Christopher Ryan

Chief Executive’s Office 
South West London and St George’s Mental Health NHS Trust 
Trinity Building 

Springfield University Hospital   
15 Springfield Drive   
London SW17 0YF 

10 May 2023 

Strictly Private & Confidential 
Lydia Brown 
Acting Senior Coroner for West London 
West London Coroner Service 
25 Bagleys Lane 
Fulham 
London  
SW6 2QA 

Dear Madam 

Re: Regulation 28 Report to Prevent Future Deaths – Mr Christopher Ryan   

I  am  writing  to  you  following  receipt  of  the  Regulation  28:  Report  to  Prevent  Future 
Deaths dated 22nd July 2022, but was not issued to the Trust until 13th February 2023, 
regarding the sad death of Mr Christopher Ryan.  You have requested that South West 
London and St George’s Mental Health NHS Trust (SWLStG) respond to the matters of 
concern that you have detailed in your correspondence.  

In order to examine all of the concerns raised, the Prevention of Future Death Report 
was  shared  with  the  clinical  leadership  team  responsible  for  Mr  Ryan’s  care  and 
treatment, to help the Trust respond to the points of concern you have raised.   

I, therefore, respond to each of your concerns and direction as they were raised in your 
correspondence: 

(1) 

The Consultant Psychiatrist had signed the agreed escorted leave form on the 
basis that Chris would be accompanied 1:1 with a nurse. The purpose of the 
leave was therapeutic, to enable Chris to access the community in a supported 
manner. Evidence was before the court that the leave was only to the adjacent 
car park, to facilitate a smoking break, and 1 member of staff accompanied up 
to  6  patients.  The  Trust's  own  Root  Cause Analysis  report confirms  that  the 
practise was at this time for 1 staff member to accompany those patients who 
wished to smoke to the adjacent car park. 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The ‘Leave of Absence – section 17’ form that covers the period in question was 
approved by the Consultant Psychiatrist on 30th September 2020.  The form did 
not include any stipulation around 1:1 escorting; however, we acknowledge that 
live evidence given to the Inquest by the consultant put forward that it was their 
expectation this would be 1:1.    

We  feel  it  is  important  to  note  that  at  the  time  of  this  incident,  23rd  December 
2020,  the  country  was  under  Tier  4  National  Lockdown,  which  had  the  strict 
government legal restrictions, which included only being able to leave residence 
for essential activities only  and  all  non-essential retail  was not  permitted  to  be 
open. An individual could only meet one other person in an outside public space 
and there were rules on support bubbles in place. 

These requirements had a significant impact on how escorted leave was carried 
out.  Escorted leave was often carried out in the context of patients being part of 
a group of six support bubble.  There was no leave permitted for anyone outside 
of the hospital grounds in line with National Covid 19 legislation.  The Trust Root 
Cause Analysis report confirmed escorted leave at the time was not carried out 
on a 1:1 basis but in a group.  The appropriate individual risk assessments were 
undertaken  at the time  and  there  had been  no  risk  incidents  with  any  patients 
having escorted leave as part of a group up to this point.  These were exceptional 
circumstances to avoid anyone leaving the site to comply with the legislation and 
keep people safe from the risks of Covid as they were understood at that time.  

It is understood that this, along with the requirements to remain in small support 
bubbles, did result in more group on-site activities, such as walking groups that 
could have seen one staff member escorting such groups.  

We have referred back to our Root Cause Analysis report and cannot find any 
mention  or  reference  of  the  practice  around  one  staff  member  to  accompany 
those  patients  who  wished  to  smoke  to  the  adjacent  car  park.    Although  we 
acknowledge  (especially  given  the  Covid  restrictions  mentioned  above)  that 
patients may have used the car park to smoke and that the family did provide 
statements that they had witnessed such smoking on the grounds. 

We recognise that understanding of Covid and the applicable restrictions have 
reduced significantly over time. Despite this, we have taken on board the spirit of 
the concerns raised and will review our leave form / guidance to help ensure we 
better capture any stipulations around staffing of escorts. Leave will be facilitated 
in  accordance  with  these  stipulations  and  non-compliance  with  be  addressed 
accordingly with the applicable members of staff. 

(2) 

The car park is entirely unsecure and open to the road. Evidence given in court 
was  that  the  hospital  site  is  non-smoking,  but  the  evidence  was  unclear 
whether the car park was considered to be part of the hospital site or separate. 

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 The car park is not owned or run by this Trust.  This car park is on the Queen 
Mary’s Hospital site, which is owned and run by St George’s University Hospital 
NHS Foundation Trust (SGH).  I can confirm that the Queen Mary’s Hospital site 
is  a  non-smoking  site  and  is  covered  by  the  SGH  ‘Smokefree  Policy’;  which 
specifically  mentions  the  Queen  Mary’s  Hospital  site,  where  smoking  is  not 
permitted and our policy is the same for our sites, where smoking is not permitted 
anywhere on our grounds (see below). 

(3)  My  concern  is  that  there  has  been  a  tolerated  blurring  of  the  boundaries 
between the intentions of escorted leave for individuals under a MHA section, 
and the ward staff's ability to facilitate this in a meaningful and therapeutic way 
to benefit the patients, and that the clinical staff were not aware of this. Chris 
had indicated his desire to access the cash point and buy Christmas presents 
for his family, but there was no suggestion these requests had been considered 
by the Trust and either approved or refused. Chris therefore made the decision 
to leave the ward, with catastrophic consequences. Has the Trust given any 
consideration to the provision of a "safe" smoking area that patients can access 
without the need to be accompanied or to use their restricted escorted leave 
for this purpose alone? 

Mr Ryan mentioned to nursing staff that his wish to go shopping once he received 
his benefit payment.  At the time, the ability for him to do this would have been 
very limited due to the Covid Restrictions, as patients were not permitted to leave 
the hospital grounds and non-essential shops were closed.  This impacted on the 
ability  of  ward  staff  to  consider  and  design  a  plan  with  Mr  Ryan  for  him  to  go 
shopping.  

From  a  holistic  perspective,  ward  staff  have  conversations  with  patients  about 
how they intend to use their leave and how best they can be supported.  Being 
able to complete daily living activities such as going shopping, viewing properties 
that patients may live in post discharge and attending appointments are seen as 
part of the patient’s recovery journey; ward staff often support patients through 
escorted leave to achieve these recovery goals. This is now greatly aided by the 
relaxation  of  the  Covid  Restrictions.  Going  forward  the  Trust  will  continue  to 
observe any further restrictions should they return, in order to protect its service 
users, its staff and the public.  The learning arising from this Inquest has been 
shared across the service line. 

In  regard  to  consideration  of  safe  smoking  area,  the  Trust  has  a  policy  titled 
‘Completely Smoke Free Policy’ which makes clear that smoking is not permitted 
anywhere in the Trust’s buildings, including inpatient settings or grounds.  This 
position follows clear national guidance from the Department of Health and Public 
Health England (now called UK Health Security Agency) and the Trust’s policy is 
underpinned by studies around links related to morbidity and mortality particularly 
in smokers with mental health problems and our desire help support their physical 

 
 
 
 
 
  
 
 
 
 
 
 health.    Leave  will  be facilitated  in  accordance  with  the  smoke free  policy  and 
compliance with it will be emphasised accordingly with the members of staff. 

As  aforementioned,  the  Queen  Mary’s  Hospital  site  is  also  covered  by  a  clear 
policy  where  smoking  is  not  permitted  in  its  buildings,  car  parks,  grounds  and 
gardens. 

However, the Trust has committed to undertaking a formal and comprehensive 
review  of  our  ‘Smoke  Free’  policy  which  has  commenced  and  is  due  to  be 
concluded  in  July  2023,  which  will  also  include  how  we  ensure  that  practice 
reflects policy, particularly around leave. 

We thank you for your consideration and commitment to prevention of future deaths and 
helping  us  and  the  wider  NHS  to  learn.    There  are  areas  in  this  response  which  are 
within our control, and we will ensure are completed.   The PFD request for the Trust to 
essentially consider establishing an area on NHS grounds to smoke would be a breach 
of the wider NHS smoke free policy, and as such this may require further support from 
you with senior Department of health NHS policy makers, which we would be happy to 
discuss. 

I would like to express our deep sympathy to the family and friends of Mr Ryan for their 
loss. Many staff at the Trust who knew Mr Ryan were greatly affected by his death. While 
we seek to make significant effort to ensure that we prevent any similar deaths in the 
future, I recognise that this cannot diminish their pain and anguish.  

The Trust remains committed to continuous learning and improvement and we are 
very grateful for all those involved in the Inquest.   

Yours faithfully 

Chief Executive  

Chief Executive, Vanessa Ford 

  Trust Chair, Ann Beasley