Wendy Telfer

Dear Ms Brown Re: Wendy Louise Telfer (deceased) DOD 20/03/16 - Inquest 11 to 12 January 2017 Regulation 28 Report to Prevent Future Deaths Thank you for your letter of 15 February 2017 which we received on the 17 February 2017 following the inquest into the death of Wendy Louise Telfer As an organisation we are committed to learning these tragic events and have since receiving your report and recommendations taken the opportunity to share your findings with the service involved as well as across the wider trust: The Trust has in collaboration with the Royal Devon and Exeter NHS Foundation Trust (RD&E) undertaken a Root Cause Analysis Investigation following the death of Wendy; the report was shared at the inquest and can confirm that the action for Devon Partnership Trust resulting from the report has been completed and is now part of regular management supervision What shouid havethoppaned? Happened? Rectliostion- (Inaluding Person Completion ~ccG Sign oH dato Iinks to exlsting watk Responsible Date streams and Initlatives) (Job Role) (Link to numbered recommandatlons) Accurate onid delailed records Stondards of Monitored by the CTL via line Clinical Manager 31/01/17 should be maintained at all times in documentation parlicularly management supervision Liaison Psychialry accordance to DPT policy; & MNC relating to recording of systems and documenlalion Team; responsibilities ond regulations. telephone conversations audits_ and multidisciplinary discussions were not recorded robustly within the clinical records The Liaison Psychiatry teams in Exeter have recently completed the self-review within the Psychiatric Liaison Accreditation (PLAN) process: PLAN is an initiative of the Centre for Quality Improvement: PLAN works with services to assure and improve the quality of psychiatric Iiaison in hospital settings. PLAN engages staff and patients in comprehensive process of review, through which good practice and high-quality care are recognised and services are supported to identify and address areas for improvement. Accreditation assures staff, patients and carers, commissioners and regulators of the quality of the service provided, PLAN includes core areas common for all teams, such as assessment and care planning: Record keeping is an essential part of this process and is scrutinized by completion of a case note audit; The final review of the three liaison psychiatry Chair: Julie Dent CBE Chief Executlve: Melanie Walker from What College being

services by PLAN is in May 2017. The Liaison services are continuously reviewing processes and adapting to make service quality improvements. This is also supported by managerial supervision and all clinicians are actively encouraged to seek personal clinical supervision It is clear following review of your report and consideration of your recommendations that there are continued improvements that can be made to prevent future deaths of this nature The actions we have taken or plan to take are described below, Availability of in-patient beds and Crisis Resolution and Home Treatment teams The Trust is acutely aware of pressure upon our available bed stock and has raised the issue with our commissioners through both our contract monitoring meetings and via a formal letter from our Board level clinicians highlighting the very real risk to patient safety: We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and have now extended their operational times to midnight days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards_ We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital. We have also used spare capacity in one of our recoverylrehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital: We now have in place a central trust wide bed management team to proactively manage and secure beds for those in need as quickly as we possibly can_ We temporarily secured additional contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than rely on ad hoc arrangements as we are in competition with other NHS providers for private beds. think it is important to note that securing additional capacity is compounded by both the ever tightening financial position of our commissioners , ourselves and the reducing availability of staff across the country would much like to assure you that we as a Trust are everything we can to use our available resources in the most efficient way we can to meet the increasing demand we are facing: would also like to assure you that we will always the safety of our patients first and will continue to do our level best to ensure someone needing a bed is provided with one as soon as we are able to source either internally or externally via the private sector, Training of physical healthcare staff There has been great deal of work in recent years with the site management team at the RD&E regarding the use and application of the Mental Capacity Act (MHA) This work has developed having recognised through our joint working that there had been a need to increase the awareness of the MHA and the importance it has in a hospital which is registered to take detained patients under the Act. We agreed that wider training across the hospital for nurses and medical staff was unrealistic given that the majority of staff would only come into contact with the Act infrequently, we agreed that all the training and expertise would be held by the site management team and our MHA office and Iiaison team regularly meet the site manager to discuss incidents, share learning, update in relation to any amendments to the Act and deliver rolling training to the site managers who run a 24 hour; 7 day a week rota across the whole hospital: All of the RD&E wards are instructed to contact the site manager with any MHA related issue. The site manager's office has all of the paperwork and guides and contact details for further support if needed. This has been successful in that most wardslstaff know to ring site management for MHA advice. This system is now well embedded and generally works well: Due to the high turnover of staff and medical Chair: Julie Dent CBE Chief Executive: Melanie Walker the they have doing very put

staff in training it has been the best way we have been able to disseminate learning and develop degree of expertise into the hospital. As described by our Liaison Psychiatry Clinical Team Leader during the inquest we have continued to support the training of the staff within the RD&E; have described below the general role of the Liaison Psychiatry Team in training and the specific work undertaken during the last year_ Part of Liaison Psychiatry's role is to offer training to staff in the general hospital, this is undertaken both formally and informally: During 2016 the team have formally trained at least 496 staff, having delivered 175 teaching sessions. The regular formal training delivered includes: weekly slot in the Emergency Department (various topics, including Mental Health Act) Regular slots to the Site Management Team focussed on the Mental Health Act One of our consultant Psychiatrists_ delivers training regarding the Capacity Act & MHA at least twice yearly to foundation doctors, Core Trainees and Consultants Mental Health Champion Training (5 full days to RD&E clinicians who have volunteered themselves as Mental Health Champions: Other regular slots to the Emergency Department and as part of the foundation doctors training on the role of Liaison Psychiatry in the hospital, this includes use of the Mental Health Act. A full day package has just been developed called 'Management of Challenging Behaviour Rapid Tranquilisation a last resortl' and this began monthly roll-out in March 2017 this refers to use of the MHA and Mental Capacity Act in its content; Dementia & Delirium full days training once a month that the actions described demonstrate our commitment to the learning we have undertaken and that the Trust is committed to this continued positive work with within our services and with the Royal Devon and Exeter NHS Foundation Trust If you require any further information please do not hesitate to contact me.