Steven Sanders

HSCA Further Information 
Citygate 

Gallowgate 

Newcastle upon Tyne 
NE1 4PA 

HM Area Coroner Ms Emma Brown, for Birmingham and Solihull 

Telephone: 03000 616161 
Fax: 03000 616171 

www.cqc.org.uk 

12 April 2024 

Care Quality Commission 

Dear HM Coroner Brown 

Prevention  of  future  death  report  following  inquest  into  the  death  of  Steven 
Sanders 

Thank you for addressing the Regulation 28 prevention of future deaths report to the 
Care  Quality  Commission  (CQC)  following  the  death  of  Steven  Sanders  This  letter 
represents CQC’s formal response to your Regulation 28 report. 

Relevant regulatory context 

The CQC was established on 1 April 2009 by the Health and Social Care Act 2008 
(‘the  Act’).  The  CQC  is  the  independent  regulator  of  healthcare,  adult  social  care, 
hospital and community trusts and primary care services in England. The CQC also 
protects the interests of vulnerable people, including those whose rights are restricted 
under the Mental Health Act.  

The Act introduced a single registration system which applied to both healthcare and 
adult social services. Once registered with the CQC, providers such as St Andrew’s 
Healthcare Birmingham (SAH) were required to comply with conditions placed on their 
registration,  as  well  as  the  Health  and  Social  Care  Act  2008  (Regulated  Activities) 
Regulations 2010 (‘Regulated Activities Regulations 2010’) and the Care Quality CQC 
(Registration)  Regulations  2009  (RR  2009).  The  Regulations  set  out  the  essential 
standards of quality and safety that service users had a right to expect. The Regulated 
Activities  Regulations 2010  were  replaced  by  the  Health and  Social Care  Act  2008 
(Regulated Activities) Regulations 2014 (RAR 2014), which came into effect from 1 
April 2015. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 While the essential standards contained in RAR 2014 set out the relevant standards 
that  registered  providers  must  meet,  they  do  not  prescribe  how  exactly  and  what 
precisely  registered  providers  must  do  to  meet  them;  those  are  things  that  the 
registered provider must determine in order to meet the standards and duties set out 
in Act, RAR 2014 and RR 2009. It is the primary responsibility of a registered provider 
such as SAH to develop and implement adequate policy and process to ensure that 
those duties, responsibilities, and standards are met. To assist providers, CQC have 
published details of our key lines of enquiry and rating characteristics and guidance 
for providers on meeting the regulations. 

As  a  regulator the  CQC looks  look  to  ensure  providers  have  effective  systems  and 
process in place to keep people safe. Under regulation 12 RAR 2014, for example, 
providers must do all that is reasonably practicable to mitigate risks. They should follow 
good practice guidance and must adopt control measures to make sure the risk is as low 
as is reasonably possible. They should review methods and measures and amend them 
to address changing practice. This duty to provide safe care and treatment must also 
be balanced against service users’ human rights, and specifically with the provider’s 
duties under Regulations 10 RAR 2014 (Dignity and respect) and 9 RAR 2014 (person 
centred care) to ensure both that service users’ dignity is protected and that the care 
is person centred. 

For all those providing health and social care, including those providing care in secure 
settings such as St Andrew’s Healthcare Birmingham, we expect that people's needs 
are  assessed  and  care  and  treatment  delivered  in  line  with  current  legislation, 
standards,  and  evidence-based  guidance  to  achieve  effective  outcomes.  Relevant 
legislation, standards and guidance in this context includes as follows: 

1.  Mental Health Act (MHA) 1983: Code of Practice and the Mental Capacity Act 
(MCA) 2005. Least restrictive care is a key feature and guiding principle of the 
MHA  code  of  practice.  For  example,  the  first  guiding  principle  at  page  22 
concerns  “least  restrictive  option  and  maximising  independence:   Where  it  is 
possible to treat a patient safely and lawfully without detaining them under the 
Act,  the  patient  should  not  be  detained.  Wherever  possible  a  patient’s 
independence should be encouraged and supported with a focus on promoting 
recovery wherever possible.” 

2.  Further  to  this,  the  Code  of  Practice  includes  specific  guidance  on  ‘personal 
and other searches’ at chapter 8, page 69. This chapter sets out clear principles 
for search policies. For example, “the authority to conduct a search of a person 
or their property is controlled by law, and it is important that hospital staff are 
aware  of  whether  they  have  legal  authority  to  carry  out  any  such  search. 
Searching should be proportionate to the identified risk and should involve the 
minimum possible intrusion into the individual’s privacy, and all searches will be 
undertaken with due regard to and respect for the person’s dignity and privacy” 

 
 
 
 
 
 
 
 
  
 
 3.  Where a provider puts a restriction/s in place, CQC expects providers to act in 
accordance with the principles set out in Positive and Proactive Care: reducing 
the need for restrictive interventions (publishing.service.gov.uk), and use to all 
restrictive  interventions  in  line  with  the  MHA  Code  of  Practice  2015,  Mental 
Capacity Act 2005, Human Rights Act 1998 and the common law. 

We  also  expect  providers  to  take  account  of  national  guidance  when  providing 
regulated activities. In this case CQC expects that St Andrew’s healthcare will have 
regard to the following: 

1.  National Institute for Health and Care Excellence (NICE) guidance CG120 - 
Coexisting  severe  mental  illness  (psychosis)  and  substance  misuse: 
assessment and management in healthcare settings The guidance states at 
page 9, as follows:  

“Substance misuse - All inpatient mental health services should ensure that 
they have policies and procedures for promoting a therapeutic environment 
free from drugs and alcohol that have been developed together with service 
users and their families,  carers, or significant others. These should include 
search  procedures,  visiting  arrangements,  planning,  and  reviewing  leave, 
drug  and  alcohol  testing,  disposal of  legal  and  illicit  substances,  and  other 
security measures. Soon after admission, provide all service users, and their 
families, carers, or significant others, with information about the policies and 
procedures.” 

2.  NICE  Quality  standard 

that 
challenges.  Quality  statement  10:  Review  of  restrictive  interventions  | 
Learning disability: behaviour that challenges | Quality standards | NICE: The 
standard states as follows: 

[QS101]  Learning  disability:  behaviour 

“Restrictive interventions should be used as a last resort and decisions to use 
them  should  be  based  on  the  principle  of  using  the  least  restrictive 
intervention  necessary.  Documented  risk  assessment  and  review  of 
restrictive interventions helps to ensure learning. This will reduce the use of 
future  restrictive  practices,  identify,  and  mitigate  any  risks  associated  with 
their  use  and  ensure  safety,  dignity  and  respect  for people  with  a  learning 
disability and behaviour that challenges’. 

CQC has produced guidance documents for inspectors to follow when inspecting and 
monitoring services such as St Andrew’s Healthcare, including a brief guide relating 
to  restraint  (physical  and  mechanical)  and  on  use  of  ‘blanket  restrictions’  in  mental 
health wards. 

On 1 April 2015 the CQC assumed enforcement responsibility for health and safety 
related serious incidents concerning people using services in health and social care 

 
 
 
 
 
 
 
 
 
 
 
 
 settings  in  England.  This  includes  where  people  using  services  have  sustained 
avoidable harm including death or have been exposed to a significant risk of avoidable 
harm as a result of a failure by the Registered Person. The ‘Registered Person’ (RP) 
is the Registered Provider and/or Registered Manager.  Where Registered Providers 
are  corporate  bodies  (such  as  limited  companies)  or  unincorporated  associations 
(such  as  partnerships),  individual  office  holders  or  members  may  in  certain 
circumstances be criminally liable under sections 91 and 92 Health and Social Care 
Act 2008.1 

CQC  has  a  clear  internal  process  to  follow  whenever  a  Regulation  28  report  is 
received,  including  where  CQC  are  named  within  report.  In  line  with  the  CQC’s 
enforcement  and  internal  specific  incident  guidance,  policies  and  procedures,  a 
management review meeting (MRM) takes place. This MRM considers the matters of 
concern raised, reviews the facts, and gathers additional information where required 
to  inform  regulatory  decision-making  and  identify  if  any  potential  breaches  of 
regulation  may  have  taken  place,  and  undertakes  an  initial  assessment  using  our 
specific incident guidance. In summary terms, this initial assessment enables the CQC 
to consider and/or determine any appropriate regulatory response in line with CQC’s 
published  enforcement  policy2.  More  specifically,  it  enables  CQC  to  consider  and 
determine  whether  any  formal  and/or  informal  regulatory  actions,  for  instance 
monitoring,  inspection  and/or  civil  enforcement  action,  may  be  required  to  further 
assess compliance of the provider or protect service users from ongoing risks; and to 
assess and determine  whether  there may be  reasonable  grounds  to  suspect  that  a 
service user(/s) may have sustained avoidable harm or been exposed to a significant 
risk of avoidable harm, as a result of registered person failure to provide safe care and 
treatment. 

Actions  taken  by  CQC  following  receipt  of  the  information  of  concern 
concerning Steven Sanders’ death 

Considering the service had not been inspected since June 2018, an inspector carried 
out a formal annual regulatory review with the provider on 23 June 2022 and concluded 
no  further  regulatory  activity  was  required  at  that  time.  Before  receipt  of  your 
Regulation  28  report,  and  in  line  with  its  published  inspection  priorities  CQC  had 
already  identified  SAH  Birmingham  for  a  comprehensive  inspection  alongside other 
services that have not been inspected and rated for 5 years or more. 

The  initial  assessment  and  specific  incidents  guidance  processes  identified  above 
were initiated following receipt of information of concern following the death of Steven 
Sanders.  That  information  included  notification  of  his  death  and  receipt  of  HM 
Coroner’s concerns about the provision of care to Steven and others at St Andrews 
Healthcare  Birmingham  (SAH)  arising 
investigation.  The 
assessments made are subject to continuing monitoring and review, taking account of 

the  coronial 

from 

2 https://www.cqc.org.uk/guidance-providers/regulations-enforcement/enforcement-policy 

 
 
 
 
 
 
 
 
 
 
 
 ongoing  assessment  of  any  new  information  coming  to  light,  gathered  by  CQC,  or 
shared by the coroner during the coronial investigation. A second process was initiated 
following receipt of the Regulation 28 report and linked to the on-going process opened 
in relation to the death of Steven Sanders. In the initial assessment following receipt 
of a regulation 28 report, and information of concern regarding a specific incident of 
harm  that  may  be  avoidable,  we  ask  two  key  questions,  the  first  of  which  is  most 
relevant to our response to your Regulation 28 report: 

•  Question  1:  Does  the  information  about  the  specific  incident  raise  concerns 
about ongoing risk of harm to users of the service which CQC should inspect?  

o  As part of CQC’s consideration of a response to this question, we have 
considered the on-going concerns regarding the supply and use of illicit 
drugs, and reviewed again all the information we hold in relation to SAH. 
This  includes  new  information,  such  as,  information  within  this 
Regulation  28  report,  notifications  received  from  SAH,  engagement 
meetings with the provider following receipt of your Regulation 28 report, 
action  plans  received 
the  provider  and  discussions  with 
from 
Birmingham and Solihull Mental Health Foundation Trust.  

o  Following a management review meeting in which we considered all the 
relevant information including a review of the action plan submitted by 
the provider and their implementation of ward lockdowns, we concluded 
that an urgent unannounced inspection would not take place at that time. 
We  determined  that  it  was  proportionate  to  give  the  provider  time  to 
implement the action identified following their own urgent investigation. 
This position however remained under continuous review. SAH provided 
CQC  with  weekly  reports,  which  included  actions  they  were  taking  to 
prevent  the  supply  of  illicit  drugs,  additional  staff  training,  review  of 
security protocols, risk assessments and care plans, alongside joint work 
with local substance misuse services. 

o  An  inspector  reviewed  the  notification  submitted  by  the  provider  in 
relation to the death of patient C in line with our processes. The CQC 
requested  and  reviewed  a  72-hour  report  from  the  provider,  and  the 
Initial  Management  Review,  Serious  Incidents  and  Deaths  report  that 
was received on 3 October 2024. CQC found that immediate actions had 
been taken by the provider and the CQC also concluded that there were 
not reasonable grounds to suspect an offence under Regulations 12(1) 
and  22(2)  RAR  2014.  The  CQC  did  and  will  continue  to  monitor  the 
extent  to  which  appropriate  actions  have  been  implemented  by  the 
provider as  part of on-going  engagement and  during  the  inspection  of 
the service. The CQC will also review any further or new information that 
it receives or gathers. 

 
 
 
 
 
 
 
 
 
 
 
 o  CQC  undertook  an  unannounced,  comprehensive    inspection  of  the 
service  in  January  2024.  The  inspection    focussed  on  all  five  key 
questions which are safe, effective, caring, responsive and well-led  and 
specifically  included  consideration  of  the  concerns  expressed  in  your 
report about illicit drug supply.    

o  At the inspection undertaken in January 2024 we visited five wards which 
included  both  Hurst  and  Hawkesley  ward.  We  identified  breaches  in 
regulations and rated SAH as requires improvement overall.  

o  At  the  inspection  we  also  found  that  although  staff  knew  patients’ 
individual  risks  and  took  action,  risk  assessments  were  not  always 
reviewed or updated to reflect this. Patients were not always involved in 
their care plans and there were gaps in information such as restrictions, 
plans for discharge and Do Not Attempt Cardio Pulmonary Resuscitation 
(DNACPR) decisions which had not been updated to ensure they were 
current. Patients  were  not  always  offered  regular therapeutic  activities 
as part of their care and treatment. There were policies and procedures 
to support staff to prescribe and administer medicines safely. However, 
this was not followed with controlled drugs (CDs). There were gaps in 
staffing  levels  and  staff  training.  Overall,  the  governance  systems  to 
assess,  monitor  and  improve  the  quality  and  safety  of  the  service 
required strengthening.   

o  At the January 2024 inspection we also found that there were areas of 
good  practice:  the  ward  environments  were  safe  and  clean;  staff  had 
access to supervision and appraisal and worked together well; Patients 
were treated with care and compassion and had access to a full range 
of  specialists  to  meet  their  needs;  and  there  was  evidence  of  quality 
improvement activity. 

o  At  the  January  2024  inspection  we  did  not  find  evidence  of  illicit 
substances entering the service and found that action had been taken to 
mitigate risks and address the concerns identified in the prevention of 
future  death  report.  This  included  continuing  to  improve  the  security 
arrangements  and  a  review  of  the  search  procedures  with  positive 
changes implemented. There was now a full-time specialist substance 
misuse  worker  based  at  the  service  with  a  remit  on  prevention, 
education, and harm reduction for both staff and patients. The service 
had  engaged  with  external  substance  misuse  services  to  provide 
education to patients on the impact of substances on their mental and 
physical health and ensure support for patients leaving the hospital. Staff 
were provided training to help recognise signs of substance use and to 
understand addiction. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 o  A copy of the inspection report is published on the CQC website and can 

be found here: https://www.cqc.org.uk/location/1-121538294  

In relation to HM Coroner’s concerns in relation to information not being received from 
CQC following correspondence sent on 28 July 2023: 

•  The CQC wrote to HM Coroner on 6 September 2023 to acknowledge receipt 
of  correspondence  directly  to  a  colleague  in  the  CQC  National  Customer 
Service  Centre  dated  15  August  2023.  At  that  stage  the  current  CQC 
operational team with responsibility for SAH Birmingham was unaware of your 
correspondence dated 28 July 2023; the correspondence we believe was not 
passed through to the relevant operational team and/or handled appropriately 
in accordance with CQC processes and guidance on the handling of coronial 
correspondence. The CQC relationship owner for SAH has not been employed 
by CQC since 15 August 2023. 

•  To  support  the  robust  and  systematic  handling  of  coronial  correspondence 
CQC has developed and improved clear and well-messaged internal processes 
and operational guidance products. Those  processes and products signpost, 
and  are  based  upon,  the  MoU  with  the  Coroners  Society  which  CQC 
understands  to  be  in  operation.  For  example,  the  dedicated  inbox  that  is 
referenced 
the  MoU 
(CQCInquestsandCoroners1@cqc.org.uk)  represents  a  key  component  of 
those processes: a team is responsible for overseeing that dedicated inbox and 
is required  to  catalogue,  categorise and analyse  all  coronial correspondence 
that arrives into the inbox; it is then required to promptly and reliably distribute 
that correspondence in accordance with the relevant category and associated 
established  process  to  designated  operational  colleagues  for  appropriate 
consideration and timely response. 

paragraphs 

and 

31, 

35 

34 

of 

at 

•  The CQC operational team now responsible for SAH Birmingham first became 
aware of HM Coroner’s correspondence dated 28 July 2023 on 21 August 2023; 
and first had sight of that correspondence dated 28 July 2023 upon receipt of a 
copy of as an attachment to an email kindly sent from HM Coroner’s office dated 
6 October 2023. As set out in CQC’s letter to HM Coroner dated 5 September 
2023 it is a matter of genuine regret to the Commission that your letter dated 
28 July was not handled, or responded to, in a timely and appropriate way: the 
CQC aims to provide prompt, considered and appropriate responses to all to 
coronial  correspondence  in  line  with  our  commitment  to  good  and  timely 
engagement  and  cooperation  with  coronial  investigations  and  Regulation  28 
reports. Accordingly, the CQC is making internal enquiries to establish how and 
why it was that HM Coroner’s letter dated 28 July 2023 was not forwarded to  
the  responsible  CQC  operational  team  and/or  responded  to  in  a  timely  and 
appropriate  way.  Upon  completion  of  that  review  the  CQC  will  identify, 
implement,  and  appropriately  communicate  improvements  to  internal  policy, 
process, and guidance products to seek to ensure that such delays are avoided 
in future.   

 
 
 
 
 
 
 
 
 
 
  
 
  
 
 •  A  key  feature  of  those  internal  processes  and  products  designed  to  support 
systematic  and  robust  handling  of  coronial  correspondence  is  the  dedicated 
email inbox set up to receive, record and distribute all coronial correspondence. 
In response to your regulation 28 report the CQC asked of the Chief Coroner’s 
Office that messaging was sent to all coroners to request that:  

o 

In relation to notifications of inquests: 

▪  CQC  is  notified  as  soon  as  is  reasonably  practicable  of  any 
inquest  where  concerns  exist  about  the  care  or  treatment 
received  by  the  deceased  using  the  designated  inbox.  This 
includes deaths in secure settings and detained patient deaths. 

▪  Notifications 

are 

to 
notification 
CQCInquestsandCoroners1@cqc.org.uk. 
should,  whenever  practicable,  please  include  the  deceased's 
name, date of birth, the registered provider's name and address, 
brief  details  of  the  immediate  circumstances  and  any  other 
relevant information as determined by the coroner. 

made 
This 

o 

In relation to Regulation 28 Preventing Future Deaths Reports and so 
that they can be considered properly to inform CQC's monitoring function 
and/or formal response as appropriate:  

▪  CQC are  provided  with  copies  of  any  Regulation  28  report and 
response where concerns about care or treatment provided by a 
registered  provider  have  been  identified  during  or  at  the 
conclusion  of  the  inquest.  This  includes  Regulation  28  Reports 
following  deaths  in  secure  settings  and  deaths  or  detained 
patients. 

▪  These reports and the responses thereto are sent to CQC as soon 
as  reasonably  practicable  to  the  following  email  address: 
CQCInquestsandCoroners1@cqc.org.uk 

o  Where the Coroner requires CQC to respond to a Prevention of Future 
Death report pursuant to paragraph 7 Schedule 5 of the Coroners and 
Justice 
to: 
CQCInquestsandCoroners1@cqc.org.uk. 

reports 

these 

2009 

sent 

are 

Act 

The Chief Coroner’s Office kindly acceded to the CQC’s request and messaging was 
disseminated to all Coroners to that effect in December 2023.  

Please do not hesitate to contact me if you require any further information.    

Yours sincerely 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Deputy Director of Operations 
Midlands Network