Miles Naylor

Our Ref: 2018.6152
Your ref: ORL/HK-736-2018

Private & Confidential
Mr O R Longstaff
City Court

The Tyrls

Bradford

BD1 1LA

Via email

5 March 2020

Dear Mr Longstaff

Re: Miles Glynn Naylor (deceased)

NHS)

Bradford District Care

NHS Foundation Trust

Bradford District Care NHS Foundation Trust
New Mill

Level 2

Victoria Road

Saltaire

West Yorkshire

BD18 3LD

Tel: 01274 363425

Regulations 28 and 29 of the Coroners (Investigation) Regulations 2013

| am writing in response to your letter dated 10 January 2020, in which you enclosed the

Regulation 28: Report to Prevent Future Deaths.

Please find below the Trust's response to the Matters of Concern that you raise.

The jury formally recorded their opinion as part of the conclusion to the inquest
that Bradford District Care NHS Foundation Trust should carry out a review of its
management of its ligature risks from personal items.

Since the Inquest in January 2019 the Trust has made significant improvements to
managing ligature risks within its inpatient services this is in two parts:

1. Management of Clinical Risk

The Trust continues to review the processes which are in place regarding personal
belongings. In doing this the Trust recognise there is a balance to be struck of ensuring
a patient's safety against taking steps that may be seen as negatively impacting on a
patient’s improvement in their mental health.

The Trust has reviewed the policy for Blanket Restrictions: Oversight, Use & Reporting
Policy & Procedure for Mental Health Inpatient Services. \t is important that wherever
possible the least restrictive option will be used to maximise patient experience and
independence as this is seen as an important part in the mental health of a patient
being improved.

As such, the Trust does not routinely remove potential ligature items such as
belts/laces from individuals. Where there is a clear clinical risk for example a clear
history or expressed intention to harm themselves, it may be appropriate to remove
such items. This will be risk assessed and care planned with the use of increased
observations.

In July 2019 the Trust introduced a model where each in-patient ward has a dedicated
Consultant Psychiatrist, this has provided the team with a greater opportunity for

W: www.bdct.nhs.uk 9 8: @BDCFT

better lives, together

inpatient MDT working with a daily presence of all disciplines to review individual care
and risks.

2. Managing the Environment

In April 2019 the Trust undertook a review of how ligature risks are assessed and
managed in our in-patient areas. A new approach has been introduced (Manchester
Audit Tool) which grades ligature risk based on four factors. The four factors are:

Room designation rating
Patient profile rating
Ligature point height rating
Compensating factors rating

This has led to a standard inpatient assessment of ligature risk. The assessment is
undertaken by a multi-disciplinary team. Following individual risk assessment, a
template is completed and uploaded on the Trust’s system which is visible to the ward
managers to input both any estate works required, date for the repairs/works to be
completed and the clinical actions and mitigations in place. A printed risk assessment
is made available for all staff on the ward and used as part of staff induction and
ongoing management of risks and these are reviewed yearly. Visual aids and training
for staff are provided.

All ligature risk assessments are reviewed and monitored by the monthly Ligature
Environmental Risk and Safety group. The group also assesses all new ligature
incidents that are with or without an anchor point to consider any learning
requirements.

During the course of the evidence, questions were raised about the design of the
doors on Oakburn Ward, and whether access to the hinge pin side of the doors
might be prevented by the use of covers (similar to the finger guards is use in
childrens nurseries and similar premises).

The Trust acknowledges the concerns raised during the inquest and a need to review the
design of the doors in our on in-patient wards. In June 2019, a business case was
developed and submitted to the Trust Board which included environmental improvements
and the introduction of high specification full door alarms on identified bedrooms on 8
high risk wards, including Oakburn. Work has begun installing these doors in designated
rooms on high risk wards as part of phase 1 development and is due to be completed by
April 2020.

As the coroner will appreciate, replacing all the doors has a significant capital expense
which was included in the Trusts ongoing capital improvement programme and has been
identified as a Trust priority.

In addition to the above which specifically relates to ligature risks, the Trust has made
significant improvements on ail inpatient wards over the last year. The Trust introduced
detailed daily checks in all inpatient areas. These checks include considering
admissions, leave, observations, clinical risk assessments, incidents and care plans,
maintaining the Trust's focus on the key question of: “Are we Safe Today?”.

Our Ref: 2018.6152
Your ref: ORL/HK-736-2018

| hope the above provides assurance that the Trust has taken action to mitigate against
potential patient safety incidents involving ligatures.

If you would like any further information or assurances, please do not hesitate to contact
me.

Yours sincerely

Brent Kilmurray
Chief Executive

better lives, together Wi www.bdct.nhs.uk WF: @BOCFT