Brenda Shields

St Nicholas Hospital 

Jubilee Road 

Gosforth 

Newcastle Upon Tyne 

NE3 3XT 

Dr N Shaw 

HM Coroner for County of Cumbria 

Fairfield  

Station Road 

Cockermouth 

Cumbria 

CA13 9PT 

Dear Dr Shaw 

Inquest into the death of Brenda Shields 

Regulation 28 Report to Prevent Future Deaths Response 

We write in response to your Regulation 28 Report dated 7 June 2023 following your investigation into 

the death of Brenda Shields. This response has been prepared by Cumbria, Northumberland, Tyne and 

Wear NHS Foundation Trust (“The Trust”) and addresses the concerns as set out by HM Coroner.  

By way of background context, we note that  the Trust was not invited to be Interested Persons or to 

provide  witnesses  to  give  evidence  on  the  issues  central  to  the  proceedings  both  in  the  mind  of  the 

family and HM Coroner.  

The issues you raised at the time of the inquest and within your regulation 28 report were as follows: 

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 (1) Brenda was discharged without any planned follow up. Her family were not involved  in the 

discharge  process  despite  assurances  that  they  would  be,  her  GP  did  not  receive  discharge 

notification from the Hadrian unit until 8 days after the event or from the Crisis team until 10 days 

after  Brenda's  death.  Referrals  promised  from  Hadrian  unit  to  Drug/Alcohol  services  and 

Persistent Physical Symptoms Service were not made. 

This concern suggests that Brenda's family were not involved in the discharge process from both the 

Hadrian  Unit  and  the  Crisis  Team.  By  way  of  clarification,  as  is  confirmed  in  the  Serious  Incident 

Investigation Report that was disclosed in these proceedings, Brenda attended a ward review meeting 

on 14 November 2022 with her husband and the plan in relation to Brenda's discharge from hospital 

was discussed. The plan for discharge included referring Brenda to the Community Treatment Team 

('CTT'), the drug and alcohol team, the Persistent Physical Symptoms Service and for the Crisis Team 

to offer a 72-hour review. It is however, accepted that Brenda's family were not contacted as expected 

prior to the subsequent discharge from the Crisis Team.  

In addition to the above, this concern also suggests that Brenda was discharged from the Hadrian Unit 

and the Crisis Team without any planned follow up. Again, by way of clarification and in accordance with 

the  written  evidence  provided,  immediately  following  discharge  from  the  Hadrian  Unit,  Brenda  was 

supported in the community by the Cumbria East Crisis Team, and she continued to be supported by 

this service until the date of her sad death (on which date she was also discharged from the service). 

The  role  of  crisis  services is  to  provide  people  with  safe,  effective,  compassionate,  high-quality  care 

whilst they remain in mental health crisis. Where appropriate and as in this case, the crisis service offers 

home  treatment  intervention  to  allow  people  to  be  discharged  from  hospital  earlier  whilst  still 

experiencing  an  acute  phase  of  illness.  The  plan  for  discharge  also  included  referrals  into  the  other 

services  referenced  above  and  in  particular,  the  referral  to  the  CTT  continued  to  be  discussed  with 

Brenda until the Crisis Team's final contact with Brenda, as the clinicians considered that Brenda would 

benefit from follow up from the CTT moving forward. In relation to the plan following discharge from the 

Crisis Team, the plan was documented as being for Brenda to engage with Recovery Steps, the local 

drug and alcohol service.  

We  further  note  the  reference  to  referrals  from  the  Hadrian  Unit  not  being  made.  As  HM  Coroner  is 

aware, a full Serious Incident Investigation ("SI") was completed in relation to Brenda's death.  The SI 

was conducted in line with the NHS England Serious Incident Framework [2015]. The investigation was 

undertaken by an investigating officer who examined the care and treatment offered to service users by 

the Trust and establish whether it was timely, effective and in line with Trust policies and procedures.  

The aim of the SI process is to identify any issues or concerns with care and treatment provision in an 

effort to improve standards and prevent the occurrence of incidents. The SI Report was disclosed as 

part  of  HM  Coroner's  investigation  into  Brenda's  death  and  HM  Coroner  will  be  aware  that  the 

investigation identified the same points as highlighted in this concern as follows:  

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 •  Making referrals to other services  

• 

• 

Involving other services in discharge planning; and   

Involving BS's family in discharge planning . 

As  HM  Coroner  is  aware,  the  Trust  would  ordinarily  provide  an  overview  of  the  SI  Investigation,  the 

learning from the investigation and the actions taken by the Trust during the inquest hearing. Sadly, the 

Trust  were  not  invited  to  provide  this  evidence  during  the  final  inquest  hearing  however,  to  provide 

assurance, we have set out below the relevant learning points and actions taken to address these points 

prior to the inquest hearing below:  

Findings of the Serious Incident Investigation  

Whilst the  investigation did not identify any significant findings considered to have impacted on care 

delivery and service, additional findings and learning were identified, some of which overlap with the 

areas  of  concern  in  your  report.  Although  not  central  to  the  issues  around  Brenda's  death,  they  are 

nevertheless important elements of learning from a Trust perspective:  

a)  Referrals to other services: The planned referrals agreed to the addictions service were not 

completed as expected on  Brenda’s discharge from  Hadrian Ward. At the point of discharge 

there was a lack of clarification in responsibility of assuring onward referrals were made; and 

there was a delay in chasing up the referral to addictions by the crisis team during home-based 

treatment. 

b) 

Involving family in discharge planning: Brenda's daughter's concerns were not adequately 

explored in terms of the decision to discharge from Crisis Team.  

c) 

Involving  other  services  in  discharge  planning:  The  crisis  team  did  not  liaise  with  the 

Persistent  Physical  Symptoms  Service  around  Brenda’s  discharge  from  their  service. 

Consideration should be given to follow up plans regarding physical health needs. 

Action Plan  

This learning was used to formulate an action plan and identified the following recommendations and 

actions to be implemented:  

a) 

'Referrals to other services' Actions/Recommendations: 

The recommendations/actions implemented in relation to  the  learning identified  at  'a' above were as 

follows:  

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 Actions/Recommendations:  

"Discharge  processes  to  be  reviewed  by  Hadrian  Ward  to  ensure  onward  referrals  are 

communicated with receiving teams 

The senior leads who attend MDT along with clinical staff will now capture onwards referrals 

and the acceptance of these referrals as evidence on the MDT proforma on Rio." 

The Trust can confirm that the discharge processes have been reviewed and discussed with the staff 

on the Hadrian Unit during a Team meeting with minutes provided as evidence of this discussion. This 

meeting took place 5 April 2023. We are satisfied that processes are in place and that communication 

around these areas has improved.  

In relation to the second recommendation, the Trust has reviewed completed MDT audits and they have 

shown good compliance with capturing onward referrals and the acceptance of referrals as evidence on 

the  MDT  Proforma  on  the  Trust's  electronics  records  system.  This  is  now  audited  monthly.  The 

compliance figures are January 2023 93%, February 93%, March 2023 95%, April 87%, May 88% and 

June 95%.  Senior leads now attend MDTs 7 days a week to ensure that senior leadership is now offered 

at all MDTs.  

b) 

'Involving family in discharge planning' Actions/ Recommendations: 

The recommendations/actions implemented in relation to  the learning  identified  at  'b' above were as 

follows:  

Actions/Recommendations:  

"For the team to continue monitoring and assurance of care giver inclusion in safety planning 

and discharge planning. 

An Audit will be undertaken to understand compliance as well as continued carer awareness 

training to be offered to all staff." 

Carer inclusion is reviewed at the daily MDT. This is to ensure that the triangle of care is maintained and 

to confirm that care givers are supported and understand the service user’s needs, thus supporting care 

givers in safety planning, care planning and discharge planning. Carer contact is still offered to those 

where no consent has been given using common sense confidentiality principles to support the care 

giver and assess and offer support. The last audit to ascertain if care givers' views had been included 

was in May 2023. This is due to be repeated in August. May's audit indicates an improvement in carers 

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 being involved in safety/discharge planning. A supervisory check at time of writing of 5 recent discharges 

confirms that care giver views were included in 100% of cases.  

Carer leads continue to roll out carer awareness training. This is at 80% across the service currently. A 

further 8 staff have had Carer Awareness and Getting to Know You training over the past 4 months. 

Carer leads also offer 1:1 Training for new staff working within CRHT.  

c) 

'Involving other services in discharge planning' Actions/Recommendations:  

The recommendations/actions implemented in relation to  the  learning identified  at  'c' above were as 

follows:  

Actions/Recommendations:  

"An  Audit  will  be  completed  to  monitor  compliance  with  discussion  and  documentation  of 

physical health within MDT." 

The  Monthly  MDT  audit  captures  if  discussions  around  Physical  Health  monitoring  are  taking  place 

during the MDT process. A weekly report for the crisis team shows the completion of the Physical Health 

checks,  which  is  then  used  to  feedback  to  Senior  leads  around  outstanding  actions  during  MDT 

meetings.    Twice  weekly  caseload  audits  also  take  place  where  the  pathway  coordinator  adds  a 

progress  note  to  reflect  any  missing  documentation/actions  including  Physical  health  checks.  The 

monthly audits completed in January, February and March identified 100% compliance in the completion 

of physical health checks and the documentation of these within the MDT meeting. 

(2)  Inadequate  weight  seems  to  have  been  given  to  Brenda's  alcohol  problems  and  her 

assurances that all was and would continue to be well were accepted at face value despite her 

recent history, her family find it hard to understand how she could be graded low risk on the day 

she died. 

The  Serious  Incident  Investigation  Report  identified  that  the  clinicians  involved  in  Brenda's  care 

considered her alcohol use throughout the care and treatment provided and the plan following discharge 

from crisis services was for Brenda to engage with Recovery Steps, the local drug and alcohol service, 

which was considered to be appropriate in light of the presenting risks. Whilst the most recent planned 

referral had not been made prior to her death as outlined above, it should be noted that professionals 

had  promoted  engagement  with  addictions  services  throughout  Brenda's  history.  The  nature  of  this 

service is that engagement with drug and alcohol services is entirely voluntarily, and Brenda did often 

decline referrals to drug and alcohol services throughout her care and treatment with the Crisis Team.  

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 In relation to the risk assessment conducted on the day Brenda was discharged, the Serious Incident 

Investigation Report found that the FACE risk assessment contained all of the relevant risks and scoring 

was appropriate for the presenting risks.  

It is difficult to predict suicidality entirely on an empirical basis. Studies have examined the range of tools 

currently in place across mental health services and their effectiveness in respect of patients rated as 

"low risk" of suicide during what is later identified as their final contact with mental health services prior 

to taking their own life. Statistics presented by the National Confidential Inquiry into Suicide and Safety 

in Mental Health in 2006 looking at preventable suicide do indicate that 86% of patients who had been 

in recent contact with mental health services at their final contact, suicide risk was rated to be low or 

absent.  Consequently, the Trust is in the process of reviewing its approach to risk assessment with the 

intention  of  moving  away  from  quantification  of  risk  to  that  of  a  more  narrative  approach  in  line  with 

recommendations  made  by  NICE  in  their  Self  Harm:  assessment,  management  and  preventing 

recurrence [NG225] guidance of 2022. 

(3) I refer you to the PFD report I issued referring to Charlotte Grace on 29/10/19. Assurances 

were  given  in  response  to  that  report  which  again  focused  on  discharge  without  family/carer 

involvement which is surely paramount. I note actions mentioned in the incident report in this 

case but am still concerned that similar events may occur in future. 

This concern relates to a Regulation 28 report regarding an unrelated individual in 2019 on account of 

the fact that there are alleged overlapping issues regarding involvement of family and carers in discharge 

decisions. Firstly, it is important to note that the 2019 report related to care provided by a different NHS 

Trust, CNTW responding to the Regulation 28 report only as a result of taking over that service at the 

time the report was issued. Secondly, appropriately involving families and carers is fundamental in all 

of the services that we provide, and the Trust strives to continually learn lessons as to how to build and 

improve on this involvement. That said, the implications of not involving family and carers to the fullest 

extent  will  vary  on  a  case-by-case  basis.  We  note  that  the  extent  to  which  the  issues  with  family 

involvement  in  this  case  were  not  explored  in  evidence  due  to  the  absence  of  any  Trust  witnesses 

however, the written evidence from the SI investigation concluded that the findings/learning identified in 

this investigation were not considered to be causative or contributory to Brenda's death, particularly as 

carers' views had been sought at a number of points during Brenda's care and treatment and the Getting 

To Know You documentation had been completed. 

In any event, the detail above sets out the work that has been carried out by the Trust in response to 

this case and more broadly regarding involvement of families and carers.  This work is supported by the 

Trust  Together:  Service  User  and  Carer  involvement  Strategy  which  sets  out  that  service  users  and 

carers should be at the heart of everything we do and getting this right is the single most important thing 

we can do as an organisation. 

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 We hope that the information provided offers you the necessary assurances that the Trust have invested 

time,  effort  and  resource  into  investigating  the  issues  you  have  highlighted  with  a  view  to  improving 

patient care and safety and reducing the risk of any adverse incidents or outcome in the future.  

Yours Sincerely  

Executive Medical Director / Deputy Chief Executive 

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