7 Feb 2023 Ania Sohail · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to separately record post-leave assessment completion and outcomes View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Ania Sohail · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to separately record post-leave assessment completion and outcomes
Wider context from the report “(7) There is no requirement to make a separate entry evidencing that a post-leave assessment has been undertaken . The post-leave assessments are currently subsumed within Day Notes and do not clearly state whether an assessment was undertaken, what was discussed and the outcome of the assessment .
” Source location Ania Sohail · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and share an inpatient leave care bundle covering safe community leave, return, and pre- and post-leave assessments.
Verbatim wording from the response “The Trust has developed an inpatient ‘Care Bundle – Leave from inpatient units’. The care bundle provides guidance to staff when supporting service users who are inpatients to access leave into the community and return to the ward safely. The care bundle prompts staff to complete pre and post-leave assessments and where to document these. This care bundle has been shared with all inpatient staff through established communication systems and was featured in the Patient safety Newsletter in January 2023.” Source location Response from Greater Manchester Mental Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit pre- and post-leave assessments and related documentation.
Verbatim wording from the response “An audit of pre and post leave assessments and related documentation will be carried out by the ward manager by the end of May 2023.” Source location Response from Greater Manchester Mental Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Inpatient Leave Care Bundle sets clear expectations for undertaking and recording pre- and post-leave assessments.
Verbatim wording from the response “(7) There is no requirement to make a separate entry evidencing that a post-leave assessment has been undertaken. The post-leave assessments are currently subsumed within Day Notes and do not clearly state whether an assessment was undertaken, what was discussed and the outcome of the assessment.” Source location Response from Greater Manchester Mental Health
Open published response
27 Jan 2023 Jayden Andrew Booroff · Prevention of Future Deaths report Essex
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Concerns raised 1
Lack of understanding of the distinction between an unauthorised absence after section 17 leave and an escape from a detained ward patient View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jayden Andrew Booroff · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jayden Andrew Booroff died after absconding from The Linden Centre and being struck by a train on 23 October 2020. The report identified concerns about risk assessments, observation levels, ward security, absconsion procedures, record keeping, medication, and communication between healthcare professionals and emergency services.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of understanding of the distinction between an unauthorised absence after section 17 leave and an escape from a detained ward patient
Wider context from the report “(2) There is a lack of understanding at Essex Partnership NHS Foundation Trust level about the difference between :
a. a patient who has been granted section 17 leave under the Mental Health Act who does not return from a period of authorised leave , and
b. a patient who being subject to detention under the Mental Health Act, who has escaped from the confines of the ward and who has not been granted section 17 leave by the Responsible Clinician
and therefore, there is a concern as to how this information is then communicated to emergency services searching for the patient of the risks of self-harm.
” Source location Jayden Andrew Booroff · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
Verbatim wording from the response “In light of communication with emergency services, in collaboration with the Trust’s Lessons Team, a one-page aide-mémoire was created to support staff to escalate concerns to the police for incidents where a patient does not return from leave or they have absconded from the ward. This guidance provided information regarding the impact factors that should be verbalised to the police when reporting a person missing. This would then enable the police to make an informed decision in relation to their response. This document uses the SBARD communication tool (Situation, Background, Assessment, Recommendation, Decision). This document was shared with operational managers for cascading to front line staff and calls will be audited between EPUT and Essex Police to ascertain the effectiveness of the tool.” Source location Response from Essex Partnership University
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21 Oct 2022 Daniel John O’Sullivan · Prevention of Future Deaths report Inner South London
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Concerns raised 2
Delays in alerting police when psychiatric patients fail to return from leave View source Poor contemporaneous documentation of unescorted leave View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Central and North West London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Central and North West London NHS Foundation Trust
Update the Missing Informal Patient Policy with a risk-assessment checklist and flow chart for managing patients who fail to return from leave.
View source
Central and North West London NHS Foundation Trust
Establish hourly ward accounting of patients during each shift, with responsibility allocated to the nurse in charge.
View source
Central and North West London NHS Foundation Trust
Review Datix recording of police contact during AWOL incidents to monitor reporting timeliness and escalate unnecessary delays.
View source
Central and North West London NHS Foundation Trust
Update the Missing Informal Patient Policy to specify police-contact information required in SystmOne and Datix records.
View source
Central and North West London NHS Foundation Trust
Develop Quick Reference Guides supporting staff use of the electronic clinical record system and care-planning templates.
View source
Central and North West London NHS Foundation Trust
Record each informal-leave episode on a paper form and upload it to the clinical record.
View source See 3 more actions
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Daniel John O’Sullivan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel John O’Sullivan was found deceased on 27 March 2019 while a voluntary psychiatric patient at St Charles Hospital, after leaving the hospital unescorted and failing to return. The principal concerns were failures to update his self-harm risk assessment, formulate a care and treatment plan, document unescorted leave, and promptly notify police when he did not return. The report also raised concerns that the hospital’s serious incident investigation did not identify or investigate these issues adequately.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in alerting police when psychiatric patients fail to return from leave
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Source location Daniel John O’Sullivan · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Poor contemporaneous documentation of unescorted leave
Wider context from the report “2) My second concern is the poor contemporaneous documentation of the grant of unescorted leave from the hospital and the time taken to alert the police when Daniel failed to return on 26/3/19 by 21:00 pm. A ward nurse eventually contacted the police after midnight.
i) I am concerned that an earlier call to the police may have prevented the death, because Daniel was recorded on General Security Zone (GSZ) cameras at 22:21 leaving Vauxhall bridge, and returning, on foot at 23:48. An earlier call might have enabled police to intervene before he was able to commence the actions which ended his life.
ii) The ward manager claimed in evidence that he had instructed others to call the police when Daniel failed to return at 21:00. However, this was not documented anywhere in the medical records and a leave book with handwritten entries went missing after the death. The missing leave book was not investigated by the SII.
iii) A nurse who called the police, sometime before 00:30 according to the medical records, at 01:10 according to police records, was not interviewed by the SII.
I found these investigative deficits troubling because the learning of lessons in patient care depends, in part, on an early SII by the hospital concerned so that risks to patient safety can be identified to enable recommendations and improvements long before an inquest conclusion.
The delay in reporting the failure to return to the Ward was a factor that contributed to the dangerous situation already created by rescinding s.2.
I am nonetheless concerned that, in general, psychiatric patients being tested on voluntary leave are a vulnerable group and as such failures to return should be reported with expedition not only because they may be a danger to themselves, but also due to a risk of being preyed upon by others.
” Source location Daniel John O’Sullivan · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Missing Informal Patient Policy with a risk-assessment checklist and flow chart for managing patients who fail to return from leave.
Verbatim wording from the response “The Missing Informal Patient Policy was updated in March 2020. It now requires a checklist to be completed which was not in the previous version. This is a risk assessment checklist that is now used by staff for managing informal leave from the wards. The checklist records the time that the patient leaves the ward and expected time of return (which is agreed in advance with the patient). There is also a risk assessment and an action plan for completion to mitigate against any risk identified. The Missing Informal Patient Policy also now provides a useful flow chart with the steps that are required to be taken in the event of someone not returning at the agreed time. The approach is balanced by the perceived risk.” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish hourly ward accounting of patients during each shift, with responsibility allocated to the nurse in charge.
Verbatim wording from the response “Each patient is allocated a nurse for each shift. The nurse is responsible for completing the leave form for their identified patients and these forms are then uploaded by administration staff to the patient clinical record. The Nurse in Charge of each shift has the responsibility of ensuring that every patient is accounted for hourly. This task is allocated at the beginning of each shift and is recorded hourly, on a separate reporting sheet for every 24-hour period.” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Datix recording of police contact during AWOL incidents to monitor reporting timeliness and escalate unnecessary delays.
Verbatim wording from the response “In response to the audit the following further actions were agreed:” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Missing Informal Patient Policy to specify police-contact information required in SystmOne and Datix records.
Verbatim wording from the response “In response to the audit the following further actions were agreed:” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop Quick Reference Guides supporting staff use of the electronic clinical record system and care-planning templates.
Verbatim wording from the response “A number of changes have occurred within the Trust and more locally at St Charles Mental Health Unit since the incident in March 2019. The Trust began using SystmOne as its electronic clinical system in February 2019. As staff transitioned to the new electronic clinical record system they were learning about the operation and functionality of the system, and this also involved use of templates within the system and recording of information. It is fair to say that in March 2019 St Charles Mental Health Unit was at the start of the process of using SystmOne. Three and a half years later staff are now proficient in its use. This has been assisted by the use of Quick Reference Guides (QRG) developed to support staff.” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record each informal-leave episode on a paper form and upload it to the clinical record.
Verbatim wording from the response “Each episode of leave is also now recorded on a paper document which is then scanned and uploaded onto the clinical record system each week.” Source location Response from Central and North West London NHS Foundation Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police reporting after voluntary-leave failures need not be immediate or automatic; individualized risk assessment and ward-team discussion determine the response.
Verbatim wording from the response “The timing of contact with the police if a patient fails to return is not standardised or mandated within the Missing Informal Patient Policy. This should be reviewed as part of planning for leave and incorporated into the plan for leave as agreed with the patient. Assessment of capacity and assessment of risk form part of the overall decision making and will be informed by the views of the multidisciplinary team and the aims and intended outcomes as provided for in the care plan. Although police involvement is sometimes necessary it is not always the default position when a patient fails to return the ward. Failure to return should prompt a discussion between the members of the ward team, involving the RC as necessary.” Source location Response from Central and North West London NHS Foundation Trust
Open published response
22 Jul 2022 Christopher Thomas Ace Ryan · Prevention of Future Deaths report West London
View report summary
Concerns raised 2
Failure to consider and approve or refuse patients' escorted leave requests View source Blurring of the boundaries between escorted leave intentions and ward staff's ability to facilitate therapeutic leave View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Christopher Thomas Ace Ryan · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Christopher Thomas Ace Ryan was detained under section 3 of the Mental Health Act and absconded from escorted leave on 23 December 2020. He obtained and smoked heroin, developed laboured breathing, lost consciousness, and died despite CPR. Concerns included repeated absconding during escorted leave, access to illicit drugs, unclear boundaries around escorted leave, and the security and smoking arrangements at the hospital car park.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider and approve or refuse patients' escorted leave requests
Wider context from the report “Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions.
(1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients, and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused . Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?
” Source location Christopher Thomas Ace Ryan · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Blurring of the boundaries between escorted leave intentions and ward staff's ability to facilitate therapeutic leave
Wider context from the report “Chris was known to abscond from secure mental health detention during periods of "escorted leave". He had left the care of the Trust on 6 occasions during his final 3 month detention and was known to purchase and take illicit drugs on these occasions. His Consultant had discussed this high risk behaviour with him on many occasions.
(1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.
(3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients , and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused. Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?
” Source location Christopher Thomas Ace Ryan · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the section 17 leave form and guidance to capture escort staffing stipulations.
Verbatim wording from the response “We recognise that understanding of Covid and the applicable restrictions have reduced significantly over time. Despite this, we have taken on board the spirit of the concerns raised and will review our leave form / guidance to help ensure we better capture any stipulations around staffing of escorts. Leave will be facilitated in accordance with these stipulations and non-compliance with be addressed accordingly with the applicable members of staff.” Source location Response from South West London and St George's Mental Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Facilitate escorted leave according to documented staffing stipulations and address non-compliance with applicable staff.
Verbatim wording from the response “We recognise that understanding of Covid and the applicable restrictions have reduced significantly over time. Despite this, we have taken on board the spirit of the concerns raised and will review our leave form / guidance to help ensure we better capture any stipulations around staffing of escorts. Leave will be facilitated in accordance with these stipulations and non-compliance with be addressed accordingly with the applicable members of staff.” Source location Response from South West London and St George's Mental Health
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning from the Inquest across the service line.
Verbatim wording from the response “From a holistic perspective, ward staff have conversations with patients about how they intend to use their leave and how best they can be supported. Being able to complete daily living activities such as going shopping, viewing properties that patients may live in post discharge and attending appointments are seen as part of the patient’s recovery journey; ward staff often support patients through escorted leave to achieve these recovery goals. This is now greatly aided by the relaxation of the Covid Restrictions. Going forward the Trust will continue to observe any further restrictions should they return, in order to protect its service users, its staff and the public. The learning arising from this Inquest has been shared across the service line.” Source location Response from South West London and St George's Mental Health
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11 Apr 2022 Tracy Dawn WOOD · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to recover and check restricted items when patients return to the ward View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Tracy Dawn WOOD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident report.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recover and check restricted items when patients return to the ward
Wider context from the report “4. Part of the Risk Assessment for giving a ████████ to Tracy was that she was to hand the ████████ back on her return to the ward. Tracy did not return the ████████ and was not asked to return the ████████ . That Tracy had been given an ████████ was overlooked on her return .
” Source location Tracy Dawn WOOD · Prevention of Future Deaths report
Open source report
7 Mar 2022 Melanie Jane ELMS · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2
Lack of a missing-person plan with timeframes and escalation steps for leave View source Failure to record risk assessments prior to leave View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Melanie Jane ELMS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Melanie Jane Elms, an informal patient at the Abraham Cowley Unit with a history of schizo-affective disorder and suicidal attempts, left the unit on day leave on 30 January 2018 and was fatally struck by a train. The inquest identified that a mandatory pre-leave risk assessment was not carried out, concerns raised by her husband were not properly recorded or acted upon, and her leave was not adequately documented or managed. The report also raised concerns about the failure to provide the planned care package and the absence of a missing-person plan and contingency planning.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a missing-person plan with timeframes and escalation steps for leave
Wider context from the report “4. There was no missing person plan in place with timeframe and steps of escalation for Melanie’s leave .
” Source location Melanie Jane ELMS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record risk assessments prior to leave
Wider context from the report “6. Risk assessment prior to leave was not recorded .
” Source location Melanie Jane ELMS · Prevention of Future Deaths report
Open source report
28 Jan 2022 Jack Stephen TAYLOR · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2
Mismatch between AWOL and missing-person risk assessment grading criteria View source Failure to require early provision of current risk assessments and completed AWOL forms View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Sussex Partnership NHS Foundation Trust Sussex Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Sussex Police
Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.
View source
Sussex Partnership NHS Foundation Trust
Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.
View source
Sussex Police
Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.
View source
Sussex Partnership NHS Foundation Trust
Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.
View source See 1 more action
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AI-generated summary
Jack Stephen TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Mismatch between AWOL and missing-person risk assessment grading criteria
Wider context from the report “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’
I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing .
I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded.
I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document.
I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection.
” Source location Jack Stephen TAYLOR · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to require early provision of current risk assessments and completed AWOL forms
Wider context from the report “2. The joint Sussex Partnership NHS Trust & Sussex Police ‘Absent Without Leave (AWOL) Policy’
I heard evidence that the risk assessment grading criteria set out in Appendix B of this policy did not match the risk assessment grading criteria for missing persons as defined by the College of Policing.
I heard evidence that the policy did not require the PICU staff to provide a copy of an up-to-date risk assessment document or their completed AWOL forms at an early stage when reporting a patient as having absconded.
I heard evidence that the PICU staff did not routinely discuss the clinician’s assessment of the grading of the level of risk (i.e. high, medium, low) with the police call-taker nor ask for the police call-taker’s decision on such risk level despite it being a requirement of the policy document.
I am concerned that the lack of effective joint working may hamper the swift return of high risk patients to the secure environment of the ward which is necessary for their own and others protection.
” Source location Jack Stephen TAYLOR · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the completed Missing Persons Template, protocol and joint action plan into the revised multi-agency AWOL policy and practice.
Verbatim wording from the response “Work will take place to move towards having a final draft in May 2022, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absence Without Leave (AWOL) policy which is currently subject to multi-agency review and revision.” Source location 2022-0029-Response-from-Sussex-Police_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the multi-agency AWOL Policy and embed the missing persons template, protocol and action plan into policy and practice.
Verbatim wording from the response “Work will take place to move towards having a final draft in May, when the completed template and accompanying protocol surrounding it will then be embedded into the multi-agency Absent Without Leave (AWOL) Policy which is currently subject to multi-agency review and revision.” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Co-develop a Missing Persons Template and accompanying action plan to improve information sharing and joint risk assessment.
Verbatim wording from the response “Developing a Missing Persons Template (including an action plan)” Source location 2022-0029-Response-from-Sussex-Police_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Co-develop a missing persons template and accompanying protocol for timely information-sharing and joint risk assessment.
Verbatim wording from the response “Developing a Missing Persons Template (including an action plan)” Source location 2022-0029-Response-from-Sussex-Partnership-NHS-Foundation-Trust_Published
Open published response
Concerns raised 3
Lack of a written policy specifying the circumstances for group leave and responsibility for granting it View source Failure to require and define mandatory risk assessments before group leave View source Lack of defined staff-to-patient ratios and criteria for group leave View source
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AI-generated summary
Mazielle MacKenzie · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mazielle MacKenzie was a looked after child receiving care in a tier 4 hospital for young people with mental health issues. On 23 June 2018, after leaving the hospital during an organised period of leave and not returning, she was found several hours later and died despite CPR; the inquest conclusion was suicide. Concerns included the absence of a written policy for group leave, inadequate risk assessment and staffing arrangements, and shortcomings in care planning, communication and record-keeping.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a written policy specifying the circumstances for group leave and responsibility for granting it
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out :-
(1) The circumstances in which group leave from the Cove ( and other tier 4 units) is granted and who is responsible for the granting of such leave.
(2) That a mandatory risk assessment is required and setting out a list of factors/criteria that must be considered before any group leave is granted.
(3) Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.
” Source location Mazielle MacKenzie · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to require and define mandatory risk assessments before group leave
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out :-
(1) The circumstances in which group leave from the Cove ( and other tier 4 units) is granted and who is responsible for the granting of such leave.
(2) That a mandatory risk assessment is required and setting out a list of factors/criteria that must be considered before any group leave is granted.
(3) Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.
” Source location Mazielle MacKenzie · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of defined staff-to-patient ratios and criteria for group leave
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
Expert evidence was heard (and accepted) at inquest that there was no written policy/document in place by the Trust which set out :-
(1) The circumstances in which group leave from the Cove ( and other tier 4 units) is granted and who is responsible for the granting of such leave.
(2) That a mandatory risk assessment is required and setting out a list of factors/criteria that must be considered before any group leave is granted.
(3) Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.
” Source location Mazielle MacKenzie · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and disseminate a written group-leave procedure covering approval circumstances, mandatory risk assessment, MDT agreement, observation eligibility, cancellation safeguards and staffing requirements.
Verbatim wording from the response “The Trust have developed a written procedure (enclosed), which identifies the circumstances in which group leave from The Cove is granted. The Cove is the only Tier 4 CAMHS unit within the Trust. The procedure was approved at the Specialist Network Governance Group on 3 February 2022 and has been subsequently shared with staff. Until the procedure was ratified, group leave at The Cove was temporarily suspended, following receipt of your Regulation 28 notification.” Source location 2022-0005-Response-from-Lancashire-and-South-Cumbria-NHS-Foundation-Trust_Published
Open published response
14 Oct 2021 Alexandra Jane Tolley · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 5
Failure to review wound-dressing materials before ground leave View source Lack of documented ground-leave approval criteria and staff-grade requirements View source Lack of dynamic risk-assessment discretion for escorts responding to absconding View source
Failure to determine sufficient escort numbers for ground leave View source Failure to define permissible physical interventions during escorted leave View source See 2 more concerns
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leeds and York Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Leeds and York Partnership NHS Foundation Trust
Scope alternative wound-covering options and contact other mental health trusts to capture and share relevant practice.
View source
Leeds and York Partnership NHS Foundation Trust
Undertake same-day leave risk assessments, decide whether leave should be altered, and document the decision, rationale and discussion in care records.
View source
Leeds and York Partnership NHS Foundation Trust
Undertake a tabletop review of patients granted time off the ward to check that leave discussions occurred and were appropriately documented.
View source
Leeds and York Partnership NHS Foundation Trust
Develop and incorporate scenario-based escorting and leave-risk decision-making training into initial and updated PMVA training for all staff, including bank staff.
View source
Leeds and York Partnership NHS Foundation Trust
Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.
View source See 2 more actions
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AI-generated summary
Alexandra Jane Tolley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alexandra Jane Tolley, aged 20, was detained in a psychiatric hospital and absconded while being escorted in the hospital grounds on 27 October 2019. She was found in cardiac arrest and died at hospital the following day. Concerns included instructions not to restrain or follow her, the informal approval of ground leave without documented criteria, and the continued use of similar absconding instructions despite an ongoing risk of further deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to review wound-dressing materials before ground leave
Wider context from the report “5. The permission given to walk in the grounds of the hospital was not considered to amount to section 17 MHA 1983 leave. The informality involved in the decision missed an opportunity to consider issues such as:
(a) Whether two escorts would be appropriate in view of Ms Tolley having absconded three days earlier. This would have facilitated one person following her to monitor and report on her whereabouts. In a time critical situation this could have altered the tragic outcome;
(b) Providing the escort with a discretion in the manner of a dynamic risk assessment whether or not to follow Ms Tolley.
(c) Reviewing the type of ████████ applied to her wounds, before she was permitted to leave the ward, in the light of her misuse of these ████████ .
” Source location Alexandra Jane Tolley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of documented ground-leave approval criteria and staff-grade requirements
Wider context from the report “3. The decision to permit ground leave so shortly after a ████████ incident (and only three days after a previous absconding incident) was made on a relatively informal basis. There were no documented criteria to be considered before it was approved , nor was the grade of staff required to make the decision stipulated .
” Source location Alexandra Jane Tolley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of dynamic risk-assessment discretion for escorts responding to absconding
Wider context from the report “5. The permission given to walk in the grounds of the hospital was not considered to amount to section 17 MHA 1983 leave. The informality involved in the decision missed an opportunity to consider issues such as:
(a) Whether two escorts would be appropriate in view of Ms Tolley having absconded three days earlier. This would have facilitated one person following her to monitor and report on her whereabouts. In a time critical situation this could have altered the tragic outcome;
(b) Providing the escort with a discretion in the manner of a dynamic risk assessment whether or not to follow Ms Tolley .
(c) Reviewing the type of ████████ applied to her wounds, before she was permitted to leave the ward, in the light of her misuse of these ████████.
” Source location Alexandra Jane Tolley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to determine sufficient escort numbers for ground leave
Wider context from the report “5. The permission given to walk in the grounds of the hospital was not considered to amount to section 17 MHA 1983 leave. The informality involved in the decision missed an opportunity to consider issues such as:
(a) Whether two escorts would be appropriate in view of Ms Tolley having absconded three days earlier. This would have facilitated one person following her to monitor and report on her whereabouts . In a time critical situation this could have altered the tragic outcome;
(b) Providing the escort with a discretion in the manner of a dynamic risk assessment whether or not to follow Ms Tolley.
(c) Reviewing the type of ████████ applied to her wounds, before she was permitted to leave the ward, in the light of her misuse of these ████████.
” Source location Alexandra Jane Tolley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to define permissible physical interventions during escorted leave
Wider context from the report “4. The instruction to staff stipulated ‘physical interventions’ will not be used to restrain Ms Tolley, yet this expression was not defined or particularised . Greater clarity might assist a staff escort (likely to be a relatively junior individual) to know whether it was permissible, for example, to put a gentle hand on Ms Tolley’s shoulder to steer her back towards the hospital.
” Source location Alexandra Jane Tolley · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scope alternative wound-covering options and contact other mental health trusts to capture and share relevant practice.
Verbatim wording from the response “We acknowledge that Ms Tolley had previously used her ████████. The ward team considered this along with the risk that her wound would become infected. Further learning is that the Ward Team could have requested guidance and support from the Trusts Physical Health Team to support them in considering the prevention of infection and the types of bandages that could have been used as an alternative.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake same-day leave risk assessments, decide whether leave should be altered, and document the decision, rationale and discussion in care records.
Verbatim wording from the response “Despite a patient being granted ground leave, a further assessment should be undertaken on the day taking into consideration a number of factors including compliance with previous leave, consideration of benefits of further leave, and flexibility versus senior guidance. Additionally, the following points should be taken into consideration:” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Undertake a tabletop review of patients granted time off the ward to check that leave discussions occurred and were appropriately documented.
Verbatim wording from the response “Consideration for leave from the hospital ward is discussed via the MDT, it is at this meeting that the type of leave is discussed and agreed upon. This decision is based on risk, current presentation, and history in relation to what is appropriate and therapeutic for the patient at that time. The same principles would occur when discussing whether section 17 leave is appropriate. It was considered by the MDT that Ms Tolley was suitable for periods of leave within the hospital grounds as a first step on her recovery. Although ground leave had been granted by the Registered Clinician, there is an expectation that the nursing staff will dynamically review risk prior to letting a patient off the Ward.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and incorporate scenario-based escorting and leave-risk decision-making training into initial and updated PMVA training for all staff, including bank staff.
Verbatim wording from the response “The Trust has reviewed its Prevention, Management of Violence and Aggression (PMVA) training provision offered to staff regarding the role of escorting patients outside of the ward and is developing training for all staff, including bank staff. This training will be included in the initial and updated PMVA training provision. The training will be scenario and role play based and will include discussions regarding decision making related to risk whilst escorting somebody outside of the ward.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate case learning through procedures and provide staff with clear guidance on actions when escorted leave breaks down or a patient leaves the escort.
Verbatim wording from the response “We will ensure that the learning from this case is communicated within our procedure – ensure that staff are provided with clear guidance when escorting patients of the action to be taken should leave start to break down or the patient leaves the member of staff.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Physical touch was considered likely to increase distress and emotional dysregulation, so alternative support strategies were preferred.
Verbatim wording from the response “The care plan developed by the team and Ms Tolley considered the intervention of placing any form of touch to Ms Tolley. It was deemed this would increase the risk of further distress to Ms Tolley and may further increase the risk of emotional deregulation in the event of an individual placing a hand on her. However more consideration should have been given to the need to think about alternative means to support Ms Tolley, enabling her to maintain her self-control at the point of feeling distressed whilst out on leave. Alternative strategies that could have been considered at the point Ms Tolley indicated either physically or verbally that she was becoming distressed or that she was not coping with the period of escorted leave.” Source location 2021-0344-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
Open published response
11 Dec 2020 Ms Katy Ann SAMUELS · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 2
Failure to verify escort identity and presence for escorted leave View source Insufficient handover arrangements for escorted leave View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Coventry and Warwickshire Partnership NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Coventry and Warwickshire Partnership NHS Trust
Require identified carers to collect and return patients on Section 17 leave rather than allowing unaccompanied departure to meet them.
View source
Coventry and Warwickshire Partnership NHS Trust
Amend and approve the Trust-wide Section 17 Leave Policy, including defined leave categories, revised safety forms, accompanied-leave checks, return-time escalation and shift monitoring.
View source
Coventry and Warwickshire Partnership NHS Trust
Develop and apply a Standard Operating Procedure to standardise clinical handover content and processes across clinical handover situations.
View source
Coventry and Warwickshire Partnership NHS Trust
Adopt SBAR as the communication tool for all identified clinical handover situations.
View source
Coventry and Warwickshire Partnership NHS Trust
Embed revised handover arrangements through staff engagement events and disseminated briefings.
View source
Coventry and Warwickshire Partnership NHS Trust
Include revised handover responsibilities in future local induction and preceptorship for new staff.
View source
Coventry and Warwickshire Partnership NHS Trust
Review rosters and supporting processes, consult staff-side representatives, and establish a consistent longer protected handover timeframe.
View source See 4 more actions
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AI-generated summary
Ms Katy Ann SAMUELS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Katy Ann Samuels, a detained patient at The Caludon Centre, returned from escorted leave intoxicated after consuming alcohol and cocaine. She was later found with a dressing-gown cord around her neck in her room and died on 25 April 2019 despite resuscitation and hospital treatment. The principal concerns were unclear arrangements for escorted leave, including failure to verify or record the escort and departure time, and insufficient handover and communication procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to verify escort identity and presence for escorted leave
Wider context from the report “iii. The circumstances of this inquest touching upon the death of Katy Samuels accentuated this point. The evidence was that Ms Samuels (a detained patient) can and did leave the hospital grounds without an escort seen to attend the hospital. An escort’s identity is not verified, even if seen, for escorted leave e.g. photo identification. A consequence was no member of staff was aware of precisely what time Ms Samuels left the hospital and if it was in fact with anyone at all. No escort was seen and there is no requirement regarding this. It was on this occasion (20th April 2019) that Ms Samuels returned from leave either alone or with an escort not seen and she was intoxicated from alcohol (toxicological evidence confirmed she had also consumed cocaine). Within hours of her return to the ward she was to be discovered with a ligature around neck.
” Source location Ms Katy Ann SAMUELS · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient handover arrangements for escorted leave
Wider context from the report “iv. An aspect of the evidence was staff handovers are vital and therefore time to enable the same very important. The time set aside for a handover was considered insufficient by some staff. By way of analogy there was no handover to the escort for escorted leave. The evidence was that such a process of ‘handover’ would enable better patient safety, detained patients undoubtedly very vulnerable and at risk of significant harm to themselves.
” Source location Ms Katy Ann SAMUELS · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require identified carers to collect and return patients on Section 17 leave rather than allowing unaccompanied departure to meet them.
Verbatim wording from the response “Following conclusion of the inquest, immediate action was taken to ensure that patients going on leave under the care of family or friends, would be collected from and returned to the ward, by the identified person and not permitted to leave the ward unaccompanied to meet family or friends in the reception area or hospital grounds.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend and approve the Trust-wide Section 17 Leave Policy, including defined leave categories, revised safety forms, accompanied-leave checks, return-time escalation and shift monitoring.
Verbatim wording from the response “To strengthen and formalise our Section 17 leave arrangements across the Trust's inpatient services, we have consulted with our staff and amended our Section 17 Leave Policy. The changes to this policy include clear definitions of the types of leave:” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and apply a Standard Operating Procedure to standardise clinical handover content and processes across clinical handover situations.
Verbatim wording from the response “A working group was established that consulted with staff in respect of the role and function of the handover process to strengthen and ensure patient safety and wellbeing. The working group have developed a Standard Operating Procedure to both standardise the handover content and the way in which a handover functions and operates. The Standard Operating Procedure applies to all clinical handover situations including:” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt SBAR as the communication tool for all identified clinical handover situations.
Verbatim wording from the response “The working group reviewed best practice for handover methodologies and tools across other NHS Trusts and have adopted the ‘Situation, Background, Assessment and Recommendation’ (SBAR) tool, which is a nationally recognised communication tool that facilitates the effective and efficient handover of concise, accurate and relevant information between clinicians and clinical teams. SBAR supports the timely and effective handover of pertinent information which includes, but is not limited to, all” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed revised handover arrangements through staff engagement events and disseminated briefings.
Verbatim wording from the response “To embed our revised arrangements for the management of handover and to ensure that staff are aware of their responsibilities in respect of the Standard Operating Procedure, staff engagement events have been held as well as a series of briefings disseminated. This work will also form part of future local staff induction and preceptorship for new staff. Working with our staff I believe that the revised arrangements will strengthen handover and provide staff with a clear focus and safe handover practice.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include revised handover responsibilities in future local induction and preceptorship for new staff.
Verbatim wording from the response “To embed our revised arrangements for the management of handover and to ensure that staff are aware of their responsibilities in respect of the Standard Operating Procedure, staff engagement events have been held as well as a series of briefings disseminated. This work will also form part of future local staff induction and preceptorship for new staff. Working with our staff I believe that the revised arrangements will strengthen handover and provide staff with a clear focus and safe handover practice.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review rosters and supporting processes, consult staff-side representatives, and establish a consistent longer protected handover timeframe.
Verbatim wording from the response “The Trust has identified that there is mixed practice across Mental Health providers, with Trusts operating handovers of different duration and taking different approaches. The Trust is using this intelligence to inform its own work in respect of its handover arrangements. The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation to ensure this takes place in accordance with Trust policy.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot change handover shift patterns until a robust consultation with unions and staff representatives is completed.
Verbatim wording from the response “The Trust has identified that there is mixed practice across Mental Health providers, with Trusts operating handovers of different duration and taking different approaches. The Trust is using this intelligence to inform its own work in respect of its handover arrangements. The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation to ensure this takes place in accordance with Trust policy.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers handovers currently more effective because of work already undertaken, while a consistent timeframe is established after consultation.
Verbatim wording from the response “The Trust will continue to establish a consistent time frame for handover after the required consultation process, however the Trust are confident handovers are currently more effective based on the work already undertaken.” Source location 2020-0282-Response-from-Coventry-and-Warwickshire-Partnership-NHS-Trust-Redacted
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.