Eliot Harris

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 

11th October 2022 

Regulation 28 notification made in response to the death of Eliot Harris. 

I write to you in respect of Eliot Harris who died in April 2020 and who’s inquest was heard in the Summer 
this  year  by  you.  Firstly,  however  please  accept  my  sincere  apologies  for  this  delayed  response  to  the 
concerns raised by you post the conclusion of the inquest in August 2022. 

In recognising  that  this  response  will  be  shared  with  Eliot’s family,  I  would  like  to  take  this  opportunity  to 
apologise wholeheartedly to Eliot’s family for the tragic loss of Eliot whilst under our care as an inpatient. 

The concerns you raised are outlined below with our trust response to each point: 

1) Substantial evidence was heard at the inquest with regard to observations which 
were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and 
with regard to staff not undergoing training and assessment of their competency to 
carry out observations correctly. Quality audits undertaken following Eliot Harris’s 
death, show that observations are still not being carried out and recorded in 
accordance with NSFT’s most recent policy – more than two years following Eliot’s 
death. Not all staff have completed training with regard to carrying out of 
observations or have undergone and assessment of their competency to carry out 
observations. 

Therapeutic Observations are an intervention that supports safety. They are also a restrictive intervention 
thereby requiring clarity of understanding, training, clear team processes and strong individual accountability 
in order to support safety and dignity. You heard at the inquest the work the Trust has taken following Eliot’s 
death  observing  that  the  processes  of  training  and  competency  on  the  ward,  and  the  application  of 
observations required further improvement. 

Locally, within Great Yarmouth Acute Service the team have implemented a Safety Day, which is training 
specifically developed for the ward and includes sessions on clinical risk assessment, care planning, learning 
from  incidents  with  a  detailed  focus  on  therapeutic  observations  policy.  To  date,  19  of  the  27  staff  have 
attended  the  day  with  two  further  days  planned.  In  addition,  the  Matron  is  leading  on  refreshing  staffs 
understanding of the therapeutic observation policy by re-completion of the competency assessment. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Learning from the inquest has been shared with the ward team which has included the vital importance of 
completing  therapeutic  observations  in  line  with  the  policy.    The  learning  will  be  further  shared  within  a 
Registered Nurses Day scheduled for November.   

The goal of improving the application of therapeutic observations is important with a continuing improvement 
and monitoring focus. Training and audits form parts of the system to manage the safety and quality. The 
Trust  is  commencing  a  planned  review  of  the  Therapeutic  Observations  Policy,  examining  options  to 
strengthen  all  areas  including  training,  documentation,  ward  controls,  guidance  for  staff  and  assurance 
processes. In addition, the ward has reviewed and significantly enhanced their local induction process which 
is overseen by the Clinical Team Leader. 

2) On the night of Eliot’s death, a Nurse in Charge had not been allocated and 
members of staff were not allocated specific tasks – they were told to “muck in”, as 
a result there was some confusion as to who was responsible for specific jobs. The 
evidence at the inquest was not clear as to whether specific tasks are allocated to 
specific members of staff on Night Duty and whether and how a Nurse in Charge is 
appointed for each night’s rota. 

Clarity of role within a shift is important to ensure all the required actions are completed in an effective way. 
The  ward  has  improved  their  processes  which  now  ensures  the  nurse  in  charge  is  identified  and  roles 
allocated  to  the  shift  team  members. To  achieve  this,  the  daily  allocation  form  has  been  reviewed  which 
clearly identifies the nurse in charge.  In addition, the Matron oversees the off duty rota and delegates nurse-
in-charge duties each shift.   This is monitored by the Clinical Team Leader and Modern Matron. Additional 
to this aspect the trust is formulating a seminar on shift co-ordination and accountability this will be rolled out 
to all Charge Nurses including those joining from an agency, the timescale for sign off of this is three months. 

3) Multi Team Meetings were not fully and properly recorded in the clinical records. At 
the inquest, evidence was heard there “is still some way to go” with regard to 
improving record keeping and for ensuring important matters such as rationale for 
decisions is fully recorded. 

Comprehensive recording of the Multi-Disciplinary Team (MDT) meeting is essential as this supports high 
quality effective care. Record keeping is an essential action to support the evidence of care provided. The 
ward has developed an aide memoire to guide staff as to the areas to be considered as part of the MDT 
review.  This serves as a Terms of Reference for the meeting in order to improve the comprehensiveness of 
record keeping. In addition, the MDT hold a daily brief review of each patient which is recorded in the patient’s 
records. An audit of the quality of MDT meetings was completed in August by the Nurse Consultant which 
demonstrated sustained improvement.   An anonymised copy of the audit is attached. The changes are being 
monitored on a monthly basis with results fed back to the team by the Nurse Consultant.  

The ward has a new dedicated substantive Consultant Psychiatrist commencing in mid-October 2022. 

4) Eliot’s Care Plan was not up to date at the time of his death. At the inquest 
evidence was heard that although audits show there has been an improvement in 
completion of Care Plans, there “is still some way to go” and staff still need to be 
prompted to complete these. 

 
 
                                       
 
 
 
 
 
 
 
 
 
 
 
 Care plans provide details of the agreed interventions between the patient, family and team to support an 
individual’s recovery. Alongside other clinical documents, they assist the staff in their communication of the 
assessed  needs  of  the  individual,  and  the  actions  being  taken.  In  November  2021,  The  Trust  started  the 
process of implementing a new style of care plan referred to as Dialog +.   This care plan is recovery focused 
and is designed to work with the patient to understand the areas of their life which are important to them 
which they wish to improve.   As part of the implementation within the ward, a training session was held within 
the Safety Day and the team awayday which were further supported by individual sessions with staff when 
required.   

As an individual’s care and treatment progresses, the ward employs a process to support the completion and 
revisions to of care plans as an individual’s care and treatment progresses. This includes strengthening the 
wards  systems  through  the  allocation  of  primary  nursing  responsibilities  and  the  use  of  audit  to  monitor 
required improvements.  The provides feedback Clinical Team Leader leads the review of care plans and 
other  clinical  documentation  as  part  of  management  supervision,  all  of  which  will  enable  further 
improvements. The care plans are used alongside the multi-disciplinary team meetings and handovers to 
support communication of care amongst the team 

5) Staff were reluctant to enter Eliot’s room following concern for his wellbeing. The 
evidence did not reveal what is now in place to ensure staff enter a patient’s room 
immediately if there are concerns for a patient’s welfare (having considered their 
(staff’s) own safety). 

Supporting people, during times of risk and harm, as soon as it is safe to do so is important part of providing 
good care. Through our physical interventions training we promote consideration of safety, accompanied with 
message  to  seek  support.  Alongside  this  consideration  of  safety,  human  factors  can  influence  people’s 
thinking  when  experiencing  unfamiliar  or  intense  situations.  We  are  therefore  seeking  insights  from  other 
mental health Trusts as to any actions and programmes that they apply. In addition, the Safety Day includes 
a session on the Therapeutic Observation policy which includes a discussion on entering a room when there 
are immediate concerns for the patient’s welfare and how seek help if there are potential concerns for their 
own safety.  This message has been strengthened within the Therapeutic Observations ‘ Policy on a Page’ 

To  enable  easy  access  to  the  key  clinical  policies,  the  ward  has  implemented  a  Safety  Folder,  which  is 
prominently displayed on a wall within the ward office and contains brief summary of each policy. 

6) It is not clear from the evidence what is now in place to ensure that relevant and 
requested physical health checks are carried out. The process of ensuring health 
checks are carried out has not changed since Eliot’s death and remains a retrospective process. 

Physical health is a priority in caring for people during an admission to hospital. For many vulnerable people, 
admission to hospital is an opportunity for an assessment of their physical health enabling the Trust’s clinical 
teams to link the individual with primary care (GP) or specialist assessment and support. 

To meet this priority the Trust has a Physical Health Policy which provides guidance for staff on the practical 
actions to take in completing an initial physical health assessment. Understandably, an admission to hospital 
is an intensive, worrying time for people and they may not be able to initially engage in the assessment. The 
policy directs action of follow up attempts to complete this.  The ward had made changes following Eliot’s 
death applying this through their handover and diary systems which support keeping an action open until 
completed.  

 
 
                                       
 
 
 
 
 
 
 
 
 
 
 The  ward  has  implemented  a  revised  physical  health  audit  which  is  completed  monthly.  The  audit  is 
completed  for  all  patients  admitted  to  the  ward  with  the  results  shared  with  the  medical,  nursing,  Clinical 
Team Leader and Matron.  The dedicated physical health nurse on the ward has improved staff training who 
can now complete ECGs and phlebotomy. 

I would like to thank you for taking the time to raise these issues. I hope that I have given you assurance of 
our commitment to improve the quality of care received by all our service users with particular attention given 
this case to those who find themselves in unusual and very specifically stressful situations. 

Yours sincerely 

Chief Executive Officer