Paige Bell

Derek Winter
Senior Coroner for the City of Sunderland

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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:
Rt Hon Jeremy Hunt
Secretary of State for Health
Department of Health
Richmond House
79 Whitehall
London SW1A 2NS

4 CORONER

| am Derek Winter, Senior Coroner for the City of Sunderland

2 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.

http://www. legislation. gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www legislation .gov.uk/uksi/2013/1629/part/7/made

3 INVESTIGATION and INQUEST

On 15/08/2014 | commenced an investigation into the death of Paige Louise Bell, aged 20, who
died on 14/08/2014 at Sunderland Royal Hospital. The investigation concluded at the end of the
inquest on 26/02/2015. The conclusion of the Inquest was Misadventure, the cause of death
being: -

la Hypoxic Brain Injury; due to

Ib Pressure on the Neck; due to

Ic Hanging

4 CIRCUMSTANCES OF THE DEATH

Paige Louise Bell was admitted to Sunderland Royal Hospital on 06/08/2014 after being found
hanging in room at East Willows ward Cherry Knowle Hospital Sunderland. The Jury found that
“As a result of an Emotional Unstable Personality Disorder Borderline owing to chronic self harm
and parasuicidal tendencies, Paige Louise Bell attempted an act of self harm by applying a
ligature to her neck resulting in her death. A contributing factor to this was contradictions within
the observation policy creating ambiguity in its application.”

5 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. -

The case notes were not held in one place and not all transferred with the patient. | wondered if
there were any ongoing plans to allow medical personnel to have immediate access to all notes
electronically rather than notes following the patient as they will contain essential information for
a patient’s healthcare and treatment.

The Trust concerned is due to implement a new Engagement and Observation Policy. | should

Civie Centre, Burdon Road, Sunderland, S$R2 7DN
Tei 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland
www. sunderland.gov.uk/coroner

be grateful to learn of any plans for a National policy/template to ensure consistency between
Trusts.

Also are there any plans to update guidance on the treatment and management of patients with
Borderline Personality Disorder? | was directed to a NICE publication from January 2009.

| enclose a copy of my report to the Trust concerned.

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you 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 Thursday 30" April 2015. |, 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 the following Interested Persons: -
e Northumberland, Tyne & Wear Foundation Trust and their Solicitors and Counsel

° Clinical Risk Manager, Northumberland, Tyne & Wear Foundation Trust

e City Hospitals Sunderland NHS Foundation Trust

« Family and their Solicitors and Counsel

e Care Quality Commission

{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.

Dated this 3° day of March 2015

Signature
Senior Coroner for the City of Sunderland

ah Tamara Finkelstein

Chief Operating Officer
Department
of Health
Richmond House
79 Whitehall
London
SWIA 2NS
Mr D Winter
Senior Coroner
Civic Centre
Burdon Road
Sunderland
SR2 7DN
28 April 2015
Dear Mr Winter

Thank you for your letter following the inquest into the death of Paige Bell.

I was very sorry to hear of Ms Bell’s death and wish to extend my sincere condolences to her
family.

Matters revealed at the inquest have led you to raise the following concerns:

e That case notes were not held in one place and not all transferred with the patient. You ask if
there are plans to allow medical personnel to have immediate access to all notes
electronically rather than notes following the patient, as they contain essential information
for patient care and treatment.

e The Trust concemed is due to implement a new Engagement and Observation Policy. You
ask if there are plans for a National policy or template to ensure consistency between Trusts.

e You ask if there are plans to update guidance on the treatment and management of patients
with Borderline Personality Disorder — you are aware that National Institute for Health and
Care Excellence (NICE) guidelines were published in 2009.

The benefits of electronic patient records have long been known. Such electronic systems help
healthcare staff to treat patients more effectively by giving quicker and easier access to up-to-date
information about medical treatment and history.

The Summary Care Record (SCR) was introduced to improve the safety and quality of patient care.
The SCR is an electronic record which gives healthcare staff access to essential information about
patients, and ensures patients receive safe treatment during an emergency or when a GP surgery is
closed.

An SCR contains information about prescription medications a patient is taking, including allergies
and reactions to medicines prescribed in the past. The information is derived from GP records. By
August 2014, 40 million patients had a SCR and the number is constantly increasing.

Only the healthcare staff directly involved in a patient's care can see that patient’s SCR. Information
is obtained by use of a smartcard with a chip and pass code, similar to a bank card and PIN.

Healthcare staff only see the information they need to do their job, and need to ask permission of
the patient to read the SCR.

If the patient’s permission cannot be obtained because, for example, the patient is unconscious, staff
are able to read the SCR without permission. However, if this happens, the system records the
access and a note would have to be made on the SCR to show why the record has been accessed
without permission from the patient.

In addition, there are a number of versions of electronic patient record and health record systems
being used in many hospitals across the UK. These systems are being used to provide accurate, up-
to-date, and complete information about patients at the point of care. However, the choice and
implementation of these systems is a matter for individual NHS Trusts.

You ask if there is national policy on patient engagement and observation. NHS England is
planning to update its Suicide Prevention Audit Tool for Emergency Care, in light of learning from
suicides in acute care settings. This stresses the importance of engagement with the patient, the
recording of observations and timeliness of mental health assessment.

Further guidelines for patient observation are contained in the Mental Health Act 1983 Code of
Practice. This has recently been reviewed by the Department of Health and the revised edition came
into effect on 1" April 2015. Within this code is a section which advises on enhanced observation
for patients in hospital wards and services.

The Code of Practice provides a legal framework for the NHS. Individual NHS Trusts are expected
to develop and implement their own patient observation policies that are appropriate to the needs of
their patients and in line with this statutory guidance.

Lastly, you refer to a NICE publication on the treatment and management of patients with
Borderline Personality Disorder. We assume you are referring to NICE guideline CG78,
“Borderline personality disorder: Treatment and management” which was published in January
2009.

NICE very recently reviewed this guidance. In January 2015 it concluded that the guideline did not
need to be updated at present, and will next review the guideline in March 2017. NICE would
be happy to answer any further questions you might have about this.

I hope that this response is helpful and I am grateful to you for bringing the circumstances of Ms
Bell’s death to my attention.

Yours sincerely

TAMARA FINKELSTEIN

Northumberland, Tyne and Wear INHS|
NHS Foundation Trust

Executive Corridor

1* Floor

Main Building

St Nicholas Hospital
Jubilee Road
Gosforth

Newcastle upon Tyne
NES 3XT

Tel: 0191 2232975

Our Ref: | |

24 April 2015

Private and Confidential :

Mr Derek Winter LLB 5 ; - i
HM Coroner for the City of Sunderland £2 ARN an 7
Civic Centre

Burdon Road

Sunderland ee
SR2 7DN SSS conan

Dear Mr Winter

Inquest into the death of Paige Bell - Response to Regulation 28 Report to Prevent
Future Deaths

| write in response to your Regulation 28 Report following your investigation into the death of
Paige Louise Bell. As you are no doubt aware, the Trust takes all patient deaths very
seriously and investigates them very thoroughly to establish if lessons can be learned or
services improved. This case was no exception. The Trust carried out a detailed Serious
Incident Review and addressed the recommendations which were identified. | understand
that you heard detailed evidence about those recommendations and the implementation of
them at the inquest. | am informed that , the group nursing director at the
relevant time, provided a statement and addressed these issues in some detail at the
inquest. | have asked relevant staff to consider the issues identified again and respond as
follows:

Engagement and Observation Policy

While the Trust must and does accept the conclusion of the jury, | believe it is important for
me to express concern that our staff present throughout the proceedings were confused by
the finding that there were contradictions and ambiguities in the Observation Policy. | am
informed that the primary issue of concern at the inquest related to the choice made by the
relevant clinicians regarding the level of observation (which is of course a complex and
challenging clinical issue for patients with Emotionally Unstable Personality Disorder) rather
than the policy or its implementation.

As set out in the evidence of the Trust has already invested a significant
amount of time and resource into developing the new Engagement and Observation Policy.
This has included consultation amongst internal senior clinical staff, obtaining external
expertise from national leading figures, looking carefully at the approach of other Trusts and
considering available research into the usefulness of the NICE observation guidelines.

The Trust have carefully considered the changes made to the policy and with expert input
have decided to put greater emphasis on clinical assessments and engagement with
patients rather than time based observations. It is believed this will reduce risk to patients.

As you heard in some detail in the evidence, the Engagement and Observation Policy clearly
sets out the different categories of observation available and gives guidance as to when
each of these categories should be considered. Having already invested significant time and
both internal and external expertise in the revision of this policy, we do not feel that it is
ambiguous. As explained at the inquest, all staff are aware of what each category requires of
them. The policy sets out guidance as to when a particular level of observation should be
used. However, this is no more than guidance and will need to be considered in conjunction
with other factors. Ultimately, observation is a clinical decision and must be specific to the
patient and the circumstances. This is particularly important in the context of patients with
Emotionally Unstable Personality Disorder as they are always at significant risk. If a risk
based observation policy was applied without any flexibility, such patients would always be
on “within eyesight” observations and would never leave hospital. That would have
significant negative implications for their mental health and ability to integrate into society.
The policy therefore takes this into account and acknowledges that if a higher level of
observation is going to increase the risk to a patient, other options can be considered.

Record Keeping

In relation to the concerns about space on the new observation record, staff are aware that
they can write in the box below if necessary. The RiO number (on our electronic patient
record system) is not required on the front sheet, as unlike the continuation sheets, the front
sheet has the patient's name and hospital number written on it which will enable the patient
to be found on RiO.

With regard to the concerns about the lack of completion of the observation record, staff
acknowledged at the inquest that this was not done on this occasion but they were aware
that it should have been. Staff are aware that all parts of the document should be completed
and this should include a rationale as to why a level of observation is changed. As discussed
in EEE vidence, the importance of record keeping has been reiterated to staff.
Furthermore, EE confirmed that as the revised policy is rolled out across the
Trust, staff will receive training on the policy which will include appropriate completion of the
new observation record.

In i ation records and incident report forms being completed electronically,
_ he this is something which the Trust has considered and will
continue to do so for observation records. As you will appreciate, introducing such an
electronic system is complex. In relation to electronic incident reporting, | can confirm the
web based incident reporting project has commenced, with the first site reporting on 1 April
2015, a potential for Hopewood Park to report electronically in June 2015, and the full
organisation reporting electronic incidents by October 2015. Itis worthy to note that this
project has been planned for a number of years, and pre-project planning commenced in
July 2014. This project was unrelated to this incident, but the Trust acknowledges the
benefits that timely reporting and escalation of incidents brings to improve the quality and
safety of care.

In respect to the stated over the presentation of written copies of RiO records
explained that this is something which was identified in the Serious Incident Review. He
explained that the RiO records are used by staff electronically, and a printed version does
not properly reflect how they would be seen or used by staff. in particular the date and time
of a meeting or incident is recorded in addition to when the record was made. This allows the
entries to be recorded chronologically in relation to the date and time of the meeting or
incident. As you heard in evidence, in a very busy and demanding mental health ward

environment siaff have to prioritise dealing with patients first and it would be impossible for
every decision or action to be recorded immediately. Information can be and is shared in
other ways such as through team meetings and handovers. | am informed that staff in this
case gave evidence that information was shared and was available to decision makers
throughout the relevant timeline. As made clear, we acknowledge that entries
should be detailed and always made as soon as practically possible and we provide regular
staff training to this effect.

| hope that the information provided offers you the assurance that the Trust have invested
significant time, effort and resource in investigating the issues you have highlighted with a
view to improving patient care and safety and reducing the risk of any adverse incidents or
outcomes in the future. Paige Bell's death was a tragedy and we will continue to strive to
make improvements wherever possible to minimise the risk of further such tragic incidents.

Yours sincerely

John Lawlor
Chief Executive