Emma Burbury

Dear Mr Cox Regulation 28 - Prevention of Future Deaths report following the inquest into the death of Ms Emma Burbury (concluded 9 November 2021) Cornwall Partnership NHS Foundation Trust (the Trust) noted the Regulation 28 Report issued to Cornwall Council and Kernow Clinical Commissioning Group (NHS Kernow) following the Inquest into the death of Ms Burbury. I would first like to offer my sincere condolences to Ms Burbury’s family and to say that I am truly sorry for their loss. Every death in these circumstances is such a tragic experience for a family. The implementation of learning from this is an absolute priority for me and for the Trust. The Trust would appreciate the opportunity to contribute to responding to the concerns that you have raised and I have discussed these with the Trust’s Associate Director for Community Mental Health Services, and the Trust’s Chief Information Officer. I set out below the Trust’s response to the matters you have raised. Dual Diagnosis Policy The Trust has engaged with partner agencies in contributing to the implementation of the systemwide Cornwall and Isle of Scilly Dual Diagnosis Strategy (Adults) 2019 to 2022. The purpose of this strategy is to improve the delivery and experience of services for people with co-existing mental health, alcohol and drug problems; and recognises that these vulnerabilities do not exist in isolation, and that residents affected, will also have other associated complex needs, which require integrated, co-ordinated and consistently collaborative working. Having recently ‘signed-up’ to this strategy, the Trust is fully committed to its delivery across all services and are active members of the Cornwall Council led multi-agency steering group. The Trust is currently planning “what this means to me” workshops to support patient facing staff groups embed the principles of the strategy into their clinical practice and this is regularly reviewed as part of the directorate’s Clinical Quality Assurance Group. Additionally, the Trust’s Medical Director and Associate Director for Community Mental Health Services are keen to work closely with We Are With You (WAWY) colleagues in implementing the principles of the strategy across both services.

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Access to Medical Records

There are clearly benefits to partner agencies accessing an individual’s health record and, in addition to the National Record Locator project led by NHS Digital, the Trust is currently working on the Shared Care Record project, for which phase one trials commence in the spring of 2022.

A shared care record is a collection of patient information, stored in one area, that care providers both contribute to and have access to, giving a full picture of those in their care. Care providers that typically contribute to a shared care record include GPs, hospitals, community and mental health trusts and social care providers. By implementing a shared care record, professionals have all the information they need at the point of care, enabling them to make informed decisions, not only in hospitals and GP surgeries but also in the community.

There are of course caveats around record sharing not least of which are the visiting agency’s understanding of the Caldicott Principles, information governance framework responsibilities, data privacy and Data Protection Act requirements. There are a number of formal processes in support of providing access to records to partner agencies and delays may occur at any point if requirements are not met. Medical records should also be viewed with caution as there may be a lack of understanding of the clinical information recorded.

We Are With You were provided with access to the Trust’s medical record system in the past under their previous name (Addaction) and this was a reciprocal arrangement. The Trust has requested an updated Data Sharing Agreement and Memorandum of Understanding to allow this access to continue – to date this is still outstanding. The Trust intends to set-up a task and finish group with WAWY to look at resolving these issues, along with how best to remind staff that this access is available.

Additionally, the Trust has worked with WAWY to implement regular multi-disciplinary team (MDT) meetings where care and treatment pathways for patients may be discussed. This has been met with a varied uptake across the county and the Trust is eager to engage with WAWY to embed this consistently. An escalation route has also recently been provided to WAWY via the mental health Matrons and / or operational leads where concerns can be reviewed if a patient is not receiving care or their risks are not being considered.

The newly created role of the Primary Mental Health (PMH) Practitioner will also provide a valuable conduit in sharing medical information across organisations. These Trust employed members of staff will be co-located in GP surgeries and will work alongside community, mental health, social care, pharmacy, hospital and voluntary sector colleagues focusing on a personalised care approach to achieve the best possible care outcome for patients. Whilst this role is still in its infancy, relationships with primary care colleagues have already been enhanced where PMH Practitioners are in post.

Discharge process from Community Mental Health Team and signposting to wider services

The Trust’s Integrated Community Mental Health Team (ICMHT) aims to meet the needs of eligible patients (those who are in an acute mental health episode and / or have a severe and enduring mental health condition) within the commissioned framework and services are provided in line with recommended National Institute for Health and Care Excellence (NICE) guidelines, legislation and good practice. The ICMHT recognises the need to work in partnership and form collaborative relationships with patients, however, there are situations where patients may have difficulties engaging with the ICMHT. In order to achieve successful engagement the ICMHT ensures that it is providing a service that meets the individual needs of the patient, respecting their qualities, strengths, rights and responsibilities. Having a mental health difficulty does not in itself negate an individual’s right to make the same decisions as any other member of the community. This includes the right to make decisions that others would not necessarily agree with, for example refusing any mental health care by the ICMHT.

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The decision to discharge a patient follows a robust process as described in detail in the ICMHT Standard Operating Procedure, and this includes discussion at a MDT meeting which will consider the reasons why the patient has not engaged / attended, their existing needs and alternative ways in which engagement could be achieved; and the referring clinician and the patient’s GP must be informed of the patient’s disengagement to enable the exploration of alternative methods to encourage engagement in partnership with other key stakeholders in the patient’s care and any on-going need to risk management.

Where discharge does occur, it is the Trust’s expectation that this is followed up in writing to both the patient, the referral agent and the patient’s GP and that this should include advice and recommendations, with the relevant contact information, so that the person could access support from wider services in the future if they chose to.

The continued Community Mental Health transformation work, currently underway in the Trust, will work to address the collaborative and joint working between the ICMHT and other partners, but primarily the issues are culturally related in a complex health system, which will take time to solve through the development and strengthening of relationships with one another. Processes and policy will support this and our commitment to the multi-agency steering group demonstrates our willingness and commitment to work with other agencies.

Thank you for considering the Trust’s response to the concerns you have raised - they are clearly relevant and important issues around a crucial aspect of care regarding information sharing between partner organisations. I trust that this response provides assurance that action is being taken by the Trust to address the matters that you have raised.

Dear Mr Cox Prevention of Future Death Report following inquest into the death of Emma Burbury (EB) Thank you for your Regulation 28 Report to Prevent Future Deaths pertaining to EB. In your report you identify a number of concerns and the action to be taken by NHS Kernow as the commissioners of mental health services. The matters of concern you have raised are as follows:
1. You heard that community mental health team’s (CMHT) staff at Cornwall Foundation Partnership NHS Trust (CFT), have read-only access to We Are with You (WAWY) notes and records, but this fact is not widely known amongst Trust staff. It was recognised that a reciprocal arrangement allowing WAWY clinicians to have read-only access to the Trust’s RiO records would be of benefit. You understand a formal request in this regard has been made and is receiving due consideration. You stated that one of the most common concerns you hear at inquest is the difficulty with communication between separate organisations and this may also be an initiative you felt we would be able to support in delivering for a more integrated service.

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2. There was concern raised on the part of WAWY that clients referred to CFT were too easily discharged, for example, where they failed to attend for two appointments. It was felt a more assertive approach towards engagement would be beneficial. You asked us to consider whether we feel it would be desirable to try and minimise the amount of wasted and limited CMHT/WAWY resource through non-attendance at appointments or otherwise and consider reflecting on how this can best be achieved through a more joined up approach.

3. It was felt patients referred to the CFT who did not fall within the strict parameters of a severe and enduring mental illness were discharged without sufficient thought being given by the Trust’s clinicians to whether another agency such as Valued Lives may be able to provide support. You suggested it may be a worthwhile exercise to consider how to join up the wider services available within CFT, the voluntary sector or elsewhere.

Since receiving your initial correspondence, NHS Kernow Clinical Commissioning Group’s (CCG) Associate Director for Strategic Commissioning for Mental Health and Learning Disability, has been in close dialogue with , Cornwall Council’s Joint Commissioning Manager for Communities and Public Protection/Public Health, who we are aware you also wrote to regarding these recommendations. In addition, and as was agreed by yourself, CFT have also contributed to this response given many of the concerns raised in the report directly relate to CFT, namely the sharing of records between CFT and We Are with You (WAWY); the approach to engagement and discharging patients who do not attend appointments and onward referrals where patients do not have a severe and enduring mental illness.

This report therefore represents a collective response to the Regulation 28 provided on behalf of CFT, Cornwall Council and NHS Kernow CCG, where CFT will provide a response from an operational perspective whereas Cornwall Council and NHS Kernow CCG will respond from their strategic perspective.

Cornwall and the Isles of Scilly has witnessed a significant programme of transformation and improvement since 2018/19 with a particular focus on ensuring that mental health and wellbeing shares a parity of esteem with physical health. An ambitious programme of transformation was established to deliver both national strategy as well as a local response to the needs of our urban, rural and island communities and this includes the integration of several existing services and the development of new networks of community-based support particularly with the voluntary, charitable and social enterprise (VCSE) sectors.

As previously reported to your office, the Dual Diagnosis (DD) strategy for Cornwall and the Isles of Scilly was re-launched in 2018/19 after a period of review. This work was led by NHS Kernow CCG and Cornwall Council and culminated in a co-produced and jointly owned document supported by a range of multiagency partners and stakeholders including people with lived experience, carers and professionals from across statutory as well as the voluntary and third sectors. In 2021 the strategy was updated to incorporate emergent best practice guidance and executive level signatures from representative organisational leads, including CPFT and WAWY, demonstrate a clear commitment to continue to deliver the journey of change and improvement.

In 2021 a dedicated role was jointly funded by both the NHS and local authority, to specifically provide additional oversight and scrutiny of the implementation and delivery of the dual diagnosis strategy. This work is ongoing and regular reporting serves robust governance

Page 3 Information Classification: CONTROLLED including formal oversight of the plan, maintenance of risk log and mitigations plan with onward reporting to Safer Cornwall Partnership within Cornwall Council.

Alongside this and associated with elements of the existing dual diagnosis strategy, the Adult Mental Health strategy, ‘Future’s in Mind’ for Cornwall and the Isle of Scilly was formally launched in 2020. The joint strategy, and associated implementation plan, set out the key ambitions and outcomes including a clear focus on preventions and integration. A clear commitment was made across the NHS and local authority to, amongst many other things, ensure that care and support was holistic, personalised and joined up. One of the overarching principles was to develop a culture of inclusivity and hands-on support, which sees ‘no wrong door’ for those trying to access care and support. Service providers from across all sectors are now working in close collaboration to jointly plan and share information in a timely fashion, deliver the most meaningful and personalised support, and promote an environment where people’s mental health and wellbeing is felt to be ‘everybody’s business’ no matter what health or care organisation they work for.

In respect of your first concern, it is acknowledged that messaging and training is of vital importance in ensuring continuity and equity of approach. We can report that a task and finish group, which includes WAWY and all NHS and Local Authority Commissioned mental health providers, are developing a revised Data Protection Impact Assessment (DPIA), to provide additional governance and ensure continuity of approach and adherence to system operational and strategic intention. The DPIA makes clear the justification and rationale for access to, and/or the process of, personal information to enhance existing information sharing agreements between organisations. It will help to address the request for reciprocal access to data and specifically RIO clinical records systems operated by CFT. CFT will work with WAWY to include them in relevant regular meetings and to embed this access to data as business as usual. In the meantime, there is an escalation route via the Associate Director of Operations and the CMHT matrons, when there are concerns from WAWY that someone is not receiving care, or they feel risks are not being considered. This provides a two-way flow function and demonstrates integrated operational working to maintain safe and timely service responses.

On your second concern, it has been acknowledged that our system is experiencing unprecedented demands amidst the backdrop of the national COVID-19 pandemic. Front line services are experiencing significant workforce challenges with a higher-than-normal vacancy rate. Commissioners (NHS Kernow and Cornwall Council) receive regular updates and receive risk and mitigations plans which include workforce expansion plans many of which have been supported by additional investment to bolster numbers and provide a more robust safety to ensure future continuity. In addition, CMHT’s carry out regular case load risk analysis and reviews and have been working closely with VCSE partners to ensure that additional follow up support is available and maintain a robust waiting list management process. Other response plans include complex case review panels, which again, represents improved integrated working to the benefit of patient level outcomes and experiences.

We can report that the CFT policy for discharge after 2 missed appointments is primarily for the assessment team, and at point of discharge notification is made to partners and referrer organisations which includes advice and recommendations including contact points. Both WAWY and CMHT policies include specific detailed on the discharge process and operational procedures, with specific reference to those who are hard to engage. Discharge is not enacted in isolation but rather via a Multi-Disciplinary Team (MDT) discussion, a discussion with the GP and other involved parties to ensure risks and understand the person’s ability and

Page 4 Information Classification: CONTROLLED capacity to make decisions are considered. This is further supported by WAWY outreach, which seeks to engage those who are not yet able to utilise office or appointment-based systems. Further safeguards are maintained by ensuring that all letters and associated correspondence from assessment team’s, include advice and recommendations alongside clearly stated contact information and detail to enable individuals to re-establish contact with services and access support again should they so choose. For further assurance on these matters, please refer to the attached Annex 1. document, provided by Dr , Medical Director, CFT. Finally, in response to your third concern we can confirm that we are currently working through an exciting period of transformation in community mental health across our counties. Significant funding has been made available to Cornwall and the Isles of Scilly to bring about transformation in the collaboration and delivery of community mental health support to improve the outcomes and experiences of those utilising care and support. Much of that funding is aimed at additional provision being developed in partnership with Voluntary, Community and Social Enterprise (VCSE) sectors, as key delivery partners in larger scale integrated mental health workforce transformation. Robust governance via a transformation board and steering group committee, provides oversight on a number of working groups focused on bringing about positive and sustainable change. The transformation will offer a better way of providing mental health help and support to people in the community based on bringing together all current health services, including GP surgeries, with voluntary organisations and social care services. It will enable the provision of a larger range of options that are available quickly and more conveniently for everyone.

With specific regard to alcohol and drug treatment services, Cornwall Council have identified that that across Cornwall and the Isles of Scilly we have a slightly lower number of opiate users than the national average for people entering treatment who have an assessed mental health need, but much higher rates of non opiate users. Investigation is underway into this matter in an attempt to better understand key factors. One hypothesis is that this cohort is made up of the higher rates of crack cocaine users, and that we now have high rates of illict benzodiazepines.

In addition, numbers and rates of people who have both drug and alcohol dependency with mental health needs is low. Significant numbers of people already open and engaged with our CMHT and other mental health services. Our Improved Access to Psychological Therapies (IAPT) service ensures people have access to and are receiving NICE recommended psychosocial interventions. There also appears to be a higher percentage of people with a treatment need but where no treatment is being received and/or treatment is declined. This is the second cohort being investigated to better inform system planing and decision making.

In terms of inclusion and a more holistic approach to care and support, WAWY are specified to work with depression, anxiety and sleep problems, and have an extensive toolkit to do so. People with complex emotional difficulties (formerly known as personality disorder) and psychotic conditions will be referred to CFT, with an undertaking to joint work. WAWY attend the DD Implementation Group to progress joint working with these individuals.

As a fundamental element of ongoing improvement to standards of care and support, WAWY are required to routinely report on the compliance and numbers of staff who have completed the following training via a workforce reporting template provieded to commissioners, which is governed via standard contract review processes with a clear expectation that all staff will have completed the following modules to improve knowledge and skills:

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• Mental Health First Aid (MHFA)
• Suicide Prevention and ASSIST
• Dual Diagnosis

We trust that this response adequately addresses the concerns set out in your letter of recommendation, but should you require further detail, clarification or assurance please do not hesitate to contact us.