Roberto Bottello
PFD Report
All Responded
Ref: 2024-0087
All 3 responses received
· Deadline: 12 Apr 2024
Response Status
Responses
3 of 3
56-Day Deadline
12 Apr 2024
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
Matters Of Concern
1. That CNWL failed in its duty of candour in relation to provision of evidence in this case.
2. That the evidence given by the SPA witnesses was at times not credible.
2. That the evidence given by the SPA witnesses was at times not credible.
Responses
NHS England has national programs supporting Shared Care Records, publishes guidance for patient information sharing, and has a Regulation 28 Working Group to share learnings from PFD reports. The NHS Long Term Workforce Plan aims to significantly increase psychological professions and mental health nursing training places.
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Roberto Bottello who died on 16th September 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16th February 2024 concerning the death of Roberto Bottello on 16th September 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Roberto’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Roberto’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Roberto’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
We note that you have also sent your Report to Central and North West London NHS Foundation Trust (“the Trust”) and The Commissioner of Police of the Metropolis for whom the majority of the concerns relate to. We have been sighted on the Trust’s response to you and note that it details a number of changes to the provision of care and services across the Trust. This response addresses those concerns which come under the remit of NHS England national policy or programmes, referenced below.
Concern number 6 - Psychiatric liaison nurses and psychiatric liaison doctors should have regard to diagnoses made by other doctors
All healthcare professionals should have regard to a patient’s medical history and diagnoses. There are several patient record sharing options available to clinicians to access an individual’s medical history. These include Shared Care Records, Summary Care Records and the National Care Records Service.
Concern numbers’ 7 & 10 - That most Section 136 usage is out of hours when there is less resource to respond to psychiatric services and that there are continued shortages in psychiatric care provision
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
26 April 2024
In 2016, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute Trusts to provide board assurance compliance. The Programme focuses on the provision of acute medical care in such a way that there is no difference in quality for patients, whichever day they attend at hospital. The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise helps NHS providers to consider ways to recruit and retain staff.
Workforce and staffing levels continue to be a challenge across the NHS, and we know that this can present issues to Trusts. In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history and includes focus on growing the psychiatric care workforce.
Psychological professionals, comprising psychologists, psychological therapists, and psychological practitioners, are making a rapidly growing contribution to the NHS across mental health and physical health services. Education and training places for clinical psychology and child and adolescent psychotherapy are estimated to need to grow by at least 20–33%, reaching 1,258–1,397 by 2033/34. Our ambition is to grow these training places by 26% by 2031/32. To support working towards this ambition, training places for clinical psychology and child and adolescent psychotherapy will be more than 1,000 each year up to 2028/29.
In addition to education and training for clinical psychologists and child and adolescent psychotherapists, over the next three years NHS England has committed funding of over £600 million to grow the wider psychological professions workforce through training approximately 15,000 more individuals to undertake psychological therapist and psychological practitioner roles. Training places for mental health nursing will also increase by 38%. The Long-Term Workforce Plan makes a commitment to keep the mental health workforce under review.
Concern number 9: The use of film over glass should be more widespread in the NHS England estate
Estate management is the responsibility of each individual NHS Trust. I note that a Serious Incident Investigation was undertaken by the Trust in this matter and recommendations were made to consider reconfiguring the space to provide a more appropriate place of safety for mental health patients. We are advised that the Trust will be reviewing their windows to ascertain whether reinforced toughened glass can be fitted.
Your Report has been shared with my colleagues within our national Mental Health and Specialised Commissioning Teams who will consider whether any further action needs to be taken regarding your concerns. Colleagues from each of the seven regions will also be asked to share the learnings from Roberto’s care within their health and care systems.
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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16th February 2024 concerning the death of Roberto Bottello on 16th September 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Roberto’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Roberto’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Roberto’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
We note that you have also sent your Report to Central and North West London NHS Foundation Trust (“the Trust”) and The Commissioner of Police of the Metropolis for whom the majority of the concerns relate to. We have been sighted on the Trust’s response to you and note that it details a number of changes to the provision of care and services across the Trust. This response addresses those concerns which come under the remit of NHS England national policy or programmes, referenced below.
Concern number 6 - Psychiatric liaison nurses and psychiatric liaison doctors should have regard to diagnoses made by other doctors
All healthcare professionals should have regard to a patient’s medical history and diagnoses. There are several patient record sharing options available to clinicians to access an individual’s medical history. These include Shared Care Records, Summary Care Records and the National Care Records Service.
Concern numbers’ 7 & 10 - That most Section 136 usage is out of hours when there is less resource to respond to psychiatric services and that there are continued shortages in psychiatric care provision
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
26 April 2024
In 2016, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute Trusts to provide board assurance compliance. The Programme focuses on the provision of acute medical care in such a way that there is no difference in quality for patients, whichever day they attend at hospital. The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise helps NHS providers to consider ways to recruit and retain staff.
Workforce and staffing levels continue to be a challenge across the NHS, and we know that this can present issues to Trusts. In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history and includes focus on growing the psychiatric care workforce.
Psychological professionals, comprising psychologists, psychological therapists, and psychological practitioners, are making a rapidly growing contribution to the NHS across mental health and physical health services. Education and training places for clinical psychology and child and adolescent psychotherapy are estimated to need to grow by at least 20–33%, reaching 1,258–1,397 by 2033/34. Our ambition is to grow these training places by 26% by 2031/32. To support working towards this ambition, training places for clinical psychology and child and adolescent psychotherapy will be more than 1,000 each year up to 2028/29.
In addition to education and training for clinical psychologists and child and adolescent psychotherapists, over the next three years NHS England has committed funding of over £600 million to grow the wider psychological professions workforce through training approximately 15,000 more individuals to undertake psychological therapist and psychological practitioner roles. Training places for mental health nursing will also increase by 38%. The Long-Term Workforce Plan makes a commitment to keep the mental health workforce under review.
Concern number 9: The use of film over glass should be more widespread in the NHS England estate
Estate management is the responsibility of each individual NHS Trust. I note that a Serious Incident Investigation was undertaken by the Trust in this matter and recommendations were made to consider reconfiguring the space to provide a more appropriate place of safety for mental health patients. We are advised that the Trust will be reviewing their windows to ascertain whether reinforced toughened glass can be fitted.
Your Report has been shared with my colleagues within our national Mental Health and Specialised Commissioning Teams who will consider whether any further action needs to be taken regarding your concerns. Colleagues from each of the seven regions will also be asked to share the learnings from Roberto’s care within their health and care systems.
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.
Central and North West London NHS Foundation Trust has restructured its SPA, which no longer exists, and introduced new London-wide s136 hubs to manage mental health calls. They have also implemented duty of candour training, a new 'Lessons Learned' policy and committee, and a new assessment process for mental health access points.
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Dear Madam Coroner,
Regulation 28 Report to prevent future deaths in relation to Roberto Bottello
I am responding to the Regulation 28 Report issued on 16 February 2024 following the inquest into the death of Mr. Roberto Bottello commencing on 16 September
2020. The inquest concluded on 1 February 2024.
Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of Mr. Bottello and the distress that this has caused his family.
We accept the findings of the jury and have evaluated our response to the tragic death of Mr. Bottello in light of the findings.
Following the death of Mr. Bottello, we made a number of changes to the provision of care and services across the Trust. We have considered the concerns raised by you and where possible we have grouped together details of assurance measures where these appear to deal with more than one area of concern. There are matters of practice and procedure identified where the need for improvement has been recognised. I will respond to the matters of concern, setting out what we have already done, what we are doing now, and what we intend to do in the future.
Matters of Concern
1. That CNWL failed in its duty of candour in relation to provision of evidence in this case.
2. That the evidence given by the SPA witnesses was at times not credible.
3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth.
4. That police officers may need reminding to use the phonetic alphabet and using the word for the month in a person’s date of birth.
5. That CNWL were and may still be unaware that CNWL staff operate outside policy.
6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E as in this case.
7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.
8. That other areas in England could learn from how section 136 suite access has been restructured in London.
9. That the use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate.
10. That there are continued shortages in psychiatric care provision.
I have addressed these concerns where they relate to CNWL below:
Duty of Candour
• CNWL takes the concerns which you have raised very seriously. We have discussed the findings of the inquest and matters of concern identified by you during the course of the inquest hearing with our staff.
• CNWL is very sorry that the Learned Coroner considers that CNWL did not provide evidence in accordance with its duty of candour. The Trust has always taken its duty of candour very seriously.
• It is always our approach to work with coroners and their officers collaboratively and to respond to inquiries and directions in a candid and swift manner. We provided evidence from our witnesses to the coronial investigation and cannot locate any requests from your office or from other Interested Persons or their legal representatives for clarification or further evidence, and having attended the pre-inquest hearings, we proceeded on the basis that no further evidence in relation to the issues was required.
• This was an unusual situation whereby whilst there was involvement with CNWL services the incident occurred whilst Mr Bottello was under the care and responsibility of St Mary’s Hospital. The Serious Incident Investigation was undertaken and directed by Imperial College Healthcare NHS Trust. CNWL contributed to and collaborated with the investigation as is usual in cases where a lead investigation organisation is assigned. The collaboration was primarily through engagement with the CNWL Psychiatric Team Leader at St Mary’s Hospital and with one of our Senior Nurses who participated in
the investigation throughout and was actively involved in collaborating with the investigating team and agreeing actions to be embedded in the subsequent report and action plan. CNWL did not undertake a separate full serious incident investigation into the circumstances of the incident and this was in accordance with the Serious Incident Framework as published by NHS England. The focus of the Serious Incident Investigation on this occasion was on the events which took place at St Mary’s Hospital.
• As part of our learning from this incident we will remind our services that where another organisation is leading on a serious incident investigation, in addition to working collaboratively with that organisation, there should be ongoing and robust consideration of CNWL’s involvement with the patient even if certain events do not form part of the remit of the serious incident investigation. This will assist as to whether further internal investigation is required.
Witness Credibility
• We have spoken to the witnesses about your concern and are confident that they understand the importance of being open and transparent when giving evidence. We will reinforce this message as part of the support provided to all witnesses who attend court to give evidence.
• From the feedback we have received from witnesses in this and other inquests, the response of the witness is often related to the situation in which they are being questioned rather than the subject matter of the questioning. It is a unique experience that typically arouses strong emotions. The ability of a witness to withstand questioning in these circumstances can be variable. Both of the witnesses were extremely nervous and anxious about giving evidence which of course is not unusual and neither had attended Coroner’s court before and found the experience daunting particularly because this was a jury inquest.
Communications
• A weekly meeting between the acute hospital clinicians at St Marys and CNWL now occurs. A joint venture between the two organisations for mental health patients attending the emergency department in the form of an assessment centre for mental health patients (The Lighthouse), at St Marys Hospital opened in the autumn of 2023 and has seen improved communication and partnership working.
• We appreciate there is a need to ensure that Psychiatric Liaison nurses and Liaison doctors have regard to and consider diagnoses made by other doctors who see a patient repeatedly in A&E. CNWL will ensure that the established channels of communications are strengthened through improved consultation and collaboration of patient care and a feedback mechanism is used where A&E doctors provide input on the effectiveness of psychiatric diagnoses and interventions at the weekly meeting referred to above,
Training
• SPA staff attend SystmOne (CNWL electronic record keeping system) training as part of their induction.
• SPA has evolved considerably since this incident and various improvements have been implemented.
• SPA has developed an induction pack, which specifically includes guidance on various ways of searching or identifying patient vis system one/SPINE. All SPA staff now use phonetic alphabet when clarifying patients or callers’ details. On each desk within SPA there is a list of the phonetic alphabet, to support and prompt staff to ensure they have the correct spelling. SPA also has a checklist for call handlers, which prompts them to ask certain questions as a minimum, so information is not missed during calls.
• There have been changes in process and systems regarding police contact and as an aid to effective communication we will remind the police that during telephone calls we require the use of the phonetic alphabet to avoid miscommunication.
• By way of assurance to the Learned Coroner, I can confirm that all CNWL policies and procedures are available and communicated to staff through training sessions, staff handbooks and regular updates on the CNWL Trust intranet.
• We operate a comprehensive internal training programme and ensures that all new starters to the organisation have a wide-ranging induction to familiarise staff with policy relevant to their area of work.
• We use established protocols for monitoring staff adherence to policy such as regular audits, supervision and performance reviews.
• We strive for continuous improvement and conducts regular reviews and updates of policies and procedures to ensure they remain relevant and fit for purpose.
S136 (HBPOS) suites
• Recent changes as of November 2023 mean that the Police now have a generic 0300 number, through which they can access immediate support from mental health services. Police can call for advice, or to inform the new 136 hubs, that they have detained a patient under a Section 136 (MHA). London has two s136 hubs, one in the north and one in the south of London. Depending on where the Police are calling from, they will be directed to one of these hubs.
• SPA no longer manages calls from the Police or support with locating Health Based Place of Safety (HBPOS) suites. The s136 hubs have access to all
HBPOS suites across London, for which they check capacity through using a SMART Tool.
• All HBPOS suites across London update the SMART Tool in real time, as and when patients arrive or are discharged from HBPOS suites. In addition, the 136 hubs call to confirm availability, before sending patients to a suite.
• Police can call the 136 hubs whilst with a patient in the emergency department or in the community with a patient. This has helped Police, as they no longer need to liaise with several different mental health trusts across London. This has contributed to a reduction in Police attending emergency departments unnecessarily, due to lack of HBPOS capacity.
Staffing and recruitment
• Whilst there is a national challenge to recruit and retain Registered Mental Health Nurses (RMN’s), CNWL has maintained safer staffing levels and provided a full liaison psychiatry staff complement at all times at the St Marys Hospital site.
• CNWL currently has a trust vacancy level of 5.9%, and a 12.7% vacancy rate for qualified nurses which is well below the national average.
• At CNWL, we recognise the fluid nature of this situation and affirm our dedication to consistently recruiting and retaining our valuable staff. We are committed to continuously monitoring recruitment and vacancies, as well as implementing supportive initiatives.
Thank you for raising these concerns. I hope that the content of this letter provides sufficient assurance that CNWL takes the concerns raised seriously and has taken action following the death of Mr Bottello. CNWL continues to work to improve the service we provide. Should you have any further questions, please do not hesitate to contact me directly.
Regulation 28 Report to prevent future deaths in relation to Roberto Bottello
I am responding to the Regulation 28 Report issued on 16 February 2024 following the inquest into the death of Mr. Roberto Bottello commencing on 16 September
2020. The inquest concluded on 1 February 2024.
Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of Mr. Bottello and the distress that this has caused his family.
We accept the findings of the jury and have evaluated our response to the tragic death of Mr. Bottello in light of the findings.
Following the death of Mr. Bottello, we made a number of changes to the provision of care and services across the Trust. We have considered the concerns raised by you and where possible we have grouped together details of assurance measures where these appear to deal with more than one area of concern. There are matters of practice and procedure identified where the need for improvement has been recognised. I will respond to the matters of concern, setting out what we have already done, what we are doing now, and what we intend to do in the future.
Matters of Concern
1. That CNWL failed in its duty of candour in relation to provision of evidence in this case.
2. That the evidence given by the SPA witnesses was at times not credible.
3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth.
4. That police officers may need reminding to use the phonetic alphabet and using the word for the month in a person’s date of birth.
5. That CNWL were and may still be unaware that CNWL staff operate outside policy.
6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E as in this case.
7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.
8. That other areas in England could learn from how section 136 suite access has been restructured in London.
9. That the use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate.
10. That there are continued shortages in psychiatric care provision.
I have addressed these concerns where they relate to CNWL below:
Duty of Candour
• CNWL takes the concerns which you have raised very seriously. We have discussed the findings of the inquest and matters of concern identified by you during the course of the inquest hearing with our staff.
• CNWL is very sorry that the Learned Coroner considers that CNWL did not provide evidence in accordance with its duty of candour. The Trust has always taken its duty of candour very seriously.
• It is always our approach to work with coroners and their officers collaboratively and to respond to inquiries and directions in a candid and swift manner. We provided evidence from our witnesses to the coronial investigation and cannot locate any requests from your office or from other Interested Persons or their legal representatives for clarification or further evidence, and having attended the pre-inquest hearings, we proceeded on the basis that no further evidence in relation to the issues was required.
• This was an unusual situation whereby whilst there was involvement with CNWL services the incident occurred whilst Mr Bottello was under the care and responsibility of St Mary’s Hospital. The Serious Incident Investigation was undertaken and directed by Imperial College Healthcare NHS Trust. CNWL contributed to and collaborated with the investigation as is usual in cases where a lead investigation organisation is assigned. The collaboration was primarily through engagement with the CNWL Psychiatric Team Leader at St Mary’s Hospital and with one of our Senior Nurses who participated in
the investigation throughout and was actively involved in collaborating with the investigating team and agreeing actions to be embedded in the subsequent report and action plan. CNWL did not undertake a separate full serious incident investigation into the circumstances of the incident and this was in accordance with the Serious Incident Framework as published by NHS England. The focus of the Serious Incident Investigation on this occasion was on the events which took place at St Mary’s Hospital.
• As part of our learning from this incident we will remind our services that where another organisation is leading on a serious incident investigation, in addition to working collaboratively with that organisation, there should be ongoing and robust consideration of CNWL’s involvement with the patient even if certain events do not form part of the remit of the serious incident investigation. This will assist as to whether further internal investigation is required.
Witness Credibility
• We have spoken to the witnesses about your concern and are confident that they understand the importance of being open and transparent when giving evidence. We will reinforce this message as part of the support provided to all witnesses who attend court to give evidence.
• From the feedback we have received from witnesses in this and other inquests, the response of the witness is often related to the situation in which they are being questioned rather than the subject matter of the questioning. It is a unique experience that typically arouses strong emotions. The ability of a witness to withstand questioning in these circumstances can be variable. Both of the witnesses were extremely nervous and anxious about giving evidence which of course is not unusual and neither had attended Coroner’s court before and found the experience daunting particularly because this was a jury inquest.
Communications
• A weekly meeting between the acute hospital clinicians at St Marys and CNWL now occurs. A joint venture between the two organisations for mental health patients attending the emergency department in the form of an assessment centre for mental health patients (The Lighthouse), at St Marys Hospital opened in the autumn of 2023 and has seen improved communication and partnership working.
• We appreciate there is a need to ensure that Psychiatric Liaison nurses and Liaison doctors have regard to and consider diagnoses made by other doctors who see a patient repeatedly in A&E. CNWL will ensure that the established channels of communications are strengthened through improved consultation and collaboration of patient care and a feedback mechanism is used where A&E doctors provide input on the effectiveness of psychiatric diagnoses and interventions at the weekly meeting referred to above,
Training
• SPA staff attend SystmOne (CNWL electronic record keeping system) training as part of their induction.
• SPA has evolved considerably since this incident and various improvements have been implemented.
• SPA has developed an induction pack, which specifically includes guidance on various ways of searching or identifying patient vis system one/SPINE. All SPA staff now use phonetic alphabet when clarifying patients or callers’ details. On each desk within SPA there is a list of the phonetic alphabet, to support and prompt staff to ensure they have the correct spelling. SPA also has a checklist for call handlers, which prompts them to ask certain questions as a minimum, so information is not missed during calls.
• There have been changes in process and systems regarding police contact and as an aid to effective communication we will remind the police that during telephone calls we require the use of the phonetic alphabet to avoid miscommunication.
• By way of assurance to the Learned Coroner, I can confirm that all CNWL policies and procedures are available and communicated to staff through training sessions, staff handbooks and regular updates on the CNWL Trust intranet.
• We operate a comprehensive internal training programme and ensures that all new starters to the organisation have a wide-ranging induction to familiarise staff with policy relevant to their area of work.
• We use established protocols for monitoring staff adherence to policy such as regular audits, supervision and performance reviews.
• We strive for continuous improvement and conducts regular reviews and updates of policies and procedures to ensure they remain relevant and fit for purpose.
S136 (HBPOS) suites
• Recent changes as of November 2023 mean that the Police now have a generic 0300 number, through which they can access immediate support from mental health services. Police can call for advice, or to inform the new 136 hubs, that they have detained a patient under a Section 136 (MHA). London has two s136 hubs, one in the north and one in the south of London. Depending on where the Police are calling from, they will be directed to one of these hubs.
• SPA no longer manages calls from the Police or support with locating Health Based Place of Safety (HBPOS) suites. The s136 hubs have access to all
HBPOS suites across London, for which they check capacity through using a SMART Tool.
• All HBPOS suites across London update the SMART Tool in real time, as and when patients arrive or are discharged from HBPOS suites. In addition, the 136 hubs call to confirm availability, before sending patients to a suite.
• Police can call the 136 hubs whilst with a patient in the emergency department or in the community with a patient. This has helped Police, as they no longer need to liaise with several different mental health trusts across London. This has contributed to a reduction in Police attending emergency departments unnecessarily, due to lack of HBPOS capacity.
Staffing and recruitment
• Whilst there is a national challenge to recruit and retain Registered Mental Health Nurses (RMN’s), CNWL has maintained safer staffing levels and provided a full liaison psychiatry staff complement at all times at the St Marys Hospital site.
• CNWL currently has a trust vacancy level of 5.9%, and a 12.7% vacancy rate for qualified nurses which is well below the national average.
• At CNWL, we recognise the fluid nature of this situation and affirm our dedication to consistently recruiting and retaining our valuable staff. We are committed to continuously monitoring recruitment and vacancies, as well as implementing supportive initiatives.
Thank you for raising these concerns. I hope that the content of this letter provides sufficient assurance that CNWL takes the concerns raised seriously and has taken action following the death of Mr Bottello. CNWL continues to work to improve the service we provide. Should you have any further questions, please do not hesitate to contact me directly.
The Metropolitan Police Service confirmed that new recruits receive mandatory training and handouts on using the phonetic alphabet and airwave etiquette, and existing learning provision is considered sufficient. An internal document is being amended to further emphasize phonetic alphabet use for name checks.
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Dear Professor Wilcox Iam the Director for Learning Development in the Metropolitan Police Service (MPS ) On behalf ofthe Commissioner of Police ofthe Metropolis; write to provide the response to the matter of concer addressed to the MPS in your Report to Prevent Future Deaths dated 16th February 2024. On behalf of the MPS, may [ first of all express my sincere condolences to the family and friends of Mr Roberto Bottello, our thoughts and sympathies are very much with them The Coroner's ' Matter_of Concem The Prevention of Future Deaths report dated 16th February 2024 records: - That police officers may need reminding to use the phonetic alphabet and using the word for the month in a person'$ date of birth MPS Response Training given to Recruit Police Officers in use of the phonetic alphabet All MPS officers complete a mandatory training package developed by the College of Policing (the professional body setting training standards for forces across England and Wales) called Airwaves Radios" This is hosted on College Learn (the national online training platform for police officers and staff) Within the first three weeks of initial learning, recruit police officers are provided with a handout and "4.
METROPOLITAN POLICE regarding airwave etiquette (attached'), including use of the phonetic alphabet. Within every role play activity they conduct the initial learning phase, recruits are expected to demonstrate competence in line with this handout where the scenario includes use of radio transmission. This includes use of the phonetic alphabet during simulated radio transmissions. Following the initial leamning phase; recruits are deployed onto Street Duties teams working alongside a tutor constable for approximately 10 weeks _ this time conduct further role plays which include use of the phonetic alphabet to practice use of the airwaves_ Embedding organisational learning within initial recruit learning programmes MPS Learning and Development undertake a leamning needs analysis following any recommendations (for example; from external reports and inquiries) to understand if there is an organisational learning need and who the learner audience is_ Where the learner audience is exclusively new recruits, the Centre for Initial Recruit Learning will address the learning need through an established Curriculum Design Authority This will include an assessment of whether the learning need is met through our current provision, or whether new or updated content is required. This will be assessed in the context of the National Police Curriculum set by the College of Policing: With regards to the matter of concern set out within this Prevention of Future Death Report relating to use of the phonetic alphabet; the assessment is that this learning need is met within our current provision for new recruits as outlined above. Where the learner audience is broader than just new recruits, wider MPS Learning and Development will work in partnership with the Centre for Initial Recruit Leamning to agree an implementation approach and prioritisation of related activity:
METROPOLITAN POLICE regarding airwave etiquette (attached'), including use of the phonetic alphabet. Within every role play activity they conduct the initial learning phase, recruits are expected to demonstrate competence in line with this handout where the scenario includes use of radio transmission. This includes use of the phonetic alphabet during simulated radio transmissions. Following the initial leamning phase; recruits are deployed onto Street Duties teams working alongside a tutor constable for approximately 10 weeks _ this time conduct further role plays which include use of the phonetic alphabet to practice use of the airwaves_ Embedding organisational learning within initial recruit learning programmes MPS Learning and Development undertake a leamning needs analysis following any recommendations (for example; from external reports and inquiries) to understand if there is an organisational learning need and who the learner audience is_ Where the learner audience is exclusively new recruits, the Centre for Initial Recruit Learning will address the learning need through an established Curriculum Design Authority This will include an assessment of whether the learning need is met through our current provision, or whether new or updated content is required. This will be assessed in the context of the National Police Curriculum set by the College of Policing: With regards to the matter of concern set out within this Prevention of Future Death Report relating to use of the phonetic alphabet; the assessment is that this learning need is met within our current provision for new recruits as outlined above. Where the learner audience is broader than just new recruits, wider MPS Learning and Development will work in partnership with the Centre for Initial Recruit Leamning to agree an implementation approach and prioritisation of related activity:
Action Should Be Taken
It is for each addressee to respond to matters relevant to them.
Report Sections
Investigation and Inquest
From the 22nd January until 1st February 2024, evidence was heard before a jury touching the death of Mr Roberto Bottello. He had died on the 16th September 2020, aged 44 years.
Medical Cause of Death
1 a. Multiple Injuries
How, when, where and in what circumstances the deceased came by his death:
Roberto Bottello had been suffering problems with depression, anxiety and panic attacks in the months leading up to his death. On the 25th August 2020 he attended the urgent care centre at Hillingdon Hospital presenting with sleeplessness and visual hallucinations. He was referred to the psychiatric liaison nurse and discharged to be followed up by Addiction Recovery Community Hillingdon (ARCH). This referral was followed by 2 GP referrals and a self referral, He was not seen or assessed by ARCH prior to his death.
Over the 13th and 14th of September 2020, Roberto presented to police officers on 4 occasions, presenting with paranoia. These presentations resulted in 3 Merlin reports of Adult Come to Notice made by police, which were on Roberto’s psychiatric record by 15th September 2020. Roberto’s last contact with his family was a telephone call on 14th September 2020. At around 21:00 on 14th September Roberto’s mother called the Single
Point of Access (SPA) and was advised to report him missing. His parents reported Roberto missing to police at around 10:00 on 15th September 2020, and a missing person report was made.
Roberto came to the attention of police when he was in Berkely Square, London at around 00:10 on 16th September 2020. He was acting in an acutely disturbed manner. Hs body was tense, he was grinding his teeth and largely unresponsive. He had no shirt or shoes on. He began screaming at the sky. The police officers suspected ABD/ excited delirium. Roberto charged at the police officers. One officer pushed him back with an open hand and both officers challenged him with their taser red dot. He then became calm again. Further police officers and an ambulance attended Roberto.
After further agitation, Roberto was placed in handcuffs, place in an ambulance, and then his legs were placed in restraints. He was detained under section 136 of the Mental Health Act (MHA) and was transported to St Mary’s Hospital by ambulance.
At hospital, Roberto remained under guard by 2 police officers. The police liaise with the SPA to try to find a s.136 suite for Roberto. Roberto was medically cleared by 03.20 by the Accident and Emergency (A&E) doctors and he was referred to psychiatric liaison at 03.26. The differential diagnosis at the time of referral to psychiatric liaison was that Roberto was not intoxicated and was experiencing an acute psychotic episode. Roberto was seen by psychiatric liaison at 03.55 and referred to the psychiatrist for a MHA assessment at 04.34. A place was made to defer the MHA assessment until after 09.00. The deferral of the assessment was reasonable based on his presentation and past history as known to the psychiatric team at the time.
Roberto’s identification was unclear to the police in the hospital, the SPA agents and hospital staff. Inadequate steps were taken to identify Roberto until his identity was established by the psychiatric liaison nurse prior to 04.34. Identification details were passed to police at the hospital but there were missed opportunities to clarify his identity, especially in the final call between police and the SPA. The SPA and Hillingdon bed manager made assumptions about his identity.
If a s.136 suite had been made available to Roberto he would have been transferred but there is uncertainty about whether he would have been transferred before the time at which he fell from the window.
The SPA asked police officers to contact bed managers in an attempt to secure a
s.136 suite for Roberto, against the policy at the time that the SPA find the suite.
At the time of the incident that led to his death, Roberto was in cubicle 5 in St Mary’s Hospital. 2 police officers and one emergency departmental lead registrar were with him.
At around 06.00 Roberto began to show agitation again. An A&E nurse was dismissive about his behaviour. At around 06.20 he took his remaining clothes off and also took his medical stickers off. He was spoken to by the police officers who asked him if he wanted to go to the toilet. An officer called a doctor to help who entered cubicle 5 with the officer.
They tried to calm Roberto and talk to him. He became more agitated. A police officer asked him to move back on the bed.
Roberto started rocking on the bed, which was level with the windowsill. He put his foot on the sink and rolled himself backwards and moved himself onto the sill. He kicked the window and broke the glass. He moved himself backwards through the window. He was cut by broken glass as he exited the window. He fell 25 feet to the canal path below.
Roberto’s state of mind at the time, insofar as it may be determined, was that he was psychotic and in a state of agitation. He would not have acted as he did if he had not been psychotic.
After Roberto exited the window, there was a short delay before medical staff reached him because a gate was locked. He was attended by medical staff and the two police officers on the canal path.
As a result of the incident, Roberto suffered injuries:
- cuts, bruises and grazes;
- injuries to his limbs;
- his lift upper limb suffered a large cut and his axillary vein and artery were divided;
- he lost a large amount of blood; and
- both of his lungs collapsed
Roberto was given CPR. He was administered adrenalin and regained a pulse. He was given a bilateral theracostomy. The trauma surgeon was alerted at 06.31. Roberto was transferred from the canal path to the emergency department. He proceeded directly to the surgical department. His blood vessels were clamped. He was given a blood transfusion. He lost circulatory output. He was given further CPR and shocked twice. He had minimal heart function and suffered cardiac arrest. His heart rhythm had become incompatible with life.
Roberto Bottello’s death was announced at 07.27 on 16th September 2020.
Matters which may have possibly caused or contributed to Roberto Bottello’s death:
The following matters may have possibly caused or contributed to Roberto’s death:
Cubicle 5 in which Roberto was placed in hospital was inadequate and unsuitable because it was a rm with windows rather than a designated mental health cubicle, and the bed was next to the windowsill and at the same or similar level. There were no effective measures in place to prevent patients breaking or exiting through the windows, notwithstanding that the windows were compliant with the legal requirements at the time.
There was insufficient communication between various parties involved, including:
- The SPA and police;
- A&E and the psychiatric liaison team;
- Psychiatric liaison team and police;
- Within the psychiatric liaison team;
- The Hillingdon bed manager and the SPA and Central Flow Hub; and
- The Hillingdon bed manager and the police.
The information management systems involved were inefficient and inadequate.
Roberto was not cared for by a Registered Mental Health Nurse (RMN) but was cared for by police officers, who are not mental health specialists. There was insufficient RMN provision at the time. An RMN would have been better placed than police officers to monitor Robert’s mental state, identify any issues such as increased agitation and developing risks.
The confusion of Roberto’s identity with a patient who had just been discharged from Hillingdon and the section 136 suite being made unavailable to him.
The apparent lack of available s.136 suites.
Conclusion of the Jury as to the death:
Roberto Bottello was experiencing an acute psychotic episode. He was detained under
s.136 of the Mental Health Act. he broke the window of his hospital cubicle with his feet and exited the window falling to the canal path below. In doing so, he suffered multiple injuries including cuts from broken glass that divided his axillary vein and artery and led to his death. Extensive evidence was taken during the inquest from multiple live witnesses, written statements, reports, body worn footage and recordings of telephone calls between the police and SPA. Please see the extensive findings made by the jury in this case as set out above.
Of relevance to this report:
It was clear from the evidence that SPA were asking police officers to ring around various s. 136 suite providers to try and find a space for him, against policy at that time.
That a suite was available in Hillingdon that had not been declared as vacant as it should have been against policy.
That this space should have been made available to Roberto and it was not against policy.
This meant that the Central Flow Hub advised the psychiatric liaison nurse that there were no spaces available in London and as such the psychiatric liaison nurse drew up management plans that centred on getting Roberto’s required Mental Health Act assessment undertaken by the psychiatric liaison team, which is often slow and difficult to arrange, rather than having the option to consider transferring him more promptly to a section 136 suite.
That identification assumptions were made by the Hillingdon Bed manager and SPA based solely upon his sex and a similar first name to a person who had been discharged earlier in the day by Hillingdon that the person discharged was Roberto.
This identification assumption could have been easily put aside even with the minimal identification evidence being sought, but staff at Hillingdon, and SPA did not do this. On this basis Roberto was refused a space in Hillingdon against policy, which he should have been allowed access to, even if had been the person with whom he had been confused who had just been discharged.
SPA staff colluded with the actions of the bed manager even though they knew it was against policy.
Simple identification checks that could have been made were not. For example using the international phonetic alphabet in relation to Roberto’s surname in communication between police and SPA staff, and relying on numeric date of birth rather than using the name of the month. Both police and SPA staff did this which caused delay in identification.
The manager of SPA and Central Flow Hub at the time stated that she was completely unaware that staff were acting against training and policy.
The court had experienced immense difficulty in getting evidence from CNWL in relation to the Hillingdon issues despite repeated requests, such that the evidence was not clarified until the last day of evidence and after further directions had been give live in court. This was in my view a failure of the duty of candour by CNWL.
The court was grateful to the current senior manager from CNWL who worked over the weekend to secure the evidence that the court had been requesting for years.
It was also clear to the court and jury that the evidence of SPA witnesses was at times not credible despite recordings of the calls they made and transcripts of these calls being used as part of the evidence.
There were clearly issues in relation to communications at all levels as set out by the jury.
There were obvious errors made by SPA staff in relation to how they search their computer systems to identify individuals.
Together these matters meant that a section 136 suite was not made available to Roberto that should have been and it was possible that this contributed to his death.
The psychiatric liaison nurse did not share the assessment and differential diagnosis made by the A&E doctors with the psychiatric registrar. This was especially poignant in this case as it became clear that Roberto was not intoxicated at the time and was psychotic, rather than his symptoms being due to acute intoxication with drugs and/or alcohol as was assumed by the psychiatric liaison nurse and passed to the psychiatric registrar. The A&E doctor had diagnosed Roberto correctly some hours before his death and medically discharged Roberto. This was recognised by the psychiatric registrar, who is now a consultant, as a point of learning for her and psychiatric liaison.
All witnesses confirmed that there are at times still shortages of section 136 suites and heavy demand from psychiatrically unwell people despite definite improvements in service.
Further that most s136 incidents occur out of hours when there is less resource to manage them from psychiatric services.
Evidence from the psychiatric doctor was that there are severe resource shortages in the area in which she now works with up to 50% of psychiatric nursing staff posts being vacant.
There is now direct access by police on many occasions to section 136 suites within London, a practice that could be adopted nationally, with general improvement in service provision.
Extensive evidence was taken in relation to the window through which Roberto had exited to his death. This window was consistent with building regulations but film has now been applied by Imperial to windows in situations where disturbed persons may be more at risk of smashing them to make these windows more difficult to smash and if they do, then be less likely to shatter and cause lacerations. Matters of Concern
1. That CNWL failed in its duty of candour in relation to provision of evidence in this case.
2. That the evidence given by the SPA witnesses was at times not credible.
3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth.
4. That police officers may need reminding to use the phonetic alphabet and using the word for the month in a person’s date of birth.
5. That CNWL were and may still be unaware that CNWL staff operate outside policy.
6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E as in this case.
7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.
8. That other areas in England could learn from how section 136 suite access has been restructured in London.
9. That the use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate.
10. That there are continued shortages in psychiatric care provision.
Medical Cause of Death
1 a. Multiple Injuries
How, when, where and in what circumstances the deceased came by his death:
Roberto Bottello had been suffering problems with depression, anxiety and panic attacks in the months leading up to his death. On the 25th August 2020 he attended the urgent care centre at Hillingdon Hospital presenting with sleeplessness and visual hallucinations. He was referred to the psychiatric liaison nurse and discharged to be followed up by Addiction Recovery Community Hillingdon (ARCH). This referral was followed by 2 GP referrals and a self referral, He was not seen or assessed by ARCH prior to his death.
Over the 13th and 14th of September 2020, Roberto presented to police officers on 4 occasions, presenting with paranoia. These presentations resulted in 3 Merlin reports of Adult Come to Notice made by police, which were on Roberto’s psychiatric record by 15th September 2020. Roberto’s last contact with his family was a telephone call on 14th September 2020. At around 21:00 on 14th September Roberto’s mother called the Single
Point of Access (SPA) and was advised to report him missing. His parents reported Roberto missing to police at around 10:00 on 15th September 2020, and a missing person report was made.
Roberto came to the attention of police when he was in Berkely Square, London at around 00:10 on 16th September 2020. He was acting in an acutely disturbed manner. Hs body was tense, he was grinding his teeth and largely unresponsive. He had no shirt or shoes on. He began screaming at the sky. The police officers suspected ABD/ excited delirium. Roberto charged at the police officers. One officer pushed him back with an open hand and both officers challenged him with their taser red dot. He then became calm again. Further police officers and an ambulance attended Roberto.
After further agitation, Roberto was placed in handcuffs, place in an ambulance, and then his legs were placed in restraints. He was detained under section 136 of the Mental Health Act (MHA) and was transported to St Mary’s Hospital by ambulance.
At hospital, Roberto remained under guard by 2 police officers. The police liaise with the SPA to try to find a s.136 suite for Roberto. Roberto was medically cleared by 03.20 by the Accident and Emergency (A&E) doctors and he was referred to psychiatric liaison at 03.26. The differential diagnosis at the time of referral to psychiatric liaison was that Roberto was not intoxicated and was experiencing an acute psychotic episode. Roberto was seen by psychiatric liaison at 03.55 and referred to the psychiatrist for a MHA assessment at 04.34. A place was made to defer the MHA assessment until after 09.00. The deferral of the assessment was reasonable based on his presentation and past history as known to the psychiatric team at the time.
Roberto’s identification was unclear to the police in the hospital, the SPA agents and hospital staff. Inadequate steps were taken to identify Roberto until his identity was established by the psychiatric liaison nurse prior to 04.34. Identification details were passed to police at the hospital but there were missed opportunities to clarify his identity, especially in the final call between police and the SPA. The SPA and Hillingdon bed manager made assumptions about his identity.
If a s.136 suite had been made available to Roberto he would have been transferred but there is uncertainty about whether he would have been transferred before the time at which he fell from the window.
The SPA asked police officers to contact bed managers in an attempt to secure a
s.136 suite for Roberto, against the policy at the time that the SPA find the suite.
At the time of the incident that led to his death, Roberto was in cubicle 5 in St Mary’s Hospital. 2 police officers and one emergency departmental lead registrar were with him.
At around 06.00 Roberto began to show agitation again. An A&E nurse was dismissive about his behaviour. At around 06.20 he took his remaining clothes off and also took his medical stickers off. He was spoken to by the police officers who asked him if he wanted to go to the toilet. An officer called a doctor to help who entered cubicle 5 with the officer.
They tried to calm Roberto and talk to him. He became more agitated. A police officer asked him to move back on the bed.
Roberto started rocking on the bed, which was level with the windowsill. He put his foot on the sink and rolled himself backwards and moved himself onto the sill. He kicked the window and broke the glass. He moved himself backwards through the window. He was cut by broken glass as he exited the window. He fell 25 feet to the canal path below.
Roberto’s state of mind at the time, insofar as it may be determined, was that he was psychotic and in a state of agitation. He would not have acted as he did if he had not been psychotic.
After Roberto exited the window, there was a short delay before medical staff reached him because a gate was locked. He was attended by medical staff and the two police officers on the canal path.
As a result of the incident, Roberto suffered injuries:
- cuts, bruises and grazes;
- injuries to his limbs;
- his lift upper limb suffered a large cut and his axillary vein and artery were divided;
- he lost a large amount of blood; and
- both of his lungs collapsed
Roberto was given CPR. He was administered adrenalin and regained a pulse. He was given a bilateral theracostomy. The trauma surgeon was alerted at 06.31. Roberto was transferred from the canal path to the emergency department. He proceeded directly to the surgical department. His blood vessels were clamped. He was given a blood transfusion. He lost circulatory output. He was given further CPR and shocked twice. He had minimal heart function and suffered cardiac arrest. His heart rhythm had become incompatible with life.
Roberto Bottello’s death was announced at 07.27 on 16th September 2020.
Matters which may have possibly caused or contributed to Roberto Bottello’s death:
The following matters may have possibly caused or contributed to Roberto’s death:
Cubicle 5 in which Roberto was placed in hospital was inadequate and unsuitable because it was a rm with windows rather than a designated mental health cubicle, and the bed was next to the windowsill and at the same or similar level. There were no effective measures in place to prevent patients breaking or exiting through the windows, notwithstanding that the windows were compliant with the legal requirements at the time.
There was insufficient communication between various parties involved, including:
- The SPA and police;
- A&E and the psychiatric liaison team;
- Psychiatric liaison team and police;
- Within the psychiatric liaison team;
- The Hillingdon bed manager and the SPA and Central Flow Hub; and
- The Hillingdon bed manager and the police.
The information management systems involved were inefficient and inadequate.
Roberto was not cared for by a Registered Mental Health Nurse (RMN) but was cared for by police officers, who are not mental health specialists. There was insufficient RMN provision at the time. An RMN would have been better placed than police officers to monitor Robert’s mental state, identify any issues such as increased agitation and developing risks.
The confusion of Roberto’s identity with a patient who had just been discharged from Hillingdon and the section 136 suite being made unavailable to him.
The apparent lack of available s.136 suites.
Conclusion of the Jury as to the death:
Roberto Bottello was experiencing an acute psychotic episode. He was detained under
s.136 of the Mental Health Act. he broke the window of his hospital cubicle with his feet and exited the window falling to the canal path below. In doing so, he suffered multiple injuries including cuts from broken glass that divided his axillary vein and artery and led to his death. Extensive evidence was taken during the inquest from multiple live witnesses, written statements, reports, body worn footage and recordings of telephone calls between the police and SPA. Please see the extensive findings made by the jury in this case as set out above.
Of relevance to this report:
It was clear from the evidence that SPA were asking police officers to ring around various s. 136 suite providers to try and find a space for him, against policy at that time.
That a suite was available in Hillingdon that had not been declared as vacant as it should have been against policy.
That this space should have been made available to Roberto and it was not against policy.
This meant that the Central Flow Hub advised the psychiatric liaison nurse that there were no spaces available in London and as such the psychiatric liaison nurse drew up management plans that centred on getting Roberto’s required Mental Health Act assessment undertaken by the psychiatric liaison team, which is often slow and difficult to arrange, rather than having the option to consider transferring him more promptly to a section 136 suite.
That identification assumptions were made by the Hillingdon Bed manager and SPA based solely upon his sex and a similar first name to a person who had been discharged earlier in the day by Hillingdon that the person discharged was Roberto.
This identification assumption could have been easily put aside even with the minimal identification evidence being sought, but staff at Hillingdon, and SPA did not do this. On this basis Roberto was refused a space in Hillingdon against policy, which he should have been allowed access to, even if had been the person with whom he had been confused who had just been discharged.
SPA staff colluded with the actions of the bed manager even though they knew it was against policy.
Simple identification checks that could have been made were not. For example using the international phonetic alphabet in relation to Roberto’s surname in communication between police and SPA staff, and relying on numeric date of birth rather than using the name of the month. Both police and SPA staff did this which caused delay in identification.
The manager of SPA and Central Flow Hub at the time stated that she was completely unaware that staff were acting against training and policy.
The court had experienced immense difficulty in getting evidence from CNWL in relation to the Hillingdon issues despite repeated requests, such that the evidence was not clarified until the last day of evidence and after further directions had been give live in court. This was in my view a failure of the duty of candour by CNWL.
The court was grateful to the current senior manager from CNWL who worked over the weekend to secure the evidence that the court had been requesting for years.
It was also clear to the court and jury that the evidence of SPA witnesses was at times not credible despite recordings of the calls they made and transcripts of these calls being used as part of the evidence.
There were clearly issues in relation to communications at all levels as set out by the jury.
There were obvious errors made by SPA staff in relation to how they search their computer systems to identify individuals.
Together these matters meant that a section 136 suite was not made available to Roberto that should have been and it was possible that this contributed to his death.
The psychiatric liaison nurse did not share the assessment and differential diagnosis made by the A&E doctors with the psychiatric registrar. This was especially poignant in this case as it became clear that Roberto was not intoxicated at the time and was psychotic, rather than his symptoms being due to acute intoxication with drugs and/or alcohol as was assumed by the psychiatric liaison nurse and passed to the psychiatric registrar. The A&E doctor had diagnosed Roberto correctly some hours before his death and medically discharged Roberto. This was recognised by the psychiatric registrar, who is now a consultant, as a point of learning for her and psychiatric liaison.
All witnesses confirmed that there are at times still shortages of section 136 suites and heavy demand from psychiatrically unwell people despite definite improvements in service.
Further that most s136 incidents occur out of hours when there is less resource to manage them from psychiatric services.
Evidence from the psychiatric doctor was that there are severe resource shortages in the area in which she now works with up to 50% of psychiatric nursing staff posts being vacant.
There is now direct access by police on many occasions to section 136 suites within London, a practice that could be adopted nationally, with general improvement in service provision.
Extensive evidence was taken in relation to the window through which Roberto had exited to his death. This window was consistent with building regulations but film has now been applied by Imperial to windows in situations where disturbed persons may be more at risk of smashing them to make these windows more difficult to smash and if they do, then be less likely to shatter and cause lacerations. Matters of Concern
1. That CNWL failed in its duty of candour in relation to provision of evidence in this case.
2. That the evidence given by the SPA witnesses was at times not credible.
3. That SPA call handlers were not sufficiently trained in how to identify patients by using computer searches and by not seeking information appropriately for example by using the international phonetic alphabet and using the word for the month in a person’s date of birth.
4. That police officers may need reminding to use the phonetic alphabet and using the word for the month in a person’s date of birth.
5. That CNWL were and may still be unaware that CNWL staff operate outside policy.
6. That the psychiatric liaison nurses and psychiatric liaison doctors should have regard to and specifically consider diagnoses made by other doctors for example those who see such patients repeatedly in A&E as in this case.
7. That most section 136 usage is out of hours when there is less resource to respond from psychiatric services.
8. That other areas in England could learn from how section 136 suite access has been restructured in London.
9. That the use of film over glass in areas where patients are at increased risk of smashing windows should be more widespread in the NHSE estate.
10. That there are continued shortages in psychiatric care provision.
Copies Sent To
Chief Executive, Imperial Health Care Trust
. IOPC
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