Maria Stancliffe-Cook

Avon and Wiltshire 
Mental Health Partnership NHS Trust 
Bath NHS House 
 Combe Park 
Bath 
BA1 3QE 
  1 September, 2021

M E Voisin 
HM Senior Coroner (Avon) 
The Coroner's Court 
Old Weston Road 
Flax Bourton  
BS48 1UL 

Inquest into the death of Maria Stancliffe-Cook 

Regulation 28 Report to Prevent Future Deaths 

Dear Ms Voisin, 

Thank you for your Regulation 28 report dated 8 July 2021, issued following the Inquest into the tragic 

death of Maria Stancliffe-Cook who died on 1 August 2019. We are very sorry that Maria lost her life 

and we have accepted the findings of the independent report that we commissioned from Niche. We 

know that you will share a copy of this response with Maria’s family and would like to express again our 

sincere condolences for their loss.  

At  the  conclusion  of  the  inquest  held  on  5  July  2021  you  shared  your  concerns  with  regard  to  the 

downgrading of risk status by practitioners who had ‘no previous dealings with Maria’. We acknowledge 

your concerns alongside the recommendations made within the Niche report. Please be assured, we 

have  completed  a  full  multi-professional  review  to  consider  how  we  can  ensure  that  our  staff  can 

continue to work  in an  autonomous manner  whilst maintaining the  safe care  of  patients  as  indicated 

within your Regulation 28 report. The implementation of learning from this is our absolute priority. 

We have approximately  3000  service users  within  our  Bristol  services across  three  local geographic 

areas and a number of speciality work-streams. We have carefully considered the proportionality of risk 

in changing policy, balanced with the quality improvement process directly related to risk assessment 

and management. Whilst our staff work within teams, individual practitioners undertake the majority of 

patient  engagement,  assessment,  formulation  and  review.  All  registered  practitioners  are  held  to 

account by their professional body as well as the Trust policy, procedures, values and expectations. We 

have supervision, appraisal and audit systems in place to ensure the competence and capability of our 

staff. However, we are continuously using experiences and feedback as a means to learn and improve 

our standards of care and practice. 

We have updated and continue to work with the action plan shared during the inquest. We will continue 

to support staff, patients and carers to ensure that all systems, policy, procedures and guidelines are 

consistently and robustly implemented in practice.  

Trust Headquarters 
Bath NHS House, Newbridge Hill, Bath BA1 3QE 

_______________________________________________________________________________ 
'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, 
unless you tell us otherwise.' 

 
 
 
 
 
                    
 
 We will achieve this through; audit, governance and assurance across all levels of the Trust. We do not 

believe that a change of policy would support the quality improvement work that has commenced and 

is already being introduced into practice. Instead, the Trust is continuing to support the delivery of these 

commitments  with  the  actions  detailed  below,  to  improve  the  understanding  and  application  of  risk 

assessment and ensure that practitioners are able to demonstrate a clear and informed decision making 

process whenever risk is assessed.  

Risk Assessments  

The  Trust  has  in  place  a  regular  monthly  audit  of  sample  records  for  risk  and  care  management  of 

patients  in  the  community  and  in-patient  services.  The  most  recent  audit  data  has  shown  90% 

compliance with Trust standards and performance indicators.  

A ‘care planning steering group’ is in place, which is working with (and is co-produced alongside) those 

with  lived  experience  to  ensure  quality  improvements  and  compliance  indicators  are  developed  to 

support staff in practice.  

A new care plan and risk supervision tool has been introduced as a means to support staff to audit their 

patient records through management supervision each month. The tool is more comprehensive than the 

Trust sample audit and is specific to risk assessment, management, crisis and contingency, formulation 

of care and how individual practitioners are meeting the standards as indicated within the tool.  

The  tool  was  developed  as  a quality  improvement  measure.  It  is  completed  through the  supervision 

structure, which allows any areas of concern with record management or care delivery to be addressed 

with immediacy and plans introduced for performance support if this is indicated.  

The tool also identifies; patient, carer and family involvement to ensure that collaborative care is being 

provided or clearly identified if it is not indicated. 

The new tool has received positive feedback from staff using it, as it provides a framework of protected 

time to consider the safe aspects of patient care. 

A  ‘task  and  finish  group’  has  also  been  formed  to  specifically  develop  a  new  face-to-face  training 

package to address risk assessment and management including suicidality, self-injurious and complex 

behaviours. Again, this is a co-produced delivery group and to the training is expected to commence in 

the next couple of months.  

A report published by the Royal College of Psychiatrists in July 2020 on Self-Harm and Suicide in Adults, 

provides a comprehensive overview of the evidence base for suicide prevention measures and the role 

of mental health services within the wider system. This report highlights the increasing awareness of the 

limitations of risk assessment with regard to suicide risk and notes that ‘use of terms such as ‘low risk 

or ‘high risk’ are unreliable, open to misinterpretation and potentially unsafe (Cole-King and Platt, 2016)’. 

The  report  also  highlights  some  best  practice,  including  the  importance  of  Safety  Plans  that  are  co-

produced  with  the  patient.  One  of  the  report  authors  is  Dr 

,  who  is  a  Consultant 

Psychiatrist, Suicide Prevention expert and Director of ‘4Mental Health’, a reputable training provider. 
2 

 
 Dr 

 is a strong advocate of using Safety Plans for all service users and not just those seen as 

‘High Risk’.  

Earlier this year, the Trust procured the services of ‘4Mental Health’ to provide AWP staff with a training 

package  to  be  delivered  in  September  and  October  2021.  The  training  package  is  3.5  days  and  will 

initially be delivered to 60 members of staff. This is anticipated to promote consistency and benchmark 

standards  of  competency,  linking  the  research  of  Dr 

.  It  specifically  includes  the  co-

production of Safety Plans. This training was identified to provide support to address the quality of risk 

assessments  and  care  plans.  These  are  areas  of  practice  which  have  been  recognised  as  thematic 

learning from investigations.   

Update on Niche Recommendations 

You  have  kindly  acknowledged  that  we  have  taken  some  positive  steps  to  make  changes.  The 

independent  investigation  conducted  by  Niche  made  five  recommendations  and  also  noted  areas  of 

good practice where trust staff made efforts to obtain information from partner  agencies and to share 

information to develop a greater understanding of risk. We have provided further updates on the five 

recommendations from the independent report below, but also attach a copy of the current action plan:  

Recommendation 1 (staff access and consistency of care plans, risk assessments) 

We have detailed the changes being implemented in respect of care plans and risk assessments above 

and therefore will not repeat this information here.  

Recommendation 2 (capacity assessments) 

We have started detailed work to review and audit the quality of capacity assessments. There has been 

wide  communication  (including,  but  not  limited  to  the  Trust’s  intranet)  giving  staff  advice  on  how  to 

complete capacity assessments. We intend to review how effective this is and continue to make further 

improvements. 

Recommendation 3 (research into suicide prevention) 

Suicide prevention remains a key area of development and concern. We are particularly focussing on 

developing guidance for staff regarding autism, risk assessment and suicide prevention. These will form 

part  of  a  Clinical  Toolkit  and  RiO  Clinical  Support.  Our  Library  Services  have  started  sending  out 

literature on suicide prevention so that staff are up to date with the latest research and thinking on suicide 

prevention. 

There is a quarterly Suicide Prevention Workshop held for Bristol services that hosts guest speakers, 

reviews  identified  literature  and  explores  challenges  in  practice  through  break-out  groups.  The  next 

workshop  is  in  November  2021  and  is  hosting  the  Specialist  Autism  Team  who  are  providing  a 

presentation for staff on how to support individuals experiencing complex and/or suicide risk. 

Recommendation 4 (applying Triangle of Care principles) 

Since Maria’s death, we have ensured that there is a named carer lead in each team. We are currently 

undertaking an audit of the Triangle of Care to ensure that identification of carers has been correctly 
3 

 
 recorded.  This  will  help  us  to  ensure  that  carers’  views  and  knowledge  are  sought  throughout  the 

assessment and treatment process and that the carer is regularly updated and involved in care plans, 

medication  management  and  strategies.  The  information  from  these  audits  will  inform  improvement 

plans  which  will  be  managed through  local quality  improvement. We  are  assessed  externally  for  the 

Triangle of Care accreditation and will make our submission in autumn 2021. 

In addition to this,  an  e-learning  package  emphasising good  practice  when  dealing  with families and 

carers, is due to be released at the end of October 2021, with the aim to reach all staff. A team level, 

carer lead, training package is being developed with our expert by experience carer group which we 

hope  to  pilot  in  the  autumn.  Specific  training  sessions  are  delivered  by  the  Carer  Involvement  Co-

ordinator and Lead Psychologist for In-patients for Bristol services and has been received well by teams 

and carer involvees. 

Recommendation 5 (communication with families) 

The Trust will be recruiting 1.5 WTE Family Liaison Officers, in line with best practice, to ensure that 

family engagement is ongoing and delivered with the right resource. We attach the updated action plan 

for your information and would be happy to send you an updated version six months from today, after 

completion and quality control if you would like.  

Please be assured that learning from the circumstances of this tragic death will also be shared more 

widely with colleagues. 

Yours sincerely 

Chief Executive 

4

From Gillian Keegan MP 
Minister of State for Care and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

27 October 2021  

F.A.O Senior Coroner M. E. Voisin  
M E Voisin 
HM Senior Coroner, Avon 
The Coroner's Court 
Old Weston Road  
Flax Bourton  
BS48 1UL 

Via email 

Dear Ms Voisin, 

Thank you for your letter of 8 July 2021 about the death of Maria Stancliffe-Cook.  I 
am replying as Minister with responsibility for mental health, and I am grateful for the 
additional time allowed in order for me to do so.     

Firstly, I would like to say how saddened I was to read of the circumstances of Ms 
Stancliffe-Cook’s death and I offer my sincere condolences to her family and loved 
ones.  The circumstances your report describes are very concerning and I am 
grateful to you for bringing these matters to my attention.  

In relation to the matters of concern raised within your report, as you are aware the 
Avon and Wiltshire Mental Health Partnership NHS Trust commissioned an 
independent investigation into Ms Stancliffe-Cook's death, the findings of which have 
been shared with you.  I am advised that the Trust has also completed a multi-
professional review to consider how staff can continue to work in an autonomous 
manner whilst maintaining the safe care of patients, and that the Trust has 
implemented several changes, as a result of these investigatory activities, to improve 
the understanding and application of risk assessment across the Trust.  I am further 
advised that the Care Quality Commission, the independent regulator for quality, will 
seek assurance that these actions are undertaken by the Trust.  It is of course vital 
that the Trust takes forward the learnings from Ms Stancliffe-Cook's death.  

With regards to the assessment of mental health patients, evidence from the 
National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH)1, as 
well as National Institute for Health and Care Excellence guidance2, suggests that 
risk assessments must not be seen as a form of  risk prediction.  It is emphasised 
that whilst standardised tools may provide the impression of precision, they are poor 

1 https://sites.manchester.ac.uk/ncish/reports/the-assessment-of-clinical-risk-in-mental-health-
services/  
2 https://www.nice.org.uk/guidance  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 in terms of prediction of suicide or a particular behaviour.  Instead evidence suggests 
that assessments should be personalised according to individual circumstances. 

At a national level, the Government remains committed to ensuring that fewer people 
die by suicide each year.  Indeed, every suicide is a tragedy that can have a deep 
impact on families, friends, and communities, and even a single suicide is a suicide 
too many. 

The Department continues to work across Government and with health services and 
suicide prevention stakeholders, including people with lived experience and those 
bereaved by suicide, to put in place a scheme of work to prevent future suicides. 

In March 2021, the Department published Preventing suicide in England: Fifth 
progress report of the cross-government outcomes strategy to save lives3, which 
details work across Government and with health service and suicide prevention 
stakeholders, to reduce suicide rates.  It includes action to reduce access to the 
means to complete suicide.  As a result, a process has been established with 
partners, and across Government, to rapidly signpost emerging methods and take 
actions through a multi-agency approach.  This includes, but is not limited to, limiting 
access to the method, and reducing or removing material that promotes suicide 
methods. 

Evidence from NCISH has shown that people in contact with mental health services 
are at highest risk of suicide in the immediate days and months following discharge 
(200-fold increased risk in the three months post discharge). In view of this, NHS 
England and NHS Improvement have amended the national post-discharge 7-day 
follow up standard in the NHS standard contract, to instead require all patients to be 
followed up within 72 hours following discharge from inpatient mental health care.  

Through the NHS Long Term Plan, the Government is investing an additional 
£57million in suicide prevention by 2023/24.  This will see investment in all areas of 
the country to support local suicide prevention plans and the development of suicide 
bereavement services.  

More broadly, we are increasing investment in mental health services and expanding 
support for people in crisis. The Government remains committed to the aims of the 
NHS Long Term Plan to invest at least an additional £2.3billion a year into mental 
health services by 2023/24. In response to the pandemic, all NHS mental health 
providers acted quickly to establish 24/7 urgent mental health helplines for people 
experiencing a mental health crisis. This is an ambition of the NHS Long Term Plan 
brought forward from 2023/24 to now. 

I hope this response is helpful. 

GILLIAN KEEGAN 

3https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/97
3935/fifth-suicide-prevention-strategy-progress-report.pdf