Ashley Ponsonby

The report

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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

This report is made under paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and regulations 28 and 29 of the
Coroners (Investigations) Regulations 2013.

ASHLEY CORIN DE WINTER PONSONBY (deceased)

Recipients
This report is being set to:

The family of the deceased
« Chief Coroner for England and Wales
Bt Hon Mr y Hunt MP — Secretary of State for Health
ee and Crime Commissioner for Greater
Manchester
Sir Peter Fahy — Chief Constable, Greater Manchester Police
Ms Michele Moran — Chief Executive, MHSC

Medical Director, MHSC

Manchester North, Central and South Clinical Commissioning Groups

Copied for interest to:
e INQUEST
e Mind
e Coroners Society of England and Wales

Coroner

| am Nigel Sharman Meadows, H. M.Senior Coroner for the area of
Manchester City.

Coroner's legal powers

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.

Investigation and Inquest

On 6" July 2012 | commenced an investigation into the death of Ashley
Ponsonby, aged 32. The investigation concluded at the end of the inquest on
5™ June 2014.
The cause of death was found to be:

1a Amphetamine and paramethoxyamphetamine toxicity

The conclusion of the inquest was as follows:
Narrative conclusion:

Ashley was a detained patient under the Mental Health Act Section 3 on
Acacia Ward as a dual diagnosis patient. He was admitted in November
2011. On 3rd July he was able to inject illicit drugs. The support worker and
the Nurse in charge were concerned about his welfare, therefore the SHO
was called at about 10pm. The SHO advised to omit 10pm medication and he
would come as soon as possible.

From approximately 6am Ashley deteriorated, which prompted the Nurse in
charge to recall the SHO, who arrived promptly. Ashley's presentation
continued to deteriorate; 999 was called at 7.22am.

The SHO researched the treatment of drug overdose and displayed material
relating to that on the computer screen. This was prior to Ashley leaving the
ward in the ambulance. However the SHO did not mention Naloxone, nor did
the Nurse suggest using Naloxone.

The ambulance arrived at 7.46am. Ashley left Acacia at 8.01am in the
ambulance and arrived at A&E at 8.02am. Despite the efforts of ambulance
and A&E staff, Ashley sadly passed away. Ashley died as an unintended
consequence of a deliberate human act of injecting illicit drugs.

1. Was Ashley subject to a regime of 15 minute observations initiated by the
Nurse in charge of the ward and completed alternately between herself and
another female support worker?

Answer: No

2. After the locum SHO doctor saw and assessed Ashley at about midnight,
what form frequency and type of observations did he intend to initiate as part
of his plan?

Answer: To take basic observations (BP, pulse, temp, UDS) at the Nurse's
discretion, if the patient is awake.

3. Did the locum SHO doctor appropriately and adequately communicate that
to the Nurse in charge?
Answer: No

4. Did the locum SHO doctor mention to the nurse in charge of the ward the
medication known as Naloxone after his first assessment of Ashley?
Answer: No

5. Did the locum SHO doctor research the treatment of drug overdose and
display material relating to that on the computer screen in the office prior to
Ashley leaving the ward with the ambulance service?

Answer: Yes

6. Did the locum SHO docior, before the arrival of the crash team, comment
to one of the nursing staff that he thought that Ashley was withdrawing from
opiates (1) and that the nurse suggested using Naloxone (2)?

Answer (1): No

Answer (2): No

7. What factors, if any, do you find probably made a material contribution to
the death?

* Poor communication of relevant information between SHO and Nurse

* Inadequate escalation of information, issues and problems

* Inadequate record-keeping, e.g. AMIGOS, physical observations, datex, risk
assessment

* Failure of datex policy, its understanding and application

* Inadequate control of access to illicit drugs

* Unapparent training of staff in dual diagnosis, drugs/toxicity symptoms, and
Trust policies and procedures

* Inadequate security systems in place

* Failure of Night Manager to fulfil their roles and responsibilities

* Reaction to medical emergency was inadequate

* An insufficiently safe and secure environment

* Failure to recognise toxicity

* Failure to recognise Ashley's deterioration overnight, and at an earlier stage,
and act upon with urgency

* Culture of complacency regarding drugs

8. What factors, if any, do you find possibly made a material contribution to
the death?

* Ward management was inadequate.

* Inadequate ward formation at the outset of Acacia

* Lack of reports to the police and Trust security

* Failure of teamwork; e.g. MDT and ward staff

* Failure of care plans; e.g. long term deterioration, medical assessment and
review/progression

* Poor liaison with family and MDT; e.g. email

* Inadquate management regarding patients' access to illicit drugs by
Registered Clinician Managers

* Search policy was too flimsy

* Inconsistent approach to mangement of leave by Registered
Clinicians/Nursing Staff

* Failure to recognise Ashley's depression

* Inadequate staffing levels

* Poor equipment and facilities; e.g. oxygen equipment, maintenance, lack of
bed in clinic

Circumstances of death

Ashley was born on 1*' October 1979 and was 32 years of age at the date of
his death. In his middle teenage years he started smoking cannabis. Over
subsequent years he is reported to have consumed cannabis, but also took
cocaine, amphetamines, ecstasy, ketamine, LSD and alcohol. He had started
a university course but left partway through. He had no settled employment
for a period of time. In or about 2007 he got a job as a Support Worker in a
hostel dealing with people with drug and alcohol problems.

In 2008 he attended a music festival and took a cocktail of drugs. He was
then noted to be expressing strange and delusional thoughts. His mother was
very concerned about him. He had some initial contact with mental health
services and had time off work. By 2009 his condition was deteriorating. He
had a brief A&E admission and was subsequently started on antidepressant
medication. The dose of this was subsequently increased and by late
summer 2009, he was prescribed antipsychotic medication. That autumn he
was leading a very chaotic lifestyle and his delusional thoughts re-emerged.

Thereafter he had various contacts with A&E departments as well as mental
health units and was eventually detained under the Mental Health Act, which
tumed into a Section 3 detention in early March 2010. He remained a
detained patient at Park House psychiatric unit from then until the date of his
death.

Technically speaking, he absconded from the ward shortly after this final
admission and was not retumed by the police until some four weeks later. He
was diagnosed as suffering from schizoaffective disorder and poly-substance
misuse. He was reluctant to take oral medication and reportedly had no
insight into his illness. He was then started on a depot medication which had
to be changed. He was still suffering symptoms and was paranoid. Gradually
his condition appeared to settle and he was granted unescorted leave from
the ward. However, he returned in an intoxicated state and his leave was
temporarily suspended.

His parents were anxious that his mental state was once again beginning to
deteriorate. MHSC were making arrangements to create a rehabilitation ward
that was to be known as Acacia at Park House. It was due to house a
maximum of 20 patients, alt of whom would be male, and be detained under
the Mental Health Act. A significant proportion of these patients were known

as dual diagnosis. That means that they had a primary mental health disorder
but also drug/alcohol misuse problems.

He was transferred to Acacia Ward in early November 2011 and remained a
patient on that ward until his death. Some 80% of the patients on the ward
were also dual diagnosis.

Over the whole period of his admission to that ward, he tested negative for
drugs on about 25 occasions. He had refused to provide a urine drug screen
(UDS) on about a similar number of occasions, but over several months, he
tested positive by means of a UDS for illicit drugs on at least 9 occasions.
The drugs in question included cocaine, cannabis and in particular
amphetamines, which he predominantly abused.

The staff on the ward recognised the changing nature of his presentation
when he had taken drugs. A pattern of behaviour was noted; in that he would
be granted unescorted leave and then return either testing positive for illicit
substances or displaying symptomology associated with being under the
influence of illicit drugs. Subsequently he may admit taking drugs, or
thereafter provide a positive UDS. His unescorted leave would be restricted
for some days but then be reinstated. It was also noted that on occasion even
when his unescorted leave was restricted, he still managed to access and
ingest illicit drugs. There was significant concern that another identified
patient on the ward was a potential drug supplier. Ashley’s parents made
contact with the ward in early 2012 to report their concern and the identity of
the patient who was believed to be supplying drugs.

By April, Ashley’s parents were increasingly concerned about his condition
and what they regarded as easy access to illicit drugs, which when he took
them antidoted his psychiatric medication and led to mini-relapses. They
even wrote to his Responsible Clinician expressing their concerns in blunt
terms.

On 8" June Ashley tested positive for cocaine and his unescorted leave was
suspended, but reinstated on 18" June. On 28" June he tested positive
again for amphetamines and his unescorted leave was suspended.

On the evening of 3% July his Responsible Clinician was absent due to
sickness, but he had not been informed of the recent further positive
amphetamine test. There was a change of shift at about 9pm and staff
recognised that his presentation was similar to that when he had tested
positive and taken drugs in the past. Some vital signs were taken and this
indicated that he was significantly tachycardic and also had an abnormal
blood pressure. The psychiatric SHO doctor was contacted, who advised to
omit the night-time medication and that he would attend as soon as possible.
He arrived about an hour or so later and had a brief discussion with the nurse
in charge before examining the patient on his own. His blood pressure had
returned to within normal parameters but he was still tachycardic, but it was
not possible to do a pupillary examination due to a malfunctioning torch.

The nurse in charge accepted that she did not mention specifically about
Ashley’s recent misuse of drugs, and in particular amphetamines. However,
the SHO doctor did not review the recent medical records. If he had done,
they would have shown his recent drug misuse history. However, the doctor
did consider drug misuse to be a possible explanation for his presentation.

The jury found that the subsequent treatment plan initiated by the SHO doctor
was that the nursing staff should take basic observations (blood pressure,
pulse, temperature and UDS) ai the nurse’s discretion if the patient was
awake. However, the doctor did not appropriately and adequately
communicate that to the nurse in charge.

The nurse in charge had indicated that before the doctor arrived, she anda
nursing assistant had initiated an increased level of 15 minute observations.
The nursing assistant had told the court that this had been initiated after the
doctor had attended and was in place until she left duty in the early hours of
the morning. The jury found that Ashley was not subject to any regime of 15
minute observations.

Consequently, no physical vital signs observations were recorded for several
hours, although his location was identified every hour. Up until 5am, his
presentation remained similar to earlier in the shift. However, at about 6am, it
was noted to be markedly different. He was shaking and was pale. He
admitted feeling unwell and had difficulty in standing and was also sweating
profusely. The nurse in charge was alerted and she contacted the SHO
doctor who arrived within minutes. This must have been some time after 6.15
or 6.30am. Ashley was examined again and it was noted that he was
tachycardic and had lower than normal oxygen saturations. It was clear that a
999 call was not made until 7.22am. The SHO doctor said in evidence that he
broke off his examination after about 15 minutes or so in order that a UDS
could be undertaken and he claimed to have instructed the nurse in charge to
phone 999. She adamantly denied this and the jury were unable to determine
factually which version of events they preferred.

At 7.15am, two new nurses attended to start the next shift and immediately
noted Ashley’s condition. The SHO doctor was apparently in the process of
contacting the A&E department to advise them of the imminent arrival of
Ashley. Unfortunately it took some minutes for an ambulance to arrive and it
did so shortly after 7.40am. Just before this, Ashley’s condition deteriorated
further and he was placed on the floor from a seated position. Initially he was
breathing, but then had a cardiac arrest. Prior to this, the crash team from the
hospital had also been called and they arrived almost simultaneously. He
was given immediate first aid and CPR was commenced. Within a few
minutes, he was transported to the A&E department of the hospital, arriving
shortly after 8am. Despite continued efforts to resuscitate him, these proved
unsuccessful and he was pronounced dead at 8.29am.

Despite the nature of the ward and the fact that it would contain a high
proportion of dual diagnosis patients, staff had not been trained in recognising

and dealing with the risks of physical harm arising from the use of illicit
substances.

It had been suspected that another patient had been supplying controlled
drugs to Ashley and others on the ward. The Trust Datix incident reporting
system and the risk register were not used to record the instances of drug
taking or the specific concern about this patient. The ward manager candidly
accepted that it was not until the second day of the inquest hearing himself
that he had recognised and seen the use and importance of utilising those
procedures. The police had not been formally advised about the suspicions
involving the patient and it was understood there was no agreed local Trust
policy with the police or a wider one within the whole of Greater Manchester
regarding police involvement on mental health wards. The court was told that
the recently appointed local Police and Crime Commissioner had designated
someone to consider this, but no formal draft policy had yet been finalised.

The jury was assisted in receiving evidence from an Accident and Emergency
treatment expert, a mental health nursing expert, as well as a psychiatrist,
completely independent of the Trust. The Trust itself had carried out a
significant serious untoward incident investigation. The jury found that a
number of factors had probably materially contributed to the death, as well as
several which had possibly done so.

Coroner’s concerns

During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless
action is taken. In the circumstances it is my statutory duty to report to you.

The matters of concern are as follows.

1. It is a matter of concern that any ward could be set up and operated
involving the inherent risks of drug misuse by dual diagnosis patients
without the staff having any training in recognising and dealing with the
physical harm and risks arising from the use of illicit substances. The
evidence from the independent psychiatrist was that this was an
essential ingredient. Consequently, in rehabilitation wards or those
with dual diagnosis patients where there is a risk of continuing drug
misuse, the concern which arose was that without this, there was a risk
of a future death arising. This has implications locally for the Trust,
regionally and on a national basis.

2. There is a concern that the failure to use the Datix and Trust incident
reporting policy, as well as the risk register (or other similar procedures
available to other Mental Health Trusts), to identify the problem of drug
supply and/or consumption, if unremedied may lead to a future death.

It is a concern both locally for the Trust, regionally and nationally, that
such procedures should be appropriately used so as to prevent a future
death.

3. There was a concern that a lack of a coherent and mutually understood
policy between the Mental Health Trust and the Police as to when they
would become involved in illegal activity meant that neither the patients
nor the staff had clarity on the position. Just because patients have
mental disorder, does not absolve them of all legal responsibilities and
indeed understanding and facing possible criminal consequences may
be important in their overall clinical management and for the
administration of justice. It was suggested that this was being
considered by Greater Manchester Police and the local Police and
Crime Commissioner, but no policy had yet been finalised. Once
again, this has local, regional and national implications, and that the
concern is without such policies being formulated and implemented,
there is a continuing risk of future deaths which could be prevented.

Action should be taken

In my opinion action should be taken to prevent future deaths and | believe
you and/or your organisation have the power to take such action.

Your response

You are under a duty to respond to this report within 56 days of the date of
this report, namely by 25" August 2014. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action
is proposed.

Copies and publication

| have sent a copy of my report to the Chief Coroner and to Interested
Persons. | have also sent it to organisations who may find it useful or of
interest.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to
me, the coroner, at the time of your response, about the release or the
publication of your response by the Chief Coroner.

—/
NS Meadows~ - Date Posy pee Lo (e

H.M. Senior Coroner — Manchester City area

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

GREATER MANCHESTER

Sir Peter Fahy Q.P.M., M.A. , : L | C |=

Chief Constable =

Mr N Meadows

HM Senior Coroner

Manchester City Area

The Coroners Court Crown Square
_Manchester

M601PR 18 August 2014

Dear cic Tendon,

Re: Ashley Corin Winter De PONSONBY (Deceased)

Thank you for your report dated 27th June 2014 in respect of Ashley Corin De Winter
PONSONBY pursuant to Regulation 28, made under paragraph 7, Schedule 5 of the
Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners (Investigations)
Regulations 2013. /

You asked me to consider the below matters:

La

“There was a concern that a lack of a coherent and mutually understood policy between the
Mental Health Trust and the Police as to when they would become involved in illegal activity
meant that neither the patients nor the staff had clarity on the position. Just because the
patients have a mental disorder, does not absolve them of all legal responsibilities and
indeed understanding and facing possible criminal consequences may be important in their
overall clinical management and for the administration of justice. It was suggested that this
was being considered by Greater Manchester Police and the local Police and Crime
Commissioner, but no formal policy had yet been finalised. Once again, this has local,
regional and national implications, and that the concern is without such policies being
formulated and implemented, there is a continuing risk of future deaths which could be
prevented.”

| would like to confirm that | agree completely with your view that a mental disorder does not
absolve individuals of the criminal consequences of their actions. It is often entirely
appropriate and indeed necessary for legal proceedings to be pursued alongside and in
support of an individual who is mentally ill. We take such action routinely, and in co-
operation with the mental health services — who | must say also recognise the necessity for
criminal proceedings in appropriate cases. This action can often be necessary to support
health workers, so that they can carry out their duties as safely as possible.

Of course, sometimes there will be occasions when it is not appropriate for a criminal
prosecution to be pursued, but that should be a considered decision after completion of the
investigation, and should take into account factors such as the victim’s best interests, the
seriousness of the offence, the wider public interest, as well as the offender's mental
capacity and health.

Location address: GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP
Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS
Tel: 101

If criminal offences such as unlawful supply of drugs are reported to us, we will of course
undertake an investigation — as we are obliged to do in any such case. Given that these
offences are taking place wholly within the private space of a hospital ward, we are largely
dependent on the hospital reporting these matters to us, and we are largely dependent on
the support and co-operation of health staff in -allowing us to conduct an effective
investigation.

[ would like to confirm that we have been working together in relation to criminal offences
taking place within the hospital. For example, on 13th May 2012 and 14th May 2012 two
unrelated drug offences were reported to the police by the trust and duly investigated by
GMP. We have also deployed drugs sniffer dogs in the unit at the request of the hospital, and
there is a good level of communication between the hospital and the local division when such
issues are raised with us.

However, it is apparent that there is a desire for greater clarity among our partners about
when criminal matters should be reported to the police. | also recognise and accept fully that
there is an ongoing need for GMP officers and staff to develop their skills, confidence and
knowledge in responding to incidents at mental hospitals and at incidents involving those .
who are mentally ill. The PCC and myself have identified this as one of our priorities, and we
have been working with partner agencies across Greater Manchester to improve the
responses of all agencies.

You will probably be aware of my own appeal recently for greater information sharing
between health services and police and other agencies so that we can make better decisions
about the care of individuals we come into contact with. That may well have assisted with
decision making in this particular tragic case. . .

At the time of Mr Ponsonby’s death on 4th July 2012, there was no formal policy in place
between Greater Manchester Police and Manchester Mental Health and Social Care NHS
Trust regarding the reporting of crime committed by patients or on hospital wards. There are
4 mental health trusts covering the area of Greater Manchester. In early 2012 it was
“recognised by GMP that there were a number of issues around mental health that needed to
be addressed by the introduction of a formal policy. GMP recognised that to make this policy
effective it needed to be created with the inclusion of inputs from partner agencies. GMP
approached the Association of Greater Manchester Authorities (AGMA) to obtain a mandate
to undergo such partnership collaboration around this policy. :

| have appointed an Assistant Chief Constable to lead on mental health policy, and the PCC
has also been actively engaged in this policy area. A Mental Health Oversight Group was
been created, which was chaired by a GMP Superintendent and included Director level
membership from NHS, AGMA, Adult Social Care, Acute Trusts, Mental Health
Commissioners, Menta! Health Trusts, NWAS (North West Ambulance Service) and-
voluntary sector providers. Their work has focused on the response to ‘crisis’, and the priority
areas were: .

Section 136 Mental Health Act
Section 135 Mental Health Act
Conveyancing

Risk Assessment

The process was a thorough and at times complicated one and brought a much greater
‘understanding of each agency's role in these issues. As a result in April 2013, a
comprehensive Mental Ill Health and Learning Disabilities Policy was created to give clarity
of how the police would work with other agencies in these areas.

Location address: GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 SBP
Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS
Tel: 101

Section 5.9 specifically relates to criminal offences within mental health establishments.
There is guidance around action to be taken in these establishments and practical advice in
relation to drugs offences. This section also states:

“Criminal faw has equal application both inside and outside of mental health units. It should
be assumed that all mental health patients have capacity in law for their actions unless
proven otherwise. Such persons should be treated equally to other persons suspected of
having committed or being witness to a criminal offence. The name and qualification of a
person determining the mental capacity of that individual should be recorded on the FWIN or
crime in auditable form. The NHS has a zero tolerance policy in place against abuse of any
kind.”

This policy will be regularly reviewed to ensure it remains current with regard to best practice
and legislation. Indeed there has only recently been an update completed in relation to
Mental Health Diversion Panels.

GMP is committed to working with partners around the whole mental health agenda. We
continue to have a strategic lead at ACC level with a dedicated resource and
senior lead for mental health for the force and this has led to
the creation of robust governance to build upon the work of the Oversight Group. This is now
linked into the GM Health and Wellbeing Board, with an executive group chaired by the
Deputy PCC IJ. This has representation, at command level, from Police, Mental
Health Trusts, AGMA, Local Authority, Public Health England, NHS, Acute trusts, New
Economy and Voluntary Sector. The body will take ownership of policies across the
partnership to ensure a synergy of practice which is efficient, effective and most importantly
provides best support for service users.

Yonucs oat

Sir Peter Fahy
Chief Constable

Location address: GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP
Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS
Tel: 101 .

aB

Equality, Rights and Decency Group

. National Offender Management Service
National Offender P 4th Floor, Clive House,
Management Service 70 Petty France,

London, SW1H 9HD

on

31 October 2014 °

Mr Tom Osborne
Senior Coroner for Milton Keynes

Dear Mr Osborne,

Thank you for your Regulation 28 Report of 29 August 2014 addressed to the Minister for
Prisons, following the recent inquest into the death of Stephen Farrar at HMP Woodhill on
12 December 2013. Your letter has been passed to Equality, Rights and Decency Group in
the National Offender Management Service (NOMS), as we have the policy responsibility for
suicide prevention and self-harm management, and for sharing learning from deaths in
custody.

You have raised concerns about the assessment of the risk of self harm or suicide during the
reception process, and in particular the fact that a formal risk assessment tool is not in use
either at HMP Woodhill or across the prison estate.

| note that you raised similar concerns in a Regulation 28 Report following an inquest held in
February 2014 into a death at HMP Woodhill in May 2013, and that you received a detailed
response to that report from my cole ue on 12 June 2014. | will not repeat the
description of the policy framework given there. In summary there is a comprehensive set of
systems for identifying and assessing prisoners at risk that includes some specific tools, such as
a healthcare reception screening tool that has been made available to all prison establishments,
but, of necessity, such tools form only a small part of the very broad set of processes involved in
this complex task.

In response to your renewed expression of concern, | would like to assure you that reducing the
number of self-inflicted deaths in prisons remains a priority for NOMS, and that we continue to
work to improve our risk identification, assessment and management processes. In response
to the recent rise in the number of deaths, additional dedicated resources are being provided for
safer custody work in a number of prisons, and we have put in place additional staff at regional
level to support staff in prisons and to share good Practice. A learning and knowledge
management team at headquarters provides further support to prisons in learning from deaths
in custody and for safer custody work more generally.

Further action has also been taken locally at HMP Woodhill to address the matters about which
you have expressed concern. This is described in detail in the action plan that addresses the
recommendations of the Prisons and Probation Ombudsman’s (PPO’s) i igation i

. oh i - In , the staff involved in the reception and
first night processes have been reminded of the need to gather all relevant information, and of
the factors that they should consider when assessing risk. The risk assessment process used
by healthcare staff has also been improved and staff trained in its use.

| hope this provides assurance that the matters of concern that you have raised have been
addressed and that NOMS continues to make strenuous efforts to improve its systems and
processes in this important area.

Yours sincerely,

NOMS Equality, Rights and Decency Group

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