Uyapo Theodore Hayunga-Macha

Trust Headquarters Redesmere 
Countess of Chester Health Park 
Liverpool Road 
Chester 
CH2 1BQ 

:  

15 November 2021 

Andre Rebello 
H.M. Senior Coroner 
Liverpool and Wirral Coroner’s Court 
Gerard Majella Courthouse 
Boundary Street 
Liverpool 
L5 2QD 

Dear Mr Rebello 

Response to Regulation 28: Report to Prevent Future Deaths  

Thank you for your letter dated 20 September 2021, following the conclusion of the 
inquest  into  the  death  of  Uyapo  Theodore  Hayunga-Macha.  I  have  reviewed  the 
concerns fully and our responses and actions that we are undertaking to these are 
detailed within this letter. 

Matters of Concern: 

On 3 December 2020 Merseyside Police were called to Theo where it was 
apparent  that he  was  suffering  from poor  mental  health.  An ambulance 
was  called,  and  Theo  agreed  to  be  taken  to  Arrowe  park  Hospital.  It  is 
reported that whist waiting for Triage that he left without being seen. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Why was he not being looked after? And why was he left alone when 
waiting for assessment? 

The  Trust  are  unable  to  provide  specific  information  in  relation  to  why  on  the  3 
December  2020, Theo had not been looked after whilst waiting in A &E nor as to why 
he was left alone when waiting for an assessment at Arrowe park hospital. On this day 
the Trust Psychiatric Liaison service had not been notified of his attendance as Theo 
had  left  before  he  was  triaged  within  A  &E  and  therefore  no  referral  to  Liaison 
Psychiatry  services  was  made.  The  Trust  has  worked  collaboratively  with  Wirral 
University Teaching Hospital by providing a history of the Trust involvement in Theo’s 
care (which was prior to the attendance on the 3 December 2020) for their RCA (Root 
Cause Analysis report) following the death of Theo. 

I would like to provide assurance that the Trust is actively involved in a broader piece 
of  work  with  Wirral  University  Teaching  Hospital  (WUTH)  relating  to  the  care  of 
patients  with  mental  health  illness.  The  Trust  is  involved  in  the  Mental  Health 
Transformation  Group  which  is  currently  being  led  by  the  Interim  Chief  Nurse  at 
WUTH. This Group has identified the following areas for further focused work:  

•  Mental Health Strategy including - CQC regulated activity for the provision of 

care and treatment for patients under the Mental Health Act 

•     Escalation of patients with Mental Health Conditions 
•     Mental Capacity Act and Best Interest Training  
•     Paediatric mental health system and processes 
•     Mental Health Training (inclusive of de-escalation training)  
•     Contract monitoring and understanding service need and provision. 

The Group membership includes representatives from WUTH, and NHS Wirral CCG 
as well as the Trust, in acknowledgement of the need for partnership working.  The 
Group is in the early stages of development however leads for each of the areas above 
have been identified and work has commenced.  The Trust are committed to continue 
to  work  in  partnership  with  WUTH  and  wider  partners  to  improve  the  level  of  care 
offered to patients with Mental Health needs who attend Emergency Departments.  

Should you require any further information, please do not hesitate to contact me. 

Yours sincerely 

Interim Chief Executive

r~1:bj 

Wirral University 
Teaching  Hospital 
NHS  Foundation Trust 

Chief Executive's Office 

Wirral University Teaching  Hospital NHS  Foundation Trust 
Arrowe Park Hospital, Arrowe Park Road,  Upton, Wirral, 
Merseyside CH49 5PE 

Andre Rebello OBE 
Senior Coroner Liverpool and Wirral Area 

4th  November 2021 

Dear Mr Rebello 

Re:  Reg 28 Report (after)  HAYUNGA~MACHA U T 

I am  writing  in  response  to  the  Report to  Prevent Future Deaths, referenced  above,  which  was  received 
on  20  September  2021 ,  via  email.  This  report  raises  concerns  relating  to  why  Uyapo  Theodore 
HAYUNGA-MACHA was  left alone,  whilst awaiting  assessment,  following  attendance at  the  Emergency 
Department (ED), at this organisation, on 4 December 2020. 

I understand that we had no  involvement in  the inquest; in  view of this  I thought it was useful to share the 
following  information with you: 

We were made aware of Mr Hayunga-Macha unfortunate death early in  March 2021.  As we  understood, 
at that time,  he had  left the  emergency department before  being  assessed,  and  had  not been  seen  until 
found  deceased, we reported  the attendance as a Serious Incident, in  line with the NHS Serious Incident 
Framework. I have enclosed  a copy of the  Serious  Incident investigation  report with  this  letter,  for your 
information. The investigation identified a number of gaps in  our care including: 

•  A  failure  to  commence  the  Trust's  Mental  Health  Pathway  and  a  failure  to  undertake  a  risk 

assessment to establish  if Mr Hayunga-Macha was suitable for sitting in the waiting  room. 

•  A delay in  undertaking a triage assessment,  in  line with  national guidance 
•  A  failure  in  recognising  that  Mr  Hayunga- Macha would  be  classed  as  high  risk  due to  his  previous 

history of mental health illness. 

•  A  failure  to  implement  the  organisations  missing  person  policy to  ensure  appropriate  notification  to 

our internal security team  and the police. 

As  a  result  of the  investigation  an  action  plan  was  developed and  delivered  by the  Acute  Division  within 
the Trust,  the following  actions have been either undertaken or are  underway: 

1.  Ensure the ED  Team  are aware of the missing  patient protocol and when  it needs to be  used. 
The Lead  Nurse for the  ED  has  raised  awareness with  staff,  within  the  department, through  a series 
of  discussions  at  the  department's  safety  huddles.  In  addition  the  missing  patient  policy  and 
documentation  has  been  incorporated  into  the  new  staff induction  programme.  These  actions  were 
completed in  June 2021. 

2.  Further education  and training for staff in  relation  to  dealing with  Mental  Health  patients and 
appropriate use of the Mental  Health  Unit (MHU). The Clinical  support Workers who  provide care 
and  support  for  patients  within  the  MHU  have  completed  an  online  Mental  Health  training  session 

I}  ~ wuth.nhs.uk 

 
 
 
 
 
 Wirral  University Teaching  Hospital NHS  Foundation Trust 
Arrowe Park Hospital, Arrowe Park Road,  Upton, Wirral, 
Merseyside CH49 5PE 

Wirral University 
Teaching  Hospital 
NHS Foundation Trust 
In  addition  Cheshire  Wirral  Partnership  is  able  to  provide  training  to  all  staff, 

from  'We Can  Talk". 
and  this is currently being taken forward  by the Lead  Nurse within the ED. 

3. 

Improved  communication  between  ED  and  security  regarding  police  enquiries.  Discussions 
have  been  undertaken  to  ensure  that  when  the  Trust's  onsite  security  are  contacted  by  the  Police 
regarding  a Missing person,  there is communication with the Emergency Department. 

4.  Ensure  a  standardised  handover  process  to  alert  initial  assessment  /  triage  staff  when  a 
patient  is  placed  in  the  waiting  room  as  "fit  to  sit"  by  Ambulance  Triage  Nurse  (ATN).  All 
patients  who  arrive  under  the  care  of  the  North  West  Ambulance  Service  are  now  triaged  by  the 
ATN.  This  is  a change  in  practice;  previously,  if patients were directed to the waiting  room  on  arrival, 
as  considered  "fit  to  sit",  they would  have  been  booked  in  by  the  administrative  team,  at  the  main 
reception  and  would  have  waited  to  undergo  initial  triage  assessment.  The  ATN  now completes  a 
triage assessment on arrival for all patients,  including those presenting  with  a mental health concern. 
If this  assessment finds  the  patient  able  to  sit  in  the  waiting  room,  the  rationale  for this  decision  is 
documented. The ATN  is responsible for verbally handing over a patient to the nurse either in  charge 
of initial  assessment  within  the  MHU,  or  the  triage  nurse  if  the  patient  is  to  be  placed  within  the 
waiting  room. 

The  Emergency Department leadership team  have arranged for an  audit of 50 patients per month  to 
be  undertaken to  provide ongoing assurance around assessment/observations and triage of patients, 
who  arrive  via  the  ambulance  service,  the  results  of which  are  shared  at the  Trust's  Patient  Safety 
and Quality Board. 

Unfortunately there  are  times  when  our  MHU  is  full.  A  process  has  been  developed  to  ensure  that 
this  is  escalated  to  the  Tactical  Commander (TC}  and  the  Shift leader,  who  are  then  responsible for 
decisions regarding  either stepping  someone out of MHU to create space, or where to place patients 
who  are  just arriving.  Overnight  if the  TC  is  not on  site,  the  decision  is  made  by the  senior  Dr and 
Shift Leader. This process has been communicated to all  staff. 

Following  the  identification  of the  serious  incident,  contact  was  made  with  Mr  Hayunga-Macha's  step 
father  to  offer  our  sincere  condolences,  offer  apologies  and  inform  them  of  the  Trust's  investigation. 
Further contact,  by letter,  was  made  post the investigation  to  ascertain  if the family wished  to  receive  a 
copy of the  investigation  report;  however  I understand  that  no  response  was  received  at that time.  We 
have recently contacted  the family again  and  have  since  met with  them  to  discuss the  investigation  and 
the actions taken to date. 

I  would  also  like  to  make  you  aware  of  a  broader  piece  of work  currently  underway  within  the  Trust 
relating  to  the care  of patients with  mental  health  illness.  You  will  be  aware of the  impact of the  current 
pandemic  on  the  population's  mental  health  and  the  associated  increasing  demand  for  services.  In 
response we have established a  Mental Health Transformation Group which  is currently being led  by the 
Interim Chief Nurse. This Group has identified the following  areas for further focused work: 

•  Mental  Health  Strategy including  - CQC  regulated  activity for the  provision  of care and treatment for 

patients under the Mental Health Act 

•  Escalation of patients with  Mental Health Conditions 
•  Mental Capacity Act and  Best Interest Training 
•  Paediatric mental health system  and processes 
•  Mental Health Training (inclusive of de-escalation training} 
•  Contract monitoring and  understanding service need and provision 

I]  ~ wuth.nhs.uk 

 
 Wirral University Teaching  Hospital NHS  Foundation Trust 
Arrowe Park Hospital, Arrowe Park Road,  Upton, Wirral, 
Merseyside CH49 5PE 

r,!,:fj 

Wirral University 
Teaching  Hospital 
NHS  Foundation Trust 

The  Group  membership  includes  representatives  from  Cheshire  and  Wirral  Partnership  NHS  FT  and 
NHS  Wirral  CCG,  in  acknowledgement  of the  need  for  partnership  working.  The  Group  is  in  the  early 
stages  of development  however  leads  for each  of the  areas  above  have  been  identified  and  work  has 
commenced. 

I  hope  the  investigation  report  and  the  above  points  provides  you  with  assurance  that  we  have  taken 
appropriate  action  to  investigates  the  events  leading  to  Mr  Hayunga-Macha,  leaving  our  organisation 
before  being  assessed  and  have  reduced  the  risk  of  such  events  reoccurring  in  the  future.  However, 
please do  not  hesitate to  contact 
if you  require any additional information. 

,  Legal  Services  Manager,  via 

Yours  sincerely 

Chief Executive 

11  W wuth.nhs.uk