Toby Nieland

Dear Mr Smith Regarding: Regulation 28 report to prevent future deaths following the inquest of Toby Peter Edward Nieland Thank you for affording me the opportunity to respond to the areas of concern highlighted within Mr Brennand's regulation 28 report to prevent further deaths. I am responding to the report as the substance misuse lead for the Public Health Division a part of the Adult Care and Community Wellbeing Directorate at Lincolnshire County Council. My responsibilities encompass the programme management of substance misuse activity within the directorate including overseeing substance misuse treatment and recovery contracts with We Are With You and any commissioning activity on behalf of the Director of Public Health, Professor

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1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care;

Mr Nieland was not receiving structured treatment with We Are With You at the time of his death but was accessing the Needle Syringe Programme (NSP).

Public Health commission the NSP using NICE guidelines PH52 Needle and Syringe Programmes which details the provision required including:

 Advice on minimising the harms caused by drugs

 Help to stop using drugs by providing access to drug treatment (for example, opioid substitution therapy)

 Access to other health and welfare services

For those receiving structured treatment it would be good practice to involve the family (if appropriate to do so). However the NSP is designed to attract those

undertaking high risk behaviour so they can be accessed anonymously and only basic information is gathered for reporting purposes. This encourages those reluctant to access service to obtain clean equipment and minimise the spread of blood borne viruses such as hepatitis C and HIV. During the period Mr Nieland was struggling with his illnesses the family may have benefitted from accessing the carers support service commissioned by the council. This service has a substance misuse provision to support families and carers of those suffering from drug or alcohol misuse. It is recognised this did not take place and many people in this situation do not see themselves as carers and may not access the service, this situation is being addressed by the current service and will form part of the considerations when re-commissioning.

Future commissioning considerations and actions
i. The NSP is commissioned in line with NICE PH52 guidelines. Public Health will continue to undertake this responsibility and family members will be engaged as part of the pre-procurement work that builds the service specification and future delivery model Timeframe October 2023
ii. The council will consider commissioning a specific substance misuse family service to offer specialised support to the families and carers of people with drug and alcohol problems Timeframe June 2022

2. Unequivocal evidence established that the deceased suffered from an advanced progressive addiction overlaid with a vulnerable personality amounting to a complex Dual Diagnosis – the significance of which was not appreciated and therefore not managed adequately or appropriately;

The substance misuse services commissioned by Public Health with We Are with You are voluntary. I believe numerous attempts were made to encourage Mr Nieland in to the service but this was unsuccessful. NICE guidelines PH52 state NSP services should  Offer (or help people to access): secondary care services (for example, mental health services) This is dependent on the client wanting to access the support. Engagement cannot be forced as this can have a profound effect on long term outcomes. We Are With You are commissioned to work in partnership with other agencies including mental health services, and should a referral be received from mental health services it is expected that holistic joint working is undertaken and clear pathways should be in place for joint working.

Future commissioning considerations and actions

i. A joint working protocol is in place but has not been widely implemented across all services. The CCG, LPFT, We Are With You and Public Health should work together to review this protocol and implement a more robust

referral pathway between services to ensure timely and appropriate services can be accessed by all. Timeframe – Review to commence October 2020

3. In any event, even on the basis upon which community care was deemed appropriate, there was an absence of any co-ordination between mental health service provision and addiction services;

Mr Nieland was not in structured treatment with substance misuse services. If he had been, the substance misuse provider is commissioned to work in partnership with mental health treatment services to ensure that a comprehensive package of care is delivered. This process is not currently working universally across all services which needs to be addressed by both commissioners and providers to ensure everyone with coexisting mental health and substance misuse issues receives timely and appropriate care packages.

Future commissioning considerations and actions
i. There needs to be greater strategic and operational coordination between commissioners and providers. A group led by mental health commissioners should review and revise the existing protocol to ensure all managers and staff have clear pathways to follow within mental health and substance misuse services Timeframe – Review commenced October 2020

ii. The council and the CCG should consider different approaches to commissioning services that cater for those with dual diagnosis, this should form part of the commissioning cycle and include alternative models and joint commissioning opportunities Timeframe - October 2023

4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan;

This concern is linked to the services commissioned by the Clinical Commissioning Group and provided by Lincolnshire Partnership NHS Trust. If Care coordination is in place it is imperative that the substance misuse services work in partnership with the mental health team to provide a comprehensive individually tailored care package.

5. Inadequate evaluation of the deceased's previous history; his purported non-concordance (repeated assertions of not wanting treatment/support that ought to have been interpreted as an increase in his risk); progression of his complex vulnerabilities; his personal circumstances (reaction to accommodation and relationships); events suggestive of on-going misuse of drugs - all gave rise to a missed opportunities to appreciate a

series of ascertainable relapse signatures;

The services commissioned for substance misuse treatment have embedded assessment processes and re-engagement polices that all staff are expected to work to. Unfortunately in this case Mr Nieland was not in structured treatment and the needle syringe programmes are designed to attract those reluctant to access main stream services to ensure people do not feel pressured while doing so. Service users may use many different NSP sites. The specialist sites such as the one commissioned with We Are With You in Grantham offer a wider choice of services including more in depth harm minimisation and onward referral to any agency including mental health services.

Future commissioning considerations and actions
i. Services will continue to be commissioned in line with NICE guidelines PH52 Needle and syringe programmes. That said, We Are With You are looking to enhance the questions asked when people attend NSP's with immediate effect. These changes will be considered when developing future commissioning models to ensure service match the needs specific to Lincolnshire. This process will apply to both NSP and the wider treatment service Timeframe – October 2020 for the changes to questionnaire and October 2023 for re-commissioning

6. The absence of any "assertive outreach" to the deceased when discharged into the community (that is to say, no face to contact, no alternative welfare checks being organised, undue reliance being placed on the informal supervisory role of the landlord or other agencies) gave rise to a total disconnect between patient and healthcare provider, thereby creating a series of missed opportunities to assess the deceased, identify possible relapse signatures and potentially escalate care;

This concern is linked to the services commissioned by the Clinical Commissioning Group and provided by Lincolnshire Partnership NHS Trust.

7. The circumstances of this case evidences a gap in the provision of care to a patient with a Dual Diagnosis in Lincolnshire by reason of there being no dedicated and/or commissioned drug and alcohol recovery team/service;

Substance misuse dual diagnosis provision is not commissioned as a separate service but is included within the main treatment contract with We Are With You. Within the current contract the service is asked to:  Work in partnership with mental health teams and other Providers of mental health services to provide the best co-ordinated care possible to manage Service Users with dual diagnosis

 Develop strong partnerships and where appropriate joint working arrangements with mental health services to ensure that all clients requiring support and treatment for any identified mental health needs can access and are engaged in appropriate services  Involvement in the writing and delivery of training to generic and specialist staff regarding mental health and dual diagnosis  Ensuring staff have appropriate training and competencies, which are appropriately recorded, to enable them to address dual diagnosis

To achieve this We Are With You have developed their staffing model to include a mental health trained nurse and specialist recovery worker who is allocated any dual diagnosis cases. This process has worked well within inpatient settings but is still developing across community mental health services.

Future commissioning considerations and actions
i. All commissioners and providers should review current models and revise the joint working protocol Timeframe – To commence October 2020 – to be completed by April 2021 dependent on Covid 19 impacts

ii. The substance misuse provision for dual diagnosis will be a central point of the next service evaluation; this inspection should determine if current provision is adequate and appropriate to meet the needs of those accessing the service and make recommendations to the provider and commissioner regarding provision and future commissioning potential. Timeframe - September 2021 to complete the review (Covid 19 restrictions may delay this action)

8. The Lincolnshire Partnership NHS Trust document – "Crisis Assessment and Home Team Protocol" (Exhibit reference IJ2) makes no adequate or appropriate provision for a patient with Dual Diagnosis;

This concern is linked to the services commissioned by the Clinical Commissioning Group and provided by Lincolnshire Partnership NHS Trust.

9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to:

a. The lack of interface between senior or experienced care providers to

deal with multi-faceted or nuanced cases;

The current protocol was developed between Public Health, Lincolnshire Partnership NHS Trust and We Are With You (previously Addaction) in December 2016 (included as a separate attachment to this letter titled; 2016-12 DD Protocol V1.3.docx)

This protocol takes a 'no wrong door' approach to engaging with dual diagnosis patients and places an expectation on both providers to work together and develop integrated care pathways.

The Regulation 28 report has allowed all parties involved to review and reflect on previous shortfalls in delivery and a new impetus to resolve the remaining delivery gaps is now evident. Work has commenced in October 2020 to review and revise the protocol and look at a system wide approach to improve provision even further.

Future commissioning considerations and actions

i. There needs to be greater strategic and operational coordination between commissioners and providers. The existing protocol will be reviewed and revised to ensure all managers and staff have clear pathways to follow within mental health and substance misuse services Timeframe – Review commenced October 2020 to be completed by April 2021 dependent on Covid 19 impacts

b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases;

The response to question 7 details the provision in place from We Are With You. The specification for the service is outcome focussed and expects the provider to meet all relevant guidance and provide the support and care appropriate for those using the service to make a full and sustainable recovery. This includes dual diagnosis. The current provision is sufficient to manage need however if joint working grows significantly this will be reviewed as part of the on-going management of the contract between Public Health and We Are with You.

Future commissioning considerations and actions

i. Consider different approaches to commissioning substance misuse services including more joined up initiatives with the CCG's and other key partners Timeframe – October 2023

c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care;

The substance misuse treatment specification states:  Providing advice, support, training and skills transfer to the wider workforce in relation to prevention, identification, brief advice, early intervention and

appropriate referral into specialist treatment.' This provision is in place and available for Lincolnshire Partnership NHS Trust to access.

In addition to the training available through We Are With You, Public Health in partnership with We Are With You run four Royal Society for Public Health (RSPH) accredited courses per annum on Understanding Substance Misuse and Understanding Alcohol Misuse. These courses are open to anyone interested in raising their awareness of alcohol or drug issues. Unfortunately due to the Covid 19 Pandemic these courses are currently suspended but will be resumed as soon as possible.

Conclusion and future considerations The provision to support those with a dual diagnosis has improved over the last 18 months with many organisations working closely together and joint meetings taking place. However this is not currently uniform and work still remains to embed dual diagnosis best practice across all service areas

Public Health see the following as the main points for action going forward
i. Ensure any engagement work which informs future commissioning includes dual diagnosis support and fully involves clients and their families
ii. Consider redesigning the support service for families of those suffering from substance misuse issues so they can access support to help cope with and aid the recovery of their loved one
iii. Participate in a joint working group to review and implement a new working protocol led by mental health services and incorporating all aspects of substance misuse and mental health
iv. Continue to take into account current local and national best practice for joint working across mental health and substance misuse services when re- commissioning future drug and alcohol services
v. Undertake an operational level review of dual diagnosis provision within substance misuse services as part of the next annual inspection
vi. Consider different approaches to commissioning substance misuse services including more partnership commissioning with the CCG and other key partners

The Coexisting Severe Mental Illness and Substance Misuse: Community Health and Social Care Services guidance acknowledges there is a national system wide issue with the commissioning of services that cater for dual diagnosis, It states:  In the UK, service configurations, treatment philosophies and funding streams act as barriers to providing coordinated care. Separate mental health and substance misuse services are usually provided by different organisations, have different organisational and managerial structures, and staff within each service often lack the knowledge and skills needed to work effectively with people from another organisation. We recognise this is a national issue and Public Health is not complacent in trying to navigate complex systems to support those who are vulnerable

I hope the above has provided some reassurance that Public Health take its responsibility to commission substance misuse services very seriously and that a stronger emphasis on dual diagnosis has a part to play in current and future commissioning. We will work with all partners to develop services further and embed best practice in areas where this is not yet fully implemented.

Dear Mr Smith

In the matter of Toby Nieland deceased - REGULATION 28 REPORT TO PREVENT FUTURE DEATHS - Response of Lincolnshire Partnership NHS Foundation Trust The Trust wishes to express, once again its sincere condolences to Mr Toby Nieland’s family and loved ones on his untimely death. Owing to the seriousness of the concerns raised by both HM Senior Coroner and the deceased’s family at the inquest hearing, the Trust immediately began communicating with its commissioning and provider partners to highlight the matters raised. The Trust is grateful to HM Senior Coroner, Mr Timothy Brennand, for his report of 26 August 2020. The Clinical Commissioning Group, as the commissioning body, is submitting a coordinated response; this letter will be included as an appendix. Following consultation with the Trust’s Executive Directors, I respond to each of the points raised in Mr Brennand’s report as stated below. I have further summarised our actions at the end of this response, with the responsible leads for each action.
1. The concerns of the immediate family were not communicated to any of the agencies charged with the responsibility of caring for the deceased, nor were their views sought (directly or indirectly) as to the suitability of the deceased's accommodation and/or circumstances and/or pathway of treatment and care. Trust Response: The Trust appreciates the importance and benefits of understanding the views of patients’ families and carers. It is also recognised that concerted efforts need to be made to support staff to consider the voice of carers. To address this, the Board of Directors and Council of Governors have given a clear message of expectation that carers are seen as a priority and that their needs are considered. The Trust has put in place a range of services that support carers and provide helpful information on a routine basis:-  Upon inpatient admission, the Trust provides information to a patient’s family and/or carer. The information document is also publically available to view and download from the Trust’s website https://www.lpft.nhs.uk/download_file/1876/0

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 The Trust offers a dedicated email address for family and carers to communicate with the patient’s clinical team. lpft.carers@nhs.net

 A carers’ newsletter is produced and circulated on a monthly basis.

 At the time of writing, 93 trust staff are trained in Meriden Behavioural Family therapy and a further 50 staff members are scheduled to receive this specialist training by the end of January 2021. This is a dynamic training programme that educates staff regarding the importance of involving families and carers; it also teaches ways in which family and carers members can be supported.

 The Trust has introduced a dedicated member of staff as a ‘Carer Lead’ for each of its inpatient units across Lincolnshire. The Carer Lead is available on the ward to patients, families and carers and is identified through the wearing of an orange lanyard.

 The Trust offers specialist individual support to carers and families in times of crisis. The referral for this level of support is received via the patient’s clinical team.

 The Trust offers fortnightly education and support groups based in both Lincoln and Boston. During the Covid-19 pandemic, the groups continue to operate temporarily via virtual meetings.

 Dedicated ‘Family and Carers’ notice boards have been introduced on every inpatient ward offering a wide range of information.

 A smartphone ‘WhatsApp’ group has been set up to provide another source of information sharing and communication.

 Accreditation under the Triangle of Care initiative, with the Trust having been awarded two stars under this national scheme.

 A Carers Strategy that has been co-produced with carers and with Trust Governors.

 An Executive Director sponsor who has executive oversight and is a member of the Board of Directors.

In cases where explicit consent has not been given by a patient to share their sensitive personal information; the Trust has taken action to remind clinicians that information from families and carers can still be received. The Carers Lead for the Trust continues to work with the Divisional Leads; Learning and Development and also the Communications Team to reinforce the message to staff that they can still receive information from Carers and Families even when consent is not given from the patient to share information. In Mr Nieland’s case it was unfortunate the Trust were not made aware of any concerns held by the family, however there is the clear commitment to learn from this and to consider what needs to be in place to strengthen communication and to actively encourage feedback.

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As a provider of specialist mental healthcare, the Trust recognises the role of appropriate accommodation in a patient’s recovery, although was not aware of the details of Mr Nieland’s accommodation to which he was discharged in 2018. The Trust recognises the need for appropriate communication between partner agencies to provide collaborative health and social care and support to patients and is committed to continuously reinforce this message to all staff. The Trust now works closely with a number of partners from the Voluntary, Community and Social Enterprise sector in Lincolnshire including Carers First and Everyone, and has developed good working relationships, which have led to identified placement options for patients being discharged from hospital. The Trust is working with Local Authority, District Councils, Commissioners and NHS England/Improvement on a joint accommodation strategy for those with mental health and social care needs, to ensure the system is working together on more responsive and effective housing solutions for our service users.
2. Unequivocal evidence established that the deceased suffered from an advanced progressive addiction overlaid with a vulnerable personality amounting to a complex Dual Diagnosis – the significance of which was not appreciated and therefore not managed adequately or appropriately.

Trust Response:

The term dual diagnosis can be used to cover a broad range of coexisting mental health conditions alongside problems with drug or alcohol use, the common theme being the presence of both drug/alcohol and mental health conditions at the same time. This means that a person’s presenting needs can vary significantly. There are recognised challenges in providing effective treatment for this group of patients; most notably, the individuals’ willingness and ability to engage.

Due to Mr Nieland’s fluctuating mental health needs and the fact that he was deemed to have capacity to make his own life choices, there were times when he was not engaged with mental health services and the Trust was not legally able to enforce any treatment upon him. When Mr Nieland was engaged with the Trust’s services, there is evidence that his drug and alcohol issues were being appropriately considered and advice was being given. However, successful treatment for drug and alcohol addiction requires continued engagement, and in Mr Nieland’s case unfortunately the Trust was limited in its powers to enforce any treatment.

3. In any event, even on the basis upon which community care was deemed appropriate, there was an absence of any co-ordination between mental health service provision and addiction services.

Trust response:

There is evidence from the clinical record that Trust staff believed Mr Nieland was effectively engaging with Addaction (as it was known then) and that he was happy with the support he was receiving. Based upon information available at the time there was

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no known need for the Trust to pursue any additional support for his drug and alcohol problems. Upon reflection, subject to explicit consent, the Trust accepts that it would have been best practice for the Trust to have proactively contacted Addaction to ascertain Mr Nieland’s level of engagement as it is evident from the subsequent information provided by Addaction that Mr Nieland was not engaged in the level of structured treatment that the Trust staff believed he was. More proactive contact with Addaction would have identified this mismatch between what Mr Nieland was reporting and his actual level of engagement. In turn, this would have enabled Trust staff to challenge Mr Nieland’s claims about his drug and alcohol treatment and provide an opportunity for further encouragement to seek out appropriate support, although it would not have been able to enforce or change any such treatment without Mr Nieland’s engagement. The Trust has in place a policy which provides guidance in cases where patients present with high severity of mental health and substance misuse… “…Service users should be engaged with secondary mental health services. This would include Integrated Community Teams, forensic, rehabilitation and acute services. Case management/care coordination would rest with these services with additional support from substance misuse services. This support can include consultation, advice or direct intervention to the service user and their care network”. The Trust and ‘We Are With You’ (as Addaction is now called) will work together to ensure the implementation of robust communication systems; agree appropriate information sharing arrangements and ensure alignment of clinical pathways and protocols, with the aim to make collaborative working between the two organisations standard practice. The Trust confirms this is part of its work plan over the next six months, led by the Clinical Director for the Community Services Division working with the Quality lead for the Division.

4. There was an absence of any adequate "Care Programme Approach" (a package of care used to plan mental health care) resulting in no care coordinator being appointed to monitor the deceased within the auspices of an appropriate care plan.

Trust Response: The Trust has in place a comprehensive clinical care policy which sets out the criteria and process for assessing and putting in place care arrangements. In Mr Nieland’s case, following his discharge from inpatient services, in accordance with Trust policy and national guidance, the Trust made arrangements with Mr Nieland to meet with him to assess his needs. It is possible that Mr Nieland could have been placed on a Care Programme Approach, however he did not attend and sadly the opportunity to assess his needs in this regard did not take place. Whilst he was not managed on the Care Programme Approach framework, a lead professional was assigned to Mr Nieland and risk assessment was formulated together with a care plan. Learning from the death of Mr Nieland, the Trust will strengthen the policy in accordance with the guidance issued by the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care

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Programme Approach. Clear guidance will be given to staff regarding procedure in the case of persons with dual diagnosis. The Head of Quality and Safety will lead on the review and strengthening of the policy, working towards the policy update being approved by the Trust’s Quality Committee, within the next 6 months.

5. Inadequate evaluation of the deceased's previous history; his purported non- concordance (repeated assertions of not wanting treatment/support that ought to have been interpreted as an increase in his risk); progression of his complex vulnerabilities; his personal circumstances (reaction to accommodation and relationships); events suggestive of on-going misuse of drugs - all gave rise to missed opportunities to appreciate a series of ascertainable relapse signatures. Trust response: Learning from the tragic death of Mr Nieland, the Trust has taken steps to enhance the training offered to staff about assessing risk of suicide to reinforce the complex interplay of factors mentioned above including previous history, accommodation and employment needs, substance and alcohol misuse patterns and relationships. This revised suicide prevention training will be rolled out to all staff commensurate with their role and clinical responsibility, within the next 6-12 months. The Divisional leads are working closely with the Learning and Development Lead to develop a time table and identify appropriate staff for training.

6. The absence of any "assertive outreach" to the deceased when discharged into the community (that is to say, no face to contact, no alternative welfare checks being organised, undue reliance being placed on the informal supervisory role of the landlord or other agencies) gave rise to a total disconnect between patient and healthcare provider, thereby creating a series of missed opportunities to assess the deceased, identify possible relapse signatures and potentially escalate care. Trust response: The Trust was informed by the out of area inpatient unit that Mr Nieland had been discharged into the community. In accordance with Trust policy and national guidance, the Trust’s Crisis Resolution and Home Treatment Team offered timely follow-up appointments with Mr Nieland to assess his risk and care arrangements. Based upon the information available at the time, a clinical decision to request a police welfare check was not considered necessary. The Trust appreciate the importance the views of family and carers has in formulating appropriate care arrangements for patients. With the benefit of hindsight, it is accepted that the knowledge and concerns of Mr Nieland’s family would have better informed assessment of risk. The Trust is continuing to support staff and to emphasise the importance of working and supporting patients to include family and carers in their care. The response under section 1 of this letter outlines the initiatives behind this.

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7. The circumstances of this case evidences a gap in the provision of care to a patient with a Dual Diagnosis in Lincolnshire by reason of there being no dedicated and/or commissioned drug and alcohol recovery team/service.

Trust response: The Trust recognises there is currently a commissioning gap in the provision of care to patients identified as having a dual diagnosis. Currently mental health services and substance misuse services are commissioned separately in Lincolnshire with the services provided by two organisations. The Trust is a provider of specialist mental health services and is not commissioned to provide substance misuse services. The local Clinical Commissioning Groups (CCG) and the Local Authority’s Public Health department commission ‘We Are With You’ (formerly ‘Addaction’) to provide substance misuse services.

Learning from the death of Mr Nieland, as stated above, the Trust commits to the strengthening of its policy in accordance with the guidance issued by the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care Programme Approach which will include working together with ‘We Are with You’. Clear guidance will be given to staff regarding policy and procedures in the case of persons with dual diagnosis. Further, the Trust commits to working with its partner agency ‘We Are With You’, to review and strengthen working arrangements. Further, as stated above, the Trust and ‘We Are With You’ commit to working together to ensure the implementation of robust communication systems; agree appropriate information sharing arrangements and ensure alignment of clinical pathways, with the aim to make collaborative working between the two organisations, standard and practice. The Trust confirms this will be part of its work plan within the next six months, led by the Clinical Director for the Community Services Division working with the Quality lead for the Division

8. The Lincolnshire Partnership NHS Trust document – "Crisis Assessment and Home Team Protocol" (Exhibit reference IJ2) makes no adequate or appropriate provision for a patient with Dual Diagnosis. Trust response The Trust confirms, as stated above, that it will review its clinical policies and protocols relating to dual diagnosis and that it will continue to work with its partner agency, ‘We Are With You’ to review and strengthen robust communication systems; to agree appropriate information sharing arrangements and ensure alignment of clinical pathways through the use of a jointly agreed protocol. The aim is to make collaborative, integrated working between the two organisations standard practice. This will be part of its work plan within the next six months, led by the Clinical Director for the Community Services Division working with the Quality lead for the Division. The policies and protocols will equally apply to patients being treated within its inpatients and crisis and home treatment services too.

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9. The National Institute for Health and Care Excellence (NICE) Guideline Scope document "Severe mental illness and substance misuse (dual diagnosis): community health and social care services stipulates that there should be a Dual Diagnosis protocol setting out specifically the roles of the mental health provider and the drug and alcohol service provider (no such protocol being in place at the material time) and that whilst it is apparent that some thought has been deployed to re-install a bridge between mental health provision and drug and alcohol services this does not address the needs of a patient suffering from a complex Dual Diagnosis in Lincolnshire due to;

a. The lack of interface between senior or experienced care providers to deal with multi-faceted or nuanced cases.
b. The absence of specialist Dual Diagnosis workers to be deployed in complex cases.
c. The absence of adequate and robust guidance and training, in particular for mental health practitioners to be aware of substance misuse issues and a patient suffering from Dual Diagnosis that impact on appropriate pathways of treatment and care.

Trust response: Learning from the death of Mr Nieland, as stated above, the Trust is committed to the strengthening of its policies and protocols in accordance with the guidance issued by NICE and the Department of Health, to ensure where patients identify as having a dual diagnosis, they are provided with an enhanced Care Programme Approach which will have joint working with We Are with You’, utilising expertise of workers from both services in a collaborative manner. The Trust has already begun conversations with its Commissioning partners and We Are With You, to identify commissioning gaps and ways of ensuring workers with the right skills are deployed in both agencies. The Trust is committed to a review of the training provided to staff to ensure they are appropriately equipped with the knowledge and ability to care for patients with dual diagnosis. The Learning and Development Lead is working with Divisional staff to develop the appropriate training package, over the next 6-12 months.

We have summarised below the actions the Trust will take to learn from Mr Nieland’s death and enhance services for patients with a complex dual diagnosis presentation: To review internal policies and protocols as well as work together with “We Are With You” to embed care pathways between the two organisations to address gaps in services. (Leads: Clinical Director for Community Division and Quality Lead for the Community Division)
i. To embed care pathways between the Trust and “We Are With You” to address gaps in services. This will also be accompanied by a discussion with the Commissioners to advocate for the right level of investment in the system to meet the needs of people with a dual diagnosis. Leads: Quality Lead for the Community Division and Clinical Director for Community Division – by 31 April 2021.

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ii. To review Information sharing arrangements between the Trust and “We Are With You” to remove barriers to information sharing while complying with legal guidance Lead: Trust Caldicott Guardian – by 16 November 2020.
iii. Education and Training: The Trust commits to reviewing and updating its training and competencies programme on offer to ensure a focus on dual diagnosis, including clinical presentations, risk assessment and information sharing. We have recently developed a refreshed suicide prevention training matrix which addresses risk assessment but will work on the other areas. Leads: Learning and Development lead, People Directorate – by 31 October 2021
iv. To reinforce and further embed the important role of carers and family members in providing the right quality care to patients and to support carers in getting involved with their loved ones’ care, including receiving information from carers and sharing information with consent from patients. Lead: Service Manager for Carers and Peer Support – Ongoing
v. To review the Care Programme Approach to ensure the right decisions are made about allocating care coordinators to patients and also to ensure that all patients with a dual diagnosis are allocated a care coordinator. Lead: The Trust Quality and Safety Lead – by 31 April 2021.
vi. To continue to engage with Commissioners and all system partners including primary care, acute care services, and housing partners (not named in the letter but we recognise the importance of all partners in the system) to ensure the services required for patient with dual diagnosis are appropriately funded – clinical, management and leadership and administrative support. Lead: Director of Strategy, Planning and Partnerships - on-going
vii. Promote appropriate data gathering, benchmarking with other services, opportunities for research and learning from Serious Incidents as a system working in an open, collaborative manner. Lead: Medical Director - on-going