Abbigail Smith

HM Area Coroner  
Ms Sonia Hayes  
Seax House 
Victoria Road South 
Chelmsford  
Essex CM1 1QH 

Dear Ms Hayes  

Date: 21 July 2026 

Regulation 28 Report to Prevent Future Deaths- Ms Abbigail Smith 

I write further to your Regulation 28 Report to Prevent Future Deaths (‘PFDR’) dated 
27 May 2026, relating to the Inquest of Ms Abbigail Smith (‘Abbi’).  

We have considered your concerns and set out our formal response to each matter 
using your numbering as follows. 

Matters of Concern  

1.  There  were  not  sufficient  trained  staff  to  conduct  the  enhanced  observations 
required to monitor Abbi  with her known risk of severe self-harm whilst she was 
awaiting  assessment  under  the  Mental  Health  Act  and  actively  attempting  to 
take her own life.  

Upon review of the relevant rotas, we can confirm that staffing on the night of 26.01.22 
was  adequate  with  15  Registered  Nurses  and  9  Health  care  assistants  and  one 
registered Nurse that worked a twilight shift 1500-0300. The optimum staffing levels 
at that time for a night shift was 16 Registered Nurses and 9 Healthcare Assistants. 

We acknowledge the concerns of HM Coroner that lack of staffing led to the provision 
of a security guard in order to support the Mental Health Team. We have not identified 
any evidence of a Trust-employed security staff being allocated to patients that night, 
as would usually be documented. In any event, we are not able to comment on staffing 
of  the  mental  health  team  which  would  fall  within  the  remit  of  Essex  Partnership 
University Foundation Trust (EPUT).  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  For  a  period  of  time  Abbi  was  left  under  the  observation  of  staff  that  were 
security personnel and were not appropriate or trained to undertake this work. 
Male security staff were informed that Abbi should use a commode due to her 
presenting  risks  and  there  were  not  sufficient  trained  female  staff  available. 
There  had  been  a  previous  incident  where  actions  taken  to  restrain  Abbi  by 
security  personnel  caused  her  trauma  and  there  had  been  an  allegation  of 
assault, this was not considered in this admission. 

I  understand  that  the Court has been  provided  with  an  updated  copy  of  the  Trust’s 
Policy  for  Enhanced  Supervision  and  Engagement.  This  policy  strengthens  our 
assessment  and  guidance  for  patients  requiring  enhanced  supervision  as  per  the 
attached tool. 

Under  the  terms  of  the  policy,  where  a  patient  meets  the  threshold  for  Enhanced 
Supervision,  the  patient’s  views  should  be  considered  when  determining  the 
appropriate member of staff to conduct the observation. Staff should also engage with 
the relevant family member/ carer/ key professional/ Lasting Power of Attorney and 
keep  them  informed  about  the  care  plan  and  the  enhanced  supervision  which  is  in 
place.  

In  Abbi’s  case,  there  should  have  been  discussion  about  Abbi’s  previous  history 
regarding  restraint,  and  discussions  should  have  taken  place  as  to  how  enhanced 
supervision could have been put in place in a manner which was supportive to Abbi. 

3.  Abbi at times had to be physically and chemically restrained due to the level of 
distress and harm to herself. During her admissions Abbi was able to access 
ligature  material    that  she  tied  around  her  neck  on  multiple  occasions  over 
multiple days including her socks, cords from her clothing and pull cords in the 
bathroom.  There  were  no  appropriate  care  plan  and  risk  assessments  to 
mitigate a significant known risk.  

I am aware that the Court has been provided with an updated copy of the Trust’s Policy 
for Ligature and Self Harm Awareness.  

This policy requires the performance of ligature risk assessments and recognises the 
potential use of clothing items as a ligature. Where it is identified that clothing could 
present a ligature risk, this will be assessed on a case-by-case basis with regards to 
the need to balance the patient’s dignity. Where a ligature item is not removed, the 
rationale for not removing the item and any mitigating actions should be documented 
and communicated with staff. 

4.  Abbi  was  a  complex  mental  health  patient  awaiting  assessment  under  the 
Mental Health Act and was being cared for in a part of the hospital that was not 
suitable for a patient who was actively attempting to take her life.  

 
 
 
 
 
 
 
 
 
 
 
 
 Our  Policy  for  Ligature  and  Self  Harm  Awareness  require  environmental  risk 
assessments to be performed in regard to clinical and non-clinical areas. These risk 
assessments are considered by staff before placing a potentially at-risk patient within 
the area. 

5.  Staff  left  Abbi  unsupervised  during  the  admission  to  attend  to  other  patients 

that permitted her to tie ligatures.  

Our Policy for Enhanced Supervision and Engagement, risk assesses patients at five 
different  levels.  As  Abbi  was  risk  assessed  as  Level  4  Enhanced  Supervision,  she 
should not have been left unsupervised due to the severity of her behaviours. 

Enhanced Supervision is part of mandatory training for all staff who are involved with 
providing enhanced supervision to patients.  

6.  No  adjustments  or  plans  were  made  for  communication  for  Abbi  as  a  patient 

with Autism and learning difficulty. 

For patients with Learning Disabilities, a Hospital Passport should be completed which 
includes questions such as ‘How I communicate and how you communicate with me’ 
and any sensory issues which may impact communication. 

For patients with Autism and or learning difficulties such as Abbi,  the Trust uses the 
Autism Health Passport which has been created by the National Autistic Society. This 
includes questions such as ‘How I would like you to communicate with me’ and ‘How 
I communicate.’  

Our specialist Learning Disabilities (‘LD’) Team is trained to support and advise staff 
on patient communication needs; any sensory needs or sensitivities; pain recognition; 
interaction  with  medical  history  and  any  medication  regimens;  and  to  ensure  
reasonable  adjustments  are  considered  in  line  with  the  Equality  Act  2010  and  the 
Mental Capacity Act 2005. For example, this may be facilitating a patient being placed 
in a quiet area away from populated waiting rooms and information being given that is 
free of jargon and medical terminology.  

In addition to the above, our LD Team and Autism Lead are available to support clinical 
teams with devising individual care plans and responding to learning difficulty support 
queries. Our clinical teams work collaboratively with the LD team ensuring as far as 
possible  that  appropriate  adjustments  are  made  for  patients,  providing  the  most 
therapeutic environment for their care. 

Our teams have reflected deeply on Abbi’s experience as evidence by the changes 
and improvements detailed above. We hope that these actions will assure the Court 
we  have  made  changes  to  our  practice  within  the  Trust,  and  we  are  committed  to 
ongoing learning from this case. 

 
 
 
 
 
 
 
 
 
 
 
 If I can assist further with these matters, please do not hesitate to contact me.  

   Yours sincerely, 

   Chief Executive 
   Mid and South Essex NHS Foundation Trust     

Enc: Appendix 1 Safe and Supportive non-clinical supervision of patients tool                      

 
 
 
 
 
 
  
  
 
 
 Affix Patient ID Label wholly inside this region

NON-CLINICAL SUPERVISION OF PATIENTS

NHS Foundation Trust

Family Name:

Given Name

Hospital No:

Gender:

Version:
Order Ref:
Approved:
Review By:
File Under:

1
MSESAFESUPP
14/11/2022
14/11/2024
Health Record\Clinical Record

ADD 
BARCODE

NHS No:

                                                                 DOB:

/ 

/

Affix Patient ID Label wholly inside this region

Form ID: GNH346
Do not write on or obscure the barcode

SAFE AND SUPPORTIVE NON-CLINICAL SUPERVISION OF PATIENTS

 
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YES

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 Decision Tree for the Safe Management of an At-Risk Patient

Risk assessment completed by ward staff.
Level 2, 3 or 4 supervision identified

Can the rota be altered to provide adequate supervisions of the patient from normal staffing levels?

YES

NO

No bank / agency required

Matron/CSM contacted for discussion of level 2, 3 or 4 and
how to support the wards’ provision of enhanced supervision

Re-assess patient’s level of risk 
every 24 hours unless there is 
an immediate concern about 
the patient’s behavioural or 
mental state

If concerns are identified and 
the patient is at risk refer back 
to the staffing decision tree

Patient is re-assessed

Is existing level of supervision 
still required?

NO

De-escalate by using the 
de-escalation flow chart 
(Appendix 6) and inform 
Matron/CSM, patient and 
relatives of decision. 
Document on 
re-assessment sheet

Matron/CSM must consider:
■  Can staff be deployed from another clinical area within the 

trust to provide additional cover?

■  Cohort nursing within the ward

YES

NO

Matron/CSM communicates 
decision to relevant ward. 
Management decision 
is documented in 
clinical record

The Matron must participate 
in the re-assessment of 
level or risk & supervision 
required every 24 hours and 
re-assess the wards’ staff 
at being able to provide the 
Enhanced Supervision in 
accordance with policy

YES

Matron/CSM provides the 
ward with authorisation for 
bank nursing request or for 
additional security presence 
and the management 
decision is documented in 
clinical record

Ward request additional 
staff from hospital bank

If no staff are available from 
the wider Trust or Bank, 
then a mitigation plan must 
be agreed with the Matron/
senior nurse and an 
incident form completed

Continue supervision and re-assess daily. 
Document on re-assessment sheet

 Staffing Decision Tree

Nurse in charge agrees the need for 
enhanced supervision

Ensure MCA/DoLS are complete

Level 3 and 4 supervision

Level 2 supervision

Supervision provided by 
ward staff

Yes

Can the level of supervision 
required be provided with 
the current staff 
establishment?

Ward devises a rota 
identifying which staff 
member will supervise 
the patient

No

Yes

This must be escalated to 
the Matron or CSM* or
HOOH** who review to 
see if staff can safely be
redeployed from other 
areas or from the 
nurse pool

Staff are aware of the 
level of supervision they 
are providing.
At level 3/4 agree who will 
relieve them for breaks/if 
they are called away to 
perform other care tasks 
or are otherwise 
called away

No

Staff providing level 3/4 
supervision must change 
every 2 hours

If extra staff cannot safely be obtained, then a mitigation plan should be agreed with the Matron and 
documented in the patient’s notes and an incident form completed. Where appropriate, staff to 
discuss with the NOK/Carers to make them aware of the risk and give them the opportunity to 
provide support if they are able, willing and it is safe to do so 

During any staff changeover a handover must be given. 
Any significant change in risk or behaviour must be escalated and documented in the patient’s notes. 
The risk and the level of supervision required must be reviewed and documented at a minimum daily 
to assess for the need for continued supervision 

*CSM – Clinical Site Manager
**HOOH – Hospital Out Of Hours

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 Flow Chart for De-escalation of Constant Enhanced Supervision

Level 3 or 4 patient, requiring constant ‘arm’s length’ enhanced 
supervision where a decision has been made to reduce the level of 
enhanced supervision

15-minute intermittent 
supervision for 4 hours

Behaviour or mental 
state has deteriorated

Reinstate Constant 
‘arm’s length’ Enhanced 
Supervision and discuss 
with Matron / Medical 
Team & document

Behaviour or agitation 
has deteriorated

Behaviour or mental 
state has deteriorated

Behaviour or mental 
state has improved

15-minute intermittent 
supervision for 2 hours. 
Discuss with Matron / 
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Patient Health Record

Behaviour or mental 
state has deteriorated

Behaviour or mental 
state has improved

30-minute intermittent 
supervision minimum 
of 2 hours.
Document and inform 
Matron

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Supervision may be stopped, document in 
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Behaviour or mental 
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OR Incident or near miss

 
 
 
 
 
 
 
 
 STAFF GUIDE WHEN PROVIDING ENHANCED SUPERVISION FOR PATIENTS

 ƒ Being an inpatient can be one of the loneliest places you’ll ever be and explains why patient 

engagement is so important.

 ƒ Conversation is the most powerful form of engagement and below are some ideas of topics of 

conversation plus some other activities to promote patient engagement.

 ƒ Ensure patient activities and engagement are documented including the outcome the activity or 

engagement has had on the patient’s mood and / or behaviour.

 ƒ Always use the patients ‘This is Me’ document or Hospital Passport if available
 ƒ Please ensure your patient is not in any pain. (Consider Abbey pain scale)

Engagement can include the following
 ƒ Encourage patients to be independent with their activities of daily living including toileting, washing and 

dressing, nutrition and hydration

 ƒ Engage in activities that elicit sensory-motor feedback and assist with orientation such as reading a 

news article, providing a clock and calendar

 ƒ Mechanisms for Calming – going to a space that is less noisy and busy, or with reduced lighting, and:

 ƒ VERA (Validation, Emotion, Reassure, Activity) – acknowledge their reality (even if different to ours) and 
acknowledge their feeling and empathise. (This is me has a section about what worries the person and 
what makes them feel better)

 ƒ Mechanisms for Soothing – music, sensory activities, weighted blanket.

 ƒ Mechanisms for distracting attention – music, popping bubble wrap, colouring-in, games

 ƒ Engage the patient in a personal care activity - sensory, nutritional, self-awareness.

 ƒ Utilise the therapy staffs’ skills and knowledge to help encourage physical activity including walking 

around the ward, garden or around the grounds

 ƒ Engage the patient in a self-care task washing, dressing, make-up, hair, shaving

 ƒ Engage the patient in a food/drink-based task

 ƒ Engage the patient in a sensory activity such as self-massage, relaxation, soft music.

 ƒ Social Interaction — (Respect patient’s right for silence!). If patient wishes to talk, talk and introduce 

general conversation topics. Reminisce over their previous or current hobbies or interests.

Documentation examples
 ƒ Observed behaviour – getting up to leave, calling out, aggression, hallucination

 ƒ Observed thoughts – belief, opinion, paranoid, irrational, perception

 ƒ Observed Mood – happy, sad, anxious, frustrated, angry, content, calm

 ƒ Observed Physical – pain, withdrawn, hitting out, physiological changes (sweating / panting), urine 

retention, constipation

 ƒ Environmental – dark, noisy, bay, side room, cold, hot, day, night, bed or ward move

 ƒ What is the patient communicating? – desire to leave, pain, boredom, toileting, loneliness, fear, hunger, 

thirst

 ƒ Potential triggers – family leaving, pain, personal care, toileting

 ƒ Emotional interventions – reassurance, meaningful activities, talk about family, reminiscence

 ƒ Physical Interventions – taken to the toilet, analgesia, given food/drink, taken for a walk, changed clothes

 ƒ Environmental Interventions – trigger removed, allocated to side room, break out area found, take out to 

garden

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