PFD report

Caroline Victoria Forte · Prevention of Future Deaths report

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Issued 27 Apr 2023•West Sussex, 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.

View original report
Concerns
10

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
21

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 raised10

  1. Inadequate communication between the ward and family
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and families
  2. Failure to update the family responsibilities section of the care and safety plan
    Part of recurring concern: Unreliable care-planning processes
  3. Failure to provide the family with the Section 17 leave form
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and familiesPart of recurring concern: Unreliable mental-health patient leave arrangementsPart of recurring concern: Unsafe management of inpatient leave and absence
Responses linked to these concerns

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

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Action

    Share the Section 17 leave learning briefing with Regulation 28 Working Group regional representatives for dissemination across NHS regions.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
  2. Action

    Develop a co-produced culture of care improvement programme strengthening family and carer involvement in patient care, suicide and self-harm risk management, and safety planning.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2023.
  3. Action

    Update the Section 17 leave policy to incorporate the new form and other specified modifications.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2023.

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 communication between the ward and family

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families.

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 update the family responsibilities section of the care and safety plan

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

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

Failure to provide the family with the Section 17 leave form

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families; Unreliable mental-health patient leave arrangements; Unsafe management of inpatient leave and absence.

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 an overnight care plan

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

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 communication within the ward

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

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 a clear pathway for sharing private psychiatrist consultation and treatment details with NHS inpatient settings

Wider context from the report

“Ms Forte had for a number of years been seeing a private psychiatrist. Details of her consultations and treatments were not made readily available to those working in the NHS Trusts. It appears that there is no clear pathway for details of any private psychiatrist consultations to be shared with those in either the acute or mental health inpatient settings. The concerns are that any relevant history may be lost and details of any regular medication being prescribed may not, in a time of crisis, be immediately known. ”

Is this part of a recurring concern?

Yes — Unreliable coordination and escalation between care providers and mental health services; Unreliable inter-agency information sharing for coordinated care.

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 complete the daily care log

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable daily logs for multidisciplinary prisoner safety information.

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 senior officer knowledge of leave and clinical risk management policies

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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 record completion of a pre-leave risk assessment

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

Is this part of a recurring concern?

Yes — Unreliable mental-health patient leave arrangements.

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 communicate self-harm risk and risk-minimisation strategies to the family

Wider context from the report

“The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy. During the course of the evidence we heard that:- a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward. b) There was no record to show which nurse carried out a risk assessment before she left. c) There was no overnight care plan. d) The “My care and safety plan” had not been updated with regards to “My family will do” section. e) The family were not provided with a copy of the Section 17 leave form f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk. f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Share the Section 17 leave learning briefing with Regulation 28 Working Group regional representatives for dissemination across NHS regions.

Verbatim wording from the response

“The Trust has also shared with us a helpful learning briefing on Section 17 leave from inpatient wards. This will be shared with the national Regulation 28 Working Group regional representatives for dissemination across the seven NHS regions, to raise awareness of the issue with their Trusts and to encourage best practice.”

Source location

Response from NHS England
Page 1 · response
Published 5 May 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop a co-produced culture of care improvement programme strengthening family and carer involvement in patient care, suicide and self-harm risk management, and safety planning.

Verbatim wording from the response

“Your concern at the lack of national guidance regarding help and support for families in similar situations to that experienced by Caroline’s family has also been raised with NHS England’s national Mental Health Team. In 2022, NHS England committed £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. The Mental Health team have advised that these improvements will include developing a culture of care improvement programme which, importantly, is being co-produced with patients, carers, and families with lived experience of mental health illness. The programme, which should come to completion in 2025, addresses the concerns you raise, identifying opportunities to strengthen family/carer voice in patient care, including the risk management of suicide and self-harm and safety planning.”

Source location

Response from NHS England
Page 1 · response
Published 5 May 2023

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

Update the Section 17 leave policy to incorporate the new form and other specified modifications.

Verbatim wording from the response

“The s.17 leave policy is being updated, so that it incorporates the new form, as well as some other modifications. Once ratified, there will be corresponding training which is delivered by the Trust's Mental Health Act team which is overseen by the Trust's Legal Director. Regarding the ward's understanding of the Safe and Effective Assessment & Management of Clinical risk: Risk Management policy, I understand that this specifically centred on the aforementioned assessment of risk prior to s.17 leave and corresponding sharing of information within the ward and with the family.”

Source location

Response from Sussex Partnership Foundation Trust
Page 4 · response
Published 5 May 2023

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

Review the new Record of Patient Leaving Ward document’s effectiveness after three months and report findings to the Acute Care Forum.

Verbatim wording from the response

“During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 5 May 2023

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

Conduct a Trust-wide qualitative audit of inpatient records to assess care-plan completion and meaningful family or carer engagement, then present and monitor findings through the Effectiveness Committee.

Verbatim wording from the response

“As referred to above, completion of the new 'Record of patient leaving ward' document requires consideration of the leave safety plan which, if a patient were going on overnight leave, would require consideration of the overnight care plan and would thus identify if it were missing. Overnight care plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot checks to confirm that these are being completed and uploaded for patients going on overnight leave. Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 5 May 2023

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

Consider employing a Carers Lead to provide a primary point of contact for family members.

Verbatim wording from the response

“reviews, or been contacted after, to be given an update. The ward's aim is to invite a relevant family member to their loved ones' MDT review meetings, so the family member can participate in the review and have an opportunity to give their own views. If they have not been able to attend then a call to the relevant family member is made after the meeting to ensure they are aware of the plan. Additionally, the ward is considering employing a "Carers Lead", who would provide a primary point of contact for all family members. Further, the aforementioned trust-wide care plan and risk assessment auditing includes qualitatively auditing to ensure meaningful, appropriate family/carer engagement, as part of the Trust's ongoing 2023/4 improvement plan.”

Source location

Response from Sussex Partnership Foundation Trust
Page 4 · response
Published 5 May 2023

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

Monitor the quality of concise, precise information handovers between shifts and to multidisciplinary teams during daily handovers.

Verbatim wording from the response

“The Amberley ward Matron led the ward's discussions about the improvements needed following the Inquest which, in addition to those already mentioned, has involved on-going monitoring of the quality of concise and precise handover of information (both verbal and written) from shift to shift, and to MDT, during MDT daily handovers. Additionally, the Matron has been working with the Trust's lead trainer for clinical risk and the Trust's suicide prevention lead, to fully understand early indicators of risk to ensure his ward is capturing and fully understanding these warning signs. The Matron has also been actively involved in the formulation of the new 'Record of patient leaving ward' document which Amberley ward will be using from the trust-wide implementation date of 1 July.”

Source location

Response from Sussex Partnership Foundation Trust
Page 4 · response
Published 5 May 2023

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

Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.

Verbatim wording from the response

“During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 5 May 2023

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

Audit monthly whether families participate in ward reviews or receive follow-up contact about the care plan when unable to attend.

Verbatim wording from the response

“As indicated above, safety planning ought to be a collaborative process and I was truly saddened to hear that Caroline's family were left without strategies to support them to minimise Caroline's risks. Amberley ward have, of course, reflected, at length, on the sequence of events that led to Caroline's death. The Matron is overseeing monthly audits to check that family have either participated in ward”

Source location

Response from Sussex Partnership Foundation Trust
Page 3 · response
Published 5 May 2023

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

Conduct monthly spot checks on Amberley ward to confirm overnight care plans are completed and uploaded for patients taking overnight leave.

Verbatim wording from the response

“As referred to above, completion of the new 'Record of patient leaving ward' document requires consideration of the leave safety plan which, if a patient were going on overnight leave, would require consideration of the overnight care plan and would thus identify if it were missing. Overnight care plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot checks to confirm that these are being completed and uploaded for patients going on overnight leave. Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-”

Source location

Response from Sussex Partnership Foundation Trust
Page 2 · response
Published 5 May 2023

Open published response

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.11

  1. 1

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
  2. 2

    Commit £36 million over three years to improve mental health, learning disability and autism inpatient settings.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
  3. 3

    Apply layered, multidisciplinary quality assurance to incident reports, including executive sign-off, subject-matter expertise and independent chairs for complex investigations.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
  4. 4

    Operate a Quality and Risk Management Committee to oversee assurance and risks arising from incident learning and action plans.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
  5. 5

    Meet to discuss the transition to the Patient Safety Incident Response Framework and priorities for future investigations.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
  6. 6

    Enhance incident-report lessons-learned sections to widen the scope for capturing learning.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
  7. 7

    Assign every lessons-learned item a corresponding action in a monitored action plan, overseen by the central investigation team and clinical directorate governance.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
  8. 8

    Continue monitoring the effectiveness of recent improvements and future improvements during the transition to the Patient Safety Incident Response Framework.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
  9. 9

    Work with clinical-risk and suicide-prevention leads to understand early risk indicators and improve their identification on the ward.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2023.
  10. 10

    Circulate the Patient Safety Learning briefing to acute care teams to share learning from the Inquest.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
  11. 11

    Monitor the effectiveness of the safety improvements to assess whether they meet patients’ and families’ needs.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.

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

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 5 May 2023

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

Commit £36 million over three years to improve mental health, learning disability and autism inpatient settings.

Verbatim wording from the response

“Your concern at the lack of national guidance regarding help and support for families in similar situations to that experienced by Caroline’s family has also been raised with NHS England’s national Mental Health Team. In 2022, NHS England committed £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. The Mental Health team have advised that these improvements will include developing a culture of care improvement programme which, importantly, is being co-produced with patients, carers, and families with lived experience of mental health illness. The programme, which should come to completion in 2025, addresses the concerns you raise, identifying opportunities to strengthen family/carer voice in patient care, including the risk management of suicide and self-harm and safety planning.”

Source location

Response from NHS England
Page 1 · response
Published 5 May 2023

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

Apply layered, multidisciplinary quality assurance to incident reports, including executive sign-off, subject-matter expertise and independent chairs for complex investigations.

Verbatim wording from the response

“Turning to your specific concerns, I will address the first two concerns jointly as they relate to the intrinsic quality of the SI review itself. The most significant change the Trust has made since last year is the way in which SI reports are quality assured. Specifically, now, SIs are subject to a higher level and layered quality review process, including, ultimately, sign-off by either the Trust's Chief Nursing Officer or the Chief Medical Officer. Additionally, multi-disciplinary panel sign-off approaches are now used so that quality can be assessed and discussed with the benefit of a range of expertise to provider richer scrutiny and thus learning. This multi-disciplinary/panel approach is also now being used during earlier stages of investigations by the use of subject-matter experts, in more complex cases, as well as wider use of independent chairs.”

Source location

Response from Sussex Partnership Foundation Trust 2
Page 2 · response
Published 5 May 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Operate a Quality and Risk Management Committee to oversee assurance and risks arising from incident learning and action plans.

Verbatim wording from the response

“We have a newly established Quality and Risk Management Committee, co-chaired by the Chief Medical Officer and Chief Nursing officer, where assurance and risks relating to the learning from SIs and the action plans are overseen.”

Source location

Response from Sussex Partnership Foundation Trust 2
Page 3 · response
Published 5 May 2023

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

Meet to discuss the transition to the Patient Safety Incident Response Framework and priorities for future investigations.

Verbatim wording from the response

“PSIRF provides the Trust with a clear and welcome opportunity to affect the nationally recognised need to change from the SI framework to a more effective model of responding to incidents. So, this is where the Trust has invested in and is focusing upon, to ensure we have robust processes in place to sustain meaningful improvements to the way we respond to incidents. The Trust is aiming to transition to PSIRF at the end of August 2023. Prior to that transitioning the Trust's Legal Director would welcome the opportunity to meet with you to discuss the transition and the Trust's key priorities for future investigations, to ensure that they are in line with those matters that you feel ought to be prioritised in the forthcoming year.”

Source location

Response from Sussex Partnership Foundation Trust 2
Page 3 · response
Published 5 May 2023

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

Enhance incident-report lessons-learned sections to widen the scope for capturing learning.

Verbatim wording from the response

“Regarding your third concern, I confirm that, earlier this year, the SI team adapted their processes to enhance the 'lessons learnt' section, within all SI reports, to seek to widen the scope, for capturing learning. It is right to say that, initially, this learning, particularly if already effected, did not always have an action plan. However, since our new Chief Nursing Officer has been overseeing SIs, all 'lessons learnt' have had a corresponding action within a monitored action plan. I can also confirm that all action plans are overseen by the central SI team and their monitoring feeds into the governance structures within the clinical directorates, who are then responsible for ensuring completion of the actions.”

Source location

Response from Sussex Partnership Foundation Trust 2
Page 3 · response
Published 5 May 2023

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

Assign every lessons-learned item a corresponding action in a monitored action plan, overseen by the central investigation team and clinical directorate governance.

Verbatim wording from the response

“Regarding your third concern, I confirm that, earlier this year, the SI team adapted their processes to enhance the 'lessons learnt' section, within all SI reports, to seek to widen the scope, for capturing learning. It is right to say that, initially, this learning, particularly if already effected, did not always have an action plan. However, since our new Chief Nursing Officer has been overseeing SIs, all 'lessons learnt' have had a corresponding action within a monitored action plan. I can also confirm that all action plans are overseen by the central SI team and their monitoring feeds into the governance structures within the clinical directorates, who are then responsible for ensuring completion of the actions.”

Source location

Response from Sussex Partnership Foundation Trust 2
Page 3 · response
Published 5 May 2023

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 monitoring the effectiveness of recent improvements and future improvements during the transition to the Patient Safety Incident Response Framework.

Verbatim wording from the response

“I hope that the aforementioned actions are of assurance to you. We believe that the current Executive led governance of SI reports, followed by the implementation of PSIRF has and will continue to lead to sustainable improvements in the quality of the learning we extract from SIs, to reduce incident recurrence and thus improve patient safety. As indicated, this is an ongoing piece of work, with national change being implemented, and the Trust welcomes your involvement. We will, of course, continue to monitor both the effectiveness of the recent improvements and how we achieve the best future improvements, as we transition to PSIRF. I will add an update on the”

Source location

Response from Sussex Partnership Foundation Trust 2
Page 3 · response
Published 5 May 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Work with clinical-risk and suicide-prevention leads to understand early risk indicators and improve their identification on the ward.

Verbatim wording from the response

“The Amberley ward Matron led the ward's discussions about the improvements needed following the Inquest which, in addition to those already mentioned, has involved on-going monitoring of the quality of concise and precise handover of information (both verbal and written) from shift to shift, and to MDT, during MDT daily handovers. Additionally, the Matron has been working with the Trust's lead trainer for clinical risk and the Trust's suicide prevention lead, to fully understand early indicators of risk to ensure his ward is capturing and fully understanding these warning signs. The Matron has also been actively involved in the formulation of the new 'Record of patient leaving ward' document which Amberley ward will be using from the trust-wide implementation date of 1 July.”

Source location

Response from Sussex Partnership Foundation Trust
Page 4 · response
Published 5 May 2023

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 Patient Safety Learning briefing to acute care teams to share learning from the Inquest.

Verbatim wording from the response

“By way of further assurance, and for completeness, I have also enclosed the Patient Safety Learning briefing that the Trust circulated, following the Inquest, to all its acute care teams, for learning from the matters that arose in the Inquest.”

Source location

Response from Sussex Partnership Foundation Trust
Page 5 · response
Published 5 May 2023

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

Monitor the effectiveness of the safety improvements to assess whether they meet patients’ and families’ needs.

Verbatim wording from the response

“I hope that the aforementioned actions are of assurance to you. We believe that these actions will lead to a substantial improvement in the experience of patients and the families/carers/friends who support them when they are on leave from our hospitals. As indicated, we will be monitoring the effectiveness of these improvements to ensure they meet the needs of our patients and their families/carers/friends and will write to you with an update in 6 months' time. In the meantime, if you have any questions regarding the content of this response or if I can further assist please do not hesitate to contact me.”

Source location

Response from Sussex Partnership Foundation Trust
Page 5 · response
Published 5 May 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026