Patricia Cleghorn

Birmingham and Solihull
Mental Health NHS Foundation Trust

Unit 1, Bi

50 Summer Hill Road
Birmingham B1 3RB
Tel: 0121 301 1319
Fax: 0121 301 1301

19 September 2016

Mrs Louise Hunt

HM Coroner, Coroners Court
Birmingham and Solihull Areas
50 Newton Street

Birmingham

B4 6NE

Dear Mrs Hunt,
REPORT TO PREVENT FUTURE DEATHS: PATRICIA ANN CLEGHORN

| write in response to the Prevention of Future Deaths report that was issued following the
inquest into the death of Patricia Ann Cleghorn with assurance of the action that we are
taking in relation to your concerns.

Patricia Ann Cleghorn sadly died from an intentional overdose whilst being cared for in the
community by one of our Home Treatment Teams. She was awaiting voluntary admission to
an in-patient bed, but as none were immediately available she received twice daily visits
from the Home Treatment Team. She had stated her intention to take her own life and was
self- medicating. At 17.00 on 14 December 2015 Patricia was seen at home in her bedroom
by the Home Treatment Team and given a 5 mg diazepam tablet. This had a dramatic effect
on her which was not appreciated by the healthcare assistant despite questioning by
Patricia’s husband and soon after this Patricia was found collapsed, an ambulance was
called but she was declared dead by the Paramedics.

The conclusion by the Coroner was that her death had been contributed to by neglect.
The MATTERS OF CONCERN raised were as follows:

(1) The deceased could not be admitted to hospital as there were no inpatient beds
available. | heard evidence at ihe inquest that had she been admitted it is unlikely she
would have died when she did. The availability of acute mental health beds means the
most vulnerable people are being cared for in the community with limited resources and
care.

fF Chief Executive: John Short

PALS Patient Advice and Liaison Service Customer Care Mon-Fri, 8am - 8pm

Tel: 0800 953 0045 Text: 07985 883509 Emall: pals@bsmbhft.nhs.uk Website: www.bsmhft.nhs.uk

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(2) The deceased had repeatedly stated that she would end her life by taking an overdose.
Despite this she was left at home self-medicating drugs including amitriptyline, MST and
oramorph. No formal risk assessment was undertaken and staff failed to appreciate what
drugs she had available to her.

AVAILABILITY OF INPATIENT BEDS

In respect of issues raised in relation to the lack of availability of an inpatient bed (1) we are
very sorry that this was the experience for Mrs Cleghorn and that she took her life during this
period. We extend our apologies to her family and have undertaken significant work with the
aim of preventing any future deaths of this nature.

| can confirm that the availability of acute mental health beds is sadly a national challenge
and we are working collaboratively with Trusts across the region and nationally to try to
accommodate demand, wherever possible. We recognise that at times this means that some
vulnerable people are being cared for in the community.

As a result of the unfortunate death of Mrs Cleghorn we have taken immediate action to
review our bed management processes and community processes, so that we can ensure
that any patient awaiting access to an inpatient bed receives enhanced care from our
community staff.

Some of the immediate actions include:

* Creation of an urgent care assessment team to concentrate specifically on the
assessment of patients who are in crisis. This approach has been piloted and has
demonstrated that having an urgent care assessment team improves outcomes for
patients at this vulnerable time. The substantive team will be in place by the end of
September 2016

e One consultant psychiatrist will form part of each home treatment team to ensure that all
patients who are presenting high levels of risk have daily access to medical review or
medical opinion. This will be in place across all of our home treatment teams by the end
of October 2016

At the time of Mrs Cleghorn’s death we had an average of 30 people awaiting admission to
an inpatient bed, and a further 15 patients placed in out of area beds. At the time of writing
this response | am pleased to report that we have just 2 patients waiting for access to a bed
and only 1 patient placed in an out of area bed. This improvement is reflective of a range of
work that has taken place within the Trust over the last few months to improve the flow of
patients through our inpatient beds and enhanced skill and care provision within our
community services and home treatment teams.

All of these patients have received:

« Anupdated risk assessment

e« Anupdated mental health state assessment

e Proposed plan of inpatient care

e Anagreed plan of care in the community whilst awaiting a bed

e An agreed review timetable for the patient (all patients must have at least a daily review
but this may be increased as per need/risk

¢ Accrisis plan agreed with patients and carers where possible, to include all relevant
support contact details for service users in crisis and also highlights protective factors
and relapse management (updated plan from August 2016 and compliance daily audit
introduction)

This is now part of our standard policy approach to managing patients who are awaiting
access to a bed within the organisation.

All patients waiting are reviewed on a daily basis by the bed management team and a
Clinical director to decide the level of urgency for access to the bed. Those requiring urgent
access will be prioritised and if there is no bed capacity within the Trust all other focal
providers will be contacted to see if they have capacity, and if not private providers will be
contacted.

More strategically we are working with our MERIT partners, who include; Dudley and Walsall
Mental Health Partnership NHS Trust, Coventry and Warwickshire Partnership Trust and
Black Country Partnership NHS Foundation Trust, across the region to develop consistent
and unified pathways of care for patients in crisis.

MEDICATION

In respect of the concerns raised concerning a lack of formal risk assessment and failure to
appreciate the drugs available to Patricia (2) we have liaised with colleagues including the
Senior Nurse for Professional Standards, Head of Pharmacy Services, the lead for
investigations, Clinical Service Managers for Home Treatment Teams and Home Treatment
managers, and the following are our findings and proposed action plan:

Findings:

1. We do not consider it appropriate for a non-registered professional to have administered
the first dose of the newly instituted benzodiazepine medication. Indeed this was a
breach of our current Medicines Code which stipulates the following

“3.5.12 Staff who are not registered nurses may deliver medication for self-administration
by the service user. However where medication is to be administered, via any route, the
person supervising the administration of the medication must be a nurse whose
registration is recorded on the NMC professional register” and

3.9.4 Schedule 2 and 3. Controlled Drugs, benzodiazepines and hypnotics - The
administration of all Controlled Drugs including benzodiazepines and hypnotics must be
witnessed by a second practitioner”.

2. This has highlighted the need for us to clarify the role of non-registered staff in our
community crisis teams, with particular emphasis on the scope of their role and to ensure
that tasks delegated to them are within their sphere of competence.

3. Medicines supply and assessment of the stock of medication that the service user has
access fo should form part of the clinical risk assessment for service users in crisis in the
community.

Where risks are identified then medicines supply should be tightly controlled and overall
medicines possession checked regularly as far as possible. If indicated, following
appropriate risk assessment we will work with service users and carers to remove
excessive medication in the interests of safety. It has to be recognised that we have to
work within reasonable limits which are determined by the services user's capacity and
preparedness to fully disclose information and allow checks/searches. If our staff are in
any way unsure that it is safe to supply medication, the team will need to consider
whether to withhold supply and explain why.

Proposed Action Plan — All of the actions are in place with the exception of item 4 which will
be delivered by the end of November 2016

1.

2.

We will take action with regards to managing the breach of policy

The Senior Nurse for Professional Standards issued a formal practice alert on 12th
September 2016 to registered and unregistered clinicians in our crisis and community
teams to reinforce the requirements for:

Clinical Risk Assessments regarding risk of self-harm and/or suicide;
Risk Assessments with regard to medicines management and self-medication;
Safe administration of medication as per current Medicines Code and NMC Code.

We required staff to sign returns to say that they had read and understood the directive

3.

e
e
°

4,

We have established a Clinical Risk Management Group which is addressing:

Clinical Risk Management approaches and training;
Suicide Prevention;
Improved implementation of crisis care plans.

The Head of Pharmacy will undertake an immediate review of the Medicines Code to
ensure that these issues highlighted above are properly considered and addressed in the
revised Code and supporting direction for staff. This will be reported through our internal
governance arrangements by the end of November 2016.

We believe that the improvements identified above will enhance our current arrangements
and would like to thank you once again for bringing these matters to our attention.

You may find it helpful if | was to write to you again in six months to update you on our
progress and | will diarise this accordingly.

Yours sincerely

Rg Sens re

John Short
Chief Executive

Mrs Louise Hunt 
HM Coroner, Coroners Court 
Birmingham and Solihull Areas 
50 Newton Street 
Birmingham 
B4 6NE 

Dear Mrs Hunt 

Regulation 28 Report in relation to the Inquest touching on the death of Patricia Ann 
Cleghorn 
Ref: 112029 - Patricia Ann Cleghorn - (LH/AS) 

I write in response to the Report to Prevent Future Deaths that was issued following the 
Inquest into the death of Patricia Ann Cleghorn, with assurance of the action the Care 
Quality Commission (CQC) is taking in relation to your concerns. 

Birmingham and Solihull Mental Health NHS Foundation Trust (‘the Trust’) is the CQC 
Registered Provider of services received by Mrs Cleghorn. In May 2014 we carried out a 
comprehensive inspection of the Trust and it was rated ‘Good’ overall.  We will be carrying 
out a fully comprehensive re-inspection in 2017 and intend to use the issues highlighted in 
your Report as a ‘key line of enquiry’. 

The CQC became aware of Mrs Cleghorn’s death upon receipt of the Regulation 28 Report.   
As a result of the Report we made a request to the Trust for a copy of their investigation into 
the death and received a copy of the Trust’s Root Cause Analysis report (RCA).  Based on 
the RCA we required the Trust to provide us with the following information:  

  What training do qualified and unqualified staff receive in the home treatment 

team with regards to medication management and administration? 

  What is the Trust policy/guidance for staff on monitoring medication 

reconciliation? 

  Did the records detail whether the nurse who administered the diazepam to the 

Mrs Cleghorn at 5pm had a case discussion with the prescriber afterwards and if 
so what was the nature of the discussion? 

The Trust responded to the questions and supplied us with their checklist to support the 
process of medicine reconciliation. We were concerned that the information received 
specified that the nurse who had visited was unqualified but that the RCA did not. We 
contacted the Trust to confirm that the nurse was unqualified. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 A quarterly meeting between CQC and the Trust took place 15th September 2016 where we 
discussed what actions they had taken. We will be meeting with the Trust again in 
December 2016 to review the impact of their action plans. 

Matters of Concern raised in your Report: 

1.  The deceased could not be admitted to hospital as there were no inpatient beds 

available. I heard evidence at the Inquest that had she been admitted it is unlikely 
she would have died when she did. The availability of acute mental health beds 
means the most vulnerable people are being cared for in the community with limited 
resources and care. 

There remains a shortage of acute beds in this Trust and in other Mental Health Trusts in 
the region. This shortage will continue to impact on vulnerable people in the community. The 
provision of acute mental health beds rests with the Trust and with the clinical 
commissioning groups (CCGs),   The role of the CCGs is to get the best possible health 
outcomes for the local population, by assessing local needs, deciding priorities and 
strategies, and then buying services (including mental health services) on behalf of the 
population from providers such as this Trust. The CCGs also check on the quality and safety 
of such services.  

Whilst this shortage continues, the risk that another person will take his or her life remains 
high.  

This Trust has taken action to reduce that risk by the creation of an urgent care assessment 
team and the availability of consultant psychiatrists to provide medical review. CQC will 
continue to meet with the Trust’s nominated individual to monitor their action plan in 
December 2016 to ensure they (the Trust) continue to take action to minimise the risk to 
vulnerable people in the community.   

2.  The deceased had repeatedly stated that she would end her life by taking an 
overdose. Despite this she was left at home self-medicating drugs including 
amitriptyline, MST and oramorph. No formal risk assessment was   undertaken and 
staff failed to appreciate what drugs she had available to her. 

The likelihood of other people being exposed to the same risks remains. However, the Trust 
found that it was wrong for non-registered professionals to administer the first dose of a new 
medication and was a breach of the current medicines code. As a result, they will be 
reviewing and clarifying the role of non-registered staff in the crisis team.  The crisis teams, 
as part of the clinical risk assessment, review medicine they provide and medication that 
people have access to in their home.  CQC is currently considering whether enforcement 
action is required at this stage. 

With the actions identified by the Trust implemented, the risk to vulnerable people on home 
treatment will be low. 

The CQC local Inspection team continue to meet with ‘local services’ and in addition we will 
formally review the actions put in place by the Trust and their impact of those actions on 
patients at our quarterly meeting with the Trust in December 2016. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Should you require any further information, please do not hesitate to contact me.  

Yours sincerely 

Head of Hospital Inspections (Mental Health), Care Quality Commission

Philip Dunne MP
Minister of State for Health

Department

Richmond House
of Health 79 Whitehall
London

SWI1A 2NS

Mrs Louise Hunt 020 7210 4850

HM Senior Coroner
Birmingham & Solihull Areas
50 Newton Street
Birmingham

B4 6NE 2 2 SEP 2016

a

a

Thank you for your letter of 26 July 2016, following the inquest into the death of
Patricia Ann Cleghorn. I was very sorry to hear of Mrs Cleghorn’s death in December
2015 and wish to extend my sincere condolences to her family.

In your letter you refer to two matters of concern, the first of which is a matter for the
Department of Health and others:

e Mrs Cleghorn could not be admitted to hospital as there were no inpatient beds
available. I heard evidence at the inquest that had she been admitted it is
unlikely she would have died when she did. The availability of acute mental
health beds means the most vulnerable people are being cared for in the
community with limited resources and care.

The second issue is one for the Trust to answer:

e Mrs Cleghorn had repeatedly stated that she would end her life by taking an
overdose. Despite this she was allowed to self-medicate with amitriptyline,
MST and Oramorph. No formal risk assessment was undertaken and staff
failed to appreciate what drugs she had available to her.

The Government has made it clear that beds must always be available for those who
need them.

In its 2015-16 Mandate to NHS England, the Government stated that it expects NHS
England to make rapid progress, working with CCGs and other commissioners, to

help deliver our shared goal to have crisis services that, for an individual, are at all
times as accessible, responsive and high quality as other health emergency services.

The mental health Crisis Care Concordat (http://www. crisiscareconcordat.org.uk/)
published in February 2014 describes the roles and responsibilities of public services
for improving outcomes for people experiencing a crisis.

The Crisis Care Concordat makes it clear that local commissioners should
commission a range of mental health services that allow beds to be available for a
person in urgent need. Each local area in England has produced its own ‘Mental
Health Crisis Declaration’.

The availability of mental health beds is a matter for local commissioners and I
understand that the response from Professor Sir Bruce Keogh, National Medi¢al
Director, NHS England, has addressed both this issue and the question of inadequate
care provided by Crisis Resolution Home Treatment Teams. I understand NHS
England’s reply also includes a description of key developments in national policy in
relation to adult mental health.

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

J fiw oe”
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PHILIP DUNNE

England
Professor Sir Bruce Keogh
National Medical Director
Skipton House
80 London Road
Mrs Louise Hunt SE1 6LH
HM Senior Coroner
Birmingham & Solihull
50 Newton Street
Birmingham
B4 6NE {ot September 2016

Your ref: 112029 — PATRICIA ANN CLEGHORN (LH/AS)
Dear Mrs Hunt
Re: Regulation 28 Report to Prevent Future Deaths - Cleghorn

Thank you for your letter of 26" July 2016 and the enclosed Regulation 28
Report to Prevent Future Deaths following the tragic death of Patricia Ann
Cleghorn. | was very sorry to read of the circumstances around her death, and
would like to express my deep condolences to her family.

It is important that every death by suicide of.a patient under the care of NHS
services is fully investigated and learnt from to prevent similar occurrences in the
future; | note that this report has also been sent to Birmingham and Solihull
’ Mental Health Trust to support this learning locally.

In terms of national policy, | want to highlight some key developments which |
believe are relevant to the issues you have identified regarding the lack of
available acute inpatient beds and inadequate care provided by the Home
Treatment Team, which your report concludes were both contributory factors in
Ms Cleghorn's death.

| understand that_you recently received a letter dated g’ August from my_
— in response to a Regulation 28 report where you
raised similar concerns following a another case involving a death by suicide. |

want to acknowledge that much of the national work outlined in his response is
also relevant here and therefore worthy of reiteration.

NHS England recently established an adult mental health programme which is
taking a whole system approach comprising crisis, acute, and community/primary
care work streams. The acute care work stream has been developed in response
to a number of recommendations set out by the Commission on Acute Adult
Psychiatric Care and The Five Year Forward View for Mental Health, and is
particularly relevant to the concerns outlined in your report.

As noted in HD ve cent letter, we are aware that Crisis Resolution Home
Treatment Teams are not always resourced to fully meet their core functions in

High quality care for all, now and for future generations

line with the known evidence base. This includes providing intensive home
treatment as a safe, genuine alternative to inpatient admission and appropriately
gatekeeping acute mental health beds. Gatekeeping is the responsibility for
deciding if a person should be admitted as an in-patient, and should include an
assessment of whether the person is suitable for home treatment. Where the
clinical judgement is that a person’s acuity is such that they require an inpatient
admission, then they should be able to access a bed. As set out in the Five Year
Forward View for Mental Health , we are committed to ensuring that all areas
have Crisis Resolution Home Treatment Teams providing a high-quality, 24/7,
community-based crisis response and intensive home treatment in line with
Clinically based evidence by 2020/21. This commitment is supported by over
£400 million of investment following the Government's Autumn 2015 Spending ©
Review, which will be made available to local areas over four years from
2017/18, and is intended to address the considerable pressure and high, bed
occupancy in the acute mental health pathway. .

Further, we are working with the National Collaborating Centre for Mental Health
at the Royal College of Psychiatrists to develop a series of evidence-based
treatment pathways for mental health care with accompanying commissioning
support tools. This includes the development of an acute care pathway
comprising a comprehensive set of quality standards, which is planned for
completion within 2016/17. The work involves a range of multi-agency experts,
including clinicians, social workers, service managers, service users and carers,
and will focus on access to care, patient safety, patient experience and clinical
outcomes. . The scope of the pathway comprises both inpatient and community
settings, reflecting the need to ensure services are commissioned and delivered
in the context of a whole system approach based on clinical need and the safe
management of patients. As such, there will be significant focus on the safe
provision of alternatives to admission, including 24/7 intensive home treatment,
and system-wide demand and capacity management, which promotes the
provision of care close to home and in the least restrictive appropriate setting,
increasing the availability of in-patient beds for those that need them. This work
will draw on learning from identified areas of best practice such as North East
London, Bradford and Sheffield, with the aim of spreading innovation across the
country.

In addition to the work currently being progressed by the acute care work stream,
The Five Year Forward View for Mental Health set the national ambition of
significantly reducing the number of people taking their own lives. To this aim, all
Clinical Commissioning Groups will be expected to contribute to the development
and delivery of local multi-agency suicide prevention plans, together with their
local partners by 2017. This expectation has been underlined in guidance for
local areas regarding the development of their Sustainability & Transformation
Plans and will be supported by further national investment of £25 million from
2018/19, which is additional to the £400 million identified for expanding Crisis
Resolution Home Treatment Teams.

In line with recommendation 57 of The Five Year Forward View for Mental
Health, NHS England is working with NHS Improvement and the Care Quality
’ Commission to ensure that learning from all deaths by suicide of people in the
care of NHS services is used to try to prevent repeat events. Moreover, NHS

High quality care for all, now and for future generations

England will continue to play its part in wider national partnership work as a
member of the Department of Health’s National Suicide Prevention Strategy
Advisory Group. ;

For further detail on how the transformation of mental health services will be
delivered over the next five years, please see Implementing the Five Year
Forward View for Mental Health (https://www.england.nhs.uk/wp-
content/uploads/2016/07/fyfv-mh.pdf), published by NHS England on 19" July.

Thank you for bringing this matter to my attention.

Yours sincerely, -

Professor Sir Bruce Keogh KBE, MD, DSc, FRCS, FRCP
National Medical Director
NHS England

High quality care for all, now and for future generations