Tessa Summers

Dear Mr Horsley am writing in response to the Regulation 28 Report issued to our department under Coroners (Investigations) Regulations 2013 sent to Hampshire Adult Services following the inquest into the death of Tessa Summers on 3r July 2014. understand you have issued this report because during the course of the inquest the evidence revealed matters giving rise to concern_ You have stated that it is your opinion there is a risk of future deaths unless action is taken: Those concerns relate to the following: 1 _ You heard evidence that the social workers who decided on amendments to Tessa's risk assessment did not record in that document their rationale for downgrading her high to low risk of self harm and allowing her to have access to her medication which she could then take without supervision by her Shared Lives Carer: You were told the social workers were not required to do so as matter of routine to record why details of risk assessments for any of the clients were being changed: 2 You gained the impression from some of the inquest witnesses that Adult Services could beneficially provide more training for Shared Lives Carers where the carers would be called upon to work with clients with mental health and emotional problems You are of the opinion that action should be taken to prevent future deaths to address these concerns and that Hampshire County Council has the power to take such action_ Hampshire Adult Services were extremely saddened by Tessa's death: We are that the evidence given at the inquest has given rise to concerns about practices within our department: Director of Adult Services Gill Duncan Your 24th the from sorry

In terms of the skills and knowledge of our staff in respect of risk assessment and risk management we have in place a Positive Risk Policy which underpins the practice of social care staff. In addition, all of Hampshire's policies support positive risk taking in working with service users to maximise control and independence in their lives. There is a clear expectation set out in our polices and in our training that all staff document their rationale for any decision making in relation to risk and that there is shared understanding of risk between professionals. All social workers employed with uS have obtained diploma or degree level qualification and they will have studied risk as part of their qualification: All newly qualified social workers also undergo an Assisted and Supported Year in Employment (ASYE) in their first year post qualification where risk assessment is covered. On an ongoing basis, the management of risk is incorporated as part of our core assessment training provided to all social work staff. It is included in many of our courses and training programmes including safeguarding; Mental Capacity Act and Deprivation of Liberty Safeguards. Specialist risk assessment training is accessible for mental health staff through Southern Health NHS Foundation Trust as we have a formal partnership arrangement with the Trust to deliver integrated mental health services. In reviewing the practice in the support offered to Tessa and family, we have not identified that any action is needed in respect of the system of assessing and managing risk more generally: Following Tessa's death this department undertook a full critical incident review to analyse the services offered to her and her family. The report made a number of recommendations which have resulted in changes in practice in the following areas: We have issued guidance for the purposes of recording case notes on the social care electronic recording system for staff in mental health teams_ 2 We are working to improve the interface between our mental health services and adult social care teams including Shared Lives so that teams work more closely and communicate effectively_ 3 We have clarified the arrangements in relation to shared funding agreements for people whose needs span across more than one service. It is now the case that one team will always take the lead to avoid any confusion or delay in decision making- 4 We have re-issued guidance to staff involved in delivering services to adults at risk whose needs span across more than one service. In Tessa's case a risk assessment and risk management plan was developed on April 2013 at meeting between Tessa, her Shared Lives Carer, the Shared Lives her 2gth

Manager and Tessa's Social Worker at the time_ The risk of suicide at this time was felt to be high as Tessa had made two recent attempts_ The response to this risk was that the Shared Lives Carer was to safely and securely store Tessa's medication, ensuring that Tessa only had access to the dose required at the time This risk assessment was updated following a visit to Tessa on July 2013 when she was visited by a social worker from the mental health team in order for him to assess her mental health needs_ The records made by the social worker show that a low risk of completed suicide was indicated and he recorded his rationale as being that 'Tessa had sought appropriate help from previous overdose attempts and stated that she wants help to improve the quality of her life. The assessor did recognise that a factor likely to increase risk was Tessa's impulsive behaviour and the likelihood of her acting on this impulsivity: It was also noted that Tessa was working well within the current placement and was accepting guidance and advice. During this assessment it was established that Tessa would like to return to work at some point and that she would work towards independent living with an extension to the placement of six months proposed to enable her to prepare for more independence. Following this risk assessment carried out by the social worker; care records demonstrate that the Shared Lives Carer updated her copy of the previous risk assessment as follows 'following mental health assessment agreement was made that Tessa will be responsible for her own medication with support by myself to prepare for her move into independent living:" This document is dated July 2013. The risk assessment was further updated on 14th August 2013 following a review visit from a social worker from the physical disabilities team with the Shared Lives Carer in attendance. The purpose of this visit was to discuss supporting Tessa with building independent living skills. The Shared Lives Carer then updated her documentation on the risk issues as follows 'medication now to be kept in filing cabinet to maintain the safety of others including the Tessa has agreed not to take large quantities out of the house in case of loss and theft. In response to 2 in your Regulation 28 Report you have suggested that Shared Lives Carers may benefit from more training and support when working with people with mental health issues emotional problems: The Shared Lives Placement offers supported accommodation in homely environment where adults are supported to exercise their autonomy and independent decision making in a non restrictive and enabling environment: Suitable carers are recruited by the Shared Lives Scheme through a recruitment and selection process_ Once selected , are required to attend a full induction programme which includes mandatory training on the safe use of medication_ Other areas of 17th 17th dog: point and they

mandatory training include safeguarding and an induction course on service standards. Mental health training is available through our department training team and an independent 'service user led' training provider: All Shared Lives Carers also receive regular supervision and support from the Shared Lives Manager whose role it is to support the carers in particular geographical area. Tessa's Shared Lives Carer was very experienced. She had a history of working in care including working with people who are homeless and supporting women who are transitioning from refuge support. This case has highlighted for us the importance of Shared Lives Carers being suitably equipped to support people with emotional difficulties. We will be undertaking a review of the training and support needs of the Shared Lives Carers when working alongside people with mental health and emotional problems We will have reached conclusions on this by end of November 2014. We will also be undertaking broader review of the Hampshire Shared Lives Scheme. We expect the outcome of that review and recommendations for consideration to be available by the end of March
2015. Hampshire County Council is committed to the provision of the best possible services for the residents of Hampshire.