Prevention of Future Deaths reports · 2022

Sarah-Louise Doyle

Regulation 28 report to prevent future deaths, reference 2022-0070, written 4 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report4 Mar 2022
Reference2022-0070
DeceasedSarah-Louise Doyle
CoronerAndre Rebello
Coroner areaLiverpool and Wirral
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths
Organisation namedMersey Care NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (2) 

NOTE: This form is to be used before an inquest. 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  Mersey Care NHS Foundation Trust
2a Oakhouse Park, Liverpool L9 1EP 

2.  The family of Sarah –Louise 
3.  Merseyside Police 
4.  The Chief Coroner 

1  CORONER 

I am Andre REBELLO, Coroner for the area of Liverpool & Wirral 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 
INVESTIGATION 

3 

On 04/03/2022 I commenced an investigation into the death of Sarah-Louise 
Jennifer Doyle, aged 19. The investigation has not yet concluded and the 
inquest has not yet been heard. 

4  CIRCUMSTANCES OF THE DEATH 

Sarah Louise Doyle was 19 years old  with a history of  emotionally unstable 
personality disorder and anorexia personal eating disorder. She was detained 
under Section3 MHA. She had been a patient on Harrington  ward since 15th 
November 2021 and was moved to Clock View, Alt Ward on 16th December 
2021. 
On Saturday 26th February 2022 at 21.00pm a support worker took over 
responsibility for completing checks on patients as a result of their risk 
assessment. Sarah was on 5-minute observations due to a risk of ligaturing. 
During the 5 minute checks on there were no incidents of note. At 21:25pm the 
support worker went into Sarah's room  where she was sat on the bed, replied 
she was ok when asked and  support worker left the room and closed the door. 
On checking at 21:30pm support worker could not see her sat on her bed so 
went into her and found Sarah hanging 

. 

The support worker ran out of the room and requested assistance from 
colleagues who managed to remove ligature and commence CPR  until 
paramedics arrived and took over. She was taken to Aintree Hospital and sadly 
despite best efforts her death was pronounced at 01.40am 27th February 2022. 
An article 2 investigation has been commenced and the Forensic postmortem 
result from the 3rd March 2022 is awaited pending special examination including 
toxicology. 

5  CORONER’S CONCERNS 

1 

 
 
 During the course of the investigation my inquiries revealed matters giving rise 
to concern. In my opinion there is a risk that future deaths will occur unless 
action is taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  – 

On a review of the five minute observations these were recorded exactly on 
each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for 
evidence to be heard at the inquest whether these times were precise or 
whether they were written in anticipation of future observations. The 
observations were covered by one signature with a downward arrow. In other 
settings it is better practice for five minute observations to be 12 frequent but 
unpredictable observations within each hour – to minimise the risk of a self-harm 
attempt being planned from the timing of previous observations. 

6  ACTION SHOULD BE TAKEN 

In my opinion urgent action should be taken to prevent future deaths and I 
believe you [AND/OR your organisation] have the power to take such action. 

7  YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this 
report, namely by 29/04/2022. I, the coroner, may extend the period. 
Your response must contain details of action taken or proposed to be taken, 
setting out the timetable for action. Otherwise you must explain why no action is 
proposed. 

8  COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following 
Interested Persons Sarah-Louise’s mother and Merseyside police. I am also 
under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or 
summary form. He may send a copy of this report to any person who he 
believes may find it useful or of interest. You may make representations to me, 
the coroner, at the time of your response, about the release or the publication of 
your response by the Chief Coroner. 

9 

[DATE] 

[SIGNED BY CORONER] 

04/03/2022 

2

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Mersey Care NHS Foundation Trust (PDF)
Date:  27th April  2022 

Mersey Care NHS Foundation  Trust 
V7 Building 
Kings  Business  Park 
Prescot, Merseyside 
L34 1PJ 

Dear Mr Rebello, 

Re: Sarah Louise  Doyle (deceased)  Regulation  28 Report dated 4 March 2022 

I write under Regulation  29 in response  to your Regulation  28 Report dated 4 March 2022 in relation 

to  concerns  arising  out  of the  death  of Sarah  Louise  Doyle,  5  days earlier,  on 27  February  2022. 

The inquest  has not yet been  listed. 

The Trust always takes the death of any service users  seriously  and is  keen to learn lessons  where 

possible.   I can confirm that your report has already been shared  in the Trust Wide Executive Safety 

Huddle  which  is attended  by Trust  Executives and  representatives  from each  clinical  Division  and 

also via Divisional  Safety Huddle meetings.  Safety Huddles are weekly meetings held at both a Trust 

Wide  and  Divisional  level  and  have  in  attendance  clinical  and  other  professional  managers  from 

each  service  area.    The  purpose  of  the  meetings  is  to  highlight  any  new  safety  issues,  incident 

trends  or immediate  learning  to be shared.   

The  concern  you  identified  in  your  report  was  that  the  five  minute  observations  of  Sarah  were 

recorded  exactly  on  each  five minute  interval  and  that  these  observations  were  covered  by  one 

signature  with a downward  arrow.    

I  can  confirm  that  in  relation  to  supportive  observations  the  following  actions  are  already  either 

complete or well underway: 

1. Urgent instructions  have already been given via the Associate Director of Nursing and Patient

Experience as to the use of and recording  of intermittent  observations,  which is in addition  to

the Trust Supportive  Observation  Policy.

2. On March the  8th 2022  the  Regulation  28  was  discussed  at  the  local  division  safety huddle

with  all  inpatient  Matrons  present.  An  immediate  action  was  for them  to  discuss  with  their

 
 
 respective  ward  managers  the  need  to  ensure  changes  in  the  language  used  to  describe 

level  2  observations 

to  support  more  accurate  recording.  The  discussions  confirmed 

intermittent  observations  should  take place within  each 5, 10 or 15  minute ‘windows’,  rather 

than  saying  that  they  are  5,  10  or  15  min checks (as  they  won’t  be  taking  place  at exactly 

those  timed intervals).    

3.  A further Senior  Leadership  Team meeting was held on 14th March 2022 to ensure  oversight 

of what was  required  and  timescales  for completion.  The Inpatient  Matrons  were given  until 

25th March 2022  to ensure  the changes  in recording  of observations  to unpredictable  times 

was  rolled  about  and  discussions  held  across  all  staff groups  in  each  inpatient  ward.   This 
has been  completed. 

4.  A local audit has been developed  with Inpatient  Matrons to check and provide assurance  that 

recording the actual time service users were checked is taking place, as opposed  to rounding 

to  the  nearest  5-minute  time  window.  As  additional  assurance,  spot  checks  are  being 

undertaken  by the Senior  Leadership  Team and Inpatient  Matron/ Ward Manager group. 

5.  Inpatient  Multi  Disciplinary  teams  have  been  reminded  that  if  it  is  deemed  clinically 

appropriate  for a service user to remain on 5-minute unpredictable  times, that a clear rationale 

is  given  in  the  clinical  notes  as  to  why  this  is  required  and  not  a  full  level  3  one  to  one 

observation.  Ward Managers  and Inpatient  Matrons are overseeing  this. 

6.  Inpatient  staff are  required  to  have  yearly  competence  assessments  regarding  supportive 

observations.    All  of  the  staff  on  the  wards  in  Clock  View  will  have  had  their  yearly 

competency updated  on  the  supportive  observation  policy and  will  have  been  observed  in 

practice carrying out  at least  2 supportive  observations  checks by the  end of April 2022.  All 

of the other wards across  Local Division will be completed  by the end of May 2022. 

7.  The  Senior  Leadership  Team, Inpatient  Matrons  and  Ward Managers  have  carried out  spot 

checks on  supportive  observation  forms and  immediately  challenge  poor/inaccurate  record 

keeping.    Inpatient  Matrons  are  also  doing  extra  “dip  audits”  on  observations  records  to 

 
 
 
  
 
 
 
 
 
 
 specifically review the timings  of supportive  observations  to ensure  these  are random within 

the time ‘window’ rather  than specific to the 5 minutes. 

8.  It  is  part  of the  role  for  the  Nurse  in  Charge  of  each  shift  to  carry  out  random  checks  of 

documents  and the ward environment  throughout  the shift. 

9.  The  Trust  has  reviewed  the  existing  Ward  Assurance  Audit  in  relation  to  supportive 

observations.    An  interim  change  to  recording  has  been  made  ahead  of  a  scheduled 

electronic  system  going  live  in  May  2022  which  will  reflect  the  need  for  supportive 

observations  to be at unpredictable  intervals.   These  audits  are taking place  weekly, and the 

highlights  are shared  in safety huddles  and at divisional  clinical meetings.    

I hope  that  this  letter  assists  in  explaining  the  actions  that  the  Trust  have  already  taken  in  the 

immediate  period  following  Sarah’s  sad  death  to  address  the  specific  concerns  raised  in  your 

report.   

I can confirm that  the Trust is in the process  of carrying out a review into  Sarah’s  death and  will 

share  this  report  with you as  well  as  actions  proposed  and  taken  as  a result  of it.  A number  of 

wider  actions  have  already  been  commenced on  a trust  wide  footprint  which can  be  shared  at 

the future inquest  hearing.    

Dr 
Consultant  Forensic  Psychiatrist  
Deputy Chief Medical Officer – Patient Safety and Quality 
Director of Patient  Safety

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