Kimberley Parsons

i

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT 1S BEING SENT TO:

41. Care Quality Commission

2. mother of the deceased
3. Avon & Wiltshire Mental Health NHS Trust
4. Chief Coroner

CORONER

lam Dr. Peter Harrowing, LLM, Assistant Coroner, for the Area of Avon

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 28" March 2014 | commenced an investigation into the death of Ms. Kimberley
Parsons, age 23. The investigation concluded at the end of the inquest on 6" February.
The conclusion of the jury was that the medical cause of death was 1a) Hypoxic brain
injury; 1b) Hanging and the conclusion was that of an Accidental Death.

=
4

| CIRCUMSTANCES OF THE DEATH

Since 2008 Ms. Parsons had suffered with mental health problems with suicidal ideation.
In 2010 she was diagnosed with borderline personality disorder and in May 2010 she was
admitted for the first time to Sycamore Ward, Hillview Lodge, Bath owing to suicidal intent.
From that time until early 2014 Ms. Parsons took a number of overdoses of medication,
self-harmed by cutting herself as well as trying to set herself on fire.

Following earlier admissions to Sycamore Ward in August 2013, November 2013 and
January 2014 Ms. Parsons was again admitted to Sycamore Ward, Hillview Lodge, Bath
under Section 2, Mental Health Act 1983 on 7th March 2014. On admission it was noted
that she had a high level of risk of self-harm in the context of a relapse of her mental health
condition. Her prescribed medication on admission was mirtazapine tablets 45mg once
daily, quetiapine tablets 50mg once daily and lorazepam 1 - 2 mg when required (within
the dosage range of the British National Formulary). Ms. Parsons remained very
distressed, low in mood and expressing a wish to die.

On 9th March 2014 Ms. Parsons self-harmed on the ward by cutting her wrist with broken
crockery. The wounds were treated appropriately by nursing staff on the ward.

— Consultant Psychiatrist, reported that Ms. Parsons continued to express strong
suicidal desires and was not wishing to engage. On 12th March 2014 the staff nurse
noted that Ms. Parsons had again self-harmed on the ward and had used a piece of
broken crockery she had found in the garden to make a superficial cut to her wrist.

During the early hours of 16th March 2014 Ms. Parsons was found hanging in her room

having used an item of clothing as a ligature. Attempts at resuscitation were undertaken
by ward staff and the paramedics were summoned. Ms. Parsons was transferred to the
Royal United Hospital, Bath where she was admitted to the intensive Care Unit. However,
despite all efforts she died as a result of her injuries on 24th March 2014.

Following the incident involving Ms. Parson's and her subsequent death the Trust carried
out its own internal investigation which included a root cause analysis. Evidence was
given at the Inquest as to the findings of the root cause analysis and these included inter
alia:

1. Engagement and Observation Forms used on the ward were out of date and not fully

completed and lacking the recording of the actual time the observation of the patient

was carried out.

2. There were changes in frequency and type of engagement and observation during
Ms. Parsons’ admission. The assessments for these changes were not fully
documented and the care plan related to engagement and observation updated.

3. Weekly checks on the resuscitation equipment on the ward were not accurate.

4. The Crash trolley had some items were missing, some items were out of date; items
were in the wrong place and additional items not required were present.

5. When the incident occurred only the emergency services were summoned and not the
Crash Team as well.

6. The two bank staff involved in the incident had not received the required resuscitation
training.

7. Care plans did not outline ranges of evidence based interventions and strategies to
support staff to manage the service users acute distress and sleep hygiene.

8. There was a lack of a clear pathway for service users in intensive and inpatient
settings with a diagnosis of Emotionally Unstable Personality Disorder

During the course of my investigation | became aware that the Trust including Hillview
Lodge had been the subject of an inspection by the CQC between 10th - 413th June 2014
although the report of that inspection was not published until 18th September 2014. The
report identifies that at the time of the inspection in June 2014 a number of serious
deficiencies which had been identified following the incident in March 2014 had still to be
addressed by the Trust. During the course of the Inquest the Trust advised that a further
inspection by the CQC had been carried out in December 2014 and the outcome positive.

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) That serious deficiencies affecting the safety of patients at Hillview Lodge which had
been identified in March 2014 had not been addressed by the Trust by the time of the
CQC inspection in June 2014.

(2) The CQC should confirm that it is now satisfied that the Trust has addressed all
concerns identified at the June 2014 inspection and that they have no further
concerns with regard to patient safety.

(3) If the CQC are not so satisfied then they should undertake an unannounced inspection
of Hillview Lodge at the earliest opportunity.

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 29th 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 e000 mother of the deceased, and the
Care Quality Commission.

| shall send a copy of your response to EB ana the Avon and Wiltshire Mental
Health Partnership NHS Trust

| have sent a copy of my report to the Chief Coroner.
| 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.

04 March 2014 Assistant Coroner ,

|

Dr P Harrowing

HM Assistant Coroner
The Coroner’s Court
The Courthouse

Old Weston Road
Flax Bourton

BS48 1UL

23 April 2015

Dear Dr Harrowing

24 APR 205
Avon and Wiltshire NHS |

Mental Health Partnership NHS Trust

Chief Executive’s
Office

Jenner House
Langley Park
Chippenham
Wiltshire

SN15 1GG

Tel: 01249 468023

| am responding to the prevention of future deaths report you issued following the inquest into

the death of Kimberly Parsons.

Avon and Wiltshire Mental Health Partnership NHS Trust does not currently endorse the use
of harm minimisation strategies in deliberate self-harm. We recognise that this is a highly
specialised approach which should only be undertaken in the most controlled of situations
such as in a specialist unit. Our staff member should not have mooted the possibility of safe
self-harm with Kimberly as this is a term which is easily misinterpreted. | am sorry for the
distress that this has caused to Kimberly and her family.

The Medical Director has liaised with the national expert in this field,
who will soon be joining the University of Bristol and our trust. We will be looking at the
possibility of research into the appropriateness, or not, of employing harm minimisation

strategies.

| think it is important at this point to be clear about terminology. Our staff member, as a
witness, spoke about ‘safe self- harming’ rather than ‘assisted self- harming’. The recognised
clinical term for ‘safe self- harming’ is ‘harm minimisation’. This is a legitimate approach which
is referenced in the NICE guideline 133: ‘Self harm: longer term management’, which was

issued in November 2011:

“If stopping self-harm is unrealistic in the short term:

¢ consider strategies aimed at harm reduction; reinforce existing coping strategies
and develop new strategies as an alternative to self-harm where possible

e consider discussing less destructive or harmful methods of self-harm with the
service user, their family, carers or significant others where this has been agreed
with the service user, and the wider multidisciplinary team

e advise the service user that there is no safe way to self-poison”.

The use of harm minimisation strategies is also recognised by the Royal College of
Psychiatrists, under certain circumstances.

We plan to issue an internal safety alert to all clinical staff to remind them of the trust's
position regarding harm minimisation. The alert is prepared by our Consultant Nurse for
suicide prevention and will be considered by both the trust Critical Incident Overview Group
and the Suicide Prevention Group. Once approved, | will forward you a copy of the alert and
confirm that it has been distributed.

Thank you for bringing this matter to my attention.

Yours sincerely

lain Tulley
Chief Executive

Care Quality
Commission

Dr Peter Harrowing
HM Assistant Coroner
The Coroner Court
The Court House

Old Weston Road
Flax Bourton

BS48 1UL

Dear Dr Harrowing,
Re Kimberley Parsons (Ref: 01019/2014)

| am writing following your recent letter, dated 4 March 2015, and the attached
‘Regulation 28: Prevention of Future Death Reports’.

You may be aware that the Care Quality Commission (CQC) carried out a
comprehensive inspection of the Avon and Wiltshire Partnership NHS Trust (AVP) in
June 2014. This was one of the ‘pilot’ new style comprehensive inspections of NHS
and independent healthcare organisations. As such, whist we provided a narrative in
the report as to whether the trust was providing safe, effective care that was
responsive to people’s needs, delivered by staff that were caring and whether the
trust was well led we did not provide a rating (we now rate organisations on a four
point scale — outstanding, good, requires improvement and inadequate against these
key areas). During our inspection of AWP, our inspection team, made up of
experienced specialist advisors, experts by experience (people with experience of
using services or caring for someone using services) and CQC staff, we visited all in-
patient wards and a sample of community mental health services. ,

As a consequence of the inspection enforcement action was taken and four warning
notices were issued. The warning notices served to notify the provider (AWP) that
CQC had judged that the quality of health care provided for the regulated activities
required significant improvement. Two of the warning notices were relevant to
Hillview.

Firstly, a trust wide warning notice was issued regarding learning from incidents,
Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010. This warning notice highlighted the trust's failure to respond to an
inspection undertaken in March 2014.

Secondly, a warning notice, specific to Hillview Lodge, was issued under under the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2010,
Regulation 15. This identified that:

. The ward did not meet the required level of cleanliness and the design and
decoration of the ward did not support a therapeutic environment,

. Potential ligature risks that had not been effectively mitigated or managed;

. The:garden was not well maintained and contained overgrown trees and
shrubs that may have posed a ligature risk or a means of escape;

. Shower and bathroom facilities were in a poor state of repair;

Registered office: Finsbury Tower, 103-105 Bunhill Row, London ECTY 8TG

* Areas of the ward and grounds were staff could not easily observe
patients; and
. The design of the unit did not promote privacy or dignity.

Additionally, a number of compliance actions were issued; four were relevant to
Hillview. The compliance actions served to inform a AWP that it was not compliant
with the regulations. These included:-

. Health and Social Care Act 2008 (Regulated Activities) Regulations 2010,
Regulation 9 (1) — observation practice.

. Health and Social Care Act 2008 (Regulated Activities) Regulations 2010,
Regulation 16 (1)(b) - emergency equipment.

. Health and Social Care Act 2008 (Regulated Activities) Regulations 2010,
Regulation 10 — learning from incident.

. Health and Social Care Act 2008 (Regulated Activities) Regulations 2010,
Regulation 23 — training.

CQC maintained regular contact with AWP following the comprehensive inspection
in order to monitor progress its progress in meeting requirements and in addition, in
December 2014 carried out a programme of unannounced inspections across AWP
to establish whether the trust had complied with the warning notices.

We carried out a focussed inspection at Hillview on the 17 December 2014. This
identified:

. Significant financial investment had be made to improve the lines of site.,
For example, wall had been knocked down to open up an area thus
provided improved observation of patients

. The ward was clean;
. Observations were being carried out in line with risk assessments;
. Significant investment in both finance and time had been undertaken to

identifying ligature points across the ward resulting in a complete
‘Manchester Tool’ ligature assessment. Plans were in place to rectify or
manage the risks from existing ligatures. For example, a tree involved in a
fatal injury in the garden area had been cut down.

Therefore, CQC judged that AWP had taken all reasonably practicable steps, within
the time frame given, to comply with the relevant two warning notices.

However, the compliance actions remain in place. AWP is not yet fully compliant.
For example, not all ligature risk management processes had been completed.

As the inspection in June 2014 was part of the ‘pilot’ programme and not rated a
further comprehensive inspection will be undertaken at some time in the future
(before April 2016) when AWP will be rated. As part of the inspection Hillview Lodge
will be visited and particular attention will be paid to progress made against the
compliance actions.

In addition, CQC undertakes focused visits to assess compliance with the the
Mental Health Act. Whilst these visits look closely at issues surrounding patients
detained under the Mental Health Act they also look at environmental issues and
health and safety. An unannounced Mental Health Act visit will be made to Hillview
Lodge in the next few months.

Thank you for sending us a copy of the report that was issued to AWP regarding to
the practice of an individual clinician. We have brought this to the attention of

| Executive Director of Nursing at AWP during one of our routine
meetings EEE will establish and provide further feedback regarding this. The
practice of individual clinicians is not within CQCs remit.

Yours sincerely

Inspection Manager

Cc: (, Executive Director of Nursing (AWP)