Kenneth Baylis

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

29 April 2024 

Private and Confidential 
Dr Didcock 

Dear Dr Didcock 

Regulation 28 Response: Kenneth Stanley Baylis April 2024    

Following the Coronial enquiry into the death of Kenneth Baylis in April 2024, Nottinghamshire Health 
NHS Trust recognise and accept the further learning identified through the received Regulation 28 
report. We offer our sincere condolences to the family of Mr Baylis and extend the offer the family 
should they have any further questions. Please find below the organisational response to the specific 
concerns raised –  

Matters of concern within the Regulation 28 were identified as follows:  

1.  Family are not routinely or regularly involved in a patient’s risk assessment, care plan and 

safety planning.  

2.  Inadequate suicidal risk assessment and suicide mitigation  
3.  Lack of compliance with the Trusts Planned Leave policy.  
4.  Inadequate review and incident investigation following a serious incident.  

Following the sad death of Mr Baylis, the MHSOP General Manager and senior leads met with the 
Kingsley  Ward  team  to  commence  the  reflection  and  learning  process  with  a  subsequent  post 
inquest meeting taking place on the 11/3/24.  This included support from the inquest team, inquest 
witnesses  and  ward  leaders  to  debrief  about  the  inquest,  share  the  reflections  on  the  day  and 
specifically plan how to address the concerns raised as part of this process.    

This  report  details the  actions the  Trust  has taken  in  response  to  these concerns  and  addresses 
each one separately to assure that each point has been thoroughly addressed but acknowledging 
that these actions would be part of a whole care package for someone as part of a risk assessment 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and management plan. The actions below build upon the information contained within the inquest 
statements  of 
,  Deputy  Director  of 
Nursing which were provided in January 2024.   

,  General  Manager  MHSOP  and 

Family  is  not  routinely  or  regularly  involved  in  a  patients  risk  assessment,  care  plan  and 
safety planning   

The wards within MHSOP have reviewed their processes for involving family members in care and 
treatment and the following is now routinely in place on all wards: 

•  Each patient is allocated a named nurse upon admission and the nurse makes a plan with the 
patient  and  their  family/carers to  have  no  less than  weekly  contact.  This is  to  ensure that the 
family  is  fully  involved  in  discussions  about  care  and  treatment,  are  able  to  contribute  their 
opinions and are kept up to date. This is audited weekly for all patients and the audit template 
includes  evidence  of  family  contact,  involvement  in  care  planning  and  risk  assessment  and 
ensures  weekly  named  nurse  sessions  are  taking  place.  (Appendix  1)  The  findings  of  these 
audits are collated and presented to the MHSOP Clinical Effectiveness Group and the MHSOP 
Quality Operational Group for senior review and escalation as appropriate. The outcome of the 
audit is also discussed with the individual member of staff within their supervision session. 

•  To support the above, discussions have taken place with staff members about patient consent 
for  involvement  of  families  and  carers  and  a  guide  to  ‘Carers  and  Confidentiality’  has  been 
discussed in team meetings with staff on the ward. (Appendix 2)  

• 

In addition to this, weekly/fortnightly multi-disciplinary meetings (MDT) take place on each ward 
and  families  and  carers  are  routinely  invited  which  is  audited  on  a  weekly  basis.  There  is  a 
universal  MDT  template  (Appendix  3)  which  is  used  for  documenting  the  meetings  and  it 
specifically  asks  if  family  members  were  invited  and  details  their  involvement  in  care  and 
treatment. 

•  Each Hospital site, Highbury Hospital and Blossomwood (formerly Millbrook unit) have in place 
monthly  carers  meetings  which  are  attended  by  the  ward  managers  which  provides  an 
opportunity to receive direct feedback from carers and understand any improvements that are 
required. 

•  Kingsley Ward during March 2024 ran a patient and carer survey to ask about involvement in 
care planning and risk assessment and which they plan to continue to monitor effectiveness of 
changes made and identify further improvements required.  This initial survey has informed the 
introduction of a collaborative care planning conversation with every newly admitted patient and 
their relative/carer to all MHSOP ward.  This includes a structured conversation to co-produce 
the care plans for each patient as they are admitted to the in-patient ward. 

•  Ward  community  meetings  are  in  place  on  MHSOP  wards  which  provides  an  opportunity  for 
patients  and  carers  to  provide  feedback,  and  this  is  attended  by  the  Age  UK  Worry  Catcher 
service which is commissioned by MHSOP to provide independent advice and informal advocacy 
for patients on the ward.      

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Inadequate Suicidal Risk Assessment and Suicide Mitigation  

One of the risk assessment frameworks utilised across the MHSOP care unit, and currently being 
introduced to the wider Mental Health Care Group, is the Suicide Assessment Framework E-Tool 
(SAFETool)  –  this  is  a  suite  of  peer  reviewed  clinical  tools  to  improve  quality,  consistency  and 
documentation of assessment and response to suicidal patients.  

The following description is taken from the 4 Mental Health website:  

Used in conjunction with training, SAFETool provides a comprehensive suicide mitigation approach 
designed to: 

• 

Improve the assessment and documentation of people at risk of suicide and/or self-harm. 

•  Provide a clear structure for the recording of patient information, to ensure excellent governance. 

•  Provide effective patient-centred intervention practices and techniques. 

•  Ensure  compassionate  engagement,  tailored  triage  assessment,  appropriate  referral,  and 

student collaboration. 

•  Support the development of a common language, promoting a more integrated response across 

statutory services, third sector providers and communities. 

•  Provides a Safety Plan template which can be co-produced with the patient. This includes patient 
generated,  agreed  ways  to  deal  with  further  distress  such  as  explicit  removal  or  mitigation  of 
means, emotional and social support, telephone and online support, an immediate improvement 
on current practice. 

• 

Is extensively peer reviewed by international experts in self-harm and suicide prevention, people 
with lived experience, GPs and third sector experts. 

•  Offers potential to undertake audit post training, embedding in quality improvement plans. 

This tool has been rolled out across all MHSOP wards and requires 1 day training for each member 
of staff to ensure the tool and its principles are understood used effectively. At the time of the sad 
death of Mr Baylis this tool was utilised and had been used by members of staff who had undergone 
the Trust training. 

The use of the tool within MHSOP wards and learning from this has been identified and as a result 
the following changes are taking place: 

•  All the SAFETool paperwork is now embedded within RIO which is the Trust electronic patient 
record. This went live on the 25th of October 2023 and is available to all teams. Communication 
has gone to all staff to ensure that all forms are completed within RIO which ensures the correct 
procedure is followed and provides an audit trail. 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  All  the  staff  on  Kingsley  Ward  are  undergoing  refresher  training  on  the  SAFETool  and  the 
changes in RIO during May 2024. This will be a full day training for each member of staff and all 
staff are booked on the training to ensure they will all be trained by 1st June 2024. 

•  The training will be facilitated by one of the Trusts Clinical Educators for Suicide Prevention who 
also  has  an  extensive  clinical  background  within  MHSOP.  The  training  already  incorporates 
family/carer  involvement  within  risk  assessment  and  care  planning,  but  this  has  been  further 
strengthened  and  includes  case  studies  to  enable  staff  to  undertake  reflection  and  learning 
during the training session. 

•  Use of the SAFETool is not indicated for all patients admitted to the ward and where it is utilised 
the  learning  and  reflection  on  the  use  of  the  tool  will  be  incorporated  into  supervision  for  the 
member  of  staff  to  ensure  the  training  is  embedding  into  practice.  Clinical  and  managerial 
supervision takes place monthly for staff members and provides support to staff from a named 
senior/experienced  clinician  to  promote  reflection,  learning  and  development  within  clinical 
practice. Kingsley Ward supervision compliance is consistently within Trust targets and all staff 
have yearly mandated training from the Trust in clinical supervision to ensure this is being carried 
out  effectively.  Staff  on  Kingsley  Ward  are  all  currently  up  to  date  on  their  mandated  clinical 
supervision training. 

•  Adherence  to  training  and  supervision  compliance  is  routinely  monitored  by  senior  managers 
within MHSOP, and the Mental Health Care Group and any non-compliance is identified, and an 
action plan put in place.      

•  Suicide prevention and self-harm training is provided, overseen and evaluated by the Trust Lead 
for Self-harm and Suicide Prevention and the suicide prevention training team to ensure quality 
and consistency of training. The Suicide Prevention team also work with clinical teams to support 
implementation. This was reviewed and enhanced in early 2024, to provide assurance re quality 
and  oversight,  and  include  updated self-harm  awareness  and response  training  in  addition to 
suicide  prevention  awareness  and  response  training  for  consistent  language,  content  and 
approach.  

Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in 
line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and 
literature. The Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with 
NHSE and other leaders in suicide prevention to scope how other Trust’s have implemented this to 
inform Nottinghamshire Healthcare’s continued work. Updated guidance is reflected in the Trust’s 
new Clinical Risk and Safety Policy (due to be ratified in May 2024) and guidance documents relating 
to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self-
harm have been developed. Audits, and risk and safety forms within healthcare records are being 
reviewed and updated to ensure that these support improvement. 

Lack of Compliance with the Trusts Planned Leave Policy 

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 All wards have been supported to further review the Trust planned leave policy within team meetings 
and individual supervision. In addition, all staff were asked to read the policy again and sign to say 
that  this  has  been  read  and  understood.  To  ensure  this  is  being  routinely  followed  a  door 
board/Leave  record  has  been  put  in  place  which  has  detail  of  each  planned  leave.  Every  time  a 
patient leaves the ward on planned leave the following is entered: date and time of planned leave, 
actual time left/returned to the ward, member of staff facilitating leave, what the patient was wearing, 
presentation of patient prior and post leave and destination of leave. This door board/leave record is 
audited to ensure it is being completed fully. 

Discussion regarding planned leave takes place within the MDT at which the family/carer is invited 
and named nurse discussions during the time before MDT are considered if the family cannot be 
present.        

Inadequate Review and Incident Investigation Following a Serious Incident         

The guidance for what constitutes the requirement to complete an IR1 and for a serious incident has 
been shared and discussed via team and business meetings and within this has incorporated the 
discussions regarding the implications of not doing this.  An audit was completed during December 
2023 to confirm that serious incidents are being recognised and reported by the community teams 
in MHSOP. 

MHSOP have regular Time Out sessions with teams and in the session on the 22nd of March 2024 
had a dedicated agenda item which covered learning and reflections from this quality improvement 
plan  which  included  the learning  about IR1s.  Senior  managers  do  regularly  receive  IR1s from  all 
teams  within  MHSOP  including  ward  and  community  teams.  Following  completion  of  an  IR1  a 
manager is identified to complete an IR2 which reviews the incident and any learning that is identified 
from it. Senior managers receive monthly reports which indicate if the IR2s have been completed 
and  ensure  none  have  been  missed  and  in  addition  learning  from  incidents  is  included  within 
management  and  clinical  supervision  which  occurs  monthly  for  each  member  of  staff.    Detailed 
discussion of serious incidents within the care unit is held in the MHSOP Health, Safety and Risk 
meeting and thematic review of serious incidents is completed via the MHSOP Quality Assurance 
and  Improvement  forum.  These  forums  facilitate  discussion  and  review  across  services  and  are 
Chaired  by  the  Care  Unit  senior  management  team.    The  MHSOP  care  unit  has  a  Learning  the 
lessons bulletin which is shared across all services and teams to disseminate learning from serious 
incidents – this bulletin is featured on the agenda for the MHSOP Quality Operational Group and is 
disseminated across all service and team meetings to encourage active reporting and learning from 
incidents.   

To ensure that Serious Incident Investigators understand the requirement for staff interviews as part 
of the investigation each investigator is emailed when the investigation is allocated to ensure they 
are informed of this requirement, this is included in a standard email template to ensure consistent 
communication.  The  MHSOP  Clinical  Governance  team  maintain  contact  and  act  as  a  point  of 
reference for the investigation panel and will oversee this as a consistent practice.  Upon completion 
and approval of the Serious Incident investigation the final report is shared with the relevant service 
and team/ward manager so that they can discuss in detail with their team.  The support in sharing 
lessons learnt is tailored dependent on the incident and could include reflective discussions to team 
time  out  sessions  to  ensure  the  correct  level  of  learning  is  undertaken.    The  MHSOP  Clinical 

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

 
 
 
 
 
 
 
 
 
 
 Governance team will also ensure that all witnesses who have been part of the investigation receive 
both a copy of the investigation report but are also supported with any learning reflections as part of 
this process. 

The  Mental  Health  Care  Group,  of  which  MHSOP  is  part  of,  is  introducing  a  new  governance 
structure which includes a standardised template for ward and community meetings and within this 
data  on  incidents  will  be  included  and  discussions  take  place  within  the  team  to  reflect  on  the 
incidents  to  ascertain  whether  there  is  any  learning  and  improvements required.  This  is  currently 
being piloted within the Care Group and is due to go live across all MHSOP wards during June 2024. 

The Trust is in the process of moving towards the Patient Safety Incident Response Framework. 
(PSIRF) It represents a significant shift in the way the NHS responds to patient safety incidents 
and is a major step towards establishing a safety management system across the NHS and is also 
a key part of the NHS patient safety strategy. This new framework replaces the SI Framework and 
makes no distinction between ‘patient safety incidents’ and ‘Serious Incidents’ and so it removes 
the SI classification and the threshold for it.  

PSIRF sets out the NHS’s approach to developing and maintaining effective systems and 
processes for responding to patient safety incidents and promotes a proportionate response to 
patient safety incidents with a focus on learning and improvement. 

To date the trust has completed the PSIRF policy and PSIRP (patient safety incident response 
plan), which sets out the local priorities for the next year. As part of the development of the PSIRP 
the trust met and consulted with a number of stakeholders; commissioners, service users, clinical 
staff and services and continue to do so. 

The Patient Safety Team has been enhanced to provide greater governance, expertise and 
resource to assist in the transition and embedding of PSIRF. A clear communication plan is in 
development and will be implemented as part of the transition. Training has been commissioned 
for May by an approved external provider.The Trust transitioned from National Report Learning 
System (NRLS) to Learning from Patient Safety Events (LFPSE) in October 2023. PSIRF will be in 
place across the Trust by August 2024.  

I hope that the information contained within this response provides reassurance to your and Mr Baylis 
family that we as a Trust have heard and understood the significant concerns raised because of this 
inquest  and  that  we  are  committed  to  making  these  important  improvements  to  services  and 
processes for future patient care. 

Yours sincerely  

Executive Director of Nursing, AHPs & Quality  

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 Appendices 

Appendix 1 – Ward Manager Audit Template   

Ward Managers 
Weekly Audit.docx  
Appendix 2 – Guide to Carers and Confidentiality  

552599 091500 
Guide to carers and co 

Appendix 3 – MDT Template  

MDT Ward Round 
Template.docx

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