Benjamin Williamson

Coroner's concerns

AI summary

The CMHT repeatedly discharged a patient with co-occurring mental health and alcohol issues, while Addaction failed to communicate with his GP or address consent for information sharing, creating a significant care gap.

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_ CMHT Commissioners At inquest; heard from partner at Mullion and Constantine Group Practice and the Locality Lead for Commissioning: Mr Williamson was his patient told me that Mr Williamson had been referred twice to CMHT, On both occasions_he had been seen, assessed and discharged. described this as having a significant impact upon his patient who was left feeling he was not ill enough to be worthy of support expressed his view that the system is not set up to serve the population: He said it was his experience that patients Iike Benjamin are bounced between the various mental health services seeminalv_with no one willing or able to accept responsibility for providing professional care Isaid he anticipated CMHT had met the letter of its contractual 1a) and doing commitments but he felt it had failed to meet the needs of his patient: identified that the problem was particularly acute for patients who have a mental health issue plus an alcohol (or drug) problem: He felt that while referring Benjamin to Addaction had addressed his alcohol-related concerns, there had been a total lack of consideration of any underlying mental health issue. This is not the first occasion on which observations of this nature have been made before me although inp have rarely had a more articulate or well-placed witness Addaction Itold me that after referring Benjamin to Addaction hehad no communications or feedback from the service_ heard from lin this regard. It was accepted that there should have been more Iiaison with the GP and that; in particular, a letter from the doctor in January 2018 was answered and should have been. Upon further exploration, it emerged that Benjamin had not given full consent for disclosure to his GP was told that his Recovery Plan had been reviewed on 25/5/17 , 16/8/17, 27/10/17 and 12/2/18. was advised that the issue of consent should have been considered at these reviews buut that did not appear to have happened. Both Benjamin's mother and were of the view that if this matter had been dealt with consent for disclosure to the GP have been provided. Ifelt that the lack of feedback compromised his to provide care to his patient:

Responses

2 respondents

Addaction

12 Dec 2018 PDF

Action Taken

Addaction has reviewed and improved how they record confidentiality and consent reviews. They will provide the Health Centre with client numbers, have a designated worker attend practice multi-disciplinary team meetings with access to SystemOne, and inform GPs earlier about plans to cease structured treatment where consent exists. (AI summary)

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Dear Mr Cox Re: Regulation 28 letter (12th December 2018) ref AJC / KC Addaction recognises the importance of confidentiality which is essential to the effective running of our services; We recognise the right of individuals in having their personal information protected and as such operate strict practices to ensure that personal information is held securely and shared appropriately. We seek consent from clients in order to share this information with other organisations and people, including their General Practitioner and we have a to inform our clients and service users of how we process, store and share this data under the GDPR 2016. Many people are apprehensive about engaging with addiction services and there is a real concern within the field that routine information sharing with GPs could create a barrier to accessing treatment for some individuals_ People who use our services have right to expect that information about them will be held in confidence by their workers and that will be treated with discretion and sensitivity when accessing Addaction's services. Our Confidentiality and Consent policy is based on the principle that the client's wishes and rights are of fundamental importance and draws upon guidance produced and published by Public Health England (Confidentiality Toolkit v6.3). Following the inquest into the death of Mr Benjamin Colin Williamson on November 8th you wrote to Operations Manager asking that Addaction review the processeslprocedures in place for dealing with consent and the sharing of information with Primary Care providers. In addition you asked that we involve Iso that lessons learned would be identified and shared. am writing to confirm that we have internally reviewed and improved how we record confidentiality and consent reviews_shared copies of Addaction's consent and confidentiality policy (DQ225) and met with land colleagues at the Mullion Health Centre on 30"h January 2019 to identify lessons learned and agree any required improvements Improvements to recording confidentiality and consent reviews within Addaction Since December 2018 we have introduced a monitoring function into our patient management system (Halo): This ensure that the three monthly reviews are conducted and recorded in line with our policy requirements. We now have ability to run reports, duty they will

identify where reviews are required and monitor this through line managementlsupervision processes: Review consent and information sharing procedures with Primary Care: In the Mullion Health Centre Summary Care Record (SCR) is created for all patients that enables staff providing care for patients in an emergency, from anywhere in England, are made aware of any current medications or allergies the patient may suffer from: This information from every patient record is sent automatically. If patients wish their information to be withheld from the SCR, can choose to stop this from being shared (i.e_ Opt-out)_ At Addaction clients are asked for consent, usually by signing a consent form; detailing with whom information can be shared, what information will be shared and for what purpose (i.e. Opt-in): Consents should be reviewed and updated regularly, normally every three months for adult services as part of the client's recovery plan review: In addition when Addaction provides regulated activity, such as a home detoxification, BBV vaccination or a treatment for hepatitis C this is conditional on information routinely shared with the GP. Likewise the GP is required to provide Addaction with SCR and regular updates. Some Addaction staff work from a number of GP practices across the county, including the Mullion Health Centre, to improve accessibility and to 'normalise' obtaining help from specialist services. However we recognise that there are a number of patients who prefer to be seen away from their local Health Centre and that barriers to treatment could be created were other provision not made available. Addaction encourages workers to gain consent to share information with GPs and generally most people do not object to this_ We examine those who decline to share information with their GP to ensure that risks are identified, assessed and managed: However Addaction does not operate policy of absolute confidentiality and there are number of circumstances that legally or ethically override the need for confidentiality: Our colleagues in Primary Care recognise that some patients will be reluctant to allow information to be shared with their GPs or attend specialist provision within the practice , preferring to access help and support in other locations. In Benjamin's case decisions around information sharing with his GP and where he accessed sessions may have been influenced as his mother worked at the Mullion Health Centre. Addaction is clear that the informal communication between parent and their employer should not replace formal communication channels between those involved in a clients care and we have reinforced this with all our staff members Whilst no policy changes were recommended through the review process, moving forward the following actions have been agreed Addaction has agreed to provide the Health Centre with the numbers of clients registered at the practice who are accessing our services_ 2 In order to improve communication our designated practice worker will attend the practice multi-disciplinary team meetings They also be able to access the patient they being will

management system (SystemOne) to improve information sharing between the services and update records as required: 3_ Where consent to share information with a GP exists, Addaction will inform them at an earlier stage regarding plans to cease structured treatment move to support that the client initiates (known as Recovery Support) In summary Addaction has reviewed the processes and procedure in place for dealing with consent and the sharing of information with primary care practitioners. Since December 2018 we have implemented a number of changes to improve the timely review and recording of client consent and information sharing permissions_ We have shared our policies and improved awareness of our approaches with our Primary Care Colleagues and how they differ to those routinely implemented in General Practice. We have agreed a number of actions to improve information sharing particularly for clients like Benjamin who are not in receipt of a regulated activity_ We hope that this response demonstrates the importance Addaction attaches to learning and continuous improvement: If you need any additional information please contact me

Kernow CCG NHS Trust NHS / Health Body

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Action Planned

NHS Kernow is working with partner agencies to implement a multi-agency strategy, including developing a dynamic risk register for individuals with dual diagnosis, with priority given to immediate actions. Contract requirements for new contracts commencing April 2019 are being reviewed to strengthen monitoring of engagement with the implementation plan. (AI summary)

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Dear Mr Cox, Prevention of future death report following inquest into the death of Mr Benjamin Colin Williamson Thank you for your Regulation 28 Report to Prevent Future Deaths pertaining to Mr Benjamin Colin Williamson. In your report you identify considerations to be taken by NHS Kernowas joint commissioners of mental health in Cornwall, alongside Cornwall Council. Considerations have also been asked of Addaction which is a service commissioned by Cornwall Council: As commissioners of Cornwall Partnership NHS Foundation Trust you have asked NHS Kernow to consider whether the system is sufficiently 'joined up' to meet the needs of people like Mr Benjamin Williamson: You have asked NHS Kernow to bring any gaps in the system to your attention and to contact] Iso that his experiences and insights can be taken into account. We have made contact with and noted his concerns_ We can confirm there is a Cornwall and Isles of Scilly Dual Diagnosis Strategy for Adults covering the period 2016
2019. This is multi-agency co-produced strategy that has been developed by members of Safer Cornwall and providers of services_ Safer Cornwall is partnership made up of statutory organisations and a wide range of other public sector, voluntary, community and private organisations. The responsible authorities include NHS Kernow; Cornwall Council,; Devon and Cornwall Police , Cornwall Fire and Rescue Service , National Probation Service and Dorset; Devon and Cornwall Rehabilitation Company: The purpose of this strategy is to assist the delivery and experience of integrated and inclusive service delivery for people with co-existing mental health and substance misuse problems, and their associated complex needs through consistent collaborative working: Chair: Dr lain Chorlton 01726 627800 Chief Officer: Jackie Pendleton kccg contactus@nhs net Head office: WWW . kernowccg nhs uk Inhskernow Sedgemoor Centre , Road, St Austell, Cornwall, PL25 5AS Priory

[HS Kernow Clinical Commissioning Group wealth of evidence, both local and national, points to numerous challenges in engendering a culture of shared responsibility as well as integrated operational and clinical working which can leave people struggling to gain access to evidence based interventions as well as targeted support for substance misuse: Locally we have seen evidence of specialist services working in isolation and not adopting the principles set out in the strategy meaning individuals may not get access to the services they need_ Whilst the local Mental Health Crisis Care Concordat has made some progress with implementing actions linked to the strategy, a formal implementation plan had not been developed to ensure the strategy was delivered and monitored in its entirety. The Crisis Care Concordat is coordinated and chaired by NHS Kernow and includes multiagency group of system wide representatives. It is a national agreement between services and agencies involved in the care and support of people in crisis and sets out how organisations will work together better to make sure that people get the help need when are having mental health crisis. NHS Kernow has met with relevant providers (including Cornwall Partnership NHS Foundation Trust;, Valued Lives, Outlook South West; as well as those commissioned by Cornwall Council such as Addaction) , partners and commissioners towards the end of 2018 and in January 2019. The aim of the meetings was to escalate concerns regarding gaps in provision where individual's mental wellbeing is not always being seen as part of 'everyone's business' and is often considered the domain of highly specialised and often medicalised approaches which comes at the expense of emotional and shared support of the whole person: An exceptional Crisis Care Concordat meeting was held on the 22 January 2019. The meeting was well-attended by the relevant statutory organisations and providers_ The purpose of this meeting was for providers to agree forward and specific actions have been identified to review the Dual Diagnosis Strategy and implement a robust multi-agency implementation plan: A draft implementation strategy completed by NHS Kernow provided the focus of the meeting: The providers of services will chair a monthly Implementation Steering Group in order to develop the draft implementation plan: The chair will rotate quarterly between the various providers ensuring a sharing of responsibilities and commitment to improving integrated working: It is expected that the review of the strategy and comprehensive development of the implementation plan will be completed in six months Whilst this is being undertaken priority will be given to actions that can be undertaken immediately and will support individuals with a dual diagnosis. For example, the development of a dynamic risk register so that people at risk can be identified and reviewed collaboratively: A similar register has been implemented for another group of people who have specific needs and has provided positive outcomes_ The progress of the Multiagency Implementation Steering Group will be reported to the Crisis Care Concordat in April 2019 with a future proposal to establish this reporting line to Safer Cornwall: NHS Kernow is reviewing the contract requirements for new contract commencing April 2019, in relation to providers supporting individuals with a dual diagnosis. Whilst current contracts and the multi-agency strategy already specify how providers should meet the needs of people Page 2 they they way

NHS Kernow Clinical Commissioning Group with a dual diagnosis, any contractual amendments will strengthen the monitoring of engagement with the implementation plan: hope that this response provides you with satisfactory information that we are committed to and are already working closely with all partner agencies to take measures to prevent future deaths as set out in the Regulation 28 Report_ We have sent a letter to the Coroner's officer to share with the family to invite them to be involved should they wish to be_ We have not been contacted by the family at the time of sending this letter: We are aware that this response may be shared with them and do hope that this information will provide them with assurance that actions are being taken in relation to the concerns' identified in relation to Mr Williamson's death We would like to extend our sincere condolences to the family. Please do not hesitate to contact me if you require anything further in relation to this case.

Report sections

Investigation and inquest

An Investigation was opened into the death of Mr Benjamin Williamson on 11 April 2018 following his death on 4 April This culminated in an inquest on 8 November 2018 where found Mr Williamson had died from Asphyxia 1b) Hanging II) Alcohol intoxication recorded a Conclusion of Suicide.

Circumstances of the death

Mr Williamson had a long history of alcohol-related issues for which he had been receiving treatment from Addaction and Freshfield. He had regular contact with his GP had appeared to be well: His death was a shock to all concerned

Action should be taken

In my opinion action should be taken to prevent future deaths believe you [ANDIOR your organisation] have the power to take such action: CMHT Commissioners Please consider whether the system is sufficiently 'joined up' to meet adequately the needs of patients Iike Benjamin. If there are gaps please bring these to my attention so | may direct this concern to central government should that be appropriate_ If you have had correspondence or other discussions with government on the please bring this to my attention and provide disclosure on a confidential basis to me only. Please ensure that contact is made with so that his experiences and insights may properly be taken into account Addaction Please review the processeslprocedures in place for dealing with consent and the sharing of information with primary care practitioners Please involvel jin your review to ensure any lessons from this incident are identified and learned.

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