Sharon Halliwell
PFD Report
All Responded
Ref: 2017-0319
All 1 response received
· Deadline: 28 Jan 2018
Response Status
Responses
1 of 1
56-Day Deadline
28 Jan 2018
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
Whilst other issues addressed in evidence had been addressed by the Trust the issue of lack of connectivity as described had not been fully addressed.
Responses
Response received
View full response
Dear Ms Leeming
Re: Sharon Ann Halliwell (deceased)
Thank you for your letter of 4 August 2017, received on 8 August 2017, regarding the concerns you raised following the inquest into the death Sharon Ann Halliwell, which was heard on 31 July 2017.
You expressed concern that there was a lack of connectivity between two electronic care systems employed by the Trust, known as RiO and IAPTUS. These systems are used by the clinical teams to record service user records in line with the Trust’s record keeping policy. During the inquest you identified that there was a gap between these two systems, meaning that information obtained from a service user during triage by the mental health nurses may not be available to the another nurse when completing a further assessment several days later.
I acknowledge this concern and can now advise you of the actions which have been undertaken in this regard.
A “theme of the week” communication has been shared across the organisation to ensure that this learning is embedded. These themes are generated from learning identified from incidents, near misses and complaints and are disseminated to all staff each week in the Trust’s e-bulletin, which is called In View. To ensure all staff are made aware of the learning identified, the topics highlighted in this way also form part of the agenda at local Team Meetings as part of the Core Brief to all staff. The Assistant Clinical Directors for each of the Boroughs will seek assurance that this has been raised with each of the clinical teams across the organisation as they occur across Our Ref: INQ/17/686 Your ref: MJL/YD/1470-2017
29 September 2017
M Jennifer Leeming HM Senior Coroner HM Coroner’s Court Paderborn House Howell Croft North Bolton BL1 1QY
Chief Executive’s Office Hollins Park House Hollins Park Hollins Lane Warrington WA2 8WA
Tel: 01925 664001 Fax: 01925 664052 Email:
5 Boroughs Partnership NHS Foundation Trust has changed its name to North West Boroughs Healthcare NHS Foundation Trust Chairman: Helen Bellairs Chief Executive: Simon Barber Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Switchboard: 01925 664000
October 2017. IAPT staff have also received RiO training to enable them to check for key clinical activity.
The RiO and IAPTUS patient information systems are not integrated and due to their composition it is not possible to wholly integrate them into one electronic care record. However, there is the option of applying a ‘flag’ system to the record of both RiO and IAPTUS which would alert the clinician that a service user is open to care from another team within the Trust. This function is currently being developed by the Trust’s Information Technology team who are aiming to have a solution designed, built, tested and implemented by the end of March 2018.
In addition to this, the Trust will amend all appropriate Standard Operating Procedures by March 2018 to ensure that where clinicians identify a red flag alert, they contact the relevant clinical team and ensure that they have all the clinical information they require in relation to risk and ongoing treatment plans.
Finally, as not all of the IAPT team services within the Trust’s footprint are provided by North West Boroughs Healthcare NHS Foundation Trust there needs to be an additional mechanism in these areas for clinicians. In this respect, these clinicians will be made aware of the ‘theme of the week’ learning, and to ask all patients if they are receiving any support for their mental health needs from any other agency. This action will also be added to the Standard Operating Procedures as above and monitored for compliance via the usual monitoring arrangements.
If I can be of any further assistance, or if you require further information, please do not hesitate to contact me.
Re: Sharon Ann Halliwell (deceased)
Thank you for your letter of 4 August 2017, received on 8 August 2017, regarding the concerns you raised following the inquest into the death Sharon Ann Halliwell, which was heard on 31 July 2017.
You expressed concern that there was a lack of connectivity between two electronic care systems employed by the Trust, known as RiO and IAPTUS. These systems are used by the clinical teams to record service user records in line with the Trust’s record keeping policy. During the inquest you identified that there was a gap between these two systems, meaning that information obtained from a service user during triage by the mental health nurses may not be available to the another nurse when completing a further assessment several days later.
I acknowledge this concern and can now advise you of the actions which have been undertaken in this regard.
A “theme of the week” communication has been shared across the organisation to ensure that this learning is embedded. These themes are generated from learning identified from incidents, near misses and complaints and are disseminated to all staff each week in the Trust’s e-bulletin, which is called In View. To ensure all staff are made aware of the learning identified, the topics highlighted in this way also form part of the agenda at local Team Meetings as part of the Core Brief to all staff. The Assistant Clinical Directors for each of the Boroughs will seek assurance that this has been raised with each of the clinical teams across the organisation as they occur across Our Ref: INQ/17/686 Your ref: MJL/YD/1470-2017
29 September 2017
M Jennifer Leeming HM Senior Coroner HM Coroner’s Court Paderborn House Howell Croft North Bolton BL1 1QY
Chief Executive’s Office Hollins Park House Hollins Park Hollins Lane Warrington WA2 8WA
Tel: 01925 664001 Fax: 01925 664052 Email:
5 Boroughs Partnership NHS Foundation Trust has changed its name to North West Boroughs Healthcare NHS Foundation Trust Chairman: Helen Bellairs Chief Executive: Simon Barber Trust Headquarters, Hollins Park House, Hollins Lane, Winwick, Warrington, WA2 8WA Switchboard: 01925 664000
October 2017. IAPT staff have also received RiO training to enable them to check for key clinical activity.
The RiO and IAPTUS patient information systems are not integrated and due to their composition it is not possible to wholly integrate them into one electronic care record. However, there is the option of applying a ‘flag’ system to the record of both RiO and IAPTUS which would alert the clinician that a service user is open to care from another team within the Trust. This function is currently being developed by the Trust’s Information Technology team who are aiming to have a solution designed, built, tested and implemented by the end of March 2018.
In addition to this, the Trust will amend all appropriate Standard Operating Procedures by March 2018 to ensure that where clinicians identify a red flag alert, they contact the relevant clinical team and ensure that they have all the clinical information they require in relation to risk and ongoing treatment plans.
Finally, as not all of the IAPT team services within the Trust’s footprint are provided by North West Boroughs Healthcare NHS Foundation Trust there needs to be an additional mechanism in these areas for clinicians. In this respect, these clinicians will be made aware of the ‘theme of the week’ learning, and to ask all patients if they are receiving any support for their mental health needs from any other agency. This action will also be added to the Standard Operating Procedures as above and monitored for compliance via the usual monitoring arrangements.
If I can be of any further assistance, or if you require further information, please do not hesitate to contact me.
Report Sections
Investigation and Inquest
On the 24th April 2017 I commenced an investigation into the death of Sharon Ann Halliwell, 48 years, born 28th February 1969. The investigation concluded at the end of the Inquest on 31st July 2017.
The medical cause of death was:-
Suspension by Ligature
The conclusion of the Inquest was Suicide.
CIRCUMSTANCES OF THE DEATH
On the 18th of April 2017 Sharon Ann Halliwell was found deceased at her home address at . The cause of her death was determined to be suspension by ligature. On the 7th of February 2017 she had been triaged at the Improving Access to Psychological Therapies Service and had given information that indicated that she was at risk of suicide. On the 18th of February 2017 she had a mental health assessment that indicated that she had been at high risk of suicide during the preceding two weeks. It was determined that she should be referred to a psychiatrist, but the referral was not made. Particularly, although both the triage and the mental health assessment were carried out by departments of the North West Boroughs Healthcare NHS Foundation Trust there was a lack of connectivity, described in the Inquest as “a gap” between the systems of the two services which meant that the information obtained at the triage on the 7th of February 2017 was not accessed by the nurse carrying out the assessment on the 18th of February.
The medical cause of death was:-
Suspension by Ligature
The conclusion of the Inquest was Suicide.
CIRCUMSTANCES OF THE DEATH
On the 18th of April 2017 Sharon Ann Halliwell was found deceased at her home address at . The cause of her death was determined to be suspension by ligature. On the 7th of February 2017 she had been triaged at the Improving Access to Psychological Therapies Service and had given information that indicated that she was at risk of suicide. On the 18th of February 2017 she had a mental health assessment that indicated that she had been at high risk of suicide during the preceding two weeks. It was determined that she should be referred to a psychiatrist, but the referral was not made. Particularly, although both the triage and the mental health assessment were carried out by departments of the North West Boroughs Healthcare NHS Foundation Trust there was a lack of connectivity, described in the Inquest as “a gap” between the systems of the two services which meant that the information obtained at the triage on the 7th of February 2017 was not accessed by the nurse carrying out the assessment on the 18th of February.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.