Roy Campbell

Chief Executives Office 
Worcestershire Health and Care NHS Trust 
2 Kings Court 
Charles Hastings Way 
Worcester 
WR5 1JR 

Tel: 01905 681667 

e-mail:  

www.hacw.nhs.uk 

4 May 2020 

Mr D Reid  
HM Senior Coroner  
Worcestershire Coroner’s Court  
The Civic Centre  
Martin’s Way  
Stourport-on-Severn  
DY13 8UN   

Dear Mr Reid   

Re: Inquest touching the death of Roy Campbell - Regulation 28 report to prevent future deaths - 
response  

Thank you for your letter dated 9th March 2020, and the enclosed Regulation 28 report. I have read your 
report with great care and note the concerns that you have raised as a result of the coronial inquiry into 
the death of Roy Campbell.  

In your report, you highlighted the following points of concern and I will respond to each in turn:   

1)  During the inquest, I heard evidence from 

, who conducted the trusts own 
investigation  into  this  incident  that,  not  long  after  Mr  Campbell’s death, the trust had 
introduced a visitor book system for use at the relevant wards at Newtown Hospital. It was 
originally  thought  by  the  trust  that this system would be sufficient to prevent patients 
leaving the ward as Mr Campbell had done. It was not until evidence was giv en at the first 
(aborted) inquest into Mr Campbell’s death in October 2019, however, that the trust came 
to the view that this system was inadequate, and further work was done, which came up 
with a solution involving the use of an electronic system, which  will use photographs to 
identify whether a person wishing to leave the ward, had previously been admitted as a 
visitor.  I  am  told  that,  whilst  a  business  case  for  this  proposed  new  system  has  been 
submitted, it is still awaiting approval before it can be implemented.  

2)  I therefore remain concerned that unless and until such a system has been approved and 
put  in  place,  there  remains  a  risk  of  patients  absconding  from  the  wards  at Newtown 
Hospital, and if elderly and/or physically compromised, as Mr Campbell was, an increased 
risk of death in such patients.  

Chairman: 
Chief Executive: Sarah Dugan  

Working together for outstanding care 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Firstly, I am sorry about the delay in implementing this system. I can confirm that approval for the visitors 
system  has  now  been  granted,  and  the  system  has  been  ordered.  The trust has in fact ordered 8 
systems  to  enable  installation  of  this  system  on  all  of  the  wards  and  rehabilitation  units  in 
Worcestershire,  under  their  control.  In  addition,  on  1 st  April  2020,  Mental  Health  services  for 
Herefordshire were taken over by Worcestershire Health and Care NHS  Trust. Therefore, a further 2 
systems have been ordered for the wards in Hereford. It is important to the trust, to have a consistent 
approach across all of our sites, and I would like to assure you that security is always a priority for our 
patients. 

3)  During  the  inquest,  I  also  heard  evidence  that  environmental  checks,  introduced  by 
Athelon  Ward  to  try  to  identify  and  remedy  any  means  by which a determined patient 
could try to leave the secure confines of the ward, were not carried out properly at the 
time of these events, and are still not enshrined in trust policy, thereby ensuring that staff 
receive mandatory training on it. I was concerned to be told that only after evidence was 
heard  at  this inquest on Monday 2nd March 2020, the current form which was used for 
checks was revised and staff on both Athelon and Holt ward were instructed to start using 
it.  I  was  surprised  that  these  revisions  were  made  at  such  a  late  stage  when  the 
information given in evidence which led to those revisions must have been a vailable to 
the trust some time ago. I am also informed that it could take a further 2 months for the 
proper completion of this form to be enshrined in trust policy. 

4)  I am concerned that unless and until these environmental checks become both the subject 
of both policy and of mandatory training for all ward staff, there remains a risk that the 
means by which I vulnerable patient might try to leave the confines of the ward may not be 
identified in time. If that patient were to be elderly and/or physically compromised as Mr 
Campbell was, this will lead to an increased risk of death in any such patient.   

The  environmental  check  forms  were  originally  designed  by  Athelon  Ward as a means of, not only 
identifying modes of exit from the ward, but also other possible  environmental risks to patients. They 
were in use in their original form at the time of Mr Campbell’s death, and I am sorry to hear that they 
were not in fact used correctly at that time.  

I am informed by the ward, that during the trusts internal investigation into the incident, it was highlighted 
that  there  had  been  several  missed  checks  on  the gate adjoining the ward gardens on the day Mr 
Campbell absconded from the Athelon ward. I am also told that in evidence in the first (aborted) inquest, 
it came to light that a member of staff had noticed the gate adjoining the ward gardens to be opened, but 
had not highlighted this on the form.  

I would like to clarify one matter in relation to your  concerns around the use of these forms. It is not 
correct to say that no changes were made to the forms until 2 nd March 2020.  

Following the evidence in the first inquest in October 2019, the form was amended to ensure that it was 
simplified and clearer for all staff, and staff were instructed to use this new form from October 2019, and 
were doing so from then. I do accept that this perhaps could have been done sooner, upon the discovery 
of the missed checks in the Root Cause Analysis investigation. 

Chairman: 
Chief Executive: Sarah Dugan  

Working together for outstanding care 

 
 
 
 
 
 
 
 
 
 
 
 In  evidence  on  2nd  March  2020,  I  understand  that  a  member  of  staff  admitted  to  pre -signing  the 
environmental check form on the morning of Mr Campbell’s absconsion from the ward, rather than at the 
end of the shift when the checks had actually been completed. This is unacceptable, and the member of 
staff in question has been spoken to about this by the Ward Manager. It was this additional information, 
which the trust were not aware of before the evidence was given, which then led to another version of 
the form being introduced, and the discussion that it should be enshrined into policy.   

The form which had been introduced in October 2019 was further amended by the Ward Manager, who 
was present at Court on Monday 2 nd March 2020, and approved by a senior manager within the trust, 
that same day. By the morning of Tuesday 3 rd March 2020, the new amended form had been sent to 
Athelon Ward, and New Haven ward (a specialist dementia care unit) and staff had been instructed to 
use the new form with immediate effect.  

The new form included a provision for the nurse in charge of each shift, to carry out a check, both at the 
beginning and at the end of that shift, thus enabling the nurse in charge to ensure that all checks had 
been done in between their own checks. The nurse in charge is only to sign the form at the end of each 
shift, after checking that all checks have been completed. This system also ensures that the nurse in 
charge of both the shift handing over, and the shift receiving, are completing the checks togethe r, which 
should therefore mean a seamless handover of any issues, should any have arisen.   

This  form  and  procedure  has  now  been  enshrined  into  policy,  and  a copy of the updated policy is 
enclosed herewith for your consideration. You will note that there a re several different environmental 
checklists  in  the  appendix  to  the  policy.  As  each  ward  under  the  control  of  the  trust  has  different 
environmental  factors  and  risks,  it  is  not  possible,  or  safe,  to  have  one  single  form  for  all  wards. 
Therefore, as it is now trust policy to use the forms, different forms have been introduced for each ward, 
which are relevant for the potential risks on that particular ward.   

You  will  note,  that  the  policy  also  makes  it  clear  that  any  pre -signing  of  these  forms  may result in 
disciplinary action.  

In relation to training, the Trust have very specific general mandatory training which is covered across all 
services. It would not be appropriate to include the training on the environmental forms as part of the 
trusts mandatory training. Nor would it be possible to add it to the general list of mandatory training due 
to the differing nature of the forms.  

The use of the environmental checklists will however now be covered in every new member of the ward 
staff’s induction, to ensure that they are properly trained on the form appropriate to the ward where they 
will be working, and also the policy. All new starters must complete an observations competency form. 
Training  on  the  new  forms  and  policy  will  be  included here. In addition,  the forms are currently the 
subject of discussion in any existing member of staff’s supervision sessions to ensure they are aware of 
the new amendments to policy and the expectations around the environmental checks themselves, and 
the use of the forms.   

I trust that the foregoing has adequately addressed the Regulation 28 report issued subsequent to the 
inquest into the death of Roy Campbell.  

Should you require any further updates or clarification in relation to these matters, please do not hesitate 
to ask.  

Chairman: 
Chief Executive: Sarah Dugan  

Working together for outstanding care 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I confirm that I have not forwarded a copy of this response to any other Interested Person and would 
therefore be grateful if you could do so as appropriate.  

I also confirm that the Trust is content for both the regulation 28 report and the respon se to be released 
or published should the Chief Coroner wish.  

Yours sincerely 

Sarah Dugan 
Chief Executive 

Encl. 

Chairman: 
Chief Executive: Sarah Dugan  

Working together for outstanding care