Ellie Long

Dear Lake Re: Ms Ellie Long write in response to your prevention of future deaths report dated 18 March 2019 following the conclusion of the inquest into the death of Ms Ellie Long: know you will share a copy of this response with Ellie's family and would like to express my condolences for their loss. Ellie's death is a tragedy and it is essential the Trust takes all opportunity to learn. The report raised concern in two areas_ Record keeping The report detailed that not all records were entered on to the Trust's electronic health record system: Further; some meeting notes recorded by hand were not subsequently reflected within the record. The inquest heard evidence of the actions the team have taken to improve this area, audit as a means to provide confirmation and assurance_ Communication with external agencies The report noted the importance of recording the attempts at contact with partner agencies, but highlighted it is the actual contact being made that is the critical action It is positive to note that the team have taken action in response to this learning: However; it is foreseeable that the aspect of record keeping and communication could be present in any team. The Trust is taking the following actions which are anticipated to assist in bringing consistent and sustained improvement: All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to drive improvement: Supporting this is a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager. The session will have a specific focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication. The Trust is strengthening its clinical and service leadership to ensure they have the necessary breadth of skills and resource to lead safe and effective services. Of particular note, the Trust will be introducing Patient Participation Leads for each locality, who will work alongside new Clinical Directors to lead the components of quality and patient experience_ The Trust is finalising the recruitment to these roles which will be effective from September 2019. function of this new approach will be the Working Chair: Marie Gabriel CBE Chief Executive: Jonathan Warren together Trust Headquarters: Hellesdon Hospital, Drayton High Road, Norwich NR6 SBE for better mental health Tel: 01603 421421 Fax: 01603 421341 wnsft nhs uk MAY_ 2019 King May ` Mrs using fully key

accountability to share learning, implement and monitor recommendations from serious incidents. Their role is to support the local clinical services function effectively, working alongside their network of partner agencies_ The Trust will gain assurance these interventions are working through a number of indicators. This will include audit; user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement Thank you for providing this report to the Trust. These are important matters which require diligent attention at all levels of the Trust in order to provide safe and effective care_