Emma Butler

Oxford Health

NHS Foundation Trust

Chief Executive’s Office
Trust Headquarters

Private & Confidential Warneford Hospital
Warmeford Lane
Mr C G Butler Headington
HM Senior Coroner for Buckinghamshire Oxford
The Coroner’s Court OX3 75X
29 Windsor End
Beaconsfield Tel: 01865 902769
HP9 2JJ www.oxfordhealth.nhs.uk
19 June 2019

Dear Senior Coroner Butler,
Inquest into the death of Emma Butler

Thank you for your letter of 12 April 2019. | write to provide the response on behalf of Oxford
Health NHS Foundation Trust. The response follows the order in which you set out your
concerns.

1 set out your concerns as they appear in your letter.

1. Access to means of self-harm on the ward. Whilst evidence was given as to the difficulty
of reducing access to materials of self-harm without restricting fundamentally the rights
and activities of patients, it was clear that incidences of self-harm had, on occasions
related to the procuring of, concealment of and use of plastic cutlery available to patients
on Ruby for self-cutting. The process appears reliant upon voluntary surrender of such
items or on their being found rather than on the monitoring of the handing out and proper
return of all such items in the context of use at mealtimes. There is a risk of self-harm
within the patient cohort on Ruby Ward.

The Trust previously informed you that plastic cutlery is not issued during mealtimes, but
there are plastic spoons available at the beverage area on the ward. We acknowledged that
plastic spoons do break easily and are capable of being used for self-harm, but explained
that patients assessed as being at risk of serious (as opposed to more superficial) self-harm
using plastic spoons would either be placed on higher levels of observation, or, potentially,
would have their admission reviewed if it was seen to be leading to an increase in self-harm
behaviour, or to a change in the patient's usual method of self-harm.

The Trust does not consider that it is practically possible to monitor every plastic spoon on
the ward. The Trust is considering if plastic spoons can be replaced by an alternative
product that is more resistant to breakage. The Head of Nursing for Buckinghamshire is
working with the matrons to identify if there is alternative cutlery available that may be more
suitable for this patient group.

2. Access to means of self-harm from outside the ward. The processes for searching and
seizing potential self-harm material after return from unescorted leave did not prevent
items being brought in from the outside at risk to the particular patient, other patients and
staff and the evidence regarding the extent of strip or other searches from staff members
was variable. The risk of items being brought onto the ward from outside for use by that
patient or others remains where the system for searching and the nature and extent of
the search has not prevented the introduction of such items. The understanding of and
compliance with specific conditions of leave in the context of searches was unclear.

m7 in his evidence used the term “strip search”, but what [J intended by the term,
i.e, whether he intended to prescribe what a layperson would understand as a “strip search’,
was not explored in evidence. The use of the term does not reflect the Trust’s policy. We
agreed that the policy relating to the search of patients and their belongings ought to be
updated, and that it ought clearly to set out the hierarchy of searching based on the dynamic
assessed risk, as assessed by staff. There is clear instruction available to staff on ‘rub down’
searching, but no guidance on how to carry out a more extensive search, nor where training
could be accessed for the same. It was suggested that a review of the Searching of Patients
and their Belongings policy be undertaken. The policy is due before the Trust Quality
Committee Clinical Effectiveness Sub-Committee in September 2019. Your concern is
being fully explored as part of that review and, if required, revisions to the policy will be
implemented.

3. General observations. The process for conducting and recording hourly observations left
scope for significant variation on the actual time between and the manner in which such
observations of a particular patient were undertaken and recorded. There was an
indication that this would be reviewed but the risk remains of an incident of planned or
spontaneous self-harm occurring between observations for a patient not on a higher level
of observations.

| understand that Counsel for the family made the point during evidence that the way the
observations at the tine of Emma’s death appear to have been completed means a patient
could go much longer than an hour without being observed, and you have reiterated this
concern.

The concern is fully understood; however, | confirmed in his oral evidence that,
presently, on Ruby ward one member of staff is appointed each hour to check observations,
and that this should be done within 10-15 minutes of the hour starting. This avoids the risk
of a single patient not being observed hourly at the beginning of each hour.

The ‘Safe and Supportive Observations’ policy in place stated that:

“the minimum requirement for all in-patient clinical areas is that:

e At least hourly the allocated nurse should spend time on the ward
observing for changes in the mental state or behaviour of all clients
and being free to respond fo these.

e This observation should be recorded on the observation record
sheet and any significant interaction recorded in the patient's notes.

e tis not acceptable to observe the patient by torchlight through the
door in the window of a bedroom.”

The policy is currently undergoing a review. It was last discussed at the Clinical
Effectiveness Sub-Committee in April 2019. Your concerns are being considered as part of
that review. The revised policy will be presented to the Sub-committee on 48! July 2019 by
the Trust’s Deputy Director of Nursing for Mental Health.

| can also add that the issue of enhanced observations was the subject of a 2018/19 quality
improvement project completed by Oxford Healthcare improvement (OHI) in partnership
with one of our wards, the results of which were reported to our Quality Committee in May
2019. OHI trains and develops staff at the Trust in order to deliver better and safer care
through a programme of quality improvement projects, training and research. OHI works
with national and international organisations, universities, health and social care providers,
commissioners, the academic health science network, patient safety collaborative and
industrial partners. The outcome of the project was extremely encouraging and patients and
staff have reported very positive outcomes from new approaches to enhanced observations.
We will continue to work on this important area to make our observations policy and
practices the most effective and safe that they can be.

4, Urgent or emergency access to the ward phone. The concern remains that a patient on
unescorted leave outside the Centre who felt they were going to self-harm or who had
self-harmed may not get immediate access to support or assistance by calling the
specific ward number given to them. Whilst the evidence indicated the balance between
positive risk taking, unescorted leave and taking responsibility for decisions and actions,
the risk remains that the safety net is not sufficiently robust to ensure that if such a
potentially fatal incident occurs, or is likely to occur, a patient can self-alert the ward and
expect to receive an immediate response.

| understand that our (then) Ruby ward Modern Matron confirmed in evidence that it is
possible that the ward phone number given to patients will go unanswered at times, if a
patient on leave (or a relative) attempts to make contact; and that it is right that the focus of
ward staff on shift should be towards meeting the needs of patients who are physically
present on the ward. Although ward staff have a role in attempting to ensure the safety of

3

patients who are late returning from leave, those patients who are on leave unescorted are
out of the ward because an assessment has been made that they have both the capacity
and the capability to take responsibility for, and self-manage, their safety while off the
ward. It is recognised that for people with EUPD this frequently involves positive risk taking,
without which it is likely that they will deteriorate further in hospital.

One action that was discussed was to make it explicit within the leave documentation and
welcome pack that when patients are on leave it is possible that the ward phone may not be
answered, due to staff attending to the needs of patients on the ward: and to suggest to
patients going on leave that if they feel the need to speak to a member of staff, itis suggested
that they return to the ward, and speak with their allocated nurse. It should also underline
that the ward is not able to provide an immediate response to patients who are on leave and
that if patients require an urgent response whilst away from the ward they should contact
the emergency services.

The Head of Nursing for Mental Health Services in Buckinghamshire has taken responsibility
for the leave documentation and welcome pack to be reviewed. As you will appreciate, any
revised documentation would be used across all our wards and it is appropriate that views
are taken from colleagues across the Trust. Our aim is to complete the review over the
summer.

5. Planning for discharge. The evidence indicated the move towards and importance of
shorter periods of admission and planning for discharge into the community. However,
the process for keeping all aspects under review and communicating decision-making
within the team and with the patient was unclear. The potential lack of certainty and
structure into ongoing assessment of risk, leave decisions and monitoring of medication
effectiveness is of continuing concern in relation to the management of the risks and
behaviour of a patient with personality disorder progressing towards discharge.

The Trust has implemented significant changes since 2017 on Ruby ward in relation to the
care of patients with a diagnosis of EUPD. The changes help to provide effective means by
which clinical staff can keep under review planning for a patient's discharge into the
community, ongoing assessment of risk, leave decisions and monitoring of medication
effectiveness. The changes include:

* In line with NICE guidance, the policy is for wards and community teams to work
with the patient and their family to try to support the management of crisis in the
community. It is recognised that lengthy hospital stays may harm patients with
EUPD, and that admissions should be kept short, ideally no more than seven days.

¢ tis recognised that admission to hospital may contribute to an escalation of risk-
behaviours and therefore a deterioration in a patient's presentation. These issues
are discussed with patients and their families in weekly ward reviews, where the
benefits and risks of continued admission are explored and decisions made with
patients.

e We recognise that working with patients who are at chronic high risk is complex
and requires clear communication and good team discussion. There is now a
regular system of case discussion groups and reflective practice groups, run by
psychotherapists from the Complex Needs Service (personality disorder service).
This gives the clinical team time to have thorough discussions about complex
patients, reducing the chances of boundary shifts and ensuring there is
consistency in the way staff work with patients.

e There are MDT handovers every morning.
e There is more access to psychological therapies.

e The ward recognises that the patients on the ward regularly interact with each
other, which can often be helpful but sometimes (and in particular with peopie with
an EUPD diagnosis) can increase risk behaviours. This is a factor that the ward
considers very carefully when considering a patient for admission and, when
necessary, limits the admissions of patients with EUPD.

e We-continue to work with the clinical team on the ward to establish other measures
we can put in place for monitoring and review of a patient with EUPD if they are
admitted to the ward for a longer period of time.

Thank you for bringing your concerms to my attention. | hope that my letter provides you with
the assurance that you require.

“La

Yours sincerely

Stuart Bell
Chief Executive