Dear Dr Didcock

Regulation 28 Response: Kenneth Stanley Baylis April 2024

Following the Coronial enquiry into the death of Kenneth Baylis in April 2024, Nottinghamshire Health NHS Trust recognise and accept the further learning identified through the received Regulation 28 report. We offer our sincere condolences to the family of Mr Baylis and extend the offer the family should they have any further questions. Please find below the organisational response to the specific concerns raised –

Matters of concern within the Regulation 28 were identified as follows:

1. Family are not routinely or regularly involved in a patient’s risk assessment, care plan and safety planning.
2. Inadequate suicidal risk assessment and suicide mitigation
3. Lack of compliance with the Trusts Planned Leave policy.
4. Inadequate review and incident investigation following a serious incident.

Following the sad death of Mr Baylis, the MHSOP General Manager and senior leads met with the Kingsley Ward team to commence the reflection and learning process with a subsequent post inquest meeting taking place on the 11/3/24. This included support from the inquest team, inquest witnesses and ward leaders to debrief about the inquest, share the reflections on the day and specifically plan how to address the concerns raised as part of this process.

This report details the actions the Trust has taken in response to these concerns and addresses each one separately to assure that each point has been thoroughly addressed but acknowledging that these actions would be part of a whole care package for someone as part of a risk assessment

29 April 2024

Private and Confidential Dr Didcock

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

and management plan. The actions below build upon the information contained within the inquest statements of , General Manager MHSOP and , Deputy Director of Nursing which were provided in January 2024.

Family is not routinely or regularly involved in a patients risk assessment, care plan and safety planning

The wards within MHSOP have reviewed their processes for involving family members in care and treatment and the following is now routinely in place on all wards:

• Each patient is allocated a named nurse upon admission and the nurse makes a plan with the patient and their family/carers to have no less than weekly contact. This is to ensure that the family is fully involved in discussions about care and treatment, are able to contribute their opinions and are kept up to date. This is audited weekly for all patients and the audit template includes evidence of family contact, involvement in care planning and risk assessment and ensures weekly named nurse sessions are taking place. (Appendix 1) The findings of these audits are collated and presented to the MHSOP Clinical Effectiveness Group and the MHSOP Quality Operational Group for senior review and escalation as appropriate. The outcome of the audit is also discussed with the individual member of staff within their supervision session.

• To support the above, discussions have taken place with staff members about patient consent for involvement of families and carers and a guide to ‘Carers and Confidentiality’ has been discussed in team meetings with staff on the ward. (Appendix 2)

• In addition to this, weekly/fortnightly multi-disciplinary meetings (MDT) take place on each ward and families and carers are routinely invited which is audited on a weekly basis. There is a universal MDT template (Appendix 3) which is used for documenting the meetings and it specifically asks if family members were invited and details their involvement in care and treatment.

• Each Hospital site, Highbury Hospital and Blossomwood (formerly Millbrook unit) have in place monthly carers meetings which are attended by the ward managers which provides an opportunity to receive direct feedback from carers and understand any improvements that are required.

• Kingsley Ward during March 2024 ran a patient and carer survey to ask about involvement in care planning and risk assessment and which they plan to continue to monitor effectiveness of changes made and identify further improvements required. This initial survey has informed the introduction of a collaborative care planning conversation with every newly admitted patient and their relative/carer to all MHSOP ward. This includes a structured conversation to co-produce the care plans for each patient as they are admitted to the in-patient ward.

• Ward community meetings are in place on MHSOP wards which provides an opportunity for patients and carers to provide feedback, and this is attended by the Age UK Worry Catcher service which is commissioned by MHSOP to provide independent advice and informal advocacy for patients on the ward.

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

Inadequate Suicidal Risk Assessment and Suicide Mitigation

One of the risk assessment frameworks utilised across the MHSOP care unit, and currently being introduced to the wider Mental Health Care Group, is the Suicide Assessment Framework E-Tool (SAFETool) – this is a suite of peer reviewed clinical tools to improve quality, consistency and documentation of assessment and response to suicidal patients.

The following description is taken from the 4 Mental Health website:

Used in conjunction with training, SAFETool provides a comprehensive suicide mitigation approach designed to:

• Improve the assessment and documentation of people at risk of suicide and/or self-harm.

• Provide a clear structure for the recording of patient information, to ensure excellent governance.

• Provide effective patient-centred intervention practices and techniques.

• Ensure compassionate engagement, tailored triage assessment, appropriate referral, and student collaboration.

• Support the development of a common language, promoting a more integrated response across statutory services, third sector providers and communities.

• Provides a Safety Plan template which can be co-produced with the patient. This includes patient generated, agreed ways to deal with further distress such as explicit removal or mitigation of means, emotional and social support, telephone and online support, an immediate improvement on current practice.

• Is extensively peer reviewed by international experts in self-harm and suicide prevention, people with lived experience, GPs and third sector experts.

• Offers potential to undertake audit post training, embedding in quality improvement plans.

This tool has been rolled out across all MHSOP wards and requires 1 day training for each member of staff to ensure the tool and its principles are understood used effectively. At the time of the sad death of Mr Baylis this tool was utilised and had been used by members of staff who had undergone the Trust training.

The use of the tool within MHSOP wards and learning from this has been identified and as a result the following changes are taking place:

• All the SAFETool paperwork is now embedded within RIO which is the Trust electronic patient record. This went live on the 25th of October 2023 and is available to all teams. Communication has gone to all staff to ensure that all forms are completed within RIO which ensures the correct procedure is followed and provides an audit trail.

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

• All the staff on Kingsley Ward are undergoing refresher training on the SAFETool and the changes in RIO during May 2024. This will be a full day training for each member of staff and all staff are booked on the training to ensure they will all be trained by 1st June 2024.

• The training will be facilitated by one of the Trusts Clinical Educators for Suicide Prevention who also has an extensive clinical background within MHSOP. The training already incorporates family/carer involvement within risk assessment and care planning, but this has been further strengthened and includes case studies to enable staff to undertake reflection and learning during the training session.

• Use of the SAFETool is not indicated for all patients admitted to the ward and where it is utilised the learning and reflection on the use of the tool will be incorporated into supervision for the member of staff to ensure the training is embedding into practice. Clinical and managerial supervision takes place monthly for staff members and provides support to staff from a named senior/experienced clinician to promote reflection, learning and development within clinical practice. Kingsley Ward supervision compliance is consistently within Trust targets and all staff have yearly mandated training from the Trust in clinical supervision to ensure this is being carried out effectively. Staff on Kingsley Ward are all currently up to date on their mandated clinical supervision training.

• Adherence to training and supervision compliance is routinely monitored by senior managers within MHSOP, and the Mental Health Care Group and any non-compliance is identified, and an action plan put in place.

• Suicide prevention and self-harm training is provided, overseen and evaluated by the Trust Lead for Self-harm and Suicide Prevention and the suicide prevention training team to ensure quality and consistency of training. The Suicide Prevention team also work with clinical teams to support implementation. This was reviewed and enhanced in early 2024, to provide assurance re quality and oversight, and include updated self-harm awareness and response training in addition to suicide prevention awareness and response training for consistent language, content and approach.

Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and literature. The Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with NHSE and other leaders in suicide prevention to scope how other Trust’s have implemented this to inform Nottinghamshire Healthcare’s continued work. Updated guidance is reflected in the Trust’s new Clinical Risk and Safety Policy (due to be ratified in May 2024) and guidance documents relating to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self- harm have been developed. Audits, and risk and safety forms within healthcare records are being reviewed and updated to ensure that these support improvement.

Lack of Compliance with the Trusts Planned Leave Policy

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

All wards have been supported to further review the Trust planned leave policy within team meetings and individual supervision. In addition, all staff were asked to read the policy again and sign to say that this has been read and understood. To ensure this is being routinely followed a door board/Leave record has been put in place which has detail of each planned leave. Every time a patient leaves the ward on planned leave the following is entered: date and time of planned leave, actual time left/returned to the ward, member of staff facilitating leave, what the patient was wearing, presentation of patient prior and post leave and destination of leave. This door board/leave record is audited to ensure it is being completed fully.

Discussion regarding planned leave takes place within the MDT at which the family/carer is invited and named nurse discussions during the time before MDT are considered if the family cannot be present.

Inadequate Review and Incident Investigation Following a Serious Incident

The guidance for what constitutes the requirement to complete an IR1 and for a serious incident has been shared and discussed via team and business meetings and within this has incorporated the discussions regarding the implications of not doing this. An audit was completed during December 2023 to confirm that serious incidents are being recognised and reported by the community teams in MHSOP.

MHSOP have regular Time Out sessions with teams and in the session on the 22nd of March 2024 had a dedicated agenda item which covered learning and reflections from this quality improvement plan which included the learning about IR1s. Senior managers do regularly receive IR1s from all teams within MHSOP including ward and community teams. Following completion of an IR1 a manager is identified to complete an IR2 which reviews the incident and any learning that is identified from it. Senior managers receive monthly reports which indicate if the IR2s have been completed and ensure none have been missed and in addition learning from incidents is included within management and clinical supervision which occurs monthly for each member of staff. Detailed discussion of serious incidents within the care unit is held in the MHSOP Health, Safety and Risk meeting and thematic review of serious incidents is completed via the MHSOP Quality Assurance and Improvement forum. These forums facilitate discussion and review across services and are Chaired by the Care Unit senior management team. The MHSOP care unit has a Learning the lessons bulletin which is shared across all services and teams to disseminate learning from serious incidents – this bulletin is featured on the agenda for the MHSOP Quality Operational Group and is disseminated across all service and team meetings to encourage active reporting and learning from incidents.

To ensure that Serious Incident Investigators understand the requirement for staff interviews as part of the investigation each investigator is emailed when the investigation is allocated to ensure they are informed of this requirement, this is included in a standard email template to ensure consistent communication. The MHSOP Clinical Governance team maintain contact and act as a point of reference for the investigation panel and will oversee this as a consistent practice. Upon completion and approval of the Serious Incident investigation the final report is shared with the relevant service and team/ward manager so that they can discuss in detail with their team. The support in sharing lessons learnt is tailored dependent on the incident and could include reflective discussions to team time out sessions to ensure the correct level of learning is undertaken. The MHSOP Clinical

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

Governance team will also ensure that all witnesses who have been part of the investigation receive both a copy of the investigation report but are also supported with any learning reflections as part of this process.

The Mental Health Care Group, of which MHSOP is part of, is introducing a new governance structure which includes a standardised template for ward and community meetings and within this data on incidents will be included and discussions take place within the team to reflect on the incidents to ascertain whether there is any learning and improvements required. This is currently being piloted within the Care Group and is due to go live across all MHSOP wards during June 2024.

The Trust is in the process of moving towards the Patient Safety Incident Response Framework. (PSIRF) It represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS and is also a key part of the NHS patient safety strategy. This new framework replaces the SI Framework and makes no distinction between ‘patient safety incidents’ and ‘Serious Incidents’ and so it removes the SI classification and the threshold for it.

PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and promotes a proportionate response to patient safety incidents with a focus on learning and improvement.

To date the trust has completed the PSIRF policy and PSIRP (patient safety incident response plan), which sets out the local priorities for the next year. As part of the development of the PSIRP the trust met and consulted with a number of stakeholders; commissioners, service users, clinical staff and services and continue to do so.

The Patient Safety Team has been enhanced to provide greater governance, expertise and resource to assist in the transition and embedding of PSIRF. A clear communication plan is in development and will be implemented as part of the transition. Training has been commissioned for May by an approved external provider.The Trust transitioned from National Report Learning System (NRLS) to Learning from Patient Safety Events (LFPSE) in October 2023. PSIRF will be in place across the Trust by August 2024.

I hope that the information contained within this response provides reassurance to your and Mr Baylis family that we as a Trust have heard and understood the significant concerns raised because of this inquest and that we are committed to making these important improvements to services and processes for future patient care.