Barnaby Aylward

Date of report	14 Dec 2018
Reference	2018-0387
Deceased	Barnaby Aylward
Coroner	John Broadbridge
Coroner area	West Yorkshire (West)
Category	Community health care and emergency services related deaths
Organisation named	South West Yorkshire Partnership Teaching NHS Foundation Trust
Source	judiciary.uk record · original PDF
Responses published	1

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.

WEST YORKSHIRE WESTERN DISTRICT

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

1. Rob Webster, Chief Executive, SW Yorks Partnership NHS Foundation
Trust.

2.
3. j i r Housing.

4. John Roberts, Chief Fire Officer, West Yorkshire Fire and Rescue Service.

{1 | CORONER

lam JOHN NIGEL BROADBRIDGE, Assistant Coroner, for the Western coroner area of
West Yorkshire :

2 | 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.

3 | INVESTIGATION and INQUEST

On 8" September 2017 the Senior Coroner, Mr Martin Fleming, commenced an
investigation into the death of BARNABY LUKE AYLWARD ("Mr Aylward’) aged 49
years. The investigation concluded at the end of the inquest held over 3% and 4”
December 2018. The (narrative) conclusion of the inquest was that:

“The deceased died as a result of an accidental fire in the early hours of Monday 4
September 2017. The deceased, a heavy smoker, was overcome by smoke from a
“house fire more likely than not caused by his failure to handle safely a lit cigarette when
he was using an armchair in the living area of his home at Pa
Huddersfield. After smouldering, combustible materials in or around the armchair
affected by the lit cigarette ignited. The ensuing fire took hold quickly from which the
deceased did not escape despite the operation of fitted smoke alarms. He was found

only a short distance in front of the armchair and was pronounced deceased there at
03.55 hours that same morning.

The deceased suffered from long standing serious mental disorders which required anti-
psychotic medication treatment. He lived alone. His home regularly contained
accumulations over time of the deceased's clutter, including waste, which restricted
where he could properly rest and care for himself fully and safely. It also increased the
risk of fire and smoke in the dwelling and it contributed to the fire intensity that morning.
His ability and willingness to manage his own safety completely was inadequate
including because of persistent restlessness. He remained vulnerable to the
circumstances in which he died which whilst identifiable were not identified in any
concerted plan and not promptly and thoroughly remedied for his long term benefit. He
was not assessed to require compulsory detention under the Mental Health Act 1983, s2
on + September 2017 and remained in community mental health care at the date of his
death”

The medical cause of death was determined as 1a) asphyxia due to 1b) smoke
inhalation due to the house fire.

detain was given and the detention did not proceed. He remained at home. .

CIRCUMSTANCES OF THE DEATH

Mr Aylward was a heavy smoker, and was overcome by smoke from a house fire more
likely than not caused by his failure to handle safely a lit cigarette. The precise reason
for the cigarette to come into contact with combustible material was not able to be
established. After smouldering, combustible materials in or around the armchair (in
which he was likely to have been seated) affected by the lit cigarette ignited; the fire
intensity was increased because of combustible material discarded or stored by Mr
Aylward in his living area space which usable area had been reduced by that clutter,
which was evident on any inspection, around his home. The ensuing fire took hold
quickly from which the deceased did not escape despite the operation of fitted smoke
alarms. It was more likely than not that Mr Aylward had died from smoke inhalation
before firefighters were able to extinguish the fire. If he tried to escape he did not get
far. He had been observed to have been agitated and restless for some hours the
evening and night before. He had undergone formal assessment for detention under the
MHA 1983 on 1 September 2017 but only one independent Doctor's recommendation to

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 could 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) Mr Aylward was a social housing tenant. He exhibited certain behaviours that
were in part linked to his serious mental illness. Those presented risk of death
in a fire at home including. heavy smoking and allowing clutter and waste to
accumulate there. Those behaviours and thus risks were known to certain
individuals, including his family, and agencies but they did not except in time of
crisis or emergency:

a) review those potential risks with a multi agency preventative approach and
re assess those risks regularly over time;

b) take any collective responsibility nor for any one person or agency to take
responsibility to reduce or eliminate risk by action eg clearing clutter and fire
tisk; and education about risk and reluctance to compel Mr Aylward to
improve his environment regularly if needed;

c) did not feel empowered to make property inspections regularly or at all and
advise Mr Aylward and other agencies, or have sufficient resources at the
right level to inspect and assist;

d} may have been hampered by issues of confidentiality in communications
between agencies.

If ‘all agencies had shared the particulars of his behaviours the burden of
risk might be shared and understood and potential to reduce or eliminate
the risk attempted, reviewed and managed.

(2) The mental health care delivered to Mr Aylward was within a Care Planning
Approach. The Care Plan documentation did not identify his above behaviours in writing
and thus potential risks, nor indicate review and solutions including with housing
provision ; 7

(3) The presence of clutter and thus risk was not always evidenced in other clinical notes
as a symptom of Mr Aylward’s illness of significance as were other presentations of his
illness.

(4) There was some but not much evidence of seeking to extend support to Mr Aylward
through his family members including practical and financial help.

LL oe

(5) The appropriateness for a risk management meeting and aiso MHA assessment in j
part to be held away from the patient to enable frank discussions to take place between
mental health professionals rather than in front of the patient when perhaps more robust
views may not have been enabled.

[8 _| COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following Interested

9 14" December 2018
JINB ‘

7 + YOUR RESPONSE

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and your
organisation have the power to take such action.

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 11" February 2019 |, 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.

Persons namel
lam 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.

WOdhudae

John Broadbridge .
Assistant Coroner for Western area West Yorkshire

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 S (PDF)

West Yorkshire

Fire & Rescue Service

John Roberts

Ast February 2019 _ Chief Fire Officer/Chief Executive
Oakroyd Hall

a Birkenshaw

Mr John Nigel Broadbridge West Yorkshire

Assistant Coroner (Western) BD112DY

HM Coroner’s Office

The City Courts .

Peo Telephone; 01274 655733

BO1 1LA

Dear Mr Broadbridge

Re: Response to a Regulation 28 report to prevent further deaths following an inquest hearing
regarding the death of Barnaby Aylward, 4 Old Bank Fold, Moldgreen, Huddersfield

This response is in specific relation to Matters of Concern 1(a) to 1(d).

I refer to your report of 14th December 2018, made under paragraph 7, schedule 5, of the Coroners
and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

You will have noted the content of the report submitted by the Fire Investigation officer
of West Yorkshire Fire and Rescue Service (WYFRS). In his report, he explains how WYFRS Control
teceived a call from a neighbour alerting us to a fire at a .
03:11 on 4th September 2017. Of note is that there were mains powered ionising smoke atarms fitted
to the living room and landing ceilings and these alarms operated and alerted neighbours to the fire.

WYFRS led.a Serious Incident Review on 3rd October 2017 in relation to this incident. Representatives
from WYFRS, Together Housing, SWYFT and Kirklees Council attended this: meeting which resulted in
a number of actions to progress. Some of the key actions included a review of the partnership
arrangements with the relevant partners and to provide refresher training to staff at Together Housing
and SWYFT.

It is frustrating that WYFRS was not notified of the circumstances.in which Mr Aylward was living and
we have found no evidence that a referral to ourselves was made. | note that Mr Aylward suffered
fram long term poor mental health, had large quantities of combustible waste accumulated in his
living spaces and was a heavy smoker. Many fire fatalities within West Yorkshire involve certain risk
factors such as living alone, having poor mental health, unsafe smoking habits or use of excessive
alcohol or medication that can make one drowsy. Our new Safer Communities Strategy aims to apply
more focus to individuals who are more at risk of fire and risk factors such as those listed above (often
combined within the same household) have been evident in a number of fire fatalities across West
Yorkshire.

Making West Yorkshire Safer
www. westyorksfire.gov.uk

Our work to target resources towards risk has evolved over time. In 2017, we launched a new strategy
to build upon the success of our fire prevention programme which has seen significant reductions in
dwelling fires. In 2009/10, there were 1549 dwelling fires attended by WYFRS compared to 1094 in
2017/18. The focus of the new strategy finks to our strategic aim of ‘Making West Yorkshire Safer’
and this is achieved through improving our ability to target our resources towards those who are most
vulnerable. We will achieve this by using an intelligence and risk led approach and we recognise the
importance of partnership work to deliver this aim.

The traditional home fire safety visits have evolved into a new (broader) Safe and Well visit that
incorporates a wider assessment of health and wellbeing that includes: risk of falls, social isolation,
cold homes, crime prevention and smoking cessation. What is also worth pointing out is that if we
identify someone who is assessed as being at high risk of having a fire, then our dedicated fire
prevention staff may conduct repeat visits (at intervals that they deem necessary} in order to continue
providing education and advice in addition to safety equipment that we deliver during the visit which
include smoke detection and fire retardant bedding packs and throws.

Our list of recognised partners across West Yorkshire varies from emergency services and health and
social care partners to the voluntary sector. Within the partnership agreement documents, it explains
that in order to contribute to a reduction in accidental dwelling fires, staff working for such
organisations can refer clients on to WYFRS if they feel that we can improve safety through education
on fire safety in the home and interventions that include fitting smoke detection (where required).
The purpose of the agreements is also to enable information to be shared between agencies to
support the overall aim which is to improve the fire safety, health and wellbeing of vulnerable people
across West Yorkshire. Referrals from.partners are made through an online referral system which is
accessed through a secure web link. As referrals are placed into our system, this then generates a
‘case’ and contact is made with the client to arrange a suitable time to conduct a home visit (previously
termed home fire safety check not termed safe and well check). Home visits are prioritised based on
the risk that is present at the time of referral. During the home visit, appropriate fire safety
interventions and education is delivered to the occupant.

An essential element of the partnership Is maintaining the awareness across the staff working for the
partner agency. In regard to the partnership arrangements with the agencies involved in this case, |
shalt provide a summary below.

South and West Yorkshire Partnership Foundation Trust (SWYFT)

WYEFRS has had a formal partnership in place with SWYFT for a number of years. There is a signed
agreement dated October 2014 and we have been in the process of updating our partnership
agreements following the introduction of the new Safer Communities Strategy in 2017. Our records
show that WYFRS have received 86 referrals directly from SWYFT between 2016 and 2018. However,
we expect the actual number of referrals from staff working across SWYFT to be higher than this figure
as they may refer through their local team or department name but essentially their work falls under
the SWYFT umbrella.

WYERS started communication with officials from SWYFT In July 2017 to establish a new partnership
agreement in light of the changes to our home visit programme in April 2017. A new agreement is
currently with the directorate of SWYFT and they informed us that their Health and Safety and
Information Governance team, would be reviewing the agreement in December 2017. As a result of
this a number of queries were raised in relation to information sharing which coincided with the
introduction of GDPR in May 2018.

WYERS produced an amended information sharing and partnership agreement in June 2018 which
was subsequently shared with SWYFT for comment. This in turn raised further queries which it was
agreed would be resolved by meeting to discuss them. A meeting took place on 3rd October 2018 at
which it was agreed to reconvene discussions in January 2019 to allow system/process changes to be
implemented internally at SWYFT.

The new agreement between WYFRS and SWYFT includes a programme of reciprocal training to be
delivered in 2019. Core elements of this training will be to reinforce the partnership referral
mechanisms that are in place and to help front line workers to identify individuals who are vulnerable
to fire risk.

Together Housing

WYFRS has had a formal partnership in place with Together Housing for a number of years within the
Calderdale District and prior to this with Pennine Housing. There is a signed agreement dated May
2016 with Together Housing. We have been in the process of updating our partnership agreements
across districts following the introduction of the new Safer Communities Strategy in April 2017.

Our records show that we have received 189 referrals from Together Housing between 2016 and 2018.
WYFRS has delivered some excellent partnership working with Together Housing throughout 2018 and
both organisations received a nomination for ‘Partnership of the Year’ at the National Excellence in
Fire and Emergency Awards in December 2018. This nomination recognised our work with Together
Housing to provide a series of 60 second fire safety films for residents of Together Housing properties.

WYFRS started communication with officials from Together Housing in July 2018 to establish a new
partnership information sharing agreement to cover West Yorkshire, expanding the current
arrangements. Discussions also took place about the development of training for personne! within
both organisations to identify the support available within each service. WYFRS Dementia Resources
were also shared with Together Housing to establish whether these would be suitable for their
employees to support visits and aid the provision of key fire safety messages.

The Together Housing partnership information sharing agreement is drafted and currently sat with
their data protection team in relation to the GDPR element. Together Housing has given a
commitment to have the updated partnership agreement signed by 3ist March 2019.

There has now been a commitment given by all three organisations to deliver some training across
the specific areas of identification of fire risk and the referral methods to WYFRS to increase the
awareness of this across the workforce at SWYFT and Together Housing. This training is due to be
delivered by June 2019,

Finally, | am assured that our teams are working with partners across the five districts in the effort to
provide our prevention services to those who most need it, We accept that there is still progress to
be made around information governance and sharing data across organisational boundaries, and we
will continue to make an appropriate response to all of the referrals that we receive in relation to
people that are identified as being at risk of fire in their homes.

Yours sincerely

Chief Fire Officer

Regulation 28 Report to Prevent Further Deaths
This response is being sent to:

Coroner John Broadbridge, Assistant Coroner, West Yorkshire

In response to a Regulation 28 Report to Prevent Further Deaths following an Inquest hearing into
the death of Barnaby Aylward at iS that concluded on 4 December
2018. .

1. Together Housing

Together Housing is a registered housing provider, providing over 37000 homes across the North
of England to over 70000 people. This response has been produced by Together Housing, Bull
Green House, Bull. Green, Halifax HX1 2EB.

2. Coroners Matters of Concern
The matters of concern were identified as:

2.1 The sharing of the particulars of his behaviours the burden of risk might be shared and
understood and potential to reduce or eliminate the risk attempted, reviewed and managed.

2.2The Care Plan delivered within the mental Health care did not identify those behaviours in
writing-and thus potential risks, nor indicate review and solutions within housing provision.

2:3The presence of clutter was not always evidenced in clinical notes as a symptom of his
illness. °

2.4There was some but not much evidence of support though family members including
practical and financial help.

2.5The appropriateness of a risk management and MHA assessment away from the patient to
enable more frank discussions.

3 Action Taken

In response to the matters of concer raised in the Regulation 28 report, we have commenced a
number of actions and have planned for further actions to reduce risks and improve internal
processes and work with other agencies.

3.1 Information about our customers - We are developing further our database in relation to
vulnerabilities. including those related to fire risks. Annually we will update personal
information from higher risk customers particularly those in supported housing and high
rise flats. This database is aimed at ensuring we identify higher risk tenants and causes, it
requests details on health and lifestyle issues. We request this data from tenants and
where appropriate arrange joint safe and well visits with the fire service. The information is
updated annually but also used at the start of new tenancies or where officers identify a
safeguarding issue with a tenant.

Harrison Street, Wakefield, T: 0300 555 5561 Together Housing Association Ltd, a charitable

West Yorkshire WF1 1PS www.togetherhousing.co.uk England and Wale at it society registered in

Authority with registered number 28687R.

3.2Reviewing processes and joint working - We have instructed an independent
investigation into this and other deaths and fire incidents. The investigation will be
undertaken by a consultant, Patrick Harkness who had undertaken a similar investigation.
for another housing association and has been recommended. We anticipate that the work
will be undertaken during February and reported back in March / April with
recommendations.

3.3Safeguarding Training - We have a rolling programme of safeguarding training with all
members of staff to enable them to better identify vulnerable tenants including hoarding
and self neglect. We are also increasing visits to higher risk, more vulnerable tenants. A
review of our processes for reporting causes for concern is underway and we have recently
established a learning group on safeguarding from abuse.

3.4Strategic Fire Safety Group - The existing Fire Safety Group will take responsibility for
monitoring, learning lessons and taking policy decisions where appropriate to reduce risks.
The group consists of officers from across the Together Housing Group alongside
representatives from the West Yorkshire Fire and Rescue Service.

3.5Hoarding - We have introduced a new approach to hoarding and all relevant colleagues
have now undergone training in how to recognise and deal with tenants in these situations.
We will by the end of March 2019 have amended the hoarding procedure and included
links to local arrangements including the Kirklees Hoarding panel.

4 Details of Further action to be taken:-

In addition to the actions already underway we will also undertake following actions during 2019:-

4.1 Independent Investigation Actions - To implement any recommendations made by the
Independent Investigator to reduce the risks from March 2019.

4.2 Tenancy Audits - From April 2019 we are resuming regular visits to tenants, this
programme of visits will focus on those where we have had no previous contact (eg via
repairs or gas servicing) or have concerns regarding vulnerability. These will include a
property inspection where tenants will allow access. Any issues of concern will be acted
upon via tenancy safeguarding procedures.

5 Details of any Joint Groups/committees/evidence of working together

5.1Meeting of Partner Agencies - We have been in contact with the CEO of the SW
Yorkshire Partnership NHS Foundation Trust and have been put in contact with their lead,
in order to agree a plan to share responses and agree joint approaches going forward to
minimise further risks. A meeting was held on 18" January 2019 and a number of joint
actions have been agreed.

5.2 Joint Training — we have agreed to undertake joint training with frontline staff to discuss
fire safety issues including hoarding, vulnerability and referral processes. Training has
been planned for June 2019.

5.3Partnership Agreement with West Yorkshire Fire and Rescue Service — the existing
agreement with Together Housing and WYF&R service has been updated and includes an

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Harrison Street, Wakefield, T: 0300 555 5561 Together Housing Association Ltd, a charitable

West Yorkshire WF1 1PS www.togetherhousing.co.uk England and Wateeat the Fingnelal Conduct

Authority with registered number 28687R.

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information sharing protocol. The updated agreement is due to be signed week
commencing 21 January 2019.

As a result of the death involving Mr Aylward and the response from the coroner we have
reviewed our current practices and our work with partner agencies. We have already undertaken
a series of improvements in the procedures and practices of our staff and have further plans of
joint working. We will continue to review similar incidents and make any further changes that will
reduce risks and improve safety for our customers including with our statutory partners.

Yours sincerely

Group Chief Executive
Together Housing Group

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Harrison Street, Wakefield, T: 0300 555 5561 Together Housing tesocatien: Ltd, a Shc
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West Yorkshire WF1 1PS www.togetherhousing.co.uk England and Wales at the Financial Conduct
Authority with registered number 28687R.

NHS

South West
Yorkshire Partnership
NHS Foundation Trust
Mr. John Nigel Broadbridge creaperrrerca
Assistant Coroner edical Director
Coroner Office Trust ieee
Trafaigar House leldhea
Nelson Street Rees
Bradford
BDS ODX subha.thiyagesh@swyt.nhs.uk
7 February 2019
Dear Sir

Regulation 28 prevention of future deaths — Mr. Barnaby Luke Aylward— inquest dated 3"
and 4" December 2018

In response to the-regulation 28 the Trust wish to respond with the following information:-

(1a) Mr. Aylward was a social housing tenant. He exhibited certain behaviors that were in
part linked to his serious mental illness. Those presented risk of death in a fire at home
including heavy smoking and allowing clutter and waste to accumulate there. Those
behaviors and thus risks were known to certain individuals, including his family, and
agencies but they did not except in times of crisis or emergency

a) Review those potential risks with a multi-agency preventative approach and re
assess those risks regularly overtime;

b) Take any collective responsibility nor for any one person or agency to take
responsibility to reduce or eliminate risk by action, e.g. clearing clutter fire risk and
reluctance to compel Mr. Aylward to improve his environment regularly and if
needed;

c) Did not feel empowered to make property inspections regularly or at all and advise
Mr. Aylward and other agencies, or have sufficient resources to the right level to
inspect and assist;

d) May have been hampered by issues of confidentiality in communications between
agencies,

Chair: Angela Monaghan = Chief Executive: Rob Webster

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South West

Yorkshire Partnership
NHS Foundation Trust

The Trust has in place guidance in various forms to assist staff in supporting service users who
may be vulnerable. There are a number of partnership arrangements where both health and
local authority work together to provide care and treatment to people in the community.

It is important that staff from all agencies recognise that the management of a person who may
be at risk for a number of reasons is not the sole responsibility of one agency. Going forward
Trust staff should be encouraged to use the knowledge and expertise of other agencies such as
housing and fire and rescue services. The knowledge of family and carers is also a very
important element when caring for vulnerable people.

The Trust currently works in partnership with the West Yorkshire Fire and Rescue service in
respect of wellbeing promotion and safety and support for our vulnerable service users.
Following the death of Mr. Aylward the Trust undertook an investigation into the circumstances
and it was recognised that although agreements and partnerships were in existence these
needed to be strengthened. In order to strengthen these arrangements the Trust’s safeguarding
team set up a programme of work visiting all community teams within the Kirklees area,
providing them with information and guidance relating to the different circumstances which may
arise for people who are vulnerable within their own homes and advising staff how to have an
inclusive and collaborative approach when supporting people.

The Trust has a commitment to providing Safeguarding training to all staff which is mandatory
and requires a refresher every 3 years. In 2017 it was agreed that awareness regarding neglect
and hoarding should be included in the programme of training and has since been implemented
by our safeguarding trainers across the Trust.

The Trust currently has an inter-agency information sharing protocol with West Yorkshire Fire
and Rescue service, this protocol is currently under review and it is anticipated that this should
be agreed by the end of March 2019.

Staff do actively discuss with service users where indicated if there are problems relating to the
living conditions. However the Trust is developing an information leaflet for staff to assist them in
what to look for and what questions to ask when there are concerns for patient safety in their
own homes.

The Trust is a signatory to “Kirklees Multi agency Hoarding Framework” which was reviewed in
July 2018, and provides detailed advice to staff. A member of the Trust safeguarding team is a
member of the panel which is chaired by West Yorkshire Fire and rescue service. The Trust is

participating in partnership training with West Yorkshire Fire and rescue and Together housing,
this will be available through the months of June and July 2019.

Chair: Angela Monaghan Chief Executive: Rob Webster

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NHS

South West

Yorkshire Partnership
NHS Foundation Trust

(2)The mental health care provided to Mr. Aylward was within a Care planning Approach.
The care plan documentation did not identify his above behaviours in writing thus
potential risks, nor indicate review and solutions including with housing provisions.

An alert will be distributed to all staff working in the Trust raising awareness that where there is a
risk relating to hoarding and associated risks this should be included within the care plan and
that interventions should be planned to manage the risk. These should be reviewed on a regular
basis or as the risk changes. The alert will be distributed by the end of February 2019.

As mentioned above the Trust's safeguarding department has increased staff awareness which
includes information about the multi-agency Hoarding Panel in Kirklees

Staff will be reminded through the safeguarding training and information governance training
that where a service user is in rented accommodation, consent should be sought from the
service user to provide information regarding the condition of the property to the housing
provider.

Staff will be reminded through the alert that where there is an identified fire risk a referral should
be made to the fire service.

(3) The presence of clutter and thus risk was not always evidenced in other clinical notes
as a symptom of Mr. Aylward’s illness of significance as were other presentations of his
illness.

Mr. Aylward’s untidiness would not normaily be classified as a symptom of a psychotic illness.
Nevertheless it is recognised that where a person is vulnerable in respect of the conditions of
their property and other influencing factors such as smoking this should be included within the
care plan. This should be monitored, reviewed and updated regularly and not only at times of
heightened risk due to mental ill health. ~

(4) There was some but not much evidence of seeking to extend support to Mr. Aylward
through his family members including practical and financial help.

Learning events have previously been provided by the safeguarding team which includes raising
awareness to include carers and family in care planning and risk management, this will continue
to be reinforced through our mandatory and core clinical training programmes. This will be
reinforced through the publication of the above mentioned information leaflet and alert.

(5) “The appropriateness for a risk management meeting and also a MHA assessment to
in part held away from the patient to enable frank discussions to take place between the

Chair: Angela Monaghan Chief Executive: Rob Webster

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health professionals rather than in front of the patient where perhaps more robust views
may not have been enabled”

The role of the AMHP and the medical staff within the MHA assessment process is to act as an
independent assessor but additionally as part of that role it is their responsibility to ensure they
have collected available information and views of all involved in the person’s care. Often MHA
assessments are at the point of crisis for a service user and as.such opportunities for discussion
are limited by time, space and urgency to preserve safety, but where possible efforts should be
made for the professionals involved to have a conversation not in the presence of the service
user in order to establish a plan of care.

A separate care conference to address management of risk should be considered where
possible, before a crisis situation arises.

| hope the information provided is of assistance to you and provides assurance that the Trust is
committed to working with our partners in supporting our community.

Yours faithfully,

Medical Director
South West Yorkshire Partnership NHS Foundation Trust

Chair: Angela Monaghan - Chief Executive: Rob Webster

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Fire & Rescue Service

Mr John Nigel Broadbridge
Assistant Coroner
Coroners Office

Trafalgar House

Nelson Street

Bradford

BD11LA

Dear Sir

Re Mr Barmaby Luke Aylward

Following receipt of the prevention of future death report by our agencies, we
committed to strengthening our current partnership working in respect of education
and awareness. Senior members of staff were tasked with meeting to discuss
current arrangements and agreeing where we need to strengthen these.

It was evident from the meeting. that much work has been undertaken in respect of
highlighting areas of risk and vulnerabilities within our communities. It has been
agreed that further awareness and promotion of fire safety should be undertaken. A
multi agency programme of awareness training provided by West Yorkshire Fire and
rescue service has been agreed for the months of June and July 2019. All three
agencies have committed to this awareness training being a priority for our staff.

Each organisation has set out individually in the . attached correspondence,
responses to the prevention of future deaths report you issued.

Should you require any further information in respect of this matter please do not
hesitate to contact our organisations.

May we also take this opportunity to offer our sincere condolences to Mr Aylward’s
family and friends at this time.

Yours sincerely

Medical Director

Group Chief Executive Chief Fire Officer
South West Yorkshire Partnership Together Housing Group West Yorkshire Fire
NHS Foundation Trust & Rescue Service

te ether

HOUSING
GROUP

Fire & Rescue Service

The report

Responses

Related reports

Other reports by John Broadbridge

More reports categorised “Community health care and emergency services related deaths”

Track South West Yorkshire Partnership Teaching NHS Foundation Trust