Stephen Harte

Roisin Fallon-Williams 
Chief Executive Officer 
Trust Headquarters, B1 
50 Summer Hill Road 
Brimingham  B1 3RB 

Mr James Bennett 
Assistant Coroner, Birmingham and Solihull 
Birmingham Coroner’s Court 
50 Newton Street 
Birmingham 
B4 6NE 

26 September 2019 

Dear Mr Bennett,  

REGULATION 28 PREVENTION OF FUTURE DEATH REPORT – STEPHEN HARTE DECEASED 
On 4 September 2018 you commenced an investigation into the death of Stephen Keith Harte. The 
investigation concluded at the end of an Inquest with a jury on 13th February 2019. The jury’s 
conclusion was the death was Drug Related.  At 4.33hrs on 18 August 2018 Stephen Harte was found 
unresponsive in his room at the Tamarind Centre (a medium secure mental health unit). Despite 
emergency medical treatment he could not be resuscitated, and he was pronounced deceased at the 
scene. A post-mortem blood test revealed he had taken a recognised fatal dose of heroin. Mr Harte 
had a long history of illicit drug use but appeared to have been abstinent since 2016. 
During the course of the inquest the evidence revealed matters giving rise to concern as follows:- 

1) The potential routes for drugs to enter the medium secure unit. This included: 

(a) Residents are allowed unsupervised telephone calls to order food from external ‘takeaways’ of 
their choice and the food is not searched upon arrival. Historically, residents were only allowed to 
order from an approved list of ‘takeaways’. However, following a Care Quality Commission inspection 
the CQC deemed this was too restrictive and asked that the unit relax its rules. The evidence was 
unclear whether the CQC had similarly asked other units to relax their rules. 

Following the CQC inspection of Birmingham and Solihull Mental Health NHS Foundation Trust in 
March 2017, the Trust received notification from the CQC that it was in breach of regulation 13 due to 
the restrictions that it had in place for service users to select takeaway food from establishments with a 
hygiene rating of 4 and above. This was considered to be a ‘blanket restriction’. The CQC stated in 
their report ‘The trust had taken a blanket approach to searches and ordering of food from take away 
restaurants. The decisions made at board level in relation to the restrictions did not take account of 
individual risk assessment or patient choice’. The Trust was required to remove this restriction and 
service users now have the ability to order takeaway food from any establishment of their choice.  We 
note that this regulation 28 report has been issued to the CQC and await their response to you on this 
matter.  

Chair: Sue Davis, CBE 

        Chief Executive: Roisin Fallon-Williams 

Customer Relations   Mon – Fri, 8am – 8pm   Tel: 0800 953 0045   Text: 07985 883 509      
Email: bsmhft.customerrelations@nhs.net    Website: www.bsmhft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 (b) Those residents allowed unsupervised leave are not typically searched upon their return. They 
walk though a scanner, but this is unlikely to reveal small quantities of drugs on their person. 

The Trust Policy on the searching of service users in our secure care inpatient wards states that a 
search will be conducted on all service users returning from unescorted leave.  This is in addition to 
service users walking through the scanner. We recognise that service users may at times secrete 
drugs in body cavities and that our regular search approach may not identify these. In addition to this, 
we have therefore implemented a wide range of additional controls to detect any drugs entering the 
unit. These include:- 

  A full urine drug screen across site if there is any suspicion that drugs are on the unit 
  Random environmental searches ie room/ ward searches are conducted on the wards again based 
on intelligence, positive responses from the drug dog or just ward based regular random searches  

  Service users have at least one random monthly drug screen, but may vary dependent on 

individualised risk and care plans  

  The drug dog attends fortnightly.  We are working closely with our local police liaison officer to see 

whether we can use their police dogs on the premises in addition to our regular search dog  
  Random change of clothes search following service users returning from unescorted community 

leave if particular concerns are noted about individualised patients 

Increased security on site including the perimeter of the grounds of our inpatient unit 

  Testing of the waste water supply to try to detect whether substances are potentially in the unit.   
 
  The purchase of an amnesty box specifically for drugs. This idea came from a presentation at the 
Physical Health link workers day, from a gentleman from City Hospital who spoke about how an 
A&E department trialled it and it was successful 
Implementation of a monthly substance misuse meeting 

 

In addition to the above, we now have a substance use strategy in place in our secure care services. 
The substance use programme in the BSMHFT secure services is a multidisciplinary and multisite 
programme. It supports the patients throughout their care pathway.  The programme operates on 
principles of harm minimisation. The intervention starts before admission to the units, at time of 
assessment. 

a)  Assessment :  
1)   There are specific parts in the admission assessment documentations dealing with the substance 
use. This helps to identify the immediate needs and identifies patients in need of more detailed 
substance use assessment. 

2)   Every eligible patient will have an initial substance use assessment completed post admission.  
3)  Where a need is identified a comprehensive assessment will be undertaken by the specialist 

members of substance use programme. 

4)   In addition substance use issues are identified as part of risk reduction work, mental illness work 

and physical health assessments.  

b)  Treatment  
1)  The treatment starts as early as possible and is directed through the care plans. Treatment is 

delivered through CBIT model. Based on the needs group as well as individual treatments being 
available. The treatments are delivered by professionals trained in CBIT. The groups run in two 
phases- phase 1 is focussed on psychoeducation and phase 2 on relapse prevention.  

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 2)  Random and regular drug screening is available. We use oral fluid or urine samples. The samples 
are tested using state of art machines and can test more than a 1000 substances depending on 
needs and suspicions. 

3)  In addition to staff delivered interventions, every patient will be offered peer delivered interventions 

through a 12 step NA programme that is run within the hospitals. 

4)  Individual patients will have needs based pharmacological interventions. 
5)  Substance use treatment is delivered as part of risk reduction work where necessary. 
6)  Relapse prevention work is also available in the community on 1-1 basis.  

c)  Education:  
1)  An educational programme relating to substance use runs regularly including 2 day training 

sessions for clinical staff at all levels (level 2) and supplementary ward based training sessions.  
2)  Supervision is on offer for nursing staff members on the ward and other members of the substance 

use programme.  

3)  Patient education through the CBIT level 1 and key worker sessions is available.  
4)  The no abstinence (NA) education programme has developed a specific poster highlighting the 
risks of opiate use after a period of abstinence The NA programme serves to improve patient 
education from peers and other ex users.  

5)  Bespoke training programmes are available around specific substance use issues.  

d)  Resources:  
1)  Currently the substance use programme has two dedicated band 7 nurses and two dedicated band 
5 substance use practitioners. The programme is led by a consultant forensic psychiatrist and 
supported in advisory and development capacity by a psychologist, an occupational therapist, a 
senior nurse and a pharmacist. Every ward has a minimum of one identified substance use lead.  

2)  Specific guidelines are developed and regularly updated on various aspects of substance use.  

Reduction in risk of deaths by a drug overdose strategy 

A separate strategy is in development around reduction of harm from drug overdose. This strategy 
development process predates the incident leading to Mr Harte’s death.  

1)  The first step was development of patient and staff information leaflets about the risk of opiate use 
after a period of abstinence. The leaflet was co produced by the substance use lead and a patient. 
The leaflet has been available in the Trust since the Summer of 2018.  

2)  One of the significant outcomes has been the development of a very comprehensive risk 

assessment tool to identify patients all high risk of drug overdose.  

3)  The proposed strategy  for reducing the clinical risk of overdose at high risk times for example 
during external leave and discharge, includes identification of high risk individuals early in the 
admission, administration of a specifically developed risk assessment for suitable patients, offering 
targeted educational sessions to the identified individuals, consideration of starting the patients on 
opiate replacement in patients where the risk of opiate use continues to be high. The strategy is 
also considering making available naloxone to patients to reduce risk of death on discharge.   

The strategy is yet to be finalised, however it is anticipated that this will be approved and in place 
from January 2020.   

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 3) I also heard evidence that staff are not typically searched upon entering the unit. They also walk 
thought the scanner, but this is unlikely to reveal small quantities of drugs on their person. Further, 
whilst they are required to leave personal belongings in lockers, they are allowed to take their own 
food on to the unit which is also not searched. 

Our current arrangement within our inpatient facilities is that staff are not typically searched upon 
entering the unit and that this would only occur if we had clear grounds for concern that particular staff 
members were facilitating access to drugs on the unit. We do however have the drug dog  which visits 
our secure care and acute care wards and would detect any traces of drugs or illicit substances on 
members of staff.  

It may be of interest to note that since April 2019, there has been one incident of illicit substances 
being detected within our secure care ward environments, in comparison to a total of 9 incidents 
during the previous six months. We continue to monitor the impact of our approach to minimise the 
risk of drugs entering the unit. We hope that the additional controls that we describe above will 
continue to have a sustained impact on safety within our secure care inpatient wards and would like to 
take this opportunity to both thank you for bringing this to our attention and to express our sincere 
condolences once again to the family of Mr Harte.  

Yours sincerely 

Roisin Fallon-Williams 
Chief Executive Officer 

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For the attention of  
James Bennett 
Assistant Coroner 
Birmingham and Solihull 
03/10/2019 

Dear Mr Bennett 

Care Quality 
Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 
616161 
Fax: 03000 616171 

Re: Stephen Keith Harte (deceased) Regulation 28 report to prevent future 
deaths:  

Thank you for bringing to our attention your concerns regarding the death of Mr 
Stephen Keith Harte. May I apologise for not responding on time to your previous 
request to the Regulation 28 notice we received.  
Matters of concern: 

  Residents are allowed unsupervised telephone calls to order food from 

external ‘takeaways’ of their choice and the food is not searched upon arrival. 
Historically, residents were only allowed to order from an approved list of 
‘takeaways’. However, following a Care Quality Commission inspection the 
CQC deemed this was too restrictive and asked that the unit relax its rules. 
The evidence was unclear whether the CQC had similarly asked other units to 
relax their rules. 

  Those residents allowed unsupervised leave are not typically searched upon 
their return. They walk through a scanner, but this is unlikely to reveal small 
quantities of drugs on their person. 

  The author of Birmingham and Solihull Mental Health Foundation NHS Trust’s 
Root Cause Analysis report gave evidence that in his opinion these two routes 
were the most likely mechanism by which Stephen Harte obtained the drugs 
that killed him, and that the rules around ‘takeaways’ needed revisiting. 
I also heard evidence that staff are not typically searched upon entering the 
unit. They also walk thought the scanner, but this is unlikely to reveal small 
quantities of drugs on their person. Further, whilst they are required to leave 
personal belongings in lockers, they are allowed to take their own food on to 
the unit which is also not searched. 

 

  My ongoing concern is that drugs can too easily enter the unit. 

The Care Quality Commission commenced a comprehensive inspection of 
Birmingham and Solihull Mental Health Foundation NHS trust 27th - 31st March 2017 
and published the reports 2nd August 2017.  
At that inspection we found the trust had implemented blanket restrictions with 
regards to the ordering of food from takeaways and in relation to patient searches. 
We informed the trust that it was appropriate for them to provide patients with 
information on hygiene ratings and to explain the benefits. However, patients with 
mental capacity had the right to order takeaways from the shop of their choice, and 
the policy did not promote an individualised approach to patient’s choice or risk. We 

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 informed the trust in our report that the decision of the trust board in relation to 
searches and ordering of food from take away restaurants did not take account of 
individual risk assessment or patient choice. 

Because of our findings we told the trust that they must ensure that it undertakes 
active individual assessment of risks posed by patients returning from leave. We told 
the trust that they should review practice of not allowing patients to buy food from a 
takeaway shop of their choice.  

We found that the blanket restrictions imposed on patients was a breach of 
Regulation 13 HSCA (RA) Regulation 2014 Safeguarding service users from abuse 
and improper treatment. A requirement notice was placed on the trust for them to 
address the breach of Regulation 13. 

The Care Quality Commission did not ask the trust to relax its rules in relation to 
takeaways but as stated above the trust was asked to review its practice of not 
allowing patients to buy food from a takeaway shop of their choice if they had 
capacity to make that decision. In the case of other health providers who had similar 
blanket restrictions the Care Quality Commission would ask them to consider those 
restrictions in relation to people’s capacity to make their own informed decision or 
where the organisations mental health assessment shows there is a risk to that 
patient. 

The Care Quality Commission did tell the trust that it must ensure that active and 
individual assessment of risks posed to patients who return from leave and use this 
to base decision on searches. The trust carried out a comprehensive review of its 
search policy and implemented a security policy and a new search policy in response 
to our requirement notice. During our inspections we do not review the searching of 
staff entering units although for some services we would review the security 
arrangement. Any decisions to search staff would be a decision taken by each 
individual organisation. The Care Quality Commission would review what action an 
organisation was taking if they informed us they had a problem of drugs entering their 
units and would comment on the issue within our reports.  

We visited the trust in November and December 2018 and carried out a comprehensive 
inspection as part of our regular inspection programme. At that inspection we found the 
trust had reviewed and implemented a new search and security policy based on risk 
assessment. We did not find any breaches related to blanket restrictions.  

I hope this response helps to address your concerns. However, if you require any 
further information please do not hesitate to contact me. 

Yours sincerely 

Head of Hospital Inspection 
Hospitals Directorate 
Care Quality Commission 

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