Richard Jones

Salisbury NHG NHS Foundation Trust Salisbury NHS Foundation_Trust Reponse_to_Regulation 28 Report Touching the death of Richard JeffreyJONES RECEIVED 2 0 APR 2015 Respondents Name & Position My name is Peter Hill and am the Chief Executive Officer at Salisbury NHS Foundation Trust (SFT) Purpose of the report have received the Regulation 28 report prepared by lan Singleton, Assistant Coroner for Wiltshire and Swindon, following the investigation into the death of Richard Jeffrey Jones who received treatment at Salisbury NHS Foundation Trust in October 2012 This response is required by 2oth April 2015, Introduction The inquest touching the death of Richard Jeffrey Jones concluded on the 27th January 2015. The Regulation 28 report, arising from the inquest expresses three concerns summarised as: a) As to the way in which information such patient is recorded, with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care_ Additionally, Mr Singleton asked us to review the policy and procedures that we have in place to deal with the referral to another agency of a member of the armed forces who appears to be suffering from mental health issues having regard to the above concerns_ Response_to Coroner' s Concern The_way_in_which information _from such patient is_recorded_with_especial reference_to the perceived level ofriskand the degree of_urgencyin carrying out an assessment Since the death of Mr Jones, and following review of the case in collaboration with AWP, an immediate action taken by SFT Emergency Department was to implement a new mental health risk assessment tool as recommended by the College of Emergency Medicine. This tool provides a more accurate assessment of the risk of suicide or self harm than the SADPERSON score we were previously using: It enables clinical staff to risk assess patients and document their prior to referring the patient to the mental health team with an indication of the appropriate urgency for their response. (Mr Jones fell within the low risk category using the old and new tools): The tool is from findings

Salisbury NNHS] NHS Foundation Trust contained in the 'ED Handbook' which contains clinical guidelines and is provided to all new clinical staff at their induction. The service for mental health patients is provided by Avon & Wiltshire Mental Health Partnership (AWP) on terms agreed with the Wiltshire Clinical Commissioning Group (CCG): A liaison psychiatry team is available 9am to Spm seven days week, and operates within standard operating procedures agreed by the Trust and AWP. All patients for assessment are discussed with the Iiaison team and a response timeframe agreed. During the operating hours of the service, emergency or high risk patients are seen within 60 minutes of referral: Outside the hours of operation of the liaison team the referral for high risk and medium/high risk patients is made to the on-call team who have a response time of 4 hours. Advice can also be sought from the on-call team for medium/low risk patients where there are persisting concerns about mental health issues preventing discharge. These services and the response that AWP the Iiaison service provide are detailed in the department Action Card' which has been agreed in collaboration with AWP . The mental health 'Action Card' will be included in the next edition of ED Handbook later this year. Action Summary _ Implementation of mental health risk assessment completed following review of case. Standard Operating Procedure amended in collaboration with AWP How _information is shared with other agencies involved in the_care of that patient to_ensure_that itis accurately passed on_particularly as tothe level of risk and degree of_urgency: The sad death of Mr Jones led to considerable reflection as to the way in which information is shared with other agencies: Within the hours of 9am and Spm assessment of mental health patients is made by the Iiaison psychiatry team: This team attends the ED on arrival in the morning to obtain referrals, review patient records and agree a timeframe for assessment: Telephone contact is made to the liaison team to make them aware of additional patients who attend the ED during the day and require assessment The liaison team have access to the patient's ED records including risk assessments completed: Outside of these hours telephone contact is made with the on-call team and agreed actions documented in the patient's ED record. To ensure robust recording of information to the out-of-hours AWP service proforma will be generated for clinician use: This will include information such as the assessed level of risk as per the mental health risk assessment tool, the agreed timeframe for assessment, the name of the accepting mental health practitioner, and other agreed actions from the telephone referral conversation The proforma will safeguard against any misunderstandings between an ED clinician to an AWP any

Salisbury NHS] NHS Foundation Trust mental health worker and vice versa_ Once completed, the information will then be faxed or emailed to an agreed secure number or address for AWP to place with the AWP patient record, and the original will be held within the ED patient record at SFT. This will be incorporated within the ED upgraded electronic system by the end of the vear SO that it can be transferred and stored electronically. Action Summary _ To implement the use of a 'Mental Health referral proforma' in collaboration with AWP. To include the proforma within the ED electronic system by the end of 2015. Who_has primary_responsibility for the care of that patient and_how that_is recorded bYallthose involved_particularly where there_is a transfer of care Whilst a patient is cared for within the ED the Duty ED Consultant has primary responsibility for them. Transfer of care occurs when the patient has been referred to and accepted by another speciality. The relevant consultant within that specialty then has primary responsibility for the patient: In the same way, the transfer of care from the ED to a mental health practitioner is made when a referral is accepted by the mental health liaison team or the on-call team Should the patient leave the ED before assessment by the mental health liaison team or on-call team, immediate steps are taken by staff in ED to safeguard the patient: An assessment is completed by the most senior clinician on duty at the time: Where a patient is assessed as high risk, action then might include calling security the police, and attempting to engage with the patient and/or next of kin. For both high and low risk patients SFT ED would make contact with the mental health team to inform them that the patient was no longer in the department on site and to them with the information available_ The follow up ofa mental health assessment for a patient who had absconded would be led by, and be the responsibility of, the specialist mental health team which had accepted the referral. The GP would also be informed ofthe patient' s failure to wait for assessment; As an additional safeguard, all patients who do not wait to be seen in ED are recorded as 'absconders' and reviewed the following day by the duty ED Consultant_ The assessment made and actions taken at the time are reviewed by this senior clinician who decides whether any further action is required_ Review the policy and procedures that are_in place_to dealwith the_referral toanother agency ofa member of the armed forces who appears to be suffering_from mentalhealth _issues_having regard to the above concerns SFT treats patients presenting with mental health needs in the same way, regardless of their employer background. Therefore referral occurs in line with the Standard Operating Procedure of referring all patients to mental health services at AWP as commissioned for US With regard to update

Salisbury NNHS] NHS Foundation Trust onward referral for a member of the armed forces we understand that this would be undertaken by AWP if required, as they have an established working relationship with the armed forces: discharge letter is sent by the ED clinicians to the relevant GP, whether civilian or military by background. Conclusion It is hoped that the measures detailed above will offer reassurance that Salisbury NHS Foundation Trust has addressed the matters of concern raised by Mr Singleton. We strive to continue to improve the service that we offer patients with mental health needs. The case of Mr Jones saddened the staff involved and those who attended the inquest: have all directly contributed to the improvements we have made since the incident in 2012, the inquest in 2015,and the Regulation 28 report: Peter Hil Chief Executive Officer Salisbury District NHS Foundation Trust They