Susan Young

2nd September 2025

Yvonne K Blake
Area Coroner
Norfolk Jurisdiction
County Hall
Martineau Lane
Norwich
NR12DH

Dear Ms Blake

,,,,:;.1
James Paget
University  Hospitals
NHS Foundation Trust

IVldll I  VVVlll,I IUUC11 U,  U I "+(cid:0)V  "ti.J£'-t.JL

Email:s

www.jpaget.nhs.uk

RE:  Regulation 28 - Report to Prevent Future Deaths

I am writing to acknowledge receipt of the Regulation 28 - Report to Prevent Future
Deaths, issued to the James Paget University Hospital NHS Foundation Trust (JPUH)
following the inquest into the death of Miss Susan Young, which was heard and closed
on 7th May 2025, and received via our Legal Services Provider on 27th June 2025.

I note your concerns as follows:

During  the  course  of  the  investigation  my  inquiries  revealed  matters  giving  rise  to
concern.  In my opinion there is a risk that future deaths could occur unless action is
taken.  In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)

No clinical handover to receiving ward.
No instructions passed on from the doctor re cardiac monitoring.
Patients own medication found in her belongings which had been with her, after her
death allowing her the opportunity to take another overdose.

The medical cause of death was:
1 a) Cardiac Arrest
1 b) Mixed Overdose (Including Sertra/ine, Paracetamol and Promethazine)

Circumstances Of The Death
Miss Young was admitted to hospital on 23rd August 2024, having taken an overdose
of  prescription  medication.  This  was  not  her  first  overdose.  She  was  prescribed
amongst  others  Sertraline,  Gabapentin  and  Clonazepam  which  has  the  effect  of
prolonging  the  Q  wave,  the  heart  rhythm.  She  had  taken  an  overdose  on  the  22nd
August 2024. When this had not succeeded taken another on 23rd August 2024. She
was monitored appropriately whilst in the emergency department and transferred to a
ward with directions that she be attached to cardiac monitoring.

When nursing staff took her to the ward, they did not give any handover and certainly
no instructions about cardiac monitoring. Miss Young was found unresponsive and not
attached to any monitoring.  Resuscitation failed.  It is thought that the medication may
have had a cumulative effect. When the nurses were packing up her belongings, they
found more unused medication which had been left with the patient.  It is not known if
she had taken any of this.

1

 The inquest concluded that:
The  Patient  suffered  various  cardiac  problems,  including  a  previous  heart  attack.
Patient  was  also  prescribed  a  medication  for  epilepsy  which  has  the  side  effect  of
prolonging the QT interval in the heart rhythm and can precipitate cardiac arrhythmias.
Patient was found deceased in bed by nursing staff.

I note that the JPUH was not required to attend the inquest, and we were, therefore,
unable to provide clarification regarding these concerns. However, upon receipt of the
Regulation 28, an investigation into these matters of concern was commenced.

1.  No clinical handover to receiving ward.
2.  No instructions passed on from the doctor re cardiac monitoring.
3. Patients own medication found in her belongings which had been with her,
after her death allowing her the opportunity to take another overdose.

Our Investigation Findings:

Matters of concern
1. No clinical handover to receiving ward
2. No instructions passed on from the doctor re cardiac monitoring.

A Patient Safety Incident Investigation (PSII) was conducted regarding Miss Young's
case, and the report was shared with you before the inquest. The investigation
finding on matters of concern 1 & 2 are reported below.

a) The PSII report included the following statements:

The statements below are copied from the PSI/ report.

The JPUH Patient Transfer and Escort Policy as implemented in March 2023 lays out
the standard of in-hours and out of hours internal and external transfer and escort
that are required for the safety of all patient groups (Adult, Paediatric, Neonatal - via
web/ink and Maternity) who are admitted or being transferred and escorted within or
from the James Paget University Hospital. The policy refers to suitable escorts being
identified by the use of the risk assessment tool, National Early Warning Scoring
system and patient categories levels of care. The need for responsibility and
accountability for allocated competent escorts and for those that escort to be
competent to escort patients, to be both responsible and accountable whether
registered our unregistered staff.

The transfer of  Miss Young without a clinical  handover  had  an impact  on both  Miss
Young and staff caring for her. Reference has been made to the omissions of cardiac
monitoring, the hourly observations, and the cardiopulmonary status of Miss Young. If
cardiac monitored, it may have picked up a treatable rhythm that may have required a
cardiac  shock,  therefore  the  need  for  clear  documentation  of  the  what  ifs  with  Miss
Young, as a cardiac shock may not have been agreed to by Miss Young, and it doesn't
mean that by providing a shock this would be successful, considering the prolonged
QT, that had already received magnesium as the main treatment to reduce the risk of
a life threatening arrhythmia.

Miss  Young was transferred  to  the  Emergency Assessment and  Discharge  Unit
(EADU),  this transfer  occurred  without a clinical  handover,  this contributed  with  an
outcome of Miss Young not receiving either hourly observations or cardiac monitoring.
It is apparent that Miss Young is transferred to the EADU allocated to a bed within
the acute visible bay (a bay that allocated patients who require a higher need for

2

 visibility/monitoring), therefore it appears that a handover of source was completed,
it's difficult to ascertain if the bay was allocated due to further risk of self-harm or
cardiac monitoring or both, although the registered nurse in EADU shares that they
were not aware that Miss Young required cardiac monitoring, therefore high
probability is that a/location was assigned due to further risks of self-harm.

During Miss Young's attendance on the 23rd of August 2024, she received intravenous
medication  as  advised  by  Toxbase  (clinical 
this  was
administered to support a potential prolonged heart rhythm delay (prolonged QT) of
which was noted within a tracing of her heart as conducted on the day, further advice
was  for  cardiac  monitoring.  There  appeared  to  be  high  risk  that  Miss  Young  may
experience a life-threatening  arrhythmia  such  as  Torsades  de  Pointes,  hence  the
reason for treatment and cardiac monitoring.

toxicology  database), 

Following Toxbase advice Miss Young is attached to a cardiac monitor within the
Emergency Department, it is not apparent from documentation or on speaking with
staff as to what they would be observing for by being attached to the cardiac monitor.
It is not apparent from nursing staff caring for Miss Young of the risks of a prolonged
QT, this is corroborated by Miss Young not being monitored on transfer from ED to
EADU.

b) The PSII findings related to the Matters of Concern 1 & 2 are reported

below:

There is omission of a clinical handover from EADU to ED through a face-to-face
handover considering Miss Young has risks highlighted, such as further self-harm
and the need for cardiac monitoring.

The transfer from ED to EADU supervision and engagement assessment is not
completed within the Emergency Care Record document, in addition to the non-
completion  of the transfer checklist.

Action is required on the expectations of a clinical handover from the ED with
consideration to the request for visible acute bay on EADU, cardiac monitoring,
hourly NEWS recordings and the risk of further self-harm.

The  medical  plan  agreed  is  for  intravenous  fluids, a blood  sugar  check,  to  start
Intravenous  N-acetylcysteine  (NAG)  (medication  to  treat  paracetamol  overdose),  to
prescribe  and  administer  magnesium  2  grams  intravenously  (is  the  first  line  of
treatment for severe QT prolongation),  for cardiac  monitoring,  bloods and a venous
blood gas and to refer to the medical team.

The  actions  as  documented  within  the  plan  are  followed  and  implemented,  this
includes  the  prescribing  and  administering  of  magnesium  2  grams  intravenously
(magnesium sulphate is the first line treatment for severe QT prolongation, even if the
levels  are  normal  and  is  administered  to  prevent  Torsades  De  Pointes  (TOP),
magnesium reduces the risk of arrhythmias. It also helps in slow heart rates such as
bradycardia and therefore reduces arrythmia risk even when bradycardia is the primary
cause)  the  request  for  cardiac  monitoring,  both  to  support  the  prolonged  QT  with
referral to the medical team.

Following  Toxbase  advice  Miss  Young  is  attached  to a cardiac  monitor  within  the
Emergency  Department,  it  is  not  apparent  from  documentation  or  on  speaking  with
staff as to what they would be observing for by being attached to the cardiac monitor.
It is not apparent from nursing staff caring for Miss Young of the risks of a prolonged

3

 QT, this is corroborated  by Miss Young not being monitored  on transfer  from ED to
EADU.

Miss Young is omitted to receive cardiac monitoring whilst an inpatient on EADU as
requested

The transfer of Miss Young without a clinical handover had an impact on both Miss
Young and staff caring for her. Reference has been made to the omissions of cardiac
monitoring, the hourly observations, and the cardiopulmonary status of Miss Young.
If cardiac monitored, it may have picked up a treatable rhythm that may have
required a cardiac shock, therefore the need for clear documentation of the what ifs
with Miss Young, as a cardiac shock may not have been agreed to by Miss Young,
and it doesn't mean that by providing a shock this would be successful, considering
the prolonged QT, that had already received magnesium as the main treatment to
reduce the risk of a life threatening arrhythmia.

There is omission  of a clinical  handover  from  EADU  to  ED  through  a  face-to-face
handover considering Miss Young has risks highlighted, such as further self-harm and
the need for cardiac monitoring.

If my  mum  had  received  cardiac  monitoring  could  any  intervention  have
occurred to reduce the risk of my mum's heart stopping.
This question was asked of the lead cardiologist who shared that if cardiac monitoring
was in place prior to Miss Young's death, it potentially may have picked up a rhythm
that may have triggered further specialist discussion as to next steps, with Miss Young
being at the heart of the discussion.

Discussion  may  have  included  the most appropriate  place  to  monitor Miss Young,
considering the high risk of a life-threatening arrhythmia such as Torsades de Pointes.
Prior  to  cardiac  arrest a treatable  rhythm  may  have  been  identified,  this  may  be a
rhythm that  required a controlled  cardiac  shock;  therefore,  the  understanding  of the
what ifs are  so important for Miss Young,  considering that she wished  not to  be for
resuscitation of which includes a cardiac shock.

Miss Young had received treatment for prolonged QT,· IV magnesium as administered
in  ED  to  reduce  the  risk  of a life-threatening  arrhythmia.  The  staggered  additional
prescribed medication overdose may have lengthened the QT further considering the
QT was within normal range in June 2024.

Following  the  toxicology  of  blood  samples  there  were  traces  of  concentrations  of
Paracetamol and Promethazine were detected along with therapeutic concentrations
of  Sertraline,  Gabapentin,  and  Codeine.  Full  interpretation  of  these  findings  should
consider  the  time  between  ingestion,  hospital  admission  and  death.  Paracetamol
should  be  interpreted  along  with  findings  from  liver  histology.  There has been  prior
Clonazepam use. Roxithromycin, Atorvastatin, Bisopro/ol and Loperamide were a/so
detected.

c) The PSII Actions and their status shared with you prior to the inquest: (an

update on the progress of the actions is reported in section e)

4

 Safety Action Summary Table

(W)(cid:0) = Not yet started

(G)cua=  Gompleted

(A)m!w;= In progress

:-rt_;:;l(cid:0)--(cid:0):?l>(cid:127)::):(cid:0).:(cid:0);::/(cid:0):(cid:0):-
,_c(cid:127)(cid:0)-(cid:127)

-:
I

ID

D

L_!amlng ldenlifi(cid:0)lion Required 1 R(cid:0)pon(cid:0)ility_j_

j
Le.iming Identified - The expectations of a clinical handover from the ED with consideration to the request for visible acute b.iy on EADU,
c.irdlac monitoring, hourly NEWS recordings and the risk of further self-harm.

Comments/Evidence of Achievement/Reason for Slippage

_RAG I

Timescale

D1    Action Required - Local

To  complete the Emergency Care transfer safety
checklist as seen within the Emergency Care
record, to support safe transfer of patients from ED
to EADU, by relaunching the safety checklist with
registered nurses in Emergency Care.

30th July 2025

A

Clinical Educator
ED

D2  Action Required - Local

To include the patient transfer policy as part of the
relaunch that highlights within, the transfer escort
checklist, if one or more of the following apply to
this patient then an escort is required this includes
any patient that causes concern as in this
scenario.

1'l

30°' July 2025 w

Clinical Educator
ED

, Deputy Lead Nurse, Division of Medicine, Diagnostics & Clinical Support

Services provided a statement for the inquest on the 27th of May 2025. The
statement provided added information and assurance around the actions being
undertaken.

d) Statement Content regarding Actions D1 and D2

Action  D1  - To  complete  the  Emergency  Care  transfer  safety  checklist  as  seen
within the Emergency Care record, to support safe transfer of patients from ED to
EADU,  by  relaunching  the  safety  checklist  with  registered  nurses  in  Emergency
Care.

Action  D2  - To  include  the  patient  transfer  policy  as  part  of  the  relaunch  that
highlights within, the transfer escort checklist, if one of the following apply to this
patient then an escort is required this includes any patient  that causes concern
as in this scenario.

i.

ii.

I can confirm that the Clinical Educator has completed transfer training at the
ED  educational  away  days,  which  included  training  on  the  transfer  checklist
within the emergency care record documentation and the patient transfer and
escort policy. These were held on the 4th and 9th April and the 7th and 16th May
2025.  68% of the current ED nursing and support staff attended. In addition,
the Clinical Educator circulated the patient transfer and escort policy and the
transfer  checklist to all staff  via  email. Those who were  unable to  attend  the
away  days  due  to  sickness  or maternity  leave will attend  a  bespoke training
session at the earliest opportunity. A signatory list will be commenced to ensure
all ED nursing staff have read and understood the policy and checklist.

The  training  reviewed  the  patient  transfer  and  escort  policy  and  included
information  regarding  internal  and  external  transfers. This  highlighted  the
importance of effective communication between the transferring and receiving
department  and  undertaking  the  risk  assessment  tool  within  the  policy  to
determine who should transfer the patient. This will ensure specific information
such as cardiac monitoring is handed over in future.

5

 iii.

iv.

v.

vi.

Whilst the remaining staff are captured in the bespoke training sessions, the
Clinical Educator will complete safety checklist compliance audits monthly to
provide assurance that the process is embedded. This audit is in the planning
phase;  however,  it  is  anticipated  this  will  enable  the  team  to  monitor
compliance, identify any gaps and support the team with any additional training
needs.

EADU  nursing  leadership  have  supported  staff  to  complete  safety  huddles
following  this  incident,  which  included  information  about  this  incident,  initial
learning including the requirement  of a nurse escort when clinically required.
Additionally, staff escalate to the Nurse in Charge on EADU if they have any
clinical  concerns  about  patients  who  are  transferred  from  ED,  the  Nurse  in
Charge will discuss this with the ED nurse in charge to gain further information
about the patient. A QSAFE incident is completed if there are concerns about
patient transfers and learning from these incidents is shared with the teams.

A three month historical search of QSAFE has identified no further concerns
regarding transfers from ED to EADU.  QSAFE incidents are reviewed daily by
the matron team via the matron safety huddle and subsequently at the Trust's
daily incident triage meeting, with escalation to the safety action and assurance
group  (SAAG).  Any  themes  and  trends  are  escalated  through  the  relevant
insight  group  and  learning  is  supported  by  the  division  and  the  corporate
nursing team.

As a Trust, we are developing a communication process for handover with a
task  and  finish  group  commencing  23rd  May  2025.  This  includes  leads  from
each  department  including  ED  and  EADU.  The  flow  chart  is  in  the  design
phase,  with  an  aim  to  commence  the  new  process  mid-June.  Specialist
requirements for the patient including cardiac monitoring will be included in the
handover  template.  Once  embedded,  an  audit  will  take  place  to  monitor
compliance and identify gaps needing further education and support.

e) Reporting of the current status of the actions D1 and D2

Safety Action Summary Table

(W)!llm = Not yet started

(Gll,.m= Completed

(AJmlw;=. Inprogress

ID
D

01

Tlmescale

Respo  !lslbllity

(cid:0)ea(cid:0)ln(cid:0)Identified/ Ac1ion Required

_Com(cid:0)nts/Evldonce of Achlevemen1/Reas(cid:0) for Slippage
Leaming Identified. The expectations of a clinical handover from the ED with consideration to the request for visible acute bay on EAOU, cardiac
monitorin11, hourly NEWS recordin11s and the risk of further self.harm.
 Action Required - local
To complete the Emergency Care transfer Clinical
safety checklisl as seen within the
Emergency Care record, lo support safe
transfer of patients from ED to EADU. by
relaunching the safety checklist with
registered nurses in Emergency Care.

The Senior Nursing Team have shared during hol topics which lake
place at handovers day and nighl to ail staff within ED the importance
of completing a ltansfer checklist and how lo complole. Clinical
Educator has provided addilional teaching to workforce and how they
can support with compleUon of a transfer checklist. A learning board
has been completed on 20th January showing staff how to correclly fill
in the Emergency Care record

30"' July 2025

Educator ED

G

RAG

DZ

Action Required . Local
To include the patient transfer policy as
part of lhe relaunch lhat highlights within,
lhe transfer escort checklist, if one or
more of the following apply to this patient
then an escort is required this includes
any patient that causes concern as in
this scenario.

30111July 2025

G

Clinical
Educator ED

6

Clinical Educator transfer \raining completed at ED educational away
days (register al1ached). Internal risk assessmenl tool for transferring a
paUent shared. Key poinls from transfer policy shared with slaff. Pocket
size cards laminated and shared with staff.

(cid:0) 

If

(cid:0)

(cid:0)

tHm  away day 7th  Teilm Awry Oay(cid:0)h  team away dap  4hl'I

May registe.pdf April register pdf

Apr3 registeq:,df

il'Jr.sft(cid:127)
g-.;id.aD::l!mg

 f) Evidence of completion of actions D1 and D2 of the PSII action plan

Action D Evidence
Clinical Educator transfer training
completed at ED educational away days
(register attached).

Attachments

(cid:0)

(cid:0)

7th  May away day  9th April away day

register.pdf

register.pdf

(cid:0)

4th April away day
register. pdf

D

Transfer
guidance.msg

(cid:0)

ED SBAR Handover

2025.docx

Internal risk assessment tool for
transferring a patient shared.
Key points from transfer policy shared
with staff.

ED Patient Handover Form now in use

Matter of Concern

3. Patients own medication found in her belongings which had been with her,
after her death allowing her the opportunity to take another overdose.

a) The  PSII  report  included  the  following  statements  related  to  Matter  of

Concern 3:

The statements below are copied from the PSI/ report.

There are documented risk checklists evident within ED for those patients attending
with self-harm, in addition to further risk assessments evident within the emergency
care record for those patients being admitted to an inpatient bed.

Patients own medication found in her belongings which had been with her, after her
death allowing her the opportunity to take another overdose.

Strips  of  medications  were  found  within  Miss  Young's  property  following  her
unexpected death.

In  that  medication  bag  contained  20X  full  strips  of  X6  loperamide,  3  strips  of  10
loperamide + one empty strip of 10 tablets. 2x empty strips of 6x loperamide, 3x strips
of 10 tablets of zapain 301500mg with 3 tablets missing.

It is unclear how this was missed when the HCA was doing the property list. 2X bags
of medication were locked in the locker, we cannot be sure nothing else was taken on
the ward.

The patient was in a visible bay and all staff informed of the ligature risk. observations
were  taken  at  16:50  stable.  The  clerking  notes  do  state  that  it  was  not  just a
paracetamol OD it was multiple drugs, and patient had a prolonged QT and the plan
states cardiac monitor which patient was not put on, the patient had NAG in place.

7

 b) The PSII findings related to Matter of Concern 3 were.

JPUH Self Harm Policy
This policy and procedure as implemented in March 2024 provides clear guidance to
staff in relation to providing a safe environment for a patient who is at risk of self-harm.
This  includes  the  assessment  of  the  risk  and  the  management  of  the  patient  and
guidance on the removal of items from the patient environment which could be used
to self-harm.

The National Institute of Health and Clinical Excellence (NICE) have published a Self-
Harm  Quality  Standard  Number  34  (NICE  2022)  and  Clinical  Guidance  225  (NICE
2022). This policy does not replace the responsibility of all staff involved to apply NICE
quality standards and clinical guidance appropriately.

There appears to be no evidence of consideration of the level of enhanced
supervision or to environmental risk i.e. medications, especially as property listed
belonging to Miss Young following her death contained strips of both used and
unused medications.

The need for staff to comply and adhere to the self-harm policy to support patient
safety

To clarify expectations of a clinical handover from the ED with consideration to the
request for visible acute bay on EADU, cardiac monitoring, hourly NEWS recordings
and the risk of further self-harm.

c) The PSII Actions and their status shared with you prior to the inquest: (an

update on the progress of the actions is reported in section e)

(W)(cid:0) = Not yet started

(G)Wm = Completed

(A)(cid:0)= Inprogress

(cid:127):_:J_"'(cid:0)-'(cid:0)_'_}t?(cid:0);-'.,::-y(cid:127),-

-- ! -:.·.!!.. .1  -    -

-

;

J

ID

Leaming identified/ Action Required

Responsibility

Timescale

RAG    Comments/Evidence(cid:0)f Achievement/Reason fo

Shppaae

C j LearningIdentified - Trust Wide - To comply and adhere to the self-harm policy to support patient safety

C1 Action Required - Local

To complete the agreed process for searching
patients to maintain patient safety (this will form an  Matron Mental
addendum to the self-harm policy
Health Liaison
Team&

30th June 2025

A

D
Consultant

C2  Action Required - Local

To share the self-harm policy across Emergency
Care with a reference to this patient safety incident 
once the addendum as above has been added.

 Matron Urgent
Care

30th July 2025

w

d) Statement Content regarding Actions C1 and C2

i. Action C1 -  To complete the agreed process for searching patients to maintain

patient safety (this will form an addendum to the self-harm policy.)

8

 I can confirm that the Trust's Self Harm Policy (copy attached) now includes an
addendum (Appendix C) an SOP (Standard Operating Procedure) Search of
Patients  within  the  ED.  The  policy  describes  the  rationale  behind  searching
patients attending the ED in Mental Health crisis to reduce the risk of patients
attempting  further  overdose  or  self-harm  during  their  time  in  the  ED.  The
updated policy has been uploaded to the Trust's intranet.

ii. Action  C2  -  To  share  the  self-harm  policy  across  Emergency  Care  with  a
reference to this patient safety incident once the addendum as above has been
added.
I can confirm that the search policy has been shared with all ED clinical staff
on the 16th April 2025 and was added to the self-harm policy as an addendum
which  is  available  on  the  intranet  for  all  staff  to  access.  Following  this,  a
signatory list will be collected to ensure that all staff have read and understood
the policy and its implications for patients presenting with self harm.

e) Reporting of the current status of the actions C1 and C2

(W)(cid:0) = Not yet started

(G)(cid:0)-=Completed

(A(cid:0)= In progress

:i-/.._--:--?-.'-(cid:0):-··(cid:0)·(cid:127)t:

(cid:0)-(cid:0)►:.r:(cid:0):,'

, 

',

-

(cid:127)

11._(cid:127) 1,,

I(cid:127)

ng identified/ Action R
Leami
·
·

equired

Responsibility

I
1

llmescale
-

J RAG    Comments/Evidence(cid:0)f AchievemenVReason for

-

-

t

- .I

1

(cid:127) I

-- (cid:127)
Slippage

C1

Leaming Identified - Trust Wide - To comply and adhere to the self-harm policy to support patient safety
Action Required - Local
To complete the agreed process for searching
patients to maintain patient safety (this will form an
addendum to the self-harm policy

30th June 2025

G Self Harm Policy attached which includes

addendum 'fu!eSearch of Patients within ED'
(Appendix C) and has been uploaded to the
intranet

.

I

1

Matron Mental
Health Liaison
Team & 
ED
Consultant

C2 Action Required - Local

To share the self-harm policy across Emergency
Care with a reference to this patient safety incident
once the addendum as above has been added.

Matron Urgent
Care

30th July 2025

Self Harm Policy V3
04.2025.doc

G

 has emailed SOP to ED, EADU

and Ward 16.

(cid:0)

Self harm -
additional SOP .ms(cid:0)

f) Evidence of completion of actions C1 and C2 of the PSII action plan

Action C evidence
Self Harm Policy attached which includes
addendum 'SOP Search of Patients within
ED' (Appendix C) and has been uploaded to
the intranet.

Self Harm Appendix C -  Standard Operating
Procedure Search of Patients within the ED..

Attachments

(cid:0)
Self Harm
Policy.doc

LJ

Self harm - ED
additional Self Ham

9

 
 Conclusion and Next steps:

For matters of concern,

1.  No clinical handover to receiving ward.
2. No instructions passed on from the doctor re cardiac monitoring.

We have identified Ward Transfer and Handover as an important Patient Safety
Issue in the trust for action. There has been significant action achieved and
ongoing.

This has been highlighted at the Trust Patient Safety Improvement Group and
have discussed and agreed actions to address the issues identified , the group is
receiving ongoing update and assurance reporting, which will include audit
results going forward.

It is evident that there was a medical plan in place for cardiac monitoring,
identified during ED medical assessment and the clerking of the patient for
admission completed in ED. Cardiac Monitoring was in place in ED. However,
this requirement was not handed over via the clinical handover process between
ED and EADU nursing staff.  The patient was already clerked for admission by
the medical registrar but sadly the patient passed away before her next medical
review on EADU.

The Emergency Department Clinical Educator has completed Transfer Training
for ED at the ED educational away days, this included focussed training and
update on the Trust Patient Transfer and Escort Policy, regarding internal and
external transfers, the use of the ED transfer checklist, and the Emergency Care
Record documentation requirements.

The training highlighted the importance of effective communication between the
transferring and receiving department and undertaking the risk assessment tool
within the policy to determine who should transfer the patient. This will ensure
specific information such as cardiac monitoring is handed over in future. It is
currently being promoted as an ED hot topic at all handovers in ED.

For matters of concern,

3.  Patients own medication found in her belongings which had been with

her, after her death allowing her the opportunity to take another
overdose.

The updated Trust Self Harm Policy now contains the addendum 'Standard
Operating Procedure Search of Patients within the ED'.

This procedure describes the rationale behind searching patients attending the
ED in Mental Health crisis who are deemed to be medium to high risk of harm to
themselves or others. It lays out in detail eight points for staff to follow including,
Point3, "Patient's bags and clothing should be checked for medication, sharp
objects and potential ligatures. These should be removed and kept in a safe
place within the ED, clearly labelled with the patient's name."

 The purpose of this SOP is to reduce the risk of patients attempting further
overdose or self-harm during their time in the ED with items that they have
brought into the department with them.  Sadly, this was not fully completed in
Susan Young's case. Promotion of this SOP has been undertaken for all staff in
ED, including send ED staff a copy of the updated Self Harm Policy and ED
search of patients SOP. Face to Face promotion has been supported by our
Mental Health Liaison Matron and the lead nursing staff in ED. We acknowledge
there was a gap in monitoring of this element which we are ensuring is
addressed.

To support and evidence our addressing of all three matters of concern raised,
we have included the updated Trust Transfer Policy, including the trust handover
process which has been communicated  and promoted to staff, the summary of
the policy expectations that has been communicated  to ED staff, evidence of the
associated staff training undertaken and a copy of the ED Patient Handover Form
now in use for all patient transfers. An audit of the implemented ED Patient
Handover Form is scheduled in September and will be ongoing monthly until
results demonstrate good and consistent compliance.

Evidence of the updated Self Harm policy and addendum of Standard Operating
Procedure Search of Patients within the ED and evidence communication of this
to ED staff which has been supported by a signing list has been included in our
response.

I  trust  that  this  adequately  addresses  the  concerns  raised  in  the  Regulation  28
Report. However, should you require any further clarification regarding this, or any
other case, please do not hesitate to contact the Trust.

Yours sincerely

Executive Managing Director

11

Our ref: SG/EMD/LT/SY0825 

29th August 2025 

Yvonne K Blake 
Area Coroner 
Norfolk Jurisdiction 
County Hall 
Martineau Lane 
Norwich 
NR1 2DH 

Dear Ms Blake  

Lowestoft Road
Gorleston
Great Yarmouth
Norfolk
NR31 6LA

Main Switchboard: 01493 452452

Email:

www.jpaget.nhs.uk

RE: Regulation 28 – Report to Prevent Future Deaths 

I am writing to acknowledge receipt of the Regulation 28 - Report to Prevent Future 
Deaths,  issued  to  the  James  Paget  University  Hospital  NHS  Foundation  Trust 
(JPUH) following the inquest into the death of Miss Susan Young, which was heard 
and  closed  on  7th  May  2025,  and  received  via our  Legal  Services  Provider  on  27th 
June 2025. 

I note your concerns as follows: 

During  the  course  of  the  investigation  my  inquiries  revealed  matters  giving  rise  to 
concern.  In my opinion there is a risk that future deaths could occur unless action is 
taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows: 
(brief summary of matters of concern) 

No clinical handover to receiving ward.  
No instructions passed on from the doctor re cardiac monitoring. 
Patients own medication found in her belongings which had been with her, after her 
death allowing her the opportunity to take another overdose. 

The medical cause of death was: 
1a) Cardiac Arrest 
1b) Mixed Overdose (Including Sertraline, Paracetamol and Promethazine) 

Circumstances Of The Death 
Miss  Young  was  admitted  to  hospital  on  23rd  August  2024,  having  taken  an 
overdose  of  prescription  medication.  This  was  not  her  first  overdose.  She  was 
prescribed  amongst  others  Sertraline,  Gabapentin  and  Clonazepam  which  has  the 
effect of prolonging the Q wave, the heart rhythm. She had taken an overdose on the 
22nd  August  2024.  When  this  had  not  succeeded  taken  another  on  23rd  August 
2024.  She  was  monitored  appropriately  whilst  in  the  emergency  department  and 
transferred to a ward with directions that she be attached to cardiac monitoring.  

When nursing staff took her to the ward, they did not give any handover and certainly 
no  instructions  about  cardiac  monitoring.  Miss  Young  was  found  unresponsive  and 
not attached to any monitoring. Resuscitation failed. It is thought that the medication 
may have had a cumulative effect. When the nurses were packing up her belongings, 
they  found  more  unused  medication  which  had  been  left  with  the  patient.  It  is  not 
known if she had taken any of this. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The inquest concluded that:  
The  Patient  suffered  various  cardiac  problems,  including  a  previous  heart  attack.  
Patient  was  also  prescribed  a  medication  for  epilepsy  which  has  the  side  effect  of 
prolonging  the  QT  interval  in  the  heart  rhythm  and  can  precipitate  cardiac 
arrhythmias.  Patient was found deceased in bed by nursing staff. 

I note that the JPUH was not required to attend the inquest, and we were, therefore, 
unable  to  provide  clarification  regarding  these  concerns.  However,  upon  receipt  of 
the Regulation 28, an investigation into these matters of concern was commenced. 

1.  No clinical handover to receiving ward.  
2.  No instructions passed on from the doctor re cardiac monitoring. 
3.  Patients own medication found in her belongings which had been with her, 
after her death allowing her the opportunity to take another overdose. 

Our Investigation Findings: 

Matters of concern  
1.  No clinical handover to receiving ward 
2.  No instructions passed on from the doctor re cardiac monitoring. 

A Patient Safety Incident Investigation (PSII) was conducted regarding Miss Young's 
case, and the report was shared with you before the inquest. The investigation 
finding on matters of concern 1 & 2 are reported below.   

a)  The PSII report included the following statements: 

The statements below are copied from the PSII report. 

The JPUH Patient Transfer and Escort Policy as implemented in March 2023 lays out 
the standard of in-hours and out of hours internal and external transfer and escort 
that are required for the safety of all patient groups (Adult, Paediatric, Neonatal - via 
weblink and Maternity) who are admitted or being transferred and escorted within or 
from the James Paget University Hospital. The policy refers to suitable escorts being 
identified by the use of the risk assessment tool, National Early Warning Scoring 
system and patient categories levels of care. The need for responsibility and 
accountability for allocated competent escorts and for those that escort to be 
competent to escort patients, to be both responsible and accountable whether 
registered our unregistered staff. 

The transfer of Miss Young without a clinical handover had an impact on both Miss 
Young and staff caring for her. Reference has been made to the omissions of cardiac 
monitoring, the hourly observations, and the cardiopulmonary status of Miss Young. 
If  cardiac  monitored,  it  may  have  picked  up  a  treatable  rhythm  that  may  have 
required a cardiac shock, therefore the need for clear documentation of the what ifs 
with Miss Young, as a cardiac shock may not have been agreed to by Miss Young, 
and it doesn’t mean that by providing a shock this would be successful, considering 
the  prolonged  QT,  that  had  already  received  magnesium  as  the  main  treatment  to 
reduce the risk of a life threatening arrhythmia. 

Miss  Young  was  transferred  to  the  Emergency  Assessment  and  Discharge  Unit 
(EADU),  this  transfer  occurred  without  a  clinical  handover,  this  contributed  with  an 
outcome  of  Miss  Young  not  receiving  either  hourly  observations  or  cardiac 
monitoring. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 It is apparent that Miss Young is transferred to the EADU allocated to a bed within 
the acute visible bay (a bay that allocated patients who require a higher need for 
visibility/monitoring), therefore it appears that a handover of source was completed, 
it’s difficult to ascertain if the bay was allocated due to further risk of self-harm or 
cardiac monitoring or both, although the registered nurse in EADU shares that they 
were not aware that Miss Young required cardiac monitoring, therefore high 
probability is that allocation was assigned due to further risks of self-harm. 

During  Miss  Young’s  attendance  on  the  23rd  of  August  2024,  she  received 
intravenous  medication  as  advised  by  Toxbase  (clinical  toxicology  database),  this 
was administered to support a potential prolonged heart rhythm delay (prolonged QT) 
of  which  was  noted  within  a  tracing  of  her  heart  as  conducted  on  the  day,  further 
advice was for  cardiac monitoring.  There  appeared  to  be  high risk that Miss  Young 
may  experience  a  life-threatening  arrhythmia  such  as  Torsades  de  Pointes,  hence 
the reason for treatment and cardiac monitoring.  

Following Toxbase advice Miss Young is attached to a cardiac monitor within the 
Emergency Department, it is not apparent from documentation or on speaking with 
staff as to what they would be observing for by being attached to the cardiac monitor. 
It is not apparent from nursing staff caring for Miss Young of the risks of a prolonged 
QT, this is corroborated by Miss Young not being monitored on transfer from ED to 
EADU. 

b)  The PSII findings related to the Matters of Concern 1 & 2 are reported 

below: 

There is omission of a clinical handover from EADU to ED through a face-to-face 
handover considering Miss Young has risks highlighted, such as further self-harm 
and the need for cardiac monitoring.  

The transfer from ED to EADU supervision and engagement assessment is not 
completed within the Emergency Care Record document, in addition to the non-
completion of the transfer checklist. 

Action is required on the expectations of a clinical handover from the ED with 
consideration to the request for visible acute bay on EADU, cardiac monitoring, 
hourly NEWS recordings and the risk of further self-harm. 

The  medical  plan  agreed  is  for  intravenous  fluids,  a  blood  sugar  check,  to  start 
Intravenous  N-acetylcysteine  (NAC)  (medication  to  treat  paracetamol  overdose),  to 
prescribe  and  administer  magnesium  2  grams  intravenously  (is  the  first  line  of 
treatment for  severe QT  prolongation),  for  cardiac  monitoring,  bloods and a venous 
blood gas and to refer to the medical team. 

The  actions  as  documented  within  the  plan  are  followed  and  implemented,  this 
includes  the  prescribing  and  administering  of  magnesium  2  grams  intravenously 
(magnesium  sulphate  is  the  first  line  treatment  for  severe  QT  prolongation,  even  if 
the  levels  are  normal  and  is  administered  to  prevent  Torsades  De  Pointes  (TDP), 
magnesium reduces the risk of arrhythmias. It also helps in slow heart rates such as 
bradycardia  and  therefore  reduces  arrythmia  risk  even  when  bradycardia  is  the 
primary cause) the request for cardiac monitoring, both to support the prolonged QT 
with referral to the medical team. 

Following  Toxbase  advice  Miss  Young  is  attached  to  a  cardiac  monitor  within  the 
Emergency  Department,  it  is  not  apparent  from  documentation  or  on  speaking  with 

3 

 
 
 
 
 
 
 
 
 
 
 staff as to what they would be observing for by being attached to the cardiac monitor. 
It is not apparent from nursing staff caring for Miss Young of the risks of a prolonged 
QT, this is corroborated by Miss Young not being monitored on transfer from ED to 
EADU. 

Miss Young is omitted to receive cardiac monitoring whilst an inpatient on EADU as 
requested 

The transfer of Miss Young without a clinical handover had an impact on both Miss 
Young and staff caring for her. Reference has been made to the omissions of cardiac 
monitoring, the hourly observations, and the cardiopulmonary status of Miss Young. 
If cardiac monitored, it may have picked up a treatable rhythm that may have 
required a cardiac shock, therefore the need for clear documentation of the what ifs 
with Miss Young, as a cardiac shock may not have been agreed to by Miss Young, 
and it doesn’t mean that by providing a shock this would be successful, considering 
the prolonged QT, that had already received magnesium as the main treatment to 
reduce the risk of a life threatening arrhythmia. 

There  is  omission  of  a  clinical  handover  from  EADU  to  ED  through  a  face-to-face 
handover  considering  Miss  Young  has  risks  highlighted,  such  as  further  self-harm 
and the need for cardiac monitoring. 

If  my  mum  had  received  cardiac  monitoring  could  any  intervention  have 
occurred to reduce the risk of my mum’s heart stopping. 
This  question  was  asked  of  the  lead  cardiologist  who  shared  that  if  cardiac 
monitoring  was  in  place prior to  Miss  Young’s  death,  it  potentially  may  have  picked 
up  a  rhythm  that  may  have  triggered  further  specialist  discussion  as  to  next  steps, 
with Miss Young being at the heart of the discussion.  

Discussion  may  have  included  the  most  appropriate  place  to  monitor  Miss  Young, 
considering  the  high  risk  of  a  life-threatening  arrhythmia  such  as  Torsades  de 
Pointes. Prior to cardiac arrest a treatable rhythm may have been identified, this may 
be a rhythm that required a controlled cardiac shock; therefore, the understanding of 
the what ifs are so important for Miss Young, considering that she wished not to be 
for resuscitation of which includes a cardiac shock. 

IV  magnesium  as 
Miss  Young  had  received 
administered in ED to reduce the risk of a life-threatening arrhythmia. The staggered 
additional  prescribed  medication  overdose  may  have  lengthened  the  QT  further 
considering the QT was within normal range in June 2024.  

for  prolonged  QT; 

treatment 

Following  the  toxicology  of  blood  samples  there  were  traces  of  concentrations  of 
Paracetamol and Promethazine were detected along with therapeutic concentrations 
of  Sertraline,  Gabapentin,  and  Codeine.  Full  interpretation  of  these  findings  should 
consider  the  time  between  ingestion,  hospital  admission  and  death.  Paracetamol 
should  be  interpreted  along  with  findings  from  liver  histology.  There  has  been  prior 
Clonazepam use. Roxithromycin, Atorvastatin, Bisoprolol and Loperamide were also 
detected. 

c)  The PSII Actions and their status shared with you prior to the inquest: (an 

update on the progress of the actions is reported in section e)   

4 

 
 
 
 
 
 
 
 
 
 
 , Deputy Lead Nurse, Division of Medicine, Diagnostics & Clinical Support 

Services provided a statement for the inquest on the 27th of May 2025. The 
statement provided added information and assurance around the actions being 
undertaken.  

d)  Statement Content regarding Actions D1 and D2 

Action  D1  –  To  complete the  Emergency  Care transfer  safety  checklist as seen 
within the Emergency Care record, to support safe transfer of patients from ED to 
EADU,  by  relaunching  the  safety  checklist  with  registered  nurses  in  Emergency 
Care. 

Action  D2  –  To  include  the  patient  transfer  policy  as  part  of  the  relaunch  that 
highlights within, the transfer escort checklist, if one of the following apply to this 
patient then an escort is required this includes any patient that causes concern 
as in this scenario. 

i. 

ii. 

I can confirm that the Clinical Educator has completed transfer training at the 
ED  educational  away  days,  which  included  training  on  the  transfer  checklist 
within the emergency care record documentation and the patient transfer and 
escort policy. These were held on the 4th and 9th April and the 7th and 16th May 
2025.  68% of the current ED nursing and support staff attended. In addition, 
the Clinical Educator circulated the patient transfer and escort policy and the 
transfer  checklist to  all  staff via  email.  Those who  were  unable to  attend  the 
away  days  due to sickness or maternity  leave will  attend a bespoke training 
session  at  the  earliest  opportunity.  A  signatory  list  will  be  commenced  to 
ensure all ED nursing staff have read and understood the policy and checklist.  

The  training  reviewed  the  patient  transfer  and  escort  policy  and  included 
information  regarding  internal  and  external  transfers.  This  highlighted  the 
importance of effective communication between the transferring and receiving 
department  and  undertaking  the  risk  assessment  tool  within  the  policy  to 
determine  who  should 
the  patient.  This  will  ensure  specific 
information such as cardiac monitoring is handed over in future.  

transfer 

5 

 
 
 
 
 
 
 
 
 
 iii. 

iv. 

v. 

vi. 

Whilst the remaining staff are captured in the bespoke training sessions, the 
Clinical Educator will complete safety checklist compliance audits monthly to 
provide assurance that the process is embedded. This audit is in the planning 
phase;  however,  it  is  anticipated  this  will  enable  the  team  to  monitor 
compliance,  identify  any  gaps  and  support  the  team  with  any  additional 
training needs.  

EADU  nursing  leadership  have  supported  staff  to  complete  safety  huddles 
following  this  incident,  which  included  information  about  this  incident,  initial 
learning including the requirement of a nurse escort when clinically required.  
Additionally, staff escalate to the Nurse in Charge on EADU if they have any 
clinical  concerns  about  patients  who  are  transferred  from  ED,  the  Nurse  in 
Charge  will  discuss  this  with  the  ED  nurse  in  charge  to  gain  further 
information  about  the  patient.  A  QSAFE  incident  is  completed  if  there  are 
concerns about patient transfers and learning from these incidents is shared 
with the teams.   

A three month historical search of QSAFE has identified no further concerns 
regarding  transfers  from  ED  to  EADU.    QSAFE  incidents  are  reviewed  daily 
by  the  matron  team  via  the  matron  safety  huddle  and  subsequently  at  the 
Trust’s  daily  incident  triage  meeting,  with escalation  to the  safety  action  and 
assurance group (SAAG).  Any themes and trends are escalated through the 
relevant  insight  group  and  learning  is  supported  by  the  division  and  the 
corporate nursing team.  

As a Trust, we are developing a communication process for handover with a 
task  and  finish  group  commencing  23rd  May  2025.  This  includes  leads  from 
each  department  including  ED  and  EADU.  The  flow  chart  is  in  the  design 
phase,  with  an  aim  to  commence  the  new  process  mid-June.  Specialist 
requirements  for  the  patient  including  cardiac  monitoring  will  be  included  in 
the  handover  template.  Once  embedded,  an  audit  will  take  place  to  monitor 
compliance and identify gaps needing further education and support.   

e)  Reporting of the current status of the actions D1 and D2 

6 

 
 
 
 
 
 f)  Evidence of completion of actions D1 and D2 of the PSII action plan 

Action D Evidence  
Clinical Educator transfer training 
completed at ED educational away days 
(register attached).  

Attachments  

Internal risk assessment tool for 
transferring a patient shared.  
Key points from transfer policy shared 
with staff.  

ED Patient Handover Form now in use  

Matter of Concern  

3.  Patients own medication found in her belongings which had been with her, 

after her death allowing her the opportunity to take another overdose. 

a)  The  PSII  report  included  the  following  statements  related  to  Matter  of 

Concern 3: 

The statements below are copied from the PSII report. 

There are documented risk checklists evident within ED for those patients attending 
with self-harm, in addition to further risk assessments evident  within the emergency 
care record for those patients being admitted to an inpatient bed. 

Patients own medication found in her belongings which had been with her, after her 
death allowing her the opportunity to take another overdose. 

Strips  of  medications  were  found  within  Miss  Young’s  property  following  her 
unexpected death. 

In  that  medication  bag  contained  20X  full  strips  of  X6  loperamide,  3  strips  of  10 
loperamide  +  one  empty  strip  of  10  tablets.  2x  empty  strips  of  6x  loperamide,  3x 
strips of 10 tablets of zapain 30/500mg with 3 tablets missing.  

It is unclear how this was missed when the HCA was doing the property list. 2X bags 
of medication  were  locked  in the  locker,  we  cannot  be  sure nothing  else  was taken 
on the ward.  

The  patient  was  in  a  visible  bay  and  all  staff  informed  of  the  ligature  risk. 
observations were taken at 16:50 stable. The clerking notes do state that it was not 
just a paracetamol OD it was multiple drugs, and patient had a prolonged QT and the 
plan  states  cardiac  monitor  which  patient  was  not  put  on,  the  patient  had  NAC  in 
place. 

7 

7th May away day register.pdf9th April away day register.pdf4th April away day register.pdfED SBAR Handover 2025.docx 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 b)  The PSII findings related to Matter of Concern 3 were. 

JPUH Self Harm Policy 
This policy and procedure as implemented in March 2024 provides clear guidance to 
staff  in  relation  to  providing  a  safe  environment  for  a  patient  who  is  at  risk  of  self-
harm.  This  includes the  assessment  of  the  risk  and  the  management  of  the  patient 
and guidance on the removal of items from the patient environment which could be 
used to self-harm. 

The  National  Institute  of  Health  and  Clinical  Excellence  (NICE)  have  published  a 
Self-Harm  Quality  Standard  Number  34  (NICE  2022)  and  Clinical  Guidance  225 
(NICE  2022).  This  policy  does  not  replace  the  responsibility  of  all  staff  involved  to 
apply NICE quality standards and clinical guidance appropriately. 

There appears to be no evidence of consideration of the level of enhanced 
supervision or to environmental risk i.e. medications, especially as property listed 
belonging to Miss Young following her death contained strips of both used and 
unused medications. 

The need for staff to comply and adhere to the self-harm policy to support patient 
safety 

To clarify expectations of a clinical handover from the ED with consideration to the 
request for visible acute bay on EADU, cardiac monitoring, hourly NEWS recordings 
and the risk of further self-harm. 

c)  The PSII Actions and their status shared with you prior to the inquest: (an 

update on the progress of the actions is reported in section e)   

d)  Statement Content regarding Actions C1 and C2 

i.  Action  C1  –  To  complete  the  agreed  process  for  searching  patients  to 
maintain patient safety (this will form an addendum to the self-harm policy.) 
I can confirm that the Trust’s Self Harm Policy (copy attached) now includes 
an addendum (Appendix C) an SOP (Standard Operating Procedure) Search 
of Patients within the ED.  The policy describes the rationale behind searching 
patients attending the ED in Mental Health crisis to reduce the risk of patients 

8 

 
 
 
 
 
 
 
 
 
 
 
 
 attempting  further  overdose  or  self-harm  during  their  time  in  the  ED.    The 
updated policy has been uploaded to the Trust’s intranet. 

ii.  Action  C2  –  To  share  the  self-harm  policy  across  Emergency  Care  with  a 
reference  to  this  patient  safety  incident  once  the  addendum  as  above  has 
been added. 
I can confirm that the search policy has been shared with all ED clinical staff 
on  the  16th  April  2025  and  was  added  to  the  self-harm  policy  as  an 
addendum which is available on the intranet for all staff to access.  Following 
this,  a  signatory  list  will  be  collected  to  ensure  that  all  staff  have  read  and 
understood  the  policy  and  its  implications  for  patients  presenting  with  self 
harm.  

e)  Reporting of the current status of the actions C1 and C2  

f)  Evidence of completion of actions C1 and C2 of the PSII action plan 

Attachments  

Action C evidence  
Self Harm Policy attached which includes 
addendum ‘SOP Search of Patients within 
ED’ (Appendix C) and has been uploaded to 
the intranet. 

Self Harm Appendix C – Standard Operating 
Procedure Search of Patients within the ED..

9 

Self Harm Policy.doc 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Conclusion and Next steps:  

For matters of concern,  

1.  No clinical handover to receiving ward.  
2.  No instructions passed on from the doctor re cardiac monitoring. 

We have identified Ward Transfer and Handover as an important Patient Safety 
Issue in the trust for action. There has been significant action achieved and 
ongoing.  

This has been highlighted at the Trust Patient Safety Improvement Group and 
have discussed and agreed actions to address the issues identified , the group is 
receiving ongoing update and assurance reporting, which will include audit 
results going forward.  

It is evident that there was a medical plan in place for cardiac monitoring, 
identified during ED medical assessment and the clerking of the patient for 
admission completed in ED. Cardiac Monitoring was in place in ED. However, 
this requirement was not handed over via the clinical handover process between 
ED and EADU nursing staff.  The patient was already clerked for admission by 
the medical registrar but sadly the patient passed away before her next medical 
review on EADU.  

The Emergency Department Clinical Educator has completed Transfer Training 
for ED at the ED educational away days, this included focussed training and 
update on the Trust Patient Transfer and Escort Policy, regarding internal and 
external transfers, the use of the ED transfer checklist, and the Emergency Care 
Record documentation requirements.  

The training highlighted the importance of effective communication between the 
transferring and receiving department and undertaking the risk assessment tool 
within the policy to determine who should transfer the patient. This will ensure 
specific information such as cardiac monitoring is handed over in future. It is 
currently being promoted as an ED hot topic at all handovers in ED.  

 For matters of concern, 

3.  Patients own medication found in her belongings which had been with 

her, after her death allowing her the opportunity to take another 
overdose. 

The updated Trust Self Harm Policy now contains the addendum ‘Standard 
Operating Procedure Search of Patients within the ED’.  

This procedure describes the rationale behind searching patients attending the 
ED in Mental Health crisis who are deemed to be medium to high risk of harm to 
themselves or others. It lays out in detail eight points for staff to follow including, 
Point3, “Patient’s bags and clothing should be checked for medication, sharp 
objects and potential ligatures. These should be removed and kept in a safe 
place within the ED, clearly labelled with the patient’s name.”  

The purpose of this SOP is to reduce the risk of patients attempting further 
overdose or self-harm during their time in the ED with items that they have 

10 

 
 
 
 
 
 
 
 
 
 
 
 
 
 brought into the department with them.  Sadly, this was not fully completed in 
Susan Young’s case. Promotion of this SOP has been undertaken for all staff in 
ED, including send ED staff a copy of the updated Self Harm Policy and ED 
search of patients SOP. Face to Face promotion has been supported by our 
Mental Health Liaison Matron and the lead nursing staff in ED. We acknowledge 
there was a gap in monitoring of this element which we are ensuring is 
addressed.      

To support and evidence our addressing of all three matters of concern raised, 
we have included the updated Trust Transfer Policy, including the trust handover 
process which has been communicated and promoted to staff, the summary of 
the policy expectations that has been communicated to ED staff, evidence of the 
associated staff training undertaken and a copy of the ED Patient Handover Form 
now in use for all patient transfers. An audit of the implemented ED Patient 
Handover Form is scheduled in September and will be ongoing monthly until 
results demonstrate good and consistent compliance.  

Evidence of the updated Self Harm policy and addendum of Standard Operating 
Procedure Search of Patients within the ED and evidence communication of this 
to ED staff which has been supported by a signing list has been included in our 
response.    

I  trust  that  this  adequately  addresses  the  concerns  raised  in  the  Regulation  28 
Report.  However,  should  you  require  any  further  clarification  regarding  this,  or 
any other case, please do not hesitate to contact the Trust. 

Yours sincerely 

Chief Nurse 
Director of Infection Prevention and Control 
Honorary Fellow – University of East Anglia 

11