(a)

29 services working together as a whole system approach around shared risk, learning and integrated care, common approach, dispersed leadership and transparency;

(b)

there are two key structures and both groups generate learning –

·         System Optimisation Group – strategic level

·         Creative Solutions Forum – operational group

(c)

our aim to reduce future deaths and focussing on alcohol and drug related deaths, suicide, domestic abuse leading to homicide, homicide by a person with mental health and death by fire;

(d)

they want to develop the integrated approach at a strategic level and that the Health and Wellbeing Board becomes the strategic approach.  At the operational level have proposed to convene an expert group to adopt methods that look at deaths within a systems context, backward looking, audit and review of the death and project those findings for future learning;

(e)

they have developed a humane end of life pathways for marginal groups and have set up an designated area for homeless people to have a dignified death with support;

(f)

the number of drug related deaths were at their highest and have identified bereavement training for staff exposed to their clients dying.   Also providing better aftercare for relatives of suicides and drug overdoses.

(g)

they contact the Coroner to track where a person had died and if there was learning on the Coroner’s files they would contact the relevant people within the hospital.  Currently there was no systematic way of tracking this, an offer from the hospital was put forward to meet to discuss this;

(h)

they were aware of the gaps in the system and were in talks with the NHS and Clinical Commissioning Group to expand and include working with the mental health providers and GP.