Barbara Woodman
PFD Report
All Responded
Ref: 2024-0100
All 3 responses received
· Deadline: 19 Apr 2024
Sent To
Response Status
Responses
3 of 4
56-Day Deadline
19 Apr 2024
All responses received
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Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Although I found there was no causal link between any act or omission on behalf of those involved in the care of Ms. Woodman, either from a mental health perspective, or by any other state agent, several matters have given me cause for concern. a. evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and of which treating clinicians were aware. On at least one of those occasions spoke with Spenser Ward staff. I noted that Ms. Woodman had not given consent for staff to contact concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from ; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with . The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself.
b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
c. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community. Although not causative of the death and I noted ’ very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern.
d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
I received further evidence in writing from the Interested Persons’ subsequent to the completion of the Inquest in relation to these concerns.
This evidence included a response from Surrey and Borders Partnership NHS Foundation Trust (SABP) concerning the measures which have been put in place to address the failures identified There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
b. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF.
c. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community. Although not causative of the death and I noted ’ very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern.
d. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.
I received further evidence in writing from the Interested Persons’ subsequent to the completion of the Inquest in relation to these concerns.
This evidence included a response from Surrey and Borders Partnership NHS Foundation Trust (SABP) concerning the measures which have been put in place to address the failures identified There is a lack of a unified record keeping system which allows the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. This results in circumstances where important, relevant information for the treatment of patients is not available to treating clinicians.
The use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
Responses
Response received
View full response
Dear Coroner
Re: Regulation 28 Report to Prevent Future Deaths – Barbara Ann Woodman who died on 31 March 2021.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 22 December 2023 concerning the death of Barbara Ann Woodman on 31 March 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Barbara’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Barbara’s care have been listened to and reflected upon.
In your Report you raised the concern that there is a lack of unified record keeping which allows for the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes across Integrated Care Services (ICS) boundaries. The NCRS provide access to the Summary Care Record (SCR) which is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines. It is created from GP medical records - whenever a GP record is updated, the changes are synchronised to the SCR. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient's direct care but do not need access to the patient's full record, provided that the patient has given their permission. The approved care settings to view SCRs include mental health care settings. The SCR Team are also currently undertaking trials with other care settings, including within private hospitals and privately funded healthcare services, with a view to working towards seeking national full roll out approval. Details of long-term conditions, significant medical history, or specific communications needs are now included by default for patients within an SCR, unless they have previously told the NHS that they did not want this information to be shared. For more information, and to illustrate the type of content included in an SCR, an example SCR is available here: Additional Information in the SCR National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
4th March 2024
Additional Information in the SCR could include mental health conditions (e.g. bipolar disorder) or previous psychotic or self-harm episodes where these have been recorded in the patient’s GP record. The SCR does not contain any documents (e.g. a mental health care plan or mental health crisis plan) but the SCR can act as a signpost to clinicians to seek further information from other teams involved in a patient’s care. The Direct Care APIs programme (formally GP Connect) also supports care co- ordination both through their send document / update record capability and through their access record HTML and structured capabilities. Each of the services providing care to this patient would be expected to provide updates to the patient’s registered GP. Thus, the correspondence back to the patient’s registered GP and current and future mechanisms to share documents / correspondence / updates from the GP record would also act to support care co-ordination for similarly vulnerable patients. Another record system which should aid the sharing of health information between different organisations is the Shared Care Record. This joins up information based on an individual rather than an organisation and is a safe and secure way of bringing an individual’s separate records from different health and care organisations together. As of 2021, all primary and secondary care organisations have been able to share a subset of the patient information they hold – the core information standard – between providers within their own Integrated Care Board (ICB) footprint. There is now a target to achieve national interoperability (read only) between all Shared Care Records in England by March 2025. This project will ensure that any authorised health and care professional can have safe, secure and ready access to the person-based information they need to deliver high quality individual (direct) care. NHS England would refer you to Surrey Police, County Council and Surrey & Borders Partnership Trust (SABP) on your second concern relating to the use of the SCARF process during out of hours. NHS England has been sighted on and notes the response sent to the coroner by SABP and the County Council, detailing their mental health crisis support services. I would also like to provide further assurances on national NHS England 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 the 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.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Barbara Ann Woodman who died on 31 March 2021.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 22 December 2023 concerning the death of Barbara Ann Woodman on 31 March 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Barbara’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Barbara’s care have been listened to and reflected upon.
In your Report you raised the concern that there is a lack of unified record keeping which allows for the effective sharing of patient information between different components of the NHS, including primary and secondary care providers. The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes across Integrated Care Services (ICS) boundaries. The NCRS provide access to the Summary Care Record (SCR) which is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines. It is created from GP medical records - whenever a GP record is updated, the changes are synchronised to the SCR. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient's direct care but do not need access to the patient's full record, provided that the patient has given their permission. The approved care settings to view SCRs include mental health care settings. The SCR Team are also currently undertaking trials with other care settings, including within private hospitals and privately funded healthcare services, with a view to working towards seeking national full roll out approval. Details of long-term conditions, significant medical history, or specific communications needs are now included by default for patients within an SCR, unless they have previously told the NHS that they did not want this information to be shared. For more information, and to illustrate the type of content included in an SCR, an example SCR is available here: Additional Information in the SCR National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
4th March 2024
Additional Information in the SCR could include mental health conditions (e.g. bipolar disorder) or previous psychotic or self-harm episodes where these have been recorded in the patient’s GP record. The SCR does not contain any documents (e.g. a mental health care plan or mental health crisis plan) but the SCR can act as a signpost to clinicians to seek further information from other teams involved in a patient’s care. The Direct Care APIs programme (formally GP Connect) also supports care co- ordination both through their send document / update record capability and through their access record HTML and structured capabilities. Each of the services providing care to this patient would be expected to provide updates to the patient’s registered GP. Thus, the correspondence back to the patient’s registered GP and current and future mechanisms to share documents / correspondence / updates from the GP record would also act to support care co-ordination for similarly vulnerable patients. Another record system which should aid the sharing of health information between different organisations is the Shared Care Record. This joins up information based on an individual rather than an organisation and is a safe and secure way of bringing an individual’s separate records from different health and care organisations together. As of 2021, all primary and secondary care organisations have been able to share a subset of the patient information they hold – the core information standard – between providers within their own Integrated Care Board (ICB) footprint. There is now a target to achieve national interoperability (read only) between all Shared Care Records in England by March 2025. This project will ensure that any authorised health and care professional can have safe, secure and ready access to the person-based information they need to deliver high quality individual (direct) care. NHS England would refer you to Surrey Police, County Council and Surrey & Borders Partnership Trust (SABP) on your second concern relating to the use of the SCARF process during out of hours. NHS England has been sighted on and notes the response sent to the coroner by SABP and the County Council, detailing their mental health crisis support services. I would also like to provide further assurances on national NHS England 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 the 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.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Response received
View full response
Dear Mr Stewart
Barbara Woodman (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) and Surrey County Council
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 22nd December 2023, in relation to the inquest touching the death of Barbara Woodman. We have considered the report carefully, together with senior officers within both organisations.
In the PFD report, you highlighted a concern relating to the use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
The purpose of a Single Combined Assessment of Risk Form (SCARF) is to enable Surrey Police to inform services where they have had contact with an adult who is considered to be vulnerable and/or at risk. It provides information to partner agencies and will often add to the information that the Trust already holds about a person. This could inform further actions that might be taken by the Trust which may include revisions to assessments or care plans.
A SCARF is not designed to be used to access crisis support or as an out of hours referral tool. The Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s may use. This operates 365 days a year, 24 hours a day. In addition, there is a dedicated Professionals Line phone number, which also operates 365 days a year, 24 hours a day, which can be accessed by Surrey Police and South East Coast Ambulance Service where an urgent discussion is required. This allows emergency services to request critical information in an immediate timeframe to help inform decisions about people they have come into contact with.
Within Surrey County Council the Emergency Duty Team (EDT) operates out of normal office hours 7 days a week, 365 days a year, this includes cover for all bank holidays including Christmas and New SABP NHS Foundation Trust 18 Mole Business Park Randall’s Road Leatherhead KT22 7AD
Woodhatch Place 11 Cockshot Hill Reigate RH2 8EF
15 February 2024
Private and Confidential
Year. Any referrals or concerns from the police that require an immediate response there is a clear, well known and well used process for officers, in that they must make contact with either the Emergency Duty Team or nominated social worker, outside of PSPA hours. There should be no need to use a SCARF and a SCARF should only be used where the situation has been left in a way that it is suitable for the sharing to be delayed until the next day or over the weekend. In 2023 the EDT recorded 140 contacts from the Police directly to them.
We work collaboratively with partner agencies to review and improve our joint working processes. In relation to SCARF procedures, representatives from the Trust most recently met with Surrey County Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review of our cross agency SCARF process. As part of this consideration will be given as to how information is shared between agencies and family/carers alongside issues of confidentiality and consent.
The Community Mental Health Recovery Services, which operate Monday to Friday, 9am to 5:00pm, carry out a screening process in respect of SCARF forms received. Appropriate action will then be taken based on the information provided and the risk profile of the person this relates to.
In relation to your concern relating to the lack of a unified record keeping system allowing sharing of patient information between different components of the NHS, including primary and secondary care providers, you have also addressed the report to the Chief Executive of NHS England who will be best placed to respond to this concern.
On behalf of the Trust and Surrey County Council, we would like to offer our sincere condolences to Ms Woodman’s family for their loss. We hope that our actions outlined above assures you and Ms Woodman’s family that we have reflected on your concerns and provided reassurance as to our processes.
Barbara Woodman (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”) and Surrey County Council
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 22nd December 2023, in relation to the inquest touching the death of Barbara Woodman. We have considered the report carefully, together with senior officers within both organisations.
In the PFD report, you highlighted a concern relating to the use of the SCARF process during out of hours to provide timely and effective passage of information in relation to concerns for vulnerable persons in the community.
The purpose of a Single Combined Assessment of Risk Form (SCARF) is to enable Surrey Police to inform services where they have had contact with an adult who is considered to be vulnerable and/or at risk. It provides information to partner agencies and will often add to the information that the Trust already holds about a person. This could inform further actions that might be taken by the Trust which may include revisions to assessments or care plans.
A SCARF is not designed to be used to access crisis support or as an out of hours referral tool. The Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s may use. This operates 365 days a year, 24 hours a day. In addition, there is a dedicated Professionals Line phone number, which also operates 365 days a year, 24 hours a day, which can be accessed by Surrey Police and South East Coast Ambulance Service where an urgent discussion is required. This allows emergency services to request critical information in an immediate timeframe to help inform decisions about people they have come into contact with.
Within Surrey County Council the Emergency Duty Team (EDT) operates out of normal office hours 7 days a week, 365 days a year, this includes cover for all bank holidays including Christmas and New SABP NHS Foundation Trust 18 Mole Business Park Randall’s Road Leatherhead KT22 7AD
Woodhatch Place 11 Cockshot Hill Reigate RH2 8EF
15 February 2024
Private and Confidential
Year. Any referrals or concerns from the police that require an immediate response there is a clear, well known and well used process for officers, in that they must make contact with either the Emergency Duty Team or nominated social worker, outside of PSPA hours. There should be no need to use a SCARF and a SCARF should only be used where the situation has been left in a way that it is suitable for the sharing to be delayed until the next day or over the weekend. In 2023 the EDT recorded 140 contacts from the Police directly to them.
We work collaboratively with partner agencies to review and improve our joint working processes. In relation to SCARF procedures, representatives from the Trust most recently met with Surrey County Council and Surrey Police on 5 February 2024 and a project group will be carrying out a detailed review of our cross agency SCARF process. As part of this consideration will be given as to how information is shared between agencies and family/carers alongside issues of confidentiality and consent.
The Community Mental Health Recovery Services, which operate Monday to Friday, 9am to 5:00pm, carry out a screening process in respect of SCARF forms received. Appropriate action will then be taken based on the information provided and the risk profile of the person this relates to.
In relation to your concern relating to the lack of a unified record keeping system allowing sharing of patient information between different components of the NHS, including primary and secondary care providers, you have also addressed the report to the Chief Executive of NHS England who will be best placed to respond to this concern.
On behalf of the Trust and Surrey County Council, we would like to offer our sincere condolences to Ms Woodman’s family for their loss. We hope that our actions outlined above assures you and Ms Woodman’s family that we have reflected on your concerns and provided reassurance as to our processes.
Response received
View full response
Dear Mr Stewart OBE, I thank you for your regulaƟon 28: Report to prevent future deaths dated 22nd December 2023. Having reviewed its contents, I note that no specific issues were raised in relaƟon to Surrey Police. However, as we formed part of the inquest, I will ensure to share its findings amongst the relevant teams within the force. Kind Regards Assistant Chief Constable Surrey Police and Sussex Police
Report Sections
Investigation and Inquest
On 8th July 2021 I commenced an investigation into the death of Barbara Ann WOODMAN. The investigation concluded at the end of the inquest on 18th October 2022. The inquest was heard without a Jury. Ms. Woodman died of: 1a. Paracetamol, Codeine and Amlodipine Toxicity I returned the following narrative conclusion: Barbara Ann WOODMAN was admitted to the Abraham Cowley Unit under section on the 4th of March 2021 following an overdose on the 23rd of February 2021 which resulted in her emergency admission to Epsom General Hospital. She was initially guarded and did not engage with Spenser Ward staff seeking to provide her with care and treatment, although this subsequently improved during her period of inpatient care. The initial diagnosis of depression which had led to her section was determined inaccurate and a substitute diagnosis of personality disorder agreed, although additional work following her discharge was to be undertaken to identify the correct subcategory of personality disorder. Ms. WOODMAN was discharged from section on the 18th of March 2021 and agreed to remain at the Abraham Cowley Unit as an inpatient for a further period of assessment. On the 25th of March 2021 she was assessed as fit for discharge to the community under the care of the Community Mental Health Team. A telephone conversation between Ms. WOOMAN and her Care Coordinator occurred on the 26th of March 2021. During this call the Care Coordinator assessed Ms. WOODMAN as not posing an escalated risk to herself. There was an interaction between Ms. WOODMAN and the Police on the 27th of March 2021 when police attended at her residence. No concerns were identified in relation to her risk to self except for the possible use of alcohol. A SCARF Report was raised by Police on the 27th of March 2021 in relation to this contact. It was passed to the Community Mental Health Team by Surrey County Council Adult Social Services on the 29th of March 2021. The SCARF Report was considered by Ms. WOODMAN’s Care Coordinator on the morning of the 31st of March 2021.
After several failed attempts to contact Ms. WOODMAN for a pre-arranged call on the 31st of March 2021, Ms. WOODMAN's Care Coordinator visited her residence at around 16:30 hours to ascertain her whereabouts, posting a note through her letterbox when she could not contact Ms. WOODMAN. Following discussion within the Community Mental Health Team, Police were notified of a concern for Ms. WOODMAN’s welfare at 18:00 hours on the 31st of March 2021. Police attended Ms. WOODMAN’s residence at around 19:20 hours and having forced entry discovered Ms. WOODMAN deceased. No notes or other evidence indicating that Ms. WOODMAN had intended to take her life were found.
Post-mortem examination of Ms. WOODMAN’s body determined that she had died from Paracetamol, Codeine and Amlodipine toxicity. She had also consumed alcohol. It is not clear why Ms. WOODMAN consumed a fatal quantity of these drugs, and her death was drug and alcohol related.
After several failed attempts to contact Ms. WOODMAN for a pre-arranged call on the 31st of March 2021, Ms. WOODMAN's Care Coordinator visited her residence at around 16:30 hours to ascertain her whereabouts, posting a note through her letterbox when she could not contact Ms. WOODMAN. Following discussion within the Community Mental Health Team, Police were notified of a concern for Ms. WOODMAN’s welfare at 18:00 hours on the 31st of March 2021. Police attended Ms. WOODMAN’s residence at around 19:20 hours and having forced entry discovered Ms. WOODMAN deceased. No notes or other evidence indicating that Ms. WOODMAN had intended to take her life were found.
Post-mortem examination of Ms. WOODMAN’s body determined that she had died from Paracetamol, Codeine and Amlodipine toxicity. She had also consumed alcohol. It is not clear why Ms. WOODMAN consumed a fatal quantity of these drugs, and her death was drug and alcohol related.
Circumstances of the Death
The circumstances of the death are recorded in the Narrative Conclusion.
Copies Sent To
c. Epsom General Hospital (EGH)
d. Surrey County Council Adult Social Care (SCC ASC)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.