Ricky Barcock

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RECOVERY COMMUNITI

Date 13 December, 2019.

Martin Fleming.

HM Senior Coroner for West Yorkshire Western.
City Courts.

The Tyrls.

Bradford.

BD1 1LA

Dear Mr Fleming,

RE: Rick Barcock, deceased

Report to Prevent Future Deaths.

Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and
Regulation 28 and 29 of the Coroners (Investigations) Regulations 2013

Oasis Bradford is an independent mental health service that provides residential care
for persons with substance misuse problems. This includes medically managed
withdrawal from problematic substances and a programme of therapeutic
interventions. It is staffed with a nurse and support staff 24 hours a day and a therapy
team during the day.

Following receiving your letter and report dated 24‘ October 2019, Oasis Bradford has
reviewed and updated the Observation and Client Wellbeing Checks Policy December
2019 (previously the Client Wellbeing Checks Protocol Sept 2018). Please find a copy of
this policy enclosed. The policy has been expanded in explanation and explicit
instruction on working practice.

In addition the related risk assessments, policy and procedures have also been visited
to ensure they work collectively together. A list of the related risk assessments, policy
and procedures can be seen at the end of the Observation and Client Wellbeing Checks
Policy December 2019.

All staffs have been trained in the Client Wellbeing Checks Protocol Sept 2018.
Following the review and update of the Observation and Client Wellbeing Checks Policy
December 2019 all staffs are now to receive further training to ensure working practice
is safe and effective and in line with the policy changes. This will be complete in January
2020.

Treatment Direct Ltd, C/O Uk Addiction Treatment Group Ltd Unit 1, 1st Floor, {mperial Place,
Maxwell Road, Borehamwood, England, WD6 1JN Tel, 0203 553 1709. Company Number 10237960.

RECOVERY COMMUNITIES
The ongoing monitoring and management of safe and effective working practice will
be conducted by the registered manager at Oasis Bradford through working practice
observation, supervision, handovers and team meetings. This is already in place and will

be adapted to reflect the reviewed and updated the Observation and Client Wellbeing
Checks Policy December 2019.

If you require any further detail Oasis Bradford will respond promptly.
Yours sincerely, -.
. . :
we
Orns

Head of Performance and Compliance.
UK Addiction Treatment Group.

Treatment Direct Ltd, C/O Uk Addiction Treatment Group Ltd Unit 1, ist Floor, Imperial Place,

Maxwell Road, Borehamwood, England, WD6 1N Tel, 0203 553 1709. Company Number 10237960.

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RECOVERY COMMUNITIES

Observation and Client Well Being Checks Policy
September 2018 - updated December 2019

This policy is in relation to the monitoring and checking of the client group and replaces any
previous policy covering client wellbeing checks for the same time frames.

The purpose of this policy is to ensure the safe and effective monitoring of the wellbeing of all
clients during their stay at Oasis Bradford. The policy will ensure that staffs are maintaining
awareness of the possible risks associated with the client group, and monitoring the wellbeing
of all clients effectively.

The registered manager is responsible for ensuring this policy is adhered to by all staff. The
senior management team will support and monitor Oasis Bradford to ensure the policy and
practice remains safe and effective. This will be achieved through quality audits and compliance
checks,

Knowing the risks

As an inpatient treatment center for those with addictions, who are detoxing from different
substances, there are certain risks that all staff must be aware of so that they are able to
safeguard the clients whilst in our care. There are core risks that specifically relate to the client
group that are most prevalent which must be at the forefront of practice day to day.

Overdose; Opiates - When a person takes a higher dose of opioids than their body and brain
are able to manage, they may experience an overdose. An opioid overdose can be life-
threatening, you must seek medical help immediately if an overdose is suspected. When a
person experiences an opioid overdose, there are 3 key symptoms to look for, referred to as
the “opioid overdose triad”.

e Pinpoint pupils.

e Slowed or stopped breathing (possible respiratory depression)

e Unconsciousness/non-responsiveness.
Respiratory depression is one of the most dangerous symptoms because it can lead to hypoxia
or inadequate blood oxygenation, which can cause permanent brain damage or even death.
Another concern with opioid medications is slowed or stopped heart rate, which can also be
fatal.

Observation and Client Well Being Checks Policy — v2 Dec 19 DP

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Overdose; Benzodiazepines — A benzodiazepine overdose can occur when a person takes more
than the recommended dose or combines the sedative with another substance, such as alcohol
or Opiates.

The signs and symptoms of a benzodiazepine overdose may differ from person to person and
depend on a variety of factors. Some of the signs of an overdose include:

Trouble breathing or inability to breathe.
Bluish fingernails and lips.
Confusion and disorientation.
Extreme dizziness.

Blurred vision or double vision.
Weakness.

Uncoordinated muscle movements.
Tremors.

Profoundly altered mental status.
Stupor.

Coma.

Seizure; Alcohol/Epileptic ~ Generalised tonic-clonic seizures, involving uncontrollable jerking
movements, are the most common of seizures that occur with severe alcohol withdrawal. These
are often referred to as Grand mal seizures.

The tonic phase of a grand mal seizure involves around 20 seconds of unconsciousness and
involuntary muscle spasms. This leads into the clonic phase, which involves convulsions that can
repeat for a few minutes.

Oasis Bradford Seizure Protocol gives clear instruction and guidance on the procedure for
dealing with seizures.

General health; This a wide ranging topic and includes many differing conditions and types of
possible risks that might be associated with those conditions — some of the basic aspects to look
at when monitoring/checking on clients are breathing, chest pain, mobility issues, blood,
pressure, pulse. Does the client appear to be in any distress? Is the client responsive?

Observations

Observations; The aim of observation is to ensure patient safety where risks have been
identified. Effort must be made to ensure observation is a therapeutic interaction which is
balanced between the need to maintain safety and respect/dignity. Observations will be
reviewed at every team handover meeting (every day -morning, afternoon and evening at shift
changes) and where a higher level of risk is identified observations will be implemented or
increased. The following observations will be implemented dependent on the level of risk
presented.

Being Checks Policy — v2 Dec 19 DP

Level 1 observations;

This represents the minimum level of observation for all clients. Staff will have knowledge of the
patient’s whereabouts at all times and adhere to the standard wellbeing checks documented
below. This means that when following the timetable of events the staff member will note all
clients attendance, where a client does not attend a staff member will be sent to check on their
wellbeing.

Level 2 observations;

This category of observation is used for all clients who display an implied risk to themselves or
others with specified regular contact by a staff member at no less than 60 minute intervals. The
client’s location must be checked at regular intervals (exact times to be stipulated in

the notes and according to the risk presented). If the client is asleep, signs of life must be
observed and documented. During the day the client must be roused and spoken to. During the
night the client must be observed breathing satisfactorily and present in no difficulty, if in any
doubt they must be woken. Reasons for doubt may include — labored breathing, noisy breathing,
excessively loud snoring, insufficient rise and fall of the chest, client has not changed sleeping
position within one hour an any evidence of distress.

This level of observation is appropriate when clients are potentially, but not imminently, at risk.
Clients with depression, but no immediate plans to harm themselves or others, or clients who
have previously been at risk of harm to self or others but who are in a process of recovery,
require intermittent observation. Clients that are being titrated on any opiate based medication
in order to determine the correct levels for a substitute opioid. This task can be undertaken with
more than one patient during the normal activities in the centre.

Level 3 observations;

This category of observation is used for all clients that pose an imminent risk to themselves or
others. This represents the highest level of observations available in the service. Clients must
receive contact with staff no less than every 15 minutes or if the presenting risk has been
identified as too high for the service to manage, arm’s length care must be implemented until
the emergency services have arrived to take the client to a more suitable setting. When the
client is sleeping and requires 15 minutes observation, they must be woken and spoken too
every hour day or night.

All observations and risk management plans must be reviewed by the multi-disciplinary team at
every handover (3 times per day) and any relevant changes or step down must be documented
with a clear rationale as to why the risk has reduced.

Client Well Being Checks Policy — v2 Dec 19 DP

1.10

Wellbeing checks

Wellbeing checks must be carried out on all clients no matter how low the risk they present. All
wellbeing checks must be documented in the client wellbeing checks folder. All clients that have
not attended for medication must be visited by the nurse as soon as possible, encouraged to
attend for their medication, a minimum check is to engage in conversation with the client. Each
day the staff team will monitor all clients as follows;

Ifa client is not in group we must let the nurse know so they are aware of this with a
reason why they are not in group in case physical checks need to be carried out.

Level 2 observation. Any client that is excused by the Nurse to sit out of group sessions
to sleep must be checked each hour for the duration of the time that they are excused
from group sessions or asleep. These checks must check be rousing the client and
speaking to them, checking breathing and must be recorded on an individual
observation chart.

At breakfast time (8.30am), Lunch time (1pm), Dinner time (5pm) and every medication
round (06.00, 12.00, 18.00 and 22.00) every single client must be spoken to and have
verbally responded to basic questioning from a staff member. This is documented in the
client wellbeing checks folder

After the evening handover the nurse coming on shift at 7:30pm is to check each client
again as above; every single client needs to be checked on, to be seen and heard from
verbally (talking): to say hello and that you are now on shift, to check that they are ok
and not in distress. This is documented in the nurses notes.

Overnight checks must be carried out every hour from 23.00 until 06.00 the following
morning. The nurse must enter every client’s room and check for signs of life, ensuring
they view the client breathing normally. The checks must be documented.

During the day checks will be a physical rousing and speaking to. During the night checks
will be visual and audible checks for normal signs of life, unless on level 3 observations.
These checks are outlined in observations levels 1 to 3.

The nurse and staff must ensure that at bedtime they see and speak to all clients before
the evening wellbeing checks commence. This is documented in the nurses notes by the
nurse.

Observation and Client Well Being Checks Policy — v2 Dec 19 DP

If a client is in distress or non-responsive

1.11 Where there is any concerns then you must alert the Nurse on duty immediately and commence
emergency procedures if required

1.12 Whenever you are in doubt then you must alert the Nurse on duty to assess the situation

1.13. Naloxone must be administered if there is any reason to suspect an opiate overdoes. Outlined in
the Naloxone Standard Operating Procedure.

1.14 Resuscitation equipment must be used where required. When a respiratory depression is
suspected then oxygen must be used. Outlined in the Medical Emergency Policy.

1.15 The emergency services must be called where required.

Training and working practice
1.16 All staff must be fully trained and competent in the observation and wellbeing checks policy.
Training will be completed at the start of employment and refreshed each year.
1.17 Staff adherence to the procedures will be monitored and managed through working practice
observation, supervision, handovers, team meetings and audits.

Policy review

1.18 This policy must be reviewed yearly.

Additional policy, procedure and risk assessments that relate to and work with this policy are:

Bag and Person Search risk assessment
Visitors risk assessment

Client self-harm and suicide ideation risk assessment
Alcohol related seizure risk assessment
Ligature point risk assessment

Overdose awareness risk assessment

Medical Intervention Policy

Bag and Person Search Procedure

. Visitors Policy

10. Seizure Policy

11. Medical Emergency Policy

12. Naloxone SOP (Standard Operating Procedure)

PON AAPWNE

Policy created September 2018 by registered Manager Oasis recovery Communities
Policy review December 2019 by Head of Performance and Compliance

Observation and Client Well Being Checks Policy — v2 Dec 19 DP