Katy Samuels

Our Ref: 

5 February 2021 

Mr Delroy Henry,  
HM Assistant Coroner, 
The Coroner's Office,  
Coventry City Council,  
Cheylesmore Manor House,  
Manor House Drive,  
Coventry,  
CV1 2ND 

Dear Mr Henry  

Re: The late Ms Katy Samuels  

I am writing to you in connection with the Regulation 28: Prevention of Future Deaths 
Report which was received from your office on 12 December 2020. 

I was very grateful for the opportunity to give evidence at the inquest about the work 
that  the  Trust  have  been  doing  since  Ms  Samuels  death  in  order  to  make 
improvements for our patients at the Trust.  Although you were satisfied that the Trust 
were making good progress in many areas there were two areas of concern that you 
wanted the Trust to respond to you on. Your report focussed on our arrangements for 
managing  the  safety  of  patients  who  are  prescribed  leave  whilst  detained  in 
accordance with the Mental Health Act 1983, and the second concern focussed on the 
length  of  time  available  for  staff  to  participate  in  a  robust  ‘handover’  between  the 
incoming and outgoing ward shifts. 

1.  Managing Section 17 Leave (Mental Health Act, 1983) 

Following  conclusion  of  the  inquest,  immediate  action  was  taken  to  ensure  that 
patients going on leave under the care of family or friends, would be collected from 
and returned to the ward, by the identified person and not permitted to leave the ward 
unaccompanied to meet family or friends in the reception area or hospital grounds. 

To strengthen and formalise our Section 17 leave arrangements across the Trusts 
inpatient services, we have consulted with our staff and amended our Section 17 
Leave Policy.  The changes to this policy include clear definitions of the types of 
leave: 

- Chair 
 - Chief Executive 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 Fax: 024 7636 8949 
www.covwarkpt.nhs.uk

   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Escorted leave is defined when the Responsible Clinician (RC) directs that their 

patient remains in the care of a staff member or any person authorised, in writing, 
by hospital management.  

•  Accompanied leave is defined when the Responsible Clinician directs leave 

subject to the condition that a patient is accompanied by a friend or relative (e.g. 
on a pre-arranged day out from the hospital).  

•  Unescorted leave is defined when the Responsible Clinician directs leave that 

does not require the patient to be escorted or accompanied. 

Two existing reporting forms have been revised and improved and one additional 
reporting form has been developed [Enc: Section 17 Leave Policy, the forms are 
contained in the appendices].  Each form is required to be completed as part of the 
process of agreeing and enabling leave to commence safely: 

•  The revised “Leave of Absence (Section 17) – Patients detained under the Mental 
Health Act 1983” form has been amended to include space for the Responsible 
Clinician to detail the name(s) of the friend/family/carer identified as responsible 
for the patient when on accompanied leave.   

•  The new ‘Accompanied Leave Checklist’ form requires the accompanying person 
to sign to confirm that they are aware of their responsibilities for the patient’s 
safety and wellbeing whilst on leave when they arrive on the ward to collect the 
patient for the leave. The policy requires that ‘When a patient is to be 
accompanied, staff must ensure that the persons identified to accompany the 
patient, on the s17 leave form, is the person the patient goes on leave with.’ The 
form requires certain information to be discussed including risk.   

•  The revised ‘Leave off the Ward’ form has been revised to record the time the 
patient is due to return as this will act as an escalation trigger if the patient has 
not returned.  A designated member of staff will be appointed on each shift to 
monitor the activity at the entrance to the ward including ensuring that patients 
have returned on time or escalating to senior staff if the patient has not. 

Our  Section  17  Leave  Policy  has  been  approved  through  the  Trust’s  governance 
process with oversight  from senior clinicians and operational staff as well executive 
and non-executive director members of the Trust’s Mental Health Act Committee. 

To embed our revised arrangements for the management of Section 17 leave and to 
ensure that staff are aware of their responsibilities in respect of the revised policy, staff 
engagement events have been held as well as a series of briefings disseminated.   

A  consequence  of  the  Covid  19  pandemic  has  seen  a  reduction  in  escorted  and 
accompanied leave being utilised, and this has impacted on our ability to fully appraise 
ourselves of the impact of these changes.  As we make plans to exit the pandemic, we 
anticipate an increase in levels of leave for patients that we experienced pre-pandemic.  
To ensure our focus remains on patient safety, we will continue to monitor the safe use 
of  leave  thereby  providing  the  organisation  and  its  commissioners  with  assurance.  

 - Chair 
 - Chief Executive 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 Fax: 024 7636 8949 
www.covwarkpt.nhs.uk

   
 
 
 
 
 
 
 
 
 
 Once levels of leave are restored and to support assurance, we will commission an 
independent audit  in the 2021/22 audit programme to ensure our arrangements are 
embedded. 

2.  Handover between ward shifts 

The inquest heard evidence that the time set aside for shift handover was considered 
insufficient by some staff. 

The Trust has identified that there is mixed practice across Mental Health providers, 
with Trusts operating handovers of different duration and taking different approaches.  
The Trust is using this intelligence to inform its own work in respect of its handover 
arrangements.  The Trust has identified that extending the time for staff to handover, 
from one shift to the next, will require a thorough review of the roster and supporting 
processes that the Trust operates to generate staff shift patterns.   This work, ultimately 
leading to an increase in the protected time for handover from ten minutes will impact 
on  current  shift  patterns.    The  Trust  cannot  change  shift  patterns  without  a  robust 
consultative process and is, therefore, working with union and staff side representation 
to ensure this takes place in accordance with Trust policy. 

The  Trust  has  reflected  on  the  inquest  and  used  this  information  to  review  our 
handover arrangements across the spectrum of clinical care, rather an individual focus 
on the ward handover from one shift to another. 

A working group was established that consulted with staff in respect of the role and 
function  of  the  handover  process  to  strengthen  and  ensure  patient  safety  and 
wellbeing.    The  working  group  have  developed  a  Standard  Operating  Procedure  to 
both standardise the handover content and the way in which a handover functions and 
operates.  The Standard Operating Procedure applies to all clinical handover situations 
including:  
•  Shift handover 
•  Transfer of care (between wards or organisations) 
•  Handovers to professionals attending emergency situations 
•  Discharge/leave processes 
•  Handovers between inpatient and community clinicians 
•  Handovers to other team members outside of main shift handovers 
•  Handovers between inpatient wards and the bed management Clinical 

Coordination Centre. 

The  working  group  reviewed  best  practice  for  handover  methodologies  and  tools 
across other NHS Trusts and have adopted the ‘Situation, Background, Assessment 
and Recommendation’ (SBAR) tool, which is a nationally recognised communication 
tool  that  facilitates  the  effective  and  efficient  handover  of  concise,  accurate  and 
relevant information between clinicians and clinical teams.  SBAR supports the timely 
and effective handover of pertinent information which includes, but is not limited to, all 

 - Chair 
 - Chief Executive 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 Fax: 024 7636 8949 
www.covwarkpt.nhs.uk

   
 
 
 
 
 
 
   
 
 
 
 safeguarding  issues  or  risks,  feedback  from  periods  of  leave  from  the  ward,  the 
patients current physical health and feedback from the patient in respect of what they 
would wish the incoming staff team to be aware of.  SBAR is the tool that will be used 
for all handover situations as identified above. 

As an area of recognised good practice, supported by staff, the Trust is continuing to 
use ‘safety huddles’.  Safety huddles bring staff together each day to discuss important 
clinical events affecting patients and is targeted at immediate risks to patient and staff 
safety.  Safety huddles complement the formal handover that is in place.  

To embed our revised arrangements for the management of handover and to ensure 
that  staff  are  aware  of  their  responsibilities  in  respect  of  the  Standard  Operating 
Procedure, staff engagement events have been held as well as a series of briefings 
disseminated.  This  work  will  also  form  part  of  future  local  staff  induction  and 
preceptorship  for  new  staff.    Working  with  our  staff  I  believe  that  the  revised 
arrangements will strengthen handover and provide staff with a clear focus and safe 
handover practice.   

The  Trust  will  continue  to  establish  a  consistent  time  frame  for  handover  after  the 
required  consultation  process,  however  the  Trust  are  confident  handovers  are 
currently more effective based on the work already undertaken. 

3.  Further key actions 

Patient safety is a priority for the Trust.  In responding to the Regulation 28 PFD report, 
I also wanted to take the opportunity to inform you about other work that I am keen to 
progress and complete, which was touched upon during the inquest. 

I have requested that a dedicated Quality Improvement project be undertaken to focus 
on drilling down and addressing the key areas for improvement identified through our 
internal investigation of the tragic set of circumstances surrounding this incident,  as 
well as those factors highlighted throughout the coronial process.  The scoping for this 
work has commenced. 

I have also requested and made provision for a full staffing establishment review 
across all in-patient settings, which will include review of the safer staffing levels and 
the required skill mix with the aim of introducing new clinical focused roles across our 
wards to enhance patient safety and wellbeing. 

You will recall that you requested that the ward which had provided care to Ms Katy 
Samuels,  confirm  to  the  family  that  they  have  been  successful  with  achieving  the 
Accreditation for Inpatient Mental Health Services (AIMS).  I will confirm the outcome 
of this process and I am expecting to receive confirmation by end of March 2021. 

 - Chair 
 - Chief Executive 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 Fax: 024 7636 8949 
www.covwarkpt.nhs.uk

   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I confirmed at the inquest that I and my Trust Board colleagues have taken this matter 
extremely seriously and continue to do so.  I trust that this letter provides you with an 
appropriate level of assurance regarding the actions taken, and those to be taken, to 
continue improving patient care. 

I would be grateful if you could share a copy of my response to you, with the family of 
Ms Samuels.     

Yours sincerely 

Chief Executive 

Enc: Section 17 Leave Policy 

- Chair 
- Chief Executive 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 Fax: 024 7636 8949 
www.covwarkpt.nhs.uk