Gail Bannister

Dear Mr Cox Re: Inquest touching the death of Gail Bannister Regulation 28 report t0 prevent future dcaths rosponse Thank you for your letter dated 9 February 2018and the enclosed Regulation 28 repor; have read Your repon with great care and note the concorns (hat You raised 38 ? rosult af the coronial inquiry inlo lhe death of Gail Bannistor In your report; you highlighted the following points of concern and will respand to each in turn" The rationale behlnd discharging Mrs Bannister from the HTT to CARS was that she had becn seeing too many different poople. It was felt that by concentrating her care in the hands of the community Consultant Psychiatrist and a Care Co-ordinator; who would arrange the psycho-social serviccs she would benelit from, this would improve her treatment The fact that the Care Co-ordinator did not see her frustrated and undormined this approach; It was the expectatian of both the discharging clinicians_ ard the community Psychiatrist that & Care Co-ordinator would be frequently involved wilh Mrs Bannister_ This is also cocumented in the plan af cere set by the community Psychiatrist follcwing her appointment with Mrs Bannister on 1Bh August 2017when Ihe Co-ordinator was also in altendarce: As heard in evidence during the inquest, the Psychiatrist wa: under the impression, that following this appoirtrient weekly visits from the Care Co-ordinator were in fact taking place It is extremely concerning that it transpires that, with the exception of tho above mentioned joint appointment on 1th August 2017, no contact was made by the Care Co-ordinator with Mrs Banrister; confirm that the Trust Is addressing this matter in an appropriate Manner; am sure that you will appreciate the confidentiality obligations which {ace which mean: thai am unable to share specific details with You and other Interested Persons Chairman: Chris Rurdon Chief Exccutlve: Sarah Dugan Working together for outstanding care Way nave out Care

21 During thc inquest; [ was tald that the dereased $ husband tried to speak to members of the care team who were based at Studdart Konnedy House when a crsis developed: It took him several hours t0 through: was told that there Is only one phone line and that this Is a known and recurring problem An actizn Plan has been put In place to Install a telecommunicaticng %ystem wnich wIIll provide a digital telephone system (VOIF) This will erable call and call forwarditranster automalically An initial review of the current system has already taken place and a contractor Survey of Studdart Kennody House been agreed and funded by Worcestershire County Councii (who own the building} . This costingg survey wag undertaken on Zist and 22d March 2018, however has nolyet been received by the Trust; Itis hoped that a capital bid will be completed by the erd of April 2018 and sent to the Finance Director for approval, with work to the begin following this Unfortunately_ a date ior completion cannot yet be given 22 thi: depend upon extemal contractams; however, would like to oifer re-a83urance that Ihis malter I8 being given the atention required In thie meantime, Interim meagures have boen implemented cansisting of & mobile telephone being used by Adult Mental Health staff (o use [o contaci the sitelduty worker and communicaticn has been given t0 all staff to advise them cf this interim measure and Ihe appropriate contact telephone numbers to Vbe. trust Ihat lhe foregoing has Bdequstely addressed the Regulation 28 report issued subsequent to Ihe inquest Into the death cf Gail Bannister; Should you require any progress update: or clarincalion In relation t0 this matter; please do not hesitate to ask. confrm that have not forwarded # CoPy cf tnis response to any other Interestod Person and vould tnerefore be grateful il you could do $0 a5 appropriate also confirm that the Trust is content for bcth the regulation 28 report and the rosponse l0 b# released Dr published should the Chiel Caroner wish_ Ycurs eincerely Sarah Dugan Chiel Executive Chairman; Chris Burdlon Chlef Executive: Sarah Dugan Working together for outstanding care get waiting ha; will