Azra Hussain
PFD Report
All Responded
Ref: 2021-0082
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
All 4 responses received
· Deadline: 20 May 2021
Sent To
Response Status
Responses
4 of 4
56-Day Deadline
20 May 2021
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May. Therefore, it was not considered at an MDT meeting on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufacturers for 10 years, BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country.
2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufacturers for 10 years, BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country.
Responses
Response received
View full response
Dear Mrs Brown,
Re: Prevention of Future Deaths report into Azra Parveen Sultan
May I open this letter by reinstating the apologies of our Trust for the tragic death of Azra Parveen Sultan. Azra was an inpatient on Ward 2 at Mary Seacole House when she sadly died by suicide having attached a ligature to her en-suite bathroom door. This was clearly an immensely tragic and distressing time for Azra’s family, friends, her fellow service users on the ward and the staff that were caring for Azra. Our sincere condolences are reiterated to all who were and continue to be affected by her death.
During the course of the inquest the evidence revealed matters giving rise to concern as follows:-
1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May. Therefore, it was not considered at an MDT meeting on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's Legal Department B1 – Unit 1 50 Summer Hill Road Birmingham B1 3RB
family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
Our Family and Carer Strategy and pathway prioritises the principles and practice of high quality family and carer engagement in all aspects of care. One component of our patient safety work is the implementation of robust and consistent multidisciplinary team standards which includes enhanced family engagement. We will ensure that families views are central to the care planning process prior to and during the MDT and that there is a clear feedback process to the family post MDT so as to ensure and assure the family that their views have been considered. We are working with our family and carer network to seek views on the format of post MDT written correspondence. This will supplement verbal feedback either over the phone or via a virtual platform.
We are consistently auditing our practice around our minimum MDT team standards which includes a minimum standard about securing and reviewing the patient and carer view within the MDT meeting. The data below in figure 1 shows our position for February, March and April 2021 respectively. We report our position on this standard each month to our regulators the Care Quality Commission.
Figure 1: Audit Results for Securing and Discussing Patient and Carer View in MDT
With regard to involvement of families in formal MDT meetings we will involve families within the MDT meeting itself where this is clinically appropriate. It will not always be appropriate as such decisions will be influenced by a number of things such as:-
• Consent of the patient
• Relationship between the patient and family members
• Issues of confidentiality with regard to the content of the MDT discussions
• Issues that may impact on risk to self or others
• Safeguarding concerns
We would like to assure you that there are a range of ways in which we aim to ensure meaningful engagement with families outside the formal MDT process and this year we have specific quality goals relating to carer engagement including:-
Improve the involvement carers in service user care and recovery
Measures of success:- % of carers registered on RIO % of carers with a completed carer engagement tool
We will report on our level of improvement with this priority through our Integrated Quality Committee on a quarterly basis. On a monthly basis our Family and Carer Pathway Group will review performance to celebrate improvement and to identify any barriers that we need to remove to improve performance in challenged areas.
2. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside.
When considering the safety of our inpatient environment, we approach this using a framework that incorporates the triad of physical, relational and procedural security and controls. We have commenced a full review of all of these controls to strengthen the safety of our acute inpatient wards. The results of the review and the associated recommendations will be presented to our Integrated Quality Committee for approval, who in turn report directly to our Trust Board of Directors.
As part of this review we are recommending that we develop a work programme to apply continuous door pressure alarm systems to the bedroom doors on a number of our wards. This is a significant piece of work and we are prioritising the wards to which we will initially apply these systems based on acuity of patients and ligature history prevalence. We have established an expert group to assist us in determining the prioritisation process which includes a mental health expert from the Quality Team at NHS England and our Mental Health Quality Lead from Birmingham and Solihull Clinical Commissioning Group. We will have reached a decision on prioritisation and the associated timeline by the end of May
2021. There are a number of factors that will contribute to the timeline for delivery including:-
• Manufacturing times
• Installation Timeframes
• Safe access to operational acute inpatient wards to carry out works
• Temporary bed closures whilst the work is being undertaken which may impact on our ability to admit patients during periods of high occupancy
• The potential of a third wave of Covid
We would like to assure you in the meantime that all of our doors comply with existing standards in that there is no door furniture (such as handles, hooks etc) that could be used as an anchor point. The only anchor points are therefore the top, bottom and hinge of the door. Our choice of alarm system is one of the latest innovations in that it has pressure sensors on all of these areas of the door – so no matter where pressure is applied, the alarm will trigger.
We are also establishing a rolling capital programme to support ongoing ligature works to all of our Estate.
We are conscious that the pressure sensors are just one control to improve patient safety and we therefore feel that is important to stress that reducing harm from ligatures relies as much on the relational and procedural controls as it does on the physical. The risk review process currently being undertaken by our expert group places equal emphasis on each of the three areas, as addressing the physical environment alone will not reduce this risk to its minimal level. Examples of these other areas include; a review of our therapeutic observational practice, a review of staffing levels and skill mix and monitoring and supervision of the implementation of our new care plans.
Please be assured that as an organisation we are taking all the steps we can to reduce risk from ligatures and will continue to work with families and carers to ensure that they are involved in Patient care, where the patient wishes for this. In addition, the BSOL system continues to work to improve services and to learn from events. There is a multiagency oversight group in place which has delivered against key recommendations and continues to work to implement learning.
Re: Prevention of Future Deaths report into Azra Parveen Sultan
May I open this letter by reinstating the apologies of our Trust for the tragic death of Azra Parveen Sultan. Azra was an inpatient on Ward 2 at Mary Seacole House when she sadly died by suicide having attached a ligature to her en-suite bathroom door. This was clearly an immensely tragic and distressing time for Azra’s family, friends, her fellow service users on the ward and the staff that were caring for Azra. Our sincere condolences are reiterated to all who were and continue to be affected by her death.
During the course of the inquest the evidence revealed matters giving rise to concern as follows:-
1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May. Therefore, it was not considered at an MDT meeting on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's Legal Department B1 – Unit 1 50 Summer Hill Road Birmingham B1 3RB
family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
Our Family and Carer Strategy and pathway prioritises the principles and practice of high quality family and carer engagement in all aspects of care. One component of our patient safety work is the implementation of robust and consistent multidisciplinary team standards which includes enhanced family engagement. We will ensure that families views are central to the care planning process prior to and during the MDT and that there is a clear feedback process to the family post MDT so as to ensure and assure the family that their views have been considered. We are working with our family and carer network to seek views on the format of post MDT written correspondence. This will supplement verbal feedback either over the phone or via a virtual platform.
We are consistently auditing our practice around our minimum MDT team standards which includes a minimum standard about securing and reviewing the patient and carer view within the MDT meeting. The data below in figure 1 shows our position for February, March and April 2021 respectively. We report our position on this standard each month to our regulators the Care Quality Commission.
Figure 1: Audit Results for Securing and Discussing Patient and Carer View in MDT
With regard to involvement of families in formal MDT meetings we will involve families within the MDT meeting itself where this is clinically appropriate. It will not always be appropriate as such decisions will be influenced by a number of things such as:-
• Consent of the patient
• Relationship between the patient and family members
• Issues of confidentiality with regard to the content of the MDT discussions
• Issues that may impact on risk to self or others
• Safeguarding concerns
We would like to assure you that there are a range of ways in which we aim to ensure meaningful engagement with families outside the formal MDT process and this year we have specific quality goals relating to carer engagement including:-
Improve the involvement carers in service user care and recovery
Measures of success:- % of carers registered on RIO % of carers with a completed carer engagement tool
We will report on our level of improvement with this priority through our Integrated Quality Committee on a quarterly basis. On a monthly basis our Family and Carer Pathway Group will review performance to celebrate improvement and to identify any barriers that we need to remove to improve performance in challenged areas.
2. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside.
When considering the safety of our inpatient environment, we approach this using a framework that incorporates the triad of physical, relational and procedural security and controls. We have commenced a full review of all of these controls to strengthen the safety of our acute inpatient wards. The results of the review and the associated recommendations will be presented to our Integrated Quality Committee for approval, who in turn report directly to our Trust Board of Directors.
As part of this review we are recommending that we develop a work programme to apply continuous door pressure alarm systems to the bedroom doors on a number of our wards. This is a significant piece of work and we are prioritising the wards to which we will initially apply these systems based on acuity of patients and ligature history prevalence. We have established an expert group to assist us in determining the prioritisation process which includes a mental health expert from the Quality Team at NHS England and our Mental Health Quality Lead from Birmingham and Solihull Clinical Commissioning Group. We will have reached a decision on prioritisation and the associated timeline by the end of May
2021. There are a number of factors that will contribute to the timeline for delivery including:-
• Manufacturing times
• Installation Timeframes
• Safe access to operational acute inpatient wards to carry out works
• Temporary bed closures whilst the work is being undertaken which may impact on our ability to admit patients during periods of high occupancy
• The potential of a third wave of Covid
We would like to assure you in the meantime that all of our doors comply with existing standards in that there is no door furniture (such as handles, hooks etc) that could be used as an anchor point. The only anchor points are therefore the top, bottom and hinge of the door. Our choice of alarm system is one of the latest innovations in that it has pressure sensors on all of these areas of the door – so no matter where pressure is applied, the alarm will trigger.
We are also establishing a rolling capital programme to support ongoing ligature works to all of our Estate.
We are conscious that the pressure sensors are just one control to improve patient safety and we therefore feel that is important to stress that reducing harm from ligatures relies as much on the relational and procedural controls as it does on the physical. The risk review process currently being undertaken by our expert group places equal emphasis on each of the three areas, as addressing the physical environment alone will not reduce this risk to its minimal level. Examples of these other areas include; a review of our therapeutic observational practice, a review of staffing levels and skill mix and monitoring and supervision of the implementation of our new care plans.
Please be assured that as an organisation we are taking all the steps we can to reduce risk from ligatures and will continue to work with families and carers to ensure that they are involved in Patient care, where the patient wishes for this. In addition, the BSOL system continues to work to improve services and to learn from events. There is a multiagency oversight group in place which has delivered against key recommendations and continues to work to implement learning.
Response received
View full response
Dear Miss Brown, Prevention of future deaths report Ms Azra Hussain Thank you for your letter and Regulation 28 report to prevent future deaths issued following the inquest into the death of Azra Parveen Hussain, also known as Azra Parveen Sultan. You asked HSE to consider the second area of concern, namely: “I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country.” In England CQC is the lead inspection and enforcement body under the Health and Social Care Act 2008 for safety and quality of treatment and care matters involving
patients and service users in receipt of a health or adult social care service from a provider registered with CQC. In 2015 (revised in 2017) The Memorandum of Understanding (MoU) between the Care Quality Commission (CQC) and the Health and Safety Executive (HSE) established the respective roles and responsibilities of each organisation with regard to health and safety incidents. This means that both the safety of the environment for the patient, including management of ligature points, and any investigations following incidents would fall within the remit of CQC and not HSE. I am therefore not able to offer any further assistance with respect to the current standards at BSMHT or within England more generally, but I am aware that CQC will be providing a detailed response to your concerns. I hope this clarifies the situation but please let me know if you need anything further.
patients and service users in receipt of a health or adult social care service from a provider registered with CQC. In 2015 (revised in 2017) The Memorandum of Understanding (MoU) between the Care Quality Commission (CQC) and the Health and Safety Executive (HSE) established the respective roles and responsibilities of each organisation with regard to health and safety incidents. This means that both the safety of the environment for the patient, including management of ligature points, and any investigations following incidents would fall within the remit of CQC and not HSE. I am therefore not able to offer any further assistance with respect to the current standards at BSMHT or within England more generally, but I am aware that CQC will be providing a detailed response to your concerns. I hope this clarifies the situation but please let me know if you need anything further.
Response received
View full response
Dear Mrs Brown
Re: Regulation 28 Report to Prevent Future Deaths- Azra Hussain
Birmingham and Solihull CCG is providing this supplementary information to the Coroner, in support of the information provided by Birmingham and Solihull Mental Health Foundation Trust, in response to the Regulation 28 Report to Prevent Future Deaths issued in relation to the death of Azra Parveen Hussain.
We would like to firstly take this opportunity to pass on our condolences to Ms Hussain’s family. The Coroner and family will already be aware from evidence presented at the inquest that all serious adverse incidents are reported to the CCG, are subject to root cause investigation and monitoring to ensure that any actions identified have been implemented.
The supplementary information provided, sets out the system working that is taking place in relation to the reducing the risk of harm to Birmingham and Solihull patients and learning from any adverse events.
At the time of this incident, as described in the root cause analysis investigation, the Trust had identified a potential risk to inpatients from ligature points and was undertaking a piece of work to assess this risk along with options to mitigate it. This piece of work is continuing and is being overseen by the system and by the Care Quality Commission (CQC). Following a CQC report being issued in November 2020 an action plan was put in place with monthly updates being provided by the Trust to the CQC and to the system. Additionally, regular system risk review meetings were held at which progress was discussed. In response to a
further inpatient death, the Trust were asked to speed up the actions that were being taken to address these concerns and provide updates.
It is recognised, however, that the identification and elimination of potential ligature points is only one part of the picture and that, as identified in the root cause analysis, clinical assessment and management plays an essential role in reducing the risk of harm, issues that have also been subject to discussion and action since this incident occurred.
The monitoring of these system wide actions continues, and we will as a system continually strive to improve the quality of services that we, as a system, provide. We regret any failing in the system and would like to provide assurance that all avoidable deaths are taken very seriously.
Re: Regulation 28 Report to Prevent Future Deaths- Azra Hussain
Birmingham and Solihull CCG is providing this supplementary information to the Coroner, in support of the information provided by Birmingham and Solihull Mental Health Foundation Trust, in response to the Regulation 28 Report to Prevent Future Deaths issued in relation to the death of Azra Parveen Hussain.
We would like to firstly take this opportunity to pass on our condolences to Ms Hussain’s family. The Coroner and family will already be aware from evidence presented at the inquest that all serious adverse incidents are reported to the CCG, are subject to root cause investigation and monitoring to ensure that any actions identified have been implemented.
The supplementary information provided, sets out the system working that is taking place in relation to the reducing the risk of harm to Birmingham and Solihull patients and learning from any adverse events.
At the time of this incident, as described in the root cause analysis investigation, the Trust had identified a potential risk to inpatients from ligature points and was undertaking a piece of work to assess this risk along with options to mitigate it. This piece of work is continuing and is being overseen by the system and by the Care Quality Commission (CQC). Following a CQC report being issued in November 2020 an action plan was put in place with monthly updates being provided by the Trust to the CQC and to the system. Additionally, regular system risk review meetings were held at which progress was discussed. In response to a
further inpatient death, the Trust were asked to speed up the actions that were being taken to address these concerns and provide updates.
It is recognised, however, that the identification and elimination of potential ligature points is only one part of the picture and that, as identified in the root cause analysis, clinical assessment and management plays an essential role in reducing the risk of harm, issues that have also been subject to discussion and action since this incident occurred.
The monitoring of these system wide actions continues, and we will as a system continually strive to improve the quality of services that we, as a system, provide. We regret any failing in the system and would like to provide assurance that all avoidable deaths are taken very seriously.
Response received
View full response
Dear HM Coroner Prevention of future deaths report Ms Azra Hussain Thank you for your Regulation 28, report to prevent future deaths issued following the inquest into the sad death of Azra Parveen Hussain also known as Azra Parveen Sultan: This response will address the role of CQC, summarise the inspection history of the service and address the specific issues you have raised in the report CQC's Role The role of the Care Quality Commission (CQC) as an independent regulator is to register health and adult social care service providers in England and to inspect whether or not the fundamental standards are being met: The legislation that governs this function is The Health and Social Care Act 2008 and The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As part of CQCs regulatory role, inspectors assess whether or not a provider is meeting the needs of people in a safe way: Inspectors make judgements from their findings as to whether service has mitigated the risks posed to people, for example, physical risks arising from existing health conditions and environmental risks based on the surroundings in which they live. The CQC's website signposts the provider and registered manager to relevant guidance on how can meet our regulations and other related regulations, including approach to risk MsHussain and _Inspection History May they
Birmingham and Solihull Mental Health Foundation NHS Trust is registered with the Care Quality Commission for the following regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983: Diagnostic and screening procedures and Treatment of disease, disorder or injury. The trust has been inspected four times since 2014. It was rated good overall in 2014; in 2017 it was rated requires improvement; and in 2018 it was again rated Requires improvement The trust's last comprehensive inspection was in November 2019 when it was rated as Requires Improvement. A focused inspection was carried out in November 2020. We did not rate at that inspection because we did not review all five key questions, we ask at comprehensive inspections. CQC first became aware of the death of Ms. Hussain in May 2020 when notified by Birmingham and Solihull Mental Health Foundation NHS trust (BSMHFT) CQC requested information_ specifically Ms: Hussain's risk assessment; care plan; continuation notes and incident reports. The information was used to carry out a review of Ms Hussain's care whilst on the ward The review of the information raised concerns about {he quality of risk assessment and care planning taking place on the ward which led CQC to request information relating to other patients currently receiving care on the ward, Seacole 2. As result, CQC visited the hospital on 24th June 2020 to review patient records including risk assessment and care plans to understand the care that had been delivered on the ward _ The team also spoke to the Matron and the Clinical Service Manager about the challenges currently on the ward the death of Ms Hussain: The team met with members of the leadership team in July 2020 and: provided feedback on areas of concerns that found their visit to the hospital and which needed to be addressed by the trust. In November 2020, following further death at the trust; CQC undertook responsive inspection: There had also been several concerns received by inspectors about community services. Three inspection teams visited the trust to inspect their acute wards for adults of working age; Community mental 'health service for adults and Home treatment teams_ That inspection resulted in enforcement action that placed conditions on the trusts registration of their acute wards for adults of working age_ The conditions placed on their registration were as follows:
1. By 4 January 2021, the registered provider must inform the Commission of the order of priority in terms of addressing the ligature. risks and timescales for addressing the ligature risks across each ward.
2. The registered provider must take steps to address the ligature risks across all wards by 18 June 2021 2 Mary they - during
3. By 29 January 2021 the Registered provider must implement an effective system to improve risk assessments and care planning: The Registered Provider must report to the Commission on the steps it has taken in connection with this by 5 February 2021.
4. Commencing from 5 February 2021 the registered provider must report to the Commission on a monthly basis setting out progress being made in respect of and including mitigating measures being in place until all ligature risks are addressed_
5. Commencing from March 2021, the Registered Provider must report to the Commission on monthly basis the results of any monitoring data and audits undertaken that provide assurance that the system implemented is effective Concerns _identified in the Regulation 28 Report The Regulation 28 report sets out the following matters of concern for CQC to address: "BSMHFT had risk assessed ward 2 for ligature points, including the en-suite bathrooms; in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufacturers for 10 years, BSMHFT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHFT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHFT has 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However; this is not being considered for other doors within the bedroom area nor is there any national requirement for inpatient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. /am concerned that within BSMHFT's inpatient units there will be continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on communal corridor; service users on level and observations will periods where are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas put have they
where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country" There is currently no national requirement; regulations or guidance for in-patient mental health units to place pressure sensors on doors. Any such guidance would be produced by NHS Estates in their building's guidance. When CQC inspects service of this nature, as part of the inspection we check the providers compliance with ligature risks as part of the safe domain and we check the environment is suitable for use as part of our assessment An inspection team would not check specifically for pressure sensors on doors. If we find ligature risks to be present; we establish if the trust has identified and mitigated that risk Failure to do SO represents a breach of regulations that may result in enforcement action: Conditions were placed on the trust's registration certificate by CQC following the inspection on 23 November 2020 which identified concerns in relation to ligature risks, risk assessment and care planning: The Trust has complied with our conditions and have been submitting monthly updates on their progress to replace doors and improve care planning: Inspectors have been meeting monthly with the trust leadership team to discuss the progress and improvements made to date As result of the meetings CQC has asked for weekly reports on the ward improvements programmes to understand ongoing mitigation whilst the replacement of en-suite doors is incomplete_ The CQC has been informed by the trust that itis reviewing the timetable submitted for the replacement of the en-suite bathroom doors as requested by their clinical governance committee have sought independent review from the NHS England's quality and safety team who will present their report to the trust in 2021 . Bedroom doors did not feature as part of the conditions placed on the trust however the trust has informed CQC that are reviewing bedroom doors as part of their overall improvement strategy: We will check the provider' s compliance with the regulations on our next inspection of the service using our lines of enquiry and in accordance with CQC's regulatory remit; highlight breaches of regulation to the provider andlor registered manager ('registered person') if warranted and ask them how will make the necessary improvements_ Our next inspection of the service is not yet confirmed, however CQC have adopted a more risk-based approach to inspections should we receive negative intelligence or have further concerns about the service we would cariy out responsive inspections_ Where CQC identifies that regulations are not being met; we use our enforcement powers to require improvements to be made. We continue to do this and will share They May they key they
key learning and practice points from the inquest into the death of Ms Hussain with inspectors and registered persons_ We hope that this response addresses your concerns_ If this is not the case, please could you clarify any further details you require_
Birmingham and Solihull Mental Health Foundation NHS Trust is registered with the Care Quality Commission for the following regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983: Diagnostic and screening procedures and Treatment of disease, disorder or injury. The trust has been inspected four times since 2014. It was rated good overall in 2014; in 2017 it was rated requires improvement; and in 2018 it was again rated Requires improvement The trust's last comprehensive inspection was in November 2019 when it was rated as Requires Improvement. A focused inspection was carried out in November 2020. We did not rate at that inspection because we did not review all five key questions, we ask at comprehensive inspections. CQC first became aware of the death of Ms. Hussain in May 2020 when notified by Birmingham and Solihull Mental Health Foundation NHS trust (BSMHFT) CQC requested information_ specifically Ms: Hussain's risk assessment; care plan; continuation notes and incident reports. The information was used to carry out a review of Ms Hussain's care whilst on the ward The review of the information raised concerns about {he quality of risk assessment and care planning taking place on the ward which led CQC to request information relating to other patients currently receiving care on the ward, Seacole 2. As result, CQC visited the hospital on 24th June 2020 to review patient records including risk assessment and care plans to understand the care that had been delivered on the ward _ The team also spoke to the Matron and the Clinical Service Manager about the challenges currently on the ward the death of Ms Hussain: The team met with members of the leadership team in July 2020 and: provided feedback on areas of concerns that found their visit to the hospital and which needed to be addressed by the trust. In November 2020, following further death at the trust; CQC undertook responsive inspection: There had also been several concerns received by inspectors about community services. Three inspection teams visited the trust to inspect their acute wards for adults of working age; Community mental 'health service for adults and Home treatment teams_ That inspection resulted in enforcement action that placed conditions on the trusts registration of their acute wards for adults of working age_ The conditions placed on their registration were as follows:
1. By 4 January 2021, the registered provider must inform the Commission of the order of priority in terms of addressing the ligature. risks and timescales for addressing the ligature risks across each ward.
2. The registered provider must take steps to address the ligature risks across all wards by 18 June 2021 2 Mary they - during
3. By 29 January 2021 the Registered provider must implement an effective system to improve risk assessments and care planning: The Registered Provider must report to the Commission on the steps it has taken in connection with this by 5 February 2021.
4. Commencing from 5 February 2021 the registered provider must report to the Commission on a monthly basis setting out progress being made in respect of and including mitigating measures being in place until all ligature risks are addressed_
5. Commencing from March 2021, the Registered Provider must report to the Commission on monthly basis the results of any monitoring data and audits undertaken that provide assurance that the system implemented is effective Concerns _identified in the Regulation 28 Report The Regulation 28 report sets out the following matters of concern for CQC to address: "BSMHFT had risk assessed ward 2 for ligature points, including the en-suite bathrooms; in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufacturers for 10 years, BSMHFT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHFT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHFT has 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However; this is not being considered for other doors within the bedroom area nor is there any national requirement for inpatient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. /am concerned that within BSMHFT's inpatient units there will be continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on communal corridor; service users on level and observations will periods where are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas put have they
where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country" There is currently no national requirement; regulations or guidance for in-patient mental health units to place pressure sensors on doors. Any such guidance would be produced by NHS Estates in their building's guidance. When CQC inspects service of this nature, as part of the inspection we check the providers compliance with ligature risks as part of the safe domain and we check the environment is suitable for use as part of our assessment An inspection team would not check specifically for pressure sensors on doors. If we find ligature risks to be present; we establish if the trust has identified and mitigated that risk Failure to do SO represents a breach of regulations that may result in enforcement action: Conditions were placed on the trust's registration certificate by CQC following the inspection on 23 November 2020 which identified concerns in relation to ligature risks, risk assessment and care planning: The Trust has complied with our conditions and have been submitting monthly updates on their progress to replace doors and improve care planning: Inspectors have been meeting monthly with the trust leadership team to discuss the progress and improvements made to date As result of the meetings CQC has asked for weekly reports on the ward improvements programmes to understand ongoing mitigation whilst the replacement of en-suite doors is incomplete_ The CQC has been informed by the trust that itis reviewing the timetable submitted for the replacement of the en-suite bathroom doors as requested by their clinical governance committee have sought independent review from the NHS England's quality and safety team who will present their report to the trust in 2021 . Bedroom doors did not feature as part of the conditions placed on the trust however the trust has informed CQC that are reviewing bedroom doors as part of their overall improvement strategy: We will check the provider' s compliance with the regulations on our next inspection of the service using our lines of enquiry and in accordance with CQC's regulatory remit; highlight breaches of regulation to the provider andlor registered manager ('registered person') if warranted and ask them how will make the necessary improvements_ Our next inspection of the service is not yet confirmed, however CQC have adopted a more risk-based approach to inspections should we receive negative intelligence or have further concerns about the service we would cariy out responsive inspections_ Where CQC identifies that regulations are not being met; we use our enforcement powers to require improvements to be made. We continue to do this and will share They May they key they
key learning and practice points from the inquest into the death of Ms Hussain with inspectors and registered persons_ We hope that this response addresses your concerns_ If this is not the case, please could you clarify any further details you require_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and I believe:
1) BSMHT have the power to take such action in relation to issues 1 and 2 above; and
2) the Care Commissioning Group for Birmingham and Solihull, Care Quality Commission and the Health and Safety Executive have the power to take such action in relation to issue 2 above.
1) BSMHT have the power to take such action in relation to issues 1 and 2 above; and
2) the Care Commissioning Group for Birmingham and Solihull, Care Quality Commission and the Health and Safety Executive have the power to take such action in relation to issue 2 above.
Report Sections
Investigation and Inquest
On 15 May 2020 I commenced an investigation into the death of Azra Parveen HUSSAIN also known as Azra Parveen Sultan. The investigation concluded at the end of a 6 day inquest on the 22nd March 2021. The conclusion of the inquest was 'Suicide' and the jury also answered a set of questions which identify that they concluded:
1. On the 24th March 2020 there was a missed opportunity to commence ECT treatment and it is likely that Azra's death would have been prevented if she had undergone ECT.
2. On the 6th May 2020 there was a foreseeable risk that Azra would attempt suicide, that risk had not been adequately identified by those caring for her, adequate measures had not been taken to mitigate her risk and with adequate measures it is likely that Azra's death would have been prevented.
3. On the 6th May 2020 there was a foreseeable risk that the en-suite bathroom door would be used as a ligature point, adequate measures had not been taken to mitigate the risk and with adequate measures it is likely that Azra's death would have been prevented.
1. On the 24th March 2020 there was a missed opportunity to commence ECT treatment and it is likely that Azra's death would have been prevented if she had undergone ECT.
2. On the 6th May 2020 there was a foreseeable risk that Azra would attempt suicide, that risk had not been adequately identified by those caring for her, adequate measures had not been taken to mitigate her risk and with adequate measures it is likely that Azra's death would have been prevented.
3. On the 6th May 2020 there was a foreseeable risk that the en-suite bathroom door would be used as a ligature point, adequate measures had not been taken to mitigate the risk and with adequate measures it is likely that Azra's death would have been prevented.
Circumstances of the Death
On the 6th May 2020 Azra was found at approx 18:25 hours hanging from her en-suite bathroom door in room 14 on Ward 2 of Mary Seacole House having used her bedding to create a noose. Mary Seacole House is operated and staffed by Birmingham and Solihull Mental Health NHS Foundation Trust ('BSMHT'). Azra had been detained there on 26th December 2019 under section 2 of the Mental Health Act. She was on 15 minute observations and was last recorded as being seen at 18:09 when she was on her bed. An ambulance was called at 18:25 and arrived at 18:32. Staff had already cut Azra down and started CPR. She could not be resuscitated and was declared deceased at 19:38. Following a post mortem the medical cause of death was determined to be: 1a SUSPENSION BY LIGATURE AROUND THE NECK 1b 1c II
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