Paul Perrott

CONFIDENTIAL 

Trust Headquarters 
Wonford House 
Dryden Road 
Exeter 
EX2 9AF 

Date: 5 February 2024 

Re. Paul Perrott Regulation 28 Report for the attention of Deborah Archer – Assistant 
Coroner, Plymouth Torbay and South Devon. 

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  Devon Partnership NHS Trust 
2. 
3. 

, Langdon Hospital 

, Langdon Hospital 

ACTION SHOULD BE TAKEN 

Although there have already been changes made to policies and procedures in the hospital 
arising out of this death action should be taken: 

•  To review the procedures in place on the wards to ensure that observation charts are 
regularly checked by ward management and concerns fed back to staff quickly and 
appropriately 

•  To ensure that staff members are required and able to easily familiarise themselves 

with the full history in relation to each patient they care for as opposed to simply being 
made aware of any risks that present on the day which may not take account of 
historical or contextual risk. 

Audit Process and Checking Of Completion of Observations 

The therapeutic engagement and observation policy (CO6) appendix 1 clearly states the 
responsibilities of staff in respect of completing patient observations. In addition, “the nurse in 
charge is responsible for ensuring that there are adequate staff resources for the 
implementation of engagement and observations and that all staff required to undertake these 
are competent to carry out this task”. The policy also states the responsibilities of individual 
staff as detailed below. 

Ward Managers are responsible for ensuring that all their staff are familiar with this policy and 
are trained in the implementation of engagement and observations for the inpatients on their 

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 ward. The Therapeutic Engagement and Observation Competency Assessment has been 
developed to assist with this and to record that training has taken place. 

Nurse in Charge: The inpatient nurse in charge of the shift is responsible for ensuring that all 
staff authorised or delegated to carry out the intervention of engagement and observations are 
competent to carry out this task. This includes any Allied Health Professionals, Bank or agency 
staff who are requested to undertake this duty. 

All inpatient Registered staff - have a professional obligation and individual accountability for 
their practice and are responsible for ensuring they are familiar with this policy, adhere to its 
requirements and associated procedures. This includes ensuring all documentation is 
uploaded to the Digital Care Record in the correct place. 

Delegation to Unregistered Staff and Students: The Registered Nurse remains accountable 
for the decision to delegate engagement and observation to an unregistered member of staff 
or student in training, also for ensuring they are sufficiently knowledgeable and competent to 
undertake the role. Students may only undertake solo engagement and observation following 
an assessment of their competence and confidence by their mentor and once the Therapeutic 
Engagement and Observation Competency Assessment has been completed. 

Policy states that observation audits to check completion of observations are completed 
monthly by senior nurse managers. This process is in place through the quality review of 
clinical records and the results of those audits are submitted to the governance manager, 
feedback to staff and ward governance meetings. The audit performance is then reviewed 
monthly with ward managers at inpatient governance meeting.  Engagement and observation 
competency checklists are completed for all new staff and these are reviewed and stored by 
ward managers with the senior nurse manager’s administrator monitoring compliance for 
wards. 

An amendment to the Trust therapeutic engagement and observation policy has been 
requested to state that the nurse in charge of each shift is responsible for ensuring completion 
of observations on a shift by shift basis and taking immediate action where these are not 
completed. This will go through ratification in January 2024 and has been discussed with the 
Director and Deputy Director of Nursing. 

Evidence previously provided to the coroner highlighted there is a regular audit process in 
place regarding the quality monitoring of observations but this is a retrospective audit. The 
amendment to policy will ensure all staff are clear on responsibilities for checking observation 
completion on a shift by shift basis and actions to be taken where gaps or omissions are 
identified. 

In addition, the patient observation record has a tick box on each observation sheet where the 
nurse in charge adds their initials to evidences completion on a shift by shift basis. This has 
been reviewed on each inpatient ward by the senior nurse manager to check it is being 
completed by the nurse in charge. 

Clinical Risk Assessment for Patients 

All clinicians and practitioners are responsible for developing, updating and maintaining their 
competencies in relation to assessing, formulating and managing clinical risks. Registrant 
Clinical staff complete this training 3 yearly as a minimum requirement.  

The Clinical risk assessment policy focus on risk to self is the same as the general principles 
for clinical risk assessment. This is that each patient has a personalised risk assessment 
which outlines potential risks, the immediacy and severity of those risks, whether a clinical risk 

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 is stable, increasing or decreasing and what protective measures can be put in place to 
manage the risk. 

Mental state examination is a key factor in assessing risk as well as historical, static and 
dynamic risk factors. A mental state examination consists of a review of a patient’s 
appearance and behaviour, speech, mood, affect (observed emotional state), thoughts, 
perceptions, cognition and insight. Mental state examination focuses on a person’s state of 
mind at the time of the assessment. In addition, where applicable, patients are offered 1:1 
sessions by clinicians. 

Significant and complex risk (or the potential for those risks) should be discussed in a multi-
disciplinary team meeting and reviewed at regular intervals until the risk is felt to have 
reduced. This is regarded as a good practice (4 steps to safety programme). This is already 
embedded in the hospital. This model acknowledges the dynamic nature of risk and the 
significance of relevant historical risk factors. In addition, it allows for flexibility in making 
adjustments to risk management plans. 

The ward handover document has been re-designed. As such, there is a document for each 
patient which has a photograph of the patient and a section where key historical risk is 
recorded. This approach makes it possible for a new staff to the ward to have quick access to 
useful historical risk information during their shifts. This takes into consideration that most 
patients have lengthy hospital stay with a significant amount of information within the clinical 
patient record. The handover document is accessible to staff both in hardcopy and 
electronically. In addition, the new electronic recording platform has been designed in such a 
way that all clinically relevant risk information are captured on a single domain. This can be 
updated as new information is received. This is a departure from a system of multiple risk 
information recording domains. This document is accessible to ward staff even when a patient 
moves to another ward. 

The hospital also employs the use of HCR-20 (Historical Clinical Risk management) tool. This 
recommended tool is a structured tool to assess the risk of violence and it records historical 
risk factors in details. The task of completing the HCR-20 document is usually undertaken by 
the hospital psychology department. The document is presented and shared with members of 
the Multidisciplinary team after 3 months of admission then every 6 months till a patient is 
discharged. The HCR-20 assessment is completed for every patient. This is also stored 
electronically and available to all staff. 

Besides documentations, relevant historical factors are discussed in risk meetings attended by 
members of the multidisciplinary team. There is a daily risk meeting (except Tuesday when 
clinical review meetings take place) on all the wards. Furthermore, historical risk information 
are discussed, shared and recorded in patient’s note between teams when a patient moves 
ward. 

Relevant to risk management, the Trust operates a Risk recording system. There is an already 
embedded practice where an account of incident is recorded electronically and once uploaded, 
this is risk information is immediately cascaded electronically to members of the 
multidisciplinary team and hospital managers. This is received via their NHS emails. 

The hospital holds a Directorate operational meeting three times a week. This is attended by 
ward managers, clinicians, senior nurses, managers and profession Leads. Any significant risk 
event within the directorate is discussed and learning is shared. The risk information as part of 
the message from the meeting is cascaded via email to all staff. 

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 As part of risk management, the hospital added a practice in 2020 that ensures there is also 
staff member in the main ward area who is able to identify any risk issue and respond 
appropriately. 

 - MSc RGN RMN 

Executive Chief Nursing Officer & Allied Professions Lead 

Director of Infection Prevention & Control 

Trusts Caldicott Guardian 

Honorary Senior Lecturer University of Exeter. 

Signed: 

Date: 05/02/2024 

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