Robert Hammond

28 January 2022 

Mr Sean McGovern,  
Senior Coroner for Warwickshire, 
Warwick Justice Centre, 
Newbold Terrace, 
Royal Leamington Spa, 
CV32 4EL 

Dear Mr McGovern 

Re: The late Mr Robert Hammond 

I  am  writing  to  you  in  response  to  the  Regulation  28:  Prevention  of  Future  Deaths 
Report  which  was  received  from  your  office  on  6  December  2021  in  respect  of  the 
death of Mr Robert Hammond. 

Your report focussed on our assessment and management of risk where there was a 
risk of a person self-harming or who had suicide ideation.  Your inquest concluded that 
our  Working  with  Risk  documentation  was  not  completed  on  approximately  the  first 
nine contacts with Mr Hammond and as a result the care plan for Mr Hammond was 
deemed unsatisfactory.  I am aware that as part of your summing up of the inquest, 
you acknowledged the challenge of working with people with mental health problems 
and that your concerns in relation to this matter were in the context of the PFD issues 
that I will address in my response. 

You  heard  evidence  in  relation  to  proposed  actions  arising  from  our  internal 
investigation, but you were concerned that there was no determination for closure of 
some of those actions. 

Clinical Risk Assessment and Management Policy 

For context, I want to refer to our “Clinical Risk Assessment and Management Policy” 
which  describes how clinicians  providing  care  to  patients  should utilise  the  Working 
with Risk tools and framework.   

Working with Risk 1 tools are used to assess a patient’s “current risk”.  The Trust policy 
is that Working with Risk 1 assessments should be completed on initial assessment to 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 
www.covwarkpt.nhs.uk

 
 
 
 form  a  baseline  and  thereafter  when  there  is  reason  to  believe  that  the  risk  has 
changed  (increased).    All  clinicians  should  be  alert  to  a  person’s  “risk”  during  each 
contact  and  a  full assessment  documented when applicable.    This does  not  usually 
mean on every contact but rather when indicated.  Where risk is identified, the clinician 
and  patient  should  work  together  to  formulate  a  plan  to  reduce  that  risk.    Families 
should be involved when appropriate with the patient’s agreement. 

Working with Risk 1 is complemented by other tools that clinicians can access and use 
to support active risk assessment, and these are: 

•  Working  with  Risk  2:  which  supports  describing  historical  risk  and  risk 
management and should be completed if a patient is in receipt of care for three or 
more months.  

•  Working with Risk 3: which focusses on taking ‘positive risks’ and supports the 

clinicians clinical judgment if a positive risk can be taken. 

•  Working  with  Risk  4:    which  supports  the  development  of  ‘My  Personal  Safety 
Plan’ and is used when the patient is through the clinical crisis and can contribute 
to and implement a risk management plan.  

•  STORM (Skills Training on Risk Management) is risk documentation that is used to 

assess Suicide risk.  

Unfortunately,  whilst  the  Working  With  Risk  1  was  completed  for  Mr  Hammond  on 
some  contacts,  including  his  first  contact  with  Arden  Mental  Health  Area  Team 
(AMHAT)  on  20  December  2020,  there  were  other  times  when  he  voiced  suicide 
ideation,  and  this  was  not  formally  assessed  or  recorded  and  should  have  been, 
including when he was seen by the North Warwickshire Home Treatment Team from 
23 December 2020. 

An action agreed as part of our internal review of the care and treatment received by 
Mr  Hammond  was  to  conduct  an  audit  of  risk  assessment  within  our  Urgent  Care 
Services.    The  audit  was  completed  and  has  supported  our  understanding  of 
compliance  within  the  team  providing  care  to  Mr  Hammond  and  identifying  further 
actions  required  to  support  staff  which  included  bespoke  training  for  staff,  and  the 
implementation of a standardised monthly audit of risk management care which will be 
completed by the end of current financial year.   

The results and actions, from the routine audits will be shared within the Mental Health 
directorates safety and quality forum, with upward reporting to the Trust’s Safety and 
Quality  Committee.    I  anticipate  that  routine  data  monitoring  and  the  review  of  the 
quality of documentation would commence in February 2022.   

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 
www.covwarkpt.nhs.uk 

   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The work that I describe above will deliver a system of assurance and reporting at all 
levels  in  the  organisation  on  the  completion  and  quality  of  risk  assessments  and 
associated safety plans where indicated. 

Additional Work 
I  want  to  take  the  opportunity  to  apprise  you  of  additional  activity  the  Trust  is 
undertaking to strengthen our patient risk management activity. 

Our  current  “Clinical  Risk  Assessment  and  Management  Policy”  is  based  on  a 
recognised framework that was first published over ten years ago.  However, to further 
develop  our  policy  arrangements  for  risk  assessment,  some  of  our  senior  clinicians 
and professional leads have been involved in reviewing clinical risk assessment and 
support plans as part of co-production work with NHSE/I, academics and the Mental 
Health and Learning Disability Nurse Directors’ Forum (to be held 27 January 2022). 
The  co-production  work’s  task  is to  review and  respond  to  the  findings  of  the  “Self-
harm  and  Suicide  in  Adults”  which  is  a  report  commissioned  and  published  by  the 
Royal College of Psychiatry. 

The key learning from our engagement with the national network forum, as well as the 
findings of our local audit will support a wider  trust wide review of our “Clinical Risk 
Assessment and Management Policy” arrangements. 

I have directed that a dedicated project be undertaken to focus on drilling down and 
addressing the key areas for improvement identified through our internal investigation 
of the tragic set of circumstances surrounding this incident,  as well as those factors 
highlighted throughout the coronial process.  Some of this work I have described above 
and the working group has already started to conduct a deeper dive into diagnosing 
the root causes of the problem by the following means:- 

•  Review best practice for assessing risk, including methodologies and tools across 

other NHS Trusts.  

•  Continue to audit current practice so that specific areas for improvement can be 

identified. 

•  Commission a staff survey to identify human and cultural factors which will enhance 

practice. 

•  Conduct  observational  studies  and  process  mapping  to  aide  understanding  and 

identify areas of common errors or pinch points. 

This work will support and inform the next stage of designing improvements which can 
then be tested to include: 

•  A review of policies, standardised operating procedures, and tools for clinical risk 

management. 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 
www.covwarkpt.nhs.uk 

   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  A  review  of 
development. 

induction  programmes,  mandatory 

training  and  professional 

Both I and my Trust Board colleagues have taken this matter extremely seriously and 
will continue to do so.  I trust that this letter provides you with an appropriate level of 
assurance regarding the actions taken, and those to be taken, to continue improving 
patient care. 

I would be grateful if you could share a copy of my response to you, with the family of 
Mr Hammond. 

Yours sincerely 

Chief Executive 

Coventry & Warwickshire Partnership NHS Trust 
Wayside House, Wilsons Lane, Coventry, CV6 6NY 
Tel: 024 7636 2100 
www.covwarkpt.nhs.uk