Concerns raised 5 Failure to diagnose and treat signs and symptoms of life-threatening illnesses appropriately View source Failure of Registered Nurses to calculate early warning scores accurately View source Over-reliance on early warning score tools instead of clinical or professional judgement View source Lack of Consultant review of patients over weekends View source Poor record keeping by doctors and nurses View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ms Edith Robinson · 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
Ms Edith Robinson was admitted to Accident and Emergency after a fall, with problems identified with her prosthetic hip. Surgery was delayed and, as she deteriorated, action was not taken to rescue her; she died at Royal Oldham Hospital on 20 June 2016. The report identified concerns about weekend consultant review, early warning score calculation and use, record keeping, escalation, communication and other aspects of care.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to diagnose and treat signs and symptoms of life-threatening illnesses appropriately
Wider context from the report “1. Consultant Review over Weekends - During the course of the evidence, I heard that patients such as the deceased are not seen or reviewed by a Consultant over the weekend. I am concerned that this gap in care is putting patients at serious risk.
The signs and symptoms of life-threatening illnesses (such as sepsis) are not being diagnosed and/or treated appropriately . Diagnosis and treatment is often time critical and requires significant clinical skill and expertise as signs can be subtle .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of Registered Nurses to calculate early warning scores accurately
Wider context from the report “2. Early Warning Scores – again, during the course of the evidence it became apparent that there were problems with the Registered Nurses' ability to calculate early warning scores accurately . As early warning scores are inextricably linked to escalation and management of the critically ill/deteriorating patient , this gives me serious cause for concern. I was told that this problem is not just a local issue, but a national issue.
I am also concerned that there is over-reliance placed upon tools of this nature, rather than the exercising of clinical/professional judgement. It is not the first time that problems relating to the calculation and use of early warning scores have become apparent during the course of an inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on early warning score tools instead of clinical or professional judgement
Wider context from the report “2. Early Warning Scores – again, during the course of the evidence it became apparent that there were problems with the Registered Nurses' ability to calculate early warning scores accurately. As early warning scores are inextricably linked to escalation and management of the critically ill/deteriorating patient, this gives me serious cause for concern. I was told that this problem is not just a local issue, but a national issue.
I am also concerned that there is over-reliance placed upon tools of this nature, rather than the exercising of clinical/professional judgement . It is not the first time that problems relating to the calculation and use of early warning scores have become apparent during the course of an inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of Consultant review of patients over weekends
Wider context from the report “1. Consultant Review over Weekends - During the course of the evidence, I heard that patients such as the deceased are not seen or reviewed by a Consultant over the weekend . I am concerned that this gap in care is putting patients at serious risk .
The signs and symptoms of life-threatening illnesses (such as sepsis) are not being diagnosed and/or treated appropriately. Diagnosis and treatment is often time critical and requires significant clinical skill and expertise as signs can be subtle.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping by doctors and nurses
Wider context from the report “3. Record Keeping - the standard of record keeping by both doctors and nurses was poor . This is a recurring theme . Given that accurate record keeping is vital to patient safety (particularly where nowadays patients are no longer continuously cared for by the ‘parent' medical team for the duration of their hospital stay) I am concerned that poor record keeping is putting patient safety at risk .
” 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 Work with the NHS to make seven-day services available in all hospitals.
Verbatim wording from the response “Firstly, on the matter of consultant review over weekends, I can assure you that it is a key commitment of the Government to work with the NHS so that seven day services are available in all hospitals.” Source location Edith-Robinson-Response
Open published response
14 Jul 2017 Sabrina Michelle Walsh · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 1 Lack of CCTV in corridors and communal areas for locating vulnerable patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sabrina Michelle Walsh · 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
Sabrina Michelle Walsh was detained under the Mental Health Act at Woodlands Acute Care and was found hanging with a ligature around her neck. The inquest concluded that she deliberately attached the ligature, but the evidence did not fully explain whether she intended a fatal outcome; this was contributed to by neglect. Concerns included the lack of formal risk assessment, inadequate observations and the absence of CCTV in corridors and communal areas.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of CCTV in corridors and communal areas for locating vulnerable patients
Wider context from the report “The lack of CCTV in corridors and communal areas at Woodlands Acute Care, St Leonards on Sea , which would enhance location of vulnerable patients where observations do not immediately locate them . Valuable minutes would be saved in locating vulnerable patients if CCTV was installed .
” Open source report
Concerns raised 1 Lack of a requirement or system for a lead clinician to oversee and coordinate mental health care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jonathan Daniel Zucker · 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
Jonathan Daniel Zucker was found at home on 27 November 2016 after hanging himself with a length of rope from banisters. The principal concern was that no lead clinician or system was in place to oversee and coordinate care provided by the private and NHS mental health services.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement or system for a lead clinician to oversee and coordinate mental health care
Wider context from the report “That there was no requirement for ,or system for, a lead clinician from either the private or NHS treating teams to oversee and coordinate the care provided to Mr Zucker by the private and NHS mental health services .
” Open source report
Concerns raised 2 Failure to seek attendance by the attending spinal surgeon for postoperative instability View source Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Macrae · 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
Mrs Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to seek attendance by the attending spinal surgeon for postoperative instability
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend . Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability.
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery
Wider context from the report “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability .
2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery .
” Open source report
Concerns raised 15 Lack of timely on-site emergency laboratory testing and results View source Failure to recognise severe clinical deterioration on consultant ward rounds View source Poor multidisciplinary communication for consistent systematic patient management View source Unavailability of specialist facilities or clinicians for peri-operative PEG insertion View source Lack of assured competence for peri-operative PEG insertion View source Failure to seek expert advice during daytime working hours View source Lack of out-of-hours radiology and on-site CT diagnostic capacity View source Failure to follow written guidance for PEG insertion View source Failure to follow written guidance for post-operative abdominal pain after PEG insertion View source Lack of on-site specialist clinical support for complications View source Lack of formal PEG insertion training and independent competency assessment View source Inconsistent daytime consultant presence in the High Dependency Unit View source Delays in transferring patients requiring post-operative specialist care View source Lack of assured general surgical competence in out-of-hours cover View source Failure to risk-assess the appropriateness of PEG insertion View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dennis Allen Teesdale · 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
Dennis Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of timely on-site emergency laboratory testing and results
Wider context from the report “12. There are no haematology or biochemistry services at QVH . A courier service is required for emergency laboratory tests . This has the potential to either not request ‘bloods’ and/or a delay in obtaining results .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise severe clinical deterioration on consultant ward rounds
Wider context from the report “10. There was no recognition of how unwell Mr Teesdale was on the consultant surgical ward round at or around 0900 on the 19th October 2016, despite considerable evidence present at the time that Mr Teesdale had developed multi-organ failure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor multidisciplinary communication for consistent systematic patient management
Wider context from the report “11. Poor communication between nursing staff, anaesthetic staff and surgical staff making it difficult to provide an overall consistent and systematic approach to the management of Mr Teesdale in a small High Dependency Unit with an inconsistent consultant presence during the day.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist facilities or clinicians for peri-operative PEG insertion
Wider context from the report “2. There are no facilities or clinicians (radiologist or gastroenterologists who normally undertake such procedures) available to place a PEG prior to surgery , thereby requiring oral maxillo-facial surgeons of variable and unclear experience to undertake the procedure peri-operatively.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of assured competence for peri-operative PEG insertion
Wider context from the report “2. There are no facilities or clinicians (radiologist or gastroenterologists who normally undertake such procedures) available to place a PEG prior to surgery, thereby requiring oral maxillo-facial surgeons of variable and unclear experience to undertake the procedure peri-operatively .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to seek expert advice during daytime working hours
Wider context from the report “8. As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical specialist experience to assist when patients develop complications. As a consequence, there was no specialist available to assess Mr Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG insertion. No effort was made to seek such expert advice during ‘daytime working hours’ .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of out-of-hours radiology and on-site CT diagnostic capacity
Wider context from the report “Similarly, there is no ‘out of hours’ radiology service and there is no CT scanner on site to assist in a diagnosis (which was required as part of the management guidelines prepared by QVH).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to follow written guidance for PEG insertion
Wider context from the report “3. Written guidance by the surgeons for insertion of PEG’s was not followed with little reflection as to whether this was an acceptable procedure given Mr Teesdale’s previous extensive surgery at or around the point where the PEG was inserted with concomitant poor gastroscopic trans-illumination.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to follow written guidance for post-operative abdominal pain after PEG insertion
Wider context from the report “6. The post-operative management of Mr Teesdale did not follow the written guidance for the management of abdominal pain after PEG insertion . This resulted in a delay in seeking appropriate advice, timely intervention and optimal treatment of this complication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of on-site specialist clinical support for complications
Wider context from the report “8. As an isolated hospital, Queen Victoria Hospital has no ‘on site’ clinical specialist experience to assist when patients develop complications . As a consequence, there was no specialist available to assess Mr Teesdale’s abdominal pain as detailed in guidance of post-operative pain following PEG insertion. No effort was made to seek such expert advice during ‘daytime working hours’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of formal PEG insertion training and independent competency assessment
Wider context from the report “5. No formal ‘training’ programme for the insertion of PEG or independent competency based assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent daytime consultant presence in the High Dependency Unit
Wider context from the report “11. Poor communication between nursing staff, anaesthetic staff and surgical staff making it difficult to provide an overall consistent and systematic approach to the management of Mr Teesdale in a small High Dependency Unit with an inconsistent consultant presence during the day .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients requiring post-operative specialist care
Wider context from the report “7. Mr Teesdale’s transfer was delayed because of a reluctance to transfer in the immediate post operative period complicated by the associated logistical difficulties of doing so given his major surgery.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of assured general surgical competence in out-of-hours cover
Wider context from the report “9. Mr Teesdale was cared for ‘out of hours’ by a trainee oral-maxillo-facial surgeon with unknown general surgical experience who did not recognise or manage the severity of a surgical complication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to risk-assess the appropriateness of PEG insertion
Wider context from the report “4. No risk assessment was undertaken as to whether a PEG insertion would have been appropriate , given that a non-invasive alternative of a feeding tube for enteral feeding was available.
” 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 NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.
Verbatim wording from the response “Finally, I am satisfied that the regulators are alert to the risks you have highlighted, and it is for NHS Improvement, NHS England and the Care Quality Commission, working with the Trust and its commissioners, to ensure sufficient and appropriate action is taken to address the concerns raised. My officials have asked to be kept informed of developments.” Source location 2017-0202-Response-by-Department-of-Health
Open published response
28 May 2017 Jamie Pashley · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 4 Failure to make telephone contact between discharge and first appointment review View source Reliance on individuals to proactively manage their rehabilitation after discharge View source Limited availability of hospital alcohol liaison nurse support View source Failure to provide fixed post-discharge appointments after detoxification View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jamie Pashley · 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
Jamie Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make telephone contact between discharge and first appointment review
Wider context from the report “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed:
(1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment;
(2) whether telephone contact should also be made with an individual between discharge and first appointment review ;
(3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reliance on individuals to proactively manage their rehabilitation after discharge
Wider context from the report “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed:
(1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment;
(2) whether telephone contact should also be made with an individual between discharge and first appointment review;
(3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited availability of hospital alcohol liaison nurse support
Wider context from the report “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed:
(1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment;
(2) whether telephone contact should also be made with an individual between discharge and first appointment review;
(3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide fixed post-discharge appointments after detoxification
Wider context from the report “Whilst understanding and appreciating that dealing with anxiety and alcohol dependence can be difficult, and taking into account the issue of resources, I would ask that the reliance upon an individual to proactively manage their rehabilitation be reviewed and re-assessed. Issues concerning the younger generation and alcohol are increasing and with the risk of relapse being potentially higher in the time soon after discharge I would ask that the following be reviewed:
(1) whether, upon discharge after detoxification, individuals ought, in addition to receiving information regarding access to Lorraine Hewitt House Aftercare Programme and signposting them to a drop in clinic, to be provided with a fixed appointment ;
(2) whether telephone contact should also be made with an individual between discharge and first appointment review;
(3) whether there is a need to increase the availability of an alcohol liaison nurse currently provided between the hours of 0900-1700,Monday to Friday, at the hospital for the individual to access, given they have met that person whilst in-patient.
” Open source report
26 May 2017 Lucy Francesca Goldstone · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of automated external defibrillator availability on trams and tram stops View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lucy Francesca Goldstone · 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
Lucy Francesca Goldstone had a severe asthma attack and became unresponsive on a tram in Manchester city centre on 7 April 2016. Despite CPR by bystanders and ambulance clinicians, she died at Manchester Royal Infirmary; the recorded cause of death was bronchial asthma and aspiration of food material. The report raised concern about the availability of automated external defibrillators on trams and tram stops, and indicated that updated information and guidance would be sought.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of automated external defibrillator availability on trams and tram stops
Wider context from the report “I was informed that in relation to the availability of Automated Electronic Defibrillator that no AEDs are provided on any of the trams or any of the tram stops on the network , and that it is not a legal requirement or industry standard practise for AEDs to be available across the various tram networks in the United Kingdom.
” Open source report
15 May 2017 Stephen Leven · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of secondary care access to GP records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Leven · 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
Stephen Leven, who had haemophilia, developed a headache and visual-field changes and was later found to have a large intracerebral haemorrhage. He died on 13 December 2016; the principal concern was that hospital clinicians lacked access to GP information about his haemophilia, which could contribute to deaths in similar future circumstances.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of secondary care access to GP records
Wider context from the report “I am concerned that, in different circumstances, the lack of access to GP information regarding Mr Leven’s diagnosis of haemophilia , could have caused or contributed to his death. As such, I am concerned that deaths could occur in future similar circumstances if further action is not taken to facilitate secondary care access to GP records .
” Open source report
Concerns raised 13 Insufficient first-aid training for staff supervising pupils View source Failure to confirm replacement medication and complete its dose in the action plan View source Provision of inappropriate emergency asthma inhalers without spacers View source Failure to verify school medication directly during medication reviews View source Failure to provide and follow immediate adrenaline auto-injector administration guidance View source Failure of school staff to familiarise themselves with pupils’ care plans View source Failure to identify poor asthma control and excessive inhaler prescribing for specialist review View source Failure to maintain accurate allergy action plans with medication-use instructions View source Failure to include a school representative in medication reviews View source Failure to maintain identical current care-plan copies across care settings View source Emergency-services contact procedures causing avoidable delay View source Failure to provide effective refresher training and information sharing for trained staff View source Lack of follow-up review tracking after replacement medication is requested View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nasar AHMED · 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
Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient first-aid training for staff supervising pupils
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained , most notably not the learning assistant who was supervising the IER . She said that she would not have thought of looking for and retrieving his care plan .
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm replacement medication and complete its dose in the action plan
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box . This meant that he also did not complete the action plan with the dose of the relevant medication .
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Provision of inappropriate emergency asthma inhalers without spacers
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler , which I heard from his respiratory consultant is inappropriate for an emergency situation such as this , and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to verify school medication directly during medication reviews
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist .
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide and follow immediate adrenaline auto-injector administration guidance
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of school staff to familiarise themselves with pupils’ care plans
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion . The internal exclusion room (IER) supervisor had not done this for the pupils in the IER . Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify poor asthma control and excessive inhaler prescribing for specialist review
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor ; and his GP was prescribing 30 inhalers a year , the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position . For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate allergy action plans with medication-use instructions
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to include a school representative in medication reviews
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy .
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain identical current care-plan copies across care settings
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records .
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Emergency-services contact procedures causing avoidable delay
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay .
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide effective refresher training and information sharing for trained staff
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided.
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training . One member of staff did not share with others the fact that Nasar had asked for this asthma pump . Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan .
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of follow-up review tracking after replacement medication is requested
Wider context from the report “The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces.
Is this a suggestion that could be given wider consideration?
1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious.
However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving.
1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner.
Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death.
Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed?
2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration.
I wonder whether there is a widespread lack of understanding of the best treatment in this situation?
3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records.
4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and:
- has any respiratory compromise, or
- there is a loss of consciousness, or
- if there is doubt,
then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately.
This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely?
1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy.
2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided .
3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER.
4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan.
5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan.
6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help?
7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay.
1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist.
2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting.
3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it.
4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication.
These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools.
” 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 guidance for school staff on obtaining and appropriately using spare adrenaline auto-injectors, including general advice on adrenaline use.
Verbatim wording from the response “Our amendments to the Human Medicines Regulations 2012, Parliament permitting, will come into effect on 1 October 2017. Officials are currently working on guidance for school staff on how to obtain and use these auto-injectors appropriately, and the guidance will also provide advice on use of adrenaline more generally. Clinicians from the Anaphylaxis Campaign, as well as lay people, are advising on the content of this guidance, and we are hoping to also bring together training videos on different auto-injectors in a single website.” Source location Response from Department of Health and Social Care
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 Bring amendments to the Human Medicines Regulations 2012 into effect to allow schools to hold spare adrenaline auto-injectors for eligible children.
Verbatim wording from the response “However, I am hopeful that work underway to change the law to allow schools to hold spare auto-injectors without a named individual prescription, for use as emergency back-up to treat anaphylaxis in children registered at the school as being in receipt of a medical prescription for an auto-injector, will tackle some of the challenges which staff faced in this sad case, and which were set out in your determination.” Source location Response from Department of Health and Social Care
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 Bring the completed guidance to the attention of schools.
Verbatim wording from the response “I hope that this guidance, which we will bring to the attention of schools, will greatly reduce the likelihood of a repetition of the tragic events which led to the death of Nasar Ahmed, and so save other lives.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 6 Failure to pass on an accurate history of events View source Failure of staff to communicate with each other during emergency response View source Lack of staff first aid training and choking-sign recognition View source Failure of staff to communicate effectively with challenging behavioural unit patients View source Poor quality of staff statements after incidents View source Failure to keep acute and contemporaneous event notes with timings View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Sheppard · 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
David Sheppard choked on a doughnut at Boldmere Court on 31 July 2016 and suffered a cardiac arrest and severe hypoxic brain injury. He was taken to Good Hope Hospital, where treatment was withdrawn, and he died on 3 August 2016. The principal concerns were inadequate emergency response, poor communication, failures in record keeping, insufficient first-aid training, and inadequate post-event investigation.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to pass on an accurate history of events
Wider context from the report “b. Staff failed to pass on an accurate history of what had happened to the deceased resulting in there being a poor understanding of his initial complaint – namely that the deceased was pointing to his throat and was unable to communicate. These factors would indicate choking.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to communicate with each other during emergency response
Wider context from the report “a. The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter. The carer who started CPR had very poor English and also gave evidence through an interpreter. The evidence heard at the inquest was that the response to this emergency was chaotic. Inability of staff to communicate with each other contributed to the chaos and poor decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of staff first aid training and choking-sign recognition
Wider context from the report “3. Training. Several of the staff who gave evidence had not received first aid training . They did not understand the signs of choking displayed by the deceased .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to communicate effectively with challenging behavioural unit patients
Wider context from the report “c. The patients on the challenging behavioural unit are extremely vulnerable and many suffer from dementia and other conditions. Staff being unable to communicate effectively with these patients may cause harm and confusion.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor quality of staff statements after incidents
Wider context from the report “4. Post event investigation. The quality of statements produced by staff immediately after the event was extremely poor . Subsequently staff had a very poor recollection of what happened which seriously hampered the inquest. Direction needs to be given to ensure that accurate and contemporaneous statements are taken after such an incident to ensure events are accurately recorded to enable the correct lessons to be learnt.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to keep acute and contemporaneous event notes with timings
Wider context from the report “2. Record keeping. Staff failed to keep an acute and contemporaneous note of the events that occurred with timings . This made reconstruction of the event extremely difficult.
” 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 The registered care provider is responsible for ensuring sufficient, qualified, competent and appropriately trained staff are deployed.
Verbatim wording from the response “It is the responsibility of Boldmere Court Care Home as the registered provider to ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed and appropriately trained as necessary to enable them to carry out their duties.” Source location David-Sheppard-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Language testing is not required for non-regulated care workers, although employers must ensure they can communicate effectively.
Verbatim wording from the response “There is no requirement for language testing non-regulated workers, such as care staff. However, social care employers are responsible for ensuring that their staff are trained and competent for the tasks they are recruited to do. This includes the ability to communicate effectively.” Source location David-Sheppard-Response
Open published response
25 Apr 2017 Linsay Bushell · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 16 Failure to provide psychologically driven care and consistently available psychology interventions View source Poor quality and insufficient standardisation of handover documentation View source Unstructured risk review and intervention planning without a collaboratively developed understanding of risk View source Lack of senior clinical challenge and guidance in ward management View source Lack of process to monitor completion and currency of risk management and care plan documentation View source Lack of consistent specialist psychological guidance to staff and psychologically directed care View source Inadequate recording and documentation of self-harming behaviour and triggers View source Failure to implement a clear and understood care pathway for patients with complex personality disorder needs View source Limited specialist intervention and multidisciplinary involvement for substance misuse-related self-harm risk View source Failure of inter-organisational transfer arrangements for patients who are not stable View source Failure to coordinate specialist placement decisions and timely funding for patients' needs View source Failure to implement a coordinated post-handover patient safety check View source Unclear recording and communication of patient observation levels View source Insufficient staff training and support in Emotionally Unstable Personality Disorders and associated suicide risk View source Lack of provision or priority for therapeutic psychological services for mentally disordered female patients with EUPD View source Poor coordination and delay in referral review for specialist placement View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide psychologically driven care and consistently available psychology interventions
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor quality and insufficient standardisation of handover documentation
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unstructured risk review and intervention planning without a collaboratively developed understanding of risk
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of senior clinical challenge and guidance in ward management
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of process to monitor completion and currency of risk management and care plan documentation
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent specialist psychological guidance to staff and psychologically directed care
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording and documentation of self-harming behaviour and triggers
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to implement a clear and understood care pathway for patients with complex personality disorder 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited specialist intervention and multidisciplinary involvement for substance misuse-related self-harm risk
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of inter-organisational transfer arrangements for patients who are not stable
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to implement a coordinated post-handover patient safety check
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear recording and communication of patient observation levels
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training and support in Emotionally Unstable Personality Disorders and associated suicide risk
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of provision or priority for therapeutic psychological services for mentally disordered female patients with EUPD
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
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.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for overseeing commissioning and delivering related improvements to mental health services.
Verbatim wording from the response “You issued your Report to NHS England, alongside the Secretary of State for Health, and I understand Professor Sir Bruce Keogh replied to you on 21 July.” Source location 2017-0137-Response-by-Department-of-Health
Open published response
Concerns raised 3 Failure to ensure independent noticing and recording of unexpected significant radiological findings View source Unavailability of a system red flag for unexpected significant radiological findings View source Lack of a radiology protocol for non-cancerous significant and potentially life-threatening findings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mr John Higgs · 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
Mr John Higgs died at Barnsley General Hospital on 18 November 2015 from a ruptured abdominal aortic aneurysm. A CT scan in March 2011 had identified the aneurysm, but the finding was not communicated to Mr Higgs, other clinicians, or his general practitioner. The report raised concern that the Trust’s current system for communicating unexpected, significant non-cancerous radiological findings remained reliant on one doctor noticing and recording the information, with no red-flag facility or equivalent protocol.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure independent noticing and recording of unexpected significant radiological findings
Wider context from the report “The inquest heard that the Trust now relies on an electronic system rather than the paper system as it did in 2011. However, any unexpected significant/serious radiological finding are still included in a report that is only sent to the Consultant in charge of the care and it is a matter for that doctor to notice that part of the report and to input this information on the system as a message . In essence, the process appears to be the same, it the mode of recording the information that had changed from paper to computer. No other measures have been put in place and the system is still reliant on one doctor noticing and recording the information . In addition, the Court heard there was no facility to place a “red flag” on the system to increase the likelihood of other clinicians being made aware of these unexpected and significant findings.
The Trust has a radiology protocol for “unexpected cancer pathology” where the results are sent to the treating Consultant but also sent to the MDT Cancer Co-ordinator for action but no such protocol exists for non- cancerous but significant and potentially life threatening findings.
The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to “unexpected (non-cancerous) radiological findings because HMAC ████████ is concerned that this situation could occur again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a system red flag for unexpected significant radiological findings
Wider context from the report “The inquest heard that the Trust now relies on an electronic system rather than the paper system as it did in 2011. However, any unexpected significant/serious radiological finding are still included in a report that is only sent to the Consultant in charge of the care and it is a matter for that doctor to notice that part of the report and to input this information on the system as a message. In essence, the process appears to be the same, it the mode of recording the information that had changed from paper to computer. No other measures have been put in place and the system is still reliant on one doctor noticing and recording the information. In addition, the Court heard there was no facility to place a “red flag” on the system to increase the likelihood of other clinicians being made aware of these unexpected and significant findings .
The Trust has a radiology protocol for “unexpected cancer pathology” where the results are sent to the treating Consultant but also sent to the MDT Cancer Co-ordinator for action but no such protocol exists for non- cancerous but significant and potentially life threatening findings.
The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to “unexpected (non-cancerous) radiological findings because HMAC ████████ is concerned that this situation could occur again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a radiology protocol for non-cancerous significant and potentially life-threatening findings
Wider context from the report “The inquest heard that the Trust now relies on an electronic system rather than the paper system as it did in 2011. However, any unexpected significant/serious radiological finding are still included in a report that is only sent to the Consultant in charge of the care and it is a matter for that doctor to notice that part of the report and to input this information on the system as a message. In essence, the process appears to be the same, it the mode of recording the information that had changed from paper to computer. No other measures have been put in place and the system is still reliant on one doctor noticing and recording the information. In addition, the Court heard there was no facility to place a “red flag” on the system to increase the likelihood of other clinicians being made aware of these unexpected and significant findings.
The Trust has a radiology protocol for “unexpected cancer pathology” where the results are sent to the treating Consultant but also sent to the MDT Cancer Co-ordinator for action but no such protocol exists for non- cancerous but significant and potentially life threatening findings .
The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to “unexpected (non-cancerous) radiological findings because HMAC ████████ is concerned that this situation could occur again.
” Open source report
Concerns raised 1 Failure to include higher-risk teenagers in the meningitis B vaccination programme View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Isabel Lily GENTRY · 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
Isabel Lily Gentry became ill with meningitis on 17 May 2016, was discharged from hospital on 18 May with a diagnosis of viral gastroenteritis, and was readmitted later that day when her condition worsened. Meningitis was confirmed, but despite care and treatment she deteriorated and died on 20 May 2016. The principal concern was that extending meningitis B vaccination to the teenage group might prevent future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to include higher-risk teenagers in the meningitis B vaccination programme
Wider context from the report “1. Evidence was provided during the inquest that if Isabel had received the meningitis B vaccination that her death would have been prevented. There is therefore an ongoing risk that future deaths will occur unless action is taken in relation to extending the vaccination program to include the teenage group which is at increased risk.
” Open source report
5 Apr 2017 Ronald William Bennett · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 2 Lack of hospital bed availability delaying patient admission View source Failure to complete hospital handovers within the 30-minute national standard View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Ronald William Bennett · 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
Ronald William Bennett was the subject of an inquest whose circumstances are referred to in the Record of Inquest, which is not provided here. The substantive concerns included delays in ambulance crews reaching incidents because of hospital handover delays, inadequate urgent and emergency services, and bed availability; the report states that the delay in Mr Bennett’s admission did not contribute to his death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of hospital bed availability delaying patient admission
Wider context from the report “(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes. The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day).
(2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate.
(3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds .
(4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death.
(5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to complete hospital handovers within the 30-minute national standard
Wider context from the report “(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes . I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes . The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day).
(2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate.
(3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds.
(4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death.
(5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH.
” Open source report
Concerns raised 15 Delays in arranging urgent tests and treatment View source Absence of clinical judgement caused by over-reliance on early warning tools View source Poor ward-level leadership and supervision of nurses View source Difficulties in providing safe and effective care across split hospital sites View source Failure by doctors and nurses to escalate patient deterioration View source Failure to make timely progress in addressing previously recognised care failings View source Impact of split-site commitments and reconfiguration on patient safety and clinical care View source Poor communication between clinicians and nurses View source Inadequate on-call consultant supervision of junior colleagues View source Inaccurate and incomplete fluid balance charts View source Poor medical and nursing record keeping View source Failure to repeat indicated tests and act on the results View source Unsafe standard of hospital care out of hours and at weekends View source Failure to record accurate baseline observations and vital parameters View source Incorrect calculation of early warning scores View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Kathleen Cooper · 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
Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging urgent tests and treatment
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics )
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of clinical judgement caused by over-reliance on early warning tools
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor ward-level leadership and supervision of nurses
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulties in providing safe and effective care across split hospital sites
Wider context from the report “1. During the course of the inquest, a medical practitioner raised concerns regarding the difficulties faced by clinicians in providing safe and effective care when an acute NHS Trust has a number of hospitals/departments on different sites i.e. the difficulties faced as a result of split-site commitments as a result of NHS reconfiguration . I echo this concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure by doctors and nurses to escalate patient deterioration
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely progress in addressing previously recognised care failings
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months . Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths . My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Impact of split-site commitments and reconfiguration on patient safety and clinical care
Wider context from the report “4. Split site commitment/reconfiguration and the impact this potentially has upon patient safety and clinical care (please see 1 above).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor communication between clinicians and nurses
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate on-call consultant supervision of junior colleagues
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete fluid balance charts
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor medical and nursing record keeping
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat indicated tests and act on the results
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unsafe standard of hospital care out of hours and at weekends
Wider context from the report “2. The standard of care provided to hospital patients out of hours/weekend and the risk/s posed to patient safety as a result.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record accurate baseline observations and vital parameters
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incorrect calculation of early warning scores
Wider context from the report “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular:
- Poor communication by/between clinicians and nurses
- Poor record keeping – medical and nursing
- Poor leadership/supervision of nurses - Ward/Matron level
- Inadequate supervision by on-call consultants of junior colleagues
- Incorrectly calculated early warning scores
- Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified
- Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording)
- The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores
- Failure to repeat tests such as bloods and to act upon the results accordingly
- Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent
- Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics)
” Open source report
Concerns raised 3 Lack of a formal pump agreement View source Inadequate monitoring and review of blood sugar levels and pump-generated data View source Inconsistent national support for insulin pump users View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Natalie Ann Thornton · 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
Natalie Thornton, who had longstanding brittle type 1 diabetes and related complications, began insulin pump therapy in December 2014. On 18 January 2015 she became unwell, collapsed, and died; the inquest concluded that the medical cause of death was diabetic ketoacidosis. Concerns were raised about the adequacy of monitoring and review of blood sugar data after the pump was introduced, including that trends were not analysed, and about variable national support for insulin pump users.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal pump agreement
Wider context from the report “1. Concern was expressed as to the adequacy of the monitoring and review of blood sugar levels/data generated following the initial use of the pump provided by the Salford Royal Trust which provided Natalie’s equipment and had been caring for her over many years. More particularly trends were not analysed. Whilst noting that the introduction of insulin pump therapy was deemed an evolutionary process no formal Pump Agreement was in place at the time although such Agreements have now been implemented
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring and review of blood sugar levels and pump-generated data
Wider context from the report “1. Concern was expressed as to the adequacy of the monitoring and review of blood sugar levels/data generated following the initial use of the pump provided by the Salford Royal Trust which provided Natalie’s equipment and had been caring for her over many years. More particularly trends were not analysed. Whilst noting that the introduction of insulin pump therapy was deemed an evolutionary process no formal Pump Agreement was in place at the time although such Agreements have now been implemented
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inconsistent national support for insulin pump users
Wider context from the report “2. From the evidence given by the expert Consultant ████████ it would appear that the level of support for insulin pump users nationally is variable . Whether the need for consistency and minimum standards should be addressed by Regional Centres of Excellence would be a matter for the Department to consider.
” 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 Establishing regional centres of excellence would require major infrastructure, workforce and financial changes, and variation must first be better understood.
Verbatim wording from the response “You ask the Department to consider whether the need for consistency and minimum standards for insulin pump users would be addressed by the establishment of regional centres of excellence. NHS England advises that such a move would be a significant undertaking, involving infrastructure and workforce changes and financial investment, and there is need initially to understand better the extent of variation.” Source location 2017-0030-Response-by-Department-of-Health
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 NICE has no plans to review the insulin pump guidance at this time.
Verbatim wording from the response “The guidance does not make specific recommendations on support for insulin pump users. However, there are general recommendations in the guideline on early care plans, support and individualised care, as well as education and information provision for people with type 1 diabetes, which applies to pump users and non-pump users alike.” Source location 2017-0030-Response-by-Department-of-Health
Open published response
18 Jan 2017 Michael Parke · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 12 Lack of corporate memory for nasogastric tube risks View source Failure of the policy to remain sufficiently usable for busy practitioners View source Failure to learn from deaths and incidents View source Failure of staff to apply the policy and follow good practice View source Lack of ward-based systems to ensure compliance View source Delays in fully implementing the 2011 NPSA Alert View source Lack of staff awareness of the policy View source Failure to roll out training to all staff who need it View source Failure to maintain accurate policy cross-references View source Failure to ensure compliance with the policy View source Failure of staff to read the policy View source Lack of checks and audits of competence and policy adherence View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Parke · 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
Michael Parke, who had chronic liver disease, was admitted to West Cumberland Hospital and had a nasogastric tube inserted. The tube was misplaced into his left lung, an x-ray showing this was misinterpreted, and feeding and medication were administered through the tube before he developed aspiration pneumonia and died. The concerns included staff not following nasogastric-tube policy and systemic failures in policy implementation, training, competency checks, auditing and organisational learning.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of corporate memory for nasogastric tube risks
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register ).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the policy to remain sufficiently usable for busy practitioners
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years , making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from deaths and incidents
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to apply the policy and follow good practice
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of ward-based systems to ensure compliance
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in fully implementing the 2011 NPSA Alert
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death .
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of the policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to roll out training to all staff who need it
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate policy cross-references
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions , and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure compliance with the policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to read the policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of checks and audits of competence and policy adherence
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths were avoidable. Common themes in all are:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” 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 Amend regulations to require NHS Trusts to summarise published deaths information, learning and resulting actions in Quality Accounts.
Verbatim wording from the response “We are also amending regulations to require Trusts to summarise the published information in Quality Accounts from June 2018, including evidence of learning and action as a result of that information and an assessment of the impact of actions that a Trust has taken.” Source location 2017-0024-Response
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 Continue funding research into methods for confirming correct nasogastric tube placement.
Verbatim wording from the response “Turning to your recommendation that we take steps to ensure research is undertaken to identify a superior method of ensuring correct nasogastric tube placement. The National Institute for Health Research (NIHR), funded by the Department of Health, funds health and care research and translates discoveries into practical products, treatments, devices and procedures, involving patients and the public at every step. The NIHR ensures that the NHS is able to support research funded by all public, charity and industry research funders, which in turn encourages economic growth. The NIHR has, and continues to fund research into methods of ensuring correct nasogastric tube placement.” Source location 2017-0024-Response
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 principal patient-safety problem is inconsistent implementation, rather than unavailable guidance or ineffective current placement checks.
Verbatim wording from the response “In conclusion, I am advised that the challenge around improving patient safety in this area is not the availability or appropriateness of national guidance, or the effectiveness of current placement checks but rather their implementation. By ensuring medical and nursing staff have the right competencies to undertake procedures relating to nasogastric tube placement, NHS Trusts can ensure that patient harm and deaths are avoided.” Source location 2017-0024-Response
Open published response
18 Jan 2017 Amanda Coulthard · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 12 Lack of corporate memory for nasogastric tube safety risks View source Failure of staff to apply the nasogastric tube policy View source Failure of staff to follow good practice for nasogastric tube use View source Failure to learn from a prior nasogastric tube death View source Failure of staff to read the nasogastric tube policy View source Lack of staff awareness of the nasogastric tube policy View source Failure to maintain accurate cross-references in the nasogastric tube policy View source Nasogastric tube policy becoming difficult for practitioners to absorb View source Failure to fully implement the 2011 NPSA Alert on nasogastric tubes View source Lack of ward-level systems to ensure compliance with the nasogastric tube policy View source Lack of checks and audits of staff competence and policy adherence View source Failure to provide nasogastric tube policy training to all required staff View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Amanda Coulthard · 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
Amanda Coulthard, who had multiple sclerosis, died on 26 April 2015 after a nasogastric tube entered her right lung and feed and medication were administered into it. She developed aspiration pneumonia. The concerns included failures to follow and implement nasogastric-tube policies and best practice, inadequate checking and training, and insufficient systems to ensure compliance and learn from previous deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of corporate memory for nasogastric tube safety risks
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register ).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to apply the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to follow good practice for nasogastric tube use
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from a prior nasogastric tube death
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to read the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate cross-references in the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions , and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Nasogastric tube policy becoming difficult for practitioners to absorb
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to fully implement the 2011 NPSA Alert on nasogastric tubes
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of ward-level systems to ensure compliance with the nasogastric tube policy
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of checks and audits of staff competence and policy adherence
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide nasogastric tube policy training to all required staff
Wider context from the report “I have now held inquests into 3 deaths as a result of misplaced nasogastric tubes at North Cumbria Hospitals which occurred over a period of a little over 7 years. These types of death are described as ‘Never Events’. On the facts of these three cases the deaths are avoidable. Common themes in all were:
(a) Staff not being aware of the policy.
(b) Staff not reading the policy.
(c) Staff not applying the policy.
(d) Staff not following good practice.
(e) The Trust not ensuring compliance nor rolling out training to all who needed it.
(f) Lack of checks and audits to establish competence and adherence to policy.
(g) Failure of the Trust to learn from the first death.
(h) Lack of Corporate Memory (the issue of NGTs was not on the Risk Register).
(i) The Trust not fully implementing the 2011 NPSA Alert for over two years and only as a result of the second death.
(j) Even after the second death not having systems in place to ensure compliance on the ward which contributed to the third death.
(k) The Trust Policy growing in size from 20 to 36 pages in 7 years, making it difficult for busy practitioners to absorb (there are some 200 Policies in the Trust).
(l) The current Policy has cross-references to paragraphs which do not exist. These errors have been carried through three versions, and raise the risk of misinterpretation by staff and undermining their confidence in such an important document.
” Open source report
Concerns raised 4 Lack of specialist inpatient provision for young adults with mental health problems View source Lack of transparency in internal investigations of patient care incidents View source Lack of independence in internal investigations of patient care incidents View source Delays in completing investigations and learning lessons from patient safety incidents View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of transparency in internal investigations of patient care incidents
Wider context from the report “2. Pennine Care NHS Foundation Trust:
The internal investigation into the circumstances surrounding Dominic's death was inadequate as it lacked transparency and independence. The manager to whom the investigation was allocated subsequently delegated it to a Nurse who had been directly involved in Dominic's care - he was the HTT attending clinician on the 17th May when Dominic absconded in a floridly psychotic state.
The incident was ‘STEIS reported’ but nothing further heard in this regard.
Whilst the Trust’s Medical Director has agreed to direct that a fresh investigation into the care that Dominic received be conducted (by an independent team), it became apparent during the course of the inquest that ‘lower level’ investigations are still being conducted by those directly involved in the patient’s care – it was said - to final constraints. When potentially near-neutral alternatives were discussed, the Trust confirmed that it was already considering such options but that it had no fixed plans or timescale for implementation.
Given that time is of the essence in terms of ‘lessons learned’ from such investigations – even those purportedly described as ‘low level’ - any delays potentially go to a) patient safety and/or b) the prevention of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of independence in internal investigations of patient care incidents
Wider context from the report “2. Pennine Care NHS Foundation Trust:
The internal investigation into the circumstances surrounding Dominic's death was inadequate as it lacked transparency and independence. The manager to whom the investigation was allocated subsequently delegated it to a Nurse who had been directly involved in Dominic's care - he was the HTT attending clinician on the 17th May when Dominic absconded in a floridly psychotic state.
The incident was ‘STEIS reported’ but nothing further heard in this regard.
Whilst the Trust’s Medical Director has agreed to direct that a fresh investigation into the care that Dominic received be conducted (by an independent team), it became apparent during the course of the inquest that ‘lower level’ investigations are still being conducted by those directly involved in the patient’s care – it was said - to final constraints. When potentially near-neutral alternatives were discussed, the Trust confirmed that it was already considering such options but that it had no fixed plans or timescale for implementation.
Given that time is of the essence in terms of ‘lessons learned’ from such investigations – even those purportedly described as ‘low level’ - any delays potentially go to a) patient safety and/or b) the prevention of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in completing investigations and learning lessons from patient safety incidents
Wider context from the report “2. Pennine Care NHS Foundation Trust:
The internal investigation into the circumstances surrounding Dominic's death was inadequate as it lacked transparency and independence. The manager to whom the investigation was allocated subsequently delegated it to a Nurse who had been directly involved in Dominic's care - he was the HTT attending clinician on the 17th May when Dominic absconded in a floridly psychotic state.
The incident was ‘STEIS reported’ but nothing further heard in this regard.
Whilst the Trust’s Medical Director has agreed to direct that a fresh investigation into the care that Dominic received be conducted (by an independent team), it became apparent during the course of the inquest that ‘lower level’ investigations are still being conducted by those directly involved in the patient’s care – it was said - to final constraints. When potentially near-neutral alternatives were discussed, the Trust confirmed that it was already considering such options but that it had no fixed plans or timescale for implementation.
Given that time is of the essence in terms of ‘lessons learned’ from such investigations – even those purportedly described as ‘low level’ - any delays potentially go to a) patient safety and/or b) the prevention of future deaths.
” Open source report
Concerns raised 3 Failure to undertake an ECG before commencing QT-prolonging medication View source Failure to undertake regular ECG monitoring during continuing treatment with multiple psychotropic medication View source Failure to recognise the QT-prolonging potential of multiple psychotropic medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Marjorie Cybil Bassendine · 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
Marjorie Cybil Bassendine, aged 98, suddenly collapsed while eating breakfast at her care home on 2 October 2015 and died despite resuscitation. The inquest recorded cardiac arrhythmia, long QT syndrome and therapeutic drug use as the medical cause of death. The principal concern was that multiple medications capable of prolonging the QT interval had been prescribed without assessment of her cardiac status, including an ECG, or regular ECG monitoring.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake an ECG before commencing QT-prolonging medication
Wider context from the report “2. To undertake an Electrocardiogram (ECG) prior to commencing such medication .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake regular ECG monitoring during continuing treatment with multiple psychotropic medication
Wider context from the report “3. To undertake regular ECG's to ensure long QT syndrome has not developed and to help plan continuing treatment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the QT-prolonging potential of multiple psychotropic medication
Wider context from the report “1. To recognise use of multiple psychotropic medication has the potential to prolong the QT interval .
” Open source report
Concerns raised 6 Difficulty involving family, friends and pets in treatment during distant placements View source Failure to notify local community and home treatment teams of S17 leave View source Shortage of acute mental health beds requiring out-of-county placements View source Absence of a risk mitigation plan before S17 leave View source Limited risk assessments before S17 leave View source Difficulty for nearest relatives and Responsible Medical Officers to carry out statutory functions during distant placements View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Knight · 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
David Knight, who was detained under the Mental Health Act for chronic mental health issues, died on 23 May 2015 after walking onto a railway track in front of an oncoming train while on Section 17 leave. Concerns included a limited risk assessment before leave, no notification to local community and home treatment teams, and the difficulties associated with his out-of-county placement, including reduced family involvement and communication challenges.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulty involving family, friends and pets in treatment during distant placements
Wider context from the report “The treatment of mental health patients generally includes the involvement of significant family, friends and pets. On Mr Knight’s previous hospital admissions, his parents and dog has been considered at significant protected factors in preventing him self-harming and also aided in his recovery. Cygnet Hospital was a 5 hour drive from Mr Knight and his parent’s home. This made it difficult to physically and practically arrange S17 leave and visiting by family/friends . There was also the cost of financing the visits. It was not possible (as on other admissions) due to the distance, for his dog to be included in the treatment plan ████████
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to notify local community and home treatment teams of S17 leave
Wider context from the report “S17 leave is prescribed by the Responsible Medical Officer as part of the treatment to the hospitalised patient in order facilitate them re-integrating back into the community in a structured, safe and supported way. Typically this would start off with escorted leave in the grounds of the hospital and hospital locality, moving to unescorted leave and then to home leave. Latterly the community mental health services and Home Treatment Team are involved to ensure a smooth transition of the patient back to community living.
When Mr Knight's mental health deteriorated whilst on leave, there were concerns that a limited risk assessment was carried out by Cygnet Hospital prior to S17 leave on 21st May 2015 and there was no communication with the local community mental health team and Home Treatment Team in Cornwall notifying them of the leave . This meant that when Mr Knight's mental health deteriorated while on leave, there was no method of reducing the risk of self-harm or harm to others, as no mitigation plan had been put in place in advance of the leave and the Cornwall Community Mental Health Team and the Home Treatment Team were unaware he was on S17 leave in their area . The expert psychiatrists considered that although misjudgement about leave could occur in any hospital setting, the fact that Mr Knight was being treated out of County would have increased the risk of poor communication with the community treatment teams as the hospital would not be familiar with local service and it was very likely that this had a bearing on Mr Knight's death (████████).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Shortage of acute mental health beds requiring out-of-county placements
Wider context from the report “At the inquest, evidence was given by the Cornwall Partnership Trust and Kernow Clinical Commissioning Group and the expert Psychiatrist that there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment . In Cornwall in 2015, the average out of placement was 6/7 patients per day but on occasions up to 20 patients . In the summer of 2015, there were between 30-40 patients per day placed out of County (due in part to renovation works on a local mental health hospital).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Absence of a risk mitigation plan before S17 leave
Wider context from the report “S17 leave is prescribed by the Responsible Medical Officer as part of the treatment to the hospitalised patient in order facilitate them re-integrating back into the community in a structured, safe and supported way. Typically this would start off with escorted leave in the grounds of the hospital and hospital locality, moving to unescorted leave and then to home leave. Latterly the community mental health services and Home Treatment Team are involved to ensure a smooth transition of the patient back to community living.
When Mr Knight's mental health deteriorated whilst on leave, there were concerns that a limited risk assessment was carried out by Cygnet Hospital prior to S17 leave on 21st May 2015 and there was no communication with the local community mental health team and Home Treatment Team in Cornwall notifying them of the leave. This meant that when Mr Knight's mental health deteriorated while on leave, there was no method of reducing the risk of self-harm or harm to others , as no mitigation plan had been put in place in advance of the leave and the Cornwall Community Mental Health Team and the Home Treatment Team were unaware he was on S17 leave in their area. The expert psychiatrists considered that although misjudgement about leave could occur in any hospital setting, the fact that Mr Knight was being treated out of County would have increased the risk of poor communication with the community treatment teams as the hospital would not be familiar with local service and it was very likely that this had a bearing on Mr Knight's death (████████).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Limited risk assessments before S17 leave
Wider context from the report “S17 leave is prescribed by the Responsible Medical Officer as part of the treatment to the hospitalised patient in order facilitate them re-integrating back into the community in a structured, safe and supported way. Typically this would start off with escorted leave in the grounds of the hospital and hospital locality, moving to unescorted leave and then to home leave. Latterly the community mental health services and Home Treatment Team are involved to ensure a smooth transition of the patient back to community living.
When Mr Knight's mental health deteriorated whilst on leave, there were concerns that a limited risk assessment was carried out by Cygnet Hospital prior to S17 leave on 21st May 2015 and there was no communication with the local community mental health team and Home Treatment Team in Cornwall notifying them of the leave. This meant that when Mr Knight's mental health deteriorated while on leave, there was no method of reducing the risk of self-harm or harm to others, as no mitigation plan had been put in place in advance of the leave and the Cornwall Community Mental Health Team and the Home Treatment Team were unaware he was on S17 leave in their area. The expert psychiatrists considered that although misjudgement about leave could occur in any hospital setting, the fact that Mr Knight was being treated out of County would have increased the risk of poor communication with the community treatment teams as the hospital would not be familiar with local service and it was very likely that this had a bearing on Mr Knight's death (████████).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulty for nearest relatives and Responsible Medical Officers to carry out statutory functions during distant placements
Wider context from the report “At the inquest the Consultant Psychiatrists (including Expert Psychiatrist) gave evidence that it was not best practice to treat patients out of county. This was particularly relevant to patients with chronic mental health issues (as with Mr Knight) where they were well known to the local mental health service and their needs and issue had successfully been addressed in the past ████████ Another issues raised, was the difficulties of the “nearest relative” and the Responsible Medical Officer to adequately carry out their statutory function at such distances .
” 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 Implement comprehensive community-based mental health pathways so people receive care at the right time and place.
Verbatim wording from the response “This will help people move easily between hospital and care in the community, ensuring that beds are available for those most in need. I appreciate that this will not happen overnight but we are committed to delivering change. Through the Five Year Forward View we will implement a comprehensive set of community-based mental health pathways of care so that people have access to care at the right time in the right place.” Source location 2016-0414-Response-by-Department-of-Health
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 Eliminate clinically unnecessary out-of-area placements for adult acute mental health care by 2020/21.
Verbatim wording from the response “We will eliminate clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and will reduce significantly delayed transfers of care.” Source location 2016-0414-Response-by-Department-of-Health
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 Publish and apply a revised Mental Health Act Code of Practice strengthening family involvement and robust risk assessment, including for leave of absence.
Verbatim wording from the response “You have raised concerns about the quality of the risk assessment that was undertaken and the limited contact with Mr Knight’s family by the mental health provider to support Mr Knight’s leave in the community. These matters are the responsibility of the local health services. However, you may be aware that the Department published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code.” Source location 2016-0414-Response-by-Department-of-Health
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 clinical commissioning groups are responsible for commissioning acute mental health beds because they assess and meet local community needs.
Verbatim wording from the response “You have raised concerns about the availability of acute mental health beds nationally. As you will know, acute mental health beds are commissioned locally by clinical commissioning groups (CCGs) as they are best placed to assess and meet the needs of their local communities. You may be aware that the Commission to review the provision of acute inpatient psychiatric care for adults, led by Lord Crisp, published its review in 2015. The review found that access to acute mental health beds was not so much an issue of bed capacity but rather a problem of discharge policies and providing alternatives to hospital admission in the community. We are committed to providing a full response to the review by the end of 2016/17.” Source location 2016-0414-Response-by-Department-of-Health
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 health services are responsible for the quality of risk assessments and family contact supporting patients’ community leave.
Verbatim wording from the response “You have raised concerns about the quality of the risk assessment that was undertaken and the limited contact with Mr Knight’s family by the mental health provider to support Mr Knight’s leave in the community. These matters are the responsibility of the local health services. However, you may be aware that the Department published a revised Mental Health Act 1983 Code of Practice in 2015 which strengthened the guiding principles of the Code.” Source location 2016-0414-Response-by-Department-of-Health
Open published response
11 Nov 2016 Karen Ann Thorne · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Delays in reporting neuroradiology and radiology View source Insufficient radiologist training capacity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Karen Ann Thorne · 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
Karen Ann Thorne died at Salford Royal Hospital on 13 June 2016 following complications associated with Natalizumab treatment for Multiple Sclerosis and subsequent Plasma Exchange treatment for Progressive Multifocal Leukoencephalopathy. PML identified on scans in May and October 2015 was not reported or diagnosed until February 2016, with delays in reporting and treatment adversely affecting her response and prognosis. The report raised concerns about delays in neuroradiology reporting and the national shortage of Radiologists and training positions.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting neuroradiology and radiology
Wider context from the report “1. During the Inquest evidence was heard that:-
i. There are delays in reporting neuroradiology within the Salford Royal NHS Foundation Trust and at the present time the longest wait is 60 days, which is a slight improvement from the end of 2015 when the Scan conducted on the Deceased was not reported for 65 days but a delay of 60 days is still unacceptable.
ii. There is an increasing demand for neuroradiology, and radiology in general, and there is a national shortage of Radiologists.
iii. The delay in reporting radiology is of greater concern in cases where a patient is receiving treatment on a regular basis, namely every 28 days in the case of the Deceased, and the Scans are not reported for a period in excess of 60 working days , during which time the Deceased received 2 or 3 additional Natalizumab infusions, which would have been stopped had the Scan been reported and identified PML before the next infusion.
iv. Evidence was given at the Inquest, on the basis of information received from the Royal College of Radiologists, that the national shortage of Radiologists was due to the fact that there are a fixed number of training positions for Radiologists each year and the number is insufficient to produce the number of Radiologists required to give an appropriate service and to report radiology within a reasonable, necessary and expected time period.
The information referred to the fact that there was no shortage of clinicians prepared to train as Radiologists and that there were more applicants than training positions.
The evidence given to the Inquest was that an increase in the number of training positions would increase the number of Radiologists to address the national shortage of Radiologists, which is creating the delays in reporting radiology and delays in the diagnosis of conditions requiring either immediate treatment or the cessation of treatment with recognised complications.
2. I request you to consider the above concerns in relation to a national shortage of Radiologists and to review the number of training positions to address the national shortage of Radiologists and to address delays in the reporting of radiology and the diagnosis of disease, either requiring treatment or the cessation of treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist training capacity
Wider context from the report “1. During the Inquest evidence was heard that:-
i. There are delays in reporting neuroradiology within the Salford Royal NHS Foundation Trust and at the present time the longest wait is 60 days, which is a slight improvement from the end of 2015 when the Scan conducted on the Deceased was not reported for 65 days but a delay of 60 days is still unacceptable.
ii. There is an increasing demand for neuroradiology, and radiology in general, and there is a national shortage of Radiologists.
iii. The delay in reporting radiology is of greater concern in cases where a patient is receiving treatment on a regular basis, namely every 28 days in the case of the Deceased, and the Scans are not reported for a period in excess of 60 working days, during which time the Deceased received 2 or 3 additional Natalizumab infusions, which would have been stopped had the Scan been reported and identified PML before the next infusion.
iv. Evidence was given at the Inquest, on the basis of information received from the Royal College of Radiologists, that the national shortage of Radiologists was due to the fact that there are a fixed number of training positions for Radiologists each year and the number is insufficient to produce the number of Radiologists required to give an appropriate service and to report radiology within a reasonable, necessary and expected time period.
The information referred to the fact that there was no shortage of clinicians prepared to train as Radiologists and that there were more applicants than training positions.
The evidence given to the Inquest was that an increase in the number of training positions would increase the number of Radiologists to address the national shortage of Radiologists, which is creating the delays in reporting radiology and delays in the diagnosis of conditions requiring either immediate treatment or the cessation of treatment with recognised complications.
2. I request you to consider the above concerns in relation to a national shortage of Radiologists and to review the number of training positions to address the national shortage of Radiologists and to address delays in the reporting of radiology and the diagnosis of disease, either requiring treatment or the cessation of treatment.
” 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 Some matters raised in the concerns are the responsibility of the relevant NHS Trust rather than the Department of Health.
Verbatim wording from the response “Some of the matters you raise are for the Trust. For the concerns you raise about the shortage of radiologists, Department of Health officials have contacted Health Education England about its plans to recruit more trainees into radiology. I understand Health Education England is working in partnership with NHS England and a range of professional bodies to develop a shared vision and strategy for the diagnostics workforce. Clinical Radiology is a priority area.” Source location 2016-0408-Response-by-Department-of-Health
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 addressing radiologist shortages and developing diagnostic workforce plans lies with Health Education England and its partners.
Verbatim wording from the response “Some of the matters you raise are for the Trust. For the concerns you raise about the shortage of radiologists, Department of Health officials have contacted Health Education England about its plans to recruit more trainees into radiology. I understand Health Education England is working in partnership with NHS England and a range of professional bodies to develop a shared vision and strategy for the diagnostics workforce. Clinical Radiology is a priority area.” Source location 2016-0408-Response-by-Department-of-Health
Open published response
Concerns raised 4 Lack of audit of the appropriateness of on-the-job portable oxygen cylinder training View source Transfer of Patients Policy failing to cover portable oxygen cylinder transfers View source Failure to document portable oxygen cylinder training and trained personnel View source Failure to provide formal training on the use of portable oxygen cylinders for patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Simon Timothy Harper · 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
Mr Simon Timothy Harper was admitted to hospital with jaundice and abdominal distention and later developed multiple organ failure. During his transfer to intensive care, his portable oxygen cylinder was not turned on; he suffered a cardiorespiratory arrest, was resuscitated, and died after treatment was withdrawn. Concerns included inadequate documented training and lack of a suitable transfer policy for using portable oxygen cylinders.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of the appropriateness of on-the-job portable oxygen cylinder training
Wider context from the report “Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training .
The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this.
The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Transfer of Patients Policy failing to cover portable oxygen cylinder transfers
Wider context from the report “Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training.
The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this.
The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document portable oxygen cylinder training and trained personnel
Wider context from the report “Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time . In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training. In addition, no register of individuals trained or content of training is documented . There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training.
The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this.
The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal training on the use of portable oxygen cylinders for patients
Wider context from the report “Upon the reassignment of the task, one session of training was provided by an external company to a small number of nursing staff who were on duty at the time. There is no record regarding the contents of the induction/training or who was present at the time. In addition, the Trust confirmed that since that date there has been no formal training and they have relied on ‘peer to peer’ training . In addition, no register of individuals trained or content of training is documented. There is no record of who has and has not received relevant training and no audit is in place to assess the appropriateness of this ‘on the job’ his training.
The inquest heard that the nurse responsible for connecting the patient to the oxygen cylinder did not turn the valve to allow oxygen flow. It is probably that this lead to the cardiorespiratory arrest although it was accepted no-one could be certain of this.
The Secretary of State for Health is asked to consider whether it is appropriate for training to be provided and documented regarding the use of portable oxygen cylinders for patients. The implementation of a Transfer of Patients Policy should also be considered as those available did not cover this issue.
” Open source report
Concerns raised 3 Insufficient public education in the use of public access defibrillators View source Inadequate placement of public access defibrillators View source Insufficient availability of public access defibrillators in colleges and schools View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Jane Louise Reason · 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
Jane Louise Reason, a lecturer, collapsed at work on 28 April 2016 and was later declared deceased in hospital; the medical cause of death was recorded as hypertensive heart disease. The inquest highlighted the importance of early defibrillation and CPR and raised concern about the availability and public education surrounding public access defibrillators, particularly in colleges and schools.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient public education in the use of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate placement of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of public access defibrillators in colleges and schools
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school . Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” Open source report
25 Oct 2016 Richard Walsh · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion View source Failure of detained organisations to pass risk information consistently between one another View source Inadequate nurse assessment of fitness for segregation View source Lack of an agreed system for transferring health care information from police stations or courts to prisons View source Inadequate standard of Mental Health Act assessments View source Lack of clear responsibility for passing or seeking relevant information View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Richard Walsh · 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
Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.
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. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
Wider context from the report “There appeared to be a focus by individuals on completing the proforma or questionnaire required by the system, by rote with either no time to consider the whole person , or no sense that it was their responsibility to consider missing or discordant information or to be proactive in communicating gaps in knowledge or concerns . From the evidence of a number of witnesses, the pattern of communication was not exceptional in this instance but reflected what usually happened.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of detained organisations to pass risk information consistently between one another
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate nurse assessment of fitness for segregation
Wider context from the report “3. That the inadequacy of the nurse assessment of fitness for segregation in HMP Highdown (see m) above) is a risk. ████████ was not ACCT trained and it appeared that he was unaware of PSI 1700. The inadequacy may reflect individual or wider weaknesses in assessment or choice of assessors that mean that prisoners go to segregation when they should be in the health care wing, or that they go without observation, when they should be on an ACCT and receive extra support.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed system for transferring health care information from police stations or courts to prisons
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate standard of Mental Health Act assessments
Wider context from the report “2. That the standard of Mental Health Act assessments by these individuals needs to be improved , and, given all three were in complete agreement, that also training and provision for MHA assessments in police stations more widely may need to be reviewed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for passing or seeking relevant information
Wider context from the report “There was no agreed system for transfer of health care information from police station or court, or from either to prison. There was no functioning and consistent system of passing risk information from one detained organization to another. There was not agreement whether there just was a duty to pass the information or if it was not in possession, whether there was also one to ask for it and if so which individual bore that responsibility.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations