Prevention of Future Deaths reports · 2015

Rebecca Jones

Regulation 28 report to prevent future deaths, reference 2015-0504, written 8 Oct 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report8 Oct 2015
Reference2015-0504
DeceasedRebecca Jones
CoronerEdward Thomas
Coroner areaHertfordshire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedHertfordshire Partnership University NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

Vig sd 4

CORONER’S OFFICE
DISTRICT OF HERTFORDSHIRE

The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 OES
DX: 100702 Hatfield
Tel: 01707 292780 Fax: 01707 897399
MR EDWARD THOMAS Senior Coroner GRAHAM DANBURY Deputy Coroner

Or FRANCES CRANFIELD, ALISON GRIEF, EDWARD SOLOMONS
Assistant Coroners

8 October 2015

The Rt Hon Jeremy Hunt MP
Secretary of State for Health
Department of Health

79 Whitehail

London

SW1A 2NS

Your Ref: to be advised
Our Ref: 02049-2013

Dear Mr Hunt,

Re: Rebecca Emily JONES, deceased

| am writing to you under the provisions of Schedule 5 (paragraph 7) of the Coroners & Justice
Act 2009 which came into force in July 2013. This re-enacted the provisions of the old Rule 43
of the Coroners Rules 1984. Attached to this letter is information concerning the new rules and
regulations from which you will see requires a written response. Copies of this letter and the
response received from you will be forwarded to the other interested persons identified at the
inquest in accordance with the list attached. | am also sending a copy of this letter to the
Department of Health for their general information.

Please find enclosed a copy of the Record of Inquest from which you will note that the jury’s
findings in respect of a number of matters. Becky (a name she was always known by) was
known to mental health services since she was an adolescent and had a number of admissions
to hospital under detention and also the use of Section 136. On the 22"4 August 2013 she was
found near a railway line in a confused state and acting in a way that was dangerous to herself.
Police detained Becky under Section 136 and brought her to the 136 Suite at the Lister
Hospital, Stevenage; a facility that had been used for a number of years. | heard evidence from
the Head of Public Protection at Hertfordshire Constabulary, Detective Superintendent Hanlon,
that there had been no use of police cells in the purposes of Section 136 for a number of years.
It is clear that police cells should only be used as a very last resort in matters like this, but it is
therefore incumbent upon those providing the 136 facilities should ensure that they provide a
safe containment pending the assessment that must take place within a reasonable period of
time.

fe... Page Two Becky JONES

Becky was brought into the Section 136 Suite just after midnight on the 23 August 2015. in
accordance with their protocol (which was accepted by the jury as reasonable) police officers
left the unit following a joint assessment with the bleep holder as it was deemed that Becky
posed a Low Risk for the purpose of containment within the Section 136 Suite. She presented
no management problem, was compliant and placid and was not wanted on the police national
computer. Thereafter the assessment under Section 136 was not able to be carried out within
the three hours expected in accordance with the joint protocol, because an urgent assessment
was required for two other vulnerable persons with learning difficulties in the community who
were threatening self-harm. As Becky was “in a place of safety” it was felt that the community
assessments had to take priority. However, the jury found during evidence that there was
inadequate supervision of Becky, who was last seen at about 04:00 then discovered to be
missing when the assessing team came to interview her at 05:30. Becky was found dead at
about 09:00 later that morning in the open on ground below as service ramp near the mortuary
entrance at the Lister Hospital. Cause of death was multiple traumatic injuries, to her head as
she had fallen from a height.

The window of the 136 Suite had been left open for ventilation and although there were
restrictors the window was replaced quickly to a fixed non opening window. There was no
CCTV camera surrounding the 136 room but one has now been installed so that images can be
viewed by the mental health reception staff and staff covering the Aston Ward. The CCTV also
covers the corridor leading to and from the 136 Suite. Emergency door releases on the 136
room and on the rear corridor of the ground floor of the mental health unit, both operated by
push buttons were also replaced by key operated door release, and all windows in the mental
health unit are to be fitted with restrictors. The windows in the toilets and baby changing area
on the 136 corridor had window mesh fittings added to the fanlight opening.

The window in the 136 Suite room was at ground floor level and during the inquest our attention
was drawn to an Estates and Facilities Alert from the Department of Health under reference
EFA-2013-002 issued 23 January 2013. This indicated that window restrictors may be
inadequate in preventing a determined effort to force a window open beyond the 100mm
restriction. We were given to understand that this primarily aimed at preventing falls through
windows from a height, but it should equally apply to spaces where ventilation was needed in
rooms containing vulnerable people, irrespective of floor height, to prevent them leaving via the
window.

| am drawing your attention to these changes that have been made as it may well be that other
Section 136 Suites, particularly those that have been of longstanding use may not be designed
or equipped in such a way to prevent a person in a place of safety from absconding.

The jury found that the major contribution in Becky's absconding was the absence of
continuous observation.

We also heard evidence regarding bleep holder training. Although it was clear that some
training was given, the Hertfordshire Partnership University NHS Foundation Trust has decided
to operate a more focused training programme for bleep holders especially as it is also now
apparent that the use of Section 136 has increased dramatically over the last year. | heard
evidence that the $136 had been used over 500 times in the year up to April 2015. An
examination of bleep holder training offered by other Trusts may well be appropriate.

Cont'd

ha. Page Three Becky JONES

Becky was a student at Sheffield University and came back to Hertfordshire after a stay being
an in-patient in a psychiatric unit in Sheffield. She was brought down by the discharge nurse
with a discharge summary in July but unfortunately there was no care programme meeting
arranged for the continuation in relation to her care. In addition, perhaps in accordance with
Becky's preference, her care coordinator was her psychiatrist with whom she appears to have
had a good relationship. However, it was agreed that it might have been more appropriate for
her to have had a care coordinator from another professional from the team as the psychiatrist
was sadly not kept informed in relation to assessments that were taking place after she
presented in an Accident and Emergency Department following overdoses or thoughts of self-
harm.

The importance of good communication for patients who are being transferred to other areas
and within a team, ensures that any worrying signs can be noticed leading to support and
action as required. Although this maybe not a critical factor in relation to this tragic death, i
thought | would draw this to your attention for encouragement for other mental health trusts of
better communication between and amongst themselves.

The Hertfordshire Partnership Trust has now arranged for spot checks to be carried out by
senior staff by walking through such units and seeing what is going on. This seems to be a very
good practice that | feel other Trusts may wish to consider.

The schedule requires a response from you within 56 days of receipt which | calculate is the 3°
December 2015. Please let me know if there are difficulties in complying with this timescale. |
am retiring as Senior Coroner on the 31* October 2015 but | have discussed this report with my
successor, Mr Geoffrey Sullivan.

Yours sincerely

Edwar
Senior/Corongr

Responses

1 response 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.

Response from Department of Health (PDF)
Rt Hon Alistair Burt MP
Minister of State for Community and Sacial Care

wy “CEIVED

Department 07 DEC 2015
of Health
Richmond House
79 Whitehall
London
SWITA 2NS

Tel: 020 7210 4850
Mr E. Thomas,

Senior Coroner,

The Old Courthouse,

St Albans Road East, 03 Lie 1018
Hatfield,

Hertfordshire,

AL10 OES

Derm Me Thomas -

Thank you for your letter of 8 October 2015, following the inquest into the death of
Rebecca Jones. I was sorry to hear of Ms Jones’s death and wish to extend my
condolences to her family.

You raise four concerns as a result of this case:

the design of Section 136 Suites;

the importance of continuous observation of the mental health patient;
the training provided for bleep holders; and

the need for good communication between mental health trusts.

Although steps have already been taken by the Hertfordshire Partnership University
NHS Foundation Trust to address these concerns, you suggest that such issues might
need to be addressed across all Mental Health Trusts.

Both NHS England and the Care Quality Commission (CQC), through the winter
resilience programme and the annual survey of health based places of safety
respectively, are aware that some areas still do not have adequate capacity for health-
based places of safety. To remedy this, NHS England is spending £15m in 2016/17
to boost provision in those areas that need it most. This will include improving
standards in existing places of safety to ensure that they are equipped to care for
people safely and compassionately when detained under the Mental Health Act.

NHS England, as part of its national crisis care programme, will be developing
commissioning guidance for effective crisis response. This will include specific

guidance on health-based places of safety and the clinical and physical standards of
s.136 suites. This process will have a multi-agency group including leading experts
from healthcare, policing, social care, and other representatives. Part of this work
will see the development of national datasets so that standards of mental health crisis
care can be measured and made transparent at a national level.

The CQC has also undertaken valuable work focussing on health based places of
safety. In October 2014, they published the report, A safer place to be, which details
findings from a survey to examine the provision, use and accessibility of health-
based places of safety for people detained under section 136 of the Mental Health
Act. In June 2015, CQC published, Right here, right now, a review of the quality,
care and effectiveness of care provided to those experiencing a mental health crisis.

Both of these publications fulfilled some of CQC’s commitments under the national
Mental Health Crisis Care Concordat, a national agreement setting out how health,
policing and local government partners should improve their responses to people
experiencing a mental health crisis.

CQC has also selected health-based places of safety as one of the core services to be
regularly inspected as part of its comprehensive inspection activity for specialist
mental health services.

In addition, local multi-agency Concordat action plans have been in place across the
whole of England since May 2015, and local partnerships are working together to
review their section 136 protocols as part of this process.

Your second concern relates to patient observation. You report that the lack of
continuous observation was a factor in Becky’s absconding. However, her initial low
risk assessment on admission to Lister Hospital’s Section 136 Suite should have
determined the level of patient observation that was considered necessary at the
time.

There is guidance for professional staff in this area. The Mental Health Act Code of
Practice is clear that increased levels of observation (which includes intermittent
observations) may be used to prevent suicide or serious self-harm. Levels of
observation and risk should be regularly reviewed and a record made of agreed
decisions in relation to increasing or decreasing the observation.

NICE have also produced guidelines. Guideline 25, “The short term management of
disturbed/violent behaviour in in-patient psychiatric settings and emergency
departments” recommends nationally prescribed levels of observation based on the
patient’s risk level.

a

Department
of Health

Although such observation guidelines exist, their implementation is a matter for each
local NHS Trust. However, I would expect all hospitals to have clear written policies
on the use of observation. This should include requirements to record when
observations are carried out and the findings.

The National Confidential Inquiry into Suicide and Homicide (NCISH) undertook a
review of constant and intermittent observation on mental health units entitled, “Jn-
patient suicide under non-routine observation” published in March 2015. Current
observation approaches were found not to be safe enough and new models should be
developed and evaluated. NHS England will ensure that the recommendations of the -
NCISH report, including those which relate to improving the reliable delivery of
effective observation, are considered and implemented.

“Bleep holder” training is part of Continuing Professional Development (CPD) and
such training is primarily the responsibility of employers. However, Health
Education England (HEE) spends approximately £215million per year on activities
which together are termed as ‘workforce development’. HEE is undertaking a root
and branch review of its workforce development spend, in response to its mandated
commitment to ensuring professional and personal development beyond the end of
formal training.

The Health and Social Care Act places a duty on the health system to promote
autonomy for providers of healthcare or those that provide services that assist that
purpose. Although HEE cannot impose specific CPD activities on employers or the
workforce, it endorses the policy of Hertfordshire Partnership University NHS
Foundation Trust in providing more training for bleep holders adopted in the wake
of Ms. Jones’ death.

It is vital that there is good communication between professionals across agencies to
ensure continuity of care for the patient and to provide the most appropriate support
for patients whenever and wherever they present to a service.

NHS England recognises the importance of effective, timely and appropriate transfer
of key information that follows the patient through the healthcare system. Working

with partners, NHS England is currently developing a range of tools and guidance to
support commissioners and providers in the transformation of urgent and emergency

care services. This will include use of enhanced summary care records and will
enable better access to patient care plans, end of life care records, special patient
notes and mental health crisis notes. Such moves will help to improve
communication between mental health trusts and ensure that those caring for patients
transferred between services are kept fully informed of the patient’s care needs.

I am grateful to you for bringing the circumstances of Ms Jones’s death to my
attention and hope that you find this reply helpful.

la Sin cael
Auk #-
—

ALISTAIR BURT

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