the Summary Care Records, which gives information about diagnosis and medication. From now on when a diagnosis of an overdose gets recorded we will add a sentence to give no more controlled medication than is needed for 48 hours, so they can contact the surgery again for a further supply after. This should be visible on the summary care record that the hospital is looking at.
2. If a patient is admitted with more than 1 overdose within a 3 month period we will change their prescription to daily until they have not to overuse or overdose on their medication. We hope that with these two new ways of working in place we might be able to bring down the chance of accidental death due to an overdose as seems to have happened in Sarah’s case. Kind regards,

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