Ursula Keogh

From Jackie Doyle-Price MP Department Parliamentary Under Secretary of State for Mental Health, Inequalities and Suicide Prevention of Health & Social Care 39 Victoria Street London SWIH OEU Your Ref: MDF-HK/251-2018 020 7210 4850 Our Ref: PFD-1158450 Mr Martin Fleming HM Senior Coroner; West Yorkshire (Western) HM Coroners' Office City Courts The Tyrls Bradford BD] ILA March 2019 Dea Ac Keau-l, Thank you for= correspondence of 26 November 2018 to the Department of Health and Social Care about the death of Ursula Niamh MacEochaigh Keogh Iam replying as the Minister with responsibility for child and adolescent mental health services (CAMHS); and I am grateful for the extra time in which to do s0. Your report raises three matters of concern and is directed to NHS Calderdale Clinical Commissioning Group (CCG) and Calderdale Council, a8 well as the Department of Health and Social Care. Iam aware that the Calderdale CCG has responded to your concerns from a local perspective, advising you of a series of actions that are undertaken in light of the report We expect the local NHS to take action to respond to concerns and learn from deaths to ensure the safety of healthcare services and [ am encouraged that the local NHS is looking into these matters carefully: It may be helpful ifI set out work undertaken nationally to help local services work together to deliver improved outcomes for children and young people experiencing mental health difficulties. Future in Mind' , published by the Department and NHS England in 2015, set out & consensus across the NHS, public health; local authorities, social care, schools and youth justice sectors to work together to promote good mental health; prevention and early intervention; improve access; and deliver & clear; joined-up approach: This led utra Dly ! ikrnt bttps:ILwwwgovuklgovemmentlpublications/improving-mental-health-services-for-young-people; 2 5 MAR 2019 Ee 2S6-1g your being -

to the development ofLocal Transformation Plans that set out how local services would work together to deliver improved outcomes The Five Year Forward View for Mental Health? , published in February 2016,reconfirmed the vision set out in Future in Mind. In November 2018, the Department for Education produced an update to its guidance, Mental health and behaviour in schools? , that includes risk and protective factors for children and young people, including identifying children with possible mental health problems. Guidance is also given on making referrals to CAMHS quickly and efficiently, and allowing to access CAMHS at school. All health professionals, including GPs, are required to take account of guidance issued by the National Institute for Health and Care Excellence (NICE): The NICE Quality Standard for Self-Harm, QS344 was published in 2013 and includes guidance that people, including those aged eight to 18, who have self-harmed, should have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and risks of repetition Or suicide; and that people receiving continuing support for self-harm have a collaboratively developed risk management plan. Turning to recommendations specifically, the Department agrees that communication between health and education professionals needs to be improved Transforming Children and People '$ Mental Health Provision: a Green Papers , jointly published with the Department for Education in December 2017, together health and education to provide early intervention mental health support for children and improve communication between health and education professionals. On 20 December 2018,the Government announced the first wave of 25 trailblazer sites that will test the plans set out in the Green Paper: These new plans will significantly increase the availability of mental health support to children and young people, including creating new Mental Health Support Teams working in and near schools and colleges to support children and young people with mild to moderate mental health conditions Mental Health Support Teams will provide brand new https IIwwwengland nhsuklwp-content/uploads/2016/02Mental-Health-Taskforce-FYFV-finaL pdf https llassetspublishing service gov uklgovemmentuploads/system/uploadslattachment_data/filel755135Mental_healt h and_behaviour_in_schools epdf bttps IIwww nice Org uklguidancelgs3A/resouicez https Iwwwgovuklgovermentlconsultations/transforming-children-and-young-peoples-mental-health-provision-&- green-paper pupils your Young brings ~

services situated in schools and colleges and are intended to offer earlier help and intervention , For example; linking up with existing mental health services which may include local troubled families' coordinators; educational psychologists; school nurses; health visitors; local children'$ services; school counsellors; and voluntary and community sector provision: The Department agrees with your recommendation highlighting the importance of preventative measures and I welcome the measures taken by Calderdale Council to install preventative measures at the North Bridge Halifax by the end of
2019. One ofthe areas for action in the crOSS-government Suicide Prevention Strategy is to reduce access to the means of suicide which is known to be one of the most effective methods of preventing suicide, and this includes those places that we know about across the country that are frequently used for suicide. You may also wish to note that the Government published the first cross-Government Suicide Prevention Workplan in January 2019 which set out an ambitious programme to reduce suicides, including in children and young Furthermore, setting up 24/7 crisis care provision for children; young people and their families is a priority for the Government in the NHS Long Term Plan" , published on 7 January
2019. All children and young people experiencing crisis will be able to access crisis care 24 hours a seven a week by 2023/24 via NHSIII. Finally, although you do not raise this issue in your report; [ am aware that Ursula $ family have expressed concern about the role of harmful suicide and self-harm content on social media in relation to Ursula's death: The Department is very concerned about the impact of this sort of content and is working with the Department for Digital, Culture, Media and Sport (DCMS) and the online sector to address this. Our ambition is to make the UK the safest place to be online and we are working with internet and social media providers to tackle online harms such as these. You may be aware that the Secretary of State for Health and Social Care, Matt Hancock, wrote to social media providers in January to express his concern about suicide and self-harm: content on their platforms I also met social media providers in February, alongside the Secretary of State, and have committed to step-up their efforts to protect their users from harmful suicidal and self-harm content online. We are also action through the forthcoming joint DCMS and Home Office Online https ILwww gov uklgovemmentlpublications/suicide-prevention-cross-govemment-plan https ILwww longterplan nhsukl being May key = people6. key day;: days they taking

Harms White Paper; which will set out a range of legislative and non-legislative measures detailing how the Government will tackle online harms Ihope this information is helpful. Thank you for bringing these concerns to my attention. "&oo JACKIE DOYLE-PRICE

Dear Mr Fleming; Re: Regulation Report on the Inquest Touching the Death of Ursula Niamh MacEochaigh Keogh Action to Prevent Future Deaths Thank you for sending a copy of the above report; received on the 28th November 2018_ We have carefully considered the three matters of concern raised with us and worked in partnership with Calderdale Council to agree a set of actions which we have attached as required. Our response has been compiled in partnership with Calderdale Councills Children and Young Peoples senior managers and the CCG's clinical lead, is also a GP member of our Governing Body. A meeting was convened to produce the attached action plan which we trust will provide you with the necessary assurance that existing processes have been reviewed and revised with new actions identified to prevent future deaths occurring: Provided below is a brief response to the three recommendations raised in your report Please also see the attached action plan which sets out the existing and new actions identified. To review the current practice of referral by GP to the school for consideration as to the appropriateness of referral to CAMHS: The group reviewed the existing Child and Adolescent Mental Health Service (CAMHS) referral pathway for GPs and schools (copy enclosed) Following a comprehensive discussion, the group were satisfied with the accuracy of the process described. However; the review highlighted some gaps in respect of external training and education about the pathway which has resulted in the new actions set out in the attached 2 Consider improving communications between professionals, particularly health and education to eliminate contradictions offered in the advice. Chair Dr Steven Cleasby Chief Officer Dr Matt Walsh Sth Floor; F Mill, Dean Clough; Halifax; HX3 5AX T:01422 307400 E: ccgfeedback@calderdalecca nhs.uk WW calderdalecca nhs;uk City " Lving

NHS Calderdale Clinical Commissioning Grouj The group noted the widespread training and education programmes being delivered by services to partners, parents and carers in Calderdale_ However, it also recognised the importance of ongoing training, education and communication plans. The multi-agency Open Mind Partnership (CAMHS) Steering Group will take ownership of the attached action plan. The Steering Group will monitor delivery against this plan at its monthly meeting; reporting into the CCG's Quality Committee 3 Consider the appropriateness of fast tracking the implementation of preventative measures currently under consideration at North Bridge Halifax A discussion has been held with Calderdale Council's Public Health Consultant (Lead for Mental Health) and a full response will be provided by Calderdale Council on this recommendation: Below is a summary of the response: A review was undertaken of North Bridge in January 2018 looking io prevent further suicides at this location_ This outlined the need for installation of anti-climb mesh affixed to horizontal rails_ A resolution was passed by the Council for an application for listed building consent and an application for planning permission is submitted to the Local Planning Authority. The listed building application has been approved and consent has now been granted with the works to be completed by the end of
2019. The Council has also installed an additional CCTV camera to provide coverage of North Bridge. We hope that the above, together with the enclosed action plan, demonstrates the seriousness with which we have viewed this case and ask that our sincere condolences be passed onto the family.