Shannon Quinn

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 616161 
Fax: 03000 616171 

www.cqc.org.uk 

Mr Zafar Siddique 
Black Country Coroner’s Court 
Jack Judge House 
Halesowen Street 
Oldbury 
West Midlands 
B69 2AJ  

BY POST AND EMAIL  

03 January 2020 

Care Quality Commission 
Our Reference: MRR1-6821115121 

Dear HM Coroner,  

Prevention of future death report following inquest into the death of Shannon 
Quinn.  

Thank you for sending CQC a copy of the prevention of future death report 
issued following the death of Shannon Quinn (Miss Quinn). 

Background:  

In terms of the actions already undertaken by the CQC following receipt of 
information concerning the death of Ms Quinn, CQC first became aware of Miss 
Quinn’s in January 2019 when the provider notified us of her death. Upon receipt 
of the evidence bundle for Miss Quinn’s inquest on 30 April 2019, we reviewed 
the evidence for the purpose of informing our monitoring of the service. On that 
basis we identified potential ongoing risks for people living at Oak House. These 
risks related to the management of self-harming behaviours and suicidal ideation. 
In response, we began a comprehensive inspection of the service on 15 May 
2019. Over the course of the 15 and 16 May 2019, inspectors visiting the service 
identified serious concerns in relation to the following:  

1.  Risk management.  
2.  Incidents and allegations of abuse not being reported to external agencies.  
3.  Lack of managerial or provider oversight at the service.  

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 The seriousness of the concerns led to us taking urgent enforcement action on 
17 May 2019 imposing conditions on the provider’s registration pursuant to 
section 31 Health and Social Care Act 2008 (HSCA). Further inspection visits 
were conducted on the 21 May 2019 and 4 June 2019. In response to the 
information and evidence gathered during those further visits CQC took further 
urgent enforcement action and imposed additional conditions dated 22 May 
2019, also pursuant to section 31 HSCA. We then met with the provider on the 
27 June 2019 to discuss our concerns.  

A report of our findings from this inspection can be found at 
https://www.cqc.org.uk/location/1-1249253242. You will note that the provider 
was given an overall rating of Inadequate and placed into special measures. This 
means we will keep the service under review and, if we do not propose to cancel 
the provider’s registration, we will re-inspect within 6 months to check for 
significant improvements. 

An inspection of the other active Camino Healthcare Limited service, Cromwell 
House, was also undertaken in response to the findings at Oak House. This 
inspection took place on 13 June 2019. The provider was given a rating of 
Requires Improvement for this service.   

We intend to re-inspect Oak House in line with our inspection schedule. Whilst 
we cannot disclose the date of our next inspection, we can inform you that we will 
shortly be undertaking another inspection of Oak House to assess improvements 
made and action taken to meet the conditions placed on the provider on 17 May 
2019. In the meantime we continue to monitor the service. 

In addition, you may be aware from 1 April 2015 CQC is the lead enforcement 
body for health and safety incidents in the health and social care sector in 
England following the coming into force of the Health and Social Care Act 2008 
(Regulated Activities) Regulations 2014 (RAR 2014). CQC is currently making 
enquiries into whether criminal enforcement action should be taken in relation to 
her death. This investigation is ongoing at the time of writing this letter, so I am 
unable to provide any further updates or outcome at this time.  

Specific response to matters of concern identified in your Regulation 28 
report 

Within your Regulation 28 report, you identified the particular matters of concern. 
We respond to each in turn below:  

1.  Evidence emerged during the inquest that there was inconsistent 
sharing of documentation and case notes between the statutory 
agencies and private sector. In Particular, there was no sharing of 

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 medical notes/care plans between the Birmingham and Solihull 
Mental Health Trust and Oak House.  

During the inspection of Oak House in May and June 2019, inspectors identified 
failures in the providers systems to work with other agencies. In particular the 
inspection identified that a total of 53 safeguarding incidents had not been 
escalated to the local authority. CQC had also not been notified of these 
incidents as required by law. We are currently considering enforcement action in 
relation to this failure to notify us of incidents. These incidents were shared with 
agencies following the inspection by CQC and the provider.  

At the next planned inspection of Oak House, we will review how the provider 
shares information and works alongside external agencies to review if these 
systems have improved.  

At our next meeting with Birmingham and Solihull Mental Health Foundation 
Trust we will discuss with the senior leaders how information is shared with 
private providers who take patients from the trust and what action has been taken 
to ensure essential information is been shared. 

Additionally, at our next inspection of the Trust we will check that information 
sharing has improved. 

2.  There was inconsistent and minimal training provided to Oak House 
staff in respect of managing SQ’s Complex needs by the Mental 
Health Trust.  

At the most recent inspection of Oak House in May and June 2019, we identified 
that staff did not always receive training to enable them to support people 
effectively. The report states:  

‘Staff did not receive training and support that provided them with the skills and 
experience required to support people effectively. One member of staff told us, 
"The trainings not the best". Staff felt ill equipped to support people with their 
complex mental health needs. One member of staff told us, "They [the provider] 
sold this as a rehabilitation unit but then placed people who are not suitable for 
rehabilitation. They [people] are too complex and the training doesn't match the 
people we have here". 

In response to our inspection findings, Camino Healthcare Limited submitted an 
action plan that detailed their intention to review the training provided to staff. We 
will follow this up at our next scheduled inspection to ensure that sufficient action 
has been taken to improve the training provided to staff.  

3.  There was a lack of a Joint multi-disciplinary/trust care plan and 

insufficient contact with the care co-ordinator due to difficulties in 

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 travelling to meet the patient outside of the normal trust area and 
staff sickness absence.  

At our last inspection of Birmingham and Solihull Mental Health Foundation Trust 
in November 2018, we rated the Mental Health Crisis and Health-based place of 
safety as requires improvement. We found that the service did not have sufficient 
staff and their caseloads were high. We also found that staff did not respond 
quickly when patients contacted them, and we found that patients had to wait to 
be seen. Our report found the team worked well as a multi-disciplinary team and 
with relevant organisations.  

The local inspection team meets regularly with leaders of the Trust and will at 
their next meeting be discussing with the Trust how they currently liaise with 
organisations that take patients outside of their normal catchment area. We are 
planning an inspection of the trust in 2020 and will follow this up at that inspection 
to ensure action has been taken to improve coordination of patient care when 
patients are out of area. 

4.  There was an escalating risk of use of ligatures and incidents of self-
harm and little if any measures were introduced to try and provide a 
ligature free environment.  

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 
Regulations 2014 requires that providers must assess the risks to the health and 
safety of service users of receiving the care or treatment and do all that is 
reasonably practicable to mitigate any such risks.  

By way of background, at the inspection of Oak House in May and June 2019, we 
identified that a Ligature Risk Assessment had been completed in the weeks 
following the death of Miss Quinn. This identified that although no remedial action 
was required to the environment, consideration should be given to other 
measures that may improve the safety of the environment. At the inspection, we 
found that these suggested considerations had not been implemented and had 
the potential to pose a risk to other service user’s at Oak House.  

As a result of this, we took urgent enforcement action that required the provider 
to seek the advice of an external mental health professional in risk assessing the 
environment and required them to act on the findings of this audit. The provider 
took this action on 29 and 30 May 2019. For your information, the condition 
placed on the provider at this time was as follows:  

By 5pm on Friday 31 May 2019, you must have instructed an independent mental 
health professional to undertake a risk assessment of the environment in relation 
to the risks of service user self-harm and suicide. You must inform CQC in writing 
by 5PM on Friday 31 May 2019 of the independent mental health professional you 
have  instructed  and  the  date  the  risk  assessment  will  take  place.  The  risk 
assessment  must  include  areas  of  concern  that  you  must  address,  including, 

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 ligature  risks.  You  must  provide  CQC  with  a  copy  of  the  risk  assessment  and 
actions taken by you as a result of the risk assessment.    

We are aware that there are only currently three people living at Oak House, and 
that these people do not present risk of self-harm or suicide. However, at the next 
scheduled inspection, we will review the actions taken in response to the external 
professional’s audit, and review if the provider has systems to regularly assess 
the safety of the environment for the remaining service users.  

5.  The patient observation level of five minutes was introduced to 

minimise risk of self harm but not adhered too.  

As noted above, Regulation 12 of the Health and Social Care Act 2008 
(Regulated Activities) Regulations 2014 states that providers must assess the 
risks to the health and safety of service users of receiving the care or treatment 
and do all that is reasonably practicable to mitigate any such risks.  

At the inspection of Oak House in May and June 2019, we identified further  
serious concerns in relation to the management of risk, specifically where service 
users were at risk of self-harm or suicide. We identified that for some people, 
there were no risk assessments providing guidance to staff on how to ensure 
people’s safety. Where risk assessments were in place, these lacked details and 
we found that staff were not applying the guidance provided to them consistently.  

In response, we took urgent enforcement action and imposed the following 
condition on the provider’s registration:  

‘By 5pm on Monday 20 May 2019, you must have carried out a review of all 
service users who have a history of self-harm or suicidal ideation and ensure that 
risk assessments are in place.  The risk assessments must ensure there is clear 
guidance for staff of the actions they must take to ensure each service users’ 
safety regarding self-harm or suicidal ideation. The risk assessments must 
include an assessment of the environment and how any identified ligature risks 
will be addressed.’ 

We reviewed the provider’s compliance with this condition on 21 May 2019 and 
found that the provider had implemented these risk assessments. This condition 
remains on the provider’s registration and we will further review their compliance 
with this at the next scheduled inspection.  

6.  Evidence emerged during the inquest that there had been minimal 

training for Oak House staff in performing resuscitation on patients. 
The training received included general first aid training by e-learning.  

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 As you may be aware the fundamental standards regulations we inspect against 
do not prescribe what particular training providers must provide to their staff, nor 
in what format. However, registered providers must ensure that: 

Persons employed by the service provider in the provision of a regulated activity 
must receive such appropriate support, training, professional development, 
supervision and appraisal as is necessary to enable them to carry out the duties 
they are employed to perform.  

In the case of Oak House and its inspection, we found that the provider had not 
ensured that staff had received training relevant to their role and the needs of the 
service user’s they were supporting. In response, the provider submitted an 
action plan that detailed their plan to deliver new training to staff. We will follow 
this up at our next scheduled inspection taking account of this particular matter of 
concern to ensure that lessons are learnt, and sufficient action has been taken to 
improve the training provided to staff.  

We hope this letter fully clarifies the action we have taken to date as well as the 
ongoing regulatory activity and future monitoring and inspection action we intend 
to take in relation to Oak House and the providers Camino Healthcare Limited 
and Birmingham and Solihull Mental Health Trust in relation to the matters of 
concern you set out in your report.  

If you do have any queries, then please do contact us using the below:  

By email: 

By post: 

CQCInquestsandCoroners1@cqc.org.uk 

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Please include the reference number MRR1-6821115121. 

Thank you in advance for your assistance. 

Yours sincerely 

Head of Inspection 

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Dear Mr Siddique

We refer to the Report to Prevent Future Deaths dated 6th September 2019 in relation to the death of 
Miss Shannon Quinn. 

By of an update on the Service provided at Oak House; this is in the process of closing and there are 
only 3 remaining  residents. We continue to assist outside agencies in transitioning these residents to 
suitable placements and anticipate that the service will be closed within 6 to 8 weeks. 

Notwithstanding  the  planned  closure,  since  the  incident  Camino  Healthcare  have  undertaken  a 
significant review of the service, and the service users who we care for, in order to ensure their safety. 

We now have a new Executive team and all of the Managers who were employed at the time of the 
death  have  since  left  the  company. The  new  Management  and  Organisational  Structure  have 
maintained clear communication with outside agencies and, when necessary, have ensured that issues 
are escalated to the appropriate teams. 

We have also evaluated all of our training and our staff have received further training in Intensive Life 
Support and also Basic First Aid (where required) which includes CPR. The Intensive Life Support which 
is mandatory for our staff  exceeds the regulatory requirements of the service.

A full and thorough review of the premises was undertaken immediately after the incident and changes 
were made to make the environment anti-ligature as far as is reasonably practicable.

Yours Sincerely

Nominated Individual- Camino Healthcare