Darrell Sharples

Coroner's concerns

AI summary

A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.

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At inquest, I heard evidence from a Mr who, on behalf of CPFT, conducted a telephone triage assessment of Mr Sharples. I have set out where I felt that assessment was inadequately conducted in the attached judgment.

Of particular concern was the fact that Mr was, at best, vague about whether he was familiar with the Trust’s Operational Policy to which, at Appendix 1, were attached the relevant eligibility criterea. Of further concern was that he was not aware of the Triage guidance the Trust had produced.

I made clear my view that any clinician performing that role had to be familiar with both documents.

I have been told that the Trust has moved to a ‘needs-based’ evaluation system and that fresh guidance is being produced to assist those performing triage assessments.

You may feel that the Trust needs to be confident that all those performing triage assessments in the future will be familiar with the revised triage guidance and Operational policy and has a robust system in place to ensure this is the case. Information Classification: CONTROLLED

Responses

3 respondents

Devon and Cornwall Police and Kernow NHS Clinical Commissioning Group

17 Feb 2021 PDF

Action Planned

A former Police Superintendent has been recruited as Mental Health Liaison Officer. A trigger process to identify escalating risk in adults has been launched, including a more focused letter to GPs, with draft letter to be subject to a process of consultation. (AI summary)

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Dear Mr Cox INQUEST INTO THE DEATH OF DARRELL FRANCIS SHARPLES: REPORT UNDER REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 We are writing in relation to the above inquest_ and in the particular the above-mentioned report of 28 October 2020 ("the Regulation 28 report" that we have received from yourself: Considering the nature of the issues that you have raised within the Regulation 28 report, and giving particular recognition to the fact that your concerns are in part related to the sharing of information, it has been decided between us that joint response to the report would be appropriate_ In the first instance _ we want to take this opportunity to express our collective condolences to the family and friends of Darrell; and to anyone else who may be affected by his loss_ Secondly , we thank you for forwarding uS copy of the Regulation 28 report that was made following the inquest into Darrell's death: We always welcome opportunities to consider whether there is potential for our organisations to improve the service that provide to the public. Cox they

Thirdly , we are grateful for the additional time that you have allowed outside of the statutory time period for our response have now had the opportunity to consider the issues that you have raised within the Regulation 28 report Please therefore treat this correspondence as our formal response to the same_ The majority of this response will serve as an overview of the various developments that taken place between and on behalf of the organisations that we represent since the inquest Since the conclusion of the inquest; Cornwall Partnership NHS Foundation Trust has recruited former Police Superintendent as Mental Health Liaison Officer to provide advice, guidance and direction to mental health and community staff;, police officers and police staff on best practice in providing a service to persons suffering with mental health disorder in a criminal justice setting; in order to meet their individual needs in line with Cornwall Partnership NHS Foundation Trust polices and up to date legislation: The Mental Health Liaison Officer provides single of contact for the police as mental health advisor specialist trainer and promotes understanding and good practice relating to mental health within criminal justice and in addition will help implement and embed the Criminal Justice Liaison Service within Devon and Cornwall Police This is newly-created role which in itself represents a significant step forward in terms of creating potential for meaningful collaboration on the issues of concern that you have raised In addition, in January 2021 representatives from NHS Kernow; Cornwall Partnership NHS Foundation Trust and Devon and Cornwall Police met to discuss information sharing arrangements and to learn from the case_ Representatives included Detective Superintendent Head of the Public Protection Unit, and_Superintendent Head of Criminal Justice from Devon and Cornwall Police; Deputy Director of Primary and Deputy Director of Qualty trom NHS Kernow and Mental Health Liaison Officer from Cornwall Partnership NHS Foundation Trust The learning identified at the inquest was considered and discussed with a focus around information sharing The following actions were agreed and are now in process of being implemented: A review in relation to police access medical information out of hours regarding persons in custody at risk This review is currently underway_ Dr Consultant Clinical Psychologist; outlined in his evidence at the inquest that Cornwall Partnership NHS Foundation Trust has introduced a 24/7 mental health telephone support line for anyone worried about their own or someone else's mental health: A project is underway to develop this further to provide professionals helpline, which will support information sharing and increase professional access to mental health services, which we hope will be implemented in April 2021. Once implemented, this will provide another option for people working in police custody to seek guidance in relation to mental health services that are available_ 2 Inspector Force Mental Health Lead for Devon and Cornwall Police, and Mental Health Liaison Officer;, will now be able to discuss and Page 2 We have point Care the how

consider solutions regarding information sharing between the police and mental health services. 3 A meeting was arranged between Devon and Cornwall Police and NHS Kernow to discuss the process for adult GP referrals from the police Central Safeguarding Team ("CST") and closing the feedback loop with consideration for education of all GP's including working with GP lead for suicide prevention and dissemination via other forums_ Of particular note is that the meeting referenced in the latter above has now taken place_ At this meeting it was discussed and agreed that the sending of all ViSTs to GPs would overwhelm GPs, and create the risk of the higher risk referrals being overlooked as result of the volume. We recognised that more work could be done in the CST to improve organisational recognition of risk over time; in particular; where risk in relation to particular individual is escalating: This work has_been_progressing since 2020 and in November 2020, Detective Inspector ("DI") Ifrom the CST launched a trigger process to identify escalating risk in adults (including following the submission of a certain number of ViSTs) . Part of this process is to include a more focused letter to GPs to advise them of and alert them to the potential escalating risk: The CST already shares information from ViSTs with GPs via GP letters. The trigger process is specifically for escalating risk where for example there have been a number of ViSTs or where the CST has already written to a GP regarding ViSTs. Adrait letter has been prepared and will now be subject to a process of consultation led by including local GPs. Dl is also to produce guidance notes to accompany the letter; in addition to drafting an article for publication in the GP Bulletin to increase awareness The GP Bulletin will also be shared with safeguarding leads within GP practices. The learning points will be further raised at the Safeguarding Adult conference_ In short; DI and will ensure that the GP letter process, which follows the CST trigger process, Is improved by increasing awareness of the reasons that the letters are sent; what good practice should be, and what the expectations are for GPs_ In summary, while further work in relation to these matters is still to be progressed, we would like to emphasise that the work undertaken to date represents significant progress in the various parties collaborating in response to your concerns_ Accordingly, we hope that this demonstrates that we have taken concerns seriously_ We are again grateful for you bringing these issues to our attention, particularly as it has provided us with an opportunity to reflect on and identify opportunities for our organisations to further enhance the service that we provide to the public. Page 3 point your

Cornwall Partnership NHS Foundation Trust NHS / Health Body

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Action Taken

The Trust has introduced a 24-hour response telephone line and is developing an Initial Response Service (single point of access for people presenting with mental distress). All new staff members are required to attend a corporate welcome day induction and complete statutory training depending on their role. (AI summary)

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Dear Mr Cox

Darrell Francis Sharples, deceased Prevention of Future Deaths

As outlined at the inquest Cornwall Partnership NHS Foundation Trust has introduced a 24 hour response telephone line and is in the process of developing a single point of access for people presenting with mental distress, which we are calling an Initial Response Service.

We have worked across the whole health system to develop the model for this service which is due to be launched in the coming months. The service brings together voluntary and third sector organisations, the Improving Access to Psychological Therapy Service (Outlook South West) and the secondary care mental health services such as the Community Mental Health Teams into one place, for anyone wishing to refer themselves or anybody else for help.

The aim is to provide an immediate response in a way that will enable us to identify quickly a person’s needs and to ensure that an introduction or referral is made to the appropriate organisation or service.

A Senior Operational Lead has been appointed to the Initial Response Service. This role includes oversight of the Home Treatment Team; Crisis Hub and the 24 hour response telephone line, Mental Health Connect. In addition, six Band 7 Clinical Leads have also been appointed (equivalent seniority to ward Leaders and Clinical Nurse Specialists) to provide 24 hour clinical support to the service.

A dedicated Manager for the Single Point of Access within the integrated Community Mental Health Teams has also been appointed to manage the triage assessors across the county in addition to the development of processes and protocols for referral management. Previously the assessment teams were managed separately by the respective community mental health team mangers. The change in management structure provides additional governance and consistency to the assessment teams.

Nurse triage assessors within the Single Point of Access teams are senior clinicians of Band 6 grading. Core competencies for nurses working at this level requires consolidation of specialist knowledge and skills in mental health practice, demonstrating a depth of knowledge, understanding and competence that supports evidenced, informed, complex, autonomous and independent decision

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making. There will be occasions when Band 5 Clinicians will need to triage referrals in their capacity as duty desk clinician. This too is within the scope of competencies for a Registered Nurse, using their core professional qualification and training to conduct assessments in line with the Nursing Midwifery’s code and standards. A senior Clinician is available to the Band 5 Clinician should they require any support in guidance in complex situations.

All new members of staff are required to attend a corporate welcome day induction and each member of staff, including bank and agency staff, are required to complete statutory training depending on their role.

The Single Point of Access Manager has taken immediate action to ensure anyone performing this role within the Community Mental Health Teams has access to the Operational Policy and Triage Guidelines.

A Task and Finish group, consisting of the Initial Response Service Manager, Community Mental Health Team Clinical Lead, Associate Director for Mental Health and Learning Disabilities Nursing, Suicide Prevention Lead and involving Quality Leads from both Community Mental Health and Inpatient services; representation from Crisis Services including the Psychiatric Liaison Service with support from our governance team, is expected to commence later this month. The group will review and redesign how assessments are conducted and will include ongoing work around developing a standardised triage tool covering all adult mental health services, based on the UK Mental Health Triage Scale, as well as developing a training package for anyone performing a triage and assessment role within the Community Mental Health Team to ensure they are familiar with the assessment guidance and relevant policies and that there is a robust system in place to ensure this is the case. The Single Point of Access Manager has already commenced work with the Quality Lead for Community Based Mental Health services in reviewing the assessment team Operational Policy and triage process.

I hope that the above provides assurance in respect of the areas of concern identified in your report to prevent future deaths. On behalf of the Trust I would like to extend my sincere condolences to Mrs Sharples and to Mr Sharples’ family.

Further response and update from Cornwall Partnership NHS Foundation Trust NHS / Health Body

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Action Taken

The Trust launched the Initial Response Service as a single point of access for people in mental distress. A standardised triage tool has been developed for adult mental health services throughout the Trust, and the Trust is involved in a national project to improve access to patient information. (AI summary)

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Dear Mr Cox Re: Inquest into the death of Darrell Francis SHARPLES, concluded 12/10/2020 Regulation 28 Report to Prevent Future Deaths - update With regard to the concerns you raised following the inquest identified above, and further to the my response of 16/02/2021, and the joint response with partner agencies of the 17/02/2021, I write to provide an update of the actions taken by Cornwall Partnership NHS Foundation Trust (the Trust) to date. The Trust’s Initial Response Service has now been launched. This service provides a single point of access for people presenting in mental distress with the aim of quickly identifying an individual’s needs and ensuring they are referred to the most appropriate service. Since its launch in May 2020 this service has shown continued growth, and, as of November, handles an average of 66 calls per a day (please see appendix A for further detail). This has been further supported by the development of a standardised triage tool to be used by adult mental health services throughout the Trust, and is based on the UK Mental Health Triage Scale. A training package to support those clinicians undertaking triage assessment is currently being developed by the Community Mental Health Team (CMHT) Single Point of Access Team Manager, and this is further enhanced by clear operational policies, guidance and assessment tools ensuring that access to services is consistent throughout the county. As part of the Trust’s joint response with Devon and Cornwall Police and NHS Kernow, I advised that the Trust would build on the provision of the Mental Health Connect service with the development of the ‘Professionals Helpline’. This commenced on 01/11/2021 as a 24/7 telephone-based service to provide access to health information and advice to professionals involved in an individual’s care, be that health partners, social care or the Police. The line dealt with over 90 calls in the first month (please see appendix A for further details)

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As part of our commitment to improved joint working with the police you will be aware that

, former Police Superintendent, was appointed to the newly created role of Mental Health Liaison Officer (MHLO) within the Trust at the time of the Inquest. This substantive role has now been fully embedded within the Trust’s mental health services and shares considerable knowledge and expertise across both health and Police services. The role primarily focusses on information sharing, with access granted to both the Trust’s and the Police’s computer systems, enabling ‘live’ information to be shared in a timely manner to improve information sharing and joined up working to ensure provision of an efficient and effective service to persons presenting with a mental health disorder in the criminal justice setting.

This work has developed organically, with the MHLO identifying opportunities for further initiatives such as a pilot in the Penwith area whereby a police member of staff attends the CMHT weekly multi-disciplinary meeting, and this is reciprocated by a member of the CMHT attending the fortnightly Police Tactical Meeting, to share intelligence regarding persons of concern. This may be as simple as confirming address details, through to dealing with safeguarding concerns before they become issues, e.g. checking allegations of ‘Cuckooing’. Additionally, this approach has also served to build professional relationships between these partner agencies. If successful, this pilot will be rolled out throughout the county.

Further, the ‘136 Project’ is also currently being developed by the MHLO, with a view to providing training to 30 Police Officers to become Mental Health Tactical Advisors within the force who in turn will support their colleagues with a greater understanding of the Trust’s mental health services, Mental Health Act legislation, and Police powers under this Act.

An additional post of Neighbourhood Beat Manager for Mental Health has also been established, where a serving police officer, jointly funded by the Trust and Police Crime Commissioner, further strengthens information sharing between agencies and is currently developing a ‘Police Passport’ to support a more holistic Police response to incident management involving individuals in mental health crisis. This new initiative is being trialled with the Trust’s Community Child and Adolescent Mental Health Service (CAMHS) and focuses on creating a crisis plan with a young person, and their family and/or carers, which is then shared with the Police to provide advice and guidance on how best to support the young person should they come into contact with the police, e.g. a plan may contain details like “I am autistic, please do not handcuff me”. Once tested, this will be expanded to incorporate adult mental health services and there is a local desire to extend the work of the National Record Locator – a national project led by NHS Digital Services which enables an authorised clinician, care worker and/or administrator, in any health or care setting, to access an index of patient information to support that patient’s direct care – to be inclusive of the Police service.

I hope this update provides some assurance of the Trust’s ongoing dedication to making improvements within its services and working with partner agencies to develop an effective and proportionate response to those individuals who may find themselves in need of support due to their mental health illness.

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If you require any further information, or would like to discuss any of these points further, please do let me know.

Report sections

Investigation and inquest

On 12 October 2020, I concluded an inquest into the death of Darrell Sharples who died on 21 July 2018, then aged 49. . The medical cause of death was recorded as: 1a) Asphyxia; 1b) Hanging 1c) II)

I recorded a Conclusion of Suicide.

Circumstances of the death

The circumstances leading up to Mr Sharples death are set out in the attached summing up and judgment.

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