Health Service Guidelines (HSG)

D. Speers made this Rhyddid Gwybodaeth request to South East Coast Strategic Health Authority

This request has been closed to new correspondence from the public body. Contact us if you think it ought be re-opened.

Roedd y cais yn llwyddiannus.

Dear South East Coast Strategic Health Authority,

FOI requests please:
1) Are South East Coast Strategic Health Authority the correct authority to seek these answers from? If not who are?

2) Will HSG(94)27 be implemented by SHA following the Serious Untoward Incident (SUI) involving Sussex Partnership Trust patient Samuel Reid-Wentworth .http://www.dh.gov.uk/en/Publicationsands...

3) In the light of the recently published Broadmoor Investigation Report, how will SHA assure itself that Broadmoor Hospital is 'fit for purpose' for the treatment of Samuel Reid-Wentworth?

4) Have Lucy Yates and her family been offered post-traumatic stress counselling, following the attempt made on her life?

Yours faithfully,

D. Speers

Whitehead Sarah (NHS South East Coast), South East Coast Strategic Health Authority

1 Atodiad

Dear Sir/Madam,

Thank you for your Freedom of Information Act request received on the 14
December, regarding a serious untoward incident.

We are processing your request, and will write to you again shortly if
we require further clarification of your request or when we are in a
position to respond.

If we can be of any further assistance to you in the meantime, please do
not hesitate to contact me.

Yours sincerely,

Sarah Whitehead
Senior Communications Officer (Public Affairs)
Tel 01293 778873

NHS South East Coast
LEADING I INNOVATING I IMPROVING
www.southeastcoast.nhs.uk

Please consider the environment before printing this email

dangos adrannau a ddyfynnir

Dear Sarah Whitehead (NHS South East Coast),

Many thanks for your prompt acknowledgment. I appreciate your time and await your response.

Yours sincerely,

D. Speers

FOI SHA (NHS South East Coast), South East Coast Strategic Health Authority

1 Atodiad

Dear Sir/Madam,

Please see attached a response to your recent Freedom of Information Act
request.

Yours sincerely,

Sarah Whitehead
Senior Communications Officer (Public Affairs)
Tel 01293 778873

NHS South East Coast
LEADING I INNOVATING I IMPROVING
www.southeastcoast.nhs.uk

Please consider the environment before printing this email

dangos adrannau a ddyfynnir

Dear FOI SHA (NHS South East Coast),

Many thanks for your response and before I contact NHS London re the Broadmoor 'fit for purpose' question. Can you provide documentation on SPT's transfer of 'duty of care' to Broadmoor?

The Dept of Health's guidance wording re access criteria for HSG(94)27, seems to have changed, can you

confirm this HSG change please?

The HSG(94)27 information I have clearly states:
1: Commissioning
The Strategic Health Authority (SHA) is responsible for commissioning independent investigations and consequently the reports generated are the property of the SHA. Commissioning in this context refers to determining when an independent investigation is necessary, appointing an independent
investigation team, agreeing terms of reference, publishing and distributing the resultant report and ensuring a process for subsequent action to address
issues raised.

SHAs, Primary Care Trusts and Mental Health Trusts should come to localagreement with respect to arrangements for funding and supporting independent investigations. HAS THIS BEEN DONE?

In cases where joint commissioning occurs, then early agreement on funding arrangements should be made.

Criteria: CLEARLY STATES
An independent investigation should be undertaken in the following circumstances:

1) when a homicide has been committed by a person who is or has been under the care, i.e. subject to a regular or enhanced care programme approach, of specialist mental health services in the six months prior to
the event.

"You have written "When a homicide has been committed by a person who is or has been under the care of specialist mental health services in the six months prior to the event.

Please advise: "Did the SPT patient in question have a regular or enhanced CPA?"

2) when it is necessary to comply with the State’s obligations under Article 2 of the European Convention on Human Rights. Whenever a State agent is, or may be, responsible for a death, there is an obligation on
the State to carry out an effective investigation. This means that the investigation should be independent, reasonably prompt, provide a sufficient element of public scrutiny and involve the next of kin to an
appropriate extent.
Please advise: HAS THIS HAPPENED?

You have written "When it is necessary to comply with the government's obligations under Article 2 of the European Convention on Human Rights. Whenever a government agent is, or may be, responsible for a death, there is an obligation on the government to carry out an effective investigation."

Please advise: as the SHA have an identified Performance Management role, who is obliged in 'Government' to carry out an effective investigation?

3) where the SHA determines that an adverse event warrants independent investigation, for example if there is concern that an event may represent significant systemic service failure, such as a cluster of suicides.

You have written "Where the SHA determines that an adverse event warrants independent investigation, for example if there is concern that an event may represent significant systemic service failure, such as a cluster of unexpected deaths including suicides."
As Performance managers can SHA provide documentation on PCT/SPT Suicide Prevention strategy?

Timing
The start of local investigation processes and publication of reports shouldtake place as soon as possible after the adverse event.
WHEN DID THIS HAPPEN?

In circumstances where police investigations or other legal proceedings are ongoing, then the
timing for these processes should be agreed with the local police or Crown Prosecution Service to ensure that the legal process is not undermined in any
way, but that local NHS investigations can proceed as soon as possible.
AND THIS?

Where appropriate, early contact with the coroner is advisable to help determine the scope and timing of local investigations with respect to the
inquest process.

You also confirm "that NHS South East Coast is currently reviewing the case that you refer to ahead of making a final decision on whether an independent investigation should be commissioned into this case."

With regards to the Timings requirement of an investigation under Health Service Guidelines (HSG)
"The start of local investigation processes and publication of reports should take place as soon as possible after the adverse event investigation"

Please advise: When does the SHA anticipate publishing a final decision ?

Yours sincerely,

D. Speers

FOI SHA \(NHS South East Coast\), South East Coast Strategic Health Authority

1 Atodiad

Dear Sir/Madam,

Thank you for your subsequent request for information received on 14
January, which we are processing in accordance with the Freedom of
Information Act.

We will write to you again shortly if we require further clarification
of your request or when we are in a position to respond.

If we can be of any further assistance to you in the meantime, please do
not hesitate to contact me.

Yours sincerely,

Sarah Whitehead
Senior Communications Officer (Public Affairs)
Tel 01293 778873

NHS South East Coast
LEADING I INNOVATING I IMPROVING
www.southeastcoast.nhs.uk

Please consider the environment before printing this email

dangos adrannau a ddyfynnir

Whitehead Sarah (South East Coast Strategic Health Authority),

1 Atodiad

Dear Sir/Madam,

Please find attached a response to your Freedom of Information Act
request.

Yours Faithfully,

Sarah Whitehead
Communications Officer (Public Affairs)
NHS South East Coast

Tel: 01293 778873
[mobile number]

dangos adrannau a ddyfynnir

Dear Whitehead Sarah (South East Coast Strategic Health Authority),

Please be advised the access criteria for HSG(94)27 was indeed changed in 2005, with the expressed intention of strengthening its use.
The new guidance you refer to is still HSG(94)27 (formerally LASSEL(94) 4) This guidance replaces paragraphs 33 –36 in HSG (94) 27 (LASSL(94)4) concerning the conduct of independent inquiries into mental health services.

It clearly states and quotes publications...- "It is essential that all adverse health care events are reviewed in such a way that lessons can be learnt (An Organisation with a Memory and Building a Safer NHS)".

This strengthening was further borne out by David Nicholson's NHS CEO, letter of July 4 2007, where all SHA CEOs were advised of the importance of Independent Investigations into adverse incidents in mental health services and compliance with HSG guidance.

I trust this is helpful

Yours sincerely,

D. Speers