Hilary Guedalla

Private & Confidential 

HM Assistant Coroner Edwin Buckett 

Office of the Chief Medical Officer 
Trust Headquarters 
5th Floor 
9 Alie Street 
London E1 8DE 

4 August 2023 

Dear Sir  

RE: Regulation 28 Response for Billy Guedalla  

This is a formal response to your Regulation 28 report sent on 12 June 2023 where 
you set out concerns relating to the care of Billy Guedalla whilst under East London 
NHS Foundation Trust’s (the Trust’s) care. 

I  understand  that  at  the  inquest  into  Billy’s  death  you  heard  evidence  from  the 
Clinical Director for City and Hackney outlining the learning that has taken place as 
a consequence of their death. However, you remained concerned about the risk of 
future deaths in relation to the following areas: 

1.  The deceased  was allowed  to  leave  Gardner Ward  (“the  unit”)  which  was 
part  of  a  secure  facility  of  the  hospital  alone,  when  a  clinical  decision  had 
been taken that they should not be allowed to leave the unit unaccompanied 
by staff, because they posed a risk of suicide. 

2.  The decision that the deceased should not be allowed unescorted leave was 
not communicated to all members of staff working in the unit such that the 
person who allowed the deceased to leave was unaware that the decision 
had been made.  

3.  The  relevant  information  gathered  during  the  Ward  Round  on  the  28th 
October 2021, which included the fact that the deceased had attempted to 
take their own life, the night before, was not adequately communicated to all 
staff on the unit.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  The “Sign in/Sign Out” book which was supposed to record the movements 
of service users in the unit was frequently not completed, particularly when 
service users went out for short periods. 

5.  There was no proper system for identifying whether a service user should be 

permitted to leave the unit. 

6.  The member of staff who allowed the deceased to leave the unit made a brief 
risk assessment of them before deciding whether they should be allowed to 
leave. That person did not consult any medical notes or records about the 
deceased when making that assessment. Had that member of staff consulted 
the deceased’s medical notes and records, the serious suicide risk that they 
posed would have been evident.  

7.  Once  the  deceased  was  found  to  be  missing  from  the  unit,  there  was  an 
unexplained delay in informing the police and ambulance service, a failure to 
inform  either  of  the  serious  suicide  risk  which  the  deceased  posed  to 
themselves and a lack of appreciation of the urgency by staff generally. 

8.  The  hospital  policy  which  applied  to  missing  patients  was  not  properly 
adhered to by staff and there was confusion about who should be contacted 
and in what manner, once a patient was found to be missing.  

9.  No proper efforts were made to contact members of the deceased’s family 

once the deceased was found to be missing.  

10. The  unit  was  short  staffed  and  this  affected  the  care  provided  to  the 
deceased, the assessment of the deceased whilst in the unit and recording 
generally. 

I would like to offer my sincere apologies to Billy’s family on behalf of the Trust. I 
would also like to assure Billy’s family and the Coroner that the Trust has reviewed 
the issues highlighted by the Regulation 28 report and has planned or undertaken 
the actions outlined below. 

1)  The  clinical  decision  made,  that  Billy  should  not  leave  Gardner  Ward 
unescorted was not followed and 2) this decision was not communicated to 
all members of staff. 

I share your concern that critical information surrounding clinical decision making in 
relation to Billy’s leave was not followed nor passed  on to all Gardner Ward staff 
members.   

Expected  practice  at  the  Trust  is  that  all  clinical  decisions  made  in  relation  to  all 
inpatient  service  users’  leave  should  be  recorded  on  RIO  (the  Trust’s  electronic 
patient record) by the relevant clinician.  I understand that this information was not 
recorded nor was it reviewed or disseminated amongst the Gardner Ward staff.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In order to ensure that this does not occur again, at the next Gardner Ward away 
day on 23 August 2023 all staff will be reminded again of the importance of properly 
recording clinical decisions (whether made by themselves or in Ward Management 
Meetings  or  Ward  Rounds)  as  well  as  reviewing  the  RIO  notes  prior  to  making 
important clinical decisions. This same discussion will be repeated at the next away 
days for all City and Hackney inpatient wards. Considerations about the differences 
in  recording  such  information  between  formal  and  informal  service  users  will  be 
discussed.  A  memo  has  been  sent  out  to  all  ward  staff  on  27  July  2023  by  the 
Clinical Director reinforcing these expectations too. 

Additionally, the Clinical Director for City and Hackney has updated the junior doctor 
induction programme to include this information.  

In order to provide an additional safety net to ensure that appropriate information 
sharing occurs, a daily Safety Huddle comprised of the entire multi-disciplinary team 
now  takes  place  on  all  City  and  Hackney  inpatient  wards  each  morning.  Critical 
clinical  information  about  all  service  users  is  shared  during  the  Safety  Huddles. 
Important  clinical  decisions  and  risk  information  discussed  at  the  Safety  Huddles 
are  expected  to  be  documented  on  RIO  (this  expectation  will  also  be  further 
reinforced at the away day and junior doctor induction). 

Additionally, all inpatient leave arrangements (for both formal and informal service 
users) are now documented on the relevant nursing office whiteboard in each City 
and Hackney inpatient ward. The leave arrangements are reassessed at every shift 
handover  and  the  whiteboard  is  updated  accordingly.  It  is  expected  that  all  staff 
members check the whiteboard before allowing leave of any type.  

Further, junior stuff members are now required to speak to the shift co-ordinator (the 
most senior staff member) prior to allowing patient leave.  

3)  The  information  from  the  ward  round  that  Billy  made  a  serious  suicide 
attempt the previous night was not communicated to staff members.  

I was also troubled to hear that important risk information about Billy, highlighted at 
a Ward Round was not communicated to staff members.  

As mentioned above, I anticipate that the daily Safety Huddles will assist in ensuring  
that  important  new  risk  information  about  service  users  is  passed  onto  all  staff 
members. 

4) The ‘Sign in/Sign Out book was frequently not completed.  

I  have  been  provided  with  assurances  that  the  process  for  managing  the  Sign 
In/Sign Out book (the “book”) on all inpatient units in City and Hackney has been 
improved. The book is now located at the nursing office to enhance completion. It 
has been revised to include the following information: service user name, whether 
leave is escorted (and by whom) or not,  location of planned leave, time left and time 
returned, the validity of Section 17 leave papers for detained patients, description of 
items taken, and whether search on return was completed.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Presently, either the nurse in charge or the shift coordinator spot checks the book 
to ensure completion one time per shift. However, work is being done to develop a 
more robust audit system.  

5)  There  was  no  proper  system  for  identifying  whether  a  service  user  is 
permitted to leave. 

The Trust’s approach to address this via the whiteboard system, the Safety Huddles 
and the additional expectations on junior staff members to check leave with the shift 
co-ordinator prior to allowing leave are explained under point 1 and 2 above.  

6)  The medical notes were not reviewed prior to deciding that Billy should be 
allowed to leave.  

The  Gardner  Ward  away  day  outlined  above,  will  highlight  the  importance  of 
regularly reviewing RIO notes. Further, the implementation of Safety Huddles, the 
whiteboard system and the requirement to seek approval of senior staff members 
prior to allowing service user leave will ensure only those patients permitted to take 
leave are allowed to do so.  

7)  Once  Billy  was  found  to  be  missing,  there  was  a  delay  in  informing  the 
police  and ambulance  service,  a  failure  to convey  suicide  risk  to  the  police 
and ambulance service, and lack of appreciation of the urgency by staff. And 
8) The policy which applied to missing patients was not properly adhered to 
by staff and there was confusion about who should be contacted  

I  acknowledge  that  the  delay  in  notifying  the  police,  ambulance  and  family  when 
they were discovered missing should not have occurred. Further, when emergency 
services were notified, there was a failure to convey Billy’s suicide risk. 

The following actions have taken place to ensure that this does not occur again: 

a.  On the 13 July 2022, staff from Gardner Ward attended the “Time to 
Think” forum. There, the Trust’s Health, Safety and Security Planning 
Manager  led  the  meeting  and  reinforced  the  correct  escalation 
processes to use when a service user is missing. 

b.  In  June  2023,  the  Trust’s  Missing  and  Absent  without  Leave  policy 

was reviewed and it is now awaiting ratification. 

c.  The Trust is now engaged at a senior level with the Metropolitan Police 
to  develop  a  strategy  around,  “Right  Care,  Right  Person”  which  is 
anticipated to lead to improvements in the coordination of response to 
missing inpatients by both organisations.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 9) No efforts were made to contact Billy’s family once it was discovered they 
were missing 

I am aware that you heard oral evidence at inquest that a single attempt was made 
to call Billy’s family when they went missing. However, this call took place well after 
it was discovered and no further attempts were made to contact their family. The 
Trust wholeheartedly acknowledges  that this response was not commensurate to 
the situation. 

I can confirm that explicit information about contacting family members is provided 
in the updated policy and was discussed with Gardner Ward staff during its review 
of the policy. 

Staff  also  specifically  reflected  upon  the  impact  of  not  contacting  Billy’s  family 
promptly when they were discovered missing at the Time to Think Forum on 13 July 
2022. 

10)  Gardner  Ward  was  short  staffed  and  this  affected  the  care  provided  to 
Billy. 

Although there is a particular need to focus on the staffing levels of nurses, the issue 
of  staffing  levels  across  the  full  multi-disciplinary  team  is  relevant  to  the  care 
provided on a ward. The current vacancy rate, as of June 2023, for all staff in City 
&  Hackney  Mental  Health  Directorate  is 4.4%.  This  rate  varies  amongst  different 
staff groups, for example:  

a)  Nursing staff: 8.4%  
b)  Doctors: 5.7%  
c)  Psychologists and social workers: 3.2%  
d)  Allied Health Professionals (e.g. occupational therapists, art therapists): 14% 
e)  Support to nursing staff (e.g. Life skills recovery workers): 1.2%  

As highlighted at inquest, there are currently national challenges with staffing in the 
NHS which impact on the Trust’s efforts to achieve full recruitment with substantive 
staff. But, I can assure Billy’s family that the Trust is making best efforts to achieve 
this across all staff groups.  

City and Hackney is currently managing nursing staff vacancies using the following 
strategies: 

a)  Staffing  levels  across  the  directorate  are  discussed  face  to  face  at  a  daily 
Huddle  every  Monday  –  Friday  at  a  designated  venue.  The  Duty  Senior 
Nurse, Borough Lead Nurse, Ward Managers and matrons are present. The 
Psychiatric  Liaison  Teams  and  Home  Treatment  Team  also  feed  into  the 
Huddle.  Safe  staffing  levels  are  considered  alongside  appropriate  actions 
such as redeployment, booking temporary staff and block booking Trust bank 
staff.   

b)  A  Band  5  registered  nurse  is  currently  responsible  for  ‘red  flag’  reporting 
(reviewing staff shortages on the daily rota and the numbers of service users 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 requiring  enhanced  observations).  This  information  is  fed  into  the  daily 
Huddle (outlined above) and to the Borough Lead Nurse for consideration of 
a planned response. It also supports matrons in planning. 

c)  Twilight  Shifts  have  been  introduced.  Band  6  nursing  colleagues  from  the 
community teams attend between 5.30 to 9 pm when the wards are busiest 
to ensure smooth transitions to night shifts.  

d)  A live spreadsheet is maintained and reviewed weekly by the ward matrons 

to highlight recruitment gaps and support the recruitment process 

e)  There is a recruitment drive in City and Hackney for band 5 and 6 nurses.  

A  recent  Trust-wide  review  of  the  Trust’s  inpatient  activity  (clinical  demand  and 
benchmarking against national standards for comparable services) was undertaken 
in January 2023. This review contributes to ensuring the Trust meets Safer Staffing 
expectations for services. In particular, that the right staff with the right skills are in 
the right place at the right time. The review has resulted in an increased investment 
in inpatient staffing based on the identified needs of the services. Since April 2023, 
an  £800,000  investment  for  Safer  Staffing  has  been  provided  to  the  City  and 
Hackney directorate within ELFT. The benefits of the increased investment will be 
reduced reliance on temporary staffing at times of high acuity and better resourced 
teams to meet the needs of service users. In addition to this we have reviewed our 
recruitment strategy and processes. 

I hope I have provided reassurance to you and Billy’s family about the learning that 
has taken place as a consequence of their sad death.  

I offer my sincere and heart-felt condolences to the family at this difficult time.   

Yours sincerely,  

Chief Medical Officer