David Knight

From Nicola Blackwood MP Parliamentary Under Secretary of State for Public Health and Innovation Department Richmond House of Health I . ; 79 Whitehall London SWIA 2NS Dr EE Carlyon 77 0 JAN 2017 020 7210 4850 Senior Coroner Cornwall and Isles of Scilly BY, The New Lodge Newquay Road Penmount Truro TR4 9AA 8 JAN 2017 'Jw Thank you for your letter of [4 November 2016, following the inquest into the death of Mr David Knight. I was very sorry to hear of Mr Knight'$ death in 2015 and wish to extend my sincere condolences to his family. You have raised concerns about the availability of acute mental health beds nationally. As you will know, acute mental health beds are commissioned locally by clinical commissioning groups (CCGs) as are best placed to assess and meet the needs of their local communities. You may be aware that the Commission to review the provision of acute inpatient psychiatric care for adults, led by Lord Crisp, published its review in 2015. The review found that access to acute mental health beds was not so much an issue of bed capacity but rather a problem of discharge policies and providing alternatives to hospital admission in the community: We are committed to providing a full response to the review by the end of 2016/17. Over the decade acute mental health bed capacity has steadily reduced reflecting the shift toward more provision of care in the community. However; we acknowledge that provision of effective community services varies The lack of high quality community care in some areas, including crisis resolution home treatment care as viable alternative to hospital admission, has placed pressure on beds This has resulted in more people being admitted to hospital out of area. We are committed to delivering the vision set out in the Five Year Forward View for Mental Health published last The Prime Minister reaffirmed the Government' $ commitment t0 this aim this month when she set out the Government'$ response to the Five Forward View and further mental health reforms. We will eliminate clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and will reduce significantly delayed transfers of care. ClIr May they past year; Year

This will help people move easily between hospital and care in the community, ensuring that beds are available for those most in need. 1 appreciate that this will not happen overnight but we are committed to delivering change. Through the Five Forward View we will implement a comprehensive set of community-based mental health pathways of care so that people have access to care at the right time in the right place: You have raised concerns about the quality of the risk assessment that was undertaken and the limited contact with Mr Knight's family by the mental health provider to support Mr Knight'$ leave in the community. These matters are the responsibility of the local health services. However; You may be aware that the Department published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code. This included better involvement of patients' family, carers and friends in care to provide much needed support for patients to manage their conditions and to support recovery and independent in the community. The Code of Practice is clear on the importance of undertaking robust risk assessments of patients to support care, including leave of absence. 1 expect all mental health providers to adhere to the Code of Practice. Iam encouraged to see the action that has been taken to improve pre-section 17 discharge planning by ensuring that local care teams and patients' families are involved in these arrangements However; I would also expect the Kernow CCG to take action to improve local risk assessment processes where necessary to prevent a similar tragedy occurring in future. Ihope this response is helpful and am grateful to you for bringing the circumstances of Mr Knight's death to my attention: Yars Nab L NICOLA BLACKWOOD Year living Sawral1

Dear Dr Carlyon; Re: Regulation 28 Report to Prevent Future Deaths David Knight; deceased Thank you for your letter of 14lh November 2016 and the enclosed Regulation 28 Report to Prevent Future Deaths following the tragic death of David Knight: was sorry to read of the circumstances around David's death, and would like to express my deep condolences to his family. Every death by suicide of a patient under the care of NHS services is deeply regrettable and must be fully investigated and learnt from to prevent similar occurrences in the future note the letter from Kernow Clinical Commissioning Group providing assurance that the key issues identified during the inquest into Mr Knight's death are being addressed locally in Cornwall: In terms of national policy, want to highlight some key developments which believe are relevant to the issues you have identified regarding the lack of available acute inpatient beds and the reliance on out of area admissions for people requiring inpatient care, which your report concludes had a bearing on Mr Knight's death NHS England recently established an adult mental health programme which is taking a whole system approach comprising crisis, acute, and communitylprimary care work streams The acute care work stream has been developed in response to a number of recommendations set out by The Commission on Acute Adult Psychiatric Care (February 2016) and The Five Year Forward View for Mental Health (February 2016) , and is particularly relevant to the concerns outlined in your report: The work stream's commitments include working with relevant partners to develop access and quality standards for acute mental health care. Integral to High quality care for all, now and for future generations very key

these standards is the expectation that care is provided in the least restrictive manner and as close to home as possible, with practice of sending people out of area for non-specialist acute inpatient care due to local acute bed pressures eliminated entirely by 2021. These commitments recognise the importance of continuity of care and close proximity to existing support networks on the experience and clinical outcomes for people requiring acute mental health care To deliver on these commitments, NHS England is working with the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists (RCPsych) to develop an evidence-based treatment pathway and accompanying commissioning support tools for adult acute mental health care from referral through to discharge. This work is led by a multi-stakeholder Expert Reference Group (ERG) convened by the NCCMH involving patient experts, carers, and professionals from different NHS services, social care , public health, policing and the voluntary sector: As noted in the report published by The Commission on Acute Adult Psychiatric Care, the problems with accessing acute psychiatric care are not just a reflection of the number of beds, but the result of system-wide issues associated with inadequate community-based provision, poor multi-agency and partnership working, which all increase pressure on the acute care system: As such, the scope of the pathway comprises both inpatient and community settings, reflecting the need to ensure services are commissioned and delivered in the context of a whole system approach based on clinical need and the safe management of patients. It has a focus on the safe provision of alternatives to admission, transition and interface with other services, multi- agency working; involvement of carers, and system-wide demand and capacity management, which promotes the provision of care close to home and in the least restrictive appropriate setting, increasing the availability of inpatient beds for those that need them: This work will draw on and share learning from identified areas of best practice such as Bradford and Sheffield that have managed to significantly improve both acute system flow and quality of care through multi-agency working and taking a whole system approach when redesigning their local acute care pathways. Significantly these areas have completely eliminated acute out of area placements (OAPs) whilst also reducing their bed numbers and average bed occupancy; yielding significant financial savings which have been reinvested to continue local service improvement. We aim to publish the acute evidence-based treatment pathway and accompanying commissioning support tools by April 2017. To support the implementation of the pathway locally, NHS England is committed to ensuring that all areas have Crisis Resolution Home Treatment Teams (CRHTTs) providing a high-quality, 24/7 , community-based crisis response and intensive High quality care for all, now and for future generations the

home treatment in line with clinically based evidence by 2020/21. This commitment is supported by over E400 million of investment following the Government's Autumn 2015 Spending Review; which will be made available to local areas over four years from 2017/18, and is intended to address the considerable pressures and high bed occupancy in the acute mental health pathway: Further; we have been working with the Department of Health; NHS Digital and NHS Improvement to gain a better understanding in relation to where and why out of area placements happen. As a first we have published a national definition of an acute OAP following extensive consultation: As well as the distance patients to travel; the definition is about whether someone is admitted to an inpatient bed where their usual network of support (e.g: family, pets, care coordinator from their community mental health team) is unable to engage as often as if they were admitted in a local bed. Further to this, we have recently established the first national data collection dedicated to better understanding non-specialist adult acute OAP activity: The first report was published in December 2016, but we expect to have a reliable national baseline position for OAPs by the end of Q4 16/17 , when data quality has improved after the adjustment period following the introduction of the new collection is over: Going forwards, this will allow us to monitor progress against the national ambition to eliminate inappropriate OAPs for non-specialist adult acute mental health care by 2020/21, enabling targeted support to be provided to local areas as required: In addition to the work currently being progressed by the acute care work stream, The Five Year Forward View for Mental Health set the national ambition of significantly reducing the number of people taking their own lives. To support this aim, all Clinical Commissioning Groups are expected to contribute to the development and delivery of local multi-agency suicide prevention plans, together with their Iocal partners by 2017 in line with guidance provided by Public Health England (available from https l gov uklgovernment/uploads/system/uploadslattachment_datalfilelse 4420lphe_local_suicide prevention planning a_practice resourcepdf): This expectation has been underlined in guidance for local areas regarding the development of their Sustainability & Transformation Plans, and the NHS planning guidance for 2017-19, and will be supported by further national investment of E25 million from 2018/19, which is additional to the E400 million identified for expanding Crisis Resolution Home Treatment Teams. In line with recommendation 57 of The Five Forward View for Mental Health, NHS England is working with NHS Improvement and the Care Quality Commission to ensure that learning from all deaths by suicide of people in the care of NHS services is used to try to prevent repeat events: Moreover; NHS High quality care for all, now and for future generations step, have Year

England will continue to play its part in wider national partnership work as a member of the Department of Health's National Suicide Prevention Strategy Advisory Group. For further detail on the transformation of mental health services will be delivered over the next five years, please see Implementing the Five Year Forward View for Mental Health (https Ilw england nhs uklwp_ contentluploads/2016/07lfyfv-mhpdf), published by NHS England on 19 July
2016. trust you find this information is helpful.