Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0298, written 26 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Sep 2022 |
|---|---|
| Reference | 2022-0298 |
| Deceased | Sandra Kirk |
| Coroner | Anna Loxton |
| Coroner area | Surrey |
| Category | Suicide (from 2015) |
| Organisation named | Surrey and Borders Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT
IN THE MATTER OF:
__________________________________________________________
The Inquest Touching the Death of Sandra KIRK
A Regulation 28 Report – Action to Prevent Future Deaths
__________________________________________________________
THIS REPORT IS BEING SENT TO:
•
, Chief Executive, NHS England and NHS
Improvement, PO Box 16738, Redditch B97 9PT,
England.contactus@nhs.net
1 CORONER
Ms Anna Loxton, HM Assistant Coroner for Surrey
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7(1) of Schedule 5 to The Coroners
and Justice Act 2009.
3
INVESTIGATION and INQUEST
The inquest into the death of Sandra Kirk was opened on 5th November
2021. It was resumed on 5th September and concluded on 15th September
2022 before a Jury.
The Jury found the medical cause of death to be:
1a. Asphyxia due to ligature around her neck
The jury returned a narrative conclusion, recording that Sandra had no
mental health history until after she contracted Covid-19 in November
2020. Whilst she appeared to make a full physical recovery, she became
increasingly preoccupied by the delusional belief that she had sustained a
permanent degenerative brain disorder as a result of Covid, which was
progressive and terminal.
They recorded that as a result of this fixed belief, she attempted suicide
on 23rd February 2021 with a carefully planned overdose and carbon
monoxide poisoning, leading to a diagnosis of psychotic depression and
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inpatient care until 5th March 2021, with Community Health Recovery
Service follow up in the community.
On 15th May 2021 she attempted to end her life
She was admitted to
Cygnet Hospital Woking (“Cygnet”) under section 2 of the Mental Health
Act on 17th May 2021. Whilst on section 17 escorted leave on 9th June 2021,
she again attempted
resulting in her
being detained under section 3 of the Mental Health Act; her leave being
revoked; and observations increased to every 15 minutes before being
returned to general hourly observations.
Sandra disclosed that she was non-compliant with medication to a friend,
and this was reported to Cygnet staff on 27th July 2021 at an MDT
meeting. A search of her bedroom was undertaken later that afternoon,
following a similar disclosure via another patient that Sandra had
reported non-compliance. During this search no medication was found. A
were found and removed from her
bedroom, in accordance with Cygnet’s Restricted/Prohibited Items policy,
which identified such items as “not allowed because it would not be safe
for them to be used in this environment”. A Nurse who carried out the
search gave evidence that she had noted
during the search, but these were not removed as Sandra was
not deemed to be a specific risk of ligature.
On 30th July 2021 Sandra herself confirmed to a member of nursing staff
that she had been spitting out her lithium medication.
On the morning of 2nd August 2021, Sandra’s 57th birthday, she was
recorded as being in the bathroom at 7.02am observations with the
shower running. At 7.55am observation, she was found deceased on the
bathroom floor
The Jury recorded that “Sandra’s high risk of suicide, in combination
with the risk posed by ligatures to both other service users and Sandra
herself, and the high percentage of in-hospital suicides which are
undertaken through ligature use, mean that it is probable that the failure
to remove the dress belt when it was brought in to Sandra on 6th of June
was not removed
contributed to her death. In addition,
when it was brought in and that it remained in the room following the
search on 27th July 2021, the failure to remove it is also a probable
contribution to her death. The risk of ligatures in Sandra’s possession for
the above reasons therefore warranted its removal on both occasions”.
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Whilst Sandra’s Consultant Psychiatrist expressed surprise that Sandra
possession, nursing staff gave evidence that they would
not have expected this to be removed as Sandra was not assessed as being
at risk of ligature, although at high risk of suicide, because she had no
specific history of ligature use. They referred to a balance between
assessing risk and maintaining patient dignity in considering whether to
remove items of patient clothing, and that many items can be used as a
ligature by the determined user.
4 CIRCUMSTANCES OF THE DEATH
Sandra Kirk was found unresponsive on the floor of the ensuite bathroom
of her bedroom at Cygnet Hospital at 7.55am on the morning of 2nd
August 2021
. She could not be
resuscitated and was declared deceased by attending paramedics at
8.53am.
5 CORONER’S CONCERNS
The MATTERS OF CONCERN are:
- The evidence in this inquest was that Cygnet’s Ligature Risk
Reduction Policy and the Ligature Audit Tool/Ligature Risk
Assessment are standard documents used by Mental Health
inpatient providers, including NHS Psychiatric Trusts.
- The Ligature Risk Reduction Policy quotes the CQC guidance of
2015, that “Three-quarters of people who kill themselves whilst on
a psychiatric ward do so by hanging or strangulation”.
- Whilst these documents provide detailed guidance in respect of
minimising ligature anchor points, they do not give guidance as to
minimising potential ligatures themselves, which are defined as
“Any item which can be used to make a loop or noose with the
intention of limiting the supply of oxygen to an individual by
hanging or asphyxiation”.
- Rather than emphasising the very real risk that specific items of
, can pose to vulnerable
clothing,
patients, the document places emphasis on avoiding ‘blanket
restrictions’ which does not assist in identifying where the real
risks lie.
- Death by the use of a ligature is likely to occur within a few
minutes, whereas observations for a high-risk patient not assessed
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as being in immediate crisis, will generally be carried out four
times in every hour, which therefore provides only a limited
degree of risk reduction. Consideration should be given as to
efficacy of such a policy and whether this can be improved by
recognising that some items of clothing will be more obvious
ligature risks and may need to be removed in all cases.
Consideration should be given to whether any steps can be taken to
address the above concerns.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I
believe that the people listed in paragraph one above have the power to
take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of its date; I
may extend that period on request.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for such action. Otherwise you must
explain why no action is proposed.
8 COPIES
I have sent a copy of this report to the following:
1. See names in paragraph 1 above
2.
,
3. Cygnet Healthcare,
, DAC Beachcroft,
4. Surrey and Borders Partnership NHS Foundation Trust,
5. Care Quality Commission,
6. The Chief Coroner
In addition to this report, I am 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 at the time of your response, about the release or
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the publication of your response by the Chief Coroner.
Signed:
ANNA LOXTON
DATED this 26th day of September 2022
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5
2 responses 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.
Ms Anna Loxton
HM Assistant Coroner for Surrey
HM Coroner’s Court
Station Approach
Woking
GU22 7AP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
6 February 2023
Dear Ms Loxton,
Re: Regulation 28 Report to Prevent Future Deaths – Sandra Kirk who died on
2 August 2021.
I write in response to the email received from your colleague
25 January 2023, regarding Ms Sandra Kirk.
, dated
As per my previous correspondence dated 12 January 2023, I wish to reiterate my
condolences to Sandra’s family and loved ones. I appreciate this will have been an
incredibly difficult time for them, and I want to stress that NHS England takes the
concerns and issues raised in every PFD report very seriously. I therefore apologise
that both yourself and Sandra’s family do not feel that NHS England’s initial response
to your Report dated 26 September 2022 adequately addressed the specific concerns
raised, particularly around the risk of ligatures in the inpatient mental health unit
setting, and the guidance provided to staff in mitigating this risk (as per the Ligature
Risk Reduction Policy and the Ligature Audit Tool / Risk Assessment). I also sincerely
apologise that the previous response provided by NHS England has come across as
a “very general response to reducing the risk of suicide”, rather than addressing your
matters of concern.
In your Report dated 26 September 2022, you raised concerns regarding the relevant
Ligature Risk Reduction Policy which was in place, which does not give guidance on
minimising potential ligatures themselves (only ligature anchor points) and does not
emphasise the very real risk that specific items of clothing, such as belts and
shoelaces, can pose to vulnerable patients. Further, there is only a limited degree of
risk reduction with observations taking place four times per hour for high-risk patients
not in immediate crisis, as death by ligature can occur within a few minutes. You
therefore directed that the efficacy of the policy should be considered, including
whether it can be improved.
In respect of the specific concerns in your Report regarding Cygnet’s Ligature Risk
Reduction Policy and Ligature Audit Tool / Risk Assessment, these are outside of NHS
England’s remit and are more matters for Cygnet to action, which is why our previous
response did not fully address the same. However, I can confirm that NHS England
has had sight of the full Root Cause Analysis (RCA) report dated 4 January 2022 and
we note that the main learning points which were identified included contemporaneous
record keeping, named nurse practice and a review of general observation practice.
Our regional team have liaised further with Cygnet, who have advised that they are
providing ligature training as part of the induction process for all new staff, and they
have a contraband list in place across all in-patient areas. They are also planning on
enhancing their ligature risk reduction policy, which will include associated awareness
training and identifying risk in their patients.
Regarding the national guidance around risk assessments (relevant to your comments
around observations and risk reduction), I would like to provide my assurance that this
is currently being reviewed and work is underway to assess a move to a more
personalised safety planning approach, in line with an evidence base. The concerns
raised in PFD reports, including your Report dated 26 September 2022, are
communicated to the national policy and programme teams to help inform their work
around this.
We hope to have further updates on the above, as well as the quality programme for
Mental Health, Learning Disabilities and Autism (MHLDA) inpatient services
referenced in my last letter, in due course. We are more than happy to provide you
and/or Sandra’s family with another update once these developments have taken
place, if this would assist?
I would also like to provide further assurances that the Regulation 28 Working Group,
who closely monitor and share learnings and commitments arising from or linked to
PFD reports, will continue to do so in this case.
I hope that the above sufficiently addresses your previous concerns, and I am very
sorry that you have had to request a further response from NHS England on this
occasion.
Please do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
Ms Anna Loxton
HM Assistant Coroner for Surrey
HM Coroner’s Court
Station Approach
Woking
GU22 7AP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
12 January 2023
Dear Ms Loxton,
Re: Regulation 28 Report to Prevent Future Deaths – Sandra Kirk who died on
2 August 2021
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26
September 2022 concerning the death of Sandra Kirk on 2 August 2021. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Sandra’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Sandra’s care have
been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise to
the family for the delay, as I appreciate this will have been an incredibly difficult time
for them.
Following the inquest, you raised concerns in your Report regarding the relevant
Ligature Risk Reduction Policy which was in place, which does not give guidance on
minimising potential ligatures themselves (only ligature anchor points) and does not
emphasise the very real risk that specific items of clothing, such as belts and
shoelaces, can pose to vulnerable patients. Further, there is only a limited degree of
risk reduction with observations taking place 4 times per hour for high-risk patients not
in immediate crisis, as death by ligature can occur within a few minutes. You therefore
directed that the efficacy of the policy should be considered, including whether it can
be improved.
Suicide Prevention
•
Integrated care systems (ICSs) are partnerships of organisations that come
together to plan and deliver joined up health and care services, and to improve
the lives of people who live and work in their area. NHS England » What are
integrated care systems? As part of the £2.3 billion settlement for mental health
in the NHS Long Term Plan, NHSE are providing targeted and ring fenced
funding to ICSs so they can deliver their multi-agency plans. This includes
suicide prevention activities such as Zero Suicide Plans in inpatient services,
initiatives to prevent self-harm and putting in place postvention bereavement
support.
• With the publication of the Long Term Plan (LTP), we committed that, from
2019/20, every area of the country would receive funding for suicide prevention
and bereavement services by 2023/24, from the total pot of money of £57
million allocated through the Long Term Plan. Local areas are required to
prioritise groups at high risk of suicide in their multi-agency plans, including
mental health inpatients.
• Key components will include supporting services with safety planning, using
resources such as The National Confidential Inquiry into Suicide and Safety in
Mental Health (NCISH) ‘Safer services: A toolkit for specialist mental health
services and primary care’
Quality Programme
• NHS England has established a new programme to support the sector with
tackling significant quality and safety concerns within Mental Health, Learning
Disabilities and Autism (MHLDA) inpatient services.
• The establishment of this new programme has been co-produced with local
systems, providers, regions and clinicians and people with lived experience.
• The programme will focus both on helping systems to transform their current
service offer, so that only those models of inpatient care which can deliver safe,
high quality, therapeutic care are commissioned with community alternatives
stood up, and to ensure effective quality improvement support is in place for
appropriate models of inpatient care.
In the aftermath of recent incidents of patient safety and quality failures, NHS
England asked every MHLDA provider to review their oversight of patient
safety, mitigation for closed cultures, safeguards for patients and patient
advocacy arrangements. The outcomes of their reviews have been made
publicly available by each Trust at the end of December 2022 in their Trust
Board papers.
In addition to this, NHS England is working to drive longer-term improvements
in the following key areas:
•
•
• Providing support to those units across the NHS and independent sector
in urgent need of support today.
• Expediting our work to redesign the model of care more in line with the
latest evidence – including addressing risk factors which are more likely
to lead to poor outcomes.
• Driving cultural change and
improvement
through
leadership
development, inpatient workforce redesign and change programmes.
• Change the way we oversee the quality of MHLDA inpatient settings so
that the metrics we collect are based upon the known risk factors.
• We are also working with the sector to agree the most impactful immediate
actions they can take to improve lived experience oversight of quality and local
quality improvement
I would also like to provide further assurances on the national NHSE work taking place
around the Reports to Prevent Future Deaths. All reports received are discussed by
the Regulation 28 Working Group, comprising Regional Medical Directors and other
clinical and quality colleagues from across the regions. This ensures that key learnings
and insights around events, such as the sad death of Sandra, are shared across the
NHS at both a national and regional level, and helps us to pay close attention to any
emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England
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