William Hafele

Surrey and Borders Partnership NHS]

NHS Foundation Trust

Trust Headquarters
18 Mole Business Park

Private & Confidential Leatherhead
Mr Richard Travers Surrey KT22 7AD

HM Coroner for Surrey

Coroners Court Tel: po
Station Approach Fax:

Woking

GU22 7AP rail:

Friday, 16"" January 2015

Dear Mr Travers

Inquest into the Death of Mr William Hafele
Regulation 28 Report — Action to Prevent Future Deaths Response

Further to the conclusion of the inquest into Mr William Hafele’s death on 10"
November 2014, you wrote to Surrey and Borders Partnership NHS Foundation
Trust in accordance with Regulation 28 report to prevent future deaths, stating that
during the course of the inquest the evidence revealed matters giving rise to
concern.

We would, firstly, like to take this opportunity to offer our sincere condolences to Mr
Hafele’s family for their loss.

The areas of concern you raised that relate to our Trust and our responses are
detailed below:

Training procedures, in respect of the Police and hospital staff on Elgar Ward,
in the case of reports of missing persons. Critical information required to
make an informed risk assessment as to whether HW was missing or absent
was omitted. There was a lack of understanding of areas of responsibility and
appropriate actions.

We have further emphasised the importance of the Missing Persons (MISPER)
process to all our staff on these units, including making this a part of our
improvement work in the reduction of the numbers of people who may be Absence
Without Leave (AWOL). A member of the Clinical Assurance team is specifically
assigned to wards with the view to ensure compliance with the MISPER agreement
is tested.

Staff have been further clearly instructed to complete Appendix A of the MISPER
agreement. This outlines details such as name and location of the unit reporting the
missing person, the risk assessment zoning and clear justification for the category,
personal details of the person who may have gone missing with an option to attach a

For a better life

Trust Headquarters, 18 Mole Business Park, Leatherhead, Surrey KT22 7AD
T_0300 55 55 222 F_01372 217111 www.sabp.nhs.uk

photo and description of general appearance. To ensure that relevant information is
recorded and reported to the Police as part of the missing persons report, it is now
expected practice for all staff to ensure that they upload this document onto our
Electronic Patient System (RiO) in a timely manner. This will now be audited for
completeness.

The decision to reclassify from missing to absent was not communicated to
the hospital, as a result no enquiries or investigations were made by any
agency to ascertain Mr Hafele’s whereabouts. Ineffective communications
between the Police and Elgar Ward.

A flow chart clearly outlining the process to make inquiries further to a missing
persons report to the Police has been developed. It contains clear directions on the
process that needs to be undertaken when someone has not returned to the ward.
This standardisation of approach will support staff in making enquiries or
investigations when a person using our services goes missing from the wards.

Adequate training on the Surrey Wide Response Agreement and Surrey Police
Missing Person Procedure did not take place.

We have enhanced our focus on reducing the number of people who go missing
from our wards and we believe the work we are doing through our improvement
team as outlined in our Quality Improvement Plan will start to show positive results.
We have a close working relationship with Surrey Police which has further been
strengthened through the Crisis Concordat work we are doing. This is also providing
the opportunity for us to learn together on aspects on which we can improve.

The MISPER agreement has been widely discussed in teams and presented at our
managers meetings on a number of occasions. In addition mandatory training has
now been arranged for all staff within the unit to be completed by the end of
February 2015. To further ensure embedding of the process, we will now require our
ward managers to undertake a quarterly audit on MISPER forms Appendix A & B
and any emerging issues are discussed at our Acute Care Forum meeting.

We have included the concerns you have raised in our corporate action plan to
ensure that there is ongoing learning from these. We would like to offer our sincere
condolences again to the Hafele family for their loss and hope that the steps we
have taken as outlined above assures you and them, that we have learnt and
continue to leam from this event.

Please do not hesitate to contact me or P| Director of Quality (DoN) if you
require any further information.

Yours sincerely

Signed in the absence of Fiona Edwards by [I Director of Quality and
Deputy Chief Executive.

Our ref: Mr William HAFELE

SURREY

Mr Martin Fleming POLICE

Assistant Coroner for Surrey Wier yesh, eriaoiag

H.M. Coroner’s Court Surrey safer

Station Approach www.sutrey,police.uk

Woking

Surrey

GU22 7AP Deputy Chief Constable
21 January 2015

Dear Mr Fleming,
Mr William HAFELE- Regulation 28 Report. Response on behalf of Surrey Police Force

Thank you for your letter to Chief Constable Lynne Owens dated 25'" November 2014 and
the accompanying copy of your report following the Inquest into Mr William Hafele’s death.
Surrey Police welcome the opportunity to improve the service provided to the public
however it is unfortunate that this sometimes arises from such sad incidents. Our response
to your report is set out below and refers to the Coroner’s Concerns, listed at section 5. |
have detailed both the action taken and proposed, together with the anticipated date of
delivery.

Responses to the Coroner’s Concerns.
1. “Training procedures in respect of the police and hospital staff on Elgar Ward in the

case of reports of missing persons and lack of understanding of areas of responsibilit
and appropriate actions”.

Response:

The Force’s Missing Person Policy (MPP) is currently under review. The existing MPP, a
policy jointly produced with NHS partners, is a comprehensive document setting out the
way in which risk can be assessed and appropriate levels of responsibility:

e the risk assessment process to identify whether people missing from mental health
and medical care establishments should be categorised as being low, medium or
high risk as identified by certain criteria; and

e the responsibility for identified enquiries, into the circumstances and whereabouts
of the missing person, are also clearly articulated.

Tel
Website.www.surrey.police.uk (s Si 1 aerere
Surrey Police, PO Box 101, Guildford, GU1 9PE ici gaa acorns

This document has been recently updated to ensure that it is compliant with the new
Association of Chief Police Officers (ACPO) guidelines.

This has been shared with the Surrey Adult Safeguarding Board and feedback will be
provided and discussed at the next meeting in January 2015. The Force continues to work
with its partners to ensure compliance with existing policy.

Once the review of the MPP is complete, training and a familiarisation programme will be
implemented for officers and mental health/medical staff (which may even include
consideration for joint enterprise) to ensure that all staff understand and implement the
policy and work effectively together to deliver successful outcomes for missing individuals.

The policy will be subject to regular and on-going reviews, in line with Force process for all
existing policies/procedures.

2. “Critical information required to make an informed risk assessment as to whether
was missing or absent was omitted”.

Response:

The omission of certain information that would have better informed the risk assessment,
and thus whether the subject was ‘Absent’ or ‘Missing’, was a specific of this case. It was as
a result of a call handler failing to pass on particular details to the Duty Inspector at the
material time.

Guidance has since been circulated to all appropriate personnel to emphasise and ensure,
so far as is possible, that all necessary details are provided in order for an accurate risk
assessment to be made.

The risk of this happening again will also be significantly mitigated by the full introduction of
Mobile Data Terminals (M.D.T’s). This will ensure that officers receive the necessary
documented information first hand and do not have to rely on information being verbally
relayed to them.

3. “The decision to re-classify from missing to absent was not communicated to the
hospital”.

Response:

This was an error on behalf of the operator and, therefore, case specific. The procedure
includes a full list/flowchart of the process. The requirement to notify the hospital following
the re-classification was ignored on this occasion; the operator did not act in accordance
with procedure. The operator has been given subject to a misconduct process and given
‘words of advice’ as a formal sanction.

4. “Asa result no enquiries or investigations were made by any agency to ascertain Mr
Hafele’s whereabouts”.

Response:

It is correct that this was the result and is a specific failing in this case.

5. “Adequate training on the Surrey Wide Response Agreement and the Surrey Missing
Person Procedure did not take place”.

6. “In relation to the Police, specific training with regards to risk assessments for mental
health was lacking”.

Response:

e The Force has in place a comprehensive program of training and is developing and
enhancing this as an on-going matter.

© All officers and staff are required to complete the NCALT (College of Policing) e-learning
package on National Decision Making Model.

© Areview of the initial training provided to Probationary police officers was carried out in
accordance with peer review recommendations. This is now complete and the training
has been found to be fit for purpose.

° The Force’s Mental Health Liaison Officers (MHLOs) are a group of 21 officers and staff
from across the Force and from various roles who have opted to ‘up skill’ in this area and
develop their knowledge.

The MHLOs are available to advise colleagues on mental health queries, including
Sections 135 and 136 of the Mental Health Act 1983, the Mental Capacity Act 2005,
policies and procedures and information about local mental health charities and
organisations.

These individuals, where possible, also play a key part in building and maintaining
relationships with local partners and voluntary organisations / charities.

The MHLOs received an initial 2 day input whereby they were briefed on topics which
included legislation, the role, current policies and procedures, specialist topics e.g.
children and young people, and inputs from local mental health charities and support
services. The MHLOs also receive 6 monthly updates and have received their first one of
these in November 2014. These updates are produced taking into account requests
made by the MHLOs and any operational updates required.

The Force is aiming to increase the number of MHLOs across the force in the future;
however there are no plans to recrult to this role currently.

° Mental Health Briefings to Supervisors will begin in February 2015 and will include an
overview of issues and learning from recent cases; reminder of protocols; revision of
relevant legislation and case law.

° Two Back to Basics e-briefing/learning packages;
(i) Mental Capacity Act.
(ii) Practical Guide to Dealing with Mental Il] Health,

are to be rolled out Force wide at the beginning of February 2015 and priority will be
given to front line officers and staff.

co The Metropolitan Police Force has recommended the Vulnerability Assessment
Framework for introduction to Surrey. This model still needs to be agreed/adapted for
Surrey before training can be rolled out. This will potentially form part of a Force wide
training update programme on omni-competence commencing in March 2015.

e The Force has reviewed all its (internal and external) mental health policies and
procedures within the last 6 months and this review will be an on-going process
alongside Crisis Care Concordat partners. New policies and procedures have been
drafted where a requirement was identified as a need, for example the ‘Conveyance of
Mental Health Patients’ and ‘Restraint of Mental Health Patients within a Mental Health
or medical environment’.

e Other materials have been and are being produced to assist officers to properly and
effectively support individuals in mental health crisis. For example, s136 information is
now available on MDTs so that officers can complete appropriate $136 paperwork but
also have access to relevant data and legislation to assist them. Mental health booklets
are being drafted to enhance the awareness of officer and staff knowledge about mental
health issues. {It is proposed that this information will be made available in an
interactive format, available on officers MDTs.

7. “Surrey Police TPT briefing training did not correspond to the definition of Absent
given in the Surrey Police Missing Person Procedure”.

Response:

This was noted by the Force and the TPT briefing training will be modified to take account of
this and ensure consistency in the future.

8. “Ineffective communications between police and Elgar Ward”
Response:

This was in the context of the communication between the Contact Centre and Elgar Ward
and specifically related to the ward not being informed that the individual was being treated
as ‘Absent’ rather than ‘Missing.’ This does not relate directly to mental health in the wider

context and will be addressed through the review which is taking place into the wider issues
relating to missing persons.

Summary

HM Coroner does not express concern to the contrary but, nonetheless, it is worth noting
that we remain of the view that our policies and procedures are fit for purpose and take into
account matters referred to in current ACPO and College of Policing guidance.

The Force will endeavour to remain vigilant in ensuring that these policies are maintained
and up to date, compliant with statutory provisions and relevant guidance. The Force will
continue in its endeavours to ensure staff and officers are trained appropriately in order to
minimise the risk of breaches in procedure.

The Force is aware that there may be occasions where there are policy breaches and these
will be dealt with under appropriate management and conduct procedures, as in this case.

The Force is committed to working with NHS and other medical partners to ensure effective
channels of communication and consistent response and handling of mental ill health issues.

Should HM Coroner require further assistance or clarification of matters set out in this
letter, we will be pleased to assist as necessary.

Yours sincerely,

Deputy Chief Constable