Amanda Briley

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Professor Stephen Powis
National Medical Director
6t" Floor, Skipton House
80 London Road
SE1 6LH

16t" April 2019

Lydia Brown, Assistant Coroner
Leicester City and South
Leicestershire Coroner's Service
The Coroner's Court
Town Hall Square
Leicester
LE1 9BG

Dear Ms Brown,

Re: Regulation 28 Report to Prevent Future Deaths —Amanda
Briley 28th December 2016
Thank you for your Regulation 28 Report (hereinafter the `report') dated 11th January
2019 concerning the sad death of Amanda Briley on 28th December 2018. Firstly,
would like to express my deep condolences to Amanda's family.
Your report notes that Amanda had been diagnosed with Asperger's Syndrome and
had previously made repeated serious attempts to self-harm. She had been detained
under the Mental Health Act and was awaiting a specialist placement at the time of
her death. I  note that the inquest concluded that Amanda's death was as a result of
hypoxic brain injury,
Following the conclusion of the inquest, I  note that you now raise concerns in your
report regarding the fact that you have been advised that there is no central register
of providers who offer specialist placements for individuals diagnosed with Asperger's
Syndrome and other mental health issues, and you enquire as to whether such a
register has been considered. Specifically, you noted the difficulties that had been
encountered in  trying  to identify a suitable  placement for Amanda, and question
whether a register could eliminate this.
In response to your report I  can confirm that 'The Care Quality Commission' monitor,
inspect and regulate services that provide health and social care; and a list of the
services they regulate, including those that specialise in autistic spectrum conditions,
can  be found  on  their  website (https://www.cc~c.orq,uk/what-we-do/services-we-
re~ulate/services-we-re  qu.late).
must advise however that a central register does not exist within the NHS and the
closest comparison is this CQC list. Ultimately a central register is not workable as
there will always be 'a need for an individual assessment and dialogue with providers

Health and high quality care for all, now and for future generations

 on a case by case basis, to find the best match to meet a patient's specific needs, This
dialogue with providers based on local intelligence and the working knowledge of the
professionals involved is essential to place patients in the appropriate environment.
As such for individuals with more specific needs, such as Amanda,'services need to
be chosen based on an individual assessment of that person's individualistic needs.
To this regard I  can confirm that in October 2015 NHS England published its Care and
Treatment Review (CTR) policy and guidelines which were developed as part of a
commitment to improving the care of people with learning disabilities in England, and
its aims to reduce inappropriate admissions, and unnecessarily lengthy. stays in
learning disability and mental health hospitals.
CTR meetings review  whether a person  is  receiving  the appropriate care and
treatment and make recommendations for future care and treatment.  CTRs are
designed to ensure the voice of the person and their family are listened to, and they
are chaired by the responsible commissioner with external input from appropriate
clinical experts.  CTRs can happen in the community when someone is at risk of
admission to a learning disability or mental health hospital, or they happen once
someone is admitted to a learning disability or mental health hospital.
The CTR policy introduced key changes in March 2017, and one of these was an
emphasis that CTRs and Care Education Treatment Reviews (CETRs) are for people
of all ages with a learning disability, autism or both. This means that autistic people
of all ages, with or without an additional learning disability, should now receive a
CTR/CETR if they are either at risk of admission to or are living in a learning disability
or mental health hospital; and should be included on the Assuring Transformation (AT)
database and local dynamic support registers. Being on the AT database triggers the
need for the CTR and CETR arrangements to be followed. The local dynamic support
register should be used to alert when a person may be deteriorating or in crisis and
therefore need additional care and support in an effort to avoid admission. CTRs or
CETRs for autistic people contain autism specific key lines of enquiry, and the experts
used within  the  meeting should  be chosen  based on them  having  appropriate
knowledge and skills to understand the needs of the individual.  Although these
changes took place following Amanda's death, they will  no doubt go a long way
towards ensuring that the care and treatment needs of autistic people will be better
understood and addressed in the future. The CTR and CETR processes mean that
there is a multidisciplinary team approach to determining what is the best next step in
a patient's care, possibly avoiding admission, or where admission is unavoidable,
helping to ensure that the most appropriate placement is identified.
In addition, in  January 2019 NHS England published its `Long-Term Plan', which
highlights autism as one of its key priorities for the next ten years,  The Long-Term
Plan identifies the following areas of focus for autistic people:

• A commitment to reduce waiting times for autism diagnosis.
• Children and young people in special and residential schools will be given better
• Children and young people with the most complex needs will have a keyworker

access to hearing, sight and dental checks.

to help coordinate the support they get.

Health and high quality care for all, now and for future generations

 • Investment in specialist community teams to help support children and young

people with autism and their families.

• Piloting of annual health checks and flagging of reasonable adjustments on

health records.

• The use of more Personal Health Budgets to give people more choice and

control over how they are supported.

• The Care (Education) and Treatment Review programme will continue.
• The `STOMP': Stopping the over-medication of people with a learning disability,
autism or both, and `STOMP-STAMP': Supporting Treatment and Appropriate
Medication in Paediatrics programmes will continue.
• Local service providers will be given more control of budgets for people who
are in inpatient care, or who are at risk of it to help them spend the money on
support in the community, make stays in inpatient services shorter and stop out
of area placements.
• More money will be given to crisis and forensic services for those at risk, of
• There will be work with the wider NHS to improve .understanding of autism.
hope the information above addresses the concerns you have raised within your
report and provides you with the assurances that within the NHS we are continuing to
work towards improving access to mental health services, including the care and
treatment of people with autism. If you .require any further information, please do not
hesitate to contact me.

admission to inpatient services, or who have committed a crime.

Yours sincerely

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Professor Stephen Powis
National Medical Director
NHS England and NHS Improvement

Health and high quality care for all, now and for future generations

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Leicestershire Partnership 
NHS Trust 

A  University Teaching Trust 
Corporate Affairs 
Room 170, Penn Lloyd Building 
County Hall 
Leicester 
LE3 8TH 

8th March 2019 

Lydia Brown 
Assistant Coroner 
Leicester City and  South Leicestershire 
The Town Hall 
Town Hall Square 
Leicester LE1  9BG 

Dear Mrs Brown 

Re:  A  Briley 

Further  to  your  report  dated  11  January  2019,  in  accordance  with  paragraph  7, 
Schedule 5  of the Coroners and  Justice Act 2009  and  Regulations 28 and  29 of the 
coroners (Investigations) Regulations 2013,  I offer the following  response. 

We  have  investigated  the  matters  of concern  that  have  arisen  during  the  course  of 
the  inquest  of Amanda  Briley.  Leicestershire  Partnership  NHS  Trust  takes  these 
matters very seriously and I hope that you and Ms Briley's family will  be satisfied that 
we have taken  the appropriate measures to  prevent such  an  occurrence  happening 
again. 

The matters of concern you have raised are as follows : 

1. 

/ am concerned that too many Leicestershire Partnership Trust employees do 
not have any or any sufficient training in autistic spectrum disorders. This Jack 
of knowledge makes a difficult situation considerably worse for any presenting 
patient, with potentially dangerous consequences. I was not reassured that 
training is given at the earliest possible opportunity to reduce these risks, or 
that all appropriate staff are receiving or accessing training to a suitable 
standard.  In this case even when it was acknowledged that Amanda would 
remain an in patient for some time, front line staff including her named nurse 
and the ward matron were ill-equipped to understand-her communication needs 
and care requirements.  I ask for LPT to review and reconsider the current 
training planning in this area. 

Leicestershire Partnership NHS Trust is a smoke-free Trust. 
Please visit www.leicspart.nhs.uk/smokefree for details 

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 Response 

,  Head of Nµrsing and 

,  Director for Adult 

Mental Health and Learning Disability Services have reviewed the Trust training 
provision. The Trust introduced an e-learning Autism Awareness module in 
November 2017 which is accessible to all staff. A  recommendation went to the Trust 
Learning and Development Group in February 2018 that this training becomes role 
essential for clinical staff in AMH/LD Services; this was agreed and will be finalised 
at the Trust's Strategic Workforce Group in  March 2019. 

In  March 2018 a Recognising and Caring for People with Autistic Spectrum 
Disorders (ASD) practical workshop took place involving a range of professionals 
with experience of working with people with autism, 
 a Speech and 
Language Therapists (SL T) Assistant,  and Consultants from the Autism Diagnostic 
Service and Learning Disability Service. The Trust is currently looking at how to 
develop this training further for inpatient areas that will be working with patients with 
ASD in Mental Health Services. A training task and finish group has been set up with 
representatives from mental health wards,  learning disability serv,ices,  SLT and 
Occupational Therapy (OT) to develop a more in depth training product and this will 
be reporting  back to the Directorate Management Team in  April 2019. The group are 
considering how elements of Ms Briley's video interview with SLT can  be used to 
enhance either the existing e-learning module or further training. 

 and 

 met with Ms Briley's mum who is 

keen to support the training review.  They shared the e-learning module with  her and 
Mrs Briley felt that whilst this was a good basic awareness resource, and that it was 
important to ensure ward  staff in particular were equipped with the practical skills in 
how to apply the knowledge gained. She provided helpful insight and suggestions as 
to how the e-learning could be built on and is keen to support the development of the 
training. 

· 

In the interim the Directorate has identified some specialist mental health SL T 
resource. The individuals providing this support to the wards at the Bradgate Unit are 
skilled in .ASD diagnosis and  management. All in-patients with a diagnosis of ASD · 
will be referred to the SL T service to ensure the care plans reflect a bespoke and 
differentiated approach.  In  addition the SL Ts are looking at the best ways to support 
ward staff and are working with the OTs to develop a decision making flowchart. 
Again the feedback from Ms Briley's mum will inform this tool. 

2. 

The court was advised that it was "custom and practice" on bank holidays for 
the nursing staff to agree between themselves to ·have a shorter hand over 
and work an hour less.  This removed an important part of the expected staff 
communication and left a significant gap in the safe transfer of information,  on 
the days when senior staff are likely to be on leave and it was recognised that 
bank staff may be covering.  Furthermore,  patients on an acute mental health 
ward are likely to struggle emotionally on  these important social occasions 
when they are apart from family and familiarity.  The handover on such days 
should be more,  not less robust and I ask that the LPT conduct an urgent 
review and senior level scrutiny regarding this matter. 

Leicestershire Partnership NHS Trust is a smoke-free Trust. 
Please visit www.leicspart.nhs.uk/smokefree for details 

NHS organisations are now using 100 per cent recycled paper as part of our sustainability 

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EMPLOYER  -

 
 
 Response 

Ms Briley's inquest was just before the Christmas bank holiday period and  immediate 
action was taken by the Heads of Nursing across the Trust to ensure the working 
arrangements and expectations of staff around the handover of patient care was 
clear during this period. On the wards at the Bradgate Unit there is a senior nurse on 
duty as the.'Clinical Duty Manager' (COM) at all times (24 hours, 7 days a week). 
The COM visited wards over the Christmas and  New Year period to ensure 
handovers were taking place appropriately. 

In January 2019 the learning from Ms Briley's death and the inquest was discussed 
again at the Chief Nurse's meeting with  all Heads of Nursing and as a result the 
Trust's Handover Policy and documentation will be reviewed and a further 
programme of checking the handover on wards will be developed. In April 2019 the 
Mental Health and  Learning  Disability Wards will commence introducing Nerve 
Centre which  enables each staff member on  duty to carry a hand-held device 
allowing them immediate access to a set of patient information including the latest 
handover for that patient. Staff members can directly add  information about the 
patients care whilst with the patient, which then provides an automatic update to the 
central information for that patient held on Nerve Centre so all users can see any 
changes to care immediately. 

We hope this reassures you that we have taken appropriate action in response to 
your findings regarding training for staff around Autism, ensuring the handover at 
bank holidays periods is of the same standard as other times, and improved policies 
and support systems will provide safe and effective care in order to reduce the risk to 
our future patients. 

If I can be of any further assistance to you please do not hesitate to contact me. 

Yours sincerely 

Chief Executive 

Leicestershire Partnership NHS Trust is a smoke-free Trust. 
Please visit www.leicspart.nhs.uk/smokefree for details 

NHS organisations are now using 100 per cent recycled paper as part of our sustainability 

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EMPLOYER  -