Rohan Singh

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

39 Victoria Street 
London 
SW1H 0EU 

21 July 2021 

Mr Graeme Irvine 
HM Acting Senior Coroner, East London 
Walthamstow Coroner’s Court 
Queens Road 
London E17 8QP 

Dear Mr Irvine, 

Thank you for your correspondence of 30 April 2021 to Matt Hancock and the Prevention 
of Future Deaths report relating to the death of Rohan Dayal Singh.  I am replying as 
Minister with responsibility for mental health services and I am grateful for the additional 
time in which to do so.  

Firstly, I would like to say how sorry I was to learn the circumstances of Mr Singh’s death.  
Whilst I know it may come as little consolation, I nonetheless hope that Mr Singh’s family 
will accept my heartfelt condolences. 

I have noted carefully your very serious concerns about the conduct of search, observation 
and rapid tranquilisation procedures in relation to Mr Singh.  It is distressing that the 
inquest concluded that Mr Singh’s death was contributed to by neglect and it is vital that 
action is taken to ensure such circumstances cannot occur again.   

In preparing this response, enquiries have been made with NHS England and NHS 
Improvement (NHSE & NHSI) and their regional and local partners; and the Care Quality 
Commission (CQC). 

I understand the East London NHS Foundation Trust (ELFT) have provided a detailed 
response regarding Mr Singh’s care, which I will not repeat here.  I am reassured by the 
actions detailed by ELFT, in response to the concerns raised in your report. 

NHSE & NHSI have informed the Department that due to the seriousness of the concerns, 
the Trust took immediate action and discussed these matters with senior leads followed by 
communication to all nursing staff highlighting expectations in relation to patient searches, 
observations and rapid tranquilisation monitoring.   

The Mental Health Act 1983 Code of Practice1 provides statutory guidance on how to carry 
out functions under the Act. It outlines that hospital managers should ensure there is an 

1 *Mental Health Act 1983 (publishing.service.gov.uk) 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 operational policy for searching patients detained under the Act, their belongings and 
surroundings and their visitors.  

With regards to patient searches, sections 8.37 and 8.38 of The Code state: A 
comprehensive record of every search, including the reasons for it and details of any 
consequent risk assessment, should be made. Staff involved in undertaking searches 
should receive appropriate instruction and refresher training. 

I have been informed that the Trust has revised its search policy to explicitly include 
guidance on the handover and review of search information and the disposal or storage of 
seized items with details of the changes published on the Trust’s intranet.  Improvements 
are being made to its electronic medical records system to enable patient searches to be 
more accurately recorded and monitored and that a new electronic observation recording 
system is to be introduced. 

In addition, actions have been taken around staff training on drug awareness; search and 
ligature management training; and implementing the search policy, with all staff to receive 
annual refresher training.    

In September 2019 the Trust developed a Joint Protocol with the police regarding the 
searching of people detained under section 136 of the Mental Health Act 1983.  

With regards to the concerns raised about observation of patients, the Trust introduced 
requirements for all nursing staff to complete the observation policy competency checklist 
annually and has instituted frequent monitoring and reporting of observation practice.   

On enhanced observations, The Code (section 26.34) states levels of observation and risk 
should be regularly reviewed, and a record made of decisions agreed in relation to 
increasing or decreasing the observation. 

I understand the Trust is to provide medical records training which will focus on the legal 
standard expected for documenting medical practice in relation to observations as set out 
in The Code.  

On the issue of rapid tranquilisation monitoring, section 26.101 of The Code states, 
following the administration of rapid tranquillisation, the patient’s condition and progress 
should be closely monitored. Subsequent records should indicate the reason for the use of 
rapid tranquillisation and provide a full account of both its efficacy and any adverse effects 
observed or reported by the patient. 

Following the findings of the inquest, the Trust has introduced changes to its rapid 
tranquilisation policy and procedures to ensure monitoring is only carried out by registered 
nurses. It has also updated its training programme.   

As detailed above, a comprehensive set of actions has been put in place locally to learn 
from the circumstances of Mr Singh’s tragic death and prevent future such deaths.  

The Nursing and Midwifery Council (NMC) have informed the Department it will be 
providing a separate response to you in relation to this case.  The NMC code of practice2 
sets out the professional standards that nurses, midwives and nursing associates must 
uphold in order to be registered to practise in the UK.  

2 nmc-code.pdf 

 
 
 
 The Code requires all registrants to keep clear and accurate records relevant to their 
practice and Standard 10.3 states that registrants must not only complete records 
accurately and without any falsification, but that they have a duty to take immediate and 
appropriate action if they are aware that someone has not kept to these requirements.  

The NMC’s authority extends to investigating concerns relating to fraud or dishonest 
behaviour and to apply sanctions, which include placing restrictions on a registrant’s 
practice or removal from the register so they are no longer able to work in their profession.  

DHSC have also liaised with the Care Quality Commission. The CQC has confirmed that 
the Ivory Ward at the Newham Centre for Mental Health (NCMH) was subject to a remote 
Mental Health Act review on 23 November 2020, during which feedback for the provider 
was generally positive and no immediate concerns were identified. 

The CQC has informed the Department that ELFT has a history of acting on risks and 
concerns when identified and received an overall rating of outstanding when inspected in 
June 2018.  The safe and effective domains were rated as good, with caring, responsive 
and well-led domains rated as outstanding.   

In addition, during the spring of 2021 ELFT conducted a full review of patient safety at 
NCMH. CQC has been closely monitoring progress on this piece of work and is receiving 
updates on the subsequent actions that have taken place. Information from this review has 
been added to CQC’s monitoring activities with the Trust.  

ELFT remains on the CQC’s London inspection team risk register and is discussed 
monthly at the team level and more frequently at the relationship owner and inspection 
manager level.  Further CQC inspections are planned during 2021 and these usually take 
place unannounced. 

The CQC was set up to monitor, inspect and regulate services to make sure they meet 
fundamental standards of quality and safety, and it has a wide range of enforcement 
powers to use if needed.   

You have raised serious concerns. I am reassured that the Trust is taking action, and that 
the CQC and NMC are aware.  

I hope this response is helpful in setting out the actions that have been taken in response 
to the circumstances leading to Mr Singh’s death, and to avoid such occurrences in the 
future.   

Thank you for bringing these concerns to my attention.  

NADINE DORRIES

Trust Headquarters 
4th Floor 
9 Alie Street 
London E1 8DE 

25 June 2021 

Her Majesty’s Acting Senior Coroner Mr Graeme Irvine 
Walthamstow Coroner’s Court  
Queen’s Road  
Walthamstow  
London  
E17 8QP 

Dear Sir 

This is a formal response to your Regulation 28 report dated 30th April 2021 in which you set 
out your concerns relating to the care Mr Dayal-Singh received from East London NHS 
Foundation Trust (the Trust). 

I understand that after hearing evidence from the Trust’s Chief Nurse you were assured that 
the Trust properly investigated the death of Mr Dayal-Singh, identified learning and took 
appropriate actions. However, several issues arose during the course of your investigation 
relating to the search, observations and rapid tranquilisation (RT) of Mr Dayal-Singh that you 
would like the Trust to address with the goal of preventing future deaths. 

I wish to assure you and the family of Mr Dayal-Singh that the Trust has taken this matter 
very seriously. Whilst there were already programmes of development work underway to 
address the shortcomings related to the care Mr Dayal-Singh received; we recognise that 
this required greater oversight. The Inquest and subsequent report have significantly 
accelerated this and focussed the Trust on rapid improvement of the areas in question. I 
explain in detail the steps that we have taken to address your concerns below. 

IMMEDIATE ACTION  

Due to the seriousness of the concerns outlined in your Regulation 28 report, the content of 
this report was discussed in person with all of the Borough Lead Nurses and their deputies 
on 5 May 2021. Further to this, two letters authored by the Chief Nurse and the Directors of 
Nursing highlighting required actions were sent to the Trust’s Borough Lead Nurses and then 
to all Nursing staff in the Trust’s Mental Health Services.  

The letter sent to the Borough Lead Nurses via email on 10 May 2021 highlighted the Trust’s 
expectations in relation to patient search, observations, and RT.  It emphasised the role of 
Borough Lead Nurses in monitoring staff training, competencies and keeping records of the 

 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 same. It also highlighted immediate changes to the Trust’s RT policy. Please find a copy of 
the letter at Appendix 1. 

The letter sent out to all Nursing staff via email on 26 May 2021 highlights the same issues 
focusing on how practice will be monitored by Borough Lead Nurses regularly. Please find a 
copy of the letter at Appendix 2. 

I believe these letters relay a clear message to nursing staff about the Trust’s expectations in 
relation to search, observations, and RT. Further, they are preparing staff for the 
transformational program roll-outs outlined below.  

SEARCH 

You heard evidence at the inquest that upon admission to Ruby Triage Ward at Newham 
Mental Health Centre, Mr Dayal-Singh was subject to a property search, yet he retained 
controlled drugs and a bracelet consisting of a ligature and a blade which had previously 
been seized by police.  

I agree that patient searches must be sufficiently thorough and in-line with Trust Policy to 
ensure patient and staff safety. Your investigation highlighted that the search of Mr Dayal-
Singh was not adequate. It also concerns me that items containing contraband were seized 
by police and then given back to Mr Dayal-Singh. 

Search Policy 

In order to address the issue of contraband being handed back to Mr Dayal Singh, the Trust 
is revising its search policy to explicitly include guidance on:  

1) Handover of search information;  
2) Reviewing of search information and any relevant documentation; and  
3) Disposal/storage of seized items.  

The policy is due to be completed on 30 June 2021. It will be disseminated to all staff via the 
Trust Intranet. A letter to all registered nurses and unregistered staff will follow highlighting 
the changes.  

Search Training Module 

To ensure that nursing staff are equipped to carry out robust searches the Trust’s Director of 
Nursing and the Learning and Development Team are creating a ‘search’ training course. 
The course will reflect the Trust’s updated policy. Completion of the course will be monitored 
using the Trust’s Electronic Staff Record (ESR) data base.  

The module will be completed on 30th June and Nursing staff will undertake the training 
every two years. New joiners will receive the training upon induction.  The Lead Matron in 
each directorate will be able to access the ESR training records in real time in order that they 
are able to monitor compliance easily. This information will be sent to the Directors of 
Nursing to monitor compliance with training. The resulting compliance percentage will then 
be forwarded to the Trust Board as part of the Trust’s Annual Report for review every 
August. 

Rio Code Changes 

 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Additionally, the Quality and Performance and RiO Teams are developing a code on the 
Trust’s Electronic Medical Records System (RIO) which is to be applied every time a search 
of a patient is undertaken. This will enable Clinical Nurse Manager’s, Matron’s and Lead 
Nurses to access up-to-date information about when patient searches are undertaken and 
allow them to monitor whether such searches are taking place in compliance with the Trust 
Search Policy. This will be in use by 31 August 2021. 

The new training modules and electronic training monitoring platforms (and the interim 
measure put in place whilst these are set up) will allow senior nursing staff to closely monitor 
the implementation of the policy changes and encourage broad dissemination of the Search 
Policy through-out the Trust.  

These changes in Search Policy, training, and RiO code changes will be monitored locally 
through the Directorate Management team.  The Borough Director, Clinical Director and 
Borough Lead Nurse will ensure local actions are undertaken to ensure that the changes are 
embedded in local services and that these improvement are maintained.   

OBSERVATIONS 

You heard evidence during your investigation indicating that records of Mr Dayal-Singh’s 15 
minute intermittent observations were unreliable and falsified. Further, most staff members 
on Ivory Ward, where Mr Dayal-Singh was detained, had knowledge of this and tolerated it 
without questioning colleagues. 

Observations are a cornerstone of patient safety in Mental Health settings. I wish to assure 
you that alongside the actions the Trust is taking to address this issue outlined below, it has 
been escalated and discussed at every level of management throughout the Trust.  

Reinforcement the Existing Observation Policy 

One of the first steps being taken to address this problem is that all nursing staff (including 
new staff members and bank staff) working in Trust in-patient services must complete the 
observations competency checklist that forms part of the Trust’s Observation Policy by 30 
June 2021. This is irrespective of whether they have completed the checklist in the past.  
Local Ward Matrons managing this process have been identified. They will send the staff 
records showing completed competency training to the Trust’s Learning and Development 
Team, who will upload the information on each Nurse’s ESR. The Matrons will then feed the 
information about compliance back to the Director of Nursing for senior oversight. 

This checklist will be completed annually going forward.  

Frequent, local monitoring and reporting of observation practice 

Clinical  Nurse  Managers  have already  started reviewing  nurses’  observation  practice  daily. 
They are also undertaking weekly night visits on the wards to observe compliance with the 
observation policy at night - as this has traditionally been overlooked.   

These  reviews  will  focus  on  ensuring  there  is  adequate  staffing  to  deliver  prescribed 
observations and that practice is in keeping with both patients’ needs and the Trust’s policy. 
The outcome of the reviews will be discussed weekly with the Ward Matrons.  

The Borough Lead Nurses will review the records of this work and feed the information up to 
the Directors of Nursing. This will provide a clear view to senior management of any issues 
relating  to  observation  practice  within  teams  so  they  can  directly  ensure  that  any  remedial 

 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 action can be undertaken immediately. Further, it will allow the Directors of Nursing to identify 
and manage any broader thematic concerns. 

Observations audits 

A  new  system  for  auditing  observations  is  being  implemented.  Templates  for  monitoring 
auditing observation practice were sent to the Borough Lead Nurses as of 30 May 2021 to be 
cascaded down to their respective teams. Ward Managers will complete the audits daily and 
report to Ward Matrons on the numbers of observations being undertaken properly and any 
patterns of failures or concerns.  

A data reporting structure has been developed with the Governance Leads for each directorate 
so  that  audit  data,  review  processes,  information  and  learning  is  reliable,  accessible,  and 
transparent. This information is available to the Directorate Management Teams and Directors 
of Nursing. The Borough Directors, Clinical Directors and Borough Lead Nurses will monitor 
this within local governance meetings to ensure that locally the observation policy is adhered 
to and local plans are put in place to ensure it is embedded within local services.    

Nurse Observation Training Modules 

The Trust’s Learning and Development Team in conjunction with the Directors of Nursing 
are creating an observations module and associated compliance record on the Trust’s ESR 
data base. It is expected that nursing staff will undertake this training annually. The Lead 
Matron in each directorate will be able to access the ESR training records in real time in 
order that they are able to monitor compliance. This will then be sent to the Directors of 
Nursing for review and who in turn will forward the resulting compliance numbers to the Trust 
Board for review. This is scheduled to be in place as of 1 July 2021. 

Medical Records Training 

Two half day training sessions will be provided to the Borough Lead Nurses on medical 
record keeping by the Trust’s external solicitors within the next 6 months. The training will 
focus on the legal standard expected for documenting medical practice (especially in relation 
to observations) and will ensure staff understand when retrospective entries are and are not 
appropriate and what comprises a misleading record. 

The borough Lead Nurses and nominated Matrons will deliver training to staff on induction 
and at away days that reflects this learning. 

E-observations platform  

The Trust is developing an e-observation (e-obs) recording system to replace the current 
paper-based system. The intention is that, staff will carry an iPad with direct links to RIO so 
they can enter patient records in real time. It is expected that this will improve the timeliness 
and accuracy of observations. A full project plan will be completed by the end of July with 
anticipated roll out throughout each hospital site from early Autumn 2021.   

The Directorate Management Team will maintain local oversight of the implementation of 
these changes in observations.  The Borough Director, The Clinical Director and the 
Borough lead nurse will ensure there is local monitoring of these changes to ensure that 
observations are undertaken safely and are of good quality in the local services.   

It is my expectation that the increased focus and scrutiny of observation practice and the 
additional observation training the Trust has developed and is providing alongside 

 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 supporting systems will increase good records practice amongst in-patient staff. Further, I 
anticipate that this work will lead to an environment within the Trust where inappropriate 
observation practice will be challenged by all staff.  

RAPID TRANQUILISATION 

You heard evidence at inquest highlighting that Trust staff failed to both follow the Trust’s 
Rapid Tranquilisation (RT) and Monitoring Policy and complete the documentation that is 
required to ensure patient safety post RT. The jury determined that this failure contributed to 
Mr Dayal-Singh’s death.  

I find the evidence that the Trust’s policy, processes and procedures were not being followed 
alarming, especially in light of the jury’s conclusion.  

Policy Changes 

Given the serious implications of the above findings, the Chief Nurse made immediate 
changes to the substance of the Trust’s RT policy. On 10 May 2021(via email), she 
instructed all Lead Borough Nurses that as of 17 May 2021, RT Monitoring will only be 
undertaken by Registered Nurses. Further, patients receiving RT medicines will be placed 
on eyesight observations with a Registered Nurse, only for the first hour, post-administration. 

Observations training is a fundamental part of the training and curriculum undertaken by 
Registered Nurses to receive their diploma. Given this, and their obligations to their 
professional body to undertake their duties in line with training, I believe that going forward 
they will be best placed to carry out RT monitoring and reinforce its importance to other staff 
members.  

Additionally, the following areas of the Trust’s policy are scheduled to be reviewed by a 
Subject Matter Expert Group led by Director of Nursing. It will be updated on 19 July 2021 
with a specific focus on: 

1) Clarifying the definition of RT 
2) Describing the parameters of normal physical health limits and highlighting when to refer 
for medical attention  
3) Revising the inappropriate use of word ‘ambulatory’ with regards to post RT monitoring  
4) Mandating the consistent use of paper monitoring charts on all wards/sites (currently staff 
gather data in different ways and therefore it is not possible to tell if values on RiO are for 
rapid tranquilisation monitoring or something else). 
4) Developing an RT ‘Grab Pack’ (a succinct checklist and flowchart describing all steps of 
rapid tranquilisation monitoring) for the wards and incorporated into the Policy as an 
appendix. 

Nurse training 

In order to ensure that Nurses are fully aware of both the importance and the content of the 
Trust’s RT policy, processes and procedures the Trust is overhauling its program of training. 

Whilst the new training program is in development, as in interim measure, a slide outlining 
the Trust’s policy changes and highlighting the importance of RT monitoring has been 
included in the existing RT training provided to all Registered Nurses and Nursing 
Associates. This is delivered annually as part of the Trust’s Safe Administration of Medicines 
Electronic (SAME) training. 

 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 The more substantial stand-alone training module in relation to the administration and post-
administration monitoring of RT is expected to be completed by 31 August 2021. It will be 
undertaken alongside the SAME training annually. 

By 31 August 2021, the Trust will make an e-learning package on RT available on ESR 
where its uptake will be monitored in real time by Clinical Nurse Managers and Matrons. 

RIO Rapid Tranquilisation Form  

Finally, since the e-obs platform outlined above will only be available later this year, as of 
June 2021 a RIO RT monitoring pack is being used as an interim measure to reinforce the 
Trust’s RT policy.   

The pack will be readily available on the Wards and provides standardised guidance as to 
the process and forms to be filled out before, during and after the RT process.  It includes 
clear directions on how to monitor those who refuse vital signs physical monitoring 
(assessing level of consciousness and observable early signs of deterioration) and a trigger 
tool for escalation.  

Again, at a local level the Directorate Management Team will ensure these changes relating 
to monitoring following rapid tranquillization are fully embedded in local services.  Through 
local governance meetings the Borough Director, Clinical Director and Borough Lead Nurse 
will ensure that monitoring is occurring and that all the changes are in place.  This will 
ensure that observations following rapid tranquilization are carried out safely and are of good 
quality.      

I firmly believe that the changes to the Trust RT policy and the updated training modules will 
ensure that the events that lead to Mr Singh’s death will not reoccur. 

Progress Monitoring 

The delivery and monitoring of the above improvements is a collective task across 
disciplines.  

Although the onus is largely on the nursing profession; oversight and assurance is monitored 
jointly through the local operational leadership structures (Borough Directors, Clinical 
Directors, Borough Lead Nurses) and the corporate and executive leadership of the 
professions involved (the Directors of Nursing, Chief Pharmacist, Medical Directors, Chief 
Nursing Officer and Chief Medical Officer).  

Daily, weekly and monthly frameworks are now in place to monitor compliance, provide 
assurance and ensure timescales for implementation are achieved.   

I hope this adequately addresses your concerns.  

Yours Sincerely  

Chief Medical Officer 

 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 APPENDIX 1 

10th May 2021 

SENT VIA EMAIL TO: 

Dear  

Trust Headquarters 
9 Alie Street 
London 
E1 8DE 

Email: @nhs.net 
Website: www.elft.nhs.uk 

RE: Regulation 28: Report to Prevent Future Deaths 

Following a Coroner’s inquest in April 2021 into an inpatient death in 2018; the Trust has received a 
Regulation 28 Report to Prevent Future Deaths; this has also been sent to the Care Quality 
Commission and Nursing and Midwifery Council.  

The main areas of concern highlighted in this death are also of concern in other deaths that have 
occurred in our inpatient wards. As Lead Nurses, you all have a role to play in ensuring that any 
resulting actions from this report are carried out and evaluated to a standard that assures us all of 
the safe clinical practice and oversight.  

Over the past eighteen months, we have had several discussions about these themes. The issues 
identified for action in the report are: 

1)  Personal searches- It is evident in this case that there was insufficient oversight of how 
searches had been conducted, when and by whom. This led to the patient retaining 
dangerous items including drugs and weapons. The death was drug related. 

2)  Observations- In this case, observations were not undertaken as they should have been and 
the culture on the ward around observations meant they were a neglected activity and the 
documentation was falsified. The Coroner found this neglect contributed to the patient’s 
death.  

3)  Rapid tranquilisation monitoring- This was wholly neglected by the nurses on duty and 

records falsified. Had monitoring taken place, it is likely that the patients collapse would 
have been acted upon sooner – with the potential for life saving this implies.  

 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Additionally, although not as part of the PFD, there were concerns about the allocation, delegation 
and oversight of the shift coordinator role.  

Below are actions that you have to lead in your area. As with all systems of training and monitoring, 
there will be need to change, adapt and improve how they work. However, we need to know how 
well we are doing now and keep a close eye on this as changes occur: 

Point 1. You must have a record of who is trained to search patients. This must be current 
and the training must form part of induction for staff – in particular key staff such as 
Band 6 Clinical Practice Leads.  

You must have a systematic overview of this documentation and this must be reviewed 
regularly. This record must be maintained and staff supported to undertake this training.  
Any equipment related to searching must be maintained/replaced and staff trained in its 
use.  

For Point 2: All staff must be trained in the use of Observations and demonstrate 
competence in both undertaking and documenting observations. Records of who has 
been trained and regular monitoring of practice need to be kept by you. Monitoring must 
take into account practice on night shifts and weekends.  

For Point 3: The Chief Nurse has instructed that from 17th May 2021, all Rapid 
Tranquillisation Monitoring will be undertaken by registered nurses. A further change is 
that those patients who receive these medications in this manner will be placed on 
eyesight observations with a Registered Nurse for at least the first hour, post 
administration.  

You need to demonstrate that staff are competent and have sufficient knowledge around 
the risks associated with rapid tranquillisation; when it is indicated; when and how to 
monitor and intervene.  

All of these issues will require a level of scrutiny that is frequent, credible and robust.  

As we progress the improvement work on observations over the coming months, it is anticipated that 
practice will change. You need to be fully engaged and leading this in your areas. If you require 
support and help to progress this, then this will be provided.  
You are expected to relay and discuss these expectations with your teams – specifically with Matrons 
and Clinical Nurse Managers – and keep a record of these discussions for later scrutiny. 

Finally, we are very aware of just how busy and difficult this last year has been for all and that 
providing these assurances will be an additional task within the context of the pandemic. Please hold 
in mind that this is about working to prevent future deaths – as you pay personal attention to this, 
you will see where the relative issues are that require action or change. We will need to work 
together to keep focus and ensure that our services are meeting the obligations in relation to this 
report.  

Yours Sincerely, 

Chief Nurse                                        Director of Nursing                     Director of Nursing 

 
                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
             
 
 
 
 APPENDIX 2 

Searching, Observation and Physical Health 

Monitoring Practices 

Dear  

Information For All Nursing Staff working in Mental Health Settings 

A recent Coroner’s Inquest into a death on an inpatient ward in ELFT found that poor 
practice had contributed to the death of the patient. 

During the course of the Serious Incident Review and the Inquest, it became clear that 
certain practices around searching, observation and physical health monitoring fell 
below acceptable standards. 

In light of this, the Coroner has issued a report to the Trust, Care Quality Commission 
and the Nursing and Midwifery Council instructing that we act to prevent any future 
deaths by addressing the shortcomings in these practices and assuring the Coroner that 
any actions are credible and reliable. 

There are key requirements for all nursing staff. 

1) Patient Searches 

Unregistered and Registered Nursing Staff – must be formally trained and deemed 
competent to search patients and their belongings, know when and how this is permitted 
and what documentation is required. You must also be able be able to provide evidence 
of training. 

2) Observations 

Unregistered and Registered Nursing Staff – must be trained and deemed competent to 
undertake observations of patients. Documentation of observations must be accurate 
and contemporaneous. All staff must know the clinical indications for undertaking 
observations with patients and this activity must be manageable within the staffing 
resource available. 

3) Post Rapid Tranquillisation Patient Monitoring 

Registered Nurses – must be trained and deemed competent to undertake RT 
monitoring. As of the 17th May 2021 only Registered Nurses can undertake RT 

 
                             
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
  
 monitoring and this monitoring must be within eyesight for at least the first hour post 
administration. Note – the form of observation described is specifically for RT monitoring 
purposes and is not the same as Enhanced Observations as per the Observation Policy. 

Practice in all of these areas will be monitored very closely. Getting this right is a key 
priority. 

Each clinical area has a Matron who is responsible for each of these activities. The Lead 
Nurses will work closely with each team to ensure that you are trained and are confident 
in these clinical and security activities. 

Please talk with them for advice and support. 

If you are concerned about practices in your area and do not feel you can discuss this 
with your managers then our Freedom to Speak Up (FTSU) Guardian, can assist. 

They can be contacted via the FTSU confidential inbox of 

Your feedback is enormously important – please let us know your thoughts and opinions 
on this. 

Kind regards, 

Chief Nurse 

  Director of Nursing  

(London Mental Health) 

  Director of Nursing 
(Bedfordshire and Luton 
Mental Health) 

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PROFESSIONALISM HQ 

Senior Coroner Mr Graeme Irvine 
Walthamstow Coroners Court 
Queens Road 
Walthamstow 
London 
E17 8QP 

Deputy Assistant Commissioner 
New Scotland Yard 
Victoria Embankment 
London 
SW1A 2JL 

Date: 21 June 2021 

Dear Mr Irvine 

I  am  the  Deputy  Assistant  Commissioner  for  The  Directorate  of  Professionalism  in  the 
Metropolitan  Police  Service  (MPS)  and  I  am  responding  on  behalf  of  the  Commissioner  of 
Police  of  the  Metropolis  to  your  Regulation  28  Report  to  Prevent  Future  Deaths,  dated  30th 
April 2021. Your report was sent following the conclusion of  the inquest into the death of Mr 
Rohan-Dayal Singh who sadly died on 13th  December 2018. 

The MPS has acknowledged and reviewed all matters of concern raised by the Coroner and 
accept  that  matter  of  concern  (1)  should  be  considered  by  the  MPS.  Our  response  to  this 
matter of concern is as follows: 

Rohan Singh died on a mental health ward,  following his death he was found to be in 
possession  of  number  of  prohibited  items  including  controlled  drugs  and  a  bracelet 
consisting  of  a ligature  and  a  blade.  Before admission  into  hospital,  Rohan  had  been 
subject  to  a  personal  search  by  police  officers  when  the  bracelet  was  seized.  During 
Rohan’s  admission  his  property  was  subjected  to  a  search  and  later  he  himself  was 
searched for contraband, despite these steps he retained dangerous contraband. 

This  matter  is  concerned  with  the  search  of  Mr  Singh  and  seizure  of  his  property  by  police 
officers, before being passed onto the Health Care Professionals who were responsible for the 
wellbeing of Mr Singh. Whilst there is no clear chain of causation between police action/inaction 
in  relation  to  the  search  and  seizure,  this  matter  does  highlight  a  point  of  learning  for  the 
Metropolitan  Police  Service  in  respect  of  record  keeping.  Where  an  officer  has  cause  to 
undertake  a  search  of  a  detained  person,  in  any  context,  the  property  seized  should  be 
recorded in writing. If that property is then passed to a third party (for example, another police 
officer  or  a  Health  Care  Professional)  then  a  record  of  the  person  receiving  that  property, 
including the time and date, should be made. The Metropolitan Police Service will publish an 
Operational Notice on the MPS internal website which will be completed by 30th  June 2021 , 
instructing  all  officers  in  respect  of  these  requirements  and  emphasise  that  there  should  be 
clear communication to all parties in relation to any transfer of property,  especially where an 
element of risk is apparent. 

In  addition  to  the  Operational  Notice,  the  MPS  already  has  in  place  guidance,  policy  and 
training  for  dealing  with  property  from  the  proceeds  of  crime,  criminal  exhibits  and  further 

 
 
 
 
 
 
 
 
 
                           
            
                                                     
 
 
                                               
 
 
 
 
                                                        
            
 
 
 
                                                                         
 
 
                                                                                
 
 
                                                                                
 
 
                                                                              
 
 
                                                                                           
 
 
 
    
                                                                                            
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 guidance on dealing with lost and found property.  However, following this matter of concern, 
we  have  identified  an  opportunity to  develop  additional  training  on  recording  property which 
falls outside these categories. The MPS will seek to implement this training across all our Basic 
Command Units through our current “Street Duties” course for probationer police constables. 

In relation to the bracelet, consisting of a ligature and a blade, the MPS police officer who dealt 
with Mr Singh did not consider this to be an offensive weapon and therefore Mr Singh was not 
committing  an  offence  by  being  in  possession  of  them.  The  bracelets  were  subsequently 
passed to hospital staff in addition to his personal belongings. The officer involved has been 
spoken to  by a  supervisor  and  advised accordingly in  relation  to  recording  property  and  the 
circumstances where property can be seized by police. 

In Conclusion 

I wish to express my sincere condolences to the family of Mr Singh. The MPS is committed to 
promote a culture of learning and continuous improvement wherever possible. 

I trust this provides the reassurance that the MPS has considered the matter of concern you 
have raised.  Please do not hesitate in contacting me should you have any queries. 

Yours sincerely 

Deputy Assistant Commissioner