Gerard Murray

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

13 December 2023 

Private and Confidential 
Dr. Didcock 
Assistant Coroner for Nottingham 
and Nottinghamshire 
Nottinghamshire Coroner Office 
The Council House 
Old Market Square 
Nottingham 
NG1 2DT 

Dear Dr. Didcock, 

Please find  below the  organisational  response  to the  recently  received  Preventing Future  Deaths 
Report, following the sad death of Mr Murray.  

The  Matters  of  Concern  raised  within  the  report  that  relate  to  Nottinghamshire  Healthcare  NHS 
Foundation Trust (thereafter referred to as the Trust) are detailed below, along with our response to 
each:  

1. There was limited risk assessment and risk management plan documentation for Mr

Murray on Ward B2 now Beech Ward.

Mr Murray was admitted to the ward informally and during his admission check with one of the 
ward doctors it was agreed that he could have his psychiatric observations reduced to general 
(every  60  minutes)  and  be  allowed  to  leave the  ward  for  short  periods  of  time.  This  is  out  of 
procedure as patients should remain on 10-minute observations for a period of 48 hours post 
admission, to ensure a thorough assessment of the patients’ needs and risk can be undertaken. 
This accelerated risk decision, and agreement for Mr Murray to access leave was not reviewed 
robustly by the wider team.  

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

 
 This has been discussed with the Multi-Disciplinary Team (MDT) across the unit and agreed that 
all leave from the ward areas, will only to be decided upon during weekly ward rounds, or the 
daily board review where the full MDT is present.  To support this the ward round template has 
been  updated to  include  the  documentation of risk  assessment  analysis and clinical  rationale 
linked to leave decisions.  This will be monitored through the oversight quality checks completed 
by the Practice Development Leads and locally by the Ward Manager.  It will also be added to 
the Adult Mental Health Operational Policy. 

To ensure a consistent risk assessment skill level across the workforce, all the qualified nurses 
and MDT members at Sherwood Oaks have attended suicide awareness and response training, 
which includes a focus on risks associated with patient accessing leave. This is discussed further 
in section 4. 

In addition to the changes made at Sherwood Oaks, there is currently a service wide review of 
the risk assessment and care planning processes linked to agreeing therapeutic leave, which will 
include the definitions of where leave in the grounds and leave in the community begin. This is 
being  progressed  via  the  AMH  inpatient  Rapid  Improvement  Group  which  is  chaired  by  the 
Executive Director of Nursing and AHPs.  

At  a  Trust  level,  we  recognise  that  having  one  Policy  that  identifies  the  principles  of  risk 
assessments  and  collaborative  and  coproduced care  planning  for  children, young  people and 
adults is beneficial, and how it reduces confusion for the clinical teams. As a result, a Policy has 
been  drafted  and  outlines  the  expectations  for  the  clinical  teams,  while  allowing  flexibility  to 
ensure  that  the  correct  risk  assessment  tools  are  used  for  each  service.  The  Policy  will  also 
outline how the appropriate Risk Assessment tools are agreed, how the implementation will be 
managed and how the Trust will monitor the compliance with the Policy.   

The  Policy  is  currently  out  for  consultation  and  a  Topic  Expert  Group  had  been  convened  to 
ensure that the Policy is robust and is suitable for the services that the Trust delivers. The Topic 
Expert Group included Psychiatrists, Psychologists, Nurses and AHP’s from a broad range of 
services.  

It is foreseen that the Policy will recommend that clinical teams will receive training in the 
clinical risk assessment tools employed by each service, The training will be sourced from 
external providers or developed with the learning and development team to make sure that the 
learning materials reflect the Policy requirements and the individual needs of the people that 
we support.  We will ensure you are sighted on the completion of this policy and training roll 
out. 

2.  There was an inadequate door board system for monitoring the return of patients 

after unescorted leave on ward B2. The same arrangements remain currently, despite 
the ward move to Beech ward on new premises. 

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

SAFEToolTriage_UK2.5 (1).pdfMDT Template BLANK.docx 
 
 
 
 
 
 
 
 
 
   
 
 
 
 Historically the system of monitoring who leaves and returns to the wards, (locally known as 
the Door Board) was poorly adhered to in some areas. Significant work has been completed 
with the team on Beech (and across the site) to strengthen their adherence to the process 
which has seen a significant improvement in practice.  

Each ward has a dedicated member of staff responsible for assessing individual mental state, 
checking leave parameters, and reiterating these to the patient prior to leave, confirming 
legality and permission issues with the nurse in charge, and managing those possessions a 
patient may take on or return with from leave, IE Cigarette Lighters and items bought at the 
local shops etc.  

The staff member maintains a running log of when patients leave the ward, and are due back, 
their clothing, and a brief description to aid searching if a patient chooses not to return. 
Given the frequent use of leave from patients across the site, the Care Group has sought ways 
to enhance this monitoring. As such, an electronic device is being procured which will allow 
multiple alarms to be set for each person’s leave, ensuring an audible alarm will sound when a 
patient is due back on the ward. This will be trialled and rolled out based on the feedback of 
this pilot.  We will share with you the output of this in due course.   

This will reduce the time lag between someone failing to return and contact and search actions 
being taken. 

To ensure there is consistent compliance with the door board system, a checking process has 
been incorporated in the Senior Nurse’s daily observation spot checks. This includes a band 6 
nurse or above observing staff completing their observations rounds, and quality checking their 
understanding and performance within the role. The spot checks also test individual 
understanding of the door board process, their knowledge of who is on and off the ward, and 
discussions to ensure they understand clearly how to escalate concerns if a patient hasn’t 
returned.  

To date, these checks have found the door board to be fully completed, staff who were 
completing the role were able to describe the expectations of them, and how they would 
escalate if a patient was late back from leave. Checks will continue through into quarter 4 of 
2023/34. 

The observation handover sheet is also located with the door board, so when the handover of 
observations is completed each hour, the door board is also reviewed ensuring that the 
incoming staff are clear on who is on and off the ward at that time.  

3.  There was extremely limited family and carer involvement in Mr Murray’s care, with 
no involvement in the care plan, nor involvement in ward rounds on ward B2 now 
Beech ward. 

The involvement of patient’s family, friends and carers is vital when planning and delivering the 
patients care and treatment. We recognise that at times, we have got this wrong. 
To understand how to improve in this area, all Adult Mental Health inpatient areas have 
completed the Triangle of Care Self-Assessment.  

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 The findings from these are currently being reviewed and actions being agreed to ensure that 
families, friends, and carers voices are included in the planning and delivery of patient care. 
The Triangle of care process has also been strengthened as part of our ongoing quality 
improvement plans. Our Quality Standards Team also undertake reviews of Care Plans and 
look for clear evidence that these plans are produced with the patient, family and carers. The 
feedback from these reviews are monitored via the Senior Management Quality Review 
Meeting which takes place on a monthly basis, and progress on any identified actions is 
mapped and escalated as needed.  

To aid and support this partnership, all-acute wards have recruited a Carer Peer Support 
worker whose working week is dedicated to liaising with patients and their families/carers and 
ensuring the link with MDT members, and clinical discussions is strong. This person will also 
support the patients and their family/carers in Ward round discussions and ensure that follow 
up actions are completed and communicated effectively. 

To enhance the work of the Carer Peer Support Worker, it is planned that all patients will on 
admission complete a carer contact plan. This will include who the patient would like to be 
involved in their care and care discussions, and what level of information should be shared. 
The Carer Contact Plan is in the final stage of agreement and should be used through the in-
patient wards by the end of December 2023. The use of the Carer Contact Plan will be 
reviewed in Quarter 4 of 2023/34. 

There is also an expectation that the Responsible Clinician will oversee the involvement of the 
appropriate family member as required and this will be documented and monitored through the 
ward round oversight. 

The launch of the Collaborative Care Planning Policy (mentioned above) will have family and 
carer involvement at the heart of what we do. This Policy will identify the implementation and 
monitoring standards to ensure that we are able to evidence coproduced care. 

Finally, the family intervention team have devised a bespoke one-day training package which 
all of the Beech ward team including the MDT are booked on to attend. A copy of the training 
program is included below, and is scheduled to start in January 2023, with roll out through to 
June 2024. 

4.  There was limited awareness of the ligature risk reduction pathway by staff on B2 

now Beech ward.  

As an organisation we have been delivering updated suicide awareness and suicide response 
training using content developed by 4 Mental Health, since Dec 2022. This training includes 
updated NICE guidelines in relation to assessment, risk mitigation and safety planning for 
suicidality and provides a Suicide Assessment Framework E-Tool (SAFE Tool) which has been 
embedded in RIO and SystmOne for documentation and audit.  

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

Inpatient Family  Caregivers.pptx 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 As detailed in part 1 above, all qualified staff and MDT members at Sherwood Oaks have 
completed the above training. 

The Trust has also identified Storm Skills Training as being applicable for our inpatient 
services, and we are in the process of procuring this training package, with an anticipated roll 
out through Quarter 4 of 2023/24. The Storm Skills Training is an evidenced skills-based 
training programme with a focus on suicide prevention and self-harm reduction. These training 
courses complement each other to support staff to make informed decisions regarding an 
individual risk of suicide or self-harm including, but not exclusively regarding the risk of 
ligatures. This will then inform the overall risk formulation and allow our clinicians to make 
individualised decisions regarding access to items that could be used to ligate.  

The principles of holistic care will be employed to ensure that teams are aware of, assess and 
mitigate risk with clear documentation and decision making. This will apply to both informal and 
detained patients and will be underpinned through robust multi-Disciplinary team working. 

At a ward level, staff inductions include recognising items that could be used as a ligature, fixed 
ligature anchor points are assessed, and a risk assessment document is maintained and 
communicated within the team, and individual risk is mitigated through a range of processes 
including the prescription of psychiatric observations (checks on the patient) at varying 
intervals. 

I hope the information above provides the assurance that we have and continue to consider your 
recommendations seriously, and that we are actively seeking to improve the services we provide 
by implementing the actions outlined. 

I hope that this update is useful to you and your colleagues. 

If you require any further information, do not hesitate to contact the Trust. 

Yours sincerely  

Executive Director of Nursing AHPs and Quality 

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