Midlands Partnership NHS Foundation Trust

“MPFT has implemented a process for managing referrals and patient- related communications at HMP Hewell, centred around the EDiC (Early Days in Custody) model. MPFT staff working within the prison, have been thoroughly briefed on the EDiC model and are provided with a good practice guide, ensuring consistent and efficient handling of referrals and patient communications across services. This process has been circulated to staff by email, discussed in team business meetings and included in staff”

“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide”

“When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide”

“An exploration of risk would entail a conversation around factors such as risk to self, risk to others or self- neglect. If during that conversation any risks are identified these would be explored in further detail to include intent, severity, access to resources and following this a robust safety plan formulated collaboratively between professional, the service user and carer (if”

“The Overcoming Challenging Times plan is collaborative in nature, designed to enable the service user to identify changes in behaviours, risk and thought processes and empowers them to engage in activities that have previously proven effective in supporting them to manage their emotions and related risks”

“Family and carer engagement; ensuring that families and carers are included in safety planning”

“Monitoring; engagement in real time suicide surveillance, patient safety incident review and learning from deaths process”

“The ACCT procedure was not properly implemented, complied with or supervised. A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted. The last correct entry was at 7 am with earlier omissions.”

“All Midlands Partnership University NHS Foundation Trust staff working in HMP YOI Stoke Heath are required to complete suicide prevention training and also the ACCT training provided by HMP YOI Stoke Heath. Completion timescale July 2024.”

“In addition to the above actions the Midlands Partnership University NHS Foundation Trust have commenced discussions with NHS England regarding a review of their Standard Operating Procedure concerning the referral of and transfer of prisoners to prison establishments with a hospital wing which was an agreed outcome of the inter-agency review. Completion timescale September 2024.”

“The interagency review was conducted on 29th January 2024, as part of our on-going service delivery commitments we will conduct on-going meetings with the Shropshire Community Health NHS Trust and HMP YOI Stoke Heath.”

“I will be presenting an Operational Briefing on 21st December to all staff, taking into consideration the Governors Order GO 01/2023 which reads as follows: The purpose of this Governors Orders is to make you aware that it is the responsibility of the Cleaning Officer to ensure that ACCT observations and conversations are conducted and recorded in the ACCT document between the hours of 0745 - 1715. Between the hours of 1745 - 1915 an Officer will be detailed on the Night Orderly Officers detail”

“As a result of the concerns raised we have undertaken a review of the risk assessment processes across our Health and Justice Services. Some inconsistencies in the standards were identified which we have addressed by the development of a Standard Operating Procedure for risk assessment to be applied across Health and Justice Services. The SOP incorporates standards for conducting and sharing risk assessments for people in Police custody. Included in the SOP is a requirement for risk related information”

“We have identified a number of actions aimed at improving completeness of our documentation; including the provision of additional training and a programme of audits, to ensure improvements are made. (Please see action plan below actions 1 & 2 & 4c).”

“In response we can confirm that a policy and Standard Operating Process (SOP) existed at the time of Mrs [name redacted] death. These outline the responsibilities and expectations of inpatient staff to undertake physical health investigations on admission and also the expectation in the circumstance of refusal to consent to continue to attempt during the z”

“To develop a standard letter template which is sent out to families and carers whose family member have agreed for contact to be made. The letter will form part of our Standard Operating Procedures for assessment across our Mental Health Pathways and each letter will be modified to reflect the individual needs of the patient and their family member.”

“Following discussions within the teams involved, I ani now in a position to respond to your specific concerns, where by you. stated you heard at the inquest during the course of the evidence: 1. Delay in IAPT Counselling After turned 18 she moved to Adult Mental Health Services. She had parallel contact with her GP surgery in Shortly before 18th birthday according to the MPFT Clinical Review I (page 9 of 33), was referred to Improving Access to Psychological Therapies (IAPT) . by'the Access Team for”

“In my opinion action should be taken to prevent future deaths and | believe you and your organisation have the power to take such action.”

“My officials have made enquiries with a number of bodies on the matter of concern in your report that there should be routine therapeutic blood monitoring (testing of blood plasma levels) in patients who are prescribed clozapine.”