Peter Franklin

Dear Ms. Harding, Inquest touching the death of Peter Franklin Report under paragraph 7 Schedule 5 Coroners and Justice Act 2009 (prevention of future deaths) refer to your report in the above matter and am responding in accordance with the requirements of the Regulations: have taken careful note of the issues raised by you in the report and have required action to be taken to address your concerns As understand it you were informed at the inquest that a good deal of work had already taken place within the Trust to try to learn lessons from Mr. Franklin's sad death and to improve our systems of working in collaboration between ourselves at Kent and Medway NHS and Social Care Partnership Trust (KMPT) with Maidstone and Tunbridge Wells NHS Trust (MTW)- A Joint Action Plan has been developed between our two Trusts to ensure the learning from this tragic death is embedded: understand that this has been sent to you and Mr Franklin's family. The responsible Director has informed me that this is currently being updated by both organisations and evidence embedded and that a copy of this will be sent to you. The Action Plan also incorporates the concerns highlighted by you in your Preventing Future Death Report (PFD) The implementation of this action plan is ongoing and is being monitored by the Patient Safety Group (KMPT and Quality and Safety Committee (MTW) within each Trust. development to support the learning is the investment by West Kent Clinical Commissioning Group (CCG) to extend the hours of operation of the Liaison Psychiatry service. At the time of this death the hours of operation were 9-5 five days a week The service is now commissioned and recruitment is in process to allow it to operate seven days a week 9 to 5 and 9 to midnight Thursday to Sunday We are working with the CCG to extend the service 9-midnight seven days a week later in the year. AIl of the CCG's very key

across Kent and Medway have demonstrated a commitment to invest in additional liaison psychiatry services: So far, additional services have been in place will now seek to reply to each of the specific issues raised in paragraphs 5(1), (2) and (3) of your report in the order in which you have raised them: 5(1) - Confusion in terminology used between nursing staff or doctors and the CRISIS team when out of hours calls were made We have developed a clear process outlining the pathway for urgent referrals through a referral flow chart which includes confirmation as to whether advice or assessment is requested: This is monitored by the Liaison Psychiatry Service Manager and at the monthly interface meeting between the two Trusts. The CRISIS team are only paged by the acute hospital outside the hours of operation of the Liaison Psychiatry Service With expansion of the Liaison Psychiatry Service the need to use the resources of the CRISIS team are decreasing: KMPT has developed a SMART tool (safeguarding, management and risk tool) for use between Accident & Emergency Departments and the Psychiatric Services which has been implemented in the east of the county and has been nominated this year for a National Patient Safety Award: This is based on guidelines produced by the National Institute for Health & Care Excellence and therefore compliant with national standards. It assists the Emergency Department staff to think through the immediate management of patients who may be at risk and prioritise need according to risk MTW have agreed to use the SMART tool. Liaison Psychiatry Team are providing specialist training: ` It is being further embedded within the organisation through their junior doctor teaching programme and nursing mandatory training: It is also included in the MTW Staff handbook: Currently discussions are ongoing as to how the SMART tool and Iiaison information can be better shared with MTW. The Liaison Psychiatry Service has carried out a briefing session on the SMART Tool with CRISIS Team so that out of hours there is a consistent response to management of risk and prioritization of patient's requiring assessment: 5(2) Non provision of relevant information / advice by CRISIS team to parties who had made referrals The steps referred to above will also address this aspect of your report: In addition we have reviewed and updated the Liaison Psychiatry roles and Responsibilities Out of Hours Protocol. This provides improved guidance to staff: It has been reinforced to the CRISIS Team that we expect our staff to provide full and accurate information to carers and referring agencies The Clinical Records Policy has been amended to reflect the importance of recording the outcome of urgent patient contact immediately on Rio, the KMPT wide electronic records system. The adherence to relevant KMPT Trust policy is monitored through supervision and audit. If there are concerns about performance this is managed through the Trust's Performance Management Framework: Steps that can be taken include training; mentoring; working under supervision and where necessary formal capability management 5(3) Delays in contact with GP and ways of addressing frequent attendancesladmissions to mental health services and A&E This summer KMPT began the trial of an electronic discharge notification system. By this notification of discharge is sent to GPs electronically immediately upon discharge. It put being being the the

includes full information including diagnosis and details of medication. Unfortunately some technical issues still need to be finally resolved before wider roll out can be implemented. KMPT is continuing to use the existing practice of a Written Discharge Notification faxed to the GP within 24 hours of discharge including details of medication on the day of discharge. We are implementing an audit to ensure that this procedure is followed which will include GPs. We recognise however that further improvement can be made and in this regard the following steps are in hand: As understand it, our colleagues at MTW are also planning to roll out electronic discharge notification in October 2014 We are introducing a recovery card on discharge from hospital for the patient to have and which includes information as to what to do and who to contact in event of crisis_ The card has been designed and is at the printers and will be implemented as soon as received: Significant work has been undertaken to identify those who frequently present to services so that crisis contingency plans can be agreed and implemented across agencies: A monthly meeting is held at MTW to look at the frequent presenters to the Emergency Department which is attended by KMPT's Liaison Psychiatry Consultant This allows a proactive multiagency approach including arrangement of professional meetings to plan and manage care. Mental Health Pathways Project Group has been established including Police, CCGs, NHS and SECAMB_ Part of the project is to share each agency's list of frequent attenders so that we can provide a coordinated response. Conclusion These actions are part of the Action Plan which is being monitored by KMPT's Trust Wide Patient Safety Group (chaired by the Medical Director). hope that the information provided in this letter is adequate for your purposes but would be happy to answer any further questions you may have or to keep you updated on the developments outlined above should you wish me to do so. Once more, my thanks for raising these important issues with me_

Dear Mrs Harding

Re: Inquest touching the death of Peter Franklin Report under paragraph 7 Schedule 5 of the Coroner and Justice Act 2009 (prevention of future deaths)

Further to your report relating to the above matter, I write further to your receipt of the joint action plan formulated by both Maidstone and Tunbridge Wells NHS Trust and Kent and Medway NHS and Social Care Partnership Trust in addressing the issues raised during your enquiry. This action plan was to ensure robust learning and changes in practice to the way both organisations work together to care for patients with mental health issues who may attend our A&E departments.

Firstly I would like to address the issue of confusion in terminology 5(1).The use of a SMART Tool was discussed and agreed at the Emergency Directorate Clinical Governance meeting on 1st July 2014. It is being implemented from an Emergency Department perspective by Dr Bell, Consultant in A&E Medicine and Cliff Evans, Consultant Nurse. Once the design is finalised this will be incorporated into the Junior Doctor Handbook. A copy of the format is attached for your information. This will be used in conjunction with the Mental Health Trust.

5 (3) In the matter of discharge summaries and timely information reaching the patients GPs, the Trust is working towards implementing the Electronic Discharge Summary in line with the rest of the Trust. This is being coordinated by the Head of IT and Information Governance. This will be in place by October 2014. In the meantime all paper discharge summaries are signed and sent by post.

The inaugural frequent attenders’ meeting was held within our clinical governance meeting of 1st July. It was agreed that patient who have had high attendance numbers will be highlighted to their GP and mental health team (if necessary). This will take place monthly and will trigger Multidisciplinary Team meetings in many cases. Each quarter these cases will be reviewed within our Governance meetings with a mental health team representative in attendance.

Mental Capacity Act training for doctors and nursing staff is already mandatory training but we have added a 3 hour session to the junior doctor teaching programme dedicated to this topic.

I have attached for your information copies of our Governance Meeting Minutes and the Junior Doctor teaching programme.

As you will be aware from KMPT, there has been investment by West Kent Clinical Commissioning Group to extend the hours of operation of the Liaison Psychiatry Service. At the time of Mr Franklin’s death the hours were 9-5 for 5 days a week. The new service is going to be seven days a week 9-5 and 9-midnight Thursday to Sunday once additional recruitment is in place.

In summary I hope we have been able to demonstrate that appropriate measures have been and continue to be put in place to ensure the continued safety of our patients and meet the requirements of your report. The measures will continue to be monitored at Directorate meetings as well as at the Quality and Safety Committee.

Should you require any further information, please do not hesitate in contacting me.