James O’Brien

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Cambian Group ple A| Cambian

Mr Philip Barlow

Assistant Coroner for the Coroner Area of Inner South London
The Coroner’s Court

Tennis Street

London SEL

30 March 2017

Dear Mr Barlow }

Inquest into the death of James O'Brien

lam writing to you as the Chief Executive of Cambian Group PLC.

| refer to your Regulation 28 report dated 13 March 2017 issued following the conclusion of the
inquest into the death of Mr O’Brien.

The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited
which was then part of our Group. However, in December 2016 we sold our adult services division,
including Cambian Healthcare Limited. The Group, therefore, no longer has any executive
responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet
Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.

| have therefore passed your letter to Dr Romero, who | know is arranging for a response to your
report to be sent to you today, addressing the issues that you have raised.

Please let me know if you have any queries and | will be happy to assist.

Yours sincerely

\ Sale m Asaria
\ Chie Executive Officer, Cambian Group PLC
Ne

vl

4" Floor, Waterfront Building, Chancellors Road, Hammersmith Embankment, London, W6 9RU
Tel: +44 (0)20 8735 6150 Fax: +44 (0)20 8735 6151 www.cambiangroup.com

The Cambian Group comprises a number of companies which ore registered in England and Wales and the Baifwick of Jersey.
The details of those componies in the Cambion Group registered in England and Wales con be found of www.cambiangroup.com/about/tegal

85 Fleet Street Tel +44 (0)20 7222 7040
London Fax +44 (0)20 7222 6208
EC4Y 1AE LDE 413 London Chancery Lane

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PF

RadcliffesLeBrasseur

Mr Philip Barlow 30 March 2017

Assistant Coroner for the Coroner Area of Inner South :
'

The Coroner's Court Your Ref:

Tennis Street

London SE1 P|

Dear Sir

Inquest into the death of James O'Brien

As you know, we act for Cambian Adult Services who currently operate the Cambian Churchill Hospital at
Barkham Terrace, London.

We have been instructed by the CEO of Cambian Adult Services to write to you in response to your
Regulation 28 Report dated 13" March 2017. That Report was addressed to Mr Saleem Asaria as CEO of The
Cambian Group but as has been explained under separate cover by Mr Asaria, his Group is no longer
invoived in the management of the hospital and therefore has no control over future steps that may be
taken. This letter is therefore written to you on the instruction of the CEO of Cambian Adult Services as
explained above as he is able to confirm the matters relevant to a response to your Report.

Our client takes very seriously any issues that relate to the prevention of future deaths. As you will know,
and as your Report acknowledges, they had already considered whether there were steps that could be
taken to minimise the risk of this in future and Mr Ruffley, the Regional Operations Director, gave evidence
at the inquest in relation to that.

in response to the matters referred to at paragraph 5 of your Report, we are instructed to confirm {or
reconfirm as the case may be) the following:

i First Aid Training — corporately, Cambian Adult Services have adopted a first aid training system
which is rated between basic life support and intermediate life support. This is felt to be
appropriate for psychiatric hospitals and the hospital has never had any concerns raised at any
inspections by CQC, as the regulator of the services that it provides, to suggest that that does
not meet their requirements for such units. In addition, as they may have patients with physical
health care needs that include the need for oxygen, our client has arranged for all nursing staff
to be trained in oxygen therapy. To ensure however that practice is in accordance with best
practice, our client has commissioned an external expert review of their Resuscitation Policy
procedure and practices.

2 Training Records — to ensure that staff training is up to date, our client uses a new training
matrix that captures the attendance of staff at classroom based training sessions. They are
therefore now able to review the training records of all staff members and identify any gaps.
This supplements the database available from Cambian Adult Services’ own on-line training

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Mr Philip Barlow 30 March 2017

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system known as “Achieve”. To ensure that the Hospital Director and senior managers are fully
appraised of the position in relation to training, particularly in relation to first aid training, a
routine weekly report detailing the percentage compliance by all staff at the hospital is
produced to them.

Responding to Emergencies — ail staff are required to undertake the on-line training provided
by Cambian Adult Services on responding to emergencies.

In addition, a local protocol for the Cambian Churchill Hospital is in place to ensure that staff
are aware of how to respond to emergencies. This covers amongst other things how to raise
the alarm, who is expected to respond and the use of radios. There is also a specific alarm
protocol detailing when the alarm should be activated.

Further, to ensure a prompt staff response, staff are aggregated across ail wards at the hospital
at night to assist with responding to emergencies.

Practice Drills ~ to assist in identifying any skills gaps, unannounced resuscitation simulations
take place twice a month at the Cambian Churchill Hospital with the outcomes discussed in
monthly clinical governance meetings. A resuscitation doll has been purchased specifically for
these drills and this enables the resuscitation exercise to be as realistic as possible. Practice
drills are recorded and audited. Areas of good practice and learning points are recorded and
this information is fed back to the staff team who attended that particular simulation exercise.
It is then further discussed in clinical governance meetings so that any themes or trends can be
identified and addressed.

Induction — the hospital had already reviewed its induction processes. This specifically includes
the topics of record keeping, observation and responding to emergencies. Staff that are not
familiar with the hospital are provided with a “tour” by more experienced staff when they first
start work at the hospital. The hospital is committed to using its own staff and their pool of bank
staff wherever possible rather than agency staff. To ensure appropriate staffing levels on any
particular shift, managers are required to plan bank staff cover in advance to address planned
staff absences, Since August 2016, no agency staff have been used at the hospital. However,
notwithstanding the commitment to no longer employing agency staff on an ad hoc basis, it is
impossible to -say that this could “never” occur because of the obvious need to ensure
appropriate staffing levels and the fact that emergencies might arise where additional staff
cover is required. Accordingly, our client has developed and implemented an “agency nurse
induction protocol” aimed specifically at any staff who may be booked at short notice to cover
a shift. They are required to attend work one hour before the shift commences to go through
an induction, and receive orientation to key policies and the environment.

We hope that clarifies the matters that HE cave in evidence, and addresses the points raised in your
Report. In addition, you may be interested to know that:

1. Cambian Adult Services have introduced at the hospital the NEWS system (National early warning
signs for acutely unwell patients) developed recently by the Royal College of psychiatrists. This is a

EB

Mr Philip Barlow 30 March 2017
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scoring tool of baseline observations to help determine appropriate action when staff find an unwell
patient. All staff at the Cambian Churchill Hospital have had training in this.

2. The issues raised at the inquest {and indeed at any inquest) will form part of a debriefing session
for all staff after such incidents.

Yours faithfully

RadcliffesLeBraSseur