Department of Health and Social Care

“I have asked my officials to make your report and the circumstances of this case known to the Care Quality Commission, the independent regulator of healthcare services in England.”

“I am also under a duty to send the Chief Coroner a copy of your response.”

“The Department therefore expects care providers to ensure that those members of staff involved in the return of a patient following revocation of section 17 leave are aware of their powers and responsibilities towards that patient and that these are applied in a consistent manner.”

“The PFD stated that clarification was required as to the actions that would be taken to achieve the goals set out in a letter dated 22 May 2019 from the Deputy Chief Executive of Surrey and Borders Partnership NHS Foundation Trust (SABP). This letter committed to the development of joint working protocols across the system for the management of complex absent without leave (AWOL) cases (cases where section 17 has been revoked and a person is AWOL).”

“[SABP] has a legal responsibility to arrange for the return to hospital of patients whose s.17 leave they have revoked. If resources are not provided to allow them to fulfil this legal responsibility, there is a risk that future patients, whose s.17 leave has been revoked and who remain at risk of self-harm or suicide whilst in the community, will find the opportunity to act in such a way as results in their death, whether intentionally or not.”

“we consider that this guidance, when followed, ensures safe prescribing and protects patient safety”

“We support your recommendation for a national review of how the MARAC system can afford protection and support for these particularly vulnerable complex individuals.”

“the CCG is working with the Pennine Care NHS Foundation Trust to agree a Performance and Outcome Framework for 2019-20 to ensure activity, waiting times and outcomes are reported and monitored.”

“The CCG is formally monitoring the impact of this investment through regular Safer Staffing Reports presented to the Pennine Care Quality Group. Reports from staff on the Tameside wards and the latest CQC report indicate that this is having a positive impact.”

“The reviewing team are using this information alongside an exploration of alternative models of care to develop a new model of psychological therapy for people with complex mental health needs in Tameside and Glossop. This review will conclude by the 31 of July 2019.”

“An additional £271,000 agreed in 2018/19 will be increased by an additional £673,000 per annum by 2021 to meet a range of pressures.”

“the CCG is advised that due to actions taken internally the current waiting times for the service have improved, with a current waiting time for Cognitive Analytical Therapy of 13 weeks.”

“have asked the Secondary Care Psychological Therapy Service to ensure that that when people are advised about the waiting times that they are supported to work with their care coordinator for stabilisation, containment and pre therapy work in preparation for therapy to ensure that they do not suffer the distress and despair that Ms [name redacted] family state that Ms [name redacted] experienced and evidenced by her tragic death”

“On the availability of beds in the acute mental health sector, we are aware that the number of mental health beds overall have reduced and this is in large part due to the growth of care in the community. It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the”