Sarah Adams

London House 
London Road 
Bracknell 
Berkshire 
RG12 2UT 
Tel: 01189 046500 
http://www.berkshirehealthcare.nhs.uk 

PRIVATE AND CONFIDENTIAL 

Alison McCormick 
Assistant Coroner for Berkshire 
Coroner’s Office 
Reading Town Hall 
Blagrave Street 
Reading 
RG1 1QH 

08 May 2024 

Re: Inquest touching the death of Sarah Adams 

Dear Madam 

I write in relation to the above inquest which concluded on 18 March 2024.  

On 20 March 2024 you made a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 
2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was sent 
to Berkshire Healthcare NHS Foundation Trust ("Berkshire Healthcare"), Cygnet Hospital Harrow, and 
Reading Borough Council, Adult Social Care. I am writing to provide you with the Berkshire Healthcare 
response to your concerns which relate to ensuring practitioners are trained in the discharge process.  

The discharge process for patients admitted to our inpatient services or to out of area placement, starts at 
the point of admission. This process involves community mental health teams and partner agencies such 
as Adult Social Care and, in the case of out of area placements, agencies such as the Cygnet Hospital, 
making plans for the support required by the patient at the point of discharge. 

All clinical staff in the Mental Health Divisions undertake Clinical Risk training which includes a focus on 
admission and discharge from inpatient services. We have now reviewed and revised this training offer 
across the organisation to ensure that moving forward there will be an increased focus on high-risk 
situations such as: 

•  Periods of transition of care between services or organisations (as this is known to be a high-risk 

period). 

•  Those placed in out of area placements. 
•  The importance of clear communications and responsibilities in the discharge plan and steps that 

will be taken to ensure the plan is carried out; and 

•  72 hour follow up process.   

These modifications to the Clinical Risk training and guidance further strengthens the training already in 
place which complies with national guidance. It aims to enhance staff knowledge and skills by providing 
additional guidance and clarity on the importance of defining, agreeing, and clearly communicating roles, 
responsibilities, and timelines. The new Clinical Risk training started on 1 May 2024. An enhanced group 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 supervision process has also been developed to run alongside the training to ensure practice is reflecting 
the expected standards. 

In addition, each service has a local induction training programme for new starters to undertake. For 
services that manage discharges from inpatient settings, including out of area placements, each new 
starter to the team undergoes on the job training by way of shadowing colleagues completing discharge 
processes. New starters within inpatient settings have a period of being supernumerary to facilitate the 
experiential learning of these routine processes. Community team practitioners with caseload 
management responsibilities receive support from senior colleagues in supervision to ensure discharge 
processes are followed and managed safely. Discharging people from mental health hospital settings is a 
routine and everyday occurrence. This allows staff plenty of opportunity to embed the processes from the 
point they are inducted into their role with the trust.  

Our Crisis Response Home Treatment Team (CRHTT) have a Caseload Coordinator role who has a focus 
on CRHTT discharge planning. They are responsible for the liaison between the host ward (whether out of 
area or local) and transition into CRHTT where appropriate. They ensure that agreed discharge plans and 
actions for CRHTT are clear at the point of discharge and are documented, implemented, and followed up.   

Further guidance on discharge protocol is available for staff in our Trust policies namely, Risk Assessment 
/ Management in Secondary Care Mental Health, Learning Disabilities Services and CAMHS Policy 
[CCR003], Clinical Risk and Safety Planning Documentation Guidance, and the Admission, Discharge and 
Transfer Policy [CRR045]. We have also strengthened our guidance to teams on the 72 hour follow up to 
give staff additional information around this process including guidance on patients that refuse to be seen 
during this period. 

Finally, more broadly, the Care Programme Approach (CPA) process is presently in the process of 
changing, in line with guidance from NHS England and the national Community Mental Health Framework. 
The aim is to ensure that everyone receives the same level of care, including a named key worker for all 
service users but with a multidisciplinary approach that must be integrated with social care and the 
voluntary, community and social enterprise. Every member of the MDT will play a prominent role in 
sharing responsibility for an individual’s care, and it will be the MDT playing the coordinating role across 
the various organisations and sectors. This will include the responsibility for discharges from inpatient 
settings. Significant work has been undertaken to review caseloads, improve risk documentation and 
safety planning as well as updating pathways and links with Voluntary, Community and Social Enterprise 
organisations.   

As a Trust, the safety and wellbeing of those we provide service to is paramount and despite the 
unfortunate circumstances in which this query has arisen, we welcome the opportunity HM Assistant 
Coroner has provided for us to review our training provision concerning the discharge process and we 
have taken this opportunity, as we do with all inquests, to learn from this experience and implement steps 
to ensure that we continue to provide the best quality care. 

Yours sincerely 

Chief Executive

Alison  McCormick 
Assistant  Coroner  for Berkshire 
Coroner’s  Office 
Reading Town Hall 
Blagrave Street 
Reading 
RG1 1QH 

15 May 2024 

Dear Madam 

Inquest touching  the death of Sarah Adams 

I write to provide the response from Cygnet Health Care ("Cygnet") in relation to the Regulation 
28  report  sent  to  Cygnet  Hospital  Harrow,  alongside  Berkshire  Healthcare  NHS  Foundation 
Trust and Reading Borough Council, following the above inquest. In the Regulation 28 Report 
you  identified  a  concern  relating  to  ensuring  that  staff  are  trained  in  the  discharge  process, 
and specifically the issues which may  arise in respect of out of area placements. 

For all patients  at Cygnet  planning  for discharge  begins from  admission.  A key part of this is 
the discharge  care plan  which  is started  when  a patient  is admitted  and  updated  throughout 
their  admission  following  every  ward  round.  The objective  is  for  this  care  plan  to  provide  a 
comprehensive  picture  of  the  arrangements  for  discharge  from  the  time  of  admission; 
including risks, discharge  location, transfer arrangements  and support needs. 

Care planning and risk assessment  training is provided  to staff to support them in completing 
care  plans,  including  discharge  care  plans.  This is via  a  4.5  hour  face  to  face  session.  The 
session  is provided  by the  Regional  Nursing  Director  to  all the Clinical  Managers  to then  be 
cascaded  at each  site.  At  Cygnet  Harrow  this  session  has  been  provided  to  all members  of 
the  multi-disciplinary  team  (MDT)  and  is  due  to  be  refreshed  on  an  annual  basis,  or  more 
frequently  if a need is identified. 

This training  is aligned with Cygnet's  broader training  offering,  particularly  our  e-learning  risk 
training.  This training  is  provided  to  all  members  of  the  MDT  and  refreshed  on a  two-yearly 
basis. The session provides guidance to staff in assessing risk, utilising the relevant tools and 
ensuring  that  risk  assessments  are  of  high  quality  and  triangulated  with  the  care  plans, 
continuous  notes  and  information  from  families  and  carers.  We  are acutely  aware  that  risks 
can increase at discharge and that risk assessments  need to be undertaken carefully to ensure 
that we implement  steps to minimise  this.  The risk training has been reviewed and from 1 July 
2024  will  include  updated  and  more  specific  guidance  in  relation  to  risk  assessing  around 
discharge. 

Discharge  arrangements  are specific to each  individual  who is being discharged  and Cygnet 
needs to be flexible  as it discharges  to multiple  different  community  organisations.  To ensure 
that our processes are consistent and nothing is missed Cygnet has detailed policies covering 
the discharge process. The new discharge policy was reviewed and published  March 2024. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 This  policy  was  benchmarked  with  a  large  mental  health  Trust  to  ensure  we  had  the  best 
evidence and our policies were in line with those of the sector. The documentation  to support 
discharge  includes  the discharge  notification  form which  was also  updated  in March  2024 to 
specifically  highlight  the  need  to  document  the  plan  for  post-discharge  community  support, 
including when this support will commence.  This form is shared with the patient and all relevant 
stakeholders  on discharge  to ensure  that all relevant  agencies  are aware of the agreed  plan. 
Cygnet  also  utilises  a  discharge  checklist  which  must  be  completed  by  the  Responsible 
Clinician for every discharge. Completion  of discharge forms and summaries  is monitored  both 
locally,  via  the  Medical  Director,  and  centrally  at  Board  level  to  ensure  that  all  sites  are 
providing the necessary  documentation  in a timely  manner  to support onward care. This data 
is highly visible so that if documents  are not being sent in accordance with set timeframes  this 
can be immediately  identified and addressed. 

Further, a supplemental  set of training  slides for staff induction are in development  to provide 
support  to staff in understanding  the content  of the  discharge  policy,  including  the discharge 
checklist,  the  key  risks  to  consider,  accurate  documentation  and  communication  with 
community  teams.  These slides will be deployed by 1st June 2024 for all Cygnet Hospital sites 
to assist new staff with prompt  familiarisation  with our processes.  . 

In addition, our Group Medical Director is arranging a Safer Discharge Conference planned to 
go ahead in Summer  2024.  The learning conference will look at specific risks associated with 
discharge and the practical arrangements  surrounding discharge. Our stakeholders,  including 
community  mental  health  teams  and Local Authority  Adult  Social Care Teams,  will be invited 
to this conference to share actions taken to improve  discharge processes,  checklists, policies 
and  improved  communication  with  a  focus  on  patient  centredness  and  to  ensure  that  our 
commissioners  and collaborators are aware of our processes and what role they will undertake 
in  the  discharge  process.  The conference  will  include  panel  discussions  that  involve  carers 
and  Expert  by  Experience  leads.  It  is  also  planned  to  invite  the  Parliamentary  and  Health 
Ombudsman  to discuss  their recent  findings  and  report  "Discharge  from  mental  health  care: 
making  it safe and patient-centred". 

On  1 June  2024  we  will commence  a  quality  improvement  project  in  relation  to the  learning 
from this inquest,  this will look at exploring  a working  arrangement  with the Samaritans.  This 
would provide for any high risk patients  ready for discharge  to be, with their consent, referred 
to the Samaritans.  The Samaritans would then contact the discharged patients within 24 hours 
and  if  they  have  any  concerns  they  can  take  appropriate  action.  This  model  has  been 
successfully  utilised  in  other  mental  health  organisations  and  can  bridge  the  gap  between 
discharge and being reviewed by their community  teams providing an additional risk mitigation 
and safeguard on discharge. 

Since  this  inquest  Byron  Ward  now  also  has  a  Cygnet  Social  Worker.  This  role  provides 
coordination  of  the  discharge  arrangements  including  liaison  with  family  and  community 
services  which  further  assists  with  ensure  that  discharges  processes  run  smoothly.  Cygnet 
Health  Care takes the  care and safety  of its patients extremely  seriously  and  is continuously 
to  provide  the  highest  possible  standard  of  care. 
working  to  improve 
Representatives  from Cygnet  Harrow were present  in court throughout  the inquest  to ensure 
that the learning  from this matter  was captured and disseminated.  I hope that this response 
provides some  measure  of reassurance  to HM Assistant  Coroner  and Ms Adams’  family. 

its  practice 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely 

CEO

Executive Director for Communities and 
Adult Social Care 

Civic Offices,  
Bridge Street, Reading, RG1 2LU 

Date:    13th May 2024 

Coroner’s Court Officer 
Reading Town Hall 
Blagrave Street 
Reading  
RG1 1QH 

Your contact is:  

 – Assistant Director for Operations 

Dear sir/madam, 

This is Reading Borough Council’s (“RBC”) response to Preventing Future Death (“PFD”) 

1. 
report issued following the inquest touching upon the death of Sarah Elizabeth Adams heard 
between 5 and 8 March 2024, pursuant to coronial powers under paragraph 7, Schedule 5, of the 
Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013.  

At the conclusion of the inquest, the Coroner found “Ms Adams died by suicide; however, 
2. 
her death was more than minimally contributed to by care and service delivery issues around her 
discharge from a voluntary in-patient hospital admission for a relapse of her longstanding paranoid 
schizophrenia and an intentional medication overdose.” The subsequent PFD report was issued in 
relation to the following matter giving rise to concern: “That clinicians and other hospital, mental 
health Trust and Social Care practitioners involved in the discharge of patients from in-patient 
mental health admissions are not trained in the discharge process generally and specifically the 
issues which may arise in respect of out of area admissions”. This is RBC’s response. 

The policy governing RBC’s social care involvement in hospital discharges is our Standard 

3. 
Operating Procedure (SOP) of Psychiatric Hospital Discharge (a copy of which is attached). 

This “outlines the standard operating procedure for the timely discharge of individuals from 

4. 
psychiatric hospitals in Reading” in circumstances when an individual is classified as medically fit 
for discharge by a multi-disciplinary team. RBC is guided by an approach whereby “from the time at 
which someone is admitted to hospital, planning should begin for their discharge”. 

The SOP sets out that: “Most psychiatric hospital discharges where an individual is moving to 

5. 
a community setting (either still under section or with the section lifted) are arranged through the 
Care Programme Approach (CPA). CPA is a multidisciplinary approach to supporting individuals after 
discharge with a care plan, care coordinator and ensuring a crisis plan is in place.” Further, the SOP 
states that “the CPA will combine eligibility under each of these Acts to form a single, cohesive 
support plan”. 

The SOP sets out in pathways the processes, conditions, services provided by Adult Social 

6. 
Care dependent on assessments, review and follow ups. 

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 The SOP notes that “the pathway is dependent on the service user’s circumstances and 

7. 
whether a short-term or long-term change needs to be made to the care package. The allocated 
worker will continue to hold the case until the service user has either settled into their placement 
or they have returned to being primarily under the care of health services.” 

With regards to circumstances in which Mental health beds are occupied by patients who are 

8. 
medically ready for discharge, this is set out in Appendix A of the SOP: 

Individuals are considered medically fit and ready for discharge (MFRD) when all three of the 
following conditions are met: 
1. 
No further interventions are needed that can only be carried out in an inpatient setting 
The person could be assessed, cared for and treated in their home or a less restrictive setting 

The multidisciplinary team (MDT) conclude that the person is medically fit and ready for 

2. 
discharge 
The MDT will include parties external to the trust (for example, social care staff). This involves 
considering issues such as housing, family/carer needs and the support available in the community, 
to decide whether discharge would be appropriate. When deciding whether someone is ready for 
discharge, members of the MDT should explicitly consider the person and their family/carers’ views 
about whether the person feels ready for discharge and engage with them about the proposed 
discharge plan. 

An adequate person-centred discharge has been agreed with the person to carry out any 

3. 
necessary assessments, care and treatment in the community. 
This will provide clear information about the proposed discharge process and enable the person and 
their family/carers to shape decisions about discharge. 

Once all three criteria are met, the person is medically fit and ready for discharge. Medically fit 
does not indicate complete recovery, instead it is the point at which the person could be safely 
assessed, cared for and treated in their home or a less restrictive setting. It is important that all 
three criteria are met rather than only one or two.  
Being medically ready for discharge does not mean that the person should be rushed to discharge if 
the conditions are not in place to continue their recovery outside of hospital with the adequate 
support/services in place. 

9. 
We confirm that all Adult Social Care practitioners involved in discharge planning are 
required to know and act in accordance with the SOP. Precise processes regarding discharge 
planning may differ from Trust to Trust. 

10.  With regards to local arrangements, the SOP notes that: Berkshire Healthcare NHS 
Foundation Trust are currently funding a Social Worker and Occupational Therapist based in 
Prospect Park Hospital to facilitate discharges as part of the Reading ward liaison team alongside 
health staff. These staff have access to health databases, so can see details of all Reading patients 
and their journey towards discharge. From the time at which someone is admitted to hospital, 
planning should begin for their discharge. 

RBC is aware of the fact that out of area admissions have become more frequent over the 

11. 
last year as the bed base within Berkshire Healthcare NHS Foundation Trust is reduced and are 
frequently at capacity. As indicated, in all hospital discharges, the SOP is followed, regardless of 
area. In addition, Adult Social Care would request that no discharge is made until RBC have had 24-
hour notification of this and have confirmed or agreed that care is formally in place, or alternative 
arrangements have been made.  In the case of Sarah Adams, Adult Social Care were not informed of 
the discharge. 

Kind regards, 

Reading Borough Council 
Executive Director for Communities and Adult Social Care 

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