Christopher Higgins

Dear Ms Lake Regulation 28 report following the inquest of Mr Christopher Higgins write in response to your report dated 24 December 2015. Under paragraph 7, Schedule , of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 you requested Ihe Trust consider issues of service delivery following (he conclusion of inquest into the death of Mr Christopher Higgins on 16 December 2015. You identified four malters of concern: will address these in order: Observations Your report identified that during (he inquest staff reported areas of confusion regarding (he action of additional observations. The staff conveyed a lack of clarity regarding aspects such as amm's length or within eyesight: Following the inquest the Trusts Observation and Engagement of Service Users policy has been reviewed and updated to reflect the need for clarity in applying the observations as intended; enclose a copy of the policy_ Amending policy is one action, which must be followed by communication to ensure its adoption by all staff. The Trust uses a range of communications including updates by email, within a Patient Safety Newsleltter and discussion at governance and leadership forums Through this range of means, staff are updated of the requirement to adapt practice. Escorting/Transferring patients from one place to another when other services are involved Your report reflected the fact that Mr Higgins was transferred in the Police van back to the Fermoy Unit without a member of mental health staff present: Accepting that in Mr Higgin's case the travel time and distance was small (wilhin the site), the Trust acknowledges how important this can be for the patient. Therefore the Trust will be strenglhening its policy direction (the policy is further Chair: Gary E Chief Execulive: Mlchael Scott 2 MINDFUL Trust Headquarters: Hellesdon Hospilal, Stonewall EMPLOYER Draylon High Road, Norwich, NR6 SBE DMVERSTY CHAMPIOH Tel: 01603 421421 Fax: 01603 421440 WWnsft nhsuk the Page 1bour stive_ 1 815A8L &

Ms Lake referenced below) that staff should wherever possible, accompany (he patient during (he transfer: There may be some limited instances where (his is not possible on the grounds of safety but decisions would be made in Iiaison with the other service involved. Safety of the environment where the incident took place Following the incident the Trust reviewed the railing that sits with the disabled access ramp, adding additional height bars to reduce the likelihood {hat an individual could; from a standing position; jump over the of them_ Following Ihe inquest the Trust has revisited (he assessment of this area: Whilst there are mitigations in place such as the heightened rail and access to the area by palients is made with supervision; Ihe Trust has decided to enclose the ramp: This work has commenced and is proposed to be completed {he end of March 2016 and removes the possibility of an individual jumping from the top of the ramp area: Agreement with acute hospitals to support timely assessment of the patient's needs In addition to writing to the Trust, you have communicated with the local acute hospitals in Norfolk with the intention of raising to bolh services the consideration of how patients wilh mental heallh needs are cared for in a timely and least distressing way: The Trust is taking this matter further than the Norfolk acute hospitals instrucling managers based in Suffolk to liaise with their acute hospital colleagues as well; Each area is working to create local protocols which will be incorporated into policy: These are In progress and their complelion will be reported to the Trust board. Thank you for bringing the matters to the Trusts attention: If | can be of any further assistance please do not hesitate to contact me_

Dear Mrs Lake RE: Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mr Christopher Higgins Thank you for your letter dated 24th December 2015 following your inquest into the death of Mr Christopher Higgins: Although the Trust was not an Interested Person at the inquest, understand that the inquest raised concerns that there was no arrangement in place between Norfolk and Suffolk Mental Heallh Trust and any of the acute hospilals in Norfolk to alleviate, as far as possible, distress to any patient detained under the Menlal Health Act: Hence, you have made this report under paragraph 7 , schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013_ We have considered the issues you raised in your report and we have worked with colleagues at Norfolk and Suffolk Mental Health Trust to develop a process for ensuring that patients under lhe care of mental health services who require acute care, either planned or as an emergency, have a clear pathway which includes agreed communication channels between clinicians, to expedite lhat care and reduce any potential for distress Together we have developed flow-diagram to describe this process which is being used with immediate effect. have attached a copy of this flow-chart for your information: We will monilor adherence to this new agreed process via Ihe regular operational Iiaison meetings between our two trusts_ would like to thank you for bringing your concerns to attention. Please do not hesitate to contact me if you require anything further:

Dear Mrs. Lake, Re: Regulation 28 report to prevent future deaths following the Inquest: Mr Christopher Higgins am writing to apologise that you did not receive a response to the Regulation 28 report following the death of Mr Christopher Higgins within the timeframe set out in letter of the 24 December 2015. We have been working closely with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway which will ensure in the future that inpatients from our local mental health facility can access care and treatment in the Emergency Department in timely manner that limits stress to the individual concerned_ Norfolk and Suffolk NHS Foundation Trust has coordinated this work and has developed the written pathway and flow diagram for staff, outlining a new referral route in which a potential Emergency Department attendance is flagged with the department and mutually agreed time is arranged so that the patient can be seen immediately on arrival in the department: At the time of the inquest our understanding was that the Norfolk and Suffolk NHS Foundation Trust were already in the process of liaising with local A&E Departments and thereafter drawing up joint response incorporating these local agreements and you may already have received further details them_ We are pleased to say that this work is now complete The Trust currently experiences significant level of attendance in the Emergency Department from patients presenting with mental health problems or self-harm and as such is constantly seeking ways to improve the experience for these patients. It is hoped that this planned pathway for patients from an inpatient mental health bed will improve both the experience and safety of this particular cohort of patients. Chalr: Edward Llbbey Chlef Exccutlve: Dorothy Hoseln #a StonewaIt Palron: Her Malesty The Queen LHE[EL your from

29 February 2016 The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust_ apologise once that we did not respond within the required timeframe but would like to assure that your recommendations have been acted on and new measures agreed to improve the safety of the process of transfer and the experience for the patient,