Christopher Swain

Private & Confidential 
Her Majesty’s Coroners Court 
The Senior Coroner, Ms Penelope Schofield 
Centenary House 
Durrington Lane 
Worthing 
BN13 2PQ 

Email: 

EMAIL: 

Swandean - Trust HQ 
Arundel Road 
Worthing 
West Sussex 
BN13 3EP 

Tel: 

21st January 2021 

Dear Mrs Schofield  

Thank  you  for  your  letter  of  15th  December  and  Regulation  28  and  29  of  the  Coroner's 
(Investigations) Regulations 2013 following the inquest of Christopher Patrick Swain which 
concluded on 12th October 2020. 

As you heard during the inquest, there has been considerable reflection and action, within 
the  Trust,  following  Christopher’s  tragic  death  at  Langley  Green  Hospital  on  22nd 
September 2019. 

Christopher  did  not  receive  the  standard  of  care  we  expect  in  the  hospital.    The  clinical 
team immediately undertook an investigation in to the events leading up to Christopher’s 
death and identified a number of actions and learning that has been shared and cascaded 
within Langley Green Hospital and across our acute inpatient services. In order to provide 
you assurance that service improvements have indeed been made Trust-wide, and not just 
at  Langley  Green  Hospital,  my  Operational  and  Service  Directors  within  all  inpatient 
settings have provided me with a full update on the improvements the Trust has made in 
regards  to  the  issues  that  you  raised.  In  response  to  the  matters  of  concern  you  raise 
therefore, I shall address each point in turn, adopting your numbering below: 

a)  During  the  evidence  there  was  some  confusion  amongst  staff  as  to  what  was 
required of them when carrying out observations on patients in their rooms.  There 
were  different  practices  adopted  by  different  staff  and  there  appeared  to  be  a 
custom  of  not  entering  a  patient’s  room  on  the  hourly  observations  so  as  not  to 
disturb the patients. Sadly because of this practice it was unclear when Christopher 
had last been seen alive. Whilst the Trust has indicated that all staff have received 
further training in respect of this I am still not convinced that it is clear as to what is 
required by staff. 

Chair: 

                                                                                                                            Chief Executive: 

Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP 

www.sussexpartnership.nhs.uk 

A teaching trust of Brighton and Sussex Medical School 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 There has always, within the Trust, been a requirement on all acute inpatient hospital staff, 
to  practice  in  accordance  with  the  Trust's  Therapeutic  Engagement  and  Observation 
Policy. I was saddened to hear that some of our temporary staff and other Trust staff did 
not  adhere  to  this  Policy  during  Christopher’s  admission  to  Langley  Green  Hospital.  The 
Policy states 'when a patient appears to be sleeping/ resting, regardless of the time of day 
staff  must  continue  to  monitor  their  mental  and  physical  health  noticing  changes  in  the 
body position' - importantly it goes on to state 'If a member of staff is not able to observe 
the patient  move  or breathe  they  must ensure  the person  is  conscious  which  will  require 
entering  the  bedroom'.  In  addition  to  this,  the  Trust's  observation  recording  sheet  as 
appended to the Policy, states 'If you are unable to observe the patient move or breathe 
you  must  ensure  that  the  person  is  conscious  which  will  require  entering  the  bedroom'. 
The observation recording sheet used in Christopher's care was however out of date as it 
was the one from the previous policy (2017 policy) which stated that ‘General observations 
continue at night which will require entering the bedroom to ensure the patient is mentally 
settled  and  not  experiencing  any  physical  distress  or  loss  of  vital  signs'.  My  Clinical  and 
Operational inpatient services Directors inform me that staff, Trust-wide, are aware that a 
bedroom  must  be  entered  where  staff  cannot  ascertain  signs  of  life.  This  duty  is  to  be 
conducted in accordance with Code of Practice 8.4 [as included in the Mental Health Act 
1983] which states that 'Hospital staff should make conscious efforts to respect the privacy 
and dignity of patients as far as possible while maintaining safety' as in psychiatry, there is 
a requirement to balance the need for promoting sleep/rest and the requirement to make 
all environments and care the least restrictive  whilst ensuring a person's remains safe at 
all times. 

In light of the clinical care review conducted in the wake of Christopher’s death, the Trust 
reconsidered  its  Therapeutic  Engagement  and  Observation  Policy.  I  and  my  Clinical, 
Operational and Service Directors were satisfied that no changes to Policy were required. 
The issue that arose in Christopher’s care was quite clearly, a lack of adherence to Trust 
Policy  by  staff.    To  prevent  reoccurrence  of  non-compliance  with  Trust  Policy  within 
Langley Green Hospital and elsewhere within the Trust, the following actions were taken 
across all inpatient services: 

i.  Guidance  on  observations  was  refreshed  to  support  staff  competency  and 
implementation.  All  staff  now  have  a  pocket  guide  z  card  on  conducting 
observations,  this  can  be  utilised  as  an  aide  memoire  and  reference  guide.  The 
pocket  z  card  describes  that  'at  least  once  per  shift  a  member  of  staff  must  set 
aside dedicated time to engage positively and collaboratively with the patient and to 
assess  the  current  risks  and  mental  state  of  the  individual  'whilst  on  an  acute 
inpatient ward', to engage therapeutically on each occasion of observation’; As the 
opportunity for therapeutic engagement depends on the willingness of the individual 
and  their  activity  at  the  time,  the  onus  and  importance  of  having  a  Therapeutic 
Engagement  and  Observation  Policy  in  place  is  that  the  observations  themselves 
can  enable  positive  therapeutic  relationships  by  establishing  good  rapport,  and 
being  aware  of  patient's 

individual  needs  and  changes 

in  presentation;   

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 ii.  An  easy  read  poster  guide  on  observations  is  also  now  available  on  all  inpatient 

wards.  

iii.  Training  and  competencies  on  completing  observations  has  been  updated.  This 
training  is  mandatory  and  must  be  completed  annually  and  at  induction  for  all 
agency  and  bank  staff  before  they  are  able to  commence  a  shift. There  has  been 
evidence  submitted of  staff  completion  and ongoing  adherence to  the  requirement 
for  each  staff  member  to  complete  the  induction  checklist  which  includes 
observations. As of December 2020 there is a 100% compliance for staff who have 
completed  training  in  Therapeutic  Engagement  and  Observation  competency 
assessments at Langley Green Hospital.   

iv.  All substantive, bank and Agency staff have access to Carenotes. All observations 

are now contemporaneously recorded.   

b)  Following the evidence, the Jury concluded: 

(a) that during Christopher’s time at Langley Green Hospital no formal review, care 
plan  or  adequate  risk  assessment  was  carried  out  in  respect  of  his  mental 
health.  

The  absence  of  clinical  documentation  for  Christopher  during  his  admission  to  Langley 
Green  Hospital  was  not  completed  to  an  expected  standard  in  accordance  with  Trust 
Policy.  The  Trust  therefore  completed  a  review  of  professional  conduct  of  all  the  staff 
involved  in  Christopher’s  care  through  HR  processes  and  made  referrals  to  relevant 
Regulatory  bodies.  The  Langley  Green  Hospital  Leadership  team  and  Trust  took 
immediate  action  to  prevent  reoccurrence  of  any  non-compliance  with  Trust  Policy 
including  an  immediate  review  of  all  care  plans,  risk  assessments  and  clinical 
documentation. This has been maintained through audit and competency plans. Feedback 
was given to the whole team by the Trust Deputy Chief Nurse due to the seriousness and 
the immediate requirement to reflect and improve. There have, since Christopher's death, 
been daily risk assessment audit, daily huddles as well as notes audits by Ward Managers 
with  oversight  by  the senior  leadership  team. These audits  demonstrate  as of  December 
2020 there is 100% adherence to the training in quality record keeping.  

(b) that the nursing and clinical records were not kept in accordance with the trust 

health and record policy. 

A  new  competency  framework  has  been  developed  and  introduced  Trust  wide  to 
strengthen our systems and processes which reinforces the requirement of stating on the 
observation chart, the activity of the patient rather than ticking to evidence their presence 
on  the  ward.  Each  member  of  the  Trust  inpatient  Nursing  Team  has  been  required  to 
individually complete the competency check list and such is now integral to the Bank and 
Agency  staff  induction  checklists  -  Trust-wide.  There  is  particular  focus  on  this  point 
included in the Eight Steps to Quality and Safety poster now present in the nursing offices 
across the Trust acute wards. The evidence of all Langley Green Hospital staff completion 
and  ongoing  adherence  to  the  requirement  for  each  staff  member  to  complete  the 
induction checklist, which includes observations, has already been submitted to the Court. 

Page 3 of 5 

 
 
 
 
 
 
 
 Staff were supported with safety days which commenced in December 2019 with specific 
training  on  Clinical  Risk  Assessment  which  focusses  on  professional  responsibility, 
accountability, and clinical curiosity.  

(c) that  there  was  no  recorded  evidence  that  any  therapeutic  engagement  has 

taken place during the period of Christopher’s short stay. 

Whilst  the  Trust  have  indicated  that  there  has  been  a  review  of  the  professional 
conduct of all staff involved in this case this does not allay my concerns that these 
practices are limited to just those staff involved in this case. 

The  learning  and  actions  taken  following  the  serious  incident  review  into  Christopher’s 
death  has  been  shared  across  the  Trust.  I  accept  that  there  was  an  absence  of 
documentation  on  Christopher’s  care  during  the  period  of  his  admission.  It  was 
acknowledged at inquest and during the Serious Incident review that the nurse in charge 
and allocated nurses did not complete the care plans, risk assessment and Carenotes shift 
entries  to  an  expected  standard,  if  at  all,  and  that  the  Nurse  did  not  as  appropriate, 
delegate this to colleagues. I, the Trust, and Langley Green Hospital team were extremely 
concerned  that  this  was  the  case,  as  not  having  appropriate  documentation  reduces  a 
teams’ ability to communicate risk and give instruction to staff as to the patients expected 
outcomes.  Therefore,  a  review  of  all  the  professional  conduct  of  the  staff  involved  was 
completed at the time and managed through appropriate internal processes including HR 
and referrals to relevant Regulatory bodies. From a systems perspective, all Trust inpatient 
staff  have  completed  competency  checks  in  note  writing  and  ongoing  adherence  is 
monitored by Ward Managers who check the content of patient notes weekly in audit form 
and complete spot checks on a daily basis.  

c)  Failure  to  provide  staff  to  accompany  a  sectioned  patient  to  the  emergency 
department  of  another  Hospital  for  treatment  for  a  physical  condition.  Requesting 
family member to undertake this role puts the patient and/or the family at risk. 

The Section 17 MHA 1983 Leave of Absence Policy provides for the Responsible Clinician 
to grant a detained patient under their care leave of absence from the hospital where they 
are liable to be detained.  

Responsible Clinicians may grant leave for specific occasions or indefinite periods of time. 
Responsible  Clinicians  may  make  leave  subject  to  any  conditions  which  they  consider 
necessary  "in  the  interests  of  the  patient  or  for  the  protection  of  the  people"  (27.9  MHA 
Code of Practice 2015) 

When  completing  a  section  17  leave  form,  the  Responsible  Clinician  should  include  any 
conditions  and  support  the  patient  would  require  during  their  period  of  leave.  If  escorted 
leave is required the Responsible Clinician must state whose legal custody the patient is to 
remain  in by  completing  the appropriate  tick  box and  naming  the escort  if they  are not a 
member of the nursing staff.  

Page 4 of 5 

 
 
 
 
 
 
 
 
 
 
 In this case, the Responsible Clinician [Dr L] reviewed Christopher prior to his attendance 
at the general hospital and his section 17 leave was formally prescribed by his doctor. This 
leave form specified that Christopher was to have a hospital escort to the general hospital 
  noted  that  the  family  were  accompanying  him  as  he  would  have  familiar  faces 
and  Dr 
with him for additional reassurance, in addition to staff. All actions as far as Trust Policy is 
concerned,  were  in  place  when  Christopher  left  Langley  Green  Hospital  to  attend  the 
general hospital. However, as noted at the inquest, the issue in this particular case is that 
Trust  Policy  for  escorted  leave  was  not  followed.  The  family  are  aware  of  this  and  my 
clinical  team  have  explained  this  to  them  in  detail.  I  am  assured  that  the  weekly  audits 
being  conducted  by  Ward  Managers  are  ensuring  that  no  patient  leaves  the  Hospital 
unaccompanied if they are granted section 17 leave for any purpose. 

I  hope  my  response  herewith  provides  you  with  strong  assurance  of  the  measures  the 
Trust  has  taken  to  ensure  its  systems  are  more  robust,  and  that  the  close  monitoring  of 
staff adherence to Trust Policy following Christopher's tragic death, is being checked and 
evaluated. 

Yours sincerely 

Chief Executive Officer 

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