Liam Lyes-Watson

Trust Headquarters 
St George’s Hospital 
Corporation Street 
Stafford 
ST16 3SR 

18th November 2022 

Mr J Ellery 
Her Majesty’s Senior Coroner for Shropshire, Telford & Wrekin 

Dear Mr Ellery, 

RE: 

Liam Joseph Lyes-Watson (deceased) 
Report to Prevent Future Deaths 

Thank you for your letter dated 27th September 2022, reporting a matter to us, in accordance with 
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

May I take this opportunity to reassure you that following Mr Lyes-Watson’s death, we undertook 
a thorough investigation into the care delivered by the Midlands Partnership Foundation Trust.   

MATTER OF CONCERN:  

The four areas of concern were: 

a.  The call handler on the second occasion was not trained and needed to take professional 

advice from a colleague which colleague did not then speak directly with the caller.  

b.  The apparent blanket response that they could not discuss the case with the caller yet they 

could take information from him.  

c.  With that information more should have been done. 

d.  Consideration  should  be  given  whether  incoming  calls  to  the  Access  Team  should  be 

recorded. 

Following discussions within the mental health services in the Shropshire, Telford and Wrekin Care 
Group and with corporate services, I am now in a position to respond to the specific concerns raised 
during the course of the inquest. 

a.  The  call  handler  on  the  second  occasion  was  not  trained  and  needed  to  take  professional 

advice from a colleague which colleague did not then speak directly with the caller.  

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 Response: 

The Call Handler has discussed in supervision meetings with the Quality Lead of the Access Team on 
a monthly basis since the Serious Incident.  All concerns regarding their working practice have been 
addressed. These meetings also ensure all Mandatory Training is up to date and learning needs have 
been addressed. These meetings have led to the following further training: 

•  The Call Handler has attended a Stress and Resilience course to help them understand how 
to manage their own emotional responses to difficult calls received during their work. 

•  The Call Handler has attended the course provided by Zero Suicide Alliance. 
•  The  Call  Handler  is  due  to  attend  the  Shropshire  Council’s  Joint  Training  in  Suicide 

Prevention Awareness along with a cohort of her peers on 28th Nov 2022.  

We have reviewed the training needs for all call handlers. All new call handlers will only shadow 
trained colleagues until they have completed their training and then will be supervised whilst taking 
calls until assessed as competent by the Quality Lead. 

We have reviewed the suicide prevention awareness training for call handlers and the decision has 
been made that all call handlers will have received the training below by the end of November 2022 
https://www.zerosuicidealliance.com/training.  A  record  of  who  has  received  this  training  will  be 
held  by  the  team  manager  and  compliance  monitored  through  supervision.    In  addition  to  this 
training, it has been agreed by the service manager that the training offered by Shropshire Council’s 
Joint  Training  in  Suicide  Prevention  Awareness  Suicide  prevention  |  Shropshire  Council  is 
undertaken by all call handlers in the Access Team on a yearly basis and that this is built into their 
mandatory training for recording purposes on their electronic staff record. 

The aide memoire for call handlers is also included at Annex A.  

We  have  addressed  the  fact  that  the  shift  coordinator  did  not  then  speak  to  Mr  Heaton  is  our 
response at C. 

b.  The apparent blanket response that they could not discuss the case with the caller, yet they 

could take information from him.  

Response: 

We have shared MPFT’s Guide to Carers Confidentiality with all the staff in the Access Team. This 
reinforces  the  message  to  our  staff  that  a  confidentiality  breach  only  occurs  when  new,  person 
identifiable, information is given to a third party and does not exclude gathering information from 
carers  and  providing  them  with  support  and  advice.  This  message  has  been  reinforced  in  team 
meetings in October 2022. 

We are also  developing  new  guidance for carers which contains a range of resources  to provide 
support to carers in the form of a fact sheet which will include: 

Information on how to support their family member to make a safety plan 

•  Contact details of local organisations who can provide further support 
• 
•  How to support the person they are concerned about to have “hope” 
• 
•  How to seek help in an emergency 

Links to approved internet resources such as the Mental Health Foundation 

c.  With that information more should have been done. 

Response: 

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 We have further reviewed our actions in relation to the period immediately prior to Liam’s tragic 
death, these include: 

•  The  Call  Handler  is  due  to  attend  the  Shropshire  Council’s  Joint  Training  in  Suicide 

Prevention Awareness along with a cohort of her peers on 28th November 2022.  

•  To allow for shift patterns the remaining Call Handlers on Access Team will undertake this 

training on 11th January 2023.  

•  The  Call  Handlers  have  been  provided  with  MPFT’s  newly  published  Guide  to  Carers 
Confidentiality and are awaiting the Triangle of Care Training that all staff on the Access and 
Crisis Teams will be undertaking to enhance their skills when communicating with family 
members in contact with their teams. 

•  We have reinforced to all call handlers that concerns raised by family members are of high 
significance  and  must  be  referred  to  the  shift  co-ordinator.  We  have  stressed  the 
importance to all shift co-ordinators that, where family are expressing concerns, they must 
speak to them to clinically formulate the changes in behaviours.  

•  We have reviewed this case with shift co-ordinators and agreed that Liam should have been 

referred to the Crisis Team for them to make the decision about further action. 

•  We recognise that the shift co-ordinator should have spoken to Mr Heaton and listened to 
his and Liam’s mother’s concerns.  We apologise for this omission and learning from this 
missed opportunity has been shared with the Team to ensure all attempts are made to re-
engage service users who disengage. 

d.  Consideration  should  be  given  whether  incoming  calls  to  the  Access  Team  should  be 

recorded. 

The Trust and the investigator apologise for mistakenly stating that the calls to the Access Team 
are not recorded. All calls are recorded and are kept for audit and quality assurance and kept by 
the company who provides the service for 30 days. The Trust has requested that the company 
examine whether they can access the recording in question and will be reviewing whether calls 
can be kept for a longer period of time.  

It is not stated on the call that the calls are recorded for training and audit purposes which is a 
matter that we have rectified.  In future it has been agreed that when an unexpected death is 
reported that the relevant call will be retrieved immediately and reviewed as a part of the 
investigation process. 

Our Health Informatics Service has confirmed that we are unable to retrieve  the  specific calls  in 
relation to this case due the exceeding the period of storage for such recordings. Calls recorded are 
erased automatically after 30 days and are not able to be retrieved. We have changed our process 
and following the notification of a serious incident within 30 days of contact with MPFT, the Access 
Team Manager will retrieve the calls related to the case and secure them in preparation for any 
subsequent investigation. 

3 

 
 
 
 
 
 
 
 
 
 I hope this response helps to address your concerns. However, if you require any further information 
please do not hesitate to contact me. 

Yours sincerely 

Chief Executive Officer 

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 Annex A 

Call Handlers Aide Memoire – Self referral  

To be used to gather relevant information when patients call to self-refer.    

• 

Find patient on RiO. IF THEY ARE ALREADY OPEN TO A PATHWAY, AND ARE CALLING 
DURING THEIR WORKING HOURS, PROVIDE THE NUMBER FOR THEIR PATHWAY AND 
ADVISE THEM TO CALL THE PATHWAY DIRECTLY (END CALL).  

•  Check demographics of caller and update contact details as required. Take tel. number 

caller is calling from. Check caller’s current location. Are they with anyone?  

MENTAL HEALTH CONCERNS  

•  Ask the caller to explain in their own words why they are calling Access and what are 

their current Mental Health issues?  How do they feel this is affecting them?  
•  Are they currently receiving / or have previously received support from any other 

Mental Health services? (i.e. counselling /IAPT/ Social Services etc.).  

•  Establish risks:  

RISKS  

•  Have they ever Deliberately Self Harmed?  If yes, when was the last time? How do they harm 

themselves?  
If actively self-harming at the time of call then to go to Shift Co, or if OOH to relevant Crisis 
Team and consider calling Emergency Services (follow the UK Triage Tool) 

•  Are they having any thoughts to harm others? 
•  Are they having any suicidal thoughts? YES/N0 if Yes is there a plan? If Yes, is the plan 

imminent? 
(If Yes, call to go to Shift Co, if OOH’s this must be discussed with the relevant Crisis Team). 

Place caller on hold and ensure unvalidated progress note is inputted on RiO. Speak with 
Access shift co. who will advise how to proceed. 

Plan: 

Document next steps clearly in progress notes i.e. Referral opened to Access. Tracker sheet 
to Shift Co (document full name of Shift Co). Or Tracker sheet updated and passed to Shift 
Co etc.  

If OOH, discuss with / advice sought from CRHT Shift Co and include any advice given and 
steps to be taken either by Access or Client. 

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