Dear Mr Longstaff Re: Miles Glynn Naylor (deceased) Regulations 28 and 29 of the Coroners (Investigation) Regulations 2013 am writing in response to your letter dated 10 January 2020, in which you enclosed the Regulation 28: Report to Prevent Future Deaths_ Please find below the Trust's response to the Matters of Concern that you raise_ The jury formally recorded their opinion as part of the conclusion to the inquest that Bradford District Care NHS Foundation Trust should carry out a review of its management of its ligature risks from personal items Since the Inquest in January 2019 the Trust has made significant improvements to managing ligature risks within its inpatient services this is in two parts:
1. Management of Clinical Risk The Trust continues to review the processes which are in place regarding personal belongings. In doing this the Trust recognise there is a balance to be struck of ensuring patient s safety against taking steps that may be seen as negatively impacting on patient's improvement in their mental health_ The Trust has reviewed the policy for Blanket Restrictions: Oversight; & Reporting Policy & Procedure for Mental Health Inpatient Services. It is important that wherever possible the least restrictive will be used to maximise patient experience and independence as this is seen as an important part in the mental health of patient being improved_ As such, the Trust does not routinely remove potential ligature items such as beltsllaces from individuals Where there is a clear clinical risk for example a clear history or expressed intention to harm themselves, it may be appropriate to remove such items. This will be risk assessed and care planned with the use of increased observations. In July 2019 the Trust introduced a model where each in-patient ward has a dedicated Consultant Psychiatrist, this has provided the team with greater opportunity for W: wwwbdct nhsuk @BDCFT better lives, together City " Use option

inpatient MDT working with daily presence of all disciplines to review individual care and risks
2. Managing the Environment In April 2019 the Trust undertook a review of how ligature risks are assessed and managed in our in-patient areas_ new approach has been introduced (Manchester Audit Tool) which grades ligature risk based on four factors: The four factors are: Room designation rating Patient profile rating Ligature point height rating Compensating factors rating This has led to a standard inpatient assessment of ligature risk: The assessment is undertaken by multi-disciplinary team. Following individual risk assessment, template is completed and uploaded on the Trust's system which is visible to the ward managers to input both any estate works required_ date for the repairslworks to be completed and the clinical actions and mitigations in place: A printed risk assessment is made available for all staff on the ward and used as part of staff induction and ongoing management of risks and these are reviewed yearly. Visual aids and training for staff are provided_ All ligature risk assessments are reviewed and monitored by the monthly Ligature Environmental Risk and Safety group. The group also assesses all new ligature incidents that are with or without an anchor to consider any learning requirements_ During the course of the evidence, questions were raised about the design of the doors on Oakburn Ward, and whether access to the hinge pin side of the doors might be prevented by the use of covers (similar to the finger guards is use in childrens nurseries and similar premises) The Trust acknowledges the concerns raised during the inquest and a need to review the design of the doors in our on in-patient wards_ In June 2019, business case was developed and submitted to the Trust Board which included environmental improvements and the introduction of high specification full door alarms on identified bedrooms on 8 high risk wards, including Oakburn: Work has begun installing these doors in designated rooms on high risk wards as part of phase development and is due to be completed by April 2020. As the coroner will appreciate, replacing all the doors has significant capital expense which was included in the Trusts ongoing capital improvement programme and has been identified as a Trust priority In addition to the above which specifically relates to ligature risks, the Trust has made significant improvements on all inpatient wards over the last year. The Trust introduced detailed checks in all inpatient areas These checks include considering admissions, leave , observations clinical risk assessments , incidents and care plans, maintaining the Trust's focus on the question of: 'Are we Safe Today?" point daily key

Our Ref: 2018.6152 Your ref: ORLIHK-736-2018 hope the above provides assurance that the Trust has taken action to mitigate against potential patient safety incidents involving ligatures If you would like any further information or assurances, please do not hesitate to contact me