David Jukes

OFFICIAL 

National Medical Directorate 
NHS  England and NHS Improvement 
Skipton House 
  80 London Road 
LONDON  
SE1 6LH 

Email:

Telephone: 

20th September 2019 

Ms Emma Brown 
Area Coroner for Birmingham and 
Solihull  
The Coroner's Court 
50 Newton Street 
Birmingham 
B4 6NE 

Email:   

Dear Ms Brown,  

Re:  Regulation  28  Report  to  Prevent  Future  Deaths  –  David  Jonothan  Jukes 
(09/10/2018)  

Thank you for your Regulation 28 Report dated 12 July 2019 concerning the death of 
David Jonothan Jukes on 09 October 2018.  

I was very saddened to read of the circumstances surrounding Mr Jukes’s death and 
would  like  to  extend  my  condolences  to  his  family  and  loved  ones  during  this  very 
difficult time. 

Please note this response will address the matters of concern from a national level 
and we would expect the local NHS agencies, which I note are copied in to the letter, 
to address the local concerns raised.  

Sufficient  information  regarding  arrests  was  not  provided  to  liaison  and 
diversion practitioner: 

NHS  England  and  NHS  Improvement  will  work  with  police  forces  to  ensure  that  all 
relevant  information  from  a  police  perspective  is  given  to  the  liaison  and  diversion 
practitioner, including the nature of the detained person’s presentation at the point of 
arrest, if relevant.  

We will commit to a national event by the end of March 2020 to debrief on this matter 
and  any  other  information  sharing/exchange  issues  that  have  been  raised  in  other 
reports.  We  will  invite  liaison  and  diversion  practitioners  as  well  as  NHS 
Commissioners and police representatives in order to share lessons learnt. 
Additionally, there has been work to address this concern at a regional level: 

High quality care for all, now and for future generations 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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•  NHS  England  and  NHS  Improvement  has  been  working  with  West  Midland 
Police  regarding  their  new  IT  system  (‘Connect’)  which  the  police  are 
implementing in the summer 2020 

•  Connect will be available in custody 

•  As  part  of  its  development  NHS  England  and  NHS  Improvement  has 
supported the three liaison and diversion teams (Coventry, Black Country and 
Birmingham)  who  will  collaborate  with  West  Midlands  Police  on  a  specific 
liaison and diversion section 

•  Once  implemented,  liaison  and  diversion  teams  and  police  colleagues  will 
have increased access to immediate and relevant information. It is envisaged 
that this will not only improve the safety of individuals being managed but also 
add  quality  to  the  referral/identification  and  priority  of  those  coming  into 
custody. 

•  All  three  liaison  and  diversion  teams  will  have  access  to  partitioned  parts  of 
the  police  system  that  helps  them  understand  the  context  of  the  persons 
arrival 
information  about  historical  custody 
appearances. 

into  custody  and  more 

•  All liaison and diversion teams have had information sharing training and this 

training offer has also been made to Police Healthcare providers   

There was a lack of communication between different mental health trusts: 

The  NHS  Long  Term  Plan  is  committed  to  ensuring  that  by  2024,  secondary  care 
providers  in  England,  including  acute,  community  and  mental  health  care  settings, 
will be fully digitised, including clinical and operational processes across all settings, 
locations  and  departments.  Data  will  be  captured,  stored  and 
transmitted 
electronically,  supported  by  robust  IT  infrastructure  and  cyber  security,  and  Local 
Health and Care Records will cover the whole country.  

As  part  of  this,  a  number  of  steps  are  being  taken,  led  by  NHS  England 
/Improvement  and  NHSX,  to  enable  the  safe  and  secure  sharing  of  digital  records. 
NHSX  brings  together  teams  from  the  Department  of  Health  and  Social  Care,  and 
NHS England and NHS Improvement to drive digital transformation and lead policy, 
implementation  and  change.  The  Local  Integrated  Health  and  Care  Records 
programme,  led  by  NHSX,  will  provide  strategic  vision  for  safely  and  securely 
sharing  data  across  different  NHS  and  partner  organisations.  The  aim  of  the 
programme is to create an information sharing environment that helps our health and 
care services to continually improve the care that we deliver. This includes ensuring 
that health and care professionals have access to a comprehensive care record with 
the information they need to inform their care decisions, when and where they need 
it. As well as empowering people to look after themselves better and make informed 
choices  about  their  own  health  and  care  and  being  able  to  analyse  the  data  to 
enable  more  precise  and  actionable  interventions  and  support  the  development  of 
population health management. NHS England is also working with the mental health 
Global  Digital  Exemplar  programmes  to  develop  a  range  of  basic  and  more 

High quality care for all, now and for future generations 

 
 
 
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advanced  tools  to  support  decisions  on  care  across  the  pathway,  this  includes  the 
identification of need, detection of risk and the application of best practice.  

In  parallel to  this,  NHS  England and  NHS  Improvement and  NHS  X  are  working  to 
improve  the availability  of  mental health  information  and  evidence-based  resources 
online, this includes local crisis service directories. 

Additionally,  the  national  service  specification  for  liaison  and  diversion  services 
clearly  outlines  expectations  relating  to  providers’  IT  systems.  NHS  England  and 
NHS Improvement are updating N3 connections to Health and Social Care Network 
(HSCN)  connections  to  ensure  that  liaison  and  diversion  providers  can  access 
relevant  health  information  including  Summary  Care  Records.  HSCN  has  been 
procured  in  101  police  custody  suites,  and  84  courts  and  the  rollout  of  this 
procurement will commence in early 2020.  

NHS England and Improvement will produce an information sharing protocol for the 
NHS  and  Independent  sector  Mental  Health  Trusts  that  are  co-commissioned  with 
the  local  NHS  Clinical  Commissioning  Groups  (CCGs)  to  deliver  services  to  the 
Armed  Forces.  This  will  ensure  that  patient  information  can  be  shared  thereby 
providing a comprehensive and simultaneous patient record. This protocol will be in 
place and operational by 1 April 2020. Where NHS England and NHS Improvement 
Armed Forces co-commission mental health services  with CCGs we will strengthen 
the  commissioning  relationships  already  in  place  and  work  through  an  integrated 
approach to ensure that the appropriate Quality and Safety  systems are in place to 
identify risk and have mechanisms to respond. NHS England and NHS Improvement 
Quality and Safety meetings are currently held with the providers only. We recognise 
the  importance  of  integrated  commissioning  and,  working  with  our  local  CCGs,  will 
ensure  that  from  April  2020  the  meetings  held  with  providers  of  services  both  the 
relevant CCG and NHS England commissioners will be invited to attend.  

NHS England and  NHS Improvement recognise that quality assurance plays a vital 
role  in  ensuring  patients  receive  high  quality,  safe  care  and  therefore  intends  to 
further  strengthen  the  Quality  Assurance  role  within  a  dedicated  Armed  Forces 
Quality and Safety Manager. This role will have the responsibility of involvement and 
oversight  of  reviews  and  assurance  processes  liaising  with  internal  and  external 
stakeholders.  The  post  has  been  built  into  the  new  Operating  Model  for  NHS 
England and NHS Improvement and we will look to appoint to this position over the 
next few months in line with the organisational transition programme  

Resourcing levels in the HTT team: 

You  raised  a  significant  concern  that  a  lack  of  sufficient  capacity  within  the 
Birmingham and Solihull Mental Health Foundation Trust (BSMHT) Home Treatment 
Team was resulting in staff being unable to fulfil their professional obligations to their 
patients.  This  includes  maintaining  good  record  keeping  which  is  critical  to  patient 
safety,  particularly  to  support  people  who  come  into  contact  with  other parts of  the 
system, including the emergency services. 

Ensuring  that  all  areas  have  sufficient  resource  to  deliver  the  core  functions  of  a 
Home  Treatment  Team  24/7  is  a  key  national  commitment,  first  established  in  the 

High quality care for all, now and for future generations 

 
 
 
 
 
 
 
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publication  of  the  Five  Year  Forward  View  for  Mental  Health  and  then  reiterated  in 
the Long Term Plan (LTP) for the NHS earlier this year. Nationally, it is expected that 
the whole country will have met this ambition by the end of March 2021, resulting in 
full coverage by 24/7 teams which have the capacity to be highly responsive  and to 
offer genuinely intensive support as an alternative to hospital.  

To support the delivery of this ambition, NHS England and Improvement have made 
significant  new  funding  available  (in  addition  to  funding  already  allocated  to  CCGs 
since 2016) over the next two  years via uplifts to local CCG baselines and through 
the targeted allocation of additional centrally held transformation funds. We have just 
finished the process of allocating the centrally held funding, which will be released to 
Sustainability and Transformation Partnerships (STPs) on a quarterly basis. Overall 
the additional funding available nationally in 2019/20 and 2020/21, primarily intended 
for ensuring 24/7 coverage of crisis resolution and intensive home treatment (CRHT) 
functions, is £80m and £140m respectively. More information on the funding profile is 
available  in  the  Mental  Health  Implementation  Plan  for  the  NHS  Long  Term  Plan. 
The transformation funding has been allocated on a ‘fair shares’ basis and awarded 
following  the  submission  of  local  proposals  that  demonstrated  how  each  STP  will 
deliver  the  ambition  of  24/7,  properly  resourced  CRHT  functions  across  their 
population.  Over  the  next  two  years  we  will  be  assuring  the  use  of  this  dedicated 
funding to ensure progress towards the 2021 ambition.  

We  are  aware  that  Birmingham  and  Solihull  Mental  Health  Trust  are  experiencing 
capacity  constraints  across  their  crisis  and  acute  mental  healthcare  pathway,  and 
they  have  identified  a  number  of  areas  for  improvement  which  they  are  working  to 
address. We have provided some direct support to the trust in the form of clinically-
led  sessions  focussed  on  effective  crisis  response  and  acute  pathway  capacity 
management.  They  are  also  part  of  a  small  group  of  STPs  nationally  which  are 
subject  to  a  more  in-depth  assurance  process  related  to  their  progress  against  the 
ambition to reduce acute out of area placements. As high out of area placements are 
another  indicator  of  broader  capacity  pressures  across  a  crisis  and  acute  mental 
health system, this assurance process will include a particular focus on the effective 
use  of  transformation  funding  to  ensure  that  local  CRHT  functions  are  delivered  in 
line  with  the  evidence  base.  Further,  noting  the  report’s  similar  themes  to  the  7 
reports  issued  by  the  Birmingham  and  Solihull  Coroners  on  4th  October  2018 
regarding  system  capacity,  we  will  use  our  direct  contact  with  the  Trust  and  STP 
over  the  coming  months  to  explore  and  address  relevant  patient  safety  concerns, 
involving clinical expertise in both executive level discussions and an implementation 
support workshop focussed on transforming the crisis pathway.   

Your report acknowledged that at the time of the inquest there was evidence of work 
already underway to improve the local HTTs capacity, including introducing a system 
to  prevent  inappropriate  referrals  and  the  funding  of  further  two  CPNS  for  HTTs 
within  BSMHT.  However,  you  also  noted  concerns  that  these  changes  were  not 
sufficient  to  ensure  lives  are  not  put  at  risk  in  future.  The  new  funding  (described 
above) committed via the NHS LTP for crisis resolution and home treatment teams 
alone  is  significant  and  should  enable  the  further  expansion  required  in  BSMHT’s 
HTT  to  ensure  it  is  operating  effectively  and  safely.  It  is  important  to  note  that  this 
funding is just one small portion of a large increase in investment in crisis, acute and 
community services for adult with severe mental illness (SMI) profiled over the next 5 

High quality care for all, now and for future generations 

 
 
 
 OFFICIAL 

years. This wider system funding will be critical in helping all areas to rebalance their 
provision,  ensuring  more  people  can  be  treated  effectively  in  the  community  and 
enabling demand to be met safely and sustainably. 

Thank  you  for  bringing  these  important  patient  safety  issues  to  my  attention  and 
please do not hesitate to contact me should you need any further information. 

Yours sincerely, 

Medical Director for Clinical Effectiveness 
NHS England and NHS Improvement 

High quality care for all, now and for future generations

NHS Birmingham and Solihull CCG: Response to the Birmingham and Solihull 
Coroner’s Regulation 28 report to prevent future deaths  

1. 

Introduction 

1.1  This report provides a response to the Birmingham and Solihull Coroner, in 
respect of the Regulation 28 report to prevent future deaths issued to NHS 
Birmingham and Solihull Clinical Commissioning Group (the CCG), relating to 
the death of David Jonothon Jukes.  

1.2  The Regulation 28 report raises a number of concerns about the care provided 
to Mr Jukes between July 2018 and Mr Jukes death on 9th October 2018.   

1.3  The CCG has previously provided a comprehensive report to the Senior 

Coroner for Birmingham and Solihull on mental health services in the area, in 
response to a previous Regulation 28 report to prevent future deaths. Much of 
the information contained in that report is pertinent to the circumstances of this 
particular case and, therefore, we will not seek to repeat those details in this 
response.   

2.  Background and context  

2.1  On 17th July 2019, the CCG received a Regulation 28 Report to Prevent Future 
Deaths from the Birmingham and Solihull Coroner relating to the death, and 
subsequent inquest, of David Jonothon Jukes, who sadly passed away on 9th 
October 2018. 

2.2  The CCG commissions mental health services for over 25s from Birmingham 
and Solihull Mental Health Foundation Trust (BSMHFT) through an NHS 
standard contract. The standard contract sets out the required operational 
standards, as well as national and local quality requirements.  

2.3  The CCG, through these contractual arrangements and through its quality 
function, has quality monitoring processes in place, which include serious 
incident reporting systems and improvement monitoring. All investigations into 
serious incidents are quality assured by the CCG to ensure that necessary 
actions are identified and implemented.  

2.4  Statements submitted to the inquest confirm that Mr Jukes had been receiving 
care following a self-referral to West Midlands’ Transition, Intervention and 
Liaison Services, which prompted a referral to the Complex Treatment Service 
provided by BSMHFT.  

1 

 
 
 
 
 
 
 
 
 
 
 
 2.5 

It is further understood that Mr Jukes had contact with the Home Treatment 
Team, Black Country Partnership NHS Foundation Trust and West Midlands 
Police during the period between his initial self-referral and his death.  

2.6  The CCG has no direct knowledge of these events and has ascertained this 

information through documents provided by HM Coroner and BSMHFT.   

2.7  HM Coroner has identified a number of concerns around the care and 

treatment of Mr Jukes, which include concerns about communication, access to 
relevant information, risk assessment and record keeping.  

2.8  These issues are largely within the remit of the provider organisations to 

resolve, and the CCG confirms that an appropriate action plan has been drawn 
up and completed by BSMHFT.  

2.9  The CCG is unable to comment on actions taken by Black Country Partnership 
NHS Foundation Trust or West Midlands Police, which it is expected will be 
addressed in their respective responses to HM Coroner.  

2.10  The West Midlands’ Transition, Intervention and Liaison Services is an NHS 

England commissioned service and it is understood that NHS England will be 
commenting on this service as part of their response to the Coroner.   

2.11  There is a suggestion in evidence given to HM Coroner that risk assessment 
and record keeping may be compromised by a lack of capacity within the 
BSMHFT Home Treatment Team, and it is this issue that the CCG will address 
in this response. It is noted, however, that the root cause analysis investigation 
undertaken by BSMHFT does not identify capacity or resource as a contributing 
factor in the care and treatment issues.  

2.12  On 6th August 2019 a multi-agency round table meeting was held to review the 
findings of the root cause analysis investigation carried out by BSMHFT, to 
work towards making a multi-agency action plan.  

3.  Understanding and responding to capacity and demand  

3.1  Since 2016, the CCG (both in the current form and as three former CCGs, prior 
to the Birmingham and Solihull CCG merger on 01 April 2018) has taken a 
number of steps, with partner organisations, to understand and respond to 
concerns about capacity and demand within the local mental health system.  

3.2  The CCG recognises that there has been increased demand for crisis mental 

health services since 2016, and has responded to this additional pressure with 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 increased funding and through working with Forward Thinking Birmingham 
(providers of mental health services across Birmingham and Solihull for those 
aged up to 25), BSMHFT and the local Sustainability and Transformation 
Partnership (the STP) to look at different ways of working throughout the 
system.  

3.3 

In addition, the CCG has been, and continues to work with, system partners to 
understand the reason for the increased need, and to look at how the system 
can be improved to make best use of the existing resources.  

3.4  The CCG has participated in a meeting called by NHS England, an action from 
which was that NHS England would consider additional ways to facilitate cross 
agency working.  

3.5  Work is now underway as part of that review to explore multi-agency learning.  

3.6  The CCG is committed to establishing and maintaining a mental health system 
which facilitates timely access to inpatient care for those who need it, whilst 
ensuring that community-based provision is adequately resourced to support 
recovery in the most appropriate environment. Part of this approach involves 
the CCG being an active partner in the STP and the Mental Health Programme 
Delivery Board. The ambition of the STP is to achieve sustainability, through a 
strong focus on prevention and recovery.  

3.7 

Included in this programme is consideration of the need to reinforce services 
that already exist within secondary mental health services, by increasing the 
staffing levels in crisis resolution home treatment teams, whilst also 
understanding what an alternative crisis support service might look like.  

3.8  The CCG has been working closely with both local mental health service 

providers and the third sector, with the aim of improving the service offer for 
people experiencing a mental health crisis. Stakeholders are working on 
designing community based services, which will increase accessibility for those 
in crisis and their families, to deliver the most appropriate support at the earliest 
opportunity. 

3.9  As a result of partnership working and guidance from people with lived 

experience, the CCG has been successful in securing recurrent funding from 
two separate NHS England Transformational funds, totalling in the region of 
£2.6m (increasing to £2.9m), to support making these fundamental changes to 
how crisis is managed within the region.  

3.10  From this funding, psychiatric liaison services within acute hospitals will receive 
£1.15m to increase staffing levels within all hospitals which have an emergency 

3 

 
 
 
 
 
 
 
 
 
 
 department, with the aim of providing a more robust, specialist and diverse 
workforce, to help reduce waiting times, increase flow and improve patient 
experience. 

3.11  A further £1.4m (increasing to £1.7m) will be spent on the development of a 
crisis pathway to increase the capacity in secondary mental health crisis 
services.  

3.12  Part of this increased funding will be used to set up a network of four Crisis 

Cafés across the Birmingham and Solihull area. Each will be open seven nights 
a week and will be operated by MIND, the mental health charity. With a direct 
pathway into secondary crisis services and specialist understanding of 
available third sector interventions, this service will offer a community based 
setting for people to be able to seek the appropriate support when in a crisis. 

3.13  In the future, significant funding will be allocated towards the establishment of 

crisis houses, an evidence based initiative which will complement inpatient 
mental health facilities for those who may need support managing higher levels 
of risk. 

3.14  Through easier accessibility at an earlier opportunity, the intention is to help 

prevent people reaching crisis, and collectively these initiatives aim to improve 
the experience of those who find themselves in crisis and reduce the impact of 
crisis on other agencies across the region. 

4 

Conclusion 

4.1  The CCG aspires to there being no avoidable deaths in Birmingham and 

Solihull and takes every reported unexplained death very seriously. The CCG is 
continuously working with providers to improve the quality and safety of 
services, as well as looking at new and innovative ways to improve all mental 
health services.  

4.2  The CCG has previously provided HM Coroner with an overview of the steps 

being taken in response to the increased demand for mental health services in 
the region, and this response provides an update specifically on the measures 
taken to improve crisis care.  

4.3  The CCG recognises the need to take a multiagency approach to the delivery 

of services and the prevention of deaths, including creating robust partnerships 
with mental health support services.  

4.4  The CCG will continue to keep under review the pressures on mental health 
services and the need to develop new initiatives to manage patient flow and 
improve services. 

4

NHS

( ) Birmingham and Solihull
~ Mental Health

NHS Foundation Trust

Mrs Emma Brown Chair & Chief Executive’s Office
Area Coroner, Birmingham and Solihull Unit 1, B1
Coroner's Court 50 Summer Hill Road
50 Newton Street Ladywood
Birmingham Birmingham B1 3RB
B4 6NE

Tel: 0121 301 1111
Fax: 0121 301 1301

5 September 2019

Dear Ms Brown

Re: Regulation 28 report, prevention of future death pertaining to Mr David Jukes,
deceased

May | open this letter by reiterating on behalf of Birmingham and Solihull Mental Health NHS
Foundation Trust our most sincere condolences to Mrs Jukes following the sad death of her
husband Mr David Jukes whilst he was under the care of our Trust. We would also like to
extend our thanks to Mrs Jukes for her participation in our serious incident investigation at a
time that must have been extremely distressing for her and take this opportunity to extend an
apology to Mrs Jukes once again for any failings that occurred whilst David was within our
care.

Jukes. The investigation concluded at the end of an inquest on 11th July 2019. The
conclusion of the inquest was Mr. Jukes’ death was a result of suicide. Despite being open to
a Home Treatment Team (‘HTT’) and the Complex Treatment Service (‘CTS’) within
Birmingham and Solihull Mental Health Trust (‘BSMHT’) Mr. Jukes had not undergone an
adequate assessment of his mental health by the time of his death as a result of the following:

|
|
On 15 October 2018 you commenced an investigation into the death of David Jonothan

4. At the time of attendance by the Liaison and Diversion practitioner at Oldbury custody
suite on the 28th September 2018, the practitioner did not have full details of the events
during the evening of the 27th into 28th from West Midlands Police nor access to records
pertaining to his mental health held by his GP, the West Midlands Transition, Intervention
and Liaison Service and BSMHT. With access to this information, she would have
requested a Mental Health Act Assessment.

Chair: Sue Davis, CBE Chief Executive: Roisin Fallon-Williams na disability XSerewall
Customer Relations Mon-Fri, 8am~6pm Tel: 0800 953 0045 Text: 07985 883.509 FES confident| |DVERSITY
EMPLOYER ~

Email: bsmhft.customerrelations@nhs.net Website: www.bsmhft.nhs.uk

2.

3.

A Psychiatrist did not attend to assess Mr. Jukes whilst he was in custody on 28th
September 2019 contrary to normal HTT practice.

Clinicians within HTT did not make adequate attempts to locate and engage with Mr.
Jukes after being made aware of the events of the 27th and 28th September 2018 and
after it was reported that he was threatening harm to others and to himself in a
conversation with a psychologist on the 2nd October 2018.

Clinicians within HTT did not make adequate attempts to locate and engage with Mr.
Jukes after he failed to attend for medical review on the 4th October 2018;

Clinicians within HTT did not offer Mr. Jukes’ an urgent medical review when they spoke to
him on the morning of the 9th October 2018.

Following a post mortem the medical cause of death was determined to be: 1a) Hanging

During the course of the inquest the evidence revealed matters giving rise to concern in such
a way that there is a risk that future deaths will occur unless action is taken. The matters of
concern are as follows. —

1.

The psychiatric liaison and diversion practitioner employed by BCPFT who attended to
review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have
sufficient information about the history of arrest to inform her decision making on
assessment in custody. She was provided with a print out of the first two pages of the
custody record which included the statutory arrest reason and the circumstances of arrest
but nothing that indicated that he had barricaded himself in the loft, threated suicide and
harm to others and not come out in

We understand that the Black Country Partnership NHS Foundation Trust are responding
to you on this matter of concern.

. The above psychiatric liaison and diversion practitioner gave evidence that she contacted

either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based
at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service.
She stated that if she had been aware that he was open to the HTT she would have
sought information about his involvement and would have made the team aware that he
was in custody and the events of the previous evening. It was not established during the
inquest and has not been established in BSMHT RCA investigation how this breakdown in
communication occurred. Evidence was heard that the introduction of the Merit Vanguard
system would not give a BCPFT employee in a custody suite access to some information
and would mitigate against such circumstances arising again but it doesn’t explain why the
nurse was left with the impression that he was not known to services. It is not unusual that
clinicians from different mental health trusts will need to discuss patients and as full
records are not available through the Merit Vanguard this will continue to arise. If reliable
information is not being passed there is a risk to life from ill-informed decision making.

It is difficult for us to comment on this particular finding of the PFD as the liaison nurse
remains unclear of who she spoke to or which service she contacted. Nor is there any
documented record of this contact within the Liaison and Diversion Service. Within our bed
management service we have an arrangement for the identification for patients under our
care. We do however recognise that if it were bed management that the nurse contacted,
the existing arrangement failed to identify Mr Jukes. We are therefore implementing a

documented and recognised system within our bed management team for all such calls
which includes phonetic spelling and other controls to ensure a consistent approach to this
matter.

. Despite not being informed by the BCPFT liaison and diversion nurse that Mr Jukes was in
custody the HTT were made aware by his wife that he was in custody on the 28th
September 2018. She also gave some information about the circumstances of his arrest,
further information about the incident and police involvement had been reported to Street
Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist
visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the
usual practice of the team. It is not known why this was. Not having a robust and effective
system to carry out necessary assessments whilst a patient is detained in police custody
puts lives at risk.

We are grateful to you for raising this matter with us as it has identified the need for a joint
operating protocol to be developed between BSHMFT and the Liaison and Diversion
Service in Sandwell. We have been in liaison with this team and are scheduled to meet
and develop this protocol in late September 2019.

. Following his release from custody on the 28th September 2018 and evidence from a
psychologist that he was threating suicide and harm to others, on the 2nd October 2018
the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a
single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018.
Despite the fact that his location was unknown and he had not attended a planned medical
review on the 4th October 2018 there was no email communication to Mr. Jukes (although
he had communicated this way with the team before and provided them with his email
address) nor a call to his wife to ask her for assistance. There was evidence at inquest
from the RCA Author that there should have been more effort to contact him at least from
the 4th onwards if not before. Failure to utilise all means of locating a patient whose
whereabouts are unknown, who requires assessment and who is not making contact with
the team puts lives at risk.

We sincerely apologise for this matter. The matter of communication preferences is being
addressed by the Trust in that we now have a communication preference field within the
clinical record RIO.

. Itwas planned that Mr. Jukes would be discussed at a team meeting on the 3rd October
2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he
was discussed or a plan made to locate and assess him. No explanation was provided in
evidence nor was evidence given of a strategy to guard against this occurring in future.
Therefore there continues to be a risk that plans to discuss patients in meetings will not be
followed through which puts lives at risk.

As you state, it is vitally important that clinical records are documented to evidence the
care and treatment plans for patients that are discussed between clinicians. We have
identified that when our Multi-Disciplinary Team meetings take place there is evidence of
some inconsistency in the recording of discussions and outcomes in some areas. In direct
response to this finding we have increased administrative resources within our Home
Treatment Teams to enable consistent administrative support to our Multi-Disciplinary
Team meetings which in turn will ensure that outcomes are clearly recorded. In addition,
we have commenced a Quality Improvement Project to develop clear standards for Multi-

Disciplinary Team meetings and recording requirements. We apologise sincerely for this
failing in our clinical record keeping for Mr Jukes.

. On the 9th October 2018 a HTT clinician talked to Mr. Jukes on the phone at which time
he sounded intoxicated, was calm and polite, gave his location and agreed to attend an
appointment for a medical review on the 12th October 2018 if a bus pass were provided to
his location for him to attend. No arrangements were made in an attempt to assess Mr
Jukes before the 12th October 2018. By this time there was reason to suspect Mr. Jukes
was at risk of harm to self or others, was under the influence of substances, had not had a
full assessment by the team, had recently not been engaging with services and his
location had been unknown for over a week. This evidence indicates that those making
the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not
pro-active in making contact. The staff involved maintained in evidence that they acted
appropriately, evidence was given that this was not the finding of the Root Cause Analysis
investigation review panel. In these circumstances to fail to attempt to assess as soon as
reasonably practicable a patient who has come back into contact with the team as soon as
reasonably practicable puts lives at risk. No evidence was given of specific action to
address the decisions that were made on the 9th October 2018 with the individuals
involved or the team generally and therefore the risk continues.

In direct response to this matter of concern we are now reviewing our Home Treatment
Team Operating Protocol to strengthen the requirement for nurse led triage and
assessment screening and appropriate clinical escalation to a Consultant Psychiatrist.
Consultant Psychiatrist overview and scrutiny of each case would either be through direct
clinical assessment or review or through input and direction within the multi-disciplinary
team or through formal or informal supervision of doctors and other home treatment staff.
We note the view of the team that they felt they acted appropriately and are therefore also
using this very sad incident as a Case Study in our new Clinical Risk Assessment and
Management Training so that staff are fully alert to accumulative risk factors. This training
is mandatory for all clinical staff in the Trust irrelevant of clinical profession or team. The
first pilot of the new training model which also incorporates suicide prevention training is
due to launch at the end of September 2019.

. Throughout the inquest evidence was given of alleged attempted contact and decision
making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes.
Furthermore, his Risk Screen was not updated after information came to HTT’s attention
that affected his risk assessment. There was some evidence that HTT do not have
capacity to fulfil their obligation to keep records but evidence from some witnesses
suggested that they did not view record keeping as a necessity. If, for whatever reason,
RIO notes are not an accurate reflection of contacts, actions and decision-making
clinicians maybe misled or ill-informed creating a risk to life. Evidence was given that there
is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute
video but it is not compulsory for staff to watch the video or feedback on it and staff are not
tested or individually audited. Consequently there continues to be a risk that individuals
will not comply with their duty to keep proper records and that this noncompliance will go
undetected.

We recognise the need for an improvement in clinical record keeping standards and how
this is absolutely central to the effective care of our patients. We apologise that this was
not evident within the case of Mr Jukes and are sincerely sorry for this failing. The
importance of risk identification, formulation and recording forms a central part of our new
Clinical Risk Assessment and Management Training which, as stated above, will be
piloted from September 2019. In addition to this training, all staff irrelevant of discipline are
required to undertaken annual training on information governance where the importance of
clinical record keeping standards is also highlighted.

We are conscious that our Home Treatment Teams have been operating within an
environment of high demand and acuity and that this may at times compromise their ability
to consistently meet the important standards that we expect of staff. We are investing a
significant amount of new financial resource into our Home Treatment Team to increase
workforce capacity. This includes:

e 5.0 Full time Home Treatment Team Managers — 2 positions have now been recruited
to and a further 3 are currently out to advert

¢ 3 Full time Out of Hours Practitioners — all posts are currently out to advert

e 5.0 Full time Additional Medical Middle Grades

e An additional 0.5WTE Psychologist in every Home treatment Team (currently out to
advert)

e 4 full time Administrative posts to support Home Treatment Team activity and recording
of MDT discussions

In addition to this, we have launched two critical Quality Improvement Projects — one is to
develop and implement core MDT minimum standards for recording of clinical
documentation; the second is to improve our care planning and clinical risk assessment
processes.

8. Evidence was given at the inquest that the reason HTT may not be maintaining good
record keeping was due to insufficient capacity arising from a combination of too few staff
arising from under-funding of the service and unnecessary referrals being made to the
team. Evidence was given that there is work underway to introduce a systems to prevent
inappropriate referrals and that funding has been granted for a further two CPNS for HTTs
within BSMHT. However the evidence was that this will not be enough to enable staff to
have the time to comply with their obligations to update progress notes and risk
assessments. If funding is not sufficient to enable staff to fulfil their professional
obligations to their patients, lives are at risk.

Please see the actions that we are taking in relation to an increase in resources to all Home
Treatment Teams alongside the Quality Improvement Projects that are being taken forward to
ensure that key aspects of record keeping are as effective yet streamlined as possible so that
we are able to reduce duplicative entries for staff on the RIO record.

In closing this response, we would like to assure you that we have taken the matters raised in
your Regulation 28 report extremely seriously and once again apologise to Mrs Jukes. We
hope that the above actions will make a difference to the experience of future patients in our
care and thank you for formally raising these with our organisation.

Yours sincerely

Roisin Fallon-Wifliams
Chief Executive

(econ Qn ,

wh-eoled oA

Diveotor

|
4

Tuesday 24th September 2019 

Mrs Emma Brown 
Area Coroner, Birmingham and Solihull  
Coroner’s Court 
50 Newton Street 
Birmingham 
B4 6NE 

Headquarters 
Delta House 
Delta Point 
Greets Green Road 
West Bromwich 
B70 9PL 

Tel: 0845 146 1800 
Fax: 0121 612 8090 
   Web: www.bcpft.nhs.uk 

Dear Ms Brown 

Re: Regulation 28 report, prevention of future death pertaining to Mr David Jukes, 
deceased 

Firstly on behalf of Black Country Partnership NHS Foundation Trust  may I extend our 
most sincere condolences to Mrs Jukes following the sad death of her husband Mr David 
Jukes. 

During the course of the inquest the evidence revealed matters giving rise to concern in 
such a way that there is a risk that future deaths will occur unless action is taken. In 
response to you Regulation 28 report to prevent future deaths we have outlined below the 
actions Black Country Partnership has taken to address the matters of concern that 
affected our organisation.  

1.  The psychiatric liaison and diversion practitioner employed by BCPFT who attended to 
review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have 
sufficient information about the history of arrest to inform her decision making on 
assessment in custody. She was provided with a print out of the first two pages of the 
custody record which included the statutory arrest reason and the circumstances of 
arrest but nothing that indicated that he had barricaded himself in the loft, threated 
suicide and harm to others and not come out in response to police negotiators. This 
information was not included in a verbal handover according to the nurse’s evidence 
and there is no record of it being handed over to her. She stated in evidence that if she 
had been aware of the extent of the events overnight on the 27th into the 28th she 
would have arranged a Mental Health Act assessment when he did not engage with 
her. There is a risk to life if assessments of mental health in custody are not informed 
by material information about circumstances connected with arrest 

At present Liaison and Diversion (L&D) nursing staff have read access only  to the current 
electronic custody record (ICIS) and in line with standard operational procedures are 
instructed to ensure checks are undertaken and all available content on ICIS is reviewed. 
This is further supported by obtaining a verbal update from the police. To improve 

Chair: Andrew Fry    Chief Executive: Lesley Writtle 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 information sharing arrangements with police , senior L&D staff are engaged in the West 
Midlands wide implementation of the new electronic custody record (CONNECT). Once 
fully implemented, it will enable staff to access a wider array of information relevant to 
each case prior to assessment. They will also have read and write access where risk 
information can be recorded by nursing staff.  

L&D leads will raise awareness of the outcome and learning from the regulation 28 PFD 
report through the Joint Operational Group held with police on a quarterly basis to engage 
with police colleagues and stress the need for a full handover prior to assessment in each 
and every case. 

2.  The above psychiatric liaison and diversion practitioner gave evidence that she 

contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion 
team based at Perry Barr custody suite and was informed that Mr. Jukes was not 
known to the service. She stated that if she had been aware that he was open to the 
HTT she would have sought information about his involvement and would have made 
the team aware that he was in custody and the events of the previous evening. It was 
not established during the inquest and has not been established in BSMHT RCA 
investigation how this breakdown in communication occurred. Evidence was heard that 
the introduction of the Merit Vanguard system would not give a BCPFT employee in a 
custody suite access to some information and would mitigate against such 
circumstances arising again but it doesn’t explain why the nurse was left with the 
impression that he was not known to services. It is not unusual that clinicians from 
different mental health trusts will need to discuss patients and as full records are not 
available through the Merit Vanguard this will continue to arise. If reliable information is 
not being passed there is a risk to life from ill-informed decision making.  

Before acting on any referral, L&D staff will do full background checks. This is part of the 
triage process to establish previous history, risk, current care plans, treatment,  
compliance and medication for example so staff can make an informed judgement on who 
needs to be seen and the level of urgency. Local mental health databases are reviewed 
however when staff don’t have immediate access, neighbouring services will be 
telephoned to attain all relevant information. Across the L&D services we are also rolling 
out staff access to the Spine to give staff wider access to patient information. 

Unfortunately we have yet to ascertain why on this occasion the L&D staff member was 
advised by BSMHT that the patient was not known to services however meetings with 
Trust leads from BSMHT are being planned to consider how we can jointly strengthen 
communication pathways to prevent reoccurrence.  Implementation of the MERIT system 
will further enable staff access to information from mental health Trusts in Birmingham and 
Coventry. Likewise Birmingham and Coventry staff will be authorised for access to MERIT, 
for mental health information about those records held on both Oasis systems covering the 
whole of the Black Country.   

Please note that all other concerns raised within the Regulation 28 report affected other 
NHS bodies and services not provided by BCPFT and therefore we have not commented 
on these outcomes. We have however approached both BSMHT and CWPT to consider 

Chair: Andrew Fry   Chief Executive: Lesley Writtle 

 
 
 
 
 
 engaging in a wider learning event to consider all outcomes and where processes can 
continue to be strengthened. 

I hope this provides you with assurance that the Trust has taken the concerns raised in 
your Regulation 28 response very seriously and will continue to take action to reduce the 
likelihood of a similar incident from reoccurring. We hope that the actions highlighted 
above will make a difference and we will review changes made at regular intervals to 
ensure they are embedded whilst sharing the outcome and lessons learnt  with all affected 
staff across our Liaison and Diversion teams. 

Yours sincerely 

Lesley Writtle 
Chief Executive 

Chair: Andrew Fry   Chief Executive: Lesley Writtle

Keeping our Communities Preventing crime, protecting the
Safe and Reassured public and helping those in
need

STAFFORDSHIRE AND WEST MIDLANDS POLICE

JOINT LEGAL SERVICES
Director of ee Services
Your Ref:
Birmingham Coroner Court
50 Newton Street, Our Ref: L14002183/JS
Birmingham
B4 6NE re
BY EMAIL Date: 11 September, 2019
Dear Sirs,

David Jonothan Jukes - Deceased - DOD: 09/10/2018
Response to Regulation 28 Report

We write in respect of the Regulation 28 report dated 26th July 2019 arising from the death of Dave
Jukes: Please accept this as the response provided on behalf of West Midlands Police.

In your report, you set out your concerns as follows:

The psychiatric liaison and- diversion practitioner employed by BCPFT who
attended to review Mr: Jukes in Oldbury custody suite on the 28th September
2018 did not have sufficient information about the history of arrest to inform her
decision making on assessment in custody.

She was provided with a printout of the first two pages of the custody record which
included the statutory arrest reason and the circumstances of arrest but nothing
that indicated that he had barricaded himself in the loft, threated suicide and harm
to others and not come out in response to police négotiators. This information was
not included in a verbal handover according to the nurse’s evidence and there is
no record of it being handed over to her. She stated in evidence that if she had
been aware of the extent of the events overnight on the 27th into the 28th she
would have arranged a Mental Health Act assessment when he did not engage

Please reply to: Staffordshire Office
Birmingham Office: Joint Legal Services

Joint Legal Services Staffordshire Police Headquarters
West Midlands Police PO Box 3167

Lloyd House, Colmore Circus Stafford, ST16 QJZ

Birmingham, B4 6NQ Tel: 01785 232259

Tel: 0121 626 8317
Fax: 0121 626 8272

Please be aware that all information provided to Staffordshire and West Midlands Police Joint Legal Services will be held and treated in confidence in
accordance with the Data Protection Act 2018. it may be shared with other Force departments or third party organisations including, but not limited to, external
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114002183/JS / 00192590

with her. There is a risk to life if assessments of mental health in custody are not
‘ informed by material information about circumstances connected with arrest.

The key issue appears to be what information is provided/available to the Liaison and Diversion team
in custody. In order to assess that, it is important to consider what information is recorded on the
custody record in the first place.

The arrest circumstances in this case are unusual, and fact specific. The relevant arrest circumstances
related to the attendance of police officers the night before Mr. Jukes was presented at the custody
suite.

The arresting officers were not the same officers as those who had attended the night before and as
such did not have first-hand knowledge of the circumstances. The arresting officer in this matter no
longer works for the force and as such it is not possible to ascertain the extent of their knowledge. The
arrest package provided to the arresting officer which would have been provided to them prior to arrest
cannot be located and may have destroyed due to the passage of time.

When Mr. Jukes was booked into custody, the arresting officer provided the information relating to the
arrest that day, which is what appears on the custody record.

The officer wouldn’t have told the Custody Sgt the history of the detainee, but more what he has come
into custody for as this is relevant for the purposes of the authorisation of detention.

In Mr Jukes’ case, the circumstances of his contact with the police on the 27th September were
relevant to the circumstances of his arrest the next day. However, that will not necessarily be the case
for every individual who has contact with the police shortly before they are arrested.

It is not reasonable or practicable to prescribe exactly what must be said about the circumstances of
an arrest when an individual is being detained; officers are expected to use their professional
judgement about what information is provided to custody sergeants about the material circumstances
of an arrest. This will often be encompassed within the circumstances of the arrest itself, depending
on that particular case.

It would be expected that the arresting officer prior to entering the custody suite would have considered
the detainee prompt card (a copy of which is attached to this letter) and brought to the attention
anything of relevance to the custody sergeant.

Whether further information should have been recorded on the custody record in this case was not
explored at all in the course of the inquest, and quite properly does not feature in the Regulation 28
report.

The referral process is that the officers provide the Liaison and Diversion Team with a risk assessment
form (a copy of such a form is attached) and a copy of the custody front sheet. There is nothing
further required by the Liaison and Diversion team for a referral.

This process is more onerous than the original input given to custody staff which states that all that is
required is a verbal referral and note in the custody record is all that is needed. A copy of this
PowerPoint is attached.

Whilst there was no specific reference to the incident the night previous there was evidence on the
custody record that Mr Juke presented a risk to others and made threats of self-harm.

JS /L14002183 / 00192590 Page 2

Mr Jukes had been referred to Liaison and Diversion due to being a veteran, suffering from PTSD, and
had suicidal and self-harm warning on his custody record. This can be seen at 28/9/18 at 17:43 hours.

The custody record makes it clear that the statutory reason for arrest amongst other reasons was to
“Prevent the person in question suffering physical injury’

Furthermore the custody record states the following information:

28/9/18 10:44 — PNC Notes changed for Warning signal Suicidal to States has SU thoughts
every day

28/9/18 10:44 — PNC notes changed for Warning Signal mental to MN — PTSD and depression

28/9/18 10:45 — Warning Signal Violent added with ONC notes threatened to kill officer prior
to arrest.

At 28/9/18 at 15:02 the record states “PIC has threatened [EEE has stated that if he is hurt in
the process of his fingerprint being taken he will kill.”

Therefore, it is submitted that some information was readily available on the custody record.

The Liaison and Diversion team can make verbal requests for further information. This would include
access to the full custody record which is available in custody and would extend to call out logs and
‘crime investigation logs that can be obtained by the custody staff. It would however be unlikely to
extend to intelligence.

\t is submitted that it is not for the police officers within custody to anticipate what else a liaison and
Diversion practitioner might require in addition to the custody record and there is a reasonable
expectation that a practitioner will engage with the custody staff and request information when it is
needed, depending on the circumstances of a particular individual.

It is our position that there is an adequate system in place which ensures that the circumstances of an
arrest are accurately recorded on the custody record and that a Liaison and Diversion practitioner has
access to a wide range of information within the custody setting. Therefore, it is submitted that there is
no risk of future death to be addressed and no action is required in this case.

Yours faithfully

“Legal Assistant
Staffordshire and West Midlands Police Joint Legal Services

JS /L 14002183 / 00192590 Page 3