Azra Hussain

First Floor 
Wesleyan 
Colmore Circus 
Birmingham 
B4 6AR 

Mrs Emma Brown 
HM Area Coroner 
Birmingham Coroner’s Court 
50 Newton Street 
Birmingham 
B4 6NE 

20th May 2021 

Dear Mrs Brown 

Re: Regulation 28 Report to Prevent Future Deaths- Azra Hussain  

Birmingham and Solihull CCG is providing this supplementary information to the Coroner, in 
support of the information provided by Birmingham and Solihull Mental Health Foundation 
Trust, in response to the Regulation 28 Report to Prevent Future Deaths issued in relation to 
the death of Azra Parveen Hussain.  

We would like to firstly take this opportunity to pass on our condolences to Ms Hussain’s 
family. The Coroner and family will already be aware from evidence presented at the inquest 
that all serious adverse incidents are reported to the CCG, are subject to root cause 
investigation and monitoring to ensure that any actions identified have been implemented.  

The supplementary information provided, sets out the system working that is taking place in 
relation to the reducing the risk of harm to Birmingham and Solihull patients and learning 
from any adverse events.  

At the time of this incident, as described in the root cause analysis investigation, the Trust 
had identified a potential risk to inpatients from ligature points and was undertaking a piece 
of work to assess this risk along with options to mitigate it. This piece of work is continuing 
and is being overseen by the system and by the Care Quality Commission (CQC). Following 
a CQC report being issued in November 2020 an action plan was put in place with monthly 
updates being provided by the Trust to the CQC and to the system. Additionally, regular 
system risk review meetings were held at which progress was discussed. In response to a 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 further inpatient death, the Trust were asked to speed up the actions that were being taken 
to address these concerns and provide updates.  

It is recognised, however, that the identification and elimination of potential ligature points is 
only one part of the picture and that, as identified in the root cause analysis, clinical 
assessment and management plays an essential role in reducing the risk of harm, issues 
that have also been subject to discussion and action since this incident occurred.  

The monitoring of these system wide actions continues, and we will as a system continually 
strive to improve the quality of services that we, as a system, provide. We regret any failing 
in the system and would like to provide assurance that all avoidable deaths are taken very 
seriously.  

Yours sincerely 

Chief Nurse 
Birmingham and Solihull CCG

Legal Department 
B1 – Unit 1 
50 Summer Hill Road  
Birmingham 
B1 3RB  

Date: 

17 May 2021 

Mrs Emma Brown, 
Area Coroner, 
Birmingham Coroner’s Court, 
50 Newton Street, 
BIRMINGHAM B4 6NE 

Dear Mrs Brown, 

Re: Prevention of Future Deaths report into Azra Parveen Sultan 

May I open this letter by reinstating the apologies of our Trust for the tragic death of Azra 
Parveen Sultan. Azra was an inpatient on Ward 2 at Mary Seacole House when she sadly 
died by suicide having attached a ligature to her en-suite bathroom door. This was clearly an 
immensely tragic and distressing time for Azra’s family, friends, her fellow service users on 
the ward and the staff that were caring for Azra. Our sincere condolences are reiterated to all 
who were and continue to be affected by her death.  

During the course of the inquest the evidence revealed matters giving rise to concern as 
follows:- 

1.  On the 4th May 2020 Azra's mother and daughter had been in telephone contact with 

the nurse in charge on the ward expressing concerns that Azra had messaged them 
to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to 
Azra who denied making a ligature, Azra's neck was examined and she had no 
marks from ligature use. The shoelaces from one pair of shoes were removed but 
other shoelaces, clothing and bedding were left in her possession as it was felt that 
Azra was not at an immediate risk. She was not believed to be at immediate risk 
because, whilst it was a feature of her mental state common to many patients that 
she would regularly talk about not wanting to live and requesting an overdose, there 
was no evidence that she had made an active suicide attempt and she had no history 
of suicide or self-harm attempts. The fact that she was now saying that she had 
attempted to make a ligature was a change in her presentation (her previous suicidal 
ideation had centred around requesting assistance to overdose), it was also of 
significance that she was saying one thing to her family and something different to a 
clinician. BSMHT accepted that the information was significant and therefore there 
ought to have been consideration of it by her treating team with a review of her risk 
and observation levels. However, no record at all was made of the family's concerns 
and the account given by Azra. Her risk screen was not updated, an incident report 
was not raised, and the information was not included in handover to the next shift or 
at the next MDT on the 6th May. Therefore, it was not considered at an MDT meeting 
on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend 
that meeting and raise their concerns directly. Microsoft Teams was used by some 
clinicians to attend the MDT on the 6th May but was not made available to Azra's 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 family nor was a telephone number to dial into the meeting. BSMHT has put in a 
system for a form to be completed in advance of an MDT which requires the family's 
input to be sought, placed on the form and considered in the MDT. It is my concern 
that this is equivalent to the family being included in the meeting (prior to COVID 
families were invited to attend MDTs): there is the potential that information will not 
be recorded accurately or will not be understood in written form, it also doesn't afford 
family the opportunity to hear the plan arising from the meeting and provide their 
views. There is no reason why attendance by a remote platform or telephone line at 
the meeting itself cannot be offered to family for all MDTs.  

Our Family and Carer Strategy and pathway prioritises the principles and practice of high 
quality  family and carer engagement in all aspects of care. One component of our patient 
safety work is the implementation of robust and consistent multidisciplinary team standards 
which includes enhanced family engagement. We will ensure that families views are central 
to the care planning process prior to and during the MDT and that there is a clear feedback 
process to the family post MDT so as to ensure and assure the family that their views have 
been considered. We are working with our family and carer network to seek views on the 
format of post MDT written correspondence. This will supplement verbal feedback either 
over the phone or via a virtual platform.  

We are consistently auditing our practice around our minimum MDT team standards which 
includes a minimum standard about securing and reviewing the patient and carer view within 
the MDT meeting. The data below in figure 1 shows our position for February, March and 
April 2021 respectively. We report our position on this standard each month to our regulators 
the Care Quality Commission. 

Figure 1: Audit Results for Securing and Discussing Patient and Carer View in MDT 

With regard to involvement of families in formal MDT meetings we will involve families within 
the MDT meeting itself where this is clinically appropriate. It will not always be appropriate as 
such decisions will be influenced by a number of things such as:- 
• 
• 
• 
• 
• 

Consent of the patient 
Relationship between the patient and family members 
Issues of confidentiality with regard to the content of the MDT discussions 
Issues that may impact on risk to self or others 
Safeguarding concerns 

We would like to assure you that there are a range of ways in which we aim to ensure 
meaningful engagement with families outside the formal MDT process and this year we have 
specific quality goals relating to carer engagement including:- 

Improve the involvement carers in service user 
care and recovery 

Measures of success:- 

% of carers registered on RIO 

% of carers with a completed carer 
engagement tool 

 
 
 
 
 
 
 
 
 
 
 We will report on our level of improvement with this priority through our Integrated Quality 
Committee on a quarterly basis. On a monthly basis our Family and Carer Pathway Group 
will review performance to celebrate improvement and to identify any barriers that we need 
to remove to improve performance in challenged areas.  

2. I am concerned that within BSMHT's inpatient units there will be a continuing risk from 
other doors in the bedroom area (including the main bedroom door) even when the en-suite 
bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom 
door will be on a communal corridor, service users on level 1 and 2 observations will have 
periods where they are unobserved in their rooms and could wedge a ligature at the top of a 
door so that it wasn't obviously visible from outside.  

When  considering  the  safety  of  our  inpatient  environment,  we  approach  this  using  a 
framework  that  incorporates  the  triad  of  physical,  relational  and  procedural  security  and 
controls. We have commenced a full review of all of these controls to strengthen the safety 
of our acute inpatient wards. The results of the review and the associated recommendations 
will be presented to our Integrated Quality Committee for approval, who in turn report directly 
to our Trust Board of Directors.  

As  part  of  this  review  we  are  recommending  that  we  develop  a  work  programme  to  apply 
continuous door pressure alarm systems to the bedroom doors on a number of our wards. 
This is a significant piece of work and we are prioritising the wards to which we will initially 
apply  these  systems  based  on  acuity  of  patients  and  ligature  history  prevalence.  We  have 
established  an  expert  group  to  assist  us  in  determining  the  prioritisation  process  which 
includes  a  mental  health  expert  from  the  Quality  Team  at  NHS  England  and  our  Mental 
Health  Quality  Lead  from  Birmingham  and  Solihull  Clinical  Commissioning  Group.  We  will 
have  reached  a  decision  on  prioritisation  and  the  associated  timeline  by  the  end  of  May 
2021. There are a number of factors that will contribute to the timeline for delivery including:- 

Installation Timeframes 

•  Manufacturing times 
• 
•  Safe access to operational acute inpatient wards to carry out works 
•  Temporary  bed  closures  whilst  the  work  is  being  undertaken  which  may  impact  on 

our ability to admit patients during periods of high occupancy 

•  The potential of a third wave of Covid 

We  would  like  to  assure  you  in  the  meantime  that  all  of  our  doors  comply  with  existing 
standards in that there is no door furniture (such as handles, hooks etc) that could be used 
as  an  anchor  point.  The  only  anchor  points  are  therefore  the  top,  bottom  and  hinge  of  the 
door.  Our  choice  of  alarm  system  is  one  of  the  latest  innovations  in  that  it  has  pressure 
sensors on all of these areas of the door – so no matter where pressure is applied, the alarm 
will trigger.  

We are also establishing a rolling capital programme to support ongoing ligature works to all 
of our Estate. 

We  are  conscious  that  the  pressure  sensors  are  just  one  control  to  improve  patient  safety 
and we therefore feel that is important to stress that reducing harm from ligatures relies as 
much on the relational and procedural controls as it does on the physical.  The risk review 
process currently being undertaken by our expert group places equal emphasis on each of 
the three areas, as addressing the physical environment alone will not reduce this risk to its 
minimal  level.  Examples  of  these  other  areas  include;  a  review  of  our  therapeutic 
observational  practice,  a  review  of  staffing  levels  and  skill  mix  and  monitoring  and 
supervision of the implementation of our new care plans. 

 
 
 
 
 
 
 
 Please be assured that as an organisation we are taking all the steps we can to reduce risk 
from  ligatures  and  will  continue  to  work  with  families  and  carers  to  ensure  that  they  are 
involved  in  Patient  care,  where  the  patient  wishes  for  this.  In  addition,  the  BSOL  system 
continues  to  work  to  improve  services  and  to  learn  from  events.  There  is  a  multiagency 
oversight group in place which has delivered against key recommendations and continues to 
work to implement learning. 

Yours  sincerely, 

Executive Director of Quality and Safety (Chief 
Nurse), Birmingham and Solihull Mental Health 
NHS Foundation Trust 

Chief Nurse, Birmingham and Solihull 
Clinical Commissioning Group 

Customer Relations │ Mon – Fri, 8am – 6pm  

Email: bsmhft.customerrelations@nhs.net 
Website: www.bsmhft.nhs.uk

-are Quality

Commission Citygate
, Gallowgate
Newcastle upon Tyne
NE1 4PA

HM Area Coroner Emma Brown P|

Area Coroner for Birmingham and Solihull
50 Newton Street

Birmingham

B4 6NE

18 May 2021

Care Quality Commission (CQC)
Our Reference:

Dear HM Coroner
Prevention of future deaths report Ms Azra Hussain

Thank you for your Regulation 28, report to prevent future deaths issued following
the inquest into the ‘sad death of Azra Parveen Hussain also known as Azra
Parveen Sultan. This response will address the role of CQC, summarise the
inspection history of the service and address the specific issues you have raised
in the report.

CQC’s Role

The role of the Care Quality Commission (CQC) as an independent regulator is to:
register health and adult social care service providers in England and to inspect
whether or not the fundamental standards are being met. The legislation that
governs this function is The Health and Social Care Act 2008 and The Health and
Social Care Act 2008 (Regulated Activities) Regulations 2014.

As part of CQC’s regulatory role, inspectors assess whether or not a provider is
meeting the needs of people in a safe way. Inspectors make judgements from their

findings as to whether a service has mitigated the risks posed to people, for

example, physical risks arising from existing health conditions and environmental
risks based on the surroundings in which they live. The CQC’s websité signposts
the provider and registered manager to relevant guidance on how they can meet
.our regulations and other related regulations, including approach to risk.

Ms. Hussain and Inspection History

HSCA Further Information

“yy

Birmingham and Solihull Mental Health Foundation NHS Trust is registered with
the Care Quality Commission for the following regulated activities: Assessment or
medical treatment for persons detained under the Mental Health Act 1983:
Diagnostic and screening procedures and Treatment of disease, disorder or injury.
The trust has been inspected four times since 2014. It was rated good overall in
2014; in 2017 it was rated requires improvement; and in 2018 it was again rated
Requires improvement. The trust's last comprehensive inspection was in
November 2019 when it was rated as Requires Improvement. A focused inspection
was carried out in November 2020. We did not rate at that inspection because we
did not review all five key questions, we ask at comprehensive inspections.

CQC first became aware of the death of Ms. Hussain in May 2020 when notified
by Birmingham and Solihull Mental Health Foundation NHS trust (BSMHFT) CQC
requested information, specifically Ms. Hussain’s risk assessment; care plan;
continuation notes and incident reports. The information was used to carry out a
review of Ms Hussain’s care whilst on the ward.

The review of the information raised concerns about the quality of risk assessment
and care planning taking place on the ward which led CQC to request information
relating to other patients currently receiving care on the ward, Mary Seacole 2. As
a result, CQC visited the hospital on 24 June 2020 to review patient records
including risk assessment and care plans to understand the care that had been
delivered on the ward. The team also spoke tothe Matron and the Clinical Service
Manager about the challenges currently on the ward the death of Ms Hussain.

The team met with members of the’ leadership team in July 2020 and: provided
feedback on areas of concerns that they found during their visit to the hospital and
which needed to be addressed by the trust.

In’ November 2020, following a further death at the trust, CQC undertook a
responsive inspection. There had also been several concerns received by
inspectors about community services. Three inspection teams visited the trust to
inspect their acute wards for adults of working age; Community mental health
service for adults and Home treatment teams. That inspection resulted in
enforcement action that placed conditions on the trusts registration of their acute
wards for adults of working age.

The conditions placed on their registration were as follows:

1. By 4 January 2021, the registered provider must inform the Commission of the
order of priority in terms of addressing the ligature. risks and timescales for
addressing the ligature risks across each ward.

2. The registered provider must take steps to address the ligature risks across all
wards by 18 June 2021 ;

3. By 29 January 2021 the Registered provider must implement an effective system
to improve risk assessments and care planning. The Registered Provider must
report to the Commission on the steps it has taken in connection with this by 5
February 2021. .

4. Commencing from 5 February 2021 the registered provider must report to the

Commission on a monthly basis setting out progress being made in respect of and

including mitigating measures being put in place until all ligature risks are
- addressed.

_5. Commencing from 1 March 2021, the Registered Provider must report to the
Commission on a monthly basis the results of any monitoring data and audits
undertaken that provide assurance that the system implemented is effective

Concerns identified in the Regulation 28 Report

The Regulation 28 report sets out the following matters of concern for CQC to
address:

“BSMHFT had risk assessed ward 2 for ligature points, including the en-suite
bathrooms, in November 2019. The en-suite bathroom doors were given the
highest risk score possible on an acute ward, but no corrective action was
identified to remove or mitigate the risk: the risk assessment relied on
clinical assessment and observation of the service user to mitigate the risk.
Evidence was given at the inquest that pressure sensor alarms have been
available in the UK from numerous manufacturers for 10 years, BSMHFT had
been investigating and testing different pressure sensor alarms for en-suite
bathroom doors for approximately 2 years before Azra’s death. BSMHFT has
now identified an appropriate pressure sensor for en-suite bathroom doors
and the en-suite bathroom door of room 14 on ward 2 was replaced in
November 2020 with a door incorporating a pressure sensor alarm. BSMHFT
has a 17 month program to fit pressure sensor alarms to all en-suite
bathroom doors within .its inpatient units. However, this is not being
considered for other doors within the bedroom area nor is there any national
requirement for inpatient mental health units to place, or consider placing,
pressure sensor alarms on doors within areas where patients are afforded
privacy and time alone. | am concerned that within BSMHFT's inpatient units
there will be a continuing risk from other doors in the bedroom area
(including the main bedroom door) even when the en-suite bathroom doors
are fitted with pressure sensor alarms. Although the outer face of a bedroom
door will be on a communal corridor, service users on level 1 and 2
observations will have periods where they are unobserved in their rooms
and could wedge a ligature at the top of a door so that it wasn't obviously
visible from outside. Furthermore, in the absence of any national regulations
or guidance on this topic the risk from en-suite and other doors in areas

where service users spend time unobserved will persist in mental health
units operated by other Trusts and private providers around the country”

There is currently no national requirement, regulations or guidance for in-patient
mental health units to place pressure sensors on doors. Any such guidance would
be produced by NHS Estates in their building’s guidance. When CQC inspects a
service of this nature, as part of the inspection we check the providers compliance
with ligature risks as part of the safe domain and we check the environment is
suitable for use as part of our assessment. An inspection team would not check
specifically for pressure sensors on doors. If we find ligature risks to be present,
we establish if the trust has identified and mitigated that risk. Failure to do so
represents a breach of regulations that may result in enforcement action.

Conditions were placed on the trust's registration certificate by CQC following the
inspection on 23 November 2020 which identified concerns in relation to ligature
risks, risk assessment and care planning. The Trust has complied with our
conditions and have been submitting monthly updates on their progress to replace
doors and improve care planning. Inspectors have been meeting monthly with the
trust leadership team to discuss the progress and improvements made to date. As
a result of the meetings CQC has asked for weekly reports on the ward
improvements programmes to understand ongoing mitigation whilst the
replacement of en-suite doors is incomplete.

The CQC has been informed by the trust that it is reviewing the timetable submitted
for the replacement of the en-suite bathroom doors as requested by their clinical
governance committee. They have sought independent review from the NHS
England's quality and safety team who will present their report to the trust in May
2021.

Bedroom doors did not feature as part of the conditions placed on the trust however
the trust has informed CQC that they are reviewing bedroom doors as part of their
overall improvement strategy.

We will check the provider's compliance with the regulations on our next inspection
of the service using our key lines of enquiry and in accordance with CQC’'s
regulatory remit, highlight breaches of regulation to the provider and/or registered
manager (‘registered person’) if warranted and ask them how they will make the
necessary improvements. Our next inspection of the service is not yet confirmed,
however CQC have adopted a more risk-based approach to inspections should we
receive negative intelligence or have further concerns about the service we would
carry out responsive inspections.

Where CQC identifies that regulations are not being met, we use our enforcement
powers to require improvements to be made. We continue to do this and will share

key learning and practice points from the inquest into the death of Ms Hussain with
inspectors and registered persons. ;

We hope that this response addresses your concerns. if this is not the case, please
could you clarify any further details you require.

Yours sincerely

Head of Inspection .
Hospitals (MH and CHS) ~ Midlands and East

Health and Safety 
Executive 

Redgrave Court 

Merton Road 

Bootle  

Merseyside L20 7HS 

http://www.hse.gov.uk/  

K  

Miss Emma Brown 

HM Area Coroner 

Birmingham and Solihull Area 

18th May 2021 

Dear Miss Brown, 

Prevention of future deaths report Ms Azra Hussain 

Thank  you  for  your  letter  and  Regulation  28  report  to  prevent  future  deaths  issued 
following  the  inquest  into  the  death  of  Azra  Parveen  Hussain,  also  known  as  Azra 
Parveen Sultan.    

You asked HSE to consider the second area of concern, namely: 

“I am concerned that within BSMHT's inpatient units there will be a continuing risk 
from 

other doors in the bedroom area (including the main bedroom door) even when the 

en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer 

face of a bedroom door will be on a communal corridor, service users on level 1 

and 2 observations will have periods where they are unobserved in their rooms and 

could wedge a ligature at the top of a door so that it wasn't obviously visible from 

outside. Furthermore, in the absence of any national regulations or guidance on 

this topic the risk from en-suite and other doors in areas where service users spend 

time unobserved will persist in mental health units operated by other Trusts and 

private providers around the country.” 

In England CQC is the lead inspection and enforcement body under the Health and 
Social Care Act 2008 for safety and quality of treatment and care matters involving 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 patients and service users in receipt of a health or adult social care service from a 
provider registered with CQC.   In 2015 (revised in 2017)  The Memorandum of 
Understanding (MoU) between the Care Quality Commission (CQC) and the Health 
and Safety Executive (HSE)  established the respective roles and responsibilities of 
each organisation with regard to health and safety incidents.    

This means that both the safety of the environment for the patient, including 
management of ligature points, and any investigations following incidents would fall 
within the remit of CQC and not HSE.   I am therefore not able to offer any further 
assistance with respect to the current standards at BSMHT or within England more 
generally, but I am aware that CQC will be providing a detailed response to your 
concerns.  

I hope this clarifies the situation but please let me know if you need anything further.  

Yours sincerely, 

Chief Executive