Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0154, written 19 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Mar 2025 |
|---|---|
| Reference | 2025-0154 |
| Deceased | William Grieve |
| Coroner | Emma Serrano |
| Coroner area | Staffordshire |
| Category | Suicide (from 2015) |
| Organisation named | Midlands Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: 1. Stoke Talking Therapies 2. Crisis Resolution Team 3. Midlands Partnership Foundation Trust 1 CORONER I am Emma Serrano, Area Coroner, for the coroner area of Staffordshire. 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 the 28th August 2024, I commenced an investigation into the death of Mr William Anthony Grieve. The investigation concluded at the end of the inquest on 17 March 2024. The conclusion of the inquest was a short for conclusion of suicide. The cause of death was: 1a Hanging 4 CIRCUMSTANCES OF THE DEATH i) Mr Grieve was found deceased, on the 20 August 2024, at his home address . 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to 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 report to you. The MATTERS OF CONCERN are as follows. – 1. Evidence emerged during the inquest that Mr Grieve was under the care of Stoke Talking Therapies, and had also presented at the Stoke crisis Evolution Team. Both had conducted suicide risk assessments of Mr Grieve. 2. Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system. Stoke Talking Therapies used IAPTUS and Crisis resolution used Lorenzo. There was no way for either team to see the others electronic notes. 3. It was said in evidence, that a member of staff had not carried out a risk assessment properly whoever, nothing had been done to address this 1 [IL1: PROTECT] and there were no plans to address this. The concern being that staff training needs are not being addressed. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 7 May 2025. 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; 1. The family of William Grieve. 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 19 March 2025 Miss Emma Serrano Area Coroner Staffordshire 2 [IL1: PROTECT]
2 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.
Trust Headquarters St George's Hospital Corporation Street Stafford ST16 3SR www.mpft.nhs.uk Miss Emma Serrano Area Coroner for Staffordshire By email: 6 June 2025 Dear Ma’am, Regulation 28 Report into the death of Mr William Anthony Grieve Midlands Partnership NHS Foundation Trust (“MPFT”) acknowledges receipt of the Regulation 28 Report to Prevent Future Deaths following the inquest into the tragic death of Mr Grieve. On behalf of MPFT I would first like to offer my sincere condolences to Mr Grieve’s friends and family for their tragic loss. MPFT provides the following response to the Regulation 28 Report. It is important to note at the outset that MPFT were not notified of Coroner’s investigation had no input into the inquest process, and, were not present at the final court hearing, as such, were not privy to any of the evidence which led to your concerns. This response is provided in absence of any knowledge of the evidence. Further, this response will only refer to matters which are directly under MPFT’s knowledge and control. MPFT take a collaborative approach with other colleagues and have met with representatives at North Staffordshire Combined Healthcare Trust (“NSCHT”) in relation to your concerns raised in your Regulation 28 report. MPFT are committed to continuing this collaborative approach and always take any concerns and issues with care seriously and are dedicated to continually improving patient safety and learning. Talking Therapies- MPFT MPFT holds the contract for Talking Therapies in Staffordshire and Stoke on Trent, and sub- contracts to other partners. There are 7 different organisations who sub-contract from MPFT, NSCHT are one such provider. NSCHT provide the Talking Therapies services in Stoke, who I understand provided treatment to Mr Grieve. NSCHT are responsible for the provision and performance of this service and are responsible for oversight of mandatory training of all staff working in the Stoke locality team. However, if MPFT LEGAL\118240\00072\74212422.v1-6/6/25 74212422v1 make a change to the whole contract in terms of the expectations regarding staff training MPFT would take responsibility for delivering that training. MPFT oversee the provision of the service by monthly national reporting, which is collated by the MPFT Business Intelligence Team and by quarterly reporting by partner organizations into the NHS Talking Therapies Governance Board, chaired by the MPFT Director of Operations and attended by commissioners/the ICB. MPFT would expect any concerns held by any of the sub-contractors to be raised in line with the contract. Where concerns are with MPFT Clinical Director and Deputy Clinical Director would work closely with managers in the Stoke locality to assist them in rectify any issues. Electronic Record Keeping Systems Talking Therapies use the IAPTUS electronic record system. This is a nationally recognised bespoke clinical record system used by Talking Therapies services nationwide and is one of only two systems which are nationally recommended for use in this context. The system LORENZO is the electronic record system used by secondary care and Crisis staff in North Staffordshire and Stoke on Trent. Rio is the electronic record system used by secondary care and Crisis staff in South Staffordshire Secondary care providers do not have access to the IAPTUS system. There are important, considered, reasons for this. 1. Talking Therapies in Staffordshire and Stoke on Trent treat a large number of NHS staff for therapy. They have been consented that their notes will remain confidential from other NHS services unless there are issues of risk or safeguarding, to assure them that their colleagues will not be able to view those psychological therapy notes. To open this access to IAPTUS and other NHS Staff poses a risks of breaches of confidentiality and a risk that staff will no longer come forward to access the service. 2. All patients have been consented on the basis that only their direct care team will have access to their notes. As around 30,000- 40,000 patient records are created annually on the system, it would be impossible to re-consent those people historically if access to the system was to change. 3. Staff supervision notes, which are notes which document oversight and input from a supervisor and any guidance provided to ensure the quality of the service provided and to ensure that staff receive the necessary support and feedback to perform their roles effectively, are held on IAPTUS. They are held separately to patient records. There is no way of restricting access to these notes to other users. 4. If access were to be widened (which due to points 1,2 and 3 above is currently not something we are considering) additional user accounts would need to be created. 5. If access were given to NSCHT staff, equivalent access would need to be offered to all partners organisations on the contract making the system unwieldy. Very complex Data Protection Impact Assessments would be required regarding information sharing due to the complexities of the number of partner organisations working on the contract and the information all of them would be able to view. LEGAL\118240\00072\74212422.v1-6/6/25 6. Nationally, it is not usual practice that secondary care staff have access to the Talking Therapies record system for the clinical and cost reasons outlined above. If urgent or serious risk presents in Talking Therapies services, it is standard and expected practice that these risks should be escalated to secondary care within the system immediately as per Talking Therapies national guidance, due to there being no medical staff in the team to advise on this. 7. There is no block within the IAPTUS system to enable users to access only parts of the notes – if access is grated the entire record, plus supervision notes, will be viewable. Risk Assessments As a service, Staffordshire and Stoke on Trent Talking Therapies introduced a new process of assessing and documenting risk which came into force on 1 May 2025. This is in response to the new national guidance regarding the removal of risk stratification from risk assessment and notes. The process has been undertaken by all Talking Therapies Services led by MPFT and for Staffordshire and Stoke on Trent, this has been led by the MPFT employed Clinical Director and senior clinicians in the service employed by MPFT and NSCHT, under the supervision of the MPFT Associate Director of Safety, Risk and Compliance and MPFT Director of Psychological Services. All staff working in the service received training on the new processes in April 2025. The training comprised of a live training session which was recorded for staff who were absent to watch at their earliest opportunity. A resource pack was also provided to all staff outlining in writing the new processes and requirements for assessing risk and writing this in notes. Following implementation, a robust auditing process will be taking place monthly from July 2025 to ensure compliance and address any further staff training needs. Should you have any further questions please do not hesitate to contact Legal.services@mpft.nhs.uk. Yours Sincerely, Chief Executive Midlands Partnership NHS University NHS Foundation Trust LEGAL\118240\00072\74212422.v1-6/6/25
Date: 6th June 2025
Reference:
Emma Serrano, Area Coroner
Stoke-on-Trent & North Staffordshire Coroner
Stoke on Trent and North Staffordshire
Stoke Town Hall,
Kingsway,
Stoke-on-Trent,
ST4 1HH
Email:
Dear Miss Serrano
Chief Medical Officer
Trust Headquarters
Lawton House
Bellringer Road
Trentham
ST4 8HH
Regulation 28 Report – Prevent Future Deaths – William Anthony Grieve
During the course of the inquest for William Anthony Grieve which concluded on 17th March 2025,
the evidence revealed matters giving rise to 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 report to you.
The MATTERS OF CONCERN are as follows:
(1)
(2)
(3)
Evidence emerged during the inquest that Mr Grieve was under the care of Stoke Talking
Therapies, and had also presented at the Stoke Crisis Resolution Evolution Team. Both had
conducted suicide risk assessments of Mr Grieve.
Both assessments, were incorrect, and took account of incorrect information because neither
team had access to the others computer system. Stoke Talking Therapies used IAPTUS
and Crisis resolution used Lorenzo. There was no way for either team to see the others
electronic notes.
It was said in evidence, that a member of staff had not carried out a risk assessment properly
whoever, nothing had been done to address this and there were no plans to address this.
The concern being that staff training needs are not being addressed.
Trust responses to Matters of Concern Above (see appendix 1 for Action Plan)
(1) We agree with this statement.
A patient at any given time can have touch points/points of entry with different mental health
services dependent upon their clinical need at that time. Each clinical team will undertake a
clinical assessment in that moment including risk assessment in order to formulate how best
to support those needs. More than one risk assessment could be open at any given time
when patients are accessing different services.
Chair:
Chief Executive:
www.combined.nhs.uk
Follow us on Twitter: @CombinedNHS
Follow us on Facebook: www.facebook.com/NorthStaffsCombined
It is important that services are accessible and responsive to changeable and different needs
at any time, it is quite often the case that people can be open to several services at the same
time.
(2)
Nationally IAPTUS are not set up to share their electronic patient records as the provider of
this system has outlined below the reasons for this:
Secondary care providers do not have access to the IAPTUS system. There are important,
considered, reasons for this.
i.
Talking Therapies in Staffordshire and Stoke on Trent treat a large number of NHS
staff for therapy. They have been consented that their notes will remain confidential
from other NHS services unless there are issues of risk or safeguarding, to assure
them that their colleagues will not be able to view those psychological therapy notes.
To open this access to IAPTUS and other NHS Staff poses a risks of breaches of
confidentiality and a risk that staff will no longer come forward to access the service.
ii.
iii.
iv.
v.
vi.
All patients have been consented on the basis that only their direct care team will have
access to their notes. As around 30,000- 40,000 patient records are created annually
on the system, it would be impossible to re-consent those people historically if access
to the system was to change.
Staff supervision notes, which are notes which document oversight and input from a
supervisor and any guidance provided to ensure the quality of the service provided and
to ensure that staff receive the necessary support and feedback to perform their roles
effectively, are held on IAPTUS. They are held separately to patient records. There is
no way of restricting access to these notes to other users.
If access were to be widened (which due to points 1,2 and 3 above is currently not
something we are considering) additional user accounts would need to be created.
If access were given to NSCHT staff, equivalent access would need to be offered to all
partners organisations on the contract making the system unwieldy. Very complex Data
Protection Impact Assessments would be required regarding information sharing due
to the complexities of the number of partner organisations working on the contract and
the information all of them would be able to view.
Nationally, it is not usual practice that secondary care staff have access to the Talking
Therapies record system for the clinical and cost reasons outlined above. If urgent or
serious risk presents in Talking Therapies services, it is standard and expected practice
that these risks should be escalated to secondary care within the system immediately
as per Talking Therapies national guidance, due to there being no medical staff in the
team to advise on this.
Chair:
Chief Executive:
www.combined.nhs.uk
Follow us on Twitter: @CombinedNHS
Follow us on Facebook: www.facebook.com/NorthStaffsCombined
vii.
There is no block within the IAPTUS system to enable users to access only parts of
the notes – if access is grated the entire record, plus supervision notes, will be
viewable.
An Integrated Care Record (ICR) – already exists and NSCHT, MPFT, UHNM and GP
services each extracts an agreed dataset of information to this ICR system and NSCHT aim
to take forward discussions with MPFT to do the same from IAPTUS electronic patient record
to mitigate some of the system issues raised.
(3)
This evidence was in relation to a member of staff within the Crisis Resolution Home
Treatment Team (CRHTT), not Talking Therapies.
Upon further review, risk assessments were completed for Mr Grieve. Early organisational
learning has led to a review of the standard operational procedure for service users who do
not attend appointments the principles of this being adopted immediately whilst awaiting
Trust governance approval processes.
Please see attached action plan below. Do not hesitate to contact me should you need any further
information.
Yours sincerely
Consultant Psychiatrist
Chief Medical Director
Chair:
Chief Executive:
www.combined.nhs.uk
Follow us on Twitter: @CombinedNHS
Follow us on Facebook: www.facebook.com/NorthStaffsCombined
Action Plan Appendix 1
No
1.
Area of Concern
Both
were
assessments,
incorrect, and took account of
incorrect
information because
neither team had access to the
others computer system. Stoke
Talking Therapies used IAPTUS
and Crisis
resolution used
Lorenzo. There was no way for
either team to see the others
electronic notes.
team
talking
Identified Action
NSCHT will initiate discussions with
MPFT Information Governance Team
regarding
and Digital
the
therapies data
inclusion of
within the integrated care record. This
will include a discussion regarding the
proposed dataset of information to be
integrated Care
extracted
Record.
the
to
Lead
Completion date
31st July 2025
Assurance
Ongoing
2.
the
Assurance in the interim NSCHT plan
to:
o Protocol agreed – IAPT (now
Talking Therapy Services) check
Lorenzo when new referrals are
received – this is done once. At
Assessment
first
and
treatment appointment the patient
is asked if they are involved in
services. Note: there are issues
sometimes
person
with
remembering who
they are
involved with.
o Crisis Resolution and Home
Treatment Team (CRHTT)/IAPT –
have in place a process – ask at
every contact (not every contact-
beginning of treatment, during and
towards the end) if they are open
to any other services, which works
as follows:
IAPT (now Talking Therapies) - At
initial assessment we ask if patient
is or has accessed other mental
health services, we are adding
some narrative to this to advise
o
patient to make us aware that if
this occurs between appointments
then they need to let us know.
Risk and safety plan is reviewed at
each appointment and should pick
up any changes to risk and the
initial risk assessment.
if
o CRHTT every patient is asked on
each occasion
they are
accessing other mental health
services.
o CRHTT – If the person is open to
Talking Therapies, CRHTT will
inform Talking Therapies of this
through
the
appropriate Talking Therapies
team email address and consider
this
the
assessment and review of risks.
information
during
email
o Onus is still on the clinician to find
regarding
out
current access to services.
information
the
an
to
Chair:
Chief Executive:
www.combined.nhs.uk
Follow us on Twitter: @CombinedNHS
Follow us on Facebook: www.facebook.com/NorthStaffsCombined
It was said in evidence, that a
member of staff had not carried
out a risk assessment properly
whoever, nothing had been done
to address this and there were no
plans
The
concern being that staff training
needs are not being addressed.
to address
this.
1.
2.
This was not done as a response to
receiving this PFD – this work was
already planned in line with national
guidance and MPFT/Talking Therapies
have
risk
assessment process which was
launched on 01/05/2025 – all staff have
been either offered training, attended
or watch a video.
introduced
new
a
the Management
Early organisational learning from this
incident has led to a review of the
standard operational procedure (SOP)
for
of Non-
‘did not
attendance (DNA means
attend’ and WNB means ‘were not
brought’) and
Ineffective Contacts
within the Crisis Resolution and Home
Treatment Team (CRHTT) has been
developed by NSCHT and is currently
the Trust’s
proceeding
through
governance channels.
Completed.
31st July 2025
Chair:
Chief Executive:
www.combined.nhs.uk
Follow us on Twitter: @CombinedNHS
Follow us on Facebook: www.facebook.com/NorthStaffsCombined
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