Michelle Whitehead

Nottinghamshire Healthcare NHS Foundation Trust 
Duncan Macmillan House 
The Resource 
Porchester Road 
Mapperley 
NG3 6AA 

21 November 2023 

Private and Confidential 

Dear Miss Bower 

Regulation 28 Response - Michelle Whitehead November 2023 

Please  find  below  the  Organisational  response  to  the  received  Regulation  28  Report  to 
Prevent Deaths following the death of Mrs Michelle Whitehead, the inquest of which was 
concluded  on  the  21st  of  September  2023.  We  offer  our  sincere  condolences  to  Mrs 
Whitehead’s family and will ensure we also update Mr Whitehead with regards to actions in 
support of this. 

1.  The  Trust’s  Rapid  Tranquilisation  policy  has  not  been  sufficiently  embedded 
through  learning  and  development  to  ensure  that  all  staff  have  a  good  working 
knowledge of the requirements for safely monitoring patients following the use of 
sedative medications. I heard evidence that ward staff had all received training on the 
policy as part of their initial induction, but all staff in this case had consistently failed to 
follow the policy, including senior ward leaders and medical staff, who informed the court 
that  they  were  simply  not  aware  of  the  necessary  safeguards  to  monitor  a  patient’s 
consciousness  level  after  administering  tranquilisation  medications,  or  how  to  do  so 
when the patient was thought to be sleeping. 

Response:  

The Trust’s mandatory training requirements for Rapid Tranquilisation includes:  
•  All medical and nursing staff working in clinical areas that perform Rapid Tranquilisation 
must attend face to face training session every three years. As an annual refresher, an 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 e-learning update or training video is required to be completed to ensure awareness of 
current issues in Rapid Tranquilisation and any procedural updates.  

•  Trainee Nursing Associates, Nursing associates and healthcare assistants, as important 
members of the ward team, are required to complete the e-learning package or training 
video annually to raise their awareness of the issues. They may also attend the face-to-
face training as optional. 
It is also acknowledged that local training is delivered by Clinical Leads to support the 
face to face offer and understanding of the tools used in practice. 

• 

Our  Learning  and  Development  team  oversee  training  delivery  for  Rapid  Tranquilisation 
sessions  to  all  staff  in  line  with  the  mandatory  requirements,  face  to  face  sessions  are 
delivered by our Pharmacy colleagues.  In addition to this, the Rapid Tranquilisation video 
is played following all Hospital Life Support (HLS) training sessions to ensure all staff who 
are  required  to  complete  an  annual  HLS  refresher  will  also  receive  an  update  on  rapid 
Tranquilisation.   

The policy changes that have since been made will be reflected within the training offer to 
ensure all staff are aware of the additional monitoring requirements. We recognise that staff 
did not understand the policy standards as necessary and whilst training will be amended to 
reflect the subsequent changes relating to monitoring, a full training review in line with the 
learning from the inquest will be undertaken in relation to Rapid Tranquilisation to ensure 
we have the correct approaches in place post induction. For example, a review of the e-
learning  package  to  Health  Care  Support  workers  to  ensure  competency  assessment 
features as part of this process. 

To  ensure  training  is  embedded  into  practice,  as  an  immediate  action  we  have  shared 
resource across our Forensics and Adult Mental Health care groups of the expertise of a 
Quality Improvement lead role who will be supporting the Trust is working with wards and 
services to embed the standards within the policy and ensuring that staff are familiar with 
this  policy  and  expectations.  This  will  include  review  of  individual  cases  of  RT  post 
observation and staff case-based discussion learning. This is now in place and will remain 
under  review  with  the  learning  and  improvements  monitored  through  Quality  Oversight 
group.  

The above resource will additionally be delivering bite-size teaching across the In-Patient 
units  with  a  focus  on  post  Rapid  Tranquilisation  Observations  including  NEWS2  and 
escalation.  

All  training  that  is  offered  will  be  amended  in  line  with  the  policy  changes outlined below 
regarding the post observation period. 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 There is a learning space for Junior Doctors within the Organisation will which be utilised to 
share the learning related to the use of Rapid Tranquilisation, ensuring those are sighted on 
the policy and the related changes.  

Amendments to the policy as outlined further in this letter will be communicated Trust Wide 
in  our  Chief  Executive  briefing.    Leaders  will  be  tasked  with  cascading  through  team 
meetings,  through  supervision  and  overseeing  the  changes  in  practice.    Associated 
monitoring  tools  are  also  in  the  process  of  being  updated  to  understand  compliance  in 
practice. 

2.  The  Trust’s  Rapid  Tranquilisation  policy  is  not  sufficiently  clear  on  what  action 
should  be  taken  if  a  patient  is  considered  to  be  unconscious  during  the  period  of 
monitoring  or  is  felt  to  be  asleep.  The  current  iteration  of  the  policy  (revised  after 
Michelle’s death) does not make it clear that any suspected unconsciousness should result 
in  the  immediate  summoning  of  a  doctor  and  alerting  the  ambulance  service  via  999. 
Further, the revised policy does not make it clear which vital sign observations should be 
undertaken  and  recorded  if  a  patient  is  thought  to  be  asleep  in  the  period  post  rapidly 
tranquilisation and until the patient is ambulatory. This is despite the policy listing reduced 
consciousness and respiratory depression as known risks of sedative use, which can lead 
to death. 

Response: 

Immediate actions  
The  Trust  have  responded  to  the  concerns  raised  regarding  the  clarity  within  the  Rapid 
Tranquilisation policy about the escalation requirements relating to known risks associated 
with the use of medication with Rapid Tranquilisation. The relevant section within the policy 
concerning escalation of a deteriorating patient has been amended to specifically respond 
to  the  risks  of  reduced  consciousness,  monitoring  when  a  patient  is  asleep  post  rapid 
tranquilisation and the use of NEWS2 escalation.  

In response to the learning, the Trust have revised our policy recommendations regarding 
the Rapid Tranquilisation post monitoring physical health monitoring, with consideration and 
focus to a patient who is asleep.  
The  policy  standard  now  states  that  for  every  patient  who  has  received  Rapid 
Tranquilisation,  physical  health  monitoring  must  include  NEWS2  observations  every  15 
minutes for the first hour and then hourly until the patient becomes ambulatory. If the patient 
is asleep post administration, the patient will be woken to assess the level of consciousness 
and to complete NEWS2 observations, every 15 minutes until ambulatory, or for a minimum 
of  3  hours with  escalation  as  clinically indicated.  The  rationale for 3  hours of  15  minutes 
NEWS2 is derived from the peak concentrations of the medications used as part of Rapid 
Tranquilisation, recognising this is the period of increased risk of adverse effects. The use 
of  continuous  pulse  oximetry  to  measure  levels  of  oxygen  saturation  should  be  used 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 whenever possible, in addition to direct line of sight observations every 15 minutes. This is 
in addition to the requirements for more frequent and intensive monitoring being necessary 
for  those  patients  with  additional  risk  factors  including  seclusion,  intoxication  of  illicit 
substances and where there is a relevant medical diagnosis which may place the patient at 
greater harm.  

This is in addition to the expectation that all patients are continually observed by a competent 
staff member until ambulatory. 

The use of NEWS2 monitoring includes the expectation that the observations include heart 
rate,  blood  pressure,  respiratory  rate,  oxygen  saturation,  the  use  of  ACVPU  and 
temperature.  

The  above  changes  are  to  be  reflected,  with  immediate  effect,  within  the  training  offer 
provided for Rapid Tranquilisation as outlined in above section. In addition, Within the Trust 
Hospital  Life  Support  training,  the  use  of  ACVPU  scale  for  assessment  of  reduced 
consciousness  is  included,  this  has  been  strengthened  to  include  the  considerations  and 
ability to differentiate a patient that is asleep versus a patient with reduced consciousness.   

The  changes  made  to  this  policy  have  been  supported  through  the  Trust  senior  medical 
colleagues and agreement for the significant policy changes to be communicated through 
the Associate Medical Directors into the Care Groups, the policy changes will be shared at 
the Medicines Optimisation Groups and Restrictive Practice groups which have a triumvirate 
representation.  

Ongoing Monitoring and continued quality improvement.  

Compliance with the application of this policy in practice will be monitored through the data 
collected from the Rapid Tranquilisation weekly ward-based audits. The oversight for this 
data is through the Care Group Restrictive Practice Groups with escalations and assurances 
reported to the Trust Medicines Optimisation Group.  This work will be led by the Associate 
Director of Nursing Leads. 

As outlined in the response above to the first concern within the report, to ensure training is 
embedded  into  practice,  as  an  immediate  action  we  have  shared  resource  across  our 
Forensics and Adult Mental Health services of the expertise of a Quality Improvement lead 
role  who  will  be  supporting  the  Trust  in  working  with  wards  and  services  to  embed  the 
standards  within  the  policy.  This  will  include  review  of  individual  cases  of  Rapid 
Tranquilisation and the post monitoring phase. These reviews will be held with staff involved, 
following  a  case-based  discussion  learning  method.  This  approach  will  ensure  greater 
compliance  with  the policy  expectations,  improve  staff  confidence  with  embedding this in 
practice and increase oversight of the challenges. This is now in place and will remain under 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 review with the learning and improvements monitored through Care Group Quality Oversight 
group and Medicines Optimisation group.  

The Trust recognise the need to continually engage with staff to understand the challenges 
faced when adhering to the expectations of the application of NEWS2. Staff focus groups 
for the use of NEWs2 will begin in December 2023 providing the opportunities to be clear 
on challenges faced in practice and appropriate actions.   

The  NEWS2  and  Non-Contact  Observations  templates  on  RiO  have  been  amended  to 
create  an  alert  for  ward  staff  that  when  these  observations  are  carried  out  due  to  Rapid 
Tranquilisation there is a mandatory requirement to change the frequency of observations 
as per the policy. This change will support the changes in practice and act as a reminder to 
clinicians as to the monitoring requirements.  

In  December  2022,  our  Learning  and  Development  team  began  a  roll  out  of  a  two-day 
Physical Health training package for Mental Health clinicians. The aim of the course is to 
support  staff  with  the  knowledge  and  skills  to  assess,  monitor  and  manage  the  physical 
health  needs  of  patients.  The  programme  is  based  on  recommendations  by  Health 
Education England (NHS England) Physical Healthcare competency Framework for Mental 
Health and Learning Disability Settings. The course content has also taken on board findings 
from clinical incident reviews, training needs survey and Trust physical healthcare objective 
agenda. With regards to this response, relevant sections within this include the assessment 
of  the  deteriorating  patient  including  NEWS2  and  SBARD,  Medicine  and  the  risk  factors 
associated with antipsychotic medications. Since the introduction of this programme, a total 
of 233 staff have received this training.  

3. The Trust’s current policy appears to depart from National guidance – NICE issued 
Rapid Tranquilisation Guidance in Notice NG10 in May 2015 

The Trust advised me during the inquest that their policy was in line with other local mental 
health Trusts. However, a review of NICE guidance and other Mental Health Trust policies, 
available  via  a  brief  internet  search,  demonstrates  differences  in  the  advised  monitoring 
protocols. I have shared with the Trust both the NICE guideline and a copy of the publicly 
available policy issued by a London Trust in February 2022 for comparison.  
The  Trust  should  take  urgent  action  to  ensure  their  guidance  is  in  line  with  National 
guidance, or where it departs, ensure there is sound clinical reason for doing so. 

Response:  

During the development of the Trust Rapid Tranquilisation Policy significant and extensive 
review  of  other  Organisation’s  policies  took  place  in  order  to  assist  with  benchmarking 
appropriate monitoring protocols this included national literature and evidence base.  It is 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 
 acknowledged that there is significant variance in the monitoring protocols in place across 
similar Organisations.  

Following  subsequent  review  in  the  learning  from  this  serious  event,  amendments  to  the 
Policy have been made and clarity has been added to the relevant sections that required 
ensure adequate safeguards are in place to manage the risks associated with the use of 
Rapid Tranquilisation.   

During this review, consideration from the Trust Clinical Policies Group has taken place as 
to the need for primary evidence base and national body recommendations to form the basis 
of  approval  of  Policies  prior  to  the  considerations  of  benchmarking  against  other 
Organisations.  

4.  Psychogenic  Polydipsia  –  there  appears  to  be  no  guidance,  either  locally  or 
nationally,  on  the  management  of  this  condition,  despite  the  research  literature 
demonstrating that 50% of reported cases of over-hydration appear to be linked to 
psychosis. The Mental Health Commission for Scotland issued a report on the final 
day of Michelle’s inquest, related to the death of another mental health patient, Mr D, 
making  recommendations  for  all  NHS  bodies  to  ensure  staff  have  information  to 
detect and manage acute physical health scenarios including polydipsia and water 
intoxication. 

The  Trust  should  take  urgent  action  to  ensure  their  staff  are  able  to  detect  and 
manage this rare but potentially fatal condition. I shall include the Department for Health 
and Social Care, NHS England, NICE and the Royal College of Psychiatrists as recipients 
of this report, for information sharing purposes, as it may inform future discussion about the 
management of two important but separate features of metal health care that each carry a 
risk  of  death,  namely,  (a)  the  use  of  Rapid  Tranquilisation  and  (b)  the  detection  and 
management of Psychogenic Polydipsia. 

Response: 

Immediate actions  
The Trust have included a teaching session within the ‘Trustwide 2-day Physical healthcare 
Training’  for  mental  health  staff  on  the  symptoms,  risk,  and  necessary  escalation  of 
overhydration including Psychogenic Polydipsia as a core training section. 
The sharing of the learning from Michelle’s inquest has and will continue to be shared to 
raise  awareness  in  relation  to  Psychogenic  polydipsia  within  staff  groups.  This  includes 
within the Trustwide Dietitians Professional Advisory Group, physical healthcare staff and 
medical  teams  though  continued  professional  development  sessions,  journal  clubs,  and 
Trustwide Physical Healthcare meetings as well as inclusion within the Trustwide Learning 
the Lessons Safety Bulletin circulated to all staff.  

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA 

 
 
 
 
 
 
 
 
 
 
 
 The learning from Psychogenic Polydipsia will be shared at the next Junior Doctor Journal 
Club as a conduit to ensuring that senior clinicians are familiar with this condition, are able 
to detect and consider the risks associated with this.  

Short term actions 
The  Trustwide  Nutrition  and  Hydration  Policy  is  currently  under  review  –  psychogenic 
polydipsia  will  be  specifically  referenced  within  the  overhydration  section,  including  risks, 
signs  and  symptoms  and  escalation  –  this  review  has  commenced  and  planned  to  be 
finalised by the end of February 2024.  

Following the learning from the inquest, the Trust have identified of a number of cases of 
polydipsia  within  our  secure  settings.  A  clinical  case  review  of  these  patients  will  be 
undertaken  to  ensure  the  management  of  these  patients  is  appropriate  and  support  any 
learning  and  guideline  development.  The  case  reviews  will  be  undertaken  in  December 
2023, the learning from which will inform further actions necessary.  

Yours sincerely  

Executive Director of Nursing AHPs and Quality 

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA