Hannah Browning

Dear Mr Gittins 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Hannah Elizabeth Browning (DOB 18.4.96 DOD 12.10.18) 

This report has been developed in response to the Coroner’s issuing of a Rule 28 
jointly to Wrexham County Borough Council Social Services department and Betsi 
Cadwaladr University Health Board (BCUHB), following the Coroner’s inquest into 
the death of Hannah Browning, which concluded on the 12th April 2021. 

The Local Authority would like to offer their sincere condolences to the family of 
Hannah on their tragic loss. 

Response 

In response to the concerns raised by the coroner in relation to the inquest of the 
death of Hannah Browning the following actions have been taken in May 2021 to 
address and manage the areas of concern identified by the coroner, including 
communication and crisis planning. 

Actions to Date – development of a checklist. (Please see Checklist attached as 
Appendix 1) 

1.  The  Local  Authority  has  developed  a  social  work  checklist  for  all  open  and 
active cases to the mental health social work team and for all duty cases where 
the  social  worker  is  the  designated  daily  duty  worker  in  Ty  Derbyn.  This 
procedure  has  been  developed  to  provide  clear  guidance  to  social  workers 
regarding the local authorities’ expectations of them in their social work role and 
to  ensure  that  all  social  workers  are  aware  of  the  process  that  needs  to  be 
followed in the event of a similar situation to that which occurred with Hannah 
Browning. 

2.   This checklist will be given to the social workers in a word document format 
with a check box which will need to be completed, the social worker will also 
sign  and  date  and time  the document.  The document  will  be attached  to  the 
individuals’ case record (currently a paper file) for each occurrence where the 
social worker has identified risks or concern regarding a person’s wellbeing or 
welfare or where a duty assessment has taken place. Where a case needs to 
be  escalated  to  the  daily  AM  or  PM  Community  Mental  Health  Team  safety 
huddle due to concerns or risks to the  person’s welfare or wellbeing  (point 3 
below), the social worker will scan a copy of the checklist and email the relevant 
duty manager with a copy. The social worker will also hand a paper copy to the 
daily duty manager as soon as the social worker identifies concerns/ risks, if 
the social worker is not in the building when the concerns are identified then 
telephone contact must be made with the duty manager immediately. The daily 
duty  manger  is  one  of  3  team  managers  or  equivalents  (  deputy  county 
managers Betsi Cadwaladr University Health Board post) within the Community 
Mental Health integrated team and will take responsibility for the safety huddle 
(see 4 below) 

 
 
 3.  Duty assessments and Case check list: is a clear step by step approach of what 
actions are needed and required when managing or dealing with duty cases as 
well  as  social  workers  own  cases.  The  check  list  is  a  6  step  approach  and 
prompts  social  workers  to  act,  plan,  record  and  communicate  all  risks  and 
concerns to the safety huddle duty manager (as outlined in paragraph 2) and 
subsequently the case record. The 2 points below which are steps 5 and 6 of 
the  procedure  clearly  identify  what  specific  actions  need  to  be  taken  without 
delay  and  as  a  priority  when  a  person,  known  or  open  to  a  social  worker, 
indicates or identifies that they intend to harm themselves. These steps also 
reflect the areas of concern identified by the coroner; communication and crisis 
planning. 

•  Any disclosure of overdose/self-harm, social workers to ensure there 
is clear plan of how this is being managed to reduce risks and make 
appropriate  referrals  to  Duty  Manager,  on-call  Consultant,  HTT, 
AMHP and update Health Liaison team/Emergency Duty Team with 
any relevant information for out of hours.  

•  Where  an  individual  states  that  they  intend  or  plan  harm  to 
themselves and leave a meeting or discussion prematurely the social 
worker will not delay in escalating this to the daily duty manager (for 
BCUHB Safety huddle process to be followed), the social worker will 
also  attempt  immediate  telephone  contact  with  the  individual  and 
continue to attempt contact until the safety huddle duty manager has 
been handed the checklist and information and has agreed that they 
will escalate it to the agreed agencies. 

The Local Authority believe that the measures taken above provide a clear and 
robust procedure for social workers within Community Mental Health Team to 
follow  if  a  person  they  are  supporting  or  assessing  presents  as  a  risk  to 
themselves or the social worker believes that there is any intention to self-harm.  

4.  BCUHB implementation of an additional Safety huddle. A morning safety 

huddle is already in place, BCUHB have developed a further safety huddle at 
the end of each day (4.30pm) which::  

• 

• 

• 
• 

• 

Ensures  that  the  duty  manager  is  appraised  by  ALL  team 
members of any ongoing concerns for consideration at the Safety 
huddle  
Chair  will  ensure  that  the  huddle  discussions  are  appropriately 
minuted, and all agreed actions are clearly identified 
Will discuss all known heightened and / or unmitigated risk 
Will identify solutions or mitigation plans for the proceeding out of 
hours  period  to  maintain  patient  and  staff  safety  and  ensure 
handover outcomes to the next morning Safety huddle 
Will ensure all local out of hours teams eg  Emergency Duty Team 
(EDT)/  Home  Treatment  Teams  (HTT)  /  Psychiatric  liaison/ 
Inpatient  duty  nurses  /  on  call  medical  staff  are  aware  of  risk 

 
 
 
 
 
 • 

issues and fully engaged in formulating management plans for the 
out of hours period 
Will escalate and alert the tactical on call system (bronze, silver, 
gold)  and  EDT,  of  any  heightened  or  unmitigated  risk  including 
solutions where possible 

All of the above actions have been shared with the Community Mental Health Team 
Social work team manager who has disseminated these to all social work staff within 
the team. In addition to the above actions the below actions are planned over the time 
period identified below.  

Future Planning 

Actions Planned for development over the next 6-9 months include: 

•  The development of Local Authority policies and procedures including 
•  Mental Health policy 
•  Escalation policy 
•  Risk management process and policy ( this will include crisis plan 
•  Pathway procedures ( WCBC & BCUHB)  
•  Reporting and recording procedures ( WCCIS)  

The above actions I believe demonstrate the joint commitment by both organisations 
to put measures in place to prevent a similar incident occurring in the future. The 
learning outcomes from inquest have enabled Social Services to review and reflect 
on previous, current and future practices, specifically communication and crisis 
planning and to implement prevention strategies as identified in this report. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 1 

Checklist for Duty 

This checklist is to be used by all social workers, where risks of potential harm to the 
person or potential harm towards others, has been identified.  

The local Authority has developed a social work checklist for all open and active cases 
to the Community Mental Health Social Work Team and for all duty cases where the 
social worker is the designated daily duty worker in Ty Derbyn.  

This  procedure  has  been  developed  to  provide  clear  guidance  to  social  workers 
regarding  the  local authorities’ expectations of  them  in  their  social work  role and  to 
ensure that all social workers are aware of the process that needs to be followed in 
the  event of  risks  being  identified of  potential harm  to  the  person or potential harm 
towards others.  

Name:  
Date:  
Time:  

CRN:  
Address: 
Contact Number:  

1,Background checks:   
Is the person open/known to 
PCMHT/CMHT, if 
current/previous involvement 
with team, review all 
documentation prior to the duty 
assessment. 
If open case, please record the 
information and refer to the 
relevant practitioner.  

2, Assess/Update: If the 
person is known to the team 
and there is no active 
practitioner involved or the 
practitioner is off site, ensure 
any existing documentation is 
updated even if there are no 
changes. Following the 
assessment, ensure Part C 
formulation is completed and a 
signed copy is given to the 
person and a copy for file.  
Update duty log on share-point.  
3, Record / Share: If the person 
is open to PCMHT or awaiting 

 
 
                                
 
 
 
 
 
 
 
 
 
 
 
 
 appointment, record all relevant 
information, if risks are 
identified, duty process to be 
followed. If none are identified 
and it is information only, record 
all relevant information and 
handover to appropriate 
PCMHT practitioner or 
manager.  
Update duty log on share-point.  

4, Record/ Share: If person is 
not known to team, complete all 
measures documentation; 
record any risks that are 
identified; complete the Part C 
formulation ensuring a signed 
copy is given to the person and 
a copy on file.  

5, Plan/ Share/ Communicate: 
Any disclosure of overdose/self-
harm, please ensure there is 
clear plan of how this is being 
managed to reduce risks.  
Make appropriate referrals to 
the Duty Manager who will 
report to the daily Huddle.  
If further advice/support is 
needed, discuss with Consultant 
or on-call Consultant, HTT, 
AMHP ect and update Health 
Liaison team/Emergency Duty 
Team with any relevant 
information for out of hours.  
6, Escalate/ Communicate: If 
the person states that they 
intend or plan harm to 
themselves and leave a meeting 
or discussion prematurely the 
social worker will not delay in 
escalating this to the Duty  
Manager (for BCUHB Safety 
huddle process to be followed).  
The social worker will also 
attempt.   
Immediate telephone contact 
with the individual and if 
needed, their carers/family and 
continue to attempt contact until 

 
 
 
 
 
 the Duty Manager/ Safety 
Huddle agree further that they 
will escalate it to the agreed 
agencies. 

Social Worker Name and  
Signature