Amanda Briley

Dear Mrs Brown Re: A Briley Further to your report dated 11 January 2019, in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the coroners (Investigations) Regulations 2013, I offer the following response. We have investigated the matters of concern that have arisen during the course of the inquest of Amanda Briley. Leicestershire Partnership NHS Trust takes these matters very seriously and I hope that you and Ms Briley's family will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again. The matters of concern you have raised are as follows:
1. / am concerned that too many Leicestershire Partnership Trust employees do not have any or any sufficient training in autistic spectrum disorders. This Jack ofknowledge makes a difficult situation considerably worse for any presenting patient, with potentially dangerous consequences. I was not reassured that training is given at the earliest possible opportunity to reduce these risks, or that all appropriate staff are receiving or accessing training to a suitable standard. In this case even when it was acknowledged that Amanda would remain an in patient for some time, front line staffincluding her named nurse and the ward matron were ill-equipped to understand-her communication needs and care requirements. I ask for LPT to review and reconsider the current training planning in this area.

m=disabilit} Leicestershire Partnership NHS Trust is a smoke-free Trust. Please visit www.leicspart.nhs.uk/smokefree for details B f:i confiden1 EMPLOYER ­ NHS organisations are now using 100 per cent recycled paper as part of our sustainability

Response , Head of Nµrsing and , Director for Adult Mental Health and Learning Disability Services have reviewed the Trust training provision. The Trust introduced an e-learning Autism Awareness module in November 2017 which is accessible to all staff. A recommendation went to the Trust Learning and Development Group in February 2018 that this training becomes role essential for clinical staff in AMH/LD Services; this was agreed and will be finalised at the Trust's Strategic Workforce Group in March 2019. In March 2018 a Recognising and Caring for People with Autistic Spectrum Disorders (ASD) practical workshop took place involving a range of professionals with experience of working with people with autism, a Speech and Language Therapists (SL T) Assistant, and Consultants from the Autism Diagnostic Service and Learning Disability Service. The Trust is currently looking at how to develop this training further for inpatient areas that will be working with patients with ASD in Mental Health Services. A training task and finish group has been set up with representatives from mental health wards, learning disability serv,ices, SLT and Occupational Therapy (OT) to develop a more in depth training product and this will be reporting back to the Directorate Management Team in April 2019. The group are considering how elements of Ms Briley's video interview with SLT can be used to enhance either the existing e-learning module or further training. and met with Ms Briley's mum who is keen to support the training review. They shared the e-learning module with her and Mrs Briley felt that whilst this was a good basic awareness resource, and that it was important to ensure ward staff in particular were equipped with the practical skills in how to apply the knowledge gained. She provided helpful insight and suggestions as to how the e-learning could be built on and is keen to support the development of the training. · In the interim the Directorate has identified some specialist mental health SL T resource. The individuals providing this support to the wards at the Bradgate Unit are skilled in .ASD diagnosis and management. All in-patients with a diagnosis of ASD· will be referred to the SL T service to ensure the care plans reflect a bespoke and differentiated approach. In addition the SL Ts are looking at the best ways to support ward staff and are working with the OTs to develop a decision making flowchart. Again the feedback from Ms Briley's mum will inform this tool.
2. The court was advised that it was "custom and practice" on bank holidays for the nursing staffto agree between themselves to ·have a shorter hand over and work an hour less. This removed an important part of the expected staff communication and left a significant gap in the safe transfer of information, on the days when senior staff are likely to be on leave and it was recognised that bank staffmay be covering. Furthermore, patients on an acute mental health ward are likely to struggle emotionally on these important social occasions when they are apart from family and familiarity. The handover on such days should be more, not less robust and I ask that the LPT conduct an urgent review and senior level scrutiny regarding this matter.

m=disabilit) Leicestershire Partnership NHS Trust is a smoke-free Trust. Please visit www.leicspart.nhs.uk/smokefree for details B!iconfiden1 EMPLOYER ­ NHS organisations are now using 100 per cent recycled paper as part of our sustainability

Response Ms Briley's inquest was just before the Christmas bank holiday period and immediate action was taken by the Heads of Nursing across the Trust to ensure the working arrangements and expectations of staff around the handover of patient care was clear during this period. On the wards at the Bradgate Unit there is a senior nurse on duty as the.'Clinical Duty Manager' (COM) at all times (24 hours, 7 days a week). The COM visited wards over the Christmas and New Year period to ensure handovers were taking place appropriately. In January 2019 the learning from Ms Briley's death and the inquest was discussed again at the Chief Nurse's meeting with all Heads of Nursing and as a result the Trust's Handover Policy and documentation will be reviewed and a further programme of checking the handover on wards will be developed. In April 2019 the Mental Health and Learning Disability Wards will commence introducing Nerve Centre which enables each staff member on duty to carry a hand-held device allowing them immediate access to a set of patient information including the latest handover for that patient. Staff members can directly add information about the patients care whilst with the patient, which then provides an automatic update to the central information for that patient held on Nerve Centre so all users can see any changes to care immediately. We hope this reassures you that we have taken appropriate action in response to your findings regarding training for staff around Autism, ensuring the handover at bank holidays periods is of the same standard as other times, and improved policies and support systems will provide safe and effective care in order to reduce the risk to our future patients. If I can be of any further assistance to you please do not hesitate to contact me.