Sasha Forster

Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This from is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1. Chief Executive, Surrey and Borders Partnership NHS Foundation Trust
2. Chief Executive, Hampshire Clinical Commissioning Group Partnership
3. Joint Accountable Officer, NHS Guildford and Waverley Clinical Commissioning
Group, NHS North West Surrey Clinical Commissioning Group and NHS Surrey
Downs Clinical Commissioning Group

4. Chief Executive, Frimley Health NHS Foundation Trust
5. Chief Executive, Royal Surrey County Hospital NHS Foundation Trust
6. Chief Executive, Ashford and St. Peter’s Hospitals NHS Foundation Trust
7. Chief Executive, Epsom and St. Helier University Hospitals NHS Trust
8. Chief Constable, Surrey Police
9. Chief Constable, Hampshire Constabulary
10. The Rt. Hon. Matt Hancock MP, Secretary of State for Health and Social Care

1 CORONER

I am David REID, HM Assistant Coroner for the coroner area of Central Hampshire.

2 CORONER’S LEGAL POWERS

I 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 07/04/2017 00:00 I commenced an investigation into the death of Sasha Sabrina FORSTER
aged 20. The investigation concluded at the end of the inquest on 23 May 2019. The conclusion of
the inquest was that Sasha died as the result of suicide, following her deliberate ingestion of a fatal
overdose of Propranol tablets.

4 CIRCUMSTANCES OF THE DEATH

(1) Sasha was a young woman who had struggled for many years with a number of mental health
disorders, and had been under the care of mental health services since early adolescence. Her
diagnoses were:
(i)
(ii)
(iii)

severe Obsessive Compulsive Disorder;
complex Post Traumatic Stress Disorder;
Autistic Spectrum Disorder ( although the results of the assessment which confirmed
this diagnosis were not available until after Sasha’s death );
traits of Emotionally Unstable Personality Disorder ( although this was strongly
disputed by Sasha and her family )

(iv)

(2) Sasha had a lengthy history of self-harm, both through cutting herself and through taking

deliberate overdoses of paracetamol. More recently, she had taken a number of overdoses of
Propranolol ( a drug which she had managed to source despite it not being prescribed to her,
and which in overdose carried a significant risk of death ); one such overdose in January 2017
had resulted in her suffering a near-fatal cardiac arrest.

(3) Sasha’s OCD meant that she remained at risk even when detained in hospital under the

Mental Health Act 1983. This is because she felt compelled to refuse food or drink provided to
her, and any resulting application of restraint to ensure forced feeding/hydration would prove
extremely distressing and potentially damaging. As a result, Sasha having been detained
under s.3 MHA 1983 following the near-fatal overdose in January 2017, those treating her
sought to balance the risks she presented by granting her regular periods of s.17 leave, initially

 to allow her to leave the hospital ward for a fixed period of time so that she could buy her own
food and drink, and latterly to allow her to stay overnight at home in an environment which she
found less distressing, this being conditional on her returning to the ward at agreed times.
(4) On occasions, however, Sasha’s behaviour whilst away from the ward on s.17 leave prompted
her responsible clinician to revoke that s.17 leave, and require her to return to the ward. In
those circumstances, legal responsibility for ensuring Sasha’s prompt return to the ward lay
with Surrey and Borders Partnership NHS Foundation Trust ( SBP ). Whilst SBP could ask the
police to assist in doing this, the police were not legally obliged to do so, and often would
decline such requests.

(5) On such occasions, SBP did not generally arrange for authorised persons to collect Sasha and
return her to the ward, but would instead seek to rely on her mother returning her and, in order
to secure Sasha’s agreement to this course, would agree not to insist on her immediate return.
Sometimes, this would involve allowing Sasha to go home overnight and be brought to the
ward the next day.

(6) On occasions during such “negotiated extension” periods, Sasha would continue to self-harm

( both through cutting and taking overdoses ) or go missing from home, and therefore could not
be returned to the ward as agreed.

(7) Throughout the time during which she was granted s.17 leave, Sasha attended a number of
different hospital Emergency Departments ( including the Royal Surrey County Hospital,
Frimley Park Hospital and the Royal Berkshire Hospital, Reading, sometimes having self-
harmed, sometimes because she was struggling with suicidal thoughts and wanted to speak to
Psychiatric Liaison. Her reasons for choosing a particular hospital were not always predictable.

5 CORONER’S CONCERNS

The MATTERS OF CONCERN are as follows:

Evidence received at the inquest suggested that the various hospitals and police forces which had
regular dealings with Sasha were not always aware of their powers and responsibilities towards her
in circumstances when her s.17 leave was being revoked, or else had not agreed and, where
required, updated a common plan of action to be followed in those circumstances.
As a result, there was inconsistency in the actions taken when her s.17 leave had been revoked,
which led to an increased risk that Sasha might act in such a way which would result in her death,
whether intentionally or not.

6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you (and/or your
organisation) have the power to take such action.

In a letter to me dated 22.5.19 the Deputy Chief Executive of SBP wrote that SBP considered that
“collaboration between partners to enhance the system’s understanding of the application of s.18
[ which relates to the revocation of s.17 leave ], using the Mental Health Act Code of Practice as a
guide, is required.” He further stated that SBP intended to “commit to the development of joint
working protocols across the system for the management of complex AWOL [ i.e. Absent Without
Leave – where s.17 leave has been revoked ] cases.”

Clarification is required as to the actions which you and/or your organisations intend to take in order
to achieve the goals set out in that letter.

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18 July 2019.

I, 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.

8 COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:

 and to the Local Safeguarding Board (where the deceased was 18).

I am 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.

9

David REID
Assistant Coroner for
SOUTHAMPTON AND NEW FOREST
Dated: 23 May 2019

Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This from is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1.
, Chair of the General Medical Council
2. The Rt. Hon. Matt Hancock MP, Secretary of State for Health and Social Care

1 CORONER

I am David REID, HM Assistant Coroner for the coroner area of Central Hampshire
2 CORONER’S LEGAL POWERS

I 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 07/04/2017 00:00 I commenced an investigation into the death of Sasha Sabrina FORSTER
aged 20. The investigation concluded at the end of the inquest on 23 May 2019. The conclusion of
the inquest was that Sasha died as the result of suicide, following her deliberate ingestion of a fatal
overdose of Propranol tablets.:

4 CIRCUMSTANCES OF THE DEATH

(1) Sasha was a young woman who had struggled for many years with a number of mental health
disorders, and had been under the care of mental health services since early adolescence. Her
diagnoses were:
(i)
(ii)
(iii)

severe Obsessive Compulsive Disorder;
complex Post Traumatic Stress Disorder;
Autistic Spectrum Disorder ( although the results of the assessment which confirmed
this diagnosis were not available until after Sasha’s death );
traits of Emotionally Unstable Personality Disorder ( although this was strongly
disputed by Sasha and her family )

(iv)

(2) Sasha had a lengthy history of self-harm, both through cutting herself and through taking

deliberate overdoses of paracetamol. More recently, she had taken a number of overdoses of
Propranolol ( a drug which she had managed to source despite it not being prescribed to her,
and which in overdose carried a significant risk of death ); one such overdose in January 2017
had resulted in her suffering a near-fatal cardiac arrest.

(3) Sasha’s OCD meant that she remained at risk even when detained in hospital under the

Mental Health Act 1983. This is because she felt compelled to refuse food or drink provided to
her, and any resulting application of restraint to ensure forced feeding/hydration would prove
extremely distressing and potentially damaging. As a result, Sasha having been detained
under s.3 MHA 1983 following the near-fatal overdose in January 2017, those treating her
sought to balance the risks she presented by granting her regular periods of s.17 leave, initially
to allow her to leave the hospital ward for a fixed period of time so that she could buy her own
food and drink, and latterly to allow her to stay overnight at home in an environment which she
found less distressing, this being conditional on her returning to the ward at agreed times.
(4) On occasions, however, Sasha’s behaviour whilst away from the ward on s.17 leave prompted
her responsible clinician to revoke that s.17 leave, and require her to return to the ward. In
those circumstances, legal responsibility for ensuring Sasha’s prompt return to the ward lay
with Surrey and Borders Partnership NHS Foundation Trust ( SBP ). Whilst SBP could ask the
police to assist in doing this, the police were not legally obliged to do so, and often would
decline such requests.

(5) On such occasions, SBP did not generally arrange for authorised persons to collect Sasha and

 return her to the ward, but would instead seek to rely on her mother returning her and, in order
to secure Sasha’s agreement to this course, would agree not to insist on her immediate return.
Sometimes, this would involve allowing Sasha to go home overnight and be brought to the
ward the next day.

(6) On occasions during such “negotiated extension” periods, Sasha would continue to self-harm

( both through cutting and taking overdoses ) or go missing from home, and therefore could not
be returned to the ward as agreed.

(7) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave should be
revoked was on the afternoon of her death on 31.3.17. Although formal revocation of leave
was never finalised, Sasha’s mother was given to believe that it would be, and again
reluctantly agreed to bring Sasha back to the ward. Whilst with her mother, Sasha was able to
run off and take the substantial Propranolol overdose which proved to be fatal.

5 CORONER’S CONCERNS

The MATTERS OF CONCERN are as follows:

Evidence was heard at the inquest that after her treating psychiatrist had stopped prescribing her
Propranolol, due to the risk of overdose, Sasha visited two private GPs at a clinic in London, on
occasions two weeks apart.
In each consultation Sasha:
- requested Propranolol, on the basis that it was currently being prescribed to her for anxiety;
- revealed a limited history of mental health issues;
- failed to reveal either her extensive overdose history or the fact that her treating psychiatrist had
stopped prescribing her Propranolol.
Without details of Sasha’s GP or her treating psychiatrist, or her consent to contact them ( neither
of which was given ), neither GP had the means of discovering her worrying psychiatric
background. Had they had those means, it is likely that neither GP would have given her a 28 day
supply of Propranolol.
Whilst it could not be proven that the Propranolol prescribed by these GPs was the Propranolol
used by Sasha for her final, fatal overdose, there remained at the time a considerable risk that she
would so use it.

6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you (and/or your
organisation) have the power to take such action.

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18 July 2019.

I, 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.

8 COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:

;

and to the Local Safeguarding Board (where the deceased was 18).

I am 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.

 9

David REID
Assistant Coroner for
SOUTHAMPTON AND NEW FOREST
Dated: 23 May 2019

Regulation 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This from is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Chief Executive, Guildford and Waverley Clinical

Commissioning Group

2 Chief Executive, North East Hampshire and Farnham

Clinical Commissioning Group

3 Chief Executive, Surrey and Borders Partnership NHS

4

Foundation Trust
The Rt. Hon. Matt Hancock MP, Secretary of State for
Health and Social Care

1 CORONER

I am David REID, HM Assistant Coroner for the coroner area of Central Hampshire
2 CORONER’S LEGAL POWERS

I 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 07/04/2017 I commenced an investigation into the death of Sasha Sabrina FORSTER aged 20.
The investigation concluded at the end of the inquest on 23 May 2019. The conclusion of the
inquest was that Sasha died as the result of suicide, following her deliberate ingestion of a fatal
overdose of Propranol tablets.

4 CIRCUMSTANCES OF THE DEATH

(1) Sasha was a young woman who had struggled for many years with a number of mental health
disorders, and had been under the care of mental health services since early adolescence. Her
diagnoses were:
(i)
(ii)
(iii)

severe Obsessive Compulsive Disorder;
complex Post Traumatic Stress Disorder;
Autistic Spectrum Disorder ( although the results of the assessment which confirmed
this diagnosis were not available until after Sasha’s death );
traits of Emotionally Unstable Personality Disorder ( although this was strongly
disputed by Sasha and her family )

(iv)

(2) Sasha had a lengthy history of self-harm, both through cutting herself and through taking

deliberate overdoses of paracetamol. More recently, she had taken a number of overdoses of
Propranolol ( a drug which she had managed to source despite it not being prescribed to her,
and which in overdose carried a significant risk of death ); one such overdose in January 2017
had resulted in her suffering a near-fatal cardiac arrest.

(3) Sasha’s OCD meant that she remained at risk even when detained in hospital under the

Mental Health Act 1983. This is because she felt compelled to refuse food or drink provided to
her, and any resulting application of restraint to ensure forced feeding/hydration would prove
extremely distressing and potentially damaging. As a result, Sasha having been detained
under s.3 MHA 1983 following the near-fatal overdose in January 2017, those treating her
sought to balance the risks she presented by granting her regular periods of s.17 leave, initially
to allow her to leave the hospital ward for a fixed period of time so that she could buy her own
food and drink, and latterly to allow her to stay overnight at home in an environment which she
found less distressing, this being conditional on her returning to the ward at agreed times.
(4) On occasions, however, Sasha’s behaviour whilst away from the ward on s.17 leave prompted
her responsible clinician to revoke that s.17 leave, and require her to return to the ward. In
those circumstances, legal responsibility for ensuring Sasha’s prompt return to the ward lay

 with Surrey and Borders Partnership NHS Foundation Trust ( SBP ). Whilst SBP could ask the
police to assist in doing this, the police were not legally obliged to do so, and often would
decline such requests.

(5) On such occasions, SBP did not generally arrange for authorised persons to collect Sasha and
return her to the ward, but would instead seek to rely on her mother returning her and, in order
to secure Sasha’s agreement to this course, would agree not to insist on her immediate return.
Sometimes, this would involve allowing Sasha to go home overnight and be brought to the
ward the next day.

(6) On occasions during such “negotiated extension” periods, Sasha would continue to self-harm

( both through cutting and taking overdoses ) or go missing from home, and therefore could not
be returned to the ward as agreed.

5 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 will 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) Evidence was given during the inquest by SBP staff on the ward concerned, that the

reason SBP staff did not arrange to collect Sasha and return her to the ward when her s.17
leave had been revoked, was that they did not have the resources to allow them to do this,
despite it being their legal responsibility so to do.

(2) Sasha’s mother gave evidence that SBP’s reliance on her bringing Sasha back to the ward
when s.17 leave had been revoked, placed an unfair and intolerable burden on her, in
circumstances when she and the rest of the family were struggling to keep Sasha safe.
Knowing that SBP would not send someone out to collect Sasha made her feel that she
had no choice but to agree to their request.

(3) The last such occasion when SBP staff on the ward decided that Sasha’s s.17 leave
should be revoked was on the afternoon of her death on 31.3.17. Although formal
revocation of leave was never finalised, Sasha’s mother was given to believe that it would
be, and again reluctantly agreed to bring Sasha back to the ward. Whilst with her mother,
Sasha was able to run off and take the substantial Propranolol overdose which proved to
be fatal.

6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you ( and/or your
organisations ) have the power to take such action.

SBP has a legal responsibility to arrange for the return to hospital of patients whose s.17 leave they
have revoked. If resources are not provided to allow them to fulfil this legal responsibility, there is a
risk that future patients, whose s.17 leave has been revoked and who remain at risk of self-harm or
suicide whilst in the community, will find the opportunity to act in such a way as results in their
death, whether intentionally or not.

7 YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18 July 2019.

I, 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.

8 COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:

Gavin Stephens, Chief Constable of Surrey Police;

 Olivia Pinkney, Chief Constable of Hampshire Constabulary.

and to the Local Safeguarding Board (where the deceased was 18).

I am 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.

9

David REID
Assistant Coroner for
SOUTHAMPTON AND NEW FOREST
Dated: 23 May 2019

a From Nadine Dorries MP’

Parliamentary Under Secretary of State for Mental Health,
Department Suicide Prevention and Patient Safety

of Health &
Social Care 39 Victoria Steet
SW1H OEU
020 7210 4850

Our Ref: PFD-1178134

David Reid

HM Assistant Coroner, Central Hampshire
HM Coroner’s Office

Castle Hill

The Castle

Winchester, S023 8UL

: 03 September 2019
\ »
Yew Dor /

Thank you for your correspondence of 23 May to Matt Hancock about the death of
Sasha Sabrina Forster. I am replying as Minister with responsibility for mental health
and I am grateful for the additional time in which to do so.

Firstly, I would like to say how deeply saddened I was to read of Ms Forster’s death.
I can appreciate this must be a very distressing time for her family and loved ones
and I offer my sincerest condolences.

Where concerns are raised about the standard of care provided, we must do all we can
to learn from those incidents and make improvements where they are necessary and I
am grateful to you for bringing these concerns to my attention.

You issued three separate Prevention of Future Deaths Reports to the Secretary of
State and others, with matters of concern around leave of absence from hospital and
revocation of that leave (sections 17 and 18 of the Mental Health Act 1983'), as well
as access to patient records across private GP practitioners. I will respond to each
area of concern in turn.

In relation to leave of absence from hospital, you may wish to note that the
Department does not agree that care providers have a legal responsibility to arrange
for the return to hospital of patients whose section 17 leave has been revoked.

Section 18 of the Mental Health Act gives hospitals the power to take a patient into
custody for return to the hospital or place of treatment. However, it does not place a
legal responsibility on hospitals to arrange this. As such, it is for care providers to
decide on the best way to facilitate such returns from within the resources available to
them.

Section 18 of the Mental Health Act 1983 sets out that, where section 17 leave is
revoked, the patient may be taken into custody and returned to the hospital or place of
treatment by any approved mental health professional, any officer on the staff of the
hospital, any constable, or any person authorised in writing by the managers of the
hospital.

The Department therefore expects care providers to ensure that those members of
staff involved in the return of a patient following revocation of section 17 leave are
aware of their powers and responsibilities towards that patient and that these are
applied in a consistent manner. Wherever possible, all organisations involved in an
individual’s care and safety should work together to ensure the safe and timely return
and readmission of patients absent without leave. I hope this clarification is helpful.

The Government remains committed to reforming mental health law and will publish
a White Paper by the end of the year, which will set out the Government’s response,
in full, to the independent review of the mental health act, and pave the way for new
legislation.

Turning to the matter of concern relating to the prescribing of propranolol. My
officials have made enquiries and I am aware that the General Medical Council
(GMC) has responded to you to explain that its prescribing guidance? is clear that a
doctor must only prescribe when they have adequate knowledge of the patient’s
health. This should involve making an assessment together with the patient of their
condition and having, or taking, an adequate history. A patient’s consent to contact
their GP should be sought if more information, or confirmation of the information
available, is needed before prescribing. The GMC is confident that its guidance,
when followed, ensures safe practice and protects patient safety.

As you will know, the GMC is the independent regulator of medical doctors in the
UK. All doctors must register with the GMC, hold a license to practise and meet set
professional standards to work in the UK. The GMC guidance, Good Medical

Practice’ describes what is expected of all doctors registered with the GMC, with
supporting, explanatory guidance, Good Practice in Prescribing and Managing
Medicines and Devices, expanding on this advice. A serious or persistent failure to
follow the guidance may put a doctor’s registration with the GMC, and their licence
to practice at risk.

I hope this response is helpful.

Kj 9 ae

NADINE DORRIES

16 July 2019 

Private and Confidential 

Mr David Reid, HM Assistant Coroner for 
Central Hampshire 

Fiona Edwards  
Chief Executive &  
Lead for Frimley Integrated Care System 

Chief Executive’s Office 
Surrey and Borders Partnership NHS Foundation Trust  
18 Mole Business Park 
Leatherhead 
KT22 7AD 

E: Fiona.Edwards@sabp.nhs.uk  

Dear Mr Reid 

Re: Regulation 28 Report to Prevent Future Deaths (1) 
Surrey and Borders Partnership NHS Foundation Trust Response   

I send this letter on behalf of Surrey and Borders NHS Foundation Trust (SABP), North East 
Hampshire and Farnham Clinical Commissioning Group, and Guildford and Waverly CCG.  
We write in response to your Regulation 28 Report to Prevent Future Deaths (1), hereafter 
referred to as ‘PFD’, issued on the 23 May 2019 following the inquest touching upon the 
death of Sasha Forster. We would like to thank you for investigating this matter so 
thoroughly and for bringing the matters of concern you have to our attention.   

The PFD outlined that it was stated in evidence that a lack of resources prevented the return 
of Ms Forster to Farnham Road Hospital (FRH) by SABP staff, despite it being our legal 
responsibility to do this; that Ms Forster’s mother gave evidence that the Trust’s reliance on 
her returning Ms Forster to the ward placed an unfair and intolerable burden on her; and that 
although Ms Forster’s leave was not formally revoked on the day she died, her mother was 
given to believe that it would be and therefore reluctantly agreed to return Ms Forster to the 
ward.   

In your report you stated that the below action should be taken:   

[SABP] has a legal responsibility to arrange for the return to hospital of patients 
whose s.17 leave they have revoked. If resources are not provided to allow them to 
fulfil this legal responsibility, there is a risk that future patients, whose s.17 leave has 
been revoked and who remain at risk of self-harm or suicide whilst in the community, 
will find the opportunity to act in such a way as results in their death, whether 
intentionally or not. 

Our response 

Where a person who uses our services is absent without leave (AWOL) (where their section 
17 leave has been revoked and they have refused to return to the ward), their location is 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 known, and they are not posing a risk to themselves or others, we agree that it is the Trust’s 
responsibility to arrange for them to be returned to the ward by SABP staff; in line with our 
Absent Without Leave Missing Persons Policy. Staff have access to the hospital pool car, 
taxi services, or secure / NHS ambulance transport in order to facilitate the return of a 
person who is AWOL to the ward, depending on what is considered to be most appropriate 
in the circumstances, following a risk assessment. 

However, this will cause a reduction in the numbers of staff on the ward if we use staff on 
working on shift and may put other vulnerable patients at risk. 

The Trust therefore has the following mechanisms currently in place to manage this 
situation: 

1.  All people who use our services are risk assessed on admission and throughout their 
time in our services and reviewed daily by the staff.  If a person is assessed as a high 
AWOL risk, this should be reflected in their section 17 care plan. Our section 17 policy 
has recently been revised to ensure that section 17 care planning is more robust. We 
have devised a new section 17 leave form, which must be signed by both the 
Responsible Clinician and a member of nursing staff. This form requires the nurse to 
check that the patient has an up to date section 17 leave care plan and risk 
assessment before leave is granted. The form was reviewed by a Mental Health Act 
Reviewer from the Care Quality Commission before it was implemented. 

These individual risk assessments will then contribute to the overall assessment of 
ward risk and staffing levels of the ward.  If a person is a high risk of AWOL, then 
extra staff will be allocated to the ward in order to manage this risk. 

2.  There is also a process for escalating any developing risk in the Trust, which should 
be followed in any situation where a risk has escalated beyond the boundaries of the 
Trust’s advance planning. This includes, for example, if a person is AWOL and needs 
to be returned to the ward, but there are insufficient staff to facilitate this.  

The escalation process is outlined below.  

Escalation of incident or risk. 

Incident occurs or risk 
escalates and this 
cannot be managed 
locally.

The ward manager and 
matron is contacted (in 
hours), or the unit 
coordinator is 
contacted (out of 
hours). 

The 
manager 
on call is 
contacted. 

The 
director on 
call is 
contacted.

Therefore, if there are sufficient staff to return a person who is AWOL (and whose 
whereabouts are known) to the ward, the above escalation process should be put into 
action. In the first instance, this will mean escalation to the ward manager and matron 
of the hospital, who will be able to move staff from other wards to support the staff on 
the ward where the person is AWOL from until they are returned.  Out of hours, the 
manager on call can be contacted, who will be able to facilitate the mobilisation of 
other staff in the organisation to assist. This would include staff from our home 
treatment teams (who are connected to our inpatient services) and our community 

 
  
 
 
 
 
 
 
 
 
 teams.  If there are difficulties in reaching the manager on call, or it is not possible to 
mobilise staff from other teams, the director on call can be contacted, who will be able 
to mobilise managers to support the ward and / or facilitate the return of the person 
who is AWOL.  

It would be impractical for SABP to have extra staffing on each ward on a shift by shift 
basis for the purpose of being available to return people who are AWOL and whose 
whereabouts are known, particularly as this is an uncommon occurrence. All our 
Wards comply with National Safe Staffing standards. 

The above contingency plan allows us to manage our resources effectively and to 
ensure that staff can be mobilised in order to safely return an AWOL patient to the 
ward.  

This Inquest has highlighted that not all staff are aware that the above risk escalation 
process should be followed in the event that a person is AWOL and needs to be returned to 
the ward. We take full responsibility and we will therefore update our AWOL Policy with a 
clear process map that outlines how concerns about a person who is AWOL should be 
escalated by September 2019.  Thereafter, this will be shared with staff and added to the 
section 17 competency framework to ensure awareness of the process.  

I hope that the above reassures you that there is a process in place to facilitate the return of 
AWOL inpatients to the ward and that the Trust is committed on an ongoing basis to provide 
training through local induction to our staff and ensuring they are aware of the policy and 
process they should follow when a person is AWOL.  

Yours sincerely, 

Fiona Edwards 
Chief Executive 
Surrey and Borders Partnership NHS Foundation Trust 

Emma Boswell 
Executive Director of Quality and Nursing (on behalf of the Chief Executive Officer) 
North East Hampshire and Farnham CCG 

Matthew Tait  
Chief Officer  
Surrey Heartlands Integrated Care System

2 July 2019 

By email: Rhiannon.Warner-Harvey@hants.gov.uk 

Rhiannon Warner-Harvey 
Coroner’s Service Manager 
Coroner’s Office 
Castle Hill 
The Castle 
Winchester 
SO23 8UL 

Dear Ms Warner-Harvey 

Thank you for your recent correspondence in which you notified us of the sad passing of 
Ms Sasha Sabrina Forster; and, provided us with Mr Reid’s Regulation 28 Report. 

Within the report you explained that prior to her death Sasha had managed to obtain 
Propranolol from two private GPs having falsely stated that she was currently being 
prescribed the medication; and, having only revealed a limited history of her mental health 
issues and without disclosing her extensive overdose history. 

Our remit and guidance 
The GMC is the regulator of doctors within the UK and our role is to protect patients and 
improve medical education and practice. 

As part of our role we are responsible for setting the standards that doctors need to follow 
throughout their career and to take action when doctors fall below these standards to the 
degree warranting action upon their registration. 

The GMC publishes these standards within our ethical guidance consisting of Good Medical 
Practice (2013) and a number of supplemental publications which expand upon these 
standards.  The full suite of our ethical guidance can be accessed via our website: 

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors 

With regards to prescribing, the GMC’s guidance is clear that a doctor must only prescribe 
when they have adequate knowledge of the patient’s health.  This will involve making an 
assessment, together with the patient, of their condition and having, or taking, an adequate 
history. 

Our guidance goes on to explain that if the patient has not been referred to the doctor by 
their general practitioner they should ask for the patient’s consent to contact their GP if 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 they need more information or confirmation of the information they have before 
prescribing.  If the patient objects, the doctor should explain that they cannot prescribe 
for the patient. 

I have enclosed extracts of the relevant sections of our ethical guidance at Annex A of this 
letter; and, we consider that this guidance, when followed, ensures safe prescribing and 
protects patient safety. 

Conduct of individual doctors 
When a doctor fails to adhere to our ethical guidance the GMC must establish whether our 
threshold for investigation has been met; namely, whether the doctor’s conduct, if proven, 
is capable of amounting to impaired fitness to practise to a degree warranting action on 
their registration. 

Whilst you have noted that it cannot be established that the Propranolol prescribed by the 
private GPs in London was used by Sasha for her final, fatal, overdose it would appear 
there is a question as to whether the doctors concerned have adhered to our guidance. 

As such, I have passed the information you have provided us with to an Assistant 
Registrar (a decision maker) to determine whether the threshold for investigation has 
been met.  If the Assistant Registrar has insufficient information upon which to reach a 
decision, they may make contact with your office under separate cover to request 
additional information/documentation. 

Publication 
I note that the Chief Coroner may publish our response in complete or redacted or 
summary form.  For reasons of fairness, the fact that the GMC is considering whether to 
open an investigation is not something which is ordinarily made public at this stage.  
Accordingly, in the event there is any information in the public domain through which 
either of the two doctors may be identified, the Chief Coroner may consider it would not 
be appropriate to publish this part of our reply. 

I hope you find this letter helpful and I would be happy to take your call if you wish to 
discuss these matters further. 

Yours sincerely 

Joanna Farrell  
Assistant Director of Investigation 
General Medical Council, 3 Hardman Street, Manchester, M3 3AW 
Website: www.gmc-uk.org 
Telephone: 0161 923 6507 
Email: joanna.farrell@gmc-uk.org   

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex A – GMC Guidance 

Explanation of terminology 

We use the terms ‘you must’ and ‘you should’ in the following ways. 

• 

‘You must’ is used for an overriding duty or principle. 

• 

• 

'You should’ is used when we are providing an explanation of how you will meet the 
overriding duty. 

'You should’ is also used where the duty or principle will not apply in all situations or 
circumstances, or where there are factors outside your control that affect whether or 
how you can follow the guidance. 

Our Guidance 

Good medical practice (2013) 

16 

In providing clinical care you must: 

a. 

prescribe drugs or treatment, including repeat prescriptions, only when you 
have adequate knowledge of the patient’s health, and are satisfied that the 
drugs or treatment serve the patient’s needs. 

b. 

provide effective treatments based on the best available evidence 

f. 

check that the care or treatment you provide for each patient is compatible with 
any other treatments the patient is receiving, including (where possible) self-
prescribed over-the-counter medications 

Good practice in prescribing and managing medicines and devices (2013) 

14  You should prescribe medicines only if you have adequate knowledge of the patient’s 

health and you are satisfied that they serve the patient’s needs. 

21  Together with the patient, you should make an assessment of their condition before 
deciding to prescribe a medicine. You must have or take an adequate history, 
including: 

a. 

b. 

any previous adverse reactions to medicines 

recent use of other medicines, including non-prescription and herbal medicines, 
illegal drugs and medicines purchased online, and 

3 

 
 
 
 
 
 
 
 
 
 
 
 c. 

other medical conditions. 

22  You should encourage your patients to be open with you about their use of 

alternative remedies, illegal substances and medicines obtained online, as well as 
whether in the past they have taken prescribed medicines as directed. 

32 

If you prescribe for a patient, but are not their general practitioner, you should check 
the completeness and accuracy of the information accompanying a referral. When an 
episode of care is completed, you must tell the patient’s general practitioner about: 

a. 

changes to the patient’s medicines (existing medicines changed or stopped and 
new medicines started, with reasons) 

b. 

length of intended treatment 

c.  monitoring requirements 

d. 

any new allergies or adverse reactions identified,12unless the patient objects or 
if privacy concerns override the duty, for example in sexual health clinics. 

33 

If a patient has not been referred to you by their general practitioner, you should 
also: 

a. 

consider whether the information you have is sufficient and reliable enough to 
enable you to prescribe safely; for example, whether: 

i.  you have access to their medical records or other reliable information about 

the patient’s health and other treatments they are receiving 

ii.  you can verify other important information by examination or testing 

b. 

ask for the patient’s consent to contact their general practitioner if you need 
more information or confirmation of the information you have before 
prescribing.  If the patient objects, you should explain that you cannot 
prescribe for them and what their options are. 

4