19 Dec 2023 MORGAN-ROSE HART · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Shortfall of appropriate inpatient and community placements for autistic people with mental health and self-harm risks View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
MORGAN-ROSE HART · 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
Morgan-Rose Hart, who was detained on a female mental health ward, died on 12 July 2022 after being found unresponsive with a ligature around her neck. The report identified concerns about missed and falsified observations, failures to complete physical welfare checks after bathroom alerts, inadequate escalation of risk, shortcomings in investigation and record keeping, and insufficient suitable placements for people with autism and mental health and self-harm risks in Essex.
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 Shortfall of appropriate inpatient and community placements for autistic people with mental health and self-harm risks
Wider context from the report “(7) There is a significant shortfall of appropriate placements for people with Autism who have mental health and self-harm risks in Essex both inpatient and the community .
” Source location MORGAN-ROSE HART · Prevention of Future Deaths report
Open source report
×
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 Improve relationships with residential providers to increase access to local placements.
Verbatim wording from the response “Residential Accommodation Strategy:” Source location Response from Essex County Council
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 Operate an internally delivered solo bespoke children’s home in Colchester for young people with high needs.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 Establish a second Colchester solo children’s home through a tendered provider, subject to Ofsted registration.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 a third solo children’s home through planning and a full rebuild.
Verbatim wording from the response “The Council has approval for four solo bespoke registered Children Homes to work with Children and Young people with high needs that struggle to live with other people for a variety of reasons.” Source location Response from Essex County Council
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 Repurpose Colchester accommodation into a four-bed short-term group home staffed by a multidisciplinary team.
Verbatim wording from the response “Alongside the solo provision, the Council is repurposing another accommodation in Colchester to be a group home. This will provide a 4 bedded short term (up to 6 months) placements, staffed by a multi-disciplinary team, to support neuro-divergent young people to live in the community.” Source location Response from Essex County Council
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 a directly managed short-term service in South Essex for neuro-divergent young people.
Verbatim wording from the response “In South Essex, we are developing a similar short term service as the one referred to in Colchester. These services will be directly run and managed by the Council.” Source location Response from Essex County Council
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 Work with statutory partners, service providers and service users to identify housing needs and develop specialist care and support models.
Verbatim wording from the response “In addition to the specific developments noted above, the Council works closely with our statutory partners; the Borough & Districts and NHS along with service providers and people who use services to identify future housing needs and to develop specialist models of care and support.” Source location Response from Essex County Council
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 Submit capital bids for additional services for complex autistic young people with significant mental health issues, including single-person homes, move-on housing and preventative respite.
Verbatim wording from the response “Transforming Care Partnership:” Source location Response from Essex County Council
Open published response
×
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 Responsibility for commissioning hospital care rests with the NHS through Integrated Commissioning Boards and NHS England, not the Council.
Verbatim wording from the response “Essex County Council has a joint responsibility with three Integrated Commissioning Boards across Essex for meeting the health and care needs of the residents in Essex. This includes ensuring that there is a sufficient supply and range of specialist community placements and other forms of support for people with autism and co-existing mental health needs.” Source location Response from Essex County Council
Open published response
26 Sep 2023 Benjamin Henry Hazelden · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 1
Insufficient availability of suitable specialist placements for autistic young adults at risk of self-harm or harm to others View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin Henry Hazelden · 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
Benjamin Henry Hazelden died at the scene on 11 February 2022 after he assaulted two staff members, ran to a nearby train station and was hit by a train. The report identified limited availability of suitable specialist placements for young adults with autism and risks of self-harm or harm to others; he was discharged home with increased support because no suitable specialist bed was available.
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 Insufficient availability of suitable specialist placements for autistic young adults at risk of self-harm or harm to others
Wider context from the report “1. In the course of the hearing the evidence it was clear that young adults with autism who were at risk of self-harm as well as harm to others have very limited options in terms of placements where their needs can be met . A bespoke placement had been carefully created by those involved in Ben’s care but this had taken several months to arrange. This arrangement had worked well and all involved tried to make it a success and for quite some time it was. It was however recognised that there may come a time in the future when his risks to himself and others would mean an alternative placement would be needed.
2. When Ben’s risks to himself increased further there were no suitable beds available where he could be cared for in an environment which could meet his needs . He spent several days in an acute hospital bed despite being medically fit for discharge which although, essentially a place of safety, was totally unsuited to his needs. This stay continued whilst discussions ensued regarding where he should be placed. A bed in an acute psychiatric ward was considered but not deemed appropriate to meet his needs and as there were no specialist beds available he was discharged back to his home with increased support as the best option available . Had a bed been available in a specialist unit it is likely that he would not have died when he did.
3. In the evidence provided it became clear that a lot of units where a specialist bed may have been available had been closed in the past due to concerns about the level of care following a number of investigations. This has led to a system whereby locally and nationally there are limited options for those requiring care relating to both the management of autism and self-harm or harm to others, particularly when there is an urgent need for increased support . Whilst the inquest heard there were some counties who had specialist beds they were difficult to access as they were often full and places were not always available to meet urgent needs
” Source location Benjamin Henry Hazelden · Prevention of Future Deaths report
Open source report
×
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 Participate with Sussex and Surrey ICBs in scoping options for specialist inpatient beds for people with learning disabilities and autistic people.
Verbatim wording from the response “Kent and Medway ICB is currently involved in a project with colleagues in Sussex ICB and Surrey ICB to scope options for the provision of specialist in-patient beds for people with learning disability and for autistic people across the Kent, Surrey, and Sussex footprint. Commissioning specialist in-patient services across this broader geographical footprint provides critical mass of patient need and economies of scale which cannot be achieved by one ICB alone due to the reduced need for such services as a result of implementing national policy. PA Consulting, a private consulting firm, have been commissioned by Sussex ICB to develop and present proposals for specialist in-patient services by the end of March 2024 (Phase 1) for the three ICBs to consider and consult on with autistic people and other stakeholders (Phase 2) and implement collaboratively (Phase 3).” Source location Response from NHS Kent and Medway
Open published response
×
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 One ICB cannot independently commission specialist inpatient services because reduced demand prevents achieving sufficient critical mass and economies of scale.
Verbatim wording from the response “Kent and Medway ICB is currently involved in a project with colleagues in Sussex ICB and Surrey ICB to scope options for the provision of specialist in-patient beds for people with learning disability and for autistic people across the Kent, Surrey, and Sussex footprint. Commissioning specialist in-patient services across this broader geographical footprint provides critical mass of patient need and economies of scale which cannot be achieved by one ICB alone due to the reduced need for such services as a result of implementing national policy. PA Consulting, a private consulting firm, have been commissioned by Sussex ICB to develop and present proposals for specialist in-patient services by the end of March 2024 (Phase 1) for the three ICBs to consider and consult on with autistic people and other stakeholders (Phase 2) and implement collaboratively (Phase 3).” Source location Response from NHS Kent and Medway
Open published response
20 Apr 2023 Joseph Willy Maunick · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Insufficient provision of suitable care, including residential care placements View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joseph Willy Maunick · 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
Joseph Willy Maunick died on 15 March 2022 from a severe head injury sustained in a fall in the Emergency Department of West Suffolk Hospital, where he had been admitted as a social admission while his wife underwent emergency surgery. The report identified concerns about a national shortage of suitable care, and severe hospital pressures including insufficient staffing and resources, which prevented the constant supervision he needed and delayed transfer to a more appropriate environment.
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 Insufficient provision of suitable care, including residential care placements
Wider context from the report “1) A national care shortage contributed to a situation where a gentleman who was not experiencing a medical emergency, but who required constant supervision for his own safety in view of his cognitive impairment and very high falls risk, could not be cared for anywhere other than in a hospital Emergency Department. If there is not sufficient provision of care, including residential care placements , such that those in similar need do not receive suitable care , then circumstances creating a risk of future deaths will occur or continue to exist in the future, when they are placed in an environment that is not realistically able to provide the constant supervision needed, as occurred in this case.
” Source location Joseph Willy Maunick · Prevention of Future Deaths report
Open source report
×
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 Publish a national delivery plan setting out steps to recover urgent and emergency care services, including expanded community services for older people with frailty.
Verbatim wording from the response “In January 2023, the Delivery plan for recovering urgent and emergency care services was published by NHS England, which sets out the steps that the NHS are taking to respond to the demand being placed on urgent and emergency care (UEC) services at a national level. The plan also includes details for the expansion of community services including more joined-up care for older people living with frailty, including scaling up urgent community response, frailty and falls services across the whole country – meaning the right people delivering the right care and avoiding admission to hospital where it’s not necessary. We will also work with Integrated Care Systems (ICSs) to provide streamlined pathways for older adults, including people with dementia.” Source location Response from NHS England
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 Work with Integrated Care Systems to provide streamlined pathways for older adults, including people with dementia.
Verbatim wording from the response “In January 2023, the Delivery plan for recovering urgent and emergency care services was published by NHS England, which sets out the steps that the NHS are taking to respond to the demand being placed on urgent and emergency care (UEC) services at a national level. The plan also includes details for the expansion of community services including more joined-up care for older people living with frailty, including scaling up urgent community response, frailty and falls services across the whole country – meaning the right people delivering the right care and avoiding admission to hospital where it’s not necessary. We will also work with Integrated Care Systems (ICSs) to provide streamlined pathways for older adults, including people with dementia.” Source location Response from NHS England
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 Provide £16 million to partners to support improved local authority commissioning of adult social care.
Verbatim wording from the response “Last year, £16m was provided to partners to make support available including a focus on how local authorities commission the right kind of care to meet the needs of everyone who draws on care and support. Secretary of State also require adult social care providers to share their data with us to allow for more awareness and insight on what is happening locally and nationally.” Source location 2023-0128 - Response from Department of Health and Social Care
Open published response
×
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 DHSC is responsible for addressing the national social care shortage and is best placed to comment on it.
Verbatim wording from the response “The first concern you raised related to a national social care shortage, and the impact this has had on the quality of care provided to Will. The Department of Health and Social Care (DHSC) are best placed to comment on this issue as they hold responsibility for social care provision. The DHSC have committed to adult social care reform and have recommitted £700 million to transform and improve the adult social care system in England, to include around access to support and joining up of services as part of their ‘People at the Heart of Care’ plan.” Source location Response from NHS England
Open published response
×
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 Local authorities are responsible for shaping care markets to ensure sufficient, diverse, sustainable adult social care provision, including residential placements.
Verbatim wording from the response “With regard to your concern about a potential national care shortage and insufficient provision of care, including residential care placements, under the Care Act, local authorities are tasked with the duty to shape their care market to ensure a diverse range of high quality, sustainable, person-centred care and support services are provided.” Source location 2023-0128 - Response from Department of Health and Social Care
Open published response
30 Jul 2020 Reginald Collins · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of suitable complex EMI bed capacity View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Reginald Collins · 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
Reginald Collins fell and fractured his neck of femur, underwent surgery, and remained in hospital after becoming medically optimised because a suitable placement was unavailable. He developed aspiration pneumonia and died on 22 October 2019; concerns included delays in discharge and the lack of suitable complex EMI beds locally and nationally.
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 suitable complex EMI bed capacity
Wider context from the report “1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him .
2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not.
3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally .
4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust.
” Source location Reginald Collins · Prevention of Future Deaths report
Open source report
×
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 market-shaping and improved care models for people with complex needs.
Verbatim wording from the response “As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.” Source location 2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Open published response
×
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 local authority had potential provision and appears to have offered it, disputing that discharge was delayed solely by a lack of suitable placement.
Verbatim wording from the response “sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly (████████@stockport.gov.uk).” Source location 2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Open published response
×
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 local authority is responsible for providing further information and clarification about potential provision and the offer made.
Verbatim wording from the response “sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly (████████@stockport.gov.uk).” Source location 2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Open published response
9 Mar 2020 Rebecca Jane Hursey · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Failure to prioritise timely safer placements for patients at high risk of self-harm View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Rebecca Jane Hursey · 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
Rebecca Jane Hursey died at St George’s Hospital on 4 May 2018 after taking an aspirin overdose while detained under Section 3 of the Mental Health Act and receiving care on the Avalon Ward. The report identifies concerns about suicidal-risk information not being verbally communicated during handover, observations and searches not mitigating her self-harm risk, and the prolonged failure to find a suitable alternative placement.
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 prioritise timely safer placements for patients at high risk of self-harm
Wider context from the report “4. That placements for patients with high risk of self-harm , such as Rebecca are prioritised such that safer placements are found within a timely fashion .
” Source location Rebecca Jane Hursey · Prevention of Future Deaths report
Open source report
24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Lack of alternative mental health provision for young adults View source Lack of suitable acute mental health beds for young adults View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Hannah Dolly Kaur Bharaj · 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
Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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 alternative mental health provision for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative . The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” Source location Hannah Dolly Kaur Bharaj · 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 suitable acute mental health beds for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” Source location Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
Open source report
27 Sep 2018 Sheila Ann Hadfield · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Lack of suitable care beds for individuals with complex mental health needs View source Failure of the care home to meet residents’ complex mental health needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sheila Ann Hadfield · 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
Sheila Ann Hadfield, who had paranoid schizophrenia and lived in a residential care home, was found on the floor of her room and transferred to hospital, where the report states that she died from sepsis. The principal concern was that the care home struggled to meet her complex mental health needs and that there was a national shortage of suitable alternative placements.
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 suitable care beds for individuals with complex mental health needs
Wider context from the report “1. The inquest heard that the home that Mrs Hadfield was placed in struggled to cope with her needs. However, there was a national shortage of suitable beds for individuals of a similar age to Sheila Hadfield with her complex mental health needs . The majority of available care provision was dementia beds which would have been unsuitable . The inquest was told that this meant that had Mrs Hadfield not remained where she was she would have had to go onto a mental health ward on a voluntary basis or been sectioned if she had refused.
” Source location Sheila Ann Hadfield · 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 of the care home to meet residents’ complex mental health needs
Wider context from the report “1. The inquest heard that the home that Mrs Hadfield was placed in struggled to cope with her needs . However, there was a national shortage of suitable beds for individuals of a similar age to Sheila Hadfield with her complex mental health needs. The majority of available care provision was dementia beds which would have been unsuitable. The inquest was told that this meant that had Mrs Hadfield not remained where she was she would have had to go onto a mental health ward on a voluntary basis or been sectioned if she had refused.
” Source location Sheila Ann Hadfield · Prevention of Future Deaths report
Open source report
×
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 Local areas are responsible for determining arrangements to improve mental health care in care homes according to local need and service configuration.
Verbatim wording from the response “Building on the experience of the Vanguard sites, the development of Integrated Care Systems (ICSs) and Sustainability and Transformation Partnerships (STPs) provides a valuable opportunity to strengthen collaboration between health and social care services in a local footprint, and to help improve the provision of mental health care in care homes. Such arrangements are for local areas to determine, according to the local need and the make-up of local services.” Source location 2018-0334-Response-by-Department-of-Health-Social-Care
Open published response
2 Mar 2018 Emily Jayne Hartley · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Lack of suitable secure therapeutic environments for people with mental health problems in prison View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Emily Jayne Hartley · 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
Emily Jayne Hartley, a serving prisoner at HMP New Hall, was found suspended from a torn bed sheet in an out-of-bounds area during exercise on 23 April 2016; her death was confirmed at the scene. Concerns included serious deficiencies in the management, monitoring and recording of self-harm and suicide prevention procedures, weak information sharing and integrated planning, poor supervision, and the lack of a suitable secure therapeutic environment for people with significant mental health problems.
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 suitable secure therapeutic environments for people with mental health problems in prison
Wider context from the report “(1) It became apparent from the evidence of many Prison Officers and Healthcare Workers that Prison was not the appropriate environment for someone with Emily’s mental health problems . The emphasis should have been on treatment but within a secure environment which Prison, with the most well intentioned staff, cannot adequately provide .
(2) Coincidentally ten years ago I heard an Inquest into the death of Petra Blankbsy, also at New Hall Prison. At the conclusion of this inquest I made a recommendation pursuant to what was then Rule 43 of the Coroner’s Rules 1984. I attach a copy of my Rule 43 recommendations which I repeat in every detail in respect of the death of Emily Jayne Hartley. Furthermore I state that a Prison is not the appropriate place to accommodate Emily and that there should be facilities, particularly in the Prison’s female estate, to provide a therapeutic yet secure environment with the emphasis being on treatment .
I repeat ten years later that the Prison’s department and the Department of Health should conduct a collaborative exercise to achieve the provision of suitable, secure, therapeutic environments in order to treat those with mental health problems of the nature of those demonstrated by Petra Blanksby ten years ago and now Emily Jayne Hartley. I would refer you to a paper prepared by “Inquest” entitled Preventing the Deaths of Women in Prison and the Need for an Alternative Approach which was published in June 2013 and also a report by ████████ of a review of Women with Particular Vulnerabilities in the Criminal Justice System.
” Source location Emily Jayne Hartley · Prevention of Future Deaths report
Open source report
×
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 Deliver the female-offender personality-disorder strategy, including specialised services, staff development and enhanced community support.
Verbatim wording from the response “A strategy for improving the care and management of female offenders with personality disorders, jointly planned and delivered by HMPPS and NHS England, was implemented in 2013. It increases the availability of, and access to, specialised personality disorder services including a therapeutic community at HMP Send, and supports staff to develop their knowledge, skills and confidence in working with female offenders with personality disorders. The programme also offers enhanced community-based services for female offenders, including the delivery of community-based treatment programmes, specialist case management and mentoring and advocacy services.” Source location 2018-0063-Response-by-HM-Prisons-and-Probation-Service
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 Keep provision for women in custody with mental health problems under review with health colleagues.
Verbatim wording from the response “A considerable amount of valuable work is being done in the area of improving provision of services for women in custody with mental health problems. Please be assured that I am aware of the importance of this issue and will keep it under review, alongside health colleagues, in order to identify any further steps that can be taken to improve work in this area.” Source location 2018-0063-Response-by-HM-Prisons-and-Probation-Service
Open published response
25 Apr 2017 Linsay Bushell · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2
Failure to coordinate specialist placement decisions and timely funding for patients' needs View source Poor coordination and delay in referral review for specialist placement View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Linsay Bushell · 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
Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.
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 coordinate specialist placement decisions and timely funding for patients' needs
Wider context from the report “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area.
The Jury found:
Para 3
1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital.
2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014.
3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation.
4. Linsay put herself in the position in which she was found however her intention was unclear.
5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder.
6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death.
7. The risk was managed adequately and effectively during Linsay's period as an in-patient.
8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made.
a. In the Trust Position Statement
Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them.
2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015.
3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material.
4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest.
5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity.
6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism.
It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment.
a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour.
b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted . It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available . This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism.
c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism.
7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust.
8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows:
a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub.
b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour.
c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient.
d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases.
e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package.
9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation.
10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided.
11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels.
12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better.
b. In the implementation of Lessons learnt the Trust further accepts
1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay".
a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:-
b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan.
c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay.
d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all.
e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear.
f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan.
g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time.
h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together.
i. Poor coordination of referral to a specialist provider. The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs.
j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for.
k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission.
l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation.
m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective.
2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation.
Discontinuity of Care/Management of Care
3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B.
4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units.
5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach.
6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager.
7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse.
8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway.
9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible.
Risk Assessment/Care Planning
10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk.
11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required.
” Source location Linsay Bushell · 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 coordination and delay in referral review for specialist placement
Wider context from the report “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area.
The Jury found:
Para 3
1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital.
2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014.
3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation.
4. Linsay put herself in the position in which she was found however her intention was unclear.
5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder.
6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death.
7. The risk was managed adequately and effectively during Linsay's period as an in-patient.
8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made.
a. In the Trust Position Statement
Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them.
2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015.
3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material.
4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest.
5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity.
6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism.
It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment.
a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour.
b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism.
c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism.
7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust.
8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows:
a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub.
b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour.
c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient.
d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases.
e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package.
9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation.
10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided.
11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels.
12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better.
b. In the implementation of Lessons learnt the Trust further accepts
1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay".
a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:-
b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan.
c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay.
d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all.
e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear.
f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan.
g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time.
h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together.
i. Poor coordination of referral to a specialist provider . The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs.
j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for.
k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission.
l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation.
m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective.
2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation.
Discontinuity of Care/Management of Care
3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B.
4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units.
5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach.
6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager.
7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse.
8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway.
9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible.
Risk Assessment/Care Planning
10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk.
11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required.
” Source location Linsay Bushell · Prevention of Future Deaths report
Open source report
7 Dec 2016 Dominic Adam Travis · Prevention of Future Deaths report Manchester (North)
View report summary
Concerns raised 1
Lack of specialist inpatient provision for young adults with mental health problems View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Dominic Adam Travis · 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
Dominic Adam Travis, an 18-year-old man with mental health problems and regular use of cannabis and other substances, died in hospital on 18 May 2015 after suffering catastrophic injuries when he fell or jumped from a derelict mill following an acute psychotic deterioration and absconding from supported accommodation. The concerns raised included whether specialist inpatient provision adequately met the needs of young adults with mental health problems and whether the NHS Trust’s investigation into his care was sufficiently independent, transparent and timely.
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 specialist inpatient provision for young adults with mental health problems
Wider context from the report “1. Department of Health:
Dominic was aged just 18 when admitted to an acute psychiatric ward that cared for adults aged 18-65.
Given:
i) the very stark differences between the mental health needs of younger adults and older adults,
ii) an overall increase in the levels of vulnerability in such young people (by virtue of their age, condition, varying levels of maturity etc.),
iii) that acute psychiatric ward environments often care for older adult patients with profound and enduring mental health problems (that are extremely frightening to the younger adult inpatient)
&
iv) the very different mental health requirements of young people,
I am concerned that the needs of the latter are not being appropriately or adequately met, in the absence of specialist/specialist inpatient provision.
The vulnerability of young adults is clearly recognised and acknowledged in other areas such as young offenders under the age of 21 who are sentenced to YOI establishments rather than being sent to an adult prison, however no such recognition appears to exist in relation to young adults with mental health problems.
” Source location Dominic Adam Travis · Prevention of Future Deaths report
Open source report
Pin
Get email alerts
Request correction
Includes deficiencies in identifying, assessing, accessing or securing suitable specialist placements when the placement is intended to meet materially specialised care or risk-management needs.
