Adrian Cowan

Executive Director of Nursing, Quality and 
Governance 
Barnet, Enfield and Haringey Mental Health 
Trust 
Trust Headquarters 
 B2, St. Ann’s Hospital 
 St Ann’s Road 
 London N15 3TH 

Email: 

Tel: 020 8702 3032 

Mr A. Walker, 
Senior Coroner, 
North London Coroners Court, 
29, Wood Street, 
Barnet, 
EN5 4BE 

4th April 2014 

Dear Mr Walker, 

Re: Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulation 28 and 
29 of the Coroners (Investigations) Regulations 2013 – Mr A. Cowan (Deceased) 

I write on behalf of Barnet, Enfield and Haringey Mental Health Trust, as Executive Director of 
Nursing, Quality and Governance, in response to your Regulation 28 report, following the inquest 
which concluded on 28th January 2014 touching the death of Mr Adrian Anthony Cowan. At the 
time of his death Mr Cowan was a detained inpatient within the North London Forensic Service, 
Barnet, Enfield and Haringey Mental Health Trust. 

I would like to assure you that your concerns have been taken seriously by our Trust, and we have 
taken immediate action to address the matters of concern. 

For completeness I would like to address the concerns as they are set out in your 
correspondence: 

1.  That the Trust policy dealing with the staff response did not include a clear set of 

guidance to those staff members responding to Mr Cowan’s collapse nor did the policy 
include the need, as part of the emergency response, to request the duty doctor to 
attend. 

I would like to assure you that we have taken immediate action to review the Trust’s resuscitation 
policy, which at the time of Mr Cowan’s Death was up to date and was not due to be reviewed 
until 2015. 

Chairman:  
Michael Fox 
Chief Executive   Maria Kane 

 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The update to the policy will incorporate additional action to be taken in the future in response to 
the “deteriorating patient”, and we will update and expand the “NEWS” Score, which is a nationally 
recognised tool for assessing patients whose physical health may be deteriorating. The revised 
policy will make clear the need to contact the duty doctor in the event of a medical emergency. 

I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death 
did list the actions to be taken to determine whether a patient was breathing or not, and explained 
what action was to be taken in such events. We have now displayed a step by step guide within all 
ward areas within the Forensic Service, and we will be introducing this in all our other inpatient 
areas. I would further wish to reassure you that the training provided to frontline staff will reiterate 
the changes in our policy once it has been ratified which I anticipate will have been completed by 
30th April 2014. 

2.  Some of the nursing staff were not able, when responding to Mr Cowan being found 
collapsed, act in a calm, coordinated manner and were not able to apply the training 
they had received in basic life support. 

We recognise that during clinical emergencies some staffs ability to recall procedures and act in a 
calm manner may be affected, particularly when such practice is not exercised regularly. 

I can confirm that within the Forensic Service, all staff have attended the Basic Life Support 
Training (with the exception of recently appointed staff who have been scheduled to attend future 
training sessions). All Registered Nurses are expected to undergo Intermediate Life Support 
Training. There are robust Trust structures in place to monitor attendance at such training and 
systems to address any areas of variation in compliance across our services. 

In order to improve the confidence and competence of staff’s application of resuscitation 
techniques, regular assessments and practical sessions have been implemented using a lifelike 
manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This 
approach is being revised and will in future be run regularly across all wards within the Forensic 
Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced 
resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability 
to respond in an emergency situation.  

In addition, the Forensic service has in place regular support structures in the form of support 
groups to support those staff who may lack confidence, or require guidance on any clinical issue 
that they may feel unsure of, or lack confidence in. 

I would wish to assure you that following all Serious Incidents within the Trust we endeavour to 
ensure that systems and procedures, as well as individual clinicians’ competencies are reviewed 
to evaluate whether changes are required to reduce the likelihood of similar future events. 

Chairman:  
Michael Fox 
Chief Executive   Maria Kane 

 
 
 
 
   
 
 
 
 
 
 
 
        
 
 
 
 
 
 
 
 
 I confirm that we have as detailed above taken clear action to address the matters of concern 
raised by you and I can assure you that we will continue to actively audit resuscitation practices 
within the North London Forensic Service. If you require any further or additional information for 
clarification, please feel free to contact me directly.  

Yours sincerely, 

, Clinical Director, North London Forensic Service 

Executive Director of Nursing, Quality and Governance 
CC: 
CC: 
CC: 
CC: 

, Resuscitation Officer 

, Lead/Claims Lead 

, Medical Director 

Chairman:  
Michael Fox 
Chief Executive   Maria Kane