Mina Topley-Bird

From Nadine Dorries MP 
Minister of State for Patient Safety, 
Suicide Prevention and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

Mr James E Thompson 
HM Assistant Coroner, County Durham and Darlington 
HM Coroner's Office  
PO BOX 282 
Bishop Auckland  
DL14 4FY 

1 June 2021 

Dear Mr Thompson, 

Thank you for your correspondence of 9 April 2021 about the death of Mina Topley-Bird. I 
am responding as Minister responsible for mental health services.  

Firstly, I would like to take this opportunity to offer my sincere condolences to the family, 
friends and loved ones of Ms Topley-Bird. 

I have noted carefully your concerns about national policy to co-ordinate the transfer of 
mental health patients back to their 'Home' area, when a person is admitted as an 
emergency to an NHS Trust outside their normal locality.  You also raise concerns about 
escalation policy when a bed cannot be obtained; and also a process to ‘apply’ for a bed in 
another NHS Trust area. 

Your report also notes the ‘ad hoc’ nature of the approach taken by NHS Trusts which may 
create delays in the transfer of patients. 

The Government is committed to eliminating inappropriate out of area placements in 
mental health services for adults in acute inpatient care and in 2016 provided guidance on 
out of area placements1 to NHS Trusts to support this ambition.  

The guidance states an out of area placement may be appropriate when: “the person 
becomes acutely unwell when they are away from home (in such circumstances, the 
admitting provider should work with the person’s home team to facilitate repatriation to 
local services as soon as this is safe and clinically appropriate)”. 

In addition, the guidance advises regular reviews and assessments to enable the patient’s 
return to their local service as soon as possible. 

1 Out of area placements in mental health services for adults in acute inpatient care - GOV.UK (www.gov.uk) 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 In preparing this response, my officials have made enquiries with NHS England and NHS 
Improvement (NHSE/I) and the Care Quality Commission (CQC). 

Your report notes that medical information received from South London and Maudsley 
NHS Foundation Trust (SLAM) was not sent on to, or requested by, West Park Hospital – 
part of The Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) – upon Ms 
Topley-Bird’s admission as an emergency patient. This information would have provided a 
full understanding of Ms Topley-Bird’s mental health and previous attempts to take her 
own life.  

NHSE/I acknowledged to my officials the increased risk to patient safety and the negative 
impact on experience and outcomes associated with patients being placed out of their 
usual local network of care for acute mental health treatment.  NHSE/I has assured the 
Department it is working to eliminate all inappropriate acute mental health out of area 
placements (OAPs) as soon as possible.  

NHSE/I has told my officials that the decision to admit Ms Topley-Bird to hospital in 
Darlington was appropriate in the circumstances of her requiring emergency inpatient 
admission away from home.  NHSE/I notes that the decision about when to transfer Ms 
Topley-Bird back to London should have been clinically-led with clinicians able to access 
her full medical history during the interim period to ensure her care was as safe and 
effective as possible.  

Mental health services provided by TEWV are locally commissioned and therefore 
operational processes, such as those described, are the responsibility of local NHS 
providers and their clinical commissioning group (CCG) system partners, which 
commission the services.  

However, NHSE/I has noted your concern about an apparent lack of robust information 
sharing and established transfer protocols and will use the learning from your report to 
work with its regional teams to consider whether any further guidance or escalation 
processes should be developed to support local NHS staff to reduce the risk of similar 
tragic events reoccurring.  

I understand Tees, Esk and Wear Valleys NHS Foundation Trust are to respond to you 
directly on the matters raised at the inquest.  TEWV has informed NHSE/I of local action 
taken following Ms Topley-Bird’s death, notably: 

• 

•  where admission is indicated to a local bed, any information from the home Trust 
will be forwarded by email directed to the Nurse in Charge of the admitting ward; 
the Trust is exploring compatible electronic solutions to enable staff to print 
information at non-TEWV sites, with an interim system set up whereby staff follow 
the Out of Trust Patient Checklist on information sharing; and a new electronic 
system to be introduced by June 2022 to allow for the printing of medical notes in 
premises shared with another Trust; 

•  ongoing work at TEWV to focus on bed management and facilitate patient transfers; 
•  on admission of a new patient, comprehensive risk profile information is obtained 
from the admitting team and the home Trust Ward with a checklist to support this, 

 
 
 approved by the Adult Mental Health Speciality Development Group in August 2020 
and implemented by all wards during September 2020. 

The TEWV’s Harm Minimisation Lead has incorporated learning from this case into the 
Trust’s mandatory risk assessment training, with an emphasis on the importance of 
ensuring that historical risk information is included in the formulation of risk, risk 
management and contingency planning. 

My officials also approached the Care Quality Commission (CQC).  The CQC has sought 
assurances from the Trust in relation to its investigation and has concluded that there is no 
ongoing risk to service users and that enforcement action was not required.  

CQC requested, and was provided with, further information from the Trust to assist 
with its review of the Trust. In light of your report, the CQC has since written to the 
Trust to request further information in relation to the incident.  This information was 
provided on 4 May 2021 which is I understand is currently being reviewed by the CQC.   

I hope this information is helpful and explains the actions being taken to address the 
matters of concern.  Thank you for bringing these matters to my attention. 

NADINE DORRIES

Executive Suite 
West Park Hospital 
Edward Pease Way 
Darlington 
Co Durham 
DL2 2TS 

28 May 2021 

Mr James E Thompson 
H M Assistant Coroner for 
County Durham and Darlington 
H M Coroners Office 
PO Box 282 
Bishop Auckland  
Co Durham  
DL14 4FY 
Dear Mr Thompson 

Dear Mr Thompson 

Re:   Mina Topley-Bird, deceased 
Regulation 28 Report 

Further to your letter of 09 April 2021, I write to detail the actions the Trust has taken 
and  those  that  we  continue  to  implement  to  address  the  concerns  you  identified 
during the inquest into Mina Topley-Bird’s (MTB) death.  I would like to reassure you 
that as an organisation we have taken your concerns very seriously and for ease of 
reference I will address each of these in turn: 

Concern 1 

Evidence was heard that medical records and other important information 
could not be uploaded to the Trust's electronic notes system - PARIS when 
received in PDF form. This meant staff had to precis notes onto the system, in 
this case when one person was working alone, on a nightshift was required to 
do this whilst dealing with a variety of different tasks. Important documents 
that cannot not to be uploaded immediately and in their original form concerns 
me that attending clinicians do not have access to these documents and can 
be hindered in making clinical decisions without them. 

As described at the inquest hearing, immediate action was taken by the Trust to 
develop and implement a checklist to support the care and treatment of patients 
presenting at Accident and Emergency departments, who are from outside the area. 
(please see documents  attached at Concern 2 below). This checklist includes: 

  information gathering from the patient's home Trust 
  sharing information with other teams involved in care 
  ensuring any information received is accurately reflected in the Trust's Safety 

Summary 

  where admission of the patient is indicated to a local bed, all information from the 
home Trust will be forwarded by email to the Nurse in Charge of the admitting 
ward. 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This issue regarding access to patient information will be fully resolved by the 
implementation of Cito, which is a full electronic records management solution and 
allows documents to be scanned in, uploaded or viewed. This solution will be fully 
implemented by August 2022. 

Concern 2 

It  became  apparent  on  the  evidence  that  whilst  Trust  staff  were  working  in 
premises  operated  by  another  Trust  (in  this  case,  County  Durham  and 
Darlington NHS Foundation Trust - CDDFT) they could not print medical notes 
and  other  documents  from  the  TEWV  IT  system  onto  printers  in  'shared' 
premises  such  as  the  A&E  Department  of  the  CDDFT.  This  again  meant 
important documents can be unable to be shared with staff undertaking such 
tasks as Mental Health Assessments. 

As referenced in the inquest evidence, there is a system in place whereby staff 
follow the Out of Trust Patient Checklist which details how information is to be 
shared. In respect of any Mental Health Act documentation, this is shared with the 
relevant recipients via a secure email route.  

The Trust has also since taken action and increased the staffing establishment of the 
Liaison Team, increasing the number of staff on duty overnight night to two.  This 
means that if a document does need to be printed urgently, one member of staff can 
go to our nearby Trust premises to do this. 

Again the issues highlighted will be fully resolved by the implementation of Cito, 
which is described above and planned to be in place by August 2022. 

Concern 3 

The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital 
had been surveyed for issues related to patient safety such as ligature points. 
Whilst the evidence was that the Trust was confident this had been done, no 
assurance could be given. One such assessment did not show clearly if the 
deceased's bedroom had been inspected for issues such as ligature points. 

As described at the inquest, the suicide prevention environmental survey and risk 
assessment was reviewed by the Trust and subsequently changes had been made 
to improve recording. The revised Suicide Prevention Survey and Risk Assessment 
now references each bedroom by the actual number (bedroom 1,2,3,4 etc.), rather  

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

1 Out of Trust Liaison Checklist.pdf4 Referral and Admission OOA Approved SDG.pdf 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 than the Estates identifier (2.01, 2.93, 2.75 etc) which were used at the time of the 
incident. 

For completeness, MTB was in bedroom 4 (identifier 2.04 previously).  The Suicide 
Prevention Environmental Survey and Risk Assessment, attached below, formed 
part of the documentary evidence made available to the Coroner.   This 
demonstrated that the survey in place at the time of the incident had included 
bedroom 4 (2.04). 

The Trust has recently undertaken an extensive ligature reduction programme that 
has included the removal of taps, toilets, shower controls and sinks and replaced 
with anti-ligature sanitary ware.  The Trust is also in the process of installing 
technology that will assist with the detection of movement of patients in high risk 
areas such as bedrooms and en-suites. This technology responds to a patients 
change in vital signs or movements and will send an alert to staff to check on the 
wellbeing of the patient. This technology is already in place in other areas of the 
Trust and has been used effectively to maintain patient safety in this way.  

Concern 4 

Evidence was heard that within the Durham & Darlington area of the TEWV 
Trust funding had been secured for the post of a Bed Manager, who was to 
manage bed allocation, transfer and discharges to better manage access to 
beds for patients across this area of the Durham & Darlington area of the 
Trust. It was heard this role would be able to more proactively arrange 
transfers of patients from Trust to Trust as was a need raised in this inquest. It 
was disclosed that this post only operated in the Durham & Darlington area of 
the Trust and not across the whole Trust. On the evidence heard this post has 
obvious benefits for ensuring patients access to beds and I raise a concern 
this post is not one which cover the whole of the Trust, only one region of it. 

In the case of MTB, the issue was there were no beds available to transfer her to her 
home Trust. Each locality of the Trust has staff who manage patient flow and beds 
and facilitate patient transfers as part of their daily roles. The Trust has now agreed a 
plan to implement a bed management team. This will be introduced in the following 
phased approach: 

  Phase 1 – introduce locality based bed managers (anticipated  by October 2021) 
  Phase 2  - implement a central bed management hub (2022) 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

Suicide prevention environmental survey 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 5 

The Trust gave evidence that the Risk Assessment/Safety Summary process 
for assessing and protecting patients had been improved, but accepted it was 
still ' a work in progress' and further work was required. It is of concern that 
this aspect of area of patient safeguarding appears on the evidence given at 
inquest not to be complete. 

Following a CQC inspection in January 2021 where concerns were raised regarding 
risk assessment and management, a Rapid Process Improvement Workshop (RPIW) 
was held week commencing 1st February 2021. This was to review, clarify and 
streamline the process for assessing and managing the clinical risk of patients and to 
confirm the standards for risk assessment across all services of the organisation.  

A review of care documentation was undertaken to provide assurance that patient 
risks were being assessed and each patient had a safety plan in place in line with 
the agreed standard. Ward to Board governance arrangements were put in place to 
ensure Executive oversight and the reporting of compliance with the quality 
standards. An ongoing programme of quality assurance was implemented. This 
utilises a range of methods such as clinical audit, Matron walkabouts and direct 
clinical observation to provide assurance to the Trust Board that the actions being 
taken are having a positive impact and addressing the patient safety concerns. 
Community assurance processes have included the development of a dashboard to 
support community caseload reporting and improved clinical supervision processes.  

In line with the CQC enforcement notice, the Trust had a number of agreed actions 
to be completed by 3rd May 2021; implementation of these was achieved within 
timescale.  Leading up to this date and beyond, the Trust had recognised the need 
for further investment in increasing multidisciplinary involvement and oversight, 
improving staffing establishments, further developing our provision of training and 
expertise, ensuring sustainable support and clinical supervision as well as providing 
leadership to our clinical teams as being critical to prioritising a culture of patient 
safety and continuous quality improvement.  

In addition, work is underway to enhance and embed organisational learning from a 
range of internal and external sources.  This includes reviewing, strengthening and 
developing systems and mechanisms for capturing and communicating learning and 
importantly gaining assurance of the impact of our actions to improve care for 
services users and their families. 

A regional Quality Board has been set up by NHS England and Improvement; 
membership includes key external stakeholders such as CQC and members of the 
ICS.  The Trust provides monthly updates and assurance on its progress. We are 
also accessing a range of external expertise to support rapid improvement and 
sustainable changes in practice.  

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS 

 
 
 
 
 
 
 
 
 
 I trust this provides you with assurance that the appropriate actions are and have 
ben taken to address the concerns raised.  However, should you require any further 
information please do not hesitate to contact me. 

Yours sincerely, 

Director of Nursing and Governance and Deputy Chief Executive 
Tees, Esk and Wear Valleys NHS Foundation Trust 

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Trust headquarters  
West Park Hospital, Edward Pease Way, Darlington, DL2 2TS