Jean Pike

Bwrdd lechyd Prifysgol Bwrdd lechyd Prifysgol Bae Abertawe
ee Swansea Bay University Health Board.

Swansea Bay University
“eanmece Un Porthfa Talbot | One Talbot Gateway
Pare Ynni, Baglan | Baglan Energy Park
Port Talbot SA12 7BR

Ff6én Phone: 01639 683 334

yMP EE

Dyddiad / Date: 30/04/2025
Ein Cyf / Our Ref:

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 JEAN PIKE

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 7" March 2025 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

That Jean Pike was discharge from Ward F of Neath Port Talbot Hospital on two occasions
prior to her death by a consultant psychiatrist and that prior to the decision on both
occasions there was no multi-disciplinary meeting between the consultant on Ward F and
the professionals directly involved in caring for Jean in the community about Jean’s mental
health and the risks she posed to herself in the community. This was in circumstances
where the consultant knew before the decisions to discharge that these professionals,
which included Jean’s care co-ordinator, were clearly stating that they were extremely
concerned about Jean’s mental health and that they did not consider that they could keep
Jean safe in the community.

The coroner’s expressed a particular concerned by the evidence | heard from Jean’s care
co-ordinator that care co-ordinators are rarely, if ever, consulted by consultant
psychiatrists in Ward F of Neath Port Talbot Hospital before a decision is made to discharge
a patient/ person under secondary mental health care.

Concerned that if there is a lack of clarity or a reluctance in Ward F at the consultant level
to engage with care co-ordinators and professionals in the community (and before
decisions are made to discharge) there is a risk that the concerns of the professionals
managing a patient/person under secondary care will not be adequately considered in the

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi.

We welc,

CadeiryddiChair: | Weithredwr/Chief Executive: |

agpondence in Welsh or English. Welsh tanguage correspondence will be replied ta in Welsh, and this will not lead to a delay.

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot; Port Talbot, SA12 7BR 4
Bwrdd lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe , ry

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board

decisions made by Ward F clinicians. This also creates a continuing risk to life as it may
lead to risk being ignored or not properly considered by Ward F.

Swansea Bay University Health Board Response:

Discharge processes within the adult mental health wards have been reviewed over the last three
years and Terms of Reference were developed for the Multi-Disciplinary Team (MDT) Ward
meetings in April 2022. The MDT meeting is held on a weekly basis, with the focus being to work
collaboratively with colleagues in the Community Mental Health Services and other
agencies/providers to provide holistic and patient centred care. The Terms of Reference for the
MDT meetings and review process sets out the purpose and expectation of all parties within this
process; including collaboration with care coordinators, families, and other agencies. Prior to each
MDT meeting, a communication is sent to all Integrated team managers for CMHTs (this includes
the Local Authority and’ Health manager), informing them of the MDT meeting agenda. Care ~
Coordinators are able to attend to participate in the review and discussion of their patient(s)
through making an appointment with the ward medical secretary. However, the CMHT
representative at the meeting also acts as a conduit to cascade information and MDT decisions
back to the team and individual care coordinators. Care coordinators also take opportunity to
contact the ward for updates on patients outside of these formal meeting.

Within the adult Mental Health services, a weekly discharge planning meeting is held, where all
inpatients progress and discharge plans are discussed and prioritised. Attendees at this meeting
are representatives from each of the inpatient and community teams. The purpose of this meeting
is for information sharing, working collaboratively to inform effective patient flow and discharge
planning through the service.

There are going to be times where patients are appropriate for discharge in circumstances outside
of the above timeframes; such as a short admission, in this situation and for planned discharged,
the utilisation of a discharge checklist ensures that there is effective communication. and
collaboration with all parties. The purpose of the Pre-discharge checklist is to provide an overview
of the necessary actions required in preparation for.a patient discharge. The checklist includes
the required stakeholders who need to attend, such as family/carer or advocacy, care coordinator,
care providers and any other agencies involved. Other aspects of the checklist include social
circumstances, occupational therapy needs, safeguarding, follow up from the Crisis resolution and
home treatment team, and take-home medication requirements. The checklist provides a prompt
to the ward team to ensure the care coordinator is involved in the patient’s discharge. In addition
to this, there is also a patient discharge pack which is provided, which includes information for the
patient, family or care provider on discharge and ongoing support and signposting. The Pre-
discharge Checklist was revised and improved in July 2022. Assurance around the effective
implementation and use of the Pre-discharge Checklist is reviewed as part of a weekly audit of
clinical records. The findings are shared with the Ward Manager. and Clinical Lead and any
improvements implemented.

Discharge planning has been a focus of a:current clinical audit that is being undertaken by the
Quality Improvement and Practice Development teams. This audit is looking at Discharges from
the Adult inpatient Wards against the guidance identified in NG53 Transition between inpatient
Mental Health Settings and Community or Care home settings. This audit commenced in March
2025 and the findings are planned to be presented in July 2025.

MHLD Services in SBUHB are actively involved in the National Patient Safety Programme. This
is a programme of work led by the NHS Wales Executive Team, and includes the safe discharge
work stream. This forum is developing a set of national standards around discharge, and includes
the requirement.that all patients discharged from Adult Mental Health wards (this is for Ward F,
Clyne and Fendrod) receive a 72 hour follow up review. This has been in place since May 2024

and has been monitored for compliance since September 2024. During this six-month period,
Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at.oedi. a“
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead toa delay.

Cadeirydd/Chair: EP rif Weithredwr/Chief Executive: AD

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR
Bwrdd lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lleof Prifysge,| Bae Abertawe

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR :
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board A

there has been 230 discharges across adult inpatient wards, of these 90% have received the offer
of 72-hour follow-up. Of those who were not offered, the reasons include patient discharged out
of area, patient deceased and patients that had received an extended period of home leave as
part of transitioning/discharge planning.

There is a focus across Wales for the implementation of Patient Centred Safety planning. SBUHB
working with the NHS Wales Executives, were a pilot site for this approach within one of our
CMHTs. Following the success of this pilot, there is an MDT task and finish group chaired by the
Lead Nurse for Adult Community Mental Health Directorate, who will work towards scaling this in
a phased approach across all adult mental health services over the next year. Patient centred
safety planning is a patient led approach to managing emotional distress and crisis, through
identifying means of support, distraction, contacts and strategies to maintain safety. This will be
led by the patient and centred around them, and therefore consent and engagement will be
required.

For those patients who engage with a Patient Centred Safety plan, they will still require a risk
assessment, formulation, and plan to be in place. All patients who have been admitted to an
inpatient setting, will have a risk assessment completed within 24 hours, and for care coordinated
patients, this will form a review of their current risk assessment (as they will already have one from
the community). As part of the admission process, the patients Care and Treatment Plan would
be reviewed within 72 hours, where the care coordinator attends this meeting where possible in
Jine with the operational hours of the community mental health teams. Both of the above criteria
are reported to the NHS Wales Executives on a monthly basis. The monitoring of this has been in
place since September 2024.

MDT working requires a shared responsibility and collaborative working. However, where different
professionals are involved, this can bring different views and opinions on patient care and
treatment. In these circumstances, clinicians including care coordinators, can raise concerns.
There are a number of forums where this is possible. Within the CMHTs, there are weekly
Community MDT meetings where clinicians raise and discuss patients from their case load; there
is an item on the agenda ‘cases that are escalating/of concern’. This is an opportunity for the care
coordinator and the MDT to discuss the case; the care coordinator will receive peer supervision;
alternative interventions can be.discussed and a decision if gatekeeping or Mental Health Act
Assessment is required. The team consultant has emergency slots within their clinics, and these
can be utilised should a patient require an urgent review in the community.

Another area for support and escalation would be caseload supervision; this is a one-to-one
meeting every 6 weeks with the team manager or deputy, in line with professional standards. It
allows the care coordinator to focus on their individual caseloads, it is an opportunity for reflection,
support, and development. Outside of these, more formal processes would include escalating any
concerns they have via their Team. Manager, escalated to the Lead Nurse, Head of Nursing and
finally Nurse Director within the Service Group if required.

In addition to escalation routes, there is also a monthly community team manager meeting that is
held and chaired by the divisional manager for Mental health services. This meeting allows for
team managers to raise any concerns they have; to reflect on any trends or patterns that are
emerging across all the teams and therefore make changes and review any processes that could
improve. This is another opportunity for concerns to be escalated upwards.

Since June 2023, the NHS 111 option 2 service has been introduced. This service is accessible
for the general public, professionals, and agencies, on a 24/7 basis relating to individuals in mental
health crisis or for any urgent support. Calls to this service are answered by Mental Health
Professionals, who will assess the call to triage and ensure the appropriate support, response and
intervention is provided.

Concern 2
Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi.
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay.

CadeiryddiChair: i WeithredwriChief Executive: |

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR ly.
Bwrdd lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe / A

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR 4
Swansea Bay University Health Hoard ig the operational name of Swansea Bay University Local Health Board d

The decision not to discuss discharge with the care co-ordinator was not identified by the
internal investigation undertaken by SBUHB, rather the investigation found. ‘there is
evidence of regular and effective communication between support staff, community staff
and hospital staff.’

This raises a concern that critical lessons have not been identified and learnt by SBUHB
from Jean’s death about the importance of including care co-ordinators and professions
in the community before a decision is taken to discharge a patient from Ward F. This
creates a continuing risk to life as it may lead to risk being ignored or not properly
considered by Ward F.

Swansea Bay University Health Board Response:

The Health Board recognises that through this case, the coroner has identified additional learning
for the Mental Health services that was not identified in the original Serious Incident Review and
is grateful to the coroner for this. Following the inquest, a debrief session was convened to
consider the coroners concerns and the required actions that were to be taken, noting that some
actions had been implemented prior to the inquest hearing addressing the identified risk to life as
outlined in concern 1. In addition to these, the Medical Director and Nurse Director for MH&LD
have issued formal correspondence to all clinical areas and teams, reaffirming adherence to
Section 3.4: Discharge and Discharge Planning of the Acute Adult Mental Health Inpatient Wards
Operational Policy and the Pre-Discharge Planning Checklist and the patient/relative receives the
“Moving on” information leaflet.

This formal correspondence will also be cascaded through the relevant forums throughout May
2025, such as Ward/Team manager meetings and consultant forums.

In relation to the Serious Incident Review Process, the MH&LD team is continually working
towards improving this and in August 2024 a review was commissioned by the MH&LD Nurse
Director, requesting that Professor Jason Davies: (RDIIAL Hub Director and Consultant Forensic
and Clinical Psychologist).

Undertake a review of the purpose and processes related to the SIG (Serious Incident Group)
functions and to make recommendations to Serious Incident Group and MHLD: Quality and Safety
Committee detailing effective practice and potential changes to process.

This report was finalised and reported back to MH&LD Quality and Safety Committee in October
2024 with key recommendations which the Service Group are embedding.

One of these recommendations was around the processes of Serious Incident Strategy Meetings.
A Strategy Meeting is held following some fact finding and established contacts with the service,
and is chaired by the MHLD Nurse Director or one of the four Heads of Nursing. The chair acts as
the commissioner for the review, ensuring any immediate actions are identified and carried out;
identifies the scope of the review and terms of reference. There has been a focus on ensuring that
this process includes the identification of questions and key lines of enquiry which are set out for
the investigators. An emphasis has also been placed on the involvement of families, clinical
advisors and identification of relevant policies and guidance related to the case. This meeting
would identify cases where externality is required for the review, for example inpatient deaths are
reviewed by HB Sl investigators and cases where the chair has identified the need to request a
reviewer from a neighbouring HB.

A further change has been implemented in the development of a two-stage process for sign off
and approval of the learning and findings identified in Serious Incident Review Reports. The initial
stage is for a focused group of senior clinicians to scrutinise and critique the outcome report to
ensure that it meets the scope, terms of reference and areas of review as commissioned within

Rydym yn croesawu gohebiaeth yn y Gymraeg rieu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. ss =

We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Welsh, and this will not lead to a delay.

Cadeirydd/Chair: SBEEEP rif WeithredwriChiet Executive:

Pencadlys BIP Bae Abertawe, Un Porthia Talbot, Port Talbot, SA12 7BR
Bwrdd lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lieo! Prifysgol Bae Abertawe

Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR
Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board

‘the strategy meeting. It also acts as a panel to ensure that the review has been thorough and
whether there are any further areas that require exploration prior to it being signed off.

The second stage isa forum to share the findings and learning, identifying improvements and
actions required, identifying leads for the improvement plan with a timeframe for return. This stage
will support a wider cascade of learning and implementation of improvements. This second stage
is currently being implemented with the first SIRL (Serious Incident Review Learning) meeting
planned for May 2025. This will be evaluated as part of the ongoing SIG Review facilitated by
RDIIAL and Prof Davies, and a will be set following the 6" SIRL Meeting in November 2025.

A series of learning events have been arranged in the Service Group through RDIAL. RDIIAL
(Research, Development, Innovation, Improvement, Audit & Learning) is known as the learning
hub and reports into the MH&LD Quality & Safety Committee.

There was a learning event held on 20". September 2024, presenting shared learning from an
inquest case and thematic links. Further learning events are planned for 6 May 2025 on
implementation, monitoring and sustaining action/improvement plans, 19" May 2025 on Risk
planning and safety, relating to policy-and process and 9" July 2025 on collaboration, co- .
production, and family involvement with a particular focus.on safety planning.

In line with the above review, further training has been provided to the Serious Incident
Investigators within MH&LD Service Group. The Health Board Serious Incident Investigators
received training from Consequence UK, an organisation which provides training on techniques
and processes to increase the effectiveness of Serious Incident reviews. Following this, training
on process mapping in particular, was cascaded to the MH&LD Serious Incident investigator team
(October 2024) in line with this. This way of reviewing, aids the investigator to break down policy
and procedures into step-by-step guidance, which in turn can be used by the investigator to map
and measure the care provided. This- allows the incident investigators to make more accurate
analysis of the clinical input against the specified clinical processes and guidance. As with the
change in process for strategy meetings, the Service Group are in a transition period regards the
investigation methodology and will be monitoring and reviewing the process. To. support this the
team are implementing regular team meetings to reflect on the review process, identify themes in
the learning and reflect on feedback on the reports.

Yours sincerely,

wa a. Officer

Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg. Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi.
We welcome correspondence in Welsh or English. Welsh language correspondence will be replied to in Weish, and this will not lead to a delay.

Cadeirydd/Chair RP rit Weithredwr/Chief Executive: iy

Pencadlys BIP Bae Abertawe, Un Porthfa Talbot, Port Talbot, SA12 7BR

Bwrdd lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe
Swansea Bay UHB Headquarters, One Talbot Gateway, Port Talbot, SA12 7BR

Swansea Bay University Health Board is the operational name.of Swansea Bay University Local Health Board