Amy El-Keria

a

ae

KS

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Rt Hon Jeremy Hunt, Minster for Health, Richmond House, 79 Whitehall, London, SW1A

CORONER

| am Penelope Schofield, Senior Coroner, for the area of West Sussex, sitting as Assistant Coroner for
East Sussex.

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. 1* June 2016 |, together with a Jury, concluded the inquest into the death of Amy Rose El-Keria born
14"" May 1998 (aged 14 yrs), who died on 13" November 2012. The Jury determined that Amy had died
from the complications arising from Hypoxic Ischaemic Brain damage following the tying of a ligature
around her neck. The Jury return a narrative questionnaire in which they found that Amy’s death had
been contributed to by Neglect and they also found that there were a number of causative failures which
led to her death. A copy of the narrative questionnaire is attached.

CIRCUMSTANCES OF THE DEATH

Amy El Keria was aged 14 years old at the material time. She had a range of complex needs associated
with a number of mental health diagnoses. Up until the time of her hospital admission she lived with her
mother and sister in Hounslow. Following her exclusion from school in early 2012 her mental health
deteriorated and she started to ligature. In August 2012 she was seen for an emergency outpatient
assessment and a planned inpatient admission was sought. However there were no specialist Child and
Adolescent high dependency beds available immediately and Amy had to be admitted to the Priory
Hosptial at Roehampton. The following day she transferred to the Ticehurst House Hospital which is part
of the Priory Group. During her stay at Ticehurst Amy's mental health fluctuated and at times she had to
be forcefully restrained and sedated

On 12 November 2012, having told staff earlier in the day that she wanted to kill herself, she tied a
ligature, namely a football scarf, around her neck and suspended herself from a radiator in her room.
She subsequently died from her injuries the following day.

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) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC
staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her
care plan. It is understood that in December 2014 the Department of Health tasked NICE with
developing guidance on staffing levels for inpatient CAMHS units but this appears to have

§981872.1

been discontinued. There is currently no national guidance on staffing levels for inpatient
CAHMS

(2) There continues to be a shortage of acute mental health beds for young people close to
where they live. This means that families have to travel long distances to visit their child and
they are unable to provide the necessary day to day support to their child. Family support can
play a very significant role in managing risk of suicide by avoiding and mitigating distress.

| consider that the issues raised in this case should be addressed so that future deaths do not occur in
similar circumstances and that action should be taken to reduce the risk of deaths of other children.

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 by addressing these issues.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 28"
November 2016. I, 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:
1
2. The Priory Group
3. Hounslow LB
4.
I
6. West London Mental Health Trust
| 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.

DATE: 3 October 2016 SIGNED: Penelope Schofield, Senior Coroner,
West Sussex sitting as Assistant Coroner, East Sussex

1 5981872.1

*, ~
A From Nicola Blackwood MP

Parliamentary Under Secretary of State for Public Health and Innovation
Department

Richi dt He
of Health 079 Whitehall
London
SWIA 2NS

Ms P A Schofield

Senior Coroner | |
West Sussex Record Office

Orchard Street

Chichester

West Sussex
PO19 1DD

Dy Ms Saft

Thank you for your letter dated 5 October 2016, following the inquest into the death
of Amy Rose El-Keria.

I was very sorry to hear of Miss El-Keria’s death. Please extend my sincere
condolences to her family.

You have raised the following matters of concern:

e The staffing levels at Ticehurst House Hospital and availability of national
guidance on staffing levels for inpatient Child and Adolescent Mental Health
Services (CAMHS)

e An on-going shortage of acute mental health beds for young people close to the
community where they live.

NHS England and Health Education England (HEE) are working to improve the
capacity and capability of workforce delivering mental health care for children and
young people, so that by 2020 an additional 70,000 receive effective treatment per
year. This work extends to supporting training programmes for staff working in
inpatient CAMHS to improve team functioning and delivery of evidence-based care.

I have been advised that in 2016, NHS England commissioned the Royal College of
Psychiatrists and National Collaborating Centre for Mental Health (NCCMH) to
develop guidance on the implementation of the staffing required to deliver safe,
effective and compassionate care in inpatient and community mental health care for
children, young people and adults. The guidance will be relevant to commissioners,
providers, young people and parents, and will contain:

e A methodology for delivering safe, effective, compassionate and sustainable
staffing;

e Guidance on staffing to support delivery of the evidence-based treatment
pathways (these include pathways for children and young people);

e Recommendations on minimum staffing numbers and competences required
across different mental healthcare settings;

e Positive Practice Examples and Helpful Resources pack

This programme is expected to be completed by December 2017 and will inform
future revisions of the service standards for the Quality Network for Inpatient
CAMHS (QNIC), which are reviewed every two years.

You have also raised concerns about the quality of care provided to Miss El-Keria
whilst she was in Ticehurst House Hospital and in particular the ability of staff to
mitigate risks of suicide and self-harm.

The Government revised the Mental Health Act 183 Code of Practice in 2015, which
we expect all mental health providers to implement. The Code of Practice is clear that
patients should have in place a robust care plan developed by a multi-disciplinary
team and that this should include effective risk assessment.

The Department of Health published good practice guidance on assessing and
managing risk in mental health in 2009. This can be accessed through the GOV.UK.
website at the following address:
https://www.gov.uk/government/publications/assessing-and-managing-risk-in-

mental-health-services

You have also raised concerns about access to CAMHS inpatient beds close to where
they live.

I am aware of instances where children have had to travel too far away from home to
access care. The Prime Minister announced in January 2017 that by 2020/21 no child
will be sent out of their local area for non-specialist care. You may also be aware
that NHS England has reviewed CAMHS inpatient services nationally which has
resulted in an additional 56 CAMHS inpatient beds being commissioned across the
country to meet demand.

However, we should also be seeking to avoid unnecessary admissions to hospital
wherever possible. That is why the Government is developing a comprehensive set of
community-based mental health service pathways and standards so that more people
can be treated in the community closer to home. We have also invested £400 million
to improve crisis care services in the community so that people receive the right care

Department
of Health

in the right place when they experience a mental health crisis. Every local area now
has a mental health crisis care action plan in place.

This Government is committed to achieving parity of esteem for mental and physical
health. We have invested £1.4bn over the course of this Parliament in children and
young people’s mental! health and we remain committed to delivering the vision set
out in the Five Year Forward View for Mental Health and Future in Mind to
transform mental health services. Every area in the country now has a children and
young people’s transformation plan in place to achieve this and every area has
developed a sustainability and transformation plan to deliver long-term improvements
to health services.

Every death of a person in a mental health setting is a tragedy and every patient has
the right to expect high quality and safe care. This is why we commissioned the Care
Quality Commission (CQC) to review the way in which deaths of people in NHS
settings are investigated and learned from to avoid further tragedies.

On 13 December 2016, the CQC published the findings of its review in a report titled
Learning, candour and accountability: A review of the way NHS trusts review and
investigate deaths of patients in England. It concluded that learning from deaths is
not currently being given sufficient priority within the NHS and that bereaved
families and carers have poor experiences with providers.

The Secretary of State accepted the CQC’s recommendations for improvement and a
programme to deliver his commitments is underway. The first stage will be the
delivery this year of a National Framework on Learning from Deaths for NHS
providers. The aim is to standardise and improve practice across providers by
providing clear expectations in relation to identifying, reporting, reviewing,
investigating and learning from deaths, and significantly, engaging with bereaved
families and carers. From April 2017, Trusts will be required to publish specified
information on deaths each quarter, including estimates of how many deaths were
judged more likely than not to have been associated with problems in care. Trusts
will also be required to publish evidence of learning and action as a result of the
information. This increased transparency, through improved data collection and
reporting, is about supporting a systemic, NHS-wide approach to learning from
deaths. The CQC will also strengthen its assessment of providers by covering
learning from deaths.

In addition, as a result of cases such as that of Miss El-Keria’s, earlier this year I set
out measures for how we will improve the recording and monitoring of deaths of
patients under the care of inpatient child and adolescent mental health services, with
every death now directly reported to Ministers.

I hope that this response is helpful and I am grateful to you for bringing the
circumstances of Miss El-Keria’s death to my attention.

ows acer.

2@

NICOLA Oh ooD

PRIORY

GROUP OF COMPANIES

27" January 2017

Ms Penelope Schofield
Senior Coroner: West Sussex
Coroner’s Office

West Sussex Record Office
Orchard Street

Chichester

West Sussex, PO19 1DD

Private and confidential

Dear Ms Schofield

Re. Regulation 28 Report to Prevent Future Deaths following the Inquest
concerning the death of Ms Amy El Keria

Thank you for your Regulation 28 report dated 18 November 2016 addressed to
MMM of the Priory Group. Please note that I—Mhas now stepped down as Chief Executive
Officer of the Priory Group and I have been appointed to that position with effect from 1
December 2016. I am therefore responding to your report on behalf of the Priory Group as
Chief Executive Officer.

Addressing your concerns
1. Adequacy of staffing levels

We note your comments in relation to the QNIC guidance published by the Royal College of
Psychiatrists and we consider that this is still an appropriate reference point for the staffing
of CAMHS units and continues to be used by many providers in determining and monitoring
appropriate staffing levels.

More generally, staffing levels at the Child and Adolescent High Dependency Unit (HDU) at
Priory Hospital Ticehurst (and indeed on all our wards) are kept under constant review to
ensure they are appropriate to the ever-changing needs and numbers of patients. Reviews
of patient behaviours and their needs (as set out in care plans and risk assessments) are
carried out at the beginning of each shift as part of the formal handover and adjustments
made to staffing levels and mix as appropriate. In assessing adequacy, the following factors
also need to be taken into account:

i. nursing staff on a ward should not be considered in isolation from the support and input
provided by other professionals on the ward (for example, one to one sessions are
provided by a number of clinical professionals including therapists and doctors);

ii. CAMHs patients attend school and therapy in the day (this therefore increases the
staff/patients ratios remaining on the wards);

iii. ward managers and other supernumerary staff are not taken into account in
determining appropriate staff/patient ratios (but they do of course interact with patients
throughout their shift);

iv. staff can be called in from other wards at any time but particularly in an emergency;

Priory Centrat Services are accredited by

Priory Group, Fifth Floor, 80 Hammersmith Road, London, W1i4 8UD
Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup.com www.priorygroup.com
Priory Group No. 1 Limited trading as the Priory Group, Registered Office: Fifth Floor, 80 Hammersmith Road, London, W14 8UD.
Registered in England No. 07480152. Part of the Priory Group of Companies,

PGO1381/Oct13

vy. there are robust on-call arrangements which all senior managers must participate in;
and

vi. we encourage a culture of openness and team working and if employees have concerns
around staffing they can raise those with the ward manager, clinical services manager
or hospital director.

2. Risk assessment and management including the Risk Assessment Tool

I am pleased to advise you that an enhanced Risk Assessment Tool was launched on 28
November 2016 and that staff briefings in relation to using the too! are underway. The new
tool enables a better assessment of behavioural risk prior to admission and encourages
patients to become more involved in understanding their risks and how to manage them.
Feedback from our staff about the tool has been very positive.

3. Observations and information sharing

In common with all healthcare providers and as part of its commitment to continuous
improvement, Priory Group keeps all of its operational policies and procedures under
constant review including in relation to observation and engagement. Observation recording
forms have been enhanced and are now more user friendly with clear instructions on what
should be recorded. We have also endeavoured to make the policy clearer in relation to
information sharing. Local site compliance with observation procedures is monitored. via
out-of-hours unannounced internal audits.

4. Emergency procedures

Please note that in relation to BLS and ILS, monthly simulation drills are undertaken and
these involve all staff and involve a variety of different emergency life support scenarios.
Feedback from the drills has been very positive and indicates that staff are continually
putting into practise the skills that they have been taught.

Having reviewed your comments in relation to ALS training carefully, we consider there is
greater overall benefit for the hospital if we retain an expert in ALS/resuscitation who will
deliver training and coaching to our staff. The expert is to be retained under appropriate
contractual arrangements and will provide face-to-face training for nursing and medical staff
and will work with the hospital management team on developing and implementing the
emergency scenarios and provide objective feedback.

I do hope that these actions will provide you with the reassurance that you require. If I can
be of further assistance then please do not hesitate to contact me.

Yours sincerely
‘

Trevor Torrington
Chief Executive Officer
Priory Group

From Nicola Blackwood MP 
Parliamentary Under Secretary of State for Public Health and Innovation 

Richmond House
79  Whitehall 
London 
SW1A 2NS

I©
02  MAR  2017 

Department 
of Health 

Ms P A Schofield 
Senior Coroner 
West Sussex Record Office 
Orchard Street 
Chichester 
West Sussex 
P019  1DD 

Thank you for your letter dated 5  October 2016, following the inquest into the death 
of Amy Rose El-Keria. 

I was very sorry to hear of Miss El-Keria’s death. Please extend my sincere 
condolences to her family. 

You have raised the following matters of concern: 

•  The  staffing  levels  at  Ticehurst  House  Hospital  and  availability  of national 
guidance  on  staffing  levels  for  inpatient  Child  and  Adolescent Mental  Health 
Services (CAMHS) 

•  An on-going shortage of acute mental health beds for young people close to the 

community where they live. 

NHS England and Health Education England (HEE) are working to improve the 
capacity and capability of workforce delivering mental health care for children and 
young people, so that by 2020 an additional 70,000 receive effective treatment per 
year. This work extends to supporting training programmes for staff working in 
inpatient CAMHS to improve team functioning and delivery of evidence-based care. 

I have been advised that in 2016, NHS England commissioned the Royal College of 
Psychiatrists and National Collaborating Centre for Mental Health (NCCMH) to 
develop guidance on the implementation of the staffing required to deliver safe, 
effective and compassionate care in inpatient and community mental health care for 
children, young people and adults. The guidance will be relevant to commissioners, 
providers, young people and parents, and will contain: 

 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  A methodology for delivering safe, effective, compassionate and sustainable 

staffing; 

•  Guidance on staffing to support delivery of the evidence-based treatment 

pathways (these include pathways for children and young people); 

•  Recommendations on minimum staffing numbers and competences required 

across different mental healthcare settings; 

•  Positive Practice Examples and Helpful Resources pack 

This programme is expected to be completed by December 2017 and will inform 
future revisions of the service standards for the Quality Network for Inpatient 
CAMHS (QNIC), which are reviewed every two years. 

You have also raised concerns about the quality of care provided to Miss El-Keria 
whilst she was in Ticehurst House Hospital and in particular the ability of staff to 
mitigate risks of suicide and self-harm. 

The Government revised the Mental Health Act  183  Code of Practice in 2015, which 
we expect all mental health providers to implement. The Code of Practice is clear that 
patients should have in place a robust care plan developed by a multi-disciplinary 
team and that this should include effective risk assessment. 

The Department of Health published good practice guidance on assessing and 
managing risk in mental health in 2009. This can be accessed through the GOV.UK 
website at the following address: 
https://www.gov.uk/govemment/publications/assessing-and-managing-risk-in-
mental-health-services 

You have also raised concerns about access to CAMHS inpatient beds close to where 
they live. 

I am aware of instances where children have had to travel too far away from home to 
access care.  The Prime Minister announced in January 2017 that by 2020/21  no child 
will be sent out of their local area for non-specialist care.  You may also be aware 
that NHS England has reviewed CAMHS inpatient services nationally which has 
resulted in an additional 56 CAMHS inpatient beds being commissioned across the 
country to meet demand. 

However, we should also be seeking to avoid unnecessary admissions to hospital 
wherever possible. That is why the Government is developing a comprehensive set of 
community-based mental health service pathways and standards so that more people 
can be treated in the community closer to home.  We have also invested £400 million 
to improve crisis care services in the community so that people receive the right care 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Department
of Health 

in the right place when they experience a mental health crisis.  Every local area now 
has a mental health crisis care action plan in place. 

This Government is committed to achieving parity of esteem for mental and physical 
health.  We have invested £1.4bn over the course of this Parliament in children and 
young people’s mental health and we remain committed to delivering the vision set 
out in the Five Year Forward Viewfor Mental Health and Future in Mind to 
transform mental health services. Every area in the country now has a children and 
young people’s transformation plan in place to achieve this and every area has 
developed a sustainability and transformation plan to deliver long-term improvements 
to health services. 

Every death of a person in a mental health setting is a tragedy and every patient has 
the right to expect high quality and safe care. This is why we commissioned the Care 
Quality Commission (CQC) to review the way in which deaths of people in NHS 
settings are investigated and learned from to avoid further tragedies. 

On  13  December 2016, the CQC published the findings of its review in a report titled 
Learning,  candour and accountability: A review ofthe way NHS trusts review and 
investigate deaths ofpatients in England.  It concluded that learning from deaths is 
not currently being given sufficient priority within the NHS and that bereaved 
families and carers have poor experiences with providers. 

The Secretary of State accepted the CQC’s recommendations for improvement and a 
programme to deliver his commitments is underway. The first stage will be the 
delivery this year of a National Framework on Learning from Deaths for NHS 
providers. The aim is to standardise and improve practice across providers by 
providing clear expectations in relation to identifying, reporting, reviewing, 
investigating and learning from deaths, and significantly, engaging with bereaved 
families and carers. From April 2017, Trusts will be required to publish specified 
information on deaths each quarter, including estimates of how many deaths were 
judged more likely than not to have been associated with problems in care. Trusts 
will also be required to publish evidence of learning and action as a result of the 
information. This increased transparency, through improved data collection and 
reporting, is about supporting a systemic, NHS-wide approach to learning from 
deaths. The CQC will also strengthen its assessment of providers by covering 
learning from deaths. 

 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In addition, as a result of cases such as that of Miss El-Keria’s, earlier this year I set 
out measures for how we will improve the recording and monitoring of deaths of 
patients under the care of inpatient child and adolescent mental health services, with 
every death now directly reported to Ministers. 

I hope that this response is helpful and I am grateful to you for bringing the 
circumstances of Miss El-Keria’s death to my attention. 

NICOLA BLACKWOOD

lay  London  Borough 
mit of Hounslow 

, Executive Director 

Penelope A Schofield 
Senior Coroner 
Coroner’s  Office 
West Sussex Record Office 
Orchard Street 
Chichester 
West Sussex  P019 1DD 

Dear Senior Coroner Schofield, 

Children’s and Adults’ Services
Civic Centre, Lampton Road 
Hounslow  TW34DN 

'i'l 

Date: 

24/11/2016 

I  write  to  respond  on  behalf  of  the  Chief  Executive,  Mary  Harpley,  to  whom  you  wrote  on 
05/10/2016. 

On  03/10/2016,  and  following  the  Inquest  hearing  touching  upon  the  death  of  Amy  Rose  El-
Keria,  you  issued  a  Preventing  Future  Death  Report  request  from  the  London  Borough  of 
Hounslow, to deal with three particular issues,  as follows: 

1)  The  evidence  given  at  the  Inquest  showed  that  there  was  a  clear  misapprehension  by 
Hounslow Social Services as to their role in  supporting Amy whilst at Ticehurst. 
It  appears  that  Social  Services  did  not  appreciate  their  important  ongoing  role  to  ensure  Amy’s 
welfare  whilst  placed  at  Ticehurst. 
,  the  Court  expert,  gave  evidence  that  Hounslow 
may  have  seen  this  health  funded  placement  as  a  stand-alone  intervention  that  did  not  require 
their input. 

2)  Social  Services  clearly  have a  vital  role  to  play  in  ensuring  family  contact  where  a  child  is 
placed far from their family home where difficulties arise. There was  no assessment carried out to 
assess whether there was  any need to  provide support to a  child  in  need  under Section  17 of the 
Children  Act  1989,  even  when  Amy’s  mother  had  specifically  raised  the  difficulties  she  was 
having with  contact with Amy,  including the cost of travel, with  her support worker. 

3) The family gave evidence to the extent that having  better contact with Amy and  more  input into 
her care may have brought about a  different outcome particularly when she was distressed. 

The  London  Borough  of  Hounslow  has  re-drafted  and  updated  its  Thresholds  Guidance  & 
Assessment  Protocols to  ensure specific reference  is  made to these  matters.  Advice was sought 
from  Mental  Health  professionals  as  part of this  process.  The  London  Borough  of Hounslow will 
ensure that this  information  is disseminated  across  Children’s  Social Care,  and that refresher and 
update  briefings  will  be  delivered  to  all  relevant social  workers  and  staff.  The  information  will  be 
disseminated  across Children’s  Social  Care teams the week of 28/11/2016 and  Heads of Service 
and  Team  Managers will  ensure that all  managers and  practitioners  are fully briefed.  Information 
will  be  shared  by  Heads of Service at their next Management Meetings and  with  social work staff 
at their next Team  Meetings. An  additional development session for refreshing  knowledge will  be 
delivered  to  Managers,  Independent  Reviewing  Officers,  and  Advanced  Practitioners  at the  next 
Managers’  Forum  in  the  New Year. 

www.hounslow.gov.uk  Your  online A-Z  of services 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
   
 
 
 
 
   
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
   
   
 
 
 
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
   
 
 
   
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 These  staff briefings  and  development sessions  will  specifically cover the  local  authority’s  duties 
to  children  placed  in  hospital  and  other  settings  away  from  home  under  S85  and  S86  of  the 
Children  Act  1989  and  assistance  in  those  circumstances  under  S17  Children  Act  1989.  They 
will  additionally  highlight  to  all  social  care  staff  that  when  notified  of  a  Tier  4  mental  health 
inpatient,  the  expectation  is  that the  local  authority shall  undertake  a  S17  or S47  assessment as 
commensurate  with  its  duties  under the  Children  Act  1989.  In  both  instances,  the  social  worker 
assessment  should  consider  issues  of  contact,  including  promotion  and  support  of  contact 
between those children  and their families as appropriate. 

The  threshold  document  is  available to  the  public on  the  council’s  website  and  specifically on  its 
Local  Safeguarding  Children’s  Board  site.  The document is  public facing  but is  primarily aimed  at 
assisting those professionals working with  children to  understand  how thresholds are applied  and 
how child  protection  professionals make decisions  in  respect of appropriate action.  Assistance to 
children  in  need  under  S17  of the  Children  Act  1989  for  children  placed  in  a  hospital  or  other 
setting  is  referenced  at section  3.9  (pages  12-14)  under the  headings  ‘Children  Receiving  Tier 4 
Inpatient  Provision’  and  ‘Children Act  1989  Section 85 & 86  Duties’. 

The threshold  document assists  professionals to  take  appropriate  action  in  relation  to  children  in 
need  and  now  has  a  specific section  on  children  with  mental  health  disorders  to  ensure that the 
specific  needs  of the  vulnerable  are  highlighted  and  referrals  are  made  to  children’s  social  care 
as  required.  The  threshold  document  is  also  published  on  Hounslow’s  internet,  which  is  publicly 
accessible and  contained within the Children’s  Social Care’s procedure manual. 

Specific  reference  is  made  to  promotion  and  maintenance  of contact  between  children  and  their 
families,  following  an  assessment  of  needs.  The  awareness  of  social  workers  of their duties  to 
children  placed  in  health  settings  away from their homes and  the  importance to those children  of 
regular  contact  with  their  families  will  be  reinforced  by  the  staff  briefing  sessions  referenced 
above,  as well as the express references  in  the threshold document. 

The  London  Borough  of Hounslow  is  confident that the  concerns  expressed  by  you  are  and  will 
be addressed  by these actions,  and will ensure that there  is clarity and  consistency in  social work 
practice where children are placed  in  health  and  other settings away from  home. 

Please don’t hesitate to contact me should you  require further clarification or information. 

Yours sincerely, 

Director of Children’s Safeguarding & Specialist Services 
London Borough of Hounslow 

u

P^ICRY 

GROUP  OF  COMPANIES 

27th  January  2017 

Ms  Penelope  Schofield 
Senior Coroner:  West Sussex 
Coroner's  Office 
West Sussex  Record  Office 
Orchard  Street 
Chichester 
West Sussex,  P019  1DD 

Private and confidential 

Dear  Ms  Schofield 

Re.  Regulation  28  Report  to  Prevent  Future  Deaths  following  the  Inquest 
concerning the death of Ms Amy El  Keria 

Thank  you  for  your  Regulation  28  report  dated  18  November  2016  addressed  to  Mr  Tom 
Riall  of the  Priory Group.  Please  note that 
  has  now stepped  down  as  Chief Executive 
Officer  of the  Priory  Group  and  I  have  been  appointed  to  that  position  with  effect  from  1 
December  2016.  I  am  therefore  responding  to  your  report  on  behalf of the  Priory  Group  as 
Chief Executive  Officer. 

Addressing your concerns 

1.  Adequacy of staffing  levels 

We  note  your comments  in  relation  to the QNIC  guidance  published  by  the  Royal  College  of 
Psychiatrists  and  we  consider  that this  is  still  an  appropriate  reference  point for the  staffing 
of CAMHS  units  and  continues  to  be  used  by  many  providers  in  determining  and  monitoring 
appropriate staffing  levels. 

More  generally,  staffing  levels  at  the  Child  and  Adolescent  High  Dependency  Unit  (HDU)  at 
Priory  Hospital  Ticehurst  (and  indeed  on  all  our  wards)  are  kept  under  constant  review  to 
ensure  they  are  appropriate to the  ever-changing  needs  and  numbers  of patients.  Reviews 
of  patient  behaviours  and  their  needs  (as  set  out  in  care  plans  and  risk  assessments)  are 
carried  out  at  the  beginning  of each  shift  as  part  of the  formal  handover  and  adjustments 
made to staffing  levels  and  mix as  appropriate.  In  assessing  adequacy,  the following factors 
also  need  to be taken  into account: 
i. 

nursing  staff on  a  ward  should  not be  considered  in  isolation  from the support and  input 
provided  by  other  professionals  on  the  ward  (for  example,  one  to  one  sessions  are 
provided  by a  number of clinical  professionals including therapists and  doctors); 

ii.  CAMHs  patients  attend  school  and  therapy  in  the  day  (this  therefore  increases  the 

staff/patients  ratios  remaining  on  the wards); 

iii.  ward  managers  and  other  supernumerary  staff  are  not  taken 

in 
determining  appropriate staff/patient ratios  (but they do  of course  interact with  patients 
throughout their shift); 

into  account 

iv.  staff can  be  called  in  from  other wards  at any time  but particularly in  an  emergency; 

Priory Group,  Fifth  Floor,  80  Hammersmith  Road,  London,  W14 8UD 

Tel:  020  7605  0910  Fax:  020  7605  0911 

info@priorygroup.com  www.priorygroup.com 

Priory Group  No.  1  Limited trading as the  Priory Group,  Registered Office:  Fifth Floor, 80 Hammersmith Road,  London, W14 8UD. 

Registered in  England  No.  07480152.  Part of the  Priory Group of Companies. 

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Priory Central Services are accredited by 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
   
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
   
 
 
   
 
 
 
 
   
 
   
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
   
 
 
 
 
     
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
   
 
   
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
 
   
 
   
 
 
 
 
   
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
     
   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 v. 

there  are  robust  on-call  arrangements  which  all  senior  managers  must  participate  in; 
and 

vi.  we  encourage a  culture of openness and  team  working  and  if employees  have  concerns 
around  staffing  they  can  raise  those  with  the  ward  manager,  clinical  services  manager 
or hospital  director. 

2.  Risk assessment and  management including  the  Risk Assessment Tool 

I  am  pleased  to  advise  you  that  an  enhanced  Risk  Assessment  Tool  was  launched  on  28 
November  2016  and  that staff briefings  in  relation  to  using  the tool  are  underway.  The  new 
tool  enables  a  better  assessment  of  behavioural  risk  prior  to  admission  and  encourages 
patients  to  become  more  involved  in  understanding  their  risks  and  how  to  manage  them. 
Feedback from  our staff about the tool  has  been  very positive. 

3.  Observations and  information  sharing 

In  common  with  all  healthcare  providers  and  as  part  of  its  commitment  to  continuous 
improvement,  Priory  Group  keeps  all  of  its  operational  policies  and  procedures  under 
constant review  including  in  relation to observation  and  engagement.  Observation  recording 
forms  have  been  enhanced  and  are  now  more  user  friendly with  clear  instructions  on  what 
should  be  recorded.  We  have  also  endeavoured  to  make  the  policy  clearer  in  relation  to 
information  sharing.  Local  site  compliance  with  observation  procedures  is  monitored  via 
out-of-hours unannounced  internal  audits. 

4.  Emergency  procedures 

Please  note  that  in  relation  to  BLS  and  ILS,  monthly  simulation  drills  are  undertaken  and 
these  involve  all  staff  and  involve  a  variety  of  different  emergency  life  support  scenarios. 
Feedback  from  the  drills  has  been  very  positive  and  indicates  that  staff  are  continually 
putting  into  practise the skills that they have  been  taught. 

Flaving  reviewed  your  comments  in  relation  to  ALS  training  carefully,  we  consider  there  is 
greater  overall  benefit  for  the  hospital  if we  retain  an  expert  in  ALS/resuscitation  who  will 
deliver  training  and  coaching  to  our  staff.  The  expert  is  to  be  retained  under  appropriate 
contractual  arrangements  and  will  provide face-to-face training  for nursing  and  medical  staff 
and  will  work  with  the  hospital  management  team  on  developing  and  implementing  the 
emergency scenarios and  provide objective feedback. 

I do  hope  that these  actions  will  provide you  with the  reassurance  that you  require.  If I can 
be  of further assistance then  please  do  not hesitate to contact me. 

Chief Executive Officer 
Priory Group