Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0224, written 24 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Apr 2024 |
|---|---|
| Reference | 2024-0224 |
| Deceased | Nicholas Harrison |
| Coroner | Kirsten Heaven |
| Coroner area | Swansea and Neath Port Talbot |
| Category | Other related deaths · Mental Health related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: THIS REPORT IS BEING SENT TO: CHIEF EXECUTIVE SWANSEA BAY UNIVERSITY HEALTH BOARD 1 TALBOT GATEWAY BAGLAN ENERGY PARK BAGLAN PORT TALBOT SA12 7BR DIRCTOR GENERAL OF HEALTH AND SOCIAL SERVICES / CHIEF EXECUTIVE OF NHS WALES TY DYSGU, NANTGARW, CF15 7QQ. CHIEF EXECUTIVE OF THE CITY AND COUNTY OF SWANSEA 1 CORONER I am Kirsten Heaven, Assistant Coroner, for the Coroner area of SWANSEA & NEATH PORT TALBOT 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 12 April 2022 an investigation was commenced into the death of Nicholas Kim Harrison. The investigation concluded at the end of the inquest on 16 April 2024. The medical cause of death was: 1a Hypoxic-Ischaemic Brain Injury 1b Traumatic Brain Injury The conclusion of the inquest was a narrative conclusion as follows: On 12 March 2022 Kim Harrison was seriously assaulted by his son the perpetrator at the family home. As a result of this assault Kim sustained significant head and face injuries which caused his death on 9 April 2022. At the time of the assault, the perpetrator had absconded from Ward F of Neath and Port Talbot hospital where he was subject to detention powers under section 2 of the Mental Health Act 1983 following an informal admission on 2 March 2022. The perpetrator had been detained 1 as doctors considered that he posed a potential risk of violence to others. At the time of the assault the perpetrator was suffering from untreated schizophrenia which caused him to have paranoid delusions about his father. The perpetrator had been receiving care and treatment from Swansea Bay University Health Board (‘SBUHB’) for his mental ill health from 2007 onwards which included taking the drug Olanzapine. In 2009 the perpetrator was wrongly removed from the care of Area 3 Community Mental Health Team. This contributed to a lack of continuity in care for the perpetrator in 2018 when his treating consultant left. At this point SBUHB failed to put in place appropriate and timely follow-up arrangements from a replacement consultant psychiatrist which caused the perpetrator to become disengaged from services when he was vulnerable. This caused the perpetrator to wean himself off Olanzapine in an unmanaged and unmonitored way. This led to a return of the perpetrator’s psychotic symptoms and a deterioration in the perpetrator’s mental health to the point where the perpetrator lost insight into his condition and his risk to himself, and others, began to increase. The perpetrator probably would have engaged with a suitable replacement consultant psychiatrist had one been offered by SBUHB in a timely manner in 2018 such that his mental health would not have deteriorated in the way that it did. There was a failure by SBUHB to put in place appropriate and timely follow up arrangements from a consultant psychiatrist for the perpetrator in 2018 and this contributed to Kim’s death. and Kim Harrison From June 2020 to March 2022 The perpetrator’s parents consistently raised with SBUHB and the City and County of Swansea AMPH service concerns about the perpetrator’s deteriorating mental health in their attempts to get help for the perpetrator. The perpetrator did not want to engage with mental health services, and he did not want information to be shared with his parents as he had lost insight into his mental ill health. SBUHB clinicians and the City and Country of Swansea AMPH service did not pay sufficient attention to the collateral information being provided about the perpetrator by his family. From July 2020 onwards SBUHB clinicians, including the Community Mental Health Team, should have ensured that the perpetrator was regularly and assertively visited in the community so that the perpetrator could be re-engaged with mental health services. The perpetrator was subject to a Mental Health Act Assessment on 27 April 2021 and not admitted to hospital for assessment. This assessment was flawed as there was a failure by SBUHB to gather all available collateral information to inform the assessment, a failure to have due regard to the collateral information during the assessment and inadequate consideration of the risks the perpetrator posed to himself and others. The assessment was also not informed by a detailed understanding of the perpetrator which would have occurred had SBUHB assertively engaged the perpetrator in the community from June 2020 onwards. I find that these failures possibly contributed to Kim’s death. The perpetrator was admitted to Ward F on 2 March 2022 after behaving in a psychotic manner in the family home and being verbally aggressive and confrontational towards his parents. SBUHB accept that when the perpetrator was on Ward F his risk assessments were not fully completed. SBUHB also accept that the perpetrator had not been subject to an adequate multi-disciplinary team assessment and that the perpetrator’s family members’ views and concerns had not been fully recorded and therefore could not be taken into account and recorded on the risk assessments and that there was no clear plan in place regarding the perpetrator’s non- concordance with medication. There was no documented assessment of the risk of the 2 perpetrator absconding but if it had been assessed it would have been classified as a low risk. These matters did not contribute to Kim’s death. On 12 March 2022 the perpetrator absconded through the front door of Ward F when it was being held open by a member of staff who was talking through the door. The security systems in place at the time in Ward F were not fit for purpose. This is because the infrastructure and design in relation to door access was unsafe and in turn was being operated in an unsafe manner due to a lack of adequate training of staff by SBUHB. This was at a time when Ward F was known to be under significant pressure. Further, this defective system was not picked up or identified through regulatory oversight by SBUHB because they had not conducted a review of the security of Ward F despite a significant increase in the rate of absconding. This system failure (defect in the security system and inadequate training of staff on door security in Ward F) contributed to Kim’s death. 4 CIRCUMSTANCES OF THE DEATH at the family home. As a The deceased was Nicholas Kim Harrison (‘Kim’). On 12 March 2022 Kim was seriously assaulted by his son result of this assault Kim sustained significant head and face injuries associated with a traumatic brain injury and significant neck injuries and rib fractures. Kim received intensive medical care. During this time Kim remained neurologically impaired and then died. At the time of the assault on his father, Neath and Port Talbot hospital where he was subject to detention powers under section 2 of the Mental Health Act 1983 (‘MHA 83’). was considered to be a risk to others. At the time of the assault from untreated schizophrenia which caused him to have paranoid delusions about his father, Kim. had absconded from Ward F of had been detained as he was suffering 5 CORONER’S CONCERNS During the inquest the evidence revealed matters giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make 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 The first MATTERS OF CONCERN is as follows: I heard evidence during the inquest that in January 2021, March 2021, and December 2021 the Harrison family made three formal requests for a mental health act assessment under the MHA 83 in respect of their son in their capacity as Nearest Relatives (NR). On receipt of a NR request, the local social services authority (City and County of Swansea (‘CCoS’)) is under a legal duty pursuant to s.13(4) MHA 83 to make arrangements for an Approved Mental Health Practitioner (‘AMPH’) to consider the patient’s case as part of their consideration as to whether to make an application for admission to hospital. The Mental Health Act 1983 Code of Practice for Wales (‘MHACOP Wales’) states that in considering a patients case an AMPH must come to their own independent view based on social and medical evidence and that they should recognise the value in involving other people in the decision-making process where that person is able to offer a particular perspective on the patient’s circumstances and that they should consult wherever possible with other 3 in person and prior to the formal assessment case as sufficient collateral information was not people who have been involved in the patient’s care. In respect of the request in January 2021, I found that the AMPH did not collect sufficient collateral information before visiting and assessing under the MHA 83 on 9 February 2021. I also found that the assessment of 9 February 2021 was a formal assessment under the MHA 83 and that it did not comply with the MHA 83 as only one doctor and an AMPH attended to assess in person where the requirement is that two doctors must attend to assess the patient. This was not an emergency assessment. I found that in respect of the second NR request (when was in police custody in March 2021) there was a failure by the AMPH to act in accordance with the s.13(4) MHA 83 duty because it cannot be said that the AMPH adequately considered obtained and considered prior to the decision by the AMPH not to undertake a formal mental health act assessment on by the Harrison family in their capacity as the NR. I found that the response of the AMPH service to the third NR request from the Harrison’s on 19 December 2021 (which was to refuse to carry out a formal mental health act assessment) was not in accordance with s.13(4) MHA 83 as no collateral information was sought and what had been provided by the Harrison family was not afforded sufficient weight with reliance being placed solely on the records on the system which were out of date. I heard evidence during the inquest that a senior manager in the AMPH service maintained to the Swansea University Bay Health Board (‘SBUHB’) that the assessment of 9 February 2021 complied with the MHA 83 (when it did not) and did not at any stage make clear to the SBUHB that the AMPH service had not gathered sufficient collateral information, including that suggested by the Harrison family, prior to assessing whilst he was in police custody as requested . I am concerned that an inadequate understanding within the CCOS AMPH service of the duty to gather sufficient collateral information in the context of any assessment under the MHA 83 and / or inadequate systems being employed within CCOS in relation to this issue creates a risk that information may not be captured and / or may be lost in relation to mentally unwell individuals in the community where they may pose a risk to their own lives and / or the lives of others and that this creates a risk that other deaths will occur. The second MATTERS OF CONCERN is as follows: It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this 4 creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur. The third MATTER OF CONCERN is as follows: I heard evidence that Ward F of Neath and Port Talbot hospital is being used as the Single Point of Admission (‘SPOA’) for all adults requiring hospital admission in the locality for assessment of their mental illness. I heard that Ward F is a 21 bedded unit and that the move to using just Ward F as the SPOA (as opposed to three units which had been the practice) was brought in during the Covid-19 pandemic to manage the spread of the Covid 19 virus but that this change had been under consideration in SBUHB prior to the Covid-19 pandemic. I heard that this has resulted in a significantly increased level of acuity on Ward F with a significant increase in pressure on staff, a higher turnover of mentally unwell patients, and an increased pressure on staff from, for example, the need to prepare paperwork for the Mental Health Review Tribunal for Wales in a short period of time after admission. During the inquest I heard evidence (and SBUHB accepted) that the risk assessment conducted on no assessment of Ward F due to its use as the SPOA impacted on F. I heard evidence from SBUHB that at the time there was insufficient training on risk assessments in Ward F. I heard from SBUHB that the current target is to ensure that 75% of staff on Ward F are trained in risk assessment by the end of 2024. I am concerned that only having 75% of staff trained in assessing risk means that risk may not be adequately assessed in respect of all patients on Ward F which raises a concern that risk to self and / or others and / or the risk of absconding will not be properly identified thus creating a risk that other deaths will occur. This is particularly so given the increased rates of acuity in the patients on Ward F due to it being used as the SPOA. during his time in Ward F was not adequate and that there was risk of absconding. I found that the pressure on staff in care whilst he was on Ward The fourth MATTER OF CONCERN is as follows: parents (including the deceased, Kim) During the inquest I heard that in 2021 became concerned that their son was not receiving appropriate care and treatment from SBUHB in circumstances where had a diagnosis of chronic psychotic disorder, had become lost to services after his consultant psychiatrist had unexpectedly left, and appeared to be suffering from a relapse in his mental health condition. Over five months (February – June 2021) the Harrison raised their concerns in writing to SBUHB in documents detailing their perceived failures around SBUHB’s management of respect of the CCOS AMPH service). These concerns were first raised in writing in February 2021 with various updated versions of the written concerns being send on multiple occasions to SBUHB, including to the SBUHB Interim Chief Executive, the Medical Director, the Nurse Director for the Mental Health & Learning Disabilities Service Group and other members of SBUHB’s senior management team. In June 2021 the Harrison’s submitted a formal complaint to SBUHB after being requested to do so by the SBUHB Interim Chief Executive, who then commissioned an independent consultant psychiatrist to review the Harrison’s complaint and provide an expert opinion. This expert report was received and sent to the SBUHB Interim Chief Executive in draft in November 2021 as he was directly managing the complaint. This report was critical of certain aspects of SBUHB’s management of mental health (alongside concerns raised in and raised 5 ) at any point prior to care and treatment in the admission to Ward F. Both SBUHB queries for further clarification but no action was taken for 10 weeks following receipt of the expert report. I heard that this report was not shared with the consultant psychiatrist whom it criticised (and who had assessed Kim’s death. I found that this was a significant lost opportunity for SBUHB to reflect on some independent scrutiny that had been brough to bear on their care and treatment of before Kim’s death. In the inquest I found that I had not received a satisfactory explanation for this 10-week delay and for why the report had not been shared with the treating consultant psychiatrist. Following Kim’s death SBUHB undertook a Serious Incident Review which was then elevated to a formal Patient Safety Incident Investigation which was signed off in August 2023 by the SUBHB Medical Director and the SUBHB Nurse Director of the Mental Health & Learning Disabilities Service Group (17 months after Kim’s death). I heard evidence that the Harrison family met with SBUHB after Kim’s death and asked them to include within the formal investigation the substance of their complaint and not to limit the investigation to the time following internal investigations did not look at any aspect of community (which had formed the basis of the complaint made by the Harrisons in June 2020 and which was subject to some criticism by the independent expert). Both investigations commenced their investigations at the point at which Daniel was taken by police officers to Cefn Coed hospital and then admitted to Ward F. SBUHB responded to the Harrison’s letter of compliant of June 2021 on 8 November 2023. SBUHB did not conduct a formal investigation into the Harrison’s compliant. I was told by the consultant psychiatrist, who was the focus of part of the Harrison’s complaint, and who had been criticised by the external expert, that he has not been interviewed by SBUHB about his involvement in death. I have heard that SBUHB have introduced a PSIIT Investigation Protocol to ensure effective and consistent management of patient safety incidents within SBUHB. However, under this new policy the same senior leadership team who limited the scope of the Patient Safety Investigation into Kim’s death in the way that I have described remain the team who decide on the scope of patient safety investigations under the new policy (the Mental Health & Learning Disabilities Service Group Senior Team). I am concerned that if there is a reluctance within SBUHB to conduct robust, transparent and timely investigations into complaints in line with the formal complaints process and if there is a reluctance within SBUHB to ensure that a formal patient safety investigation following a death and / or patient safety incident is conducted in a timely manner and is sufficiently wide in scope, including reflecting on and incorporating the concerns from the affected family member, then SBUHB will not learn lessons from patient safety incidents and that this creates a risk that deaths will continue to occur. care before or after Kim’s The fifth MATTER OF CONCERN is as follows: I heard evidence from a SBUHB consultant psychiatrist that where a mentally unwell person in the community refuses mental health care and treatment and / or where they are hard to engage in mental health services such persons can be referred for assertive outreach in SBUHB to facilitate their engagement with services, but only if that person consents to such outreach. I also heard that assertive outreach services are available to those under secondary mental health care in SBUHB but that to be accepted for secondary mental health care a patient must consent to first being assessed. I heard that the referral forms for assertive outreach require a referrer to indicate whether a patient is consenting and if they are not consenting then the referral will not be accepted. I also heard that when a mentally unwell person refuses to engage with mental health services in the community it can be a feature of their mental ill health and an indication of their lack of insight into their illness. I am 6 concerned that if consent is required before a mentally unwell person in the community is able to receive assertive outreach then there may be a gap in the mental health services within SBUHB that creates a risk that mentally unwell people will remain in the community without access to mental health services in circumstances where they may pose a risk to their own life or the lives of others. This is because whilst they may need access to mental health services, they may be too unwell to consent to that access. I am concerned that if there is such a systemic deficiency within SBUHB in relation to hard to engage mentally unwell people in the community then this creates a risk that deaths will continue to occur. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21 June 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Swansea Bay University Health Board, City and County of Swansea, South Wales Police, . I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 24 April 2024 7
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
FAO His Majesty's Assistant Coroner for Swansea and Neath Port Talbot Corporate Management Team The Guildhall, SWANSEA. SA1 4PE www.swansea.gov.uk Your Ref: Date: Nicholas Kim Harrison 19th June 2024 Dear His Majesty's Assistant Coroner Re: Regulation 28 Report to Prevent Future Deaths – Dr Nicholas Kim Harrison who died on 9 April 2022 Thank you for your Report in relation to the Prevention of Future Deaths (hereafter “the Report”) dated 24 April 2024 concerning the death of Dr Nicholas Kim Harrison on 9 April 2022. In advance of responding to the specific concerns raised in the Report, I would like to express my sincere condolences to Dr Harrison’s family and loved ones. City and County of Swansea (hereafter "the Council") fully acknowledge that this has been an extremely difficult time for them. I hope that my response provides Dr Harrison's family, and yourself, with assurance that the Council takes their loss seriously and that they have been listened to. The concerns raised in the Report have been reflected upon and appropriate action is being taken. I have considered the Report carefully, together with the Council's Head of Adult Services and Principal Officer the management of the Approved Mental Health Professionals (hereafter "AMHP") team. for Mental Health Services who oversees It is not within the Council's remit to respond to all of the matters of concern set out by His Majesty's Coroner in the Report, and it is appropriate that the Council responds to the first and second matters of concern. I shall address each in turn: "The first MATTERS OF CONCERN is as follows: I heard evidence during the inquest that in January 2021, March 2021, and December 2021 the Harrison family made three formal requests for a mental health act assessment under the MHA 83 in respect of their son in their Nearest Relatives (NR). On receipt of a NR request, the local capacity as social services authority (City and County of Swansea (‘CCoS’)) is under a legal duty pursuant to s.13(4) MHA 83 to make arrangements for an Approved Mental Health Practitioner (‘AMPH’) to consider the patient’s case as part of their To receive this information in alternative format, or in Welsh please contact the above. I dderbyn yr wybodaeth hon mewn fformat arall neu yn Gymraeg, cysylltwch â’r person uchod. consideration as to whether to make an application for admission to hospital. The Mental Health Act 1983 Code of Practice for Wales (‘MHACOP Wales’) states that in considering a patients case an AMPH must come to their own independent view based on social and medical evidence and that they should recognise the value in involving other people in the decision-making process where that person is able to offer a particular perspective on the patient’s circumstances and that they should consult wherever possible with other people who have been involved in the patient’s care. In respect of the request in January 2021, I found that the AMPH did not collect sufficient collateral information before visiting and assessing Daniel in person and prior to the formal assessment under the MHA 83 on 9 February 2021. I also found that the assessment of 9 February 2021 was a formal assessment under the MHA 83 and that it did not comply with the MHA 83 as only in person where the one doctor and an AMPH attended to assess requirement is that two doctors must attend to assess the patient. This was not an emergency assessment. I found that in respect of the second NR request (when was in police custody in March 2021) there was a failure by the AMPH to act in accordance with the s.13(4) MHA 83 duty because it cannot be said that the AMPH adequately considered case as sufficient collateral information was not obtained and considered prior to the decision by the AMPH not to undertake a formal mental health act assessment on whilst he was in police custody as requested by the Harrison family in their capacity as the NR. I found that the response of the AMPH service to the third NR request from the Harrison’s on 19 December 2021 (which was to refuse to carry out a formal mental health act assessment) was not in accordance with s.13(4) MHA 83 as no collateral information was sought and what had been provided by the Harrison family was not afforded sufficient weight with reliance being placed solely on the records on the system which were out of date. I heard evidence during the inquest that a senior manager in the AMPH service maintained to the Swansea University Bay Health Board (‘SBUHB’) that the assessment of 9 February 2021 complied with the MHA 83 (when it did not) and did not at any stage make clear to the SBUHB that the AMPH service had not gathered sufficient collateral information, including that suggested by the Harrison family, prior to assessing I am concerned that an inadequate understanding within the CCOS AMPH service of the duty to gather sufficient collateral information in the context of any assessment under the MHA 83 and / or inadequate systems being employed within CCOS in relation to this issue creates a risk that information may not be captured and / or may be lost in relation to mentally unwell individuals in the community where they may pose a risk to their own lives and / or the lives of others and that this creates a risk that other deaths will occur." . The Council's response: The Council recognises that families and other relevant persons are an integral part of the process for assessments carried out in accordance with the Mental Health Act 1983 (hereafter "the 1983 Act") and its associated Code of Practice. The Council also recognises the need to improve its AMHP services to ensure that (i) there is a robust understanding within the team of the duty to gather sufficient collateral information from family members and other relevant persons in the context of an assessment carried out under the 1983 Act, and that (ii) collateral information is consistently recorded in to allow subsequent AMHP and other relevant mental health sufficient detail professionals to have this information readily available. With regard to His Majesty's Coroner's concern regarding the AMHP service's understanding of the duty to gather sufficient collateral information, it is important to recognise that the AMHP training course delivered by Swansea University, which all AMHPs employed by the Council are required to complete, covers (among other competencies): (i) The application of the relevant legislation and professional code of practice; (ii) Professional decision making, (iii) Exercising the function independently with insight, authority and autonomy; and (iv) Obtaining, analysing and sharing appropriate information from individuals, other professionals and sources in order to manage decision-making processes (specifically relevant to your concern). Following completion of the AMHP training course, AMHP's employed by the Council undergo a period of shadowing and supervision by a senior and experienced AMHP and are then signed-off / approved by line management when they are deemed to be competent to fulfil the AMHP role functions on an autonomous basis. AMHPs are then required to complete 18 hours of training relevant to the role per annum. This training is arranged by the Council, and external specialist training agencies are engaged. The training includes refreshers on professional practice and legal updates. It is also an individual AMHPs' responsibility to provide evidence of continued competence during each re-warranting period (i.e. every 3 years) and in accordance with the following key areas: (i) Values-based practice; (ii) Application of knowledge (legislation and policy); (iii) Application of knowledge (mental disorder); (iv) Application of skills (effective partnership working); and (v) Application of skills (professional decision making). Nevertheless, and in light of His Majesty's Coroner's concerns, senior management have carried out a review with the aim of gaining a fuller understanding of this matter of individual AMHP practice and formulating recommendations and an action plan for improvement. Specific actions, to be taken within the next month, include: i. The Council's Principal Officer for Mental Health Services will liaise with the All- Wales AMHP Group Lead with regard to this matter and His Majesty's Coroner's specific concern, and the potential benefit of, and pathway to, requesting a review of the Code of Practice, specifically the guidance relating to the gathering, weighting and recording of collateral information. ii. The Principal Officer for Mental Health Services, in his capacity of Chair of Swansea University's AMHP training course committee, will discuss with the committee the key competence area relating to the obtaining of collateral information, and any requirement for the delivery of the course to include greater emphasis on the gathering, weighting and recording of collateral information. iii. The Council will seek to deliver, via its external training agencies, specific refresher training to its AMHP team relating to the gathering, weighting and recording of collateral information. iv. AMHPs are to be directed/instructed to record all relevant assessment referral and contact information on the AMHP assessment form. v. AMHPs are to be directed/instructed to record on the AMHP assessment form the reasons for a Nearest Relative request for an assessment in as much detail as possible. vi. The AMHP assessment form is to be updated to include an additional section for the recording of the views of relevant others or reasons for not consulting with them, and AMHPs are to be directed/instructed to complete this section in as much detail as possible. vii. AMHPs are to be directed/instructed to record all collateral information gathered and their consideration of that information in their decision making. They are to consider having face to face contact with the individual providing collateral information before concluding assessments, and to provide rationale if it is determined that it is not necessary, appropriate or possible in the circumstances. viii. AMHPs are to be directed/instructed to clearly document the reasons for progressing with the assessment or not. This includes full details of their discussions with medical professionals, such as any treating clinician/s, prior to a decision being made, and the rationale for the decision. ix. Relating to the criteria for detention in accordance with the 1983 Act, AMHPs are to be directed/instructed to clearly differentiate between and record when they are in the consideration stage and formal assessment stage. x. The AMHP assessment form is to be amended so that the analysis/comments section is positioned for earlier consideration so that there is oversight of the initial case actions for practitioners to review at an earlier stage. xi. The AMHP assessment form is to be amended so that the section referencing the doctors involved in the assessment process prompts the detailed recording of the doctors' individual views as to the individual's case and criteria for detention. The Council's Head of Adult Services has opened dialogue with Swansea Bay University Health Board's (hereafter "SBUHB") Service Group Director of Mental Health and Learning Disabilities with regard to the requirement for doctors to record their views/conclusions on the AMHP assessment form. xii. Audits of AMHP referrals and assessments are to be conducted quarterly for the first 12 months, then bi-annually from then on, depending on the findings of the initial quarterly audits. The audits will be undertaken by the Principal Officer for Mental Health Services with support from managers. "The second MATTERS OF CONCERN is as follows: It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur." The Council's response: This is a matter of concern for SBUHB and NHS Wales to primarily address, but the Council wishes to comment specifically in relation to access to its systems by Section 12 doctors. The general context of Health Board professionals accessing the WCCIS system is important to recognise. Whilst the Council holds the licence and, in effect, has "ownership" of the system, SBUHB has been committed to the WCCIS programme for a number of years and has actively been involved in transition and update activity. All professionals within the SBUHB mental health service can be granted user "read only" or "read/write" access to the WCCIS system upon request. At the point of transfer from the previous PARIS system to WCCIS, all active PARIS account holders, including SBUHB professionals, had accounts created on WCCIS and were granted access rights. A joint WCCIS Mobilisation Group was in place and hosted by SBUHB to facilitate the transition. It is a matter of SBUHB operational policy in terms of who should have WCCIS access rights and for what purpose. A new user request can be made directly to the Council's WCCIS Helpdesk or via SBUHB's service change lead. We understand that SBUHB's service change lead supports process mapping in relation to system access, and has a specific role to signpost teams and individual SBUHB users that require any access or technical support to the Helpdesk. User training can also be arranged via the Helpdesk, and there are user guides available. WCCIS Mobilisation Meetings between the Council and SBUHB is the forum by which any operational issues may be discussed. The other suitable forum would be the Divisional Board for Mental Health, which is chaired and lead by SBUHB, but attended by the Council leads. The Council also understands that there is a SBUHB Project Board that oversees the business case and full implementation of WCCIS within SBUHB. Specifically in relation to His Majesty's Coroner's matter of concern, Section 12 doctors are either directly employed by SBUHB or otherwise engaged by SBUHB on a non- employed/contractor basis. The Council's AMHP team chooses from an available list of Section 12 doctors provided by SBUHB. The Section 12 doctors, irrespective of their employment status, can have "read only" or "read/write" access to the WCCIS system where SBUHB requests it and subject to contractual arrangements being agreed as to the number of users requiring access. With regard to "read/write" access, any file can be added as long as it is an approved file type (e.g. Word, PDF, JPEG, etc.). This has always been the case since the system was introduced. The Council will continue to work with SBUHB via the various forums referred to above in order to ensure, as far as is reasonably possible, that the appropriate mental health professionals, deemed by SBUHB as requiring WCCIS access, is granted such access. Discussions have already taken place between SBUHB and the Council with the view to arranging for all patient clinical notes to be available across the relevant systems accessed by both organisations. We hope that our responses/actions outlined above assures you and Dr Harrison’s family that we have reflected on your concerns and provided reassurance as to our processes. Yours sincerely, Prif Weithredwr Chief Executive
gofalu am ein gilydd, cydweithio, gwella bob amser
caring for each other, working together, always improving
Rydym yn croesawu gohebiaeth yn y Gymraeg ac yn y Saesneg.
We welcome correspondence in Welsh or English.
Dyddiad / Date: 21st June 2024
To Kirsten Heaven, Assistant Coroner,
for the Coroner area of SWANSEA & NEATH PORT TALBOT
Dear Ms Heaven
RESPONSE BY SWANSEA BAY UNIVERSITY HEALTH BOARD TO REGULATION 28
REPORT TO PREVENT FUTURE DEATHS ISSUED IN THE INQUEST OF Dr NICHOLAS
HARRISION
Although this is a formal response letter as part of the Regulation 28 process, we would like
to start by reiterating our Health Board’s apology to the family for our role in the death of Dr
Harrison. We are deeply sorry for our failings in this case and recognise the enduring impact
they have had on the family. We are focused on learning from our failings and committed
to implementing the recommendations within the Regulation 28 report you issued.
This letter is written in response to the Report issued under paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013 dated notification dated 24th April 2024 wherein you identified the following
concerns and stated that it was your opinion there is a risk that future deaths will occur unless
action is taken.
Swansea Bay University Health Board sets out below the concerns and the action taken which
is within the power of the Health Board.
CORONER’S CONCERNS
Concern 1
“I heard evidence during the inquest that in January 2021, March 2021, and December 2021
the Harrison family made three formal requests for a mental health act assessment under the
Nearest Relatives (NR). On
in their capacity as
MHA 83 in respect of their son
Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swansea Bay UHB Headquarters,
One Talbot Gateway, Port Talbot, SA12 7BR
Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board
receipt of a NR request, the local social services authority (City and County of Swansea
(‘CCoS’)) is under a legal duty pursuant to s.13(4) MHA 83 to make arrangements for an
Approved Mental Health Practitioner (‘AMPH’) to consider the patient’s case as part of their
consideration as to whether to make an application for admission to hospital. The Mental
Health Act 1983 Code of Practice for Wales (‘MHACOP Wales’) states that in considering a
patients case an AMPH must come to their own independent view based on social and
medical evidence and that they should recognise the value in involving other people in the
decision-making process where that person is able to offer a particular perspective on the
patient’s circumstances and that they should consult wherever possible with other people who
have been involved in the patient’s care. In respect of the request in January 2021, I found
that the AMPH did not collect sufficient collateral information before visiting and assessing
case as sufficient collateral information was not obtained and
whilst he was in police custody as requested by the Harrison family in
in person where the requirement is that two doctors must attend to assess the
in person and prior to the formal assessment under the MHA 83 on 9 February 2021. I
also found that the assessment of 9 February 2021 was a formal assessment under the MHA
83 and that it did not comply with the MHA 83 as only one doctor and an AMPH attended to
assess
patient. This was not an emergency assessment. I found that in respect of the second NR
request (when
was in police custody in March 2021) there was a failure by the AMPH
to act in accordance with the s.13(4) MHA 83 duty because it cannot be said that the AMPH
adequately considered
considered prior to the decision by the AMPH not to undertake a formal mental health act
assessment on
their capacity as the NR. I found that the response of the AMPH service to the third NR
request from the Harrison’s on 19 December 2021 (which was to refuse to carry out a formal
mental health act assessment) was not in accordance with s.13(4) MHA 83 as no collateral
information was sought and what had been provided by the Harrison family was not afforded
sufficient weight with reliance being placed solely on the records on the system which were
out of date. I heard evidence during the inquest that a senior manager in the AMPH service
maintained to the Swansea University Bay Health Board (‘SBUHB’) that the assessment of 9
February 2021 complied with the MHA 83 (when it did not) and did not at any stage make
clear to the SBUHB that the AMPH service had not gathered sufficient collateral information,
including that suggested by the Harrison family, prior to assessing
I am concerned that an inadequate understanding within the CCOS AMPH service of the duty
to gather sufficient collateral information in the context of any assessment under the MHA 83
and / or inadequate systems being employed within CCOS in relation to this issue creates a
risk that information may not be captured and / or may be lost in relation to mentally unwell
individuals in the community where they may pose a risk to their own lives and / or the lives of
others and that this creates a risk that other deaths will occur.”
.
Swansea Bay University Health Board Response:
Whilst this concern relates to the actions of City and County of Swansea (CCOS) and not
Swansea Bay University Health Board (SBUHB), the two organisations are working closely
together, to ensure that all learning is identified to improve patient safety. A formal meeting
has been held between the Service and Head of Adult Services and Tackling Poverty from
CCOS, to identify specific actions.
A formal letter has previously been circulated (dated 3rd April 2024) to all clinical staff within the
Mental Health and Learning Disabilities Service Group in SBUHB. This letter from the Mental
Health and Learning Disabilities (MH&LD) Service Group Medical Director and Nurse Director,
highlights the responsibility of all clinicians to ensure that all plans of care are easily accessible,
caring for each other, working together, always improving
gofalu am ein gilydd, cydweithio, gwella bob amser
Page 2
shared with all the clinical teams and that robust and accurate records are maintained for all
clinical interventions.
Section 12 Approved Doctors (S12) are employed on an all Wales basis and are operationally
overseen by the All Wales Approval Manager for Approved Clinicians and S12 Doctors, who is
based within Betsi Cadwaladr University Health Board. The letter was previously circulated
within SBUHB only and has since been shared with the Mental Health Act team managers
within the other 6 Health Boards in Wales to share with the S12 Doctors, therefore covering the
All Wales list. In addition, the Mental Health Act Manager within SBUHB has been instructed to
send out this communication on an annual basis as a reminder of this and for any new S12
Doctors added to the list.
The training for S12 Approved Doctors is also coordinated by the All Wales Approval Manager
for Approved Clinicians and Section 12 Approved Doctors, and is facilitated throughout the
year. There is an initial two days training, followed by a one-day refresher training during the
final two years of their current approval period (5 years). The training is provided by a KC
Counsel and a Social Work Lecturer at Swansea University. The training incorporates an
understanding of the powers, functions and duties of Section 12(2) Doctors, Approved
Clinicians and others under the Mental Health Act 1983. The training is set within the context
of the wider legal, policy and guidance framework, which govern and affect situations
requiring the presence or intervention of an Approved Clinician.
The Health Board has been in contact with the All Wales Approval manager and shared the
concerns and the All Wales Approval manager has confirmed that the importance of gathering
collateral information prior to any assessment and ascertaining details from clinical records on
the history of both medical and social circumstances is included in the training programme.
Concern 2
“It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor
of a patient in a formal assessment under the MHA 83 where they are considering admission
to hospital must involve consideration by that doctor of all available relevant clinical
information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and
used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s
medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12
doctors who are not directly employed by them and / or are locum doctors. I also heard that
there is no system within SBUHB to ensure s.12 doctors are required to record the outcome
of their assessment when there is a decision not to admit a patient to hospital. I heard
evidence that there is no single digital record system / platform for Mental Health Services
and associated access for practitioners across Wales. I am concerned that there is a system
in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is
placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable
to view a patient’s medical records prior to an assessment under the MHA 83. I am
concerned that this creates a risk that assessments may be flawed and / or may not detect
that a person requires admission to hospital in circumstances where that patient may pose a
risk to their own life and / or to the lives of others and that this creates a risk that other deaths
will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s
medical records there is a risk that important information may not be documented which may
be relevant to an understanding of the risk a patient may pose to themselves or others thus
creating a risk that other deaths will occur.”
caring for each other, working together, always improving
gofalu am ein gilydd, cydweithio, gwella bob amser
Page 3
Swansea Bay University Health Board Response:
The Health Boards response to concern 2 covers three aspects:
• All Wales Digital Solution
Currently, there is not an all Wales digital solution for mental health records. Concerns
about this have been escalated within the health board, with partner organisations and on
an all Wales level. The design and procurement of an integrated system is being taken
forward via the West Glamorgan Regional Connecting Care Programme Board, with
Digital Health Care Wales (DHCW).
• Access to collateral Information
Regarding access to WCCIS for MHA Assessments, all S12 Drs employed by SBUHB will
be given read access to WCCIS to enable them to access information pertaining to the
patient being assessed under the MHA 83. AMHP also have full access to WCCIS. Both
organisations (SBUHB/CCOS) committed to reminding both the AMHP and the S12 Drs to
discuss patient history and any collateral information prior to the assessment taking place
who recognise the importance of an all Wales digital solution. The Health Board, in the
letter sent on 3rd April 2024, (referenced on page of this letter) covered this important
area.
• Recording of MHA assessments
All staff have been reminded (via letter circulated over email from the MHLD Service
Group Medical Director and the MHLD Service Group Nurse Director), that they have a
professional obligation and responsibility to record contemporaneously and to keep
accurate records of all their interventions with all patients.
S12 Doctors have been reminded of this obligation by means of the letter circulated, and
the inclusion within the training programme (as identified within the response to concern
1) of the requirement to make a record of the assessment made within the Mental Health
Act Assessment, the outcome and plan. After discussion with CCOS it has been agreed
that in relation to the Doctors recording Mental Health Act recommendations on client
records for when they decline to recommend admission, the AMHP Assessment Form is
being amended by CCOS to include a section for S12 Drs to make a direct entry to the
notes. As soon as this is received the Health Board will implement it. If there is no IT
access at the time of assessment this can be completed by the Doctor and added
retrospectively to the notes.
Concern 3
“I heard evidence that Ward F of Neath and Port Talbot hospital is being used as the Single
Point of Admission (‘SPOA’) for all adults requiring hospital admission in the locality for
assessment of their mental illness. I heard that Ward F is a 21 bedded unit and that the move
to using just Ward F as the SPOA (as opposed to three units which had been the practice)
was brought in during the Covid-19 pandemic to manage the spread of the Covid 19 virus but
that this change had been under consideration in SBUHB prior to the Covid-19 pandemic. I
heard that this has resulted in a significantly increased level of acuity on Ward F with a
significant increase in pressure on staff, a higher turnover of mentally unwell patients, and an
caring for each other, working together, always improving
gofalu am ein gilydd, cydweithio, gwella bob amser
Page 4
increased pressure on staff from, for example, the need to prepare paperwork for the Mental
Health Review Tribunal for Wales in a short period of time after admission. During the inquest
I heard evidence (and SBUHB accepted) that the risk assessment conducted on Daniel
during his time in Ward F was not adequate and that there was no assessment of Daniel’s
risk of absconding. I found that the pressure on staff in Ward F due to its use as the SPOA
impacted on Daniel’s care whilst he was on Ward F. I heard evidence from SBUHB that at the
time there was insufficient training on risk assessments in Ward F. I heard from SBUHB that
the current target is to ensure that 75% of staff on Ward F are trained in risk assessment by
the end of 2024. I am concerned that only having 75% of staff trained in assessing risk means
that risk may not be adequately assessed in respect of all patients on Ward F which raises a
concern that risk to self and / or others and / or the risk of absconding will not be properly
identified thus creating a risk that other deaths will occur. This is particularly so given the
increased rates of acuity in the patients on Ward F due to it being used as the SPOA. “
Swansea Bay University Health Board Response
The Mental Health and Learning Disability Service Group Learning and Development
Team have in place a program of training and monitoring for WARRN training, which will
ensure that the training levels are above 90% for staff working in the area. Since the
inquest additional and bespoke training has been provided for clinical staff on Ward F and
across the other 2 adult Mental Health inpatient wards. This was provided on 20th and 21st
May 2024 and again on 4th and 5th June 2024. Following these additional dates, the
current compliance for WARRN training for registered nursing staff on Ward F is 94% and
the overall percentage for Clinical staff on Ward F is 96% (this includes psychology,
Occupational Therapy and Psychiatry). It would not be possible to achieve 100%
compliance due to staff absence (e.g. maternity leave) and staff turnover. Training
compliance will be monitored by the Service Group Directors through a monthly
performance meeting.
Concern 4
parents (including the deceased, Kim)
had a diagnosis of chronic psychotic disorder, had
“During the inquest I heard that in 2021
became concerned that their son was not receiving appropriate care and treatment from
SBUHB in circumstances where
become lost to services after his consultant psychiatrist had unexpectedly left, and appeared
to be suffering from a relapse in his mental health condition. Over five months (February –
June 2021) the Harrison raised their concerns in writing to SBUHB in documents detailing
their perceived failures around SBUHB’s management of
concerns raised in respect of the CCOS AMPH service). These concerns were first raised in
writing in February 2021 with various updated versions of the written concerns being send on
multiple occasions to SBUHB, including to the SBUHB Interim Chief Executive, the Medical
Director, the Nurse Director for the Mental Health & Learning Disabilities Service Group and
other members of SBUHB’s senior management team. In June 2021 the Harrison’s submitted
a formal complaint to SBUHB after being requested to do so by the SBUHB Interim Chief
Executive, who then commissioned an independent consultant psychiatrist to review the
Harrison’s complaint and provide an expert opinion. This expert report was received and sent
to the SBUHB Interim Chief Executive in draft in November 2021 as he was directly managing
the complaint. This report was critical of certain aspects of SBUHB’s management of
and raised queries for further clarification but no action was taken for 10 weeks following
receipt of the expert report. I heard that this report was not shared with the consultant
mental health (alongside
caring for each other, working together, always improving
gofalu am ein gilydd, cydweithio, gwella bob amser
Page 5
) at any point prior to Kim’s
admission to Ward F. Both SBUHB internal investigations did not look
care and treatment in the community (which had formed the basis of
psychiatrist whom it criticised (and who had assessed
death. I found that this was a significant lost opportunity for SBUHB to reflect on some
independent scrutiny that had been brough to bear on their care and treatment of
before Kim’s death. In the inquest I found that I had not received a satisfactory explanation for
this 10-week delay and for why the report had not been shared with the treating consultant
psychiatrist. Following Kim’s death SBUHB undertook a Serious Incident Review which was
then elevated to a formal Patient Safety Incident Investigation which was signed off in August
2023 by the SUBHB Medical Director and the SUBHB Nurse Director of the Mental Health &
Learning Disabilities Service Group (17 months after Kim’s death). I heard evidence that the
Harrison family met with SBUHB after Kim’s death and asked them to include within the
formal investigation the substance of their complaint and not to limit the investigation to the
time following
at any aspect of
the complaint made by the Harrisons in June 2020 and which was subject to some criticism
by the independent expert). Both investigations commenced their investigations at the point at
which
was taken by police officers to Cefn Coed hospital and then admitted to Ward F.
SBUHB responded to the Harrison’s letter of compliant of June 2021 on 8 November 2023.
SBUHB did not conduct a formal investigation into the Harrison’s compliant. I was told by the
consultant psychiatrist, who was the focus of part of the Harrison’s complaint, and who had
been criticised by the external expert, that he has not been interviewed by SBUHB about his
involvement in
introduced a PSIIT Investigation Protocol to ensure effective and consistent management of
patient safety incidents within SBUHB. However, under this new policy the same senior
leadership team who limited the scope of the Patient Safety Investigation into Kim’s death in
the way that I have described remain the team who decide on the scope of patient safety
investigations under the new policy (the Mental Health & Learning Disabilities Service Group
Senior Team). I am concerned that if there is a reluctance within SBUHB to conduct robust,
transparent and timely investigations into complaints in line with the formal complaints
process and if there is a reluctance within SBUHB to ensure that a formal patient safety
investigation following a death and / or patient safety incident is conducted in a timely manner
and is sufficiently wide in scope, including reflecting on and incorporating the concerns from
the affected family member, then SBUHB will not learn lessons from patient safety incidents
and that this creates a risk that deaths will continue to occur.”
care before or after Kim’s death. I have heard that SBUHB have
Swansea Bay University Health Board Response
Serious Incident Reviews in Mental Health and Learning Disability Service Group are
undertaken in line with the NHS Executive National Policy on Patient Safety Incident Reporting
and Management 2023. Within the policy a mental health homicide is when a homicide has
been committed, and the alleged perpetrator has been in contact with primary, secondary or
tertiary Mental Health Services within the last year. In these circumstances, the incident is
considered to be a ‘Must Report’ and is reported to the NHS Executive as a National
Reportable Incident.
In these circumstances a Serious Incident review is commissioned to look at the care of the
patient. The process requires a strategy meeting where any immediate risks are identified and
the actions needed to resolve them, the scope of the review is determined and any requirement
for support of staff involved.
caring for each other, working together, always improving
gofalu am ein gilydd, cydweithio, gwella bob amser
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Following the strategy meeting, the review is undertaken by a trained investigator supported by
clinicians who were not involved in the care of the patient. When a patient has died, the family
are made aware of the review and asked if they would like to contribute to the scope of the
review in line with the Duty of Candour Statutory Guidance 2023.
The final stage is that the review is presented to the Serious Incident Group chaired by the
Medical Director for Mental Health & Learning Disabilities. The group is made up of clinicians
from across Mental Health and Learning Disabilities Service Group where the learning
identified is discussed and action(s) to improve the service allocated.
Complaints are managed via the NHS (Concerns, Complaints and Redress Arrangements)
(Wales) Regulations 2011. This requires the investigation of all concerns to be recorded and an
investigation undertaken into the care provided. Formal response to complaints, to families or
carers, requires the consent of a patient. However, all concerns are investigated, regardless of
consent, to gain assurance that the care provided was appropriate and identify any learning to
take forward.
The outcome of a complaint investigation is that where learning is identified, actions are put in
place to address the issues highlighted.
Both processes require a detailed review of the care provided to be undertaken, proportionate
to the concerns identified.
The Regulations and Policy for the completion of serious incident reviews and complaints, while
different, both processes can and do run alongside each other with shared outcomes and
learning.
Although the external report findings had been shared with the Clinician referred to in the concern
identified by the Coroner, the Health Board accepts it should have been shared with the Clinician
involved in a more timely manner. The Health Board has reflected and reviewed its processes
and will share clinical reviews, obtained to support the investigation of incidents and complaints,
with the Clinicians involved within 7 working days. This will enable further discussions to take
place and reflection undertaken in the care provided.
Review Commissioning and Purpose
As a commitment to ensure our internal processes remain robust, open to scrutiny, and are
responsive, we commissioned a review by the Director of the Research, Development,
Innovation, Improvement and Learning Hub of the governance in respect of the service’s
serious incident reviews.
The report provided a summary of the current processes established through this review and
provided a number of recommendations which the Service Group Directors are set to review in
July 2024 and prepare an implementation plan. One area of the Report focuses on is the
Investigative process and recommendations around:-
o Focus on the role of the investigator, clinical advisors and the function of the
report review meetings.
Involvement of families and significant others
o
o Differentiating the levels of investigation and proportionate reviews
caring for each other, working together, always improving
gofalu am ein gilydd, cydweithio, gwella bob amser
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In addition, a focus on ongoing learning and improvement is included and this will ensure
risks identified are addressed and followed up following a patient safety incident.
The Health Board accepts that the complaints made by the family in May 2021 were not
addressed in a timely manner and outside of a co-ordinated approach. All complaints received
by the Health Board are investigated under the NHS (Concerns, Complaints and Redress
Arrangements) (Wales) 2011 and Putting things Right Guidance on dealing with Complaints
since April 2011.
In accordance with the requirements of the Regulations the Health Board’s arrangements for
the handling and investigation of concerns ensures that complaints are formally logged and
acknowledged within the prescribed timescales of 5 working days. The Health Board ensures
timely and full investigation of complaints in an open and transparent manner in line with Health
Board values.
The Health Board ensures that the expectation of the complainant is met and that they are
involved with the complaints process and kept fully updated with developments. All
complainants are advised that they can seek support and assistance from Llais, the patient
advocacy service. Complainants are provided with the contact details of the complaint
investigator so that they may contact them at any time during the process.
Complainants will receive a timely and appropriate response within the bounds of receiving the
appropriate consent. If a complainant raises a concern on behalf of a patient then appropriate
consent is always sought. Under the NHS Concerns, Complaints & Redress Arrangements
when a breach of duty of care is identified consideration is always undertaken in terms of an
offer of redress if a qualifying liability is established.
The Health Board ensures that appropriate action is taken following the outcome of complaints
investigations. Shared learning is of key importance to the Health Board in terms of learning
and assurance to ensure that lessons are always learned from complaints.
The Health Board has reviewed the Standard Operating Protocol document which outlines the
process of managing a complaint which has already been identified as an incident which
ensures that incidents and complaints are managed together or individually within a timely
manner ensuring that a full investigation is undertaken, and shared learning identified. If a
complaint is received which raises issues that are not being considered within the incident
process then a complaint will be opened and investigated fully. If a complaint raises the same
concerns as the scope of the incident, then the complaint will be investigated as part of the
incident process and will be fully addressed within the incident report. For assurance, please
find attached the SOP document.
The Health Board is committed to ensuring a co-ordinated approach when an incident being
investigated and when a concern is received by the Health Board. The Health Board’s
approach is to investigate once and to investigate well in accordance with the Regulations and
the Duty of Candour Statutory Guidance. Going forward the Head of Concerns Assurance will
carry out a quarterly review of SI investigations and complaints to ensure that a coordinated
approach is being delivered and investigations are being progressed in line with process.
caring for each other, working together, always improving
gofalu am ein gilydd, cydweithio, gwella bob amser
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Concern 5
“I heard evidence from a SBUHB consultant psychiatrist that where a mentally unwell person
in the community refuses mental health care and treatment and / or where they are hard to
engage in mental health services such persons can be referred for assertive outreach in
SBUHB to facilitate their engagement with services, but only if that person consents to such
outreach. I also heard that assertive outreach services are available to those under secondary
mental health care in SBUHB but that to be accepted for secondary mental health care a
patient must consent to first being assessed. I heard that the referral forms for assertive
outreach require a referrer to indicate whether a patient is consenting and if they are not
consenting then the referral will not be accepted. I also heard that when a mentally unwell
person refuses to engage with mental health services in the community it can be a feature of
their mental ill health and an indication of their lack of insight into their illness. I am concerned
that if consent is required before a mentally unwell person in the community is able to receive
assertive outreach then there may be a gap in the mental health services within SBUHB that
creates a risk that mentally unwell people will remain in the community without access to
mental health services in circumstances where they may pose a risk to their own life or the
lives of others. This is because whilst they may need access to mental health services, they
may be too unwell to consent to that access. I am concerned that if there is such a systemic
deficiency within SBUHB in relation to hard to engage mentally unwell people in the
community then this creates a risk that deaths will continue to occur. “
Swansea Bay University Health Board Response
The core role of the Assertive Outreach Team (AOT) is to work with patients who are difficult
to engage or demonstrate poor compliance with care & treatment plans. Referral to the AOT is
not dependant on the patient giving consent to such referral. A monthly monitoring system is
now in place to scrutinise the activity of the AOT. This includes recording the reason for any
individual referral not being accepted by the team, the rationale for declining and a review and
any actions in regards to this decision making. This will allow for more oversight; and a deeper
understanding of any referrals not being accepted as part of our quality assurance process.
The AOT Operational policy was reviewed earlier this year and ratified in March 2024. This
review included the amalgamation of the policies for both the Neath Port Talbot and Swansea
AOT. The role, function and purpose of the AOT is clearly set out within the policy, including
the process of referral and eligibility criteria. This has been recirculated to all referring clinicians
and the wider teams.
In conclusion, we recognise the devastating impact of the events on the family, which was
clearly evident to those staff who attended Court during the inquest. We would like to reiterate
our Health Board’s apology to the family and assure you that we have fully taken on board the
recommendations you have made within the Regulation 28 Report.
caring for each other, working together, always improving
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We realise that these actions do not change what happened to Dr Harrison but hope this
response provides you and the family with assurance that our failings have been properly
recognised and addressed.
If you would like further information on the Health Board’s response or actions taken, then we
would be happy to assist you further.
Yours sincerely,
INTERIM CHIEF EXECUTIVE
DIRECTOR OF CORPORATE GOVERNANCE
caring for each other, working together, always improving
gofalu am ein gilydd, cydweithio, gwella bob amser
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gofalu am ein gilydd, cydweithio, gwella bob amser caring for each other, working together, always improving Rydym yn croesawu gohebiaeth yn y Gymraeg ac yn y Saesneg. We welcome correspondence in Welsh or English. Dyddiad / Date: 3rd April 2024 TO : All Clinical Staff Please reply to: Mental Health and Learning Disability Service Group Management Centre Cefn Coed Hospital Waunarlwydd Road Cockett SWANSEA SA2 0GH Dear all In our ongoing involvement in an inquest at Swansea Coroner’s Court, a further matter has been identified which we want to bring to your attention as a timely reminder regarding our responsibilities as professionals in the care of individuals who are in receipt of care from our services. It has been noted in this particular case that there was a plan for intervention when the patient represented to the service. It appears that this plan was recorded in a set of clinical notes as an integral entry to a review, which would mean that any future clinician would need to look back through the notes to know what the plan was to be. With immediate effect: • Please ensure that any plan of care is placed at the front of clinical notes or where a digital record is used (WCCIS) that the plan of care is on the digital front page. • Please ensure that in addition to the above, the plan of intervention is shared with relevant members of the team directly so that they are briefed – in the community this will be through clinical team meetings and directly with key staff, in inpatient settings this will be through MDT meetings and Nurse handover. As per our previous communication: Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR / Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR Bwrdd Iechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd Iechyd Lleol Prifysgol Bae Abertawe Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board • We are reminded that it is imperative that as professionals (Medicine, Nursing, Psychology and Allied Health Professional) we ensure that we keep robust and accurate information regarding any assessment or clinical intervention that we undertake with individual patients, and that we ensure that all significant detail, particularly that which will inform the assessment process and the ongoing management of risk is shared with all those involved in the patient’s care. We thank you for all the dedication you take in your daily commitment to the Service Group and the patients who touch our services and ask that you note the above as timely reminders of our professional responsibilities in offering the best service that each of our patients deserve. Many thanks. Yours sincerely NES NURSE DIRECTOR MH AND LD SERVICE GROUP MEDICAL DIRECTOR MH AND LD SERVICE GROUP caring for each other, working together, always improving Page 2 gofalu am ein gilydd, cydweithio, gwella bob amser
Cyfarwyddwr Cyffredinol Grŵp Iechyd, Gofal Cymdeithasol a'r Blynyddoedd Cynnar / Prif Weithredwr GIG Cymru Director General Health, Social Care & Early Years Group / NHS Wales Chief Executive Kirsten Heaven Assistant Coroner Coroner’s Office The Guildhall Swansea SA1 4PE Dear Ms Heaven 14 June 2024 I am writing in response to your letter of 26 April 2024 in which you provided me with a copy of a Regulation 28 Report (‘the report’) following the conclusion of the inquest into the death of Dr Nicholas Kim Harrison. This is a tragic case, and my sincere condolences go to all those affected. In the report, the coroner noted several serious concerns relating to the care Daniel Harrison received, as well as actions both Swansea Bay University Health Board (‘the UHB’) and the City and County of Swansea Local Authority could have taken prior to the death of Dr Nicholas Harrison. I note the report has been sent to the UHB and the City and County of Swansea for a response and action and I expect them to provide responses within your timescale that address the concerns raised. I am issuing a separate Welsh Government response to ensure lines of accountability are clear. I take the concerns raised in the report very seriously and I would like to set out the actions being taken. In brief, since devolution began in 1999, the Welsh Ministers set the policy and strategic framework within which the NHS in Wales should operate and determine the strategic distribution of overall NHS resources in Wales. Various statutory duties are imposed on the Welsh Ministers under sections 1, 3 and 6 of the National Health Service (Wales) Act 2006 (“the Act”), including the duty to provide certain services throughout Wales, to such extent as they consider necessary to meet all reasonable requirements. These services include such other services or facilities for the prevention of illness, the care of persons suffering from illness and the after-care of persons who have suffered from illness as they consider are appropriate as part of the health service. The Welsh Ministers have directed that Local Health Boards (“LHBs”), such as Swansea Bay UHB, perform those functions on their behalf. NHS Trusts provide Parc Cathays ● Cathays Park Caerdydd ● Cardiff CF10 3NQ Judith.Paget001@gov.wales Gwefan ● website: www.gov.wales goods and services for the purpose of the health service in Wales. NHS Trusts in Wales also look after public health, and ambulance services as well as cancer and blood services. The Welsh Ministers set the policy and strategic framework for the health service in Wales. The Welsh Ministers do not themselves plan or commission services, and do not themselves take clinical decisions about treatment for individuals nor do they provide services. NHS Wales bodies are accountable to the Welsh Ministers for the performance of their statutory duties. LHBs are responsible for planning, commissioning and delivering services for the population of its area within the national policy framework set by the Welsh Ministers. NHS Trusts are responsible for the delivery of services across Wales within the national policy framework set by the Welsh Ministers. LHB and NHS Trust chairs are appointed by the Cabinet Secretary for Health and Social Care (“the Minister”) and are directly accountable to the Minister for the delivery of services for their LHB or Trust. I am the Director General for Health, Social Care and Early Years Group (“HSCEY”) within the Welsh Government and the NHS Wales Chief Executive. In this dual role, I am responsible for overseeing the delivery and performance of the NHS in Wales and ensuring an effective NHS planning process is in place. I am also responsible for: implementing ‘A Healthier Wales’ as the long-term plan for health and social care in Wales; ensuring progress and collaboration in respect of Prosperity for All and the First Minister’s priorities for government. The Welsh Government has set up a National Strategic Programme for Mental Health in May 2024. This is being led by the NHS Executive, our delivery function within NHS Wales. An immediate focus for the mental health programme was the establishment of a Mental Health Patient Safety Programme, which all health boards are actively engaged in. There are five workstreams within the patient safety programme which cover procedural, relational, environmental, psychological and discharge areas. The patient safety programme is focussing on improvements within several wards across health boards in Wales, including Ward F at Neath Port Talbot Hospital. The programme will set national standards for risk assessment and discharge planning. Planning meetings with each health board will be completed by mid-July 2024. Through our assurance functions at Welsh Government, we will ensure that recommendations made following the inspections by HIW are followed through and actioned. I remain concerned about the failings of the UHB to provide effective and timely care to Mr Harrison, I am writing to the UHB to seek assurances against several measures, including the: • number of patients offered a post discharge follow up within 72 hours, and the percentage that received one; • number of staff trained in appropriate risk assessment and risk management; • number of wards with anti-ligature assessments completed in last 6 months; 2 • number and % of inpatients with updated Care Treatment Plans (CTP) within 72 hours of admission - target of 95%; and • number and % of patients with up-to-date risk assessments and risk management plans within 24 hours of admission - target of 100%. This will be monitored at regular intervals through the UHB monthly Integrated Quality, Planning and Delivery meetings. I will also seek assurances about how other health boards are performing against these metrics. I am also aware that Digital Health and Care Wales are developing an electronic patient record that will help in the sharing of patient information. The NHS Oversight and Escalation Framework, issued by the Cabinet Secretary for Health and Social Care at the end of January 2024 sets out the process by which services of concern can be escalated. I would like to thank you for bringing these issues to my attention. I hope this information is helpful. Yours sincerely 3
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