PFD report

Darrell Sharples · Prevention of Future Deaths report

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Issued 28 Oct 2020•Cornwall and Isles of Scilly

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
3

Of 1 recipient

Stated actions
28

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to appropriately share targeted ViST data about vulnerable individuals with partner agencies
    Part of recurring concern: Unreliable interagency sharing of safeguarding risk information
  2. Failure to consider the ramifications of bail conditions for vulnerable individuals
    Part of recurring concern: Failure to individualise bail conditions for vulnerable defendantsPart of recurring concern: Inadequate pre-release risk assessment for people leaving custody
  3. Failure to ensure custody access to and review of CJLDT assessments before bail conditions and release of vulnerable individuals
    Part of recurring concern: Failure to individualise bail conditions for vulnerable defendantsPart of recurring concern: Inadequate pre-release risk assessment for people leaving custody
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Consult local GPs on the draft focused letter used after the escalating-risk trigger process.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 December 2020.
  2. Action

    Operate a Central Safeguarding Team trigger process identifying escalating adult risk and prompting focused GP letters.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  3. Action

    Produce guidance notes accompanying the focused GP letter.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 December 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    All ViSTs cannot be sent to GPs because the resulting volume could overwhelm practices and cause higher-risk referrals to be overlooked.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to appropriately share targeted ViST data about vulnerable individuals with partner agencies

Wider context from the report

“ViST forms. These generate a lot of data about potentially vulnerable individuals. I consider deaths may be prevented in the future where that data could be appropriately shared with partner agencies. I have in mind, in particular, Cornwall Partnership Foundation Trust and Kernow Clinical Commissioning Group (on behalf of GPs.) I recognise there is a need to limit or prioritise the data shared so that it is manageable and targeted to the most vulnerable and/or those at greatest risk of harm or self-harm. I further recognise that there may well be legitimate concerns about data protection. I was told this may be of concern where a particular individual consents to the sharing of data. Where someone refuses to consent, however, I accept sharing may be more problematic and legal advice may be required. ”

Is this part of a recurring concern?

Yes — Unreliable interagency sharing of safeguarding risk information.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to consider the ramifications of bail conditions for vulnerable individuals

Wider context from the report

“Custody Access to CJLDT Assessments and Consideration of Ramifications of Imposing Bail Conditions on Vulnerable Individuals. At his assessment by CJLDT in May 2018, it had been recognised that ████████ was a strong protective factor keeping Darrell from harming himself. After his release from custody in July 2018, a bail condition was (correctly) imposed that he was not to contact his wife. This had the unintended consequence of removing that strong protective factor. In the event those in custody had known of the assessment in the CJLDT records, that may have had an influence on assessing Darrell’s risk to himself at the point of release. It may have led to a request to an HCP or CPFT to re-assess Darrell’s risk to himself. It may be that the standard questions completed by custody sergeants could be amended to require an Officer to review or have reviewed any assessment in CJLDT prior to the imposition of a bail condition on a vulnerable individual and his release from custody. ”

Is this part of a recurring concern?

Yes — Failure to individualise bail conditions for vulnerable defendants; Inadequate pre-release risk assessment for people leaving custody.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure custody access to and review of CJLDT assessments before bail conditions and release of vulnerable individuals

Wider context from the report

“Custody Access to CJLDT Assessments and Consideration of Ramifications of Imposing Bail Conditions on Vulnerable Individuals. At his assessment by CJLDT in May 2018, it had been recognised that ████████ was a strong protective factor keeping Darrell from harming himself. After his release from custody in July 2018, a bail condition was (correctly) imposed that he was not to contact his wife. This had the unintended consequence of removing that strong protective factor. In the event those in custody had known of the assessment in the CJLDT records, that may have had an influence on assessing Darrell’s risk to himself at the point of release. It may have led to a request to an HCP or CPFT to re-assess Darrell’s risk to himself. It may be that the standard questions completed by custody sergeants could be amended to require an Officer to review or have reviewed any assessment in CJLDT prior to the imposition of a bail condition on a vulnerable individual and his release from custody. ”

Is this part of a recurring concern?

Yes — Failure to individualise bail conditions for vulnerable defendants; Inadequate pre-release risk assessment for people leaving custody.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consult local GPs on the draft focused letter used after the escalating-risk trigger process.

Verbatim wording from the response

“A draft letter has been prepared and will now be subject to a process of consultation led by ████████ including local GPs. DI ████████ is also to produce guidance notes to accompany the letter, in addition to drafting an article for publication in the GP Bulletin to increase awareness. The GP Bulletin will also be shared with safeguarding leads within GP practices. The learning points will be further raised at the Safeguarding Adult conference.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 3 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate a Central Safeguarding Team trigger process identifying escalating adult risk and prompting focused GP letters.

Verbatim wording from the response

“At this meeting it was discussed and agreed that the sending of all ViSTs to GPs would overwhelm GPs, and create the risk of the higher risk referrals being overlooked as a result of the volume. We recognised that more work could be done in the CST to improve organisational recognition of risk over time; in particular, where risk in relation to a particular individual is escalating. This work has been progressing since 2020 and in November 2020, Detective Inspector (“DI”) ████████ from the CST launched a trigger process to identify escalating risk in adults (including following the submission of a certain number of ViSTs). Part of this process is to include a more focused letter to GPs to advise them of and alert them to the potential escalating risk. The CST already shares information from ViSTs with GPs via GP letters.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 3 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Produce guidance notes accompanying the focused GP letter.

Verbatim wording from the response

“A draft letter has been prepared and will now be subject to a process of consultation led by ████████ including local GPs. DI ████████ is also to produce guidance notes to accompany the letter, in addition to drafting an article for publication in the GP Bulletin to increase awareness. The GP Bulletin will also be shared with safeguarding leads within GP practices. The learning points will be further raised at the Safeguarding Adult conference.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 3 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the Central Safeguarding Team’s adult GP-referral process and feedback loop with NHS Kernow.

Verbatim wording from the response

“3. A meeting was arranged between Devon and Cornwall Police and NHS Kernow to discuss the process for adult GP referrals from the police Central Safeguarding Team (“CST”) and closing the feedback loop with consideration for education of all GP’s including working with GP lead for suicide prevention and dissemination via other forums.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 3 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

All ViSTs cannot be sent to GPs because the resulting volume could overwhelm practices and cause higher-risk referrals to be overlooked.

Verbatim wording from the response

“At this meeting it was discussed and agreed that the sending of all ViSTs to GPs would overwhelm GPs, and create the risk of the higher risk referrals being overlooked as a result of the volume. We recognised that more work could be done in the CST to improve organisational recognition of risk over time; in particular, where risk in relation to a particular individual is escalating. This work has been progressing since 2020 and in November 2020, Detective Inspector (“DI”) ████████ from the CST launched a trigger process to identify escalating risk in adults (including following the submission of a certain number of ViSTs). Part of this process is to include a more focused letter to GPs to advise them of and alert them to the potential escalating risk. The CST already shares information from ViSTs with GPs via GP letters.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 3 · response
Published 8 December 2020

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.24

  1. 1

    Draft and publish an article in the GP Bulletin, share it with GP safeguarding leads, and raise learning at the Safeguarding Adult conference.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 December 2020.
  2. 2

    Develop a professionals’ mental-health helpline to support information sharing and professional access to mental-health services.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2020.
  3. 3

    Recruit and establish a Mental Health Liaison Officer role providing advice, training and a police mental-health contact point.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  4. 4

    Review how police access medical information out of hours for at-risk people in custody.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2020.
  5. 5

    Maintain a 24/7 mental-health telephone support line for people concerned about their own or another person’s mental health.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  6. 6

    Enable the Force Mental Health Lead and Mental Health Liaison Officer to discuss and consider information-sharing solutions between police and mental-health services.

    Stated by Cornwall Partnership NHS Foundation Trust and Devon & Cornwall Police and NHS Cornwall and the Isles of Scilly Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 8 December 2020.
  7. 7

    Use a standardised triage tool, supported by consistent operational policies, guidance and assessment tools, across adult mental health services.

    Stated by Cornwall Partnership NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2020.
  8. 8

    Develop the 136 Project to train 30 police officers as Mental Health Tactical Advisors.

    Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2020.
  9. 9

    Operate the 24/7 Professionals Helpline providing health information and advice to professionals involved in individuals’ care.

    Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  10. 10

    Develop and trial a Police Passport crisis-planning initiative with CAMHS for sharing relevant support information with Police.

    Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2020.
  11. 11

    Develop a training package for clinicians undertaking triage assessments.

    Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2020.
  12. 12

    Establish an additional Neighbourhood Beat Manager for Mental Health post to strengthen interagency information sharing.

    Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  13. 13

    Embed the Mental Health Liaison Officer role to improve information sharing and joined-up working between Trust and Police services.

    Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  14. 14

    Operate the Initial Response Service as a single access point for people presenting in mental distress.

    Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  15. 15

    Provide Single Point of Access personnel with access to the Operational Policy and Triage Guidelines.

    Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  16. 16

    Develop a standardised triage tool for adult mental-health services based on the UK Mental Health Triage Scale.

    Stated by Cornwall Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2020.
  17. 17

    Operate a 24-hour response telephone line for people experiencing mental distress.

    Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  18. 18

    Develop and launch an Initial Response Service as a single access point for mental-health referrals.

    Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2020.
  19. 19

    Commence a multidisciplinary task-and-finish group to review and redesign assessment processes.

    Stated by Cornwall Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2020.
  20. 20

    Appoint a dedicated Single Point of Access Manager to manage triage assessors and develop referral-management processes and protocols.

    Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2020.
  21. 21

    Appoint a Senior Operational Lead to oversee the Initial Response Service and associated crisis and response functions.

    Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  22. 22

    Review the Community Mental Health assessment team’s Operational Policy and triage process.

    Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2020.
  23. 23

    Appoint six Band 7 Clinical Leads to provide 24-hour clinical support to the service.

    Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2020.
  24. 24

    Develop a training package for staff performing triage and assessment roles within Community Mental Health Teams.

    Stated by Cornwall Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2020.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Draft and publish an article in the GP Bulletin, share it with GP safeguarding leads, and raise learning at the Safeguarding Adult conference.

Verbatim wording from the response

“A draft letter has been prepared and will now be subject to a process of consultation led by ████████ including local GPs. DI ████████ is also to produce guidance notes to accompany the letter, in addition to drafting an article for publication in the GP Bulletin to increase awareness. The GP Bulletin will also be shared with safeguarding leads within GP practices. The learning points will be further raised at the Safeguarding Adult conference.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 3 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a professionals’ mental-health helpline to support information sharing and professional access to mental-health services.

Verbatim wording from the response

“1. A review in relation to how police access medical information out of hours regarding persons in custody at risk. This review is currently underway. Dr ████████, Consultant Clinical Psychologist, outlined in his evidence at the Inquest that Cornwall Partnership NHS Foundation Trust had introduced a 24/7 mental health telephone support line for anyone worried about their own or someone else’s mental health. A project is underway to develop this further to provide a professionals helpline, which will support information sharing and increase professional access to mental health services, which we hope will be implemented in April 2021. Once implemented, this will provide another option for people working in police custody to seek guidance in relation to mental health services that are available.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Recruit and establish a Mental Health Liaison Officer role providing advice, training and a police mental-health contact point.

Verbatim wording from the response

“Since the conclusion of the inquest, Cornwall Partnership NHS Foundation Trust has recruited former Police Superintendent ████████ as Mental Health Liaison Officer to provide advice, guidance and direction to mental health and community staff, police officers and police staff on best practice in providing a service to persons suffering with a mental health disorder in a criminal justice setting; in order to meet their individual needs in line with Cornwall Partnership NHS Foundation Trust polices and up to date legislation. The Mental Health Liaison Officer provides a single point of contact for the police as mental health advisor / specialist trainer and promotes understanding and good practice relating to mental health within criminal justice and in addition will help implement and embed the Criminal Justice Liaison Service within Devon and Cornwall Police.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review how police access medical information out of hours for at-risk people in custody.

Verbatim wording from the response

“In addition, in January 2021 representatives from NHS Kernow, Cornwall Partnership NHS Foundation Trust and Devon and Cornwall Police met to discuss information sharing arrangements and to learn from the case. Representatives included Detective Superintendent ████████, Head of the Public Protection Unit, and Superintendent ████████, Head of Criminal Justice, from Devon and Cornwall Police; ████████, Deputy Director of Primary Care and ████████, Deputy Director of Quality from NHS Kernow and ████████, Mental Health Liaison Officer from Cornwall Partnership NHS Foundation Trust. The learning identified at the inquest was considered and discussed with a focus around information sharing. The following actions were agreed and are now in the process of being implemented:”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain a 24/7 mental-health telephone support line for people concerned about their own or another person’s mental health.

Verbatim wording from the response

“1. A review in relation to how police access medical information out of hours regarding persons in custody at risk. This review is currently underway. Dr ████████, Consultant Clinical Psychologist, outlined in his evidence at the Inquest that Cornwall Partnership NHS Foundation Trust had introduced a 24/7 mental health telephone support line for anyone worried about their own or someone else’s mental health. A project is underway to develop this further to provide a professionals helpline, which will support information sharing and increase professional access to mental health services, which we hope will be implemented in April 2021. Once implemented, this will provide another option for people working in police custody to seek guidance in relation to mental health services that are available.”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Enable the Force Mental Health Lead and Mental Health Liaison Officer to discuss and consider information-sharing solutions between police and mental-health services.

Verbatim wording from the response

“2. Inspector ████████, Force Mental Health Lead for Devon and Cornwall Police, and ████████, Mental Health Liaison Officer, will now be able to discuss and”

Source location

2020-0219-Joint-Response-from-Devon-and-Cornwall-Police-and-Kernow-NHS-Clinical-Commissioning-Group-Redacted..pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use a standardised triage tool, supported by consistent operational policies, guidance and assessment tools, across adult mental health services.

Verbatim wording from the response

“This has been further supported by the development of a standardised triage tool to be used by adult mental health services throughout the Trust, and is based on the UK Mental Health Triage Scale. A training package to support those clinicians undertaking triage assessment is currently being developed by the Community Mental Health Team (CMHT) Single Point of Access Team Manager, and this is further enhanced by clear operational policies, guidance and assessment tools ensuring that access to services is consistent throughout the county.”

Source location

2020-0219-Further-response-and-update-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop the 136 Project to train 30 police officers as Mental Health Tactical Advisors.

Verbatim wording from the response

“Further, the ‘136 Project’ is also currently being developed by the MHLO, with a view to providing training to 30 Police Officers to become Mental Health Tactical Advisors within the force who in turn will support their colleagues with a greater understanding of the Trust’s mental health services, Mental Health Act legislation, and Police powers under this Act.”

Source location

2020-0219-Further-response-and-update-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate the 24/7 Professionals Helpline providing health information and advice to professionals involved in individuals’ care.

Verbatim wording from the response

“As part of the Trust’s joint response with Devon and Cornwall Police and NHS Kernow, I advised that the Trust would build on the provision of the Mental Health Connect service with the development of the ‘Professionals Helpline’. This commenced on 01/11/2021 as a 24/7 telephone-based service to provide access to health information and advice to professionals involved in an individual’s care, be that health partners, social care or the Police. The line dealt with over 90 calls in the first month (please see appendix A for further details).”

Source location

2020-0219-Further-response-and-update-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and trial a Police Passport crisis-planning initiative with CAMHS for sharing relevant support information with Police.

Verbatim wording from the response

“An additional post of Neighbourhood Beat Manager for Mental Health has also been established, where a serving police officer, jointly funded by the Trust and Police Crime Commissioner, further strengthens information sharing between agencies and is currently developing a ‘Police Passport’ to support a more holistic Police response to incident management involving individuals in mental health crisis. This new initiative is being trialled with the Trust’s Community Child and Adolescent Mental Health Service (CAMHS) and focuses on creating a crisis plan with a young person, and their family and/or carers, which is then shared with the Police to provide advice and guidance on how best to support the young person should they come into contact with the police, e.g. a plan may contain details like “I am autistic, please do not handcuff me”.”

Source location

2020-0219-Further-response-and-update-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a training package for clinicians undertaking triage assessments.

Verbatim wording from the response

“This has been further supported by the development of a standardised triage tool to be used by adult mental health services throughout the Trust, and is based on the UK Mental Health Triage Scale. A training package to support those clinicians undertaking triage assessment is currently being developed by the Community Mental Health Team (CMHT) Single Point of Access Team Manager, and this is further enhanced by clear operational policies, guidance and assessment tools ensuring that access to services is consistent throughout the county.”

Source location

2020-0219-Further-response-and-update-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish an additional Neighbourhood Beat Manager for Mental Health post to strengthen interagency information sharing.

Verbatim wording from the response

“An additional post of Neighbourhood Beat Manager for Mental Health has also been established, where a serving police officer, jointly funded by the Trust and Police Crime Commissioner, further strengthens information sharing between agencies and is currently developing a ‘Police Passport’ to support a more holistic Police response to incident management involving individuals in mental health crisis. This new initiative is being trialled with the Trust’s Community Child and Adolescent Mental Health Service (CAMHS) and focuses on creating a crisis plan with a young person, and their family and/or carers, which is then shared with the Police to provide advice and guidance on how best to support the young person should they come into contact with the police, e.g. a plan may contain details like “I am autistic, please do not handcuff me”.”

Source location

2020-0219-Further-response-and-update-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Embed the Mental Health Liaison Officer role to improve information sharing and joined-up working between Trust and Police services.

Verbatim wording from the response

“As part of our commitment to improved joint working with the police you will be aware that ████████, former Police Superintendent, was appointed to the newly created role of Mental Health Liaison Officer (MHLO) within the Trust at the time of the Inquest. This substantive role has now been fully embedded within the Trust’s mental health services and ████████ shares considerable knowledge and expertise across both health and Police services. The role primarily focusses on information sharing, with access granted to both the Trust’s and the Police’s computer systems, enabling ‘live’ information to be shared in a timely manner to improve information sharing and joined up working to ensure provision of an efficient and effective service to persons presenting with a mental health disorder in the criminal justice setting.”

Source location

2020-0219-Further-response-and-update-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate the Initial Response Service as a single access point for people presenting in mental distress.

Verbatim wording from the response

“The Trust’s Initial Response Service has now been launched. This service provides a single point of access for people presenting in mental distress with the aim of quickly identifying an individual’s needs and ensuring they are referred to the most appropriate service. Since its launch in May 2020 this service has shown continued growth, and, as of November, handles an average of 66 calls per day (please see appendix A for further detail).”

Source location

2020-0219-Further-response-and-update-from-Cornwall-Partnership-NHS-Foundation-Trust_Published.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide Single Point of Access personnel with access to the Operational Policy and Triage Guidelines.

Verbatim wording from the response

“The Single Point of Access Manager has taken immediate action to ensure anyone performing this role within the Community Mental Health Teams has access to the Operational Policy and Triage Guidelines.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a standardised triage tool for adult mental-health services based on the UK Mental Health Triage Scale.

Verbatim wording from the response

“The group will review and redesign how assessments are conducted and will include ongoing work around developing a standardised triage tool covering all adult mental health services, based on the UK Mental Health Triage Scale, as well as developing a training package for anyone performing a triage and assessment role within the Community Mental Health Team to ensure they are familiar with the assessment guidance and relevant policies and that there is a robust system in place to ensure this is the case. The Single Point of Access Manager has already commenced work with the Quality Lead for Community Based Mental Health services in reviewing the assessment team Operational Policy and triage process.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Operate a 24-hour response telephone line for people experiencing mental distress.

Verbatim wording from the response

“As outlined at the inquest Cornwall Partnership NHS Foundation Trust has introduced a 24 hour response telephone line and is in the process of developing a single point of access for people presenting with mental distress, which we are calling an Initial Response Service.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop and launch an Initial Response Service as a single access point for mental-health referrals.

Verbatim wording from the response

“As outlined at the inquest Cornwall Partnership NHS Foundation Trust has introduced a 24 hour response telephone line and is in the process of developing a single point of access for people presenting with mental distress, which we are calling an Initial Response Service.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Commence a multidisciplinary task-and-finish group to review and redesign assessment processes.

Verbatim wording from the response

“A Task and Finish group, consisting of the Initial Response Service Manager, Community Mental Health Team Clinical Lead, Associate Director for Mental Health and Learning Disabilities Nursing, Suicide Prevention Lead and involving Quality Leads from both Community Mental Health and Inpatient services; representation from Crisis Services including the Psychiatric Liaison Service with support from our governance team, is expected to commence later this month.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Appoint a dedicated Single Point of Access Manager to manage triage assessors and develop referral-management processes and protocols.

Verbatim wording from the response

“A dedicated Manager for the Single Point of Access within the integrated Community Mental Health Teams has also been appointed to manage the triage assessors across the county in addition to the development of processes and protocols for referral management. Previously the assessment teams were managed separately by the respective community mental health team managers. The change in management structure provides additional governance and consistency to the assessment teams.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Appoint a Senior Operational Lead to oversee the Initial Response Service and associated crisis and response functions.

Verbatim wording from the response

“A Senior Operational Lead has been appointed to the Initial Response Service. This role includes oversight of the Home Treatment Team; Crisis Hub and the 24 hour response telephone line, Mental Health Connect. In addition, six Band 7 Clinical Leads have also been appointed (equivalent seniority to ward Leaders and Clinical Nurse Specialists) to provide 24 hour clinical support to the service.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the Community Mental Health assessment team’s Operational Policy and triage process.

Verbatim wording from the response

“The group will review and redesign how assessments are conducted and will include ongoing work around developing a standardised triage tool covering all adult mental health services, based on the UK Mental Health Triage Scale, as well as developing a training package for anyone performing a triage and assessment role within the Community Mental Health Team to ensure they are familiar with the assessment guidance and relevant policies and that there is a robust system in place to ensure this is the case. The Single Point of Access Manager has already commenced work with the Quality Lead for Community Based Mental Health services in reviewing the assessment team Operational Policy and triage process.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Appoint six Band 7 Clinical Leads to provide 24-hour clinical support to the service.

Verbatim wording from the response

“A Senior Operational Lead has been appointed to the Initial Response Service. This role includes oversight of the Home Treatment Team; Crisis Hub and the 24 hour response telephone line, Mental Health Connect. In addition, six Band 7 Clinical Leads have also been appointed (equivalent seniority to ward Leaders and Clinical Nurse Specialists) to provide 24 hour clinical support to the service.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 1 · response
Published 8 December 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a training package for staff performing triage and assessment roles within Community Mental Health Teams.

Verbatim wording from the response

“The group will review and redesign how assessments are conducted and will include ongoing work around developing a standardised triage tool covering all adult mental health services, based on the UK Mental Health Triage Scale, as well as developing a training package for anyone performing a triage and assessment role within the Community Mental Health Team to ensure they are familiar with the assessment guidance and relevant policies and that there is a robust system in place to ensure this is the case. The Single Point of Access Manager has already commenced work with the Quality Lead for Community Based Mental Health services in reviewing the assessment team Operational Policy and triage process.”

Source location

2020-0219-Response-from-Cornwall-Partnership-NHS-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 8 December 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026