Safoora Alam

Dear Mr Siddique

Thank you for your report regarding Ms Alam’s inquest, and the concerns raised from the evidence revealed during the course of the inquest.

I can confirm the Service Manager from Social Work and Therapy has reviewed the concerns and actions identified, which has resulted the following outcomes.

In relation to our approaches to sharing information of risk. The Service Manager of Social Work and Therapy, and the Service Manager of Neighbourhoods have met and reviewed the identified concerns and actions within the report. As a result an operational group has been set up to explore and develop a vulnerable adult risk management protocol.

In relation to point 2, an action for Social Services to consider reviewing their training for social workers, obtaining accurate and up to date information prior to any visit. A review of our current practice guidance is being undertaken, and lessons learnt will be shared with all staff groups, through team meeting sessions.

In order to be assured of the robustness of our joint agency protocols. I can confirm the Service Manager of Social Work and Therapy has made contact with Urgent Care Manager, Mental Health Trust, and there are plans in place to undertake a review of our current protocols within the next four weeks.

I trust the information provided will satisfy you that we have acknowledged and responded to the concerns and actions identified.

Dear Mr Siddique,

Re. Regulation 28 report, prevention of future death pertaining to Ms Safoora Alam, deceased.

Firstly on behalf of Black Country Partnership NHS Foundation Trust may I extend our most sincere condolences to the family of Ms Alam.

During the course of the inquest the evidence revealed matters giving rise to concerns in such a way that there is a risk that future deaths will occur unless action is taken. In response to your regulation 28 report to prevent future deaths we have outlined below the actions, Black Country Partnership has taken with the Local Authority to address the matters of concern that affected our organisation.

1. All agencies involved may wish to consider reviewing their approaches to sharing of information and approaches to multidisciplinary risk assessments for patients with these complex needs.

Currently both organisations hold multidisciplinary risk assessment meetings in isolation, particularly since the section 75 agreement was disbanded. There is recognized a difficulty in communication between departments in this matter which needs to be resolved. As a response, the General Manager for BCPFT Urgent Care Services has met with the Service Manager for Clinical Services from the Local Authority to examine how our individual organizational processes can be optimized and joined going forward in order to prevent gaps in services.

Both senior managers were able to identify common goals and aims in existing organizational protocols and will instigate a steering group of senior clinicians and managers from both organisations to look at introducing joint complex care panels that will look at risk assessments for patients with complex needs that require joint information sharing and joint working.

It is proposed that these joint multidisciplinary complex case panels will occur monthly and be chaired on a rotational agreement by a General

Headquarters Delta House Delta Point Greets Green Road West Bromwich B70 9PL

Tel: 0845 146 1800 Fax: 0121 612 8090 Web: www.bcpft.nhs.uk

Manager from Black Country Partnership and Service Manager from the Local Authority. The joint multidisciplinary panel will determine which is the lead organisation in each case where there is disagreement and also ensure that the joint resources from both organisations are employed when discussing individual care plans and risk assessments.

2. Social Services may wish to consider reviewing their training for the social workers involved and the importance of obtaining accurate and up to date information prior to any visit.

This concern and supporting action is for the Local Authority to respond to.

3. The Mental Health Trust in conjunction with the local authority may wish to consider reviewing their joint agency protocols and developing multi- agency protocols to learn from this tragic incident.

The section 75 agreement whereby the local authority delegates responsibility to the local NHS organisation in this case Black Country Partnership has been disbanded. This has meant that services have developed independently from each other and that where services and departments used to work together and oftentimes cohabit office space, this no longer happens. Both organisations have joint protocols for working together but in a majority of cases, it is accepted that staff do not understand their counterpart service nor who to contact in the local authority and vise versa.

The General Manager for Urgent Care Services for Black Country Partnership and the Service Manager for the Local Authority have met to examine communication and interface between the two organisations. They agreed that communication and interface is often poor due to that both organisations have different departments and terminology in services which can cause confusion. This is augmented by the fact that staff and senior staff are not aware of who their counterpart is and how to contact them in some cases.

The General Manager for Black Country Partnership and the Service Manager for the Local Authority have agreed to set up task and finish groups to look at joint agency protocols in both organizations and review them. Furthermore, they agreed that there should be a joint database or protocol which contains all contacts and services that each organisation provides. This will provide staff with an up to date contact list of services in order to support and promote joint working.

Both senor managers agreed to include on the database and in joint agency protocols the hierarchy and structures of services so that there is a governance and escalation process.

Please note that concern number 2 is for the local authority to examine and therefore BCPFT have not commented on this outcome.

The senior managers also agreed to consider engaging in a wider learning event to consider outcomes and where future processes can be continued to be strengthened.

I hope this provides you with assurance that the Trust has taken the concerns raised in your regulation 28 response very seriously and will continue to take action to reduce the likelihood of a similar incident from reoccurring. We hope that the actions highlighted above will make a difference and we will review changes made at regular intervals to ensure that they are embedded whilst sharing the outcome and lessons learnt with all affected staff.