Freedom of Information Request – Ref: FOI 290-2025
Thank you for your recent Freedom of Information request. Please find our response below.
You asked:
Key learning themes and recommendations identified from care reviews relating to deaths by suicide, where individuals were open to the Crisis Team within Gloucestershire at the time of death.
In addition, could you please provide evidence of how these recommendations have been implemented into policy and practice during the following periods:
• January 2024 – January 2025
• January 2025 – present day
Our response:
We have reviewed care reviews across the time frame and there has only been one that meets the request.
The actions from this care review and how these have been implemented is as follows:
Action 1: To ensure all clinicians (registered and non-registered) who are completing NEWS2 are trained to complete the assessment.
Regular sampling of NEWS2 completed charts to ensure compliance with standards as stipulated in NEWS2 training and national guidance.
Response:
Action has been closed we received assurance that all but 2 staff members had completed their NEWS2 training and it was confirmed that an audit of NEWS2 charts take place every month.
Recent update from Stroud CRHTT Manager: 2 staff remain outstanding due maternity leave and a copy of the most recent NEWS2 audit was shared with us to provide additional assurance for this FOI request.
Action 2: To include prompting the DoC, to establish the availability of a suitable clinician to make contact with family/next of kin in the absence of a team manager (for example over the weekend).
Guidance (on call manual) to be updated to remind clinicians to clarify with the police if family have been informed when initial contact is made with the team regarding the death of a patient.
Response:
Action closed- SOP added to the On call handbook
Link below to the Standard Operating Procedure that has been added into the On-Call Handbook, which includes prompts for NOK to be contacted;
Action 3: Discuss with specialist services such as “Via” their policy on reasonable adjustments. Understand how we can work collaboratively to support individuals who are struggling to access specialist support due to their mental health.
Response:
Action closed- Co-Occurring Substance Use and Mental Health Disorders (CoSUM). Pathway sets out a process for ensuring service users with a range of severe mental illness and co-existing substance misuse problems have access to effective services that are responsive and inclusive to their complex needs. Implementation of the pathway is dependent upon all parties agreeing and working within the service parameters for all SUs regardless of their background and circumstances.
Link below to a copy of the CoSUM pathway.
Additional assurance gained from Nurse Consultant for Substance Misuse: strands of work are already occurring through the interagency dual diagnosis programme which includes practice development and specialist support provided by the dual diagnosis worker who is embedded in both services. The GHC substance misuse group (also attended by VIA senior management) provides a forum for representatives from each service to come together and discuss current working practice, commissioning and practice arrangements with respect to dual diagnosis. The pathway was agreed by both services in April of this year and represents a local attempt to respond to gaps identified between substance misuse and mental health services. It is linked in and disseminated through the wider activities of relevant agencies including clinical governance, training programmes and local information/ dissemination frameworks. The work is complex and ongoing, but the pathway reflects broader principles of joint working and forms part of health improvement planning going forward between GHC and VIA.
Next steps:
Should you have any queries in relation to our response, please do not hesitate to contact us. If you are unhappy with the response you have received in relation to your request and wish to ask us to review our response, you should write to:
Louise Moss
Head of Legal Services / Associate Director of Corporate Governance
c/o Gloucestershire Health and Care NHS Foundation Trust
Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth, GL3 4AW
E-mail: louise.moss@ghc.nhs.uk
If you are not content with the outcome of any review, you may apply directly to the Information Commissioner’s Office (ICO) for further advice/guidance. Generally, the ICO will not consider your case unless you have exhausted your enquiries with the Trust which should include considering the use of the Trust’s formal complaints procedure. The ICO can be contacted at: The Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.