Neil Bastock

Leeds and York Partnership NHS Foundation 
Trust 
2150 Century Way 
Thorpe Park 
Leeds 
LS15 8ZB 

Date: 06th January 2022 

Mr Kevin McLoughlin 
Senior Coroner, Western Yorkshire (Eastern 
District) 
Coroner’s Office and Court 
71 Northgate 
Wakefield 
WF1 3BS 

Dear Mr McLoughlin 

RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: Neil Peter BASTOCK, 
(deceased) 

Thank you for the correspondence regarding the outcome of the inquest, which was concluded on 
01 November 2021, touching upon the death of Mr Neil Peter Bastock.  I would firstly like to take 
this opportunity to express my sincere condolences to Neil’s family and friends at the tragic death 
of Neil. 

Following the Regulation 28 Report to Prevent Future Deaths issued on the 1 November 2021 to 
Leeds and York Partnership NHS Foundation Trust (LYPFT), please find below the details of our 
response to address the concerns raised. 

The Matters of Concern within the report have been broken into the points below in bold text with 
the Trust’s response following: 

1.  The decision to rescind the section on 17.09.2020 was made: 

a.  By a Responsible Clinician who had been in this role for only two weeks. 

The  core  professional  standards  require  that  any  new  Responsible  Clinician  has 
sufficient  familiarity  with  a  patient’s  past  and  current  history  to  support  robust  decision 
making. To ensure the Trust learns from the sad death of Mr Bastock, the Professional 
Medical Lead will formalise the support and supervision arrangements that are in place 
for  locum  medics  by  reviewing  the  current  induction  package  to  ensure  support  and 
supervision arrangements are explicit and proportionate. 

The  Trust  will  also  review  their  clinical  handover  process  to  ensure  it  supports  robust 
clinical decision making when locum medics commence in post. 

b.  His family were not involved in the decision at all and only became aware of it 

after it had been made. 

Page 1 of 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Improving  involvement  of  families  and  carers  is  a  priority  for  the  Trust  and  we  have 
participated  in  the  Triangle  of  Care  improvement  programme.  Triangle  of  Care  is 
recognised as a clear framework to support LYPFT’s commitment to listening to carers 
and  it  provides  a  set  of  standards  to  monitor,  evaluate  and  review  carer  support  and 
involvement.  Subsequently carers were included as a priority in LYPFT’s 3-year Patient 
and  Carer Experience and  Involvement  strategy,  launched  in  April 2020.  Progress  of 
the  Triangle  of  Care  in  LYPFT  is  overseen  by  a  ‘Carer’s  subgroup’,  comprising  staff 
members and carers.  This group reports into LYPFT’s overarching ‘Patient Experience 
and  Involvement  Strategic  Steering  Group’  chaired  by  our  Director  of  Nursing, 
Professions and Quality. 

We  acknowledge  there  was  a  missed  opportunity  to  involve  Mr  Bastock’s  sister  in  the 
decision-making  process  and  the  team  have  subsequently  reviewed  and  shared  the 
principles  set  out  in  the  Triangle  of  Care  Programme.  The  ward  manager  will  ensure 
these  principles  are  enacted  to  make  sure  a  consistent  offer  is  given  to  service  users 
and  family  members  in  line  with  the  principles.  The  service  has  also  identified  a  Carer 
Champion  who  will  attend  the  monthly  Triangle  of  Care  Steering  group  to  ensure 
progress against this work is shared and monitored.  The Patient and Carer Experience 
Team  also  have  a  dedicated  Carer  Coordinator  who  supports  carer  champions  and 
team/service leaders with their work relating to Triangle of Care. 

c.  No formalised assessment of his mental capacity was made prior to the decision. 

To  support  an  improvement  in  relation  to  this  area,  the  Trust’s  Head  of  Mental  Health 
Legislation, in conjunction with the Medical Director, will carry out a review of the current 
training provision for medical staff in relation to mental capacity assessments. 

In  January  2022,  a  Trust-wide  audit  relating  to  mental  capacity  assessments  and  best 
interest decisions will be undertaken. The Mental Health Legislation Team will review the 
audit tool to explore if the decision to rescind a detention can be incorporated within this 
audit. 

A  discussion  will  be  held  through  the  Trust’s  Mental  Health  Legislation  Operational 
Steering  Group  to  amend  the  form  completed  by  the  Responsible  Clinician  when  a 
decision  to  rescind  the  section  is  made,  this  will  include  a  prompt  for  the  Responsible 
Clinician to ensure that a mental capacity assessment is documented. 

d.  His care plan had not been updated. 

The  wards  local  system  procedure  outlines  that  care  plans  should  be  reviewed  and 
updated  weekly  or  if  there  are  changes  to  a  patient’s  presentation.  Mr  Bastock’s  care 
plan was updated to reflect his informal status however, no further updates were made. 
At  the  time  of  Mr  Bastock’s  admission,  the  Trust  had  transitioned  to  a  new  electronic 
care  record  system  which  is  now  robustly  embedded  across  the  organisation.  From 
January  2022,  an  audit  of  care  plans  will  be  undertaken  monthly  and  the  findings 
including areas for development and good practice will be shared with the team via the 
local Clinical Improvement Forums. The ward has also embedded regular care planning 

Page 2 of 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 meetings to support a consistent team approach to care plans ensuring that care plans 
are reviewed and updated appropriately. 

Trust-wide,  work  is  underway  to  simplify  the  existing  care  planning  document  on  the 
electronic  patient  record.  This  will  include  a  specifically  designed  in-patient  care  plan 
with a link to the FACE risk assessment. An initial draft of the care planning document 
will  be  shared  through  the  Trust  governance  processes  in  January  2022.  A  guide  is 
being  developed  to  support  staff  in  recording  information  consistently  and  this  will 
include the level of engagement and agreement the service user had with each element 
of the care plan.  Additional support will be given to staff to implement this new care plan 
effectively. 

e.  The pressure on bed availability in the Newsam Centre may have influenced the 

decision. 

The  decision  made  by  the  clinical  team  to  discharge  Mr  Bastock  was  in  relation  to 
detention  under  the  Mental  Health  Act  as  opposed  to  discharge  from  hospital,  which 
would have had no impact upon bed availability. 

There  are  ongoing  pressures  nationally  on  availability  of  inpatient  beds,  and  it  is 
something we pay particularly attention to at LYPFT as we strive to ensure the people of 
Leeds  can  receive  inpatient  care  locally.  I  would  like  to  reassure  you  that  decisions  to 
discharge our service users from inpatient wards are clinically based and only when it is 
safe to do so rather than in response to resource issues. 

2.  Mr  Bastock’s  treatment  in  the  Newsam  Centre  lacked  continuity.  The  responsible 
clinician was a locum who had recently taken over from another locum psychiatrist. 
There  was  no  ward  manager  on  the  ward  to  provide  leadership  for  the  care  being 
provided. There was no psychologist on the ward to contribute to care planning. The 
nursing records were incomplete, possibly due to teething problems associated with 
the recently introduced electronic recording system. 

Work is underway across the organisation to address the challenges relating to medical 
recruitment  including  a  number  of  recruitment  initiatives.  The  risk  associated  with 
medical staff vacancies is reflected on the Trust’s risk register. The use of locum staff is 
an  action  taken  by  the  Trust  to  mitigate  some  of  the  risk  relating  to  medical  staffing 
vacancies. Mr Bastock was known to one of the covering Consultants which offered him 
some  continuity  and  familiarity  but  one  Consultant  Psychiatrist  throughout  a  period  of 
care  is  undoubtedly  preferred,  and  we  acknowledge  the  potential  impact  of  this  as  Mr 
Bastock found it difficult to build up trusting relationships. 

Although  the  Ward  Manager  changed  during  Mr  Bastock’s  admission  there  was  no 
period where the ward was without a Ward Manager. The incoming Ward Manager was 
already  working  within  the  Trust  and  was  familiar  with  the  service.  A  comprehensive 
handover took place and as the Ward Manager leaving was taking up a role within the 
Trust  as  Matron  of  the  Acute  Inpatient  Services;  he  was  able  to  provide  support  and 
leadership  to  Ward  4  after  leaving  his  post.  We  recognise  that  changes  in  leadership 

Page 3 of 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 can create an element of instability for both patients and staff, therefore, to ensure we 
learn from the death of Mr Bastock, the senior leadership team has met with teams to 
provide additional support to any areas that are undergoing a transitional period. 

During  the  period  Mr  Bastock  was  a  patient  of  Ward  4  there  was  a  Consultant 
Psychologist aligned to the ward who was available to support the team in their decision 
making and care planning. 

As  previously  responded  to  at  question  1d,  the  wards  local  system  procedure  outlines 
that  care  plans  should  be  reviewed  and  updated  weekly  or  if  there  are  changes  to  a 
patient’s presentation. Mr Bastock’s care plan was updated to reflect his informal status 
however,  no  further  updates  were  made.  At  the  time  of  Mr  Bastock’s  admission,  the 
Trust  had  transitioned  to  a  new  electronic  care  record  system  which  is  now  more 
embedded  across  the  organisation.  From  January  2022,  an  audit  of  care  plans  will  be 
undertaken monthly and the findings including areas for development and good practice 
will be  shared with  the  team  via  the  local Clinical  Improvement Forums. The  ward  has 
also  embedded regular care planning meetings  to  support  a consistent team approach 
to care plans ensuring that care plans are reviewed and updated appropriately. 

3.  When the section was rescinded, Mr Bastock became a voluntary patient on the 

ward. In the three days following 17 September 2020, various factors should have 
triggered a need to reconsider the decision, including: 

a.  Mr Bastock left the ward on occasions and once did not return until 5:00am. 
b.  On his return, recorded evaluation of his situation and what action was required 

from the team treating him. 

Mr Bastock spent three periods of unplanned leave off the ward prior to his death. The 
Trust’s  Missing  Service  User  Procedure  outlines  the  actions  staff  should  take  in  the 
event a service user does not return to the ward and what should happen on their return. 
A return interview must be undertaken to explore what the service user did; where they 
went and what actions need to be taken to prevent reoccurrence. 

On  reflection,  there  was  insufficient  focus  on  the  final  aspect  of  this  process  for  Mr 
Bastock’s previous unplanned leave. This area will be reiterated to staff to ensure that if 
a patient will not engage in a discussion regarding their vulnerabilities when off the ward, 
this information is to be shared with the wider MDT team to inform an agreement about 
how and if to support ongoing leave requests made. 

In  addition  to  this,  to  ensure  the  Trust  has  learnt  lessons  from  Mr  Bastock’s  death  the 
Acute Inpatient Service have developed a template to support good practice around the 
planning and reviewing of leave and takes into consideration: 

o  Involvement of families and carers in the decision to grant leave 
o  Feedback from service users, families, and carers 
o  Evaluation of previous leave 
o  Changes to mental state and presentation 
o  Any risks associated with ongoing leave 
o  Ability of service user to engage with their personal care plan 

Page 4 of 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  template  will  be  implemented  across  the  service  following  approval  at  the  Service 
Clinical Improvement Forum in January 2022. The information gathered in the template 
will  be  used  as  part  of  the  MDT  meeting  to  inform  decision  making  regarding  ongoing 
care.  It  will  also  enable  the  team  to  review  reoccurring  concerns  following  periods  of 
leave and consider if a patient is engaging with their current care plan. We will audit the 
impact of this change in practice in July 2022. 

c.  A family member voiced concern that he was unwell and was not ready to be 

discharged, yet this warning was not heeded. 

As  responded  to  within  question  1b,  the  Trust  is  committed  to  improving  how  we  hear 
and  act  upon  the  voice  of  the  carer/family/friend  through  the  Triangle  of  Care.  The 
essence  of Triangle of Care  is  six  key elements  (standards) required  to achieve better 
collaboration and partnership with carers in the service user and carer’s journey through 
mental health services.  The six key standards state that: 

1) Carers and the essential role they play are identified at first contact or as soon as 
possible thereafter. 
2) Staff are ‘carer aware’ and trained in carer engagement strategies. 
3)  Policy  and  practice  protocols  re:  confidentiality  and  sharing  information,  are  in 
place. 
4) Defined post(s) responsible for carers are in place. 
5) A carer introduction to the service and staff is available, with a relevant range of 
information across the care pathway. 
6) A range of carer support services is available 

We  acknowledge  that  there  was  a  missed  opportunity  to  ensure  that  the  information 
shared by a family member was included with the discussions taking place regarding Mr 
Bastocks care. 

We are confident the work the Trust is engaged in with Triangle of Care will improve this 
occurrence in the future.  We would like to apologise this was not the case for the family 
of Mr Bastock. 

d.  Another family member reported that he had gone to his former partner (whom he 
had not seen for several years) to give her 250 pounds he had withdrawn from a 
cash machine for his children. The possibility that this act amounted to a farewell 
gesture was noted in the nursing record, but its significance was not sufficiently 
considered. 

  and  his  view  at  the  time  was  that  of  a 
This  incident  was  raised  with  Doctor 
positive  gesture  and  an  attempt  from  him  to  re-engage  with  other  family  members. 
Doctor 
 attempted to discuss this with Mr Bastock who at the time, did not want to 
engage  in  the  conversation.  With  the  benefit  of  hindsight,  we  acknowledge  that  this 
information could have been interpreted differently. 

As referred to in question 3, if a patient will not engage in a discussion regarding their 
vulnerabilities  when  off  the  ward,  this  information  is  to  be  shared  with  the  wider  MDT 

Page 5 of 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 team  and  an  agreement  about  how and  if  to  support  ongoing  leave  made.  To  ensure 
the Trust has learnt lessons from Mr Bastock’s death the Acute Inpatient Service have 
developed  a  template  to  support  good  practice  around  the  planning  and  reviewing  of 
leave and takes into consideration: 

o  Involvement of families and carers in the decision to grant leave 
o  Feedback from service users, families, and carers 
o  Evaluation of previous leave 
o  Changes to mental state and presentation 
o  Any risks associated with ongoing leave 
o  Ability of service user to engage with care plan 

The  template  will  be  implemented  across  the  service  following  approval  at  the  Service 
Clinical Improvement Forum in January 2022. The information gathered in the template 
will  be  used  as  part  of  the  MDT  meeting  to  inform  decision  making  regarding  ongoing 
care. It will also enable to team to review reoccurring concerns following periods of leave 
and consider if a patient is engaging with their current care plan. We will audit the impact 
of this change in practice in July 2022. 

e.  Mr Bostock had indicated he felt unable to live alone. Although a social work 

assessment had taken place, no plan in relation to alternative accommodation had 
materialised. In the absence of such transition infrastructure, it was premature to 
consider him for discharge from the section. 

Prior to  the  deterioration  of  Mr Bastock’s mental heath  in  2020  he  had made  progress 
over a number of years and worked hard with the Community Mental Health Team in the 
development of coping strategies which enabled him to live independently and utilise his 
support networks when appropriate. 

Mr  Bastock  had  indicated  he  was  fearful  about  returning  home  which  is  a  frequently 
expressed feeling for people when working towards discharge. Mr Bastock’s section was 
rescinded  because  he  agreed  to  remain  in  hospital  as  an  informal  patient  and  not 
because his imminent discharge was planned. 

Mr Bastock was assessed by an Occupational Therapist as having the functional ability 
to return home and appropriate input was sought to help with this, including a referral to 
a social worker, allocation to a CPA care co-ordinator and ongoing contact with Caring 
for  Life.  Early  input  from  the  Intensive  Support  Service  was  arranged  to  help  facilitate 
successful discharge. Unfortunately, these interventions to support Mr Bastock transition 
back home were not documented within his care plan or risk assessment. The learning 
from  Mr  Bastock’s  case  will  be  shared  with  the  team  through  the  Trust’s  clinical 
governance  structure  and  staff  will  be  reminded  of  the  importance  of  ensuring  all 
interventions are documented. An audit of care plans will be undertaken monthly by the 
ward  manager  and  the  findings  will  be  shared  with  the  team  via  the  local  Clinical 
Improvement Forums. 

f.  When Mr Bostock left the ward, there was a failure to notify the police of him as a 
missing person, given his suicide risk (irrespective of whether this complied with 
the prevailing missing person’s policy stipulated timescales). 

Page 6 of 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
  
 The  Trust  Missing Service  User Procedure outlines the actions staff  should take in the 
event a service user does not return to the ward. The Missing Service User Procedure, 
although led by the Trust is jointly agreed with West Yorkshire Police. Both organisations 
have taken a further review of the procedure to ensure it contains the learning from this 
incident. The draft procedure has been circulated to stakeholders for comment and will 
then  be  ratified  and  circulated  by  January  2022.  The  updated  procedure  will  be 
disseminated to all staff via Trust wide email, and any required adjustments will also be 
made to any associated training. 

The revised procedure will direct staff to ensure that a discussion or return interview will 
be  held  with  service  users  upon  their  return  to  the  ward  following  a  period  of 
unauthorised leave. This information should then inform the service user’s care plan with 
regards  to  directing  staff  what  action  to  take  in  the  event  that  a  service  user  does  not 
return from leave and future decision making with regards to agreeing leave. The Trust 
will audit our compliance against this aspect of the procedure in July 2022. 

To  support  the  further  learning  that  will  take  place,  the  Trust  will  be  developing  an  action  plan 
which will include all the recommendations provided within this response, we will of course share 
this  with  you.  We  would  be  pleased  to  provide  any  further  information  or  clarification  required.  If 
you  feel  that  a  meeting  with  staff  to  discuss  any  of  the  above  would  be  helpful,  please  do  not 
hesitate to contact us. 

I hope this response provides assurance of improvement, consistent with the concerns highlighted 
in the Regulation 28 and we thank you for the opportunity to further reflect on the learning following 
the sad death of Mr Bastock. 

Yours Sincerely 

Dr 
Chief Executive 

Page 7 of 7