Anthony Walker

Official 

Coroner’s Office Team Leader  
Portsmouth & South East Hampshire 
The Coroner’s Court 
1 Guildhall Square 
Portsmouth 
PO1 2GJ 

10 June 2018 

Dear Steven 

,  

Head of Approved Premises SWSC 
National Probation Service 
South West South Central Division 
3-5 Barnfield Road 
Exeter EX1 1RD 

01392 455416 (Direct) 
01392 421122 (Switchboard) 

Re: Anthony Charles Walker, Regulation 28 recommendations 

Following the Coroner’s Inquest into the death of the above named at The Grange Approved Premises, 
Purbrook, Hants the Regulation 28 recommendations below were made. The National Probation Service 
response, provided by 

, Head of SWSC Approved Premises, is also below. 

1.  I heard evidence that there was no liaison between Mr Walker’s Keyworker at The Grange and 
local Mental Health Services which were not therefore involved in Mr Walker’s care. I believe 
such liaison and advice to Probation hostel staff could help prevent future deaths. 

NPS response – During the time Mr Walker was resident at The Grange Approved Premises he was not 
actively engaged with or receiving treatment from the Local Community Mental Health Service. He did, 
however, seek support from his GP and the Crisis Support Team at the local hospital, both assisted and 
facilitated by staff at the Approved Premises.  

There is no formal arrangement in place between Approved Premises and local Community Mental 
Health Services, and staff have no mechanism for undertaking enhanced referrals to such services. In 
addition, due to medical confidentiality, such services will not provide information to Probation staff 
without the explicit consent of the individual resident. 

All residents arriving at Approved Premises are asked to sign a medical consent form to facilitate liaison 
between the National Probation Service and other agencies, and are expected to liaise as required when 
aware that any resident is engaged with such services. In the case of Mr Walker this did not happen. 

In terms of future action, I will be issuing the following instructions to all Approved Premises across the 
SWSC Division. 

  All new residents will be asked and encouraged to sign the necessary consent forms 
  All Approved Premises will seek to identify a Single Point of Contact (SPOC) at the local 

Community Mental Health Team to enhance liaison opportunities 

  Staff will be reminded of the importance of liaison with other agencies involved in the care of 

residents 

  Staff will be reminded to support and facilitate referral to appropriate agencies who can assist in 

the care and management of residents 

  Please also see the National Self-Inflicted Harm/Deaths actions outlined below 

  
 
 
 
 
 
 
 
 
 
 
 Official 

2.  I also heard evidence that there was no signposting for staff at The Grange to local Mental Health 

Services and other agencies that could have assisted with Mr Walker’s Care. I believe staff 
should have such information readily available to them at all times. 

NPS response – Although staff were instrumental in facilitating Mr Walker attending appointments with 
both his GP and the Crisis Team at the local hospital it is accepted that no pro-active signposting 
occurred. The highlighted actions required by the National Reducing Self-Inflicted Harm/Deaths Action 
Plan implemented in late 2018 address this recommendation. 

The NPS has now produced a National Reducing Self-Inflicted Harm/Deaths Action Plan requiring that 
all Approved Premises must: 

  Ensure staff attend Ligature Training and that ligature knives are available 
  Ensure staff attend Self Inflicted Harm/Deaths training 
  Ensure staff attend a one day First-Aid training and refresh every 3 years 
  Ensure all Approved Premises are linked in with their Local Authority Suicide Prevention Action 

Plans 

  Ensure that Approved Premises staff are communicating with Offender Managers effectively with 

regards to risk to self information 

  Ensure that there are processes and procedures in place to ensure that risk to self concerns are 

communicated to all Approved Premises staff 

  Approved Premises have in place a national process for identifying, assessing, monitoring and 

managing residents who may pose a risk to self 

  Ensure residents are supported to register with the local Approved Premises GP (on a full time or 
temporary basis) within a week of arrival and that all residents are encouraged to sign a consent 
for staff to contact GP if necessary and a record made of this. 

  Ensure that resident notice boards contain relevant information on suicide prevention, CMHT 
contact details, Samaritans and to provide Samaritans support cards in the induction pack 
provided to residents, during crisis and on leaving the Approved Premise. 

  Ensure Nominated Approved Premises Manager/Area Manager attends and contributes to 

 

Divisional Suicide Prevention Forum 
Implement and develop the role of local Suicide Prevention Champions within Approved 
Premises to include a Divisional Champions Network. 

  Ensure suicide prevention is a standing agenda item at Approved Premises team meetings, 

cluster Approved Premises meetings, Approved Premises manager and Area Manager meetings, 
and that emotional wellbeing is covered in Approved Premises residents’ meetings 

  Every Approved Premise has a distraction box which residents can access at times of crisis or 

difficulty 

  Each Approved Premise has a collated file of local support available for staff to access and 

provide to residents 

This plan is currently being implemented across all SWSC Approved Premises and should address not 
only the Regulation 28 recommendations but also the many of the wider issues associated with risks 
related to self-inflicted harm and deaths. 

I trust this provides a satisfactory response to the recommendations, and the reassurance sought by the 
Coroner, however, if any further detail or information is required please no not hesitate to contact me. 

Yours sincerely,  

Head of Approved Premises 

2

INHS

Portsmouth Hospitals
NHS Trust

Trust Headquarters

F Level, Queen Alexandra Hospital
Southwick Hill Road

Cosham

PORTSMOUTH, PO6 3LY

Tel: 023 9228 6877

Mark Cubbon
Chief Executive

Mr D Horsley

HM Coroner for Portsmouth & South East Hampshire
The Coroner's Court

1 Guildhall Square

Portsmouth PO1 2GJ

01 July 2019

Our Ref: MC/JH/Q131/18

Dear Mr Horsley

Regulation 28: Report to Prevent Future Deaths, concerns arising out of evidence heard at
the Inquest into the death of Anthony Walker

Following the inquest into the death of Anthony Walker, which was concluded on 29" April, you
issued a regulation 28 report addressed to several public bodies, including Portsmouth Hospitals
NHS Trust (PHT), asking them to respond to a list of 3 concerns.

Of those concerns, the following required action from PHT:

“3. | was told in evidence that the contents of 111 emergency calls to South Central Ambulance
Service involving callers’ mental health issues are not made available to the Accident and
Emergency Department at Queen Alexandra Hospital, Portsmouth. | believe making this
information available to the Accident and Emergency Department may help reduce the risk of
suicide/ self-harm to patients attending the department in consequence of such calls.”

In response to the regulation 28 report, | can report that senior representatives from the
Emergency Department at PHT have met with senior representatives from SCAS to discuss the
feasibility of introducing a process to enable 111 calls to be made available for clinical staff in the
Emergency Department (ED) to access in “real time”. It was agreed that such a process would not
currently be feasible for technical and resource reasons; however this is something that the 2
organisations will continue to discuss.

Since Mr Walker's death there have been changes within the SCAS Emergency Operations Centre
in Otterbourne. | understand that a Mental Health Team (MHT) from Southern Health Foundation
Trust is now hosted within the Ops Centre on a 24 hours a day, 7 days a week basis. As |
understand it, patients who are identified by 111 callers as being at high risk of suicide or self—
harm are referred onward to the MHT in the Ops Centre. It is possible that the SCAS hosted MHT
may occasionally consider it appropriate to advise those patients to attend ED, because they also
have a physical health need, and PHT are putting in place a process with SCAS to ensure that the
MHT team have direct telephone access to a Consultant in ED to give them advanced notice of the
attendance.

1
Chair: Melloney Poole OBE Chief Executive: Mark Cubbon
Portsmouth Hospitals NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY
Registered charity number: 1047986

| do hope this response addresses your concern, but please do not hesitate to contact me if you
require further information, or if there is any other way in which | can assist.

Yours sincerely

0X

Mark Cubbon
Chief Executive

2
Chair: Meltoney Poole OBE Chief Executive: Mark Cubbon
Portsmouth Hospitals NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY
Registered charity number: 1047986

PRIVATE AND CONFIDENTIAL 

Mr David Horsley 
Senior Coroner for Portsmouth and South East Hampshire, 
1 Guildhall Square,  
Civic Offices, 
Portsmouth,  
Hampshire,  
PO1 2GJ 

Northern House, 
 7 - 8 Talisman Business Centre, 
 Talisman Road, 
 Bicester, 
 Oxfordshire, 
 OX26 6HR 
Tel: 01869 365 000 

20th June 2019 

Dear Mr Horsley 

Re: Inquest Touching on the Death of Anthony Charles Walker 

Thank you for your report dated 14th May 2019 and for giving SCAS the opportunity to 
work with Portsmouth Hospital NHS Trust (PHT) regarding your concern. 

To confirm, your concerns relate to callers to our 111 service who are in a mental health 
crisis. You were concerned that the 111 reports were not currently made available to the 
Emergency  Department  at  Queen  Alexandra  Hospital  (QAH),  Portsmouth.  SCAS  met 
with Senior Emergency Departement Consultants and Jacqueline Haines, Head of Legal 
Services, for PHT earlier this month to discuss the matter.  

SCAS  already  has  the  technology  available  to  send  a  copy  of  the  111  report  to  the 
Emergency Department  at  Queen Alexandra Hospital.  The  report could be sent  to  the 
Emergency  Department’s  Reception  Team  via  the  nhs.net  secure  email  service  at  the 
end of the 111 call. Our meeting therefore discussed how feasible it would be for these 
reports to be read and stored by the Emergency Department Team; particularly when a 
patient record will not be created on their system until the patient arrives with them. 

Since  Mr  Walker’s  death  in  November  2017,  there  have  been  changes  within  our 
Emergency Operations Centre in Otterbourne. We now host Mental Health Nurses from 
Southern Health Foundation Trust within our call centre 24 hours a day, 7 days a week. 
This  is  on  a  long-term  trial  basis  until  December  2019  and  is  funded  by  our  local 
Commissioners, Hampshire County Council and the Police and Crime Commissioner. It 
is  sensible  for  callers  to  be  assessed  by  this  service  first  so  they  can  assess  whether 
attendance at the Emergency Department is necessary. PHT will now liaise with 

 from Southern Health to discuss how information regarding their assessment of 
patients  identified  as  being  at  high  risk  of  suicide  or  self-harm  will  be  identified  and 

Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 referred to Queen Alexandra Hospital to close the information loop. Should this service 
cease in December 2019, SCAS will work with PHT again to address the concerns you 
have raised.  

I hope this response has addressed your concern but please do come back to me if I can 
assist you further 

Yours sincerely  

Will Hancock 
Chief Executive 
South Central Ambulance Service  

Registered Headquarters: 7 and 8 Talisman Business Centre, Talisman Road, Bicester 0X26 6HR