Robert Hughes

Dear Ms Skerrett Re: Regulation 28 Report to Prevent Further Deaths - The Late Mr Robert Glyn Hughes Thank you for the notification of the Regulation 28 Report, which was issued to us on the 11th February 2019, following the inquest into the death of Mr Robert Glyn Hughes. It is always a sadness and of concern to us when someone who uses our services dies whilst in our care. We want to do all that we can to learn from the enquiry that has been undertaken into the death of Mr Hughes so that we can take action to improve our practice accordingly. Your report raises concern with us that the Triangle of Care approach, where mental health team practitioners seek permission from the patient to approach the patient's family, is not consistently applied'. We agree with you that there is more work for us to progress to ensure that our patient's family members become partners with us in the care of their loved one whenever possible. We regard this as a fundamental principle within our routine practice. We thought it helpful to outline some of our committed effort undertaken in recent years toward this goal, prior to offering you assurance that we will continue to strive for a more consistent application of this practice into the future. We recognise the need and benefits for our service users, their careers and our staff which can flow from us establishing a strong working partnership with family members in our delivery of care and support. In 2011, we published a Carers Charter which was developed with local people who both used our services and cared for people who used our services. This is published on our website, is still displayed in clinical settings, was launched at a Board level listening and learning event with local families and continues to be profiled throughout our work. Main office: Pioneer Avenue. Gloucester Business Park. Brockworth, Gloucester, Gloucestershire. GL3 4AW Chair: Ingrid Barker Chief Executive: Paul Roberts `gether is the name for 'gether NHS Foundation Trust Mental & Social Healthcare

Our Triangle of Care membership started when the scheme was launched in 2015. Developing practice to be in line with the six standards expected in the Tringale of Care (https://www.nhsconfed.orqHmedia/Confederation/Files/publie/020access/CareTriangle.pdf) has been a dedicated practice development initiative, overseen at Executive level and its progress monitored by our Governance Committee, since that time. In 2016 and together with local carer organisations, we were acknowledged and commended by the Carers Trust for our progress in involving families in the care and support we offer to their loved ones. (https://www.2aethernhs.uk/commitment-to-carers-recounised-with-qold-star- award°. Since then we have undertaken further and additional practice development work with our clinical teams and the outcomes of this were recognised in 2018 with us receiving a second acknowledgement and commendation from The Carers Trust. This acknowledgement was in recognition of our progress demonstrated through a formal audit (httos://www.atethernhs.uk/commitment-to-carers-recoonised-with-qold-star-award/ ). We would be pleased to provide the documentation submitted to the Carers Trust to you should this be helpful. We remain committed to improving this area of our practice to ensure that families/carers are always involved with us in provided care and support to their loved one wherever possible and we will continue to do all that we can to make this a reality. In response to your report, we are proposing to progress the following to move towards this requirement:
• Reinforce our aspirations and approach at one of our Senior Leaders Forum, with our Expert by Experience Carers. Our senior Leaders Forum brings together some 100+ of our service/team managers. In this Forum we discuss and involve our service/team managers in a number of strategic and practice matters and require them to be message and practice carriers up and down the organisation. We will undertake a session in relation to reinforcing the involvement of family and carers in the care and support we provide by May 2019
• Issue a further "Practice Note" from our Clinical Executives, to all clinical staff by June 2019
• Undertake a 'Carers Learning Update Week' event for clinical staff in July 2019
• Issue a blog for staff in relation to these issues from our Director of Quality by July 2019
• Include involvement of carers in our Always Event initiatives by September 2019 As part of our ongoing Quality Improvement work, led by our Director of Quality, we are progressing a project throughout 2019/20 to further our work to effectively embed lessons learned from serious incident investigations into clinical practice. We will be reporting this through our Trust Governance committee and to our Commissioners. This work will also be closely aligned to work that is under way in the county alongside Public Health colleagues and the CCG to reduce suicides, in line with national plans such as the Inpatient Zero Suicide initiative. Progress on this will also be reported to our Trust Governance committee, our Commissioners and NHS Improvement.

Our efforts to engage with all those involved in a person's care remains a consistent thread throughout our services. We believe that communication and connections of the nature outlined above will contribute to improving patient safety and we will continue our work to ensure this culture in maintained and further developed in all parts of our organisation. Please do not hesitate to contact me for clarification in relation to any aspects of our proposals, or please feel free to call me if a conversation would be helpful. We trust that the above demonstrates that we have taken your notice seriously and are committed in trying to and improve our approach to hopefully reduce adverse outcomes from poor communications between clinicians and carers/families.