Tracy Wood

Ms Jacqueline Lake 
Norfolk Coroner’s Service 
County Hall 
Martineau Lane 
Norwich 
NR1 2DH 

Dear Ms Lake 

Trust Management 
Main Administration Block 
Hellesdon Hospital  
Drayton High Road 
Norwich 
NR6 5BE 

31st May 2022 

Chair: 

Chief Executive: 

I write in response to the prevention of future deaths issued on 11th April 2022 in relation to the tragic death 
of  Tracy Wood  who  died  on  3rd  June  2021.  The  inquest concluded  on  7th  April  2022  with  a  conclusion  of 
misadventure,  a  number  of  concerns  were  raised  as  part  of  the  inquest  process  and  summed  up  in  the 
conclusion. I will address these within this response but firstly would wish to extend my heartfelt condolences 
and sincerely apologise to Tracy’s loved ones and friends for the sad loss of this young woman whilst under 
our care. 

For ease I outline the concerns raised below with our action in response: 

1.  Tracy Wood was placed on Yare Ward, an acute ward which was staffed in accordance with 

“Safer staffing levels”. We heard that additional staffing could be requested if necessary. The 
ward was described by witnesses as “busy” and at times “chaotic”. Staff were not always 
available to give Tracy one to one talk time which was recognised as being important to her 
and for her mental wellbeing, so much so a note was placed in red and bold on her SBAR 
records “If we are allocated to TW 1-1 we need to make sure we are doing it, she needs 
consistency”. Evidence was heard that steps are being taken to recruit more staff and also to 
retain existing staff and that this is a national problem. The evidence was that the staffing 
levels are still not sufficient, and that recruiting staff remains a problem.  

The Trust has committed to ensure that staffing on all our inpatient areas is within safe limits this includes 
nurses,  support  workers  and other  allied  health  professionals  as  well  as  medical  staff.  In  response to 
vacancies, within the context of a national shortage and retention crisis of staff in the NHS, the Trust has 
embarked  on  an  ambitious  recruitment  campaign  which  includes  holding  recruitment  fairs  across  the 
region, attracting overseas nurses, social media campaigns, full page adverts in national newspapers, 
medical  and  nursing  journals,  continual  refreshed  adverts  on  the  NHS  Jobs  website,  incentives  and 
improved development opportunities.  

At the time of Tracy’s stay on this ward the ward did not have a permanent Consultant Psychiatrist, this 
has  since  changed  and  a  permanent  medic  is  in  situ,  this  appointment  supports  the  multi-disciplinary 
team in providing consistency which in turn brings stability to the ward environment. Equally the senior 
nursing presence has been increased with the recruitment of a Deputy Lead Nurse to support the Lead 
Nurse and enhancing the Matron and Clinical Nurse Specialist cohort across the hospital site. 

The  inpatient  wards  are  part  of  a  quality  improvement  project  to  enhance  and  increase  therapeutic 
activities including 1:1 time, exercise and fitness, external and ward-based art and craft activities amongst  
other initiatives. 

Norfolk Headquarters 
Hellesdon Hospital,  
Drayton High Road, Norwich NR6 5BE 

Suffolk Headquarters 
Endeavour House, 
8 Russell Road, Ipswich, IP21 2BX 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 2 - 

2.  Following Tracy self-ligaturing on the evening of 1 June 2021 the Duty Psychiatric Doctor was 
called to attend to see and assess Tracy but did not attend. She was assessed by nursing 
staff but she was not seen by a Psychiatric Doctor as requested by them, until the next 
morning during a review meeting.  

In  discussion  with  the  Matron  for  this  area  her  account  is  that  the  Duty  Doctor  was  asked  to  attend 
however  had  to  prioritise  other  tasks  given  that  Tracy  was  unharmed  and  responding  well  to  1:1 
discussion with the staff on the ward. This is reflected in the patient record. The next morning Tracy was 
seen by her regular doctor who knew her well. It is noted within the record that the ward staff were aware 
the Duty Doctor had not been able to attend but they did not escalate any further concerns for the reasons 
stated. However, it is not clear if the Duty Doctor discussed this decision with the senior on-call medic; 
an action for the Trust has been to improve the induction for junior and trainee doctors to include the 
escalation process for both psychiatric and physical health concerns and to implement improvements to 
the handover format. 

3.  Tracy self-ligatured with a bandage on 30 March 2021 and a note was placed on her SBAR 
records in red and bold “Do not give Tracy bandages due to ligature risk”. On 1 June 2021 
Tracy was given a bandage, at her request, before leaving the ward for a community visit. 
Evidence was heard that following a “risk assessment” it was acceptable for this decision to 
be made by a Band 6 Nurse when the bandage was used off the ward and not on the ward 
where the original ligaturing incident had occurred. The instruction not to give the bandage did 
not specify whether this applied on or off the ward. There was no discussion with a Doctor or any 
other clinical staff when making this decision. There was no record of the bandage being given 
to Tracy in the written records and no record of the rationale for the decision being 
made.  

Senior nursing staff at Band 6 level have completed their basic training, preceptorship programme and 
gained  sufficient  work  experience  and  clinical  skills  within an  inpatient  setting  to  enable  them to be  in 
charge of the ward. Undertaking a risk assessment within the inpatient setting is inherent to this role and 
one that our nursing staff are fully capable and supported to conduct given their clinical knowledge and 
expertise. 

The decision to allow Tracy to cover her self-harm wounds with a bandage whilst out on leave due to her 
expressed concern and embarrassment was a reasonable, compassionate and considered decision to 
make at the time albeit with hindsight one which is no doubt regretted by the staff member. This was not 
the root cause of this tragic event; we would not seek to hold an individual staff member to account for 
this tragedy. This is in line with the Trust’s commitment to fully embed and apply a Just Culture Framework 
to incidents to aid learning, and more broadly to support staff to feel comfortable to raise concerns without 
fear  of  blame  or  recrimination.  This  is  in  line  with  the  new  NHSEI  Patient  Safety  Framework  which 
advocates  a  human  factors/systems-based  approach  to  improving  safety  and  is  fundamental  to  the 
Trust’s cultural improvement strategy. 

4.  Part of the Risk Assessment for giving a bandage to Tracy was that she was to hand the 

bandage back on her return to the ward. Tracy did not return the bandage and was not asked to 
return the bandage. That Tracy had been given a bandage was overlooked on her return.  

This is a regretful omission which was human error. 

5.  Following Tracy ligaturing with the bandage on the evening of 1 June 2021, there was no 
investigation as to where she obtained the bandage, despite there being a bold, red 
instruction in the SBAR records that Tracy was not to be given a bandage due to ligature risk. 
By the date of the inquest some witnesses were still unaware as to how Tracy had come by 
the bandage she had ligatured with. Some witnesses were still unaware as to what Tracy had 
used as a ligature.  

Norfolk Headquarters 
Hellesdon Hospital,  
Drayton High Road, Norwich NR6 5BE 

Suffolk Headquarters 
Endeavour House, 
8 Russell Road, Ipswich, IP21 2BX 

 
                                       
 
 
 
 
 
 
 
 
 
 - 3 - 

On discussion with the Matron for the ward the article used was a dressing gown cord not a bandage, it 
is  not  clear  however  who  this  cord  belonged too  or  if  it  was  in fact  Tracy’s  own.  Tracy  would secrete 
objects in her room to self-harm with, this was a symptom of her illness, it may be that she had obtained 
this cord from another patient or indeed hidden it on admission to the ward. The fact that some staff were 
not aware of this incident or what was used is of concern. The Lead Nurse and Matron for the area will 
ensure that all incidents are shared through the ward safety huddles and handovers, this will be monitored 
through the unannounced attendance of huddles and handovers by the Lead Nurse or Matron to embed 
and role model good practice. 

6.  Following Tracy ligaturing on 1 June 2021, there was a review meeting and then a Multi 
Disciplinary Team Meeting. She had a meeting with the Psychologist later that day. No 
evidence was heard that there was a review of her hourly observations.  

Tracy was an informal patient working towards discharge; within ward reviews, therapy and 1:1 sessions 
there were regular discussions, which are documented, with Tracy regarding the treatment approach of 
the ward which was to support and enable her to a successful discharge, and not to foster dependence 
on  ward  staff.  Increasing  observations  would  have  been  a  retrograde  step  and  may  have  increased 
Tracy’s sense of being stuck or indeed failing in her goal to be discharged to new accommodation; she 
was at this time both “happy and anxious” about moving on from the ward. To enable her to do this the 
team  utilised  clinical  judgement  and  their  knowledge  of  Tracy  by  validating  her  concerns,  being 
responsive to her needs whilst at the same time promoting independence and self-regulation.  

7.  Written records did not specify correct dates and times as to events, for instance the Event 
Date/Time of the ligaturing incident on 1 June 2021 at 20:53 hours is recorded in the Clinical 
Notes as “02 Jun 2021 06:49”. Tracy’s date of death is recorded as 5 June 2021 and her date 
of birth in the SBAR records is recorded as 1 May 1981, when it is the 1 June 1981.  

The issue of contemporaneous record keeping of a high standard is a priority for the Trust and we have 
commissioned an external law firm to provide training to staff on this subject. This will be underway within 
the next 6-8 weeks. 

8.  Certain events are not included in the records, for example that a bandage had been given to 

Tracy on 1 June 2021 on her going off ward, contrary to the instruction contained in the SBAR 
records and of 121 Talk times with Tracy. Evidence was heard that steps are being taken to 
improve record keeping. However this matter has been raised with NSFT previously and 
evidence from one witness at the inquest was that not “every discussion” with a service user 
is recorded in the Clinical Record and that entries are made by one allocated person on a 
shift who will be told orally what to put by members of staff. This witness had had a 30 to 40 
minute one to one meeting with Tracy the day prior to her ligaturing on 1 June and talk time 
with Tracy on the day following her ligaturing on 1 June, details of which may have been 
helpful to other staff and regarded of some importance to Tracy’s care.  

On discussion of this point with both the Matron and Lead Nurse for the area the allocation of one person 
to update records is not common practice. This has been discussed with the ward teams and reiterated 
that this is not good practice.  

There have been some ICT barriers to agency staff accessing the electronic patient record historically 
however this is being corrected to ensure that all staff have access and are aware of the expectation to 
record contemporaneous notes individually and comprehensively, see response to question 7. 

9.  On Tracy being found on the 2 June 2021 with a ligature around her neck, emergency lifesaving 

equipment was not brought immediately to Tracy’s room. Monitoring equipment was 
obtained by a member of staff who gave evidence they were unaware Tracy was not 
breathing. On return to Tracy’s room the emergency “crash bag” was then requested and 
obtained.  

Norfolk Headquarters 
Hellesdon Hospital,  
Drayton High Road, Norwich NR6 5BE 

Suffolk Headquarters 
Endeavour House, 
8 Russell Road, Ipswich, IP21 2BX 

 
                                       
 
 
 
 
 
 
 
 
 
 - 4 - 

Training  and  ward-based  simulations  have  been  restricted  through  the  pandemic  however  these  are 
being reinstated, the Trust is currently 85% (the Trust target is 90% allowing for sickness, maternity leave 
and  new  starters)  compliant  with  basic  life  support  training  for  the  relevant  staff  groups,  this  includes 
ensuring that clear instructions are given by the resuscitation leader in such a scenario. The trajectory to 
achieving  90%  compliance  in  this  subject  is  September  2022.  The  Trust  has  recently  revised  and 
improved the  induction of  new  starters  which means that  all  staff  will  receive all  the  necessary safety 
training in their first week of employment, this programme commences on 4th July 2022. 

10. A draft Patient Safety Incident Investigation Report (PSII) has been prepared. Evidence was 

heard that this is now used rather than a Serious Incident Requiring Investigation Report and 
has the advantage of being “more timely” and providing more learning. The report was still in 
draft form at the date of the inquest (nine months following Tracy’s death) and the draft was 
only available to me on the morning of the first day of the inquest, despite assurances at Pre 
Inquest Review Hearings that it would be available prior to the inquest.  

It is always regrettable when reviews are delayed however this occurs for many reasons and does not 
prohibit early learning safety actions from being implemented on initial screening of an incident. In this 
case a patient safety alert was sent to all ward areas to highlight the necessity to consider all forms of 
potential ligature paraphernalia and the ward in question undertook a review of incident antecedents to 
look for trends or themes which they could mitigate against to prevent further incidents amongst patients. 

The  Trust  always  would  wish  to  engage  with  family  members  and  significant  others  in  these 
circumstances to ensure that any questions they have are included in the terms of reference for a review, 
with this in mind the new review framework advises a period of 90 days to complete a review which is an 
extension on the previous framework of 30 days (60 days previously). The Trust received questions from 
Tracy’s family via your office in September 2021, at which point we had already hit the 90 day target, in 
October 2021 the author visited the family and again in November 2021 to ensure their questions were 
fully explored, this was good practice and responsive to the family’s needs.  

The sign off process for a draft report has four or in some cases five stages; firstly, it is seen and agreed 
by the family, and/or significant others, then the leadership team of the area where the incident happened, 
then it goes to a Clinical sign off panel for quality checking against the Royal College of Psychiatrists 
SIRAN standards and scrutiny of the efficacy of recommendation. If a non-complex case this is the final 
stage before being formally issued. In a complex case such as Tracy’s the review must be signed off by 
the Chief Nurse and Chief Medical Officer, this is the fifth stage. 

This review was delayed at the leadership sign off stage due to a restructure of senior leads over the 
Christmas and New Year period. Following a meeting between the family and the newly appointed Lead 
Nurse further amendments were made, the leadership team signed the draft off in early March 2022, the 
Clinical panel held on 24th March 2022 advised some amendments which took it to a further panel on 30th 
March 2022. Following this at review by the Chief Nurse and Chief Medical Officer ratification was halted 
due to further amendments being advised just prior to the inquest. Hence why the report remained a draft 
and  was  in  various  version  formats.  To  address  the  risk  of  version  control  issues  in  the  future  which 
causes distress and undue confusion no drafts will be shared with any party in hard copy format as of 
now, the final ratified version will of course be available to all relevent parties. 

Whilst  accepting  that  the  review  was  heavily  delayed,  we  would  always err  to  include the  family,  and 
significant  others  throughout  the  process  prior  to  final  ratification,  this  has  to  be  done  in  the  family’s 
timescale. The purpose of the internal review is to facilitate learning and improvement it is not a process 
to hold to account, ascertain cause of death or answer to a complaint, civil or legal process. This is a very 
clear and appreciated direction under the new framework made by NHSEI. 

11. The PSII Report contains many inaccuracies including Tracy’s date of death, stating it to be 5 

June 2021. The report refers to Tracy ligaturing again at 21:00 on 3rd June 2021. The correct 

Norfolk Headquarters 
Hellesdon Hospital,  
Drayton High Road, Norwich NR6 5BE 

Suffolk Headquarters 
Endeavour House, 
8 Russell Road, Ipswich, IP21 2BX 

 
                                       
 
 
 
 
 
 
 
 
 
 date is the 2 June 2021.  

- 5 - 

The draft version shared with your office prior to inquest was correct, the earlier version shared with the 
family is not, for this I apologise fully, see response to question 10 regarding version control. 

12. The PSII report refers to the notes of the incident on 1 June 2021 that Tracy ligatured with a 
bandage but goes on to say that in interviews a cord from her dressing gown was used. 
Confusion remained as between the events on the 1 June 2021 and the 2 June 2021. The 
report refers to the view of the MDT meeting on 2 June was to keep Tracy on hourly 
observations. There is no reference in the Clinical Notes to observations being discussed. 
Witnesses asked about observations at the inquest could not recall observations being 
discussed or that they were not discussed.  

See responses in questions 5 and 6. 

13. The PSII did not involve interviews with members of staff who had involvement with Tracy in 
the hours and days prior to her death, including staff who gave the bandage to Tracy and a 
Nurse who had regular involvement with Tracy’s care and who knew her well.  

The staff who were not spoken to were agency staff who are not compelled to comply with Trust reviews 
despite the obvious ethical and professional drivers to do so. In this review one agency staff member 
approached  did make  himself  available  however  a female staff member did  not.  However,  the  review 
panel were content that the staff who did engage knew Tracy well and were able to give a consistent 
account  of  events  as  they  knew  them,  this  included  a  range  of  professionals:  nursing,  occupational 
therapy, psychology, and psychiatry. 

14. The PSII stated that statements of members of staff “for the Coroner” were reviewed. 

However, many of these statements contained inaccurate dates and times including the date 
of death.  

See response to question 7. 

15. The PSII does not make findings with regard to areas of concern raised at the inquest such as 

with regard to Tracy being given a bandage on the morning of 1 June 2021 despite there 
being a bold red note contained in the records that Tracy should not be given a bandage, that 
this was not discussed with any other senior member of staff, no record was made of the 
decision and the rationale for the decision, nor that the bandage was not returned on Tracy’s 
return. The PSII does not include reference to inaccurate record keeping and full records of 
important events not being kept.  

It transpires the SBAR was a document not uploaded onto the electronic record. This led to the author 
nor being aware of the SBAR and reporting on what was in the electronic record only, this was a gap in 
attention to detail. This aspect regarding the risk posed by the bandage should have been included in the 
review and was an omission, the author of the review has reflected on this and will ensure this is not 
repeated.  

Equally within the review panel oversight role and the review sign off processes it is the responsibility of 
those senior staff who form those panels to ensure all information is accurately recorded, analysed and 
appropriate conclusions met which address all safety concerns. 

The SBAR tool is now routinely uploaded onto the electronic record. 

16. The first draft of the PSII Report contains a sentence “However, staff noted there was a lack 

of clinical or management leadership supervision on the ward at the time and they were often 
left to “firefight” with patients who they perceived carried a greater level of acute risk than 

Norfolk Headquarters 
Hellesdon Hospital,  
Drayton High Road, Norwich NR6 5BE 

Suffolk Headquarters 
Endeavour House, 
8 Russell Road, Ipswich, IP21 2BX 

 
                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 6 - 

Tracy.” This view of staff was not included in the final draft Report.  

See responses to questions 1 and 10. 

In respect of the care and treatment provided to Tracy by the Trust, the gaps in good practice highlighted as 
part of the internal review and further expanded during the inquest demonstrate this fell below expectations.  

We would all wish for the best quality care and treatment for our loved ones and despite the teams combined 
knowledge of Tracy, their clinical expertise and genuine desire for Tracy to succeed in her recovery this was 
not to be. For this I again fully apologise and express my condolences to Tracy’s family. 

In completing this response to you, it is also clear that there were gaps in the governance and attention to 
detail of the review process which has caused unnecessary distress to the family of Tracy and raised your 
concerns regarding the quality of the review. I hope that the steps the Trust has taken and continues to take 
to address these provides you with sufficient assurance regarding our sincerity to improve and address the 
shortfalls. 

Yours sincerely 

Chief Executive Officer 

Norfolk Headquarters 
Hellesdon Hospital,  
Drayton High Road, Norwich NR6 5BE 

Suffolk Headquarters 
Endeavour House, 
8 Russell Road, Ipswich, IP21 2BX