Erin Tillsley

Mr Darren Stewart OBE 
HM Area Coroner for Suffolk 
Ipswich Coroner’s Court 
Beacon House  
Whitehouse Road 
Ipswich  
Suffolk  
IP1 5PB 

Sent by email only: 

Dear HM Coroner 

Legal Services 
West Suffolk NHS Foundation Trust 
Hardwick Lane 
Bury St Edmunds 
Suffolk  
IP33 2QZ 

Tel: 

Email: 

18 December 2024 

Re:  Response relating to Regulation 28 Report into the death of Erin Louise Tillsley  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12 November 
2024 concerning the death of Erin Tillsley on 14 July 2023. This is a joint response prepared 
on  behalf  of  both  West  Suffolk  Hospital  NHS  Foundation  Trust  (WSFT)  and  the  Integrated 
Care Board (ICB). 

For  reference,  the  specific  work  relevant  to  WSFT  follows  first  and  from  page  5,  the  ICB’s 
specific reply is set out in full. 

WSFT 

In advance of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to Erin’s family and loved ones. WSFT are keen to assure the family 
and HM Coroner that the concerns raised about Erin’s care have been listened to and reflected 
upon. Whilst the inquest concluded on 31 May 2024, WSFT have been proactive in continuing 
improvement  work  in  respect  of  the  access  to  Mental  Health  Services  since  that  time  and 
specific details of that work, and the further work planned, is set out below. 

Your  Report  specifically  raises  concerns  over  the  failure  to  ensure  that  the  Emergency 
Department (ED) followed NICE Guidance (NG225) dated 7 September 2022 regarding the 
management  and  assessment  of  patients  presenting  with  signs  of  self-harm,  and  that  you 
received evidence during the course of the Inquest that neither the NICE Guidance, nor the 
SNEE/SCC  Policy  (Suffolk  and  North  East  Essex  Health  &  Social  Care  Protocol  for  the 
Support  of  Children  and  Young  People  in  Crisis)  were  applied  in  relation  to  the  care  and 
treatment extended to Erin. 

Please find below details of the action taken to date to address this concern, as well as some 
additional information regarding how the referral process works:  

        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  The WSFT Mental Health Liaison Team work closely with all clinical staff across the 
hospital. For those patients who attend ED with a mental health need, the aim is for 
the MHLT to review the patient within one hour. For those patients already admitted to 
the wards, they are seen within 24 hours.  

WSFT’s policy: Mental Health – supporting patients with their mental health (PP459) 
specifically highlights that:  

“All  patients  who  attend the  hospital  who  have  self-harmed  should  be  offered  to  be 
seen  by  the  MHLT  as  per  Nice  Guideline  (NG225)  Self  Harm:  assessment, 
management and preventing recurrence. 

The  service  provides  mental  health  assessment  and  support  for  service  users  who 
have attended hospital to access mental health services or those with both physical 
and mental health difficulties. This is not a Mental Health Act Assessment (see section 
Care under the Mental Health Act (1983)). The team will meet with patients to explore 
their mental state and will collaboratively create a care and risk management plan that 
helps to improve their mental health. This information will be recorded on E- Care. 

The service is available 365 days per year, 24/7 and is age inclusive. 

Referrals can be made to the Mental Health Liaison Team via E-Care or by telephoning 
01284 713386/713391.” 

We hope this reassures HM Coroner that WSFT staff are aware of the NICE guidance 
and the SNEE/SCC policy and continue to apply it regularly. For added reassurance, 
a review of WSFT data regarding referrals of patients aged under 18 accessing mental 
health services at WSFT confirms the following: 

Year 

2023 

2024* 

*YTD 

ED Referral 

Ward Referral 

Total 

313 

287 

64 

85 

377 

372 

Sadly, what this data shows is that every day a patient under 18 is referred by ED or 
the ward to the MHLT for specialist input and support. Whilst terribly sad, this does 
show that the referral system is working and WSFT staff do have a low threshold for 
making referrals so that specialist input from the MHLT can be provided. 

2.  The reason a MHLT referral was not made in Erin’s case was because of an error of 
clinical  judgment.  Staff  believed  that  Erin’s  case  was  one  of  an  accidental  not  an 
intentional  overdose.  Therefore,  they  believed  a  MHLT  referral  was  not  needed. 
Hindsight confirms that was incorrect and our work has been focused on helping staff 
make the right clinical decisions first time in future. That work, led by the Mental Health 
team and ED Matrons has consisted of the following steps: - 

        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a.  additional reminders sent to the whole team about having a low threshold for 

referrals to MHLT.  

b.  Additional training – this is targeted at specific staff groups for maximum effect: 

Adult ED Nurses have bespoke mandatory MHLT training package run by the 
MHLT.  

Junior doctors have induction training every 4 months as new cohorts join us 
and the Head of Mental Health will lead on that training moving forwards. The 
focus on the training is for staff to feel encouraged and supported to have a low 
threshold  for  suspecting  a  mental  health  condition/illness  and  for  making  a 
referral. 

Paediatric ED Nurses have been provided with additional training to make sure 
staff know when an automatic referral to the MHLT has been made and how to 
use  the  new  triage  form  (discussed  below).  This  is  in  addition  to  the  mental 
health training that is part of the new induction training for all new ED nurses. 
The  focus  of  the  training  is  on  the  team  working  together  and  nurses  are 
encouraged  to  ask  doctors  to  consider  making  a  referral  if  they  have  any 
suspicions. The above data confirms this is happening.  

3.  To further support staff to make the right decisions in future, WSFT’s policy: Mental 
Health  –  supporting  patients  with  their  mental  health  (PP459)  has  been  updated  in 
August 2024.  A new section 5.3 has specifically been added, focussing on how the 
policy applies to emergency admissions, an extract is below: 

“5.3. Emergency Admissions 
Patients admitted through ED will be triaged using the Manchester Triage Tool. If the 
patient presents following for example, overdosing and self-harm this will then trigger 
a  bespoke/extended  patient  safety checklist  which  provides  a  closer  assessment  of 
the  patient’s  mental  health  risk  state.  Part  1  of  the  Mental  Health  Risk  Assessment 
should also be completed which is triggered on E care. 

If  the  patients  are  assessed  as  vulnerable  or  at  high  risk  to  self  or  others  the 
“Observation of patients: One to one “Clinical guideline must be followed, to ensure 
that  their  safety  and  safety  others  is  met.  Observations  will  be  recorded  on  the 
observation form (Appendix 1). 

Whilst being cared for in ED staff must ensure that the patient isn’t placed in a high-
risk ligature area (as per ligature assessment) and complete the environment safety 
checklist (Appendix 2). 

Waiting can be difficult for anyone who is ill or in pain, the patient may find the waiting 
extremely difficult, and this can lead to additional problems, for example, ‘behaviours 
which  may  challenge’.  ED  staff  should  consider  offering  a  quieter  waiting  area  with 
clear information to the patient and their family/carer if they are with them. 

        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A safe room is available to be used by the MHLT for assessing the patient. This meets 
the PLAN standards: 

•  Patients without a medical need will be referred directly to the MHLT. 
•  Patients with a medical need will be referred to the MHLT once assessed as 
being medically fit enough for their mental health to be assessed. The MHLT 
will assess the patient within one hour.” 

4.  Further work following a review of Erin’s case by the ED team has resulted in the triage 
process  discussed  in  point  3  being  extended  to patients  under  18.  The Manchester 
Triage system used for suspected mental health conditions was originally designed for 
adult  patients  and  has  been  working  successfully for  some  time.  However,  that  has 
been adapted and extended for use in under 18’s care. Briefly there are 5 categories 
within  the  triage  process  that  trigger  automatically  at  the  point  of  triage  for  MHLT 
review/referral. These include patient’s that present with an overdose. This leads to an 
additional assessment by the triage nurse at that time and, once completed, that sends 
an alert to the MHLT for them to complete part 2 of the referral. Examples of the new 
process and subsequent risk assessments are included in Appendix 1. The categories 
are highlighted red in the boxes on the form. This process has been developed over 
the  summer  and  has  now  been  included  on  the  electronic  patient  record  system  – 
Ecare. It went live two weeks ago.  

5.  Whilst safety netting did work in Erin’s case, as the safeguarding team reviewed her 
case the following day and made contact with the GP so that further assistance could 
be provided, during the reviews after her sad death, we have identified the opportunity 
to improve the safeguarding process further. There is now a triage for safeguarding 
which allows them to prioritise patients attending with a mental health condition which 
are graded as red so that they are reviewed as a priority.  

6.  All under 18’s attending ED also have their discharge letter sent to the GP and school 

nurse, or if under 5 the Health Visitor, automatically in every case.   

Patient Safety Review & Learning  

WSFT also undertook a Patient Safety Review, which was completed on 24 October 2023. 
This  proved  the  catalyst  for  further  review  and  discussion  and  helped  to  bring  together  a 
number of projects and workstreams, discussed and highlighted above. Policies have been 
reviewed, training refined and extended, triage forms changed, and additional safety netting 
put into place The report was also shared with external partners and incorporated into their 
wider review. 

Future Action and Proposed timetable for implementation 

As part of the constant evolution of Mental Health Services in acute care, the Mental Health 
team, led by Natalie Bailey (Head of Mental Health at WSFT), confirms that the children and 
young people in crises protocol is currently under review by SNEE (Suffolk and North East 
Essex Integrated Care Board). Currently there is a consultation exercise underway with all key 
stakeholders, including WSFT, Norfolk and Suffolk Mental Health trust, parents, service users, 
ESNEFT and the ICB. This consultation and review will be completed next year and a working 
group will be established thereafter at WSFT to implement any changes. 

        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In order to minimise harm and prevent occurrences like this happening in future, WSFT will 
continue to work with all system partners, both to monitor and review performance as we look 
for new ways to address the difficulties treating this cohort of patients.  

ICB 
The  ICB  would  like  to  begin  its  part  of  the  formal  response  by  extending  its  deepest 
condolences  to  Erin’s  family.    The  concerns  within  the  Regulation  28  report  have  been 
carefully reviewed. 

For ease of reference, the concern relating to the ICB indicated that neither the NICE guidance 
nor  the  Suffolk  and  North  East  Essex  Health  and  Social  Care  Protocol  for  the  Support  of 
Children and Young People in Crisis was applied in relation to the care and treatment provided 
to Erin during her attendance at West Suffolk Hospital. 

Response: 
The ICB, in partnership with its provider services and system partners, regularly reviews the 
Suffolk and North East Essex Health and Social Care Protocol for the Support of Children and 
Young  People  in  Crisis.  This  is  to  ensure  it  contains  the  latest  guidance,  evidence-based 
practice,  configuration  of  local  services,  children  and  young  people’s  (CYP)  mental  health 
services,  and  support  for  our  clinicians  in  delivering  care  for  CYP  in  crisis.  An  update  is 
currently underway, which the ICB will share widely on completion, seeking robust assurance 
of local implementation across its services.  

The ICB has forums in place to review and monitor all Regulation 28 reports. This will include 
the actions taken for improvement as identified in this response.  

Thank  you  for  bringing  this  important  patient  safety  issue  to  our  attention.  We  hope  this 
information assists to address your concerns and please do not hesitate to contact us should 
you need any further information. 

Yours sincerely 

Yours sincerely  

Chief Executive, WSFT 

Chief Executive, SNEE ICB 

Encs – Appendix 1 Triage and Assessment forms 

        
 
 
 
 
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Appendix 1