Morgan-Rose Hart

Essex Partnership University NHS 
Foundation Trust 

By email only to: 

Date: 18 March 2024 

Dear Sirs 

Inquest touching upon the death of Morgan-Rose Hart – Prevention of Future Deaths 

We write on behalf of our client, 
, in respect to EPUT’s response to the Prevention 
of  Future  Deaths  Report  issued  by  HM  Area  Coroner  Sonia  Hayes  following  the  inquest 
touching upon the death of Morgan-Rose Hart. 

We note that the response state at page 5 that “Morgan Rose (RIP) was an informal patient”. 
However, Morgan-Rose was detained under section 3 of the Mental Health Act throughout the 
entire  time  that  she  was  under  the  care  of  EPUT  on  Chelmer  Ward.  We  note  that  this  is 
reflected in the records: 

-

  outlines  in  his  witness  statement  that  “Whilst  an  inpatient  in  Elysium 
Healthcare and The Derwent Centre, Morgan was detained under S3 Mental Health 
Act 1983” (B1 – Witness Statements, p84) 

- On  31 May 2022 prior  to Morgan-Rose’s transfer to  Chelmer Ward,  her  section was 

renewed by 

 (EPUT medical records bundle, p268-270) 

-

 provides a Mental Health Act renewal report for Morgan-Rose on 4 July 

2022 (B5, p24-25 and 27-41) 

We note that there is one reference in the records to Morgan-Rose being an informal patient 
on Chelmer Ward – in an incomplete inpatient admission assessment (EPUT medical records 
bundle,  p108)  – however  this  is wholly inconsistent  with the bulk  of  Morgan-Rose’s records 
and would appear to be plainly incorrect. Indeed, 
 refers in her witness evidence 
to completing a T2 form “required for detained patients under MHA” on the same date. 

Morgan-Rose was not discharged from her section until after she was transferred to the main 
Princess Alexandra Hospital on 6 July 2022 by 
, and then only on the basis that 
her primary needs at that stage were related to her physical rather than her mental health. 

As  will  be  appreciated,  our  client  is  very  concerned  by  inaccurate  information  about  her 
daughter being published. We would be grateful for confirmation therefore: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2 

-

-

That  the  reference  to  Morgan-Rose  being  an  informal  patient  in  the  EPUT  PFDR 
response is incorrect; and 
That  a  corrected  version  of  the  response  will  therefore  be  issued  and  replace  the 
currently publicly available incorrect version. 

In  the  event  of  any  queries,  please do  not  hesitate to  contact 

Yours sincerely

Essex County Council 
Adult Social Care  
PO Box 11, County Hall 
Chelmsford 
Essex CM1 1LX 

HM Area Coroner, Ms Sonia Hayes  

8 February 2024 

Dear Ms Sonia Hayes, HM Area Coroner,  

I am writing in response to the Prevention Future Deaths notice served to Essex 
County Council on 19th December 2023 following the findings of the inquest touching 
the death of Morgan Rose Hart.  

Essex County Council has been asked to respond to the following concern:  

(1) 

There is a significant shortfall of appropriate placements for people with 
Autism who have mental health and self-harm risks in Essex both 
inpatient and the community.   

Essex County Council has a joint responsibility with three Integrated Commissioning 
Boards across Essex for meeting the health and care needs of the residents in 
Essex. This includes ensuring that there is a sufficient supply and range of specialist 
community placements and other forms of support for people with autism and co-
existing mental health needs.  

The Council does not commission hospital care, this is the legal responsibility of the 
NHS through the Integrated Commissioning Boards and NHS England.   

To support people with autism and co-existing mental health needs, the Council 
leads on the design, commissioning and delivery of a range of services working in 
partnership with young people, families, and partner organisations. This work is wide 
ranging; some of the key areas relating to placement sufficiency and wider 
community supports are set out below.  

Residential Accommodation Strategy:  

The Council’s residential accommodation strategy has three key elements:  

• 

Improving relationships with residential home providers to increase access to 
local placements. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Creating  Council  run  and  managed  in-house  services  through  the  use  of 
developing ECC properties, recruiting staff  and deploying a  multi-disciplinary 
team.   

•  Creating  our  own  managed  placements  using  ECC  properties  and 
commissioning external providers to deliver the support and care within those 
properties.  

The Council has approval four solo bespoke registered Children Homes to work with 
Children and Young people with high needs that struggle to live with other people for 
a variety of reasons. 

•  One is operational and internally delivered in Colchester. 
•  The second also in Colchester and has been tendered to a service provider. 
The building has been handed over and the provider is awaiting Ofsted 
registration to be operational.  

•  The third solo is currently in planning permission stages for a full rebuild and 

is expected to be available later this year or early 2025. A decision is yet to be 
made on whether this will be run and managed directly by the Council or 
tendered to an external care provider.  

•  The fourth solo has recently been subject to governance and approval sought 
to utilise capital underspend to purchase from the private market that can be 
used to operate a Children’s Home.  

Alongside the solo provision, the Council is repurposing another accommodation in 
Colchester to be a group home. This will provide a 4 bedded short term (up to 6 
months) placements, staffed by a multi-disciplinary team, to support neuro-divergent 
young people to live in the community.  

In South Essex, we are developing a similar short term service as the one referred to 
in Colchester. These services will be directly run and managed by the Council.  

In addition to the specific developments noted above, the Council works closely with 
our statutory partners; the Borough & Districts and NHS along with service providers 
and people who use services to identify future housing needs and to develop 
specialist models of care and support.  

Transforming Care Partnership:  

As part of the Council’s work with NHS England capital bids have been submitted to 
secure the estates investment needed to develop additional services for complex 
autistic young people with significant mental health issues. These include:  

•  A small number (likely 1 a year over the next 3 years) of single person homes 

with substantial care and support packages. 

•  A move on service for 16-18 year olds coming out of mental health inpatient 

beds.  

•  Preventative respite provision available earlier in the pathway to avoid 
escalation to crisis and admission. The number of units is yet to be 
determined but we anticipate this being in the region of 8 to 11 phased in over 
a 3-4 year period.  

 
 
 
 
 
 
 
 
 Wider Community Support and Services:  

The Council commissions community based short break provision, which is directly 
accessible without requiring social care assessment. This includes: 

•  Community clubs and activities –a range of activities across the county for 
children and young people with Special Educational Needs and Disabilities 
(SEND). Organisations providing support and services complete training on 
mental health as part of this offer.  

•  Autism and nature publications based on heritage sites across Essex.  
•  Adapted subsidised caravan holidays, fully adapted to include sensory lighting 

and equipment to support families to holiday together.  

•  Free days out to local attractions and Max Cards to access national attraction 

at lower cost and with a free carer.  

Where a need is identified through social care assessment, the Council offer home 
based care packages with local agencies. This is sourced directly or through direct 
payments based on the person and family’s needs and preferences. 

Yours sincerely 

Executive Director for Adult Social Care

12 February 2024  

Private and Confidential 
Ms Sonia Hayes  
HM Area Coroner for Essex 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Ms Hayes, 

Morgan Rose Hart (RIP)  

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford  
Essex 
SS11 7XX 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 
5,  of  the  Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of  the  Coroners 
(Investigations) Regulations 2013, dated 19th December 2023 in respect of the above, which 
was issued following the inquest into the death of Morgan Rose Hart (RIP) . 

I would like to begin by extending my deepest condolences to Morgan Rose Hart’s family. 
The Trust sympathises with their very sad loss.   

The  matters  of  concern  as  noted  within  the  Regulation  28  Report  have  been  carefully 
reviewed and noted.  I will now respond in full to these concerns in the hope that this provides 
both yourself and Morgan Rose Hart’s family with comprehensive assurance of changes that 
have been made at the Trust to address the concerns you have raised.  

Concern 1: 

The Trust investigation was materially incomplete and there was a lost an opportunity to: 

a.  Understand concerns of the Family 

b.  Acknowledge errors and learn lessons from the circumstances of the death. The 
Director of Operations and Matron informed the Trust Senior Management that the 
PSII Report had omissions. The Trust evidence was that it was an early adopter of 
the new NHS investigation process. The lead investigator did not report on material 
issues  as  to  how  Morgan-Rose  was  observed  on  the  ward  and  the  report  was 
significantly  delayed.  Evidence  was  there  was  a  pressure  to  sign  the  report  off 
although it remained incomplete and did not contain a note about the limitations.  

c.  Escalate  concerns  about  staff  observations  -  About  2  weeks  after  the  death  the 
Matron  received  a  report  that  staff  observations  had  not  been  appropriately 
conducted. This prompted a review of CCTV from the afternoon of Morgan-Rose’s 
death.  There  was  insufficient  scrutiny  of  the  CCTV  that  showed  that  multiple 
observations entries made on 6 July 2022 after 14:06 hours could not be correct. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 d.  Understand  security  issues  on  a  locked  mental  health  ward  -  It  has  not  been 
possible  to  establish  the  identity  of  the  person  that  reset  the  bathroom  alert 
triggered for Morgan-Rose on 6 July 2022 at 15:31. The Trust does not have an 
accurate  records  of  Trust  staff  pass  allocation.  The  Trust  investigation  did  not 
establish that staff borrowed each other’s security passes. On the day of Morgan-
Rose’s death a visitor pass issued that had access to the nursing office. The Trust 
was unable to provide the identity of this person.  

Response:  

The Patient Safety Incident Response Framework (PSIRF) is a major step towards improving 
safety management across the healthcare system in England and will greatly support the NHS 
to  embed  the  key  principles  of  a  patient  safety  culture.  It  will  ensure  the  NHS  focuses  on 
understanding how incidents happen, rather than apportioning blame on individuals, it allows 
for  more  effective  learning  and  improvement,  and  ultimately  making  NHS  care  safer  for 
patients.  EPUT  was  an early  adopter Trust for  PSIRF  implementation  and  went  live  in  May 
2021.  However,  we  recognise  that  the  investigation  for  this  Inquest  contained  regrettable 
omissions.      Please  see  below  the  training  that  has  been  put  into  place  to  address  the 
omissions found in the investigation for this case.   

Having been part of the early adopter organisations, we remain committed to working towards 
the  required  improvement  to  ensure  PSIRF  is  fully  implemented  safely  in  the  Trust.  The 
changes are reflected in the final PSIRF guidance which was published in August 2022 by the 
National Safety team.  

The  Patient  Safety  Incident  investigation  report  in  this  matter  was  completed  under  the 
previous process that was implemented in the Trust during the early adopter period.  

The Trust has now convened a PSIRF Improvement Oversight Project Board which is chaired 
by the Executive Nurse and will report into the Safety of Care Committee which is chaired by 
the Chief Executive Officer.  

Improvement activities include: 

  Development of the Safety Improvement Plans (SIP) for identified themes form historic 
learning  (action  plans  under  the  SI  Framework  were  singular  and  related  to  the 
individual  patient,  SIPs  are  identified  in  the  Patient  Safety  Incident  Response  Plan 
(PSIRP) which are system based improvements using data and information from the 
themes from the individual incidents).  

  Steps  taken  to  ensure  our  processes  including  reporting  templates  are  refined  to 
ensure there is significant shift in the way we respond to patient safety incidents. 

  We have commissioned a series of training, learning and development activities both 
internal and external to ensure staff are trained in the new PSIRF guidance approach 
including senior leaders who provide oversight for PSIRF process. 

  We have  proposed  changes  to family  engagement  in the  new  process.  The  Family 
Liaison Officer and Learning Response Lead will meet with the family at an early stage 
to discuss Terms of reference / draft report and final report before this is shared. The 
Duty  of  Candour  requirement  will  be  met  through  engagement  with  family  by 
operational leads and learning response lead.   

 
 
 
 
 
 
 
 
 
 
 
 
 
   Governance  arrangements  have  been  reviewed  and  currently  being  adapted  which 
includes  identification  of  early  learning  through  collaborative  approach  with  the  care 
unit leadership, deputy directors of quality and safety subject matter expert and people 
with lived experience for example our patient safety partners, who are actively involved 
in the review process.  

  The PSIRF Policy is being updated to reflect best practice.  The policy includes time 
scale for completion of a learning response review and timely sign off. The policy also 
includes process for the management of safety action plan and cascading of learning 
across the trust.  

 

It  will  take  time  to  implement  and  embed  the  revised  approach,  and  there  will  be 
significant learning as we progress the improvement plan. We are however, committed 
to fully implementing the revised framework, and really changing the way we work and 
think to improve patient safety learning and make our care delivery safer. 

  Further, following a patient safety incident the following new ‘post incident immediate 
actions protocol’ will ensure that security measures in relation to the signing in and out 
of patient related records are immediately collated: 

o  The collation of staff statements of those attending to the patient in respect of the 
care, practice, interventions, roles and responsibilities during the shift enabling the 
investigator  to  triangulate  all  written  data  with  digital  data  including  CCTV, 
Oxevision and body worn camera footage.  

o  All wards have an allocated security lead/nurse 24/7 on each shift to support the 
Nurse  in  Charge  and  ensure  that  all  ward  staff  have  their  own  security  passes 
(ACT), at the beginning of a shift.   

o  Whilst the Trust has a system for ensuring that all substantive staff have their own 
ID  and  security  passes  (ACT);  temporary  staff  are  now  also  issued  their  own 
‘numbered’ security pass at the beginning of a shift. These are signed for so there 
is an accurate record kept by the ward, and returned at the end of a shift. It is the 
‘nurse in charge’ responsibility  with support from allocated security lead/nurse to 
ensure that all staff receive their own pass and sign them out and in.  

o  Each unit has its own stock of security passes (ACT cards) to ensure that the ward 
doesn’t run out if any get taken home by accident, to prevent staff from sharing. 
Unit  Administrator  leads  monitor  the  stock  and  order  more  when  needed.  The 
security passes (ACT) are numbered so they can be traced to the staff name that 
they were given to through the signed ACT record sheet.   

o  The requirement to preserve records is being re-enforced by the Trust.  The Trust’s 
Records  Management  Policy  is  being  updated,  with  the  addition  of  a  poster  for 
inpatient services which outlines records/data which need to be retained and the 
process to follow within the initial 24 hour period. This will be distributed to mental 
health  inpatient  services.   The  updated  policy  contains  further  details  of  records 
retention the Trust will take after the initial 24 hours post-incident and within non-
inpatient  services.   In  addition,  the  Trust’s  Adverse  Incidents  Policy  is  being 
updated  to include  the  actions  to  be  taken  following  an  unexpected  death  wider 

 
 
 
 
 
 
 
 
 
 
 than records retention, such as contact with family, preservation of the scene and 
informing the police of the incident. 

Concern 2:  

There was a dispute in evidence over whether it was or was not permitted for patients to have 
belts on Chelmer Ward that has not been resolved.  

a.  Morgan-Rose was on 1:1 observation due to her high risk of self-harm that including 

ligaturing and a belt was in her possession 

b.  The  Responsible  Clinician  and  a  Ward  Manager  providing  support  to  staff  gave 

evidence at that time that belts were not permitted 

c.  The Trust senior management stated that belts were permitted and referenced the 
policy. The updated ward documentation ‘Handover Checklist’ approved in October 
2023 contains belts on a list of prohibited items. The Trust has stated that this is 
not correct although this was part of the After-Action Review and is in current use 

Response:  

The Trust’s Global restrictive practice Guideline on the use of Global Restrictive Practices in 
In-Patient  Units  and  the  Restricted  and  Prohibited  Items  List  –  Inpatient  Units  CG92  – 
Appendix  1  has  been  updated  and  the  restricted  items  reviewed  through  the  Trust’s 
Restrictive Practice Trust Steering Group and Co-Production in December 2022.   

Belts continue to not be named on the prohibited items list in adherence to reducing restrictive 
practice for  all,  however,  if  a  patient  has  a risk  history  of  attempted  ligature  or  is  a  risk to 
themselves then personal belongings will be reviewed and any identified risk will be reflected 
in care plan/risk management plan.  

EPUT Trust policy states: 

‘Risk assessments and personalised care related to restricted items access will depend on 
many factors, some of which may be fixed and others subject to change. The risk assessment 
and  ensuing  management  of  access  to  security  items  should  take  a  procedural  and 
individualised  approach,  where  possible  in  collaboration with  the  patient, which  avoids  the 
implementation of unreasoned blanket bans. For items that may be considered suitable only 
for restricted use, staff should complete a thorough risk assessment and provide the patient 
with a transparent rationale that explains the management outcome.  

A  dynamic  and  personalised  risk  assessment  considers:  1.  Personal  risk:  individual’s 
historical risk and current mental state 2. Interpersonal risk: direct risk to others- patients and 
staff  3.  Environmental  risk:  ward  dynamics;  general  service  safety  (level  of  security, 
rehabilitative/acute) 4. A common sense consideration of the item in question’ 

All  clinical  areas  have  been  provided  with  a  copy  of  the  above  policy  and  prohibited  list 
including newly revised handover forms that went live January 2024. The list referenced in 
the new Trust policy is also in the ‘new information for patients, relatives and carers welcome 
pack’; in order to better facilitate family engagement.  

A new digital app providing instant and easy access to Standard Operating Procedures has 
been developed. Implementation is in progress, with the rollout commencing in May 2024. 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 The  EPUT  Culture  of  Learning  Lessons  Team  are  developing  and  circulating  a  learning 
briefing to clarify correct process and share learning regarding restricted items and highlight 
other high risk items not included on the list.  The learning brief is to be informed by existing 
policy. 

Concern 3: 

Escalation of risk – Morgan-Rose attempted to secure unescorted leave on the morning of her 
death, her Responsible Clinician had only authorised escorted leave. This was not escalated 
to the nurse in charge and the Responsible Clinician was not informed.  

Response: 

EPUT are adopting and implementing an evidence based framework within inpatient services 
to support engagement, care planning and therapeutic intervention. This is an internationally 
recognised  framework  which  will  support  a  positive  cultural  change  across  all  our  ward 
environments around therapeutic engagement, holistic care planning (including leave plans), 
whilst  considering  the  context  of  care.  This  will  include  re-establishing  the  ‘named  nurse’ 
function and responsibilities.  

It will be the responsibility of the named nurse to ensure that all their patients have completed 
a ‘‘My Care, My Leave Plan”, which is signed by the patient and Health Care Professional, and 
reviewed by the multi-disciplinary team and Consultant/Responsible Clinician in ward reviews. 
These plans are to promote the patient voice, support the overarching electronic care plan and 
include following headings: 

•  When will I go on leave 
•  Where will I go 
•  My favourite places  
•  Who will accompany me 
•  When will I return 
•  What should I do if I am running late to return to the ward 
•  How can the ward contact me 
•  How can I get help when I need it 
•  Approved by 

The plans are kept in the nursing office so the teams can easily reference and are audited by 
the Matrons.  

Communication will be improved within the multi - disciplinary team by reviewing the impact of 
the multi-disciplinary team safety huddles through a Qi methodology. As well as implementing 
improvements in the handover process with the introduction of the nurse in charge checklist 
and task allocation.  

As  the  Court  will  be  aware,  Morgan  Rose  (RIP)  was  an  informal  patient.    However,  going 
forward the International Fundamentals of Care Framework will compliment Multi – Disciplinary 
Care planning and communication whilst supporting the Trust ‘Clinical Guidelines for Managing 
Leave with Informal Patients and Patients Detained under the MHA.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 4:  

Bathroom alerts – Evidence was heard that an Oxevision alert is triggered if a person is in the 
bathroom  for  more  than  3  minutes  and  staff  are  required  to  complete  an  in-person  check. 
Morgan-Rose was left in the bathroom unobserved for approximately 50 minutes. It was not 
clear from the evidence how the Trust proposes to ensure compliance in respect of this duty. 

Response: 

Configuration changes to the Oxevision system have been implemented.  This will ensure that 
bathroom alerts continue at 3 minute intervals until an individual has exited the bathroom. This 
includes the reset functionality of a repeating audible and tile illumination of an alert with timer 
continuation after each successive reset of the alert in 3-minute intervals.  

A  clinical  review  of  the  SOPs  for  Oxevision  and  Oxevision  Observations  to  align 
terminology  and  produce  updated  versions  of  the  SOPs  has  been  implemented.    This 
includes  ensuring  the  continuity  of  terminology  in  the  SOP  and  all  communications 
mirroring system based terms and wording.  

The change of use of ‘mute alert’ to ‘reset alert’. When an alert is reset, the audible alert 
is turned off not muted. 

All clinical staff are being retrained or trained in the use of Oxevision and observations.  In 
line with the Oxevision SOP and the Therapeutic engagement and supportive observation 
policy. 

DATIX data reflects that staff are using Oxevision in adherence to policy and responding 
to alerts which has resulted in no harm. The Inpatient Leadership team continue to spot 
check ward practice and review DATIX data.   

Managers of all levels are continuing to carry our spot checks on the safe use of Oxevision.  
Training logs are also comprehensively maintained.    

Concern 5:  

Trust oversight of care – the quality of record keeping was acknowledged not to be appropriate 
by nurses and senior staff during evidence, yet had been signed off: 

a)  Observations sheets for vulnerable detained mental patients were signed off by nurses 
in  charge  as  being  appropriate  despite  an  absence  of  any  recorded  therapeutic 
engagement  

b)  Omissions  in  the  recording  of  food  and  fluid  charts  required  by  the  Responsible 
Clinician  for  a  patient  who  was  losing  weight  with  a  diagnosis  of  Body  Dysmorphic 
Disorder.   

c)  The  Responsible  Clinician’s  evidence  was  that the  absence  of appropriate food  and 
fluid charts for other patients was an ongoing issue on Chelmer Ward that had been 
raised with nursing staff. 

Response:  

The  review  of  the  Therapeutic  Engagement  and  Supportive  Observation  policy  has  been 
completed and circulated to all staff.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We  have  rolled  out  ‘e-observations’,  across  all  wards,  which  is  a  mobile  tablet  (IPAD) 
electronic observation recording system; which records the patient observation with detail of 
patient  presentation  and  engagement  in the  moment. There  is  an  audit function  within  the 
system to enable ward managers to audit the quality of recording and engagement on a daily 
basis.  There  is  an  Oxehealth  E-observations  Project  Board  that  has  oversight  of 
implementation, delivery and outcomes.  

We  are  currently  implementing  The  International  Fundamentals  of  Care  Framework  which 
outlines what is involved in the delivery of safe, effective, high-quality fundamental care, and 
what  this  care  should  look  like  in  any  healthcare  setting  and  for  any  care  recipient.  This 
programme is being jointly led by the Nursing Directorate and Operations. A Matron lead post 
has been appointed to support implementation across all inpatient teams. 

The  Framework  emphasises  the  importance  of  nurses  and  other  healthcare  professionals 
developing trusting therapeutic relationships with care recipients and their families/carers. It 
also  emphasises  the  need  to  integrate  people’s  different  fundamental  needs;  namely  their 
physical  (e.g.  nutrition,  mobility)  and  psychosocial  needs  (e.g.  Communication,  privacy, 
dignity), which are mediated through the nurses’ relational actions (e.g., active listening, being 
empathic, physical health monitoring). 

All wards now have Registered General Nurses (RGN) in addition to Registered Mental Health 
Nurses (RMN) to support physical health care including a focus on nutrition. This is an outcome 
of the EPUT ‘Time to Care Model’ and has been supported by International Recruitment. The 
wards also have physical health champions embedded into their teams. 

All inpatient nursing staff are completing the Food and Fluid Refresher training delivered by 
the Professional Development Team.  

Concern 6:  

Staff entries in patient observations sheets should have given rise to a concern that some staff 
may have been using Oxevision not just as an adjunct to face-to-face observations, but instead 
of them. This remains a concern.  

Response:  

The  review  of  the  Therapeutic  Engagement  and  Supportive  Observation  policy  has  been 
circulated and reinforced on all wards. There is much more of an emphasis on the importance 
of therapeutic engagement during observation. 

A further training programme for all clinical staff commenced on 22/01/2024 on Oxevision and 
E-obs. This will consolidate clinical staff’s knowledge and skills and ensure compliance with 
Oxevision SOPS and the Therapeutic engagement and supportive observation policy. 

Datix  data  reflects  that  staff  are  using  Oxevision  in  adherence  to  policy  and  responding  to 
alerts which has resulted in no harm. The Inpatient Leadership team continue to spot check 
ward practice and review DATIX data, providing role modelling, leadership and oversight.  

I hope that I have provided reassurances around the steps that we have taken to address the 
issues of concern contained within your report.  We know there is an acute need to embed 
and  effect  change,  hence  we  will  monitor  the  above  provisions  to  ensure  these  are 
contributing to our overall aim of keeping patents safe and delivering therapeutic care. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Please do let me know if you require any further information at this stage, including copies of 
any of the documents referred to above.   

We will await your direction before sharing a copy of this reply with the family.  

Yours sincerely, 

Chief Executive