PFD report

Bethany Tengquist · Prevention of Future Deaths report

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Issued 10 Dec 2019•Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
11

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised11

  1. Absence of dedicated entrance security staff during patient and visitor arrival hours
  2. Lack of ward management and matron leadership
    Part of recurring concern: Failure to ensure adequate senior nursing leadership for safe patient carePart of recurring concern: Failure to provide effective on-duty clinical leadership
  3. Insufficient substantive staffing and reliance on bank and agency staff
    Part of recurring concern: Failure to provide continuity of care staffingPart of recurring concern: Unsafe reliance on agency staff for clinical staffing
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Absence of dedicated entrance security staff during patient and visitor arrival hours

Wider context from the report

“1. The search policy and Beth’s access to alcohol on a frequent basis Given Beth’s extremely high risk of self-harm or suicide (described by the her Responsible Clinician, a highly experienced psychologist, as one of the very highest risk patients she had encountered in her lengthy career) and characterised by high levels of impulsivity, I have grave concerns that Beth had frequent access to alcohol whilst detained under section 3 of the MHA on an acute ward. It was, or should have been, widely recognised by all staff that an even greater elevation of the already exceptionally high risk of self-harm or suicide would be occasioned by Beth’s access to alcohol; the jury have confirmed that, notwithstanding this clear danger to her safety, there was a persistent and on-going failure to ensure all reasonable steps were taken to ensure that alcohol was not available on the ward. It has been conceded by the Trust that searching policy was inconsistent and ineffective. Whilst I have received evidence with respect to a more robust approach to daily environmental checks having now been introduced, I remain concerned that there is an insufficiently robust and effective system in place for the effective searching of voluntary patients, those detained patients returning from section 17 leave and all visitors to Caburn Ward. The continued absence of dedicated security staff at the entrance to Caburn Ward, during the hours that patients and visitors may arrive, gives rise to a risk of future deaths should alcohol continue to find a route onto the ward. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of ward management and matron leadership

Wider context from the report

“5. Staffing levels. It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time, in conjunction with a 50% reduction of substantive staff. There was a reliance on bank and agency staff, and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk of future deaths. ”

Is this part of a recurring concern?

Yes — Failure to ensure adequate senior nursing leadership for safe patient care; Failure to provide effective on-duty clinical leadership.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient substantive staffing and reliance on bank and agency staff

Wider context from the report

“5. Staffing levels. It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time, in conjunction with a 50% reduction of substantive staff. There was a reliance on bank and agency staff, and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk of future deaths. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of care staffing; Unsafe reliance on agency staff for clinical staffing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate emergency life support and first aid training for healthcare staff

Wider context from the report

“3. First aid training. I am gravely concerned by the evidence that not all health care staff working on Caburn Ward were adequately trained in emergency life support or first aid. It is axiomatic that all members of health care staff must be competent and able to deal with circumstances were first aid skills may need to be deployed. At least one member of staff admitted that she did not have these skills even when she gave evidence to the jury, notwithstanding that she had been appointed as a substantive member of staff some seven months following the death, and three months before she gave evidence. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of patient-centred involvement in care plan updating

Wider context from the report

“4. Care Plan not Up-dated. It was accepted by the Trust that Beth’s Care Plan had not, contrary to requirements of the Care Programme Arrangement, been updated in any meaningful way throughout Beth’s three month section 3 detention prior to her death. As the Clinical Lead Nurse Manager conceded, in the absence of patient centred involvement in the up-dating of the Care Plan, it risks becoming “meaningless” to the patient. In circumstances where a co-authored and co-produced document that actively involves and engages the patient is simply not up-dated meaningfully at all, then the aims and purposes of the CPA risk being undermined. In the context of a patient with Beth’s co-morbidities, the impact may be very serious indeed. The jury’s conclusions in this respect are informative and clear. ”

Is this part of a recurring concern?

Yes — Failure to provide patient-centred care and decisions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to meaningfully update care plans

Wider context from the report

“4. Care Plan not Up-dated. It was accepted by the Trust that Beth’s Care Plan had not, contrary to requirements of the Care Programme Arrangement, been updated in any meaningful way throughout Beth’s three month section 3 detention prior to her death. As the Clinical Lead Nurse Manager conceded, in the absence of patient centred involvement in the up-dating of the Care Plan, it risks becoming “meaningless” to the patient. In circumstances where a co-authored and co-produced document that actively involves and engages the patient is simply not up-dated meaningfully at all, then the aims and purposes of the CPA risk being undermined. In the context of a patient with Beth’s co-morbidities, the impact may be very serious indeed. The jury’s conclusions in this respect are informative and clear. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate completion of accompanying documentation

Wider context from the report

“2. Staff training and auditing. The evidence regarding the wholly inadequate completion of the handover and the accompanying documents in this case is of serious concern, again as reflected by the jury’s conclusion. The handover from late to night shift was chaotic and confused at best. The paperwork was in large parts either wholly inadequately completed or simply not completed at all. All of the agency and bank staff were either new, or at best, had only had a few shifts on Caburn. This clearly elevates the critical importance of a detailed, thorough and professional handover together with full and far more professional completion of the accompanying documentation. I specifically require identification of the steps proposed to dramatically improve these matters. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Inadequate shift handovers

Wider context from the report

“2. Staff training and auditing. The evidence regarding the wholly inadequate completion of the handover and the accompanying documents in this case is of serious concern, again as reflected by the jury’s conclusion. The handover from late to night shift was chaotic and confused at best. The paperwork was in large parts either wholly inadequately completed or simply not completed at all. All of the agency and bank staff were either new, or at best, had only had a few shifts on Caburn. This clearly elevates the critical importance of a detailed, thorough and professional handover together with full and far more professional completion of the accompanying documentation. I specifically require identification of the steps proposed to dramatically improve these matters. ”

Is this part of a recurring concern?

Yes — Unreliable shift handover processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain an effective searching system for patients and visitors

Wider context from the report

“1. The search policy and Beth’s access to alcohol on a frequent basis Given Beth’s extremely high risk of self-harm or suicide (described by the her Responsible Clinician, a highly experienced psychologist, as one of the very highest risk patients she had encountered in her lengthy career) and characterised by high levels of impulsivity, I have grave concerns that Beth had frequent access to alcohol whilst detained under section 3 of the MHA on an acute ward. It was, or should have been, widely recognised by all staff that an even greater elevation of the already exceptionally high risk of self-harm or suicide would be occasioned by Beth’s access to alcohol; the jury have confirmed that, notwithstanding this clear danger to her safety, there was a persistent and on-going failure to ensure all reasonable steps were taken to ensure that alcohol was not available on the ward. It has been conceded by the Trust that searching policy was inconsistent and ineffective. Whilst I have received evidence with respect to a more robust approach to daily environmental checks having now been introduced, I remain concerned that there is an insufficiently robust and effective system in place for the effective searching of voluntary patients, those detained patients returning from section 17 leave and all visitors to Caburn Ward. The continued absence of dedicated security staff at the entrance to Caburn Ward, during the hours that patients and visitors may arrive, gives rise to a risk of future deaths should alcohol continue to find a route onto the ward. ”

Is this part of a recurring concern?

Yes — Unreliable searches and screening for drugs and prohibited items in controlled environments.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Incomplete and flawed checks and removal of dangerous items from patient rooms

Wider context from the report

“During the course of the Pre-Inquest reviews it has become apparent that vulnerable patients are continuing to self-harm. The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed. The example with regard to Bethany Tengquist concerns the fact that on the 29th December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room and yet her dressing gown cord was left available for her to use to hang herself. Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them. Please tell me precisely how you are going to put this right. ”

Is this part of a recurring concern?

Yes — Inadequate control of self-harm items in inpatient settings; Unreliable controls for restricting dangerous items in inpatient care; Unreliable searches and screening for drugs and prohibited items in controlled environments.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to properly train staff to carry out patient room checks

Wider context from the report

“During the course of the Pre-Inquest reviews it has become apparent that vulnerable patients are continuing to self-harm. The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed. The example with regard to Bethany Tengquist concerns the fact that on the 29th December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room and yet her dressing gown cord was left available for her to use to hang herself. Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them. Please tell me precisely how you are going to put this right. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Improve guidance for ward staff on contacting Police when a patient survives a serious incident but has a poor prognosis.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 August 2019.
  2. 2

    Improve communication pathways with Police so investigation teams know whom to contact for information.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 August 2019.
  3. 3

    Circulate the improved Police-contact guidance to all inpatient units.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 August 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The delay in providing information was not deliberate or obstructive, as confirmed by the review and assurances from the Chief Constable.

    Stated by Sussex Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    The Police communication failure was an isolated event, inconsistent with the generally strong relationship between the services.

    Stated by Sussex Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve guidance for ward staff on contacting Police when a patient survives a serious incident but has a poor prognosis.

Verbatim wording from the response

“Regarding the ward’s communication with the Police on the night of Bethany’s hanging, it was very disappointing to hear that this did not happen; particularly, given the Trust’s established working relationship with Sussex Police. I wholly appreciate that by not informing them they did not have the opportunity to immediately secure evidence. Where an unexpected death occurs, the Trust’s policy is clear that staff need to ensure that Police are called. However, our review of this issue has found that the guidance given to staff, where a patient survives but the prognosis is poor, lacks clarity. Sometimes, as was the case on 7 March, the ambulance service makes that contact with the Police, but if that does not happen then our expectation is that the ward staff make the call.”

Source location

2019-0178-Response-by-Sussex-NHS-Trust
Page 2 · response
Published 22 August 2019

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

Improve communication pathways with Police so investigation teams know whom to contact for information.

Verbatim wording from the response

“communication pathways. The Chief Constable and I have discussed this and agreed it is timely that we will work to improve these pathways to enable the Police investigation teams to know who to contact for information and vice versa. Whilst this is an isolated event and not one we have previously experienced I am confident that our learning from this will reduce confusion and assist both services.”

Source location

2019-0178-Response-by-Sussex-NHS-Trust
Page 2 · response
Published 22 August 2019

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

Circulate the improved Police-contact guidance to all inpatient units.

Verbatim wording from the response

“We have never had any other case where Police have not been alerted following a serious incident but, because it did not happen in Bethany’s case, our guidance to staff is now in the process of being improved upon and I confirm that it will be circulated to all inpatient units so that all ward staff are wholly clear of their responsibilities.”

Source location

2019-0178-Response-by-Sussex-NHS-Trust
Page 2 · response
Published 22 August 2019

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 delay in providing information was not deliberate or obstructive, as confirmed by the review and assurances from the Chief Constable.

Verbatim wording from the response

“I am pleased to say that I have today received confirmation from ████████ that the Police investigation is now back on track. ████████ and the Chief Constable have both assured me that he was not suggesting that there was anything deliberate or obstructive in him not being able to access the information earlier. Our review confirms this too. However, it is clear that there are some lessons that can be learnt regarding”

Source location

2019-0178-Response-by-Sussex-NHS-Trust
Page 1 · response
Published 22 August 2019

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 Police communication failure was an isolated event, inconsistent with the generally strong relationship between the services.

Verbatim wording from the response

“As I said in my letter of 22 March, neither I nor anyone else here at the Trust was aware of the negative experience that ████████ reported to you. I was very surprised when I first heard of his experience as it was at odds with the excellent working relationship I’d understood we had with the Police. Therefore, in addition to immediately asking for the matter to be looked into, and personally contacting ████████ and our Police Liaison Officer ████████, I have also, today, spoken with the Chief Constable. He has assured me that he has also understood the relationship between our respective services to be strong and without issue. Whilst reassuring, I, of course, recognise and accept that ████████ experience wasn’t the positive one we would all want. It is however out of context and at odds with the excellent working relationship we have between our respective organisations.”

Source location

2019-0178-Response-by-Sussex-NHS-Trust
Page 1 · response
Published 22 August 2019

Open published response
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Data last updated 7 September 2026