Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Lauren Elizabeth Bridges who died on 26 February 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 September 2023 concerning the death of Lauren Elizabeth Bridges on 26 February
2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Lauren’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Lauren’s care have been listened to and reflected upon.

In your Report you raised concerns over underfunding of local mental health beds and the mental health impact of Out of Area (OAP) placements and an over-reliance by the NHS on independent providers. You also raised the issue of inadequate and insufficient communication between the Trust, independent provider and other relevant parties, the challenges that can be posed by having separate NHS commissioning bodies, and the need for protocols/standardised operating procedures to avoid delayed discharge from OAPs/Psychiatric Intensive Care Units (PICUs).

The NHS remains committed to eliminating the practice of adult acute Out of Area Placements. All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England’s 2023/24 Priorities and Operational Planning Guidance. An ICB is a statutory NHS organisation which is responsible for developing a plan for meeting the health needs of the population, managing the NHS budget, and arranging for the provision of health services within a given geographical area. They replace clinical commissioning groups (CCGs), taking on the NHS planning functions previously held by CCGs, as well as absorbing some planning roles from NHS England. While good progress was being made ahead of the Covid-19 pandemic in eliminating the practice of OAPs, the subsequent increase in prevalence of mental health problems against the backdrop of an existing treatment gap has made this even more difficult. Further, while the level of NHS investment in mental health services is higher than ever before and investment targets are being met nationally, pressures on both community and inpatient services remain very high. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

9 November 2023

In July 2023 NHS England published renewed guidance to support the commissioning and delivery of timely access to high quality therapeutic inpatient care, close to home and in the least restrictive setting possible. Key to this are the principles of: timely and purposeful admissions that are local, timely discharge, joined-up care and continuous improvement. To implement this, all ICBs have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the Independent Sector, as part of the mental health, learning disability and autism inpatient quality transformation programme launched in 2022. Health and Care systems across England are currently being supported to operationalise the guidance via 3-year plans with direct support from regional and national teams. The transformation programme is underpinned by a £36 million investment. NHS England recognises the critical importance of strong commissioner oversight and joint working in inpatient mental health care, and as such has made it a requirement that these 3-year plans be co-produced – including with patients, families and their carers. We are also currently engaging on how the roles and responsibilities for commissioning and assuring the quality of mental health, learning disabilities and autism inpatient care across the NHS and the independent sector can be strengthened, with a view to embed learnings and best practice in National Quality Board policy and governance frameworks from 2024 onwards. My regional colleagues in charge of quality of care in the South West have also engaged with Dorset Healthcare University NHS Foundation Trust (‘the Trust’) on the matters raised in your Report. The Trust have acknowledged that there were missed opportunities in Lauren’s care, and I understand have written to Lauren’s family separately to express their regret. They have also provided NHS England with assurances that actions have been taken to address the identified learnings. These actions have included:

• Reviewing all standard operating procedures
• Improving the way we engage and communicate with providers and families
• Better care co-ordination and involvement of local teams to address our patient’s clinical needs and plans for repatriation.
• Improved data and oversight including regular auditing of care arrangements.
• Appointment of an out of area co-ordinator and a programme of quality assurance of providers used by the Trust.

The Trust advises that the work is resulting in improvements and a reduction in the time patients are receiving care outside of area, where there is no clinical need. They have also secured planning permission to rebuild some of their mental health inpatient facilities and increase the availability of PICU for adults and younger people. Subject to business cases and plans being agreed, they hope to have new facilities in 2026. In the shorter term they have also taken the opportunity of using winter monies to create a discharge and flow team for mental health and have recently appointed a Consultant Psychiatrist to provide clinical leadership to this team.

The Trust now has a formal arrangement with Marchwood Priority in Southampton, for those occasions where an OAP may still be required based on clinical need and due to capacity. Marchwood Priory is geographically one of the closest providers to Dorset, which hopefully improves the chances of families being able to visit and maintain contact.

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.

Dear Mr Bridgman,

Re Regulation 28 Report following the inquest touching on the death of Lauren Bridges

We acknowledge receipt of the Regulation 28 Report issued to Dorset HealthCare University NHS Foundation Trust following the inquest touching on the death of Lauren Bridges. The report, dated 19th September 2023, was received by Dorset HealthCare on 24th November 2023, following contact with your office.

Our thoughts are with Lauren’s family following their loss and we are truly sorry for the circumstances in which Lauren died.

After Lauren died, we undertook a review of the care and support offered and we have made changes to the way in which we support our patients who are receiving care out of area.

In respect of the specific regulation 28 matters of concern notified to the Trust, I will respond to these in turn:

a) The omission to update the Hospital Overview timeously and correctly.

In respect of the Hospital Overview document, we have made a number of changes and improvements to ensure that this is updated in a timely and correct way. The changes we have made are detailed below:

1. The Trust has undertaken a comprehensive review to ensure that all patients who are receiving acute care funded by the Trust in Out of Area beds are accurately identified as such on our clinical system.

2. We have enhanced the daily Hospital Overview situation report which is accurate at the point it is sent, with the purpose of providing a summary at the start of the working day across the organisation to key colleagues including senior clinicians and managers. The information contained in the daily Hospital Overview template is updated manually by the night practitioners from data contained in the clinical system. It is then checked by both the Out of

Andrew Bridgman Assistant Coroner South Manchester area

Corporate Office Sentinel House Nuffield Industrial Estate 4-6 Nuffield Road Poole, Dorset BH17 0RB

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Area Co-Ordinator and the Clinical Site Managers, who are clinicians who are overseeing bed flow decisions, to ensure that the information contained in this document is correct for that point in time. The Hospital Overview is then emailed to key colleagues to provide a summary of the bed state every 24 hours.

3. In addition, the Trust has also added a specific section to the daily Hospital Overview template showing patients who are in out of area beds who require repatriation to a local bed. This ensures that Clinical Site Managers are taking these patients into account when making daily decisions on bed allocations.

4. We have also made improvements to our automated reporting. We have updated the electronic admission form template that is embedded in the patient record system so that when a patient requires admission, we capture more robust information, which is then also reportable in a bed state automated report. This automated report provides additional information in respect of patients in excess of the Hospital Overview document, for example a list of names and length of stay for every patient admitted to hospital, to an out of area bed, and those awaiting admission. This more detailed information is used by clinicians directly involved in bed flow and inpatient care to support their daily work.

b) It can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place.

In respect of this matter of concern, I have focused our response on actions we have taken to improve the oversight, routine review, and documentation in respect of admission and / or repatriation decisions including for patients whose inpatient care is provided out of area:

1. The Trust has implemented a new Standard Operating Procedure (SOP) for Enabling Purposeful Admissions. This clearly sets out the required process, roles and responsibilities of key staff and the required recording in respect of inpatient flow decisions. This SOP has been communicated to staff and included on our staff intranet.

2. We have reviewed our daily clinical meeting that takes place in respect of bed flow and set out requirements in the meeting's terms of reference, including standard items for discussion and recording standards. These terms of reference are included within the Enabling Purposeful Admissions SOP.

3. As referred to during the inquest, we have appointed a dedicated Out of Area Coordinator post, which is a clinical post. We have also written and implemented a SOP for the ‘Use of Out of Area Acute and Psychiatric Intensive Care (PICU) Mental Health Inpatient beds: Therapeutic inpatient care and proactive discharge planning’. The SOP includes standards to be met in respect of regular contact and recording of that contact with patients who are out of area, and their families / carers, as well as with clinicians working in out of area providers overseeing that care.

4. Clinical Site Managers now use a live Microsoft Teams channel for communicating updates between them on requirements around bed flow, which is linked to patient electronic records. This replaces previous paper handover records and ensures that there is documentation of bed flow discussions and decisions, for example, if there are moves of patients between wards in order to create bed capacity in a specific ward to facilitate an admission, that this is

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appropriately communicated between Clinical Site Managers. This supports better handover between Clinical Site Managers coming onto a shift, so they can understand the status of pending admissions and decisions taken in the previous shift. In addition, discussions regarding individual patients are also recorded in the patient's own electronic patient record (known as RiO) to ensure a complete up to date record for each individual patient.

5. A regular audit takes place every month involving reviewing the records of all patients receiving their care out of area against the standards set out within the SOP. This audit is undertaken by our Nursing and Quality Directorate and will remain ongoing. Audit standards include evidence of OOA coordinator input, date of last input, that the patient has an allocated Care Coordinator, date of last input from them, date of last contact with patient and family, date of Care Programme Approach meeting, date of last clinician attendance at a multi- disciplinary team review, and whether there is a discharge / repatriation plan. I can confirm that all of the actions detailed have been completed and ongoing assurance where required is monitored via the monthly audit. We hope we have provided assurances that Dorset HealthCare has addressed the areas identified in the Regulation 28 Report and that we have taken the matter extremely seriously. The DHC Board are sighted on the significance of the Regulation 28 Report. We will continue to report our progress to both our Board and NHS Dorset Integrated Care Board so there is clear visibility of the service improvements being made.

We are now confident that the circumstances for Lauren would not be repeated, which we hope will bring some comfort to Lauren’s family. We are also keen to reiterate our sorrow for the circumstances in which Lauren sadly died.

Dear Mr Bridgman,

Thank you for your Regulation 28 report to prevent future deaths dated 19 September 2023 about the death of Lauren Elizabeth Bridges. I am replying as the Minister with responsibility for mental health and patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Lauren’s death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter.

Your report raises concerns about delayed discharges from out of area placements in independent mental health inpatient settings.

In preparing this response, Departmental officials have made enquiries with NHS England and I understand that NHS England and Dorset Healthcare University NHS Foundation Trust have each already carefully considered the matters of concern in your report and have provided you with comprehensive responses setting out the actions being taken to improve care quality and patient safety.

The Department recognises that it is important that those who require inpatient care are treated as close to home as possible, which is why we publicly committed to eliminating all inappropriate acute out of area placements by 2020/21.  Unfortunately, COVID-19-related pressures contributed to services missing that target. These pressures were caused by a number of factors, including bed closures due to the need for infection control; reduced community networks; staff absences; and higher levels of demand for NHS mental health services. However, I would like to assure you that that we remain committed to eliminating all inappropriate acute out of area placements for adults aged 18 and over.  

All systems that still have inappropriate out of area placements have been required to refresh their local plans to ensure these placements are eliminated everywhere as soon as reasonably possible. NHS England continues to work with the worst performing areas and support them to improve and we are working with NHS England to ensure that systems prioritise this, including a focus on discharge and flow.  

To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, reducing bed occupancy.

The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)

More widely, through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, expanding community mental health services to reduce reliance on inpatient treatment, so that patients are supported to stay well in their communities. This major expansion in funding for community mental health services commenced in all areas in 2021/22 and has been key to managing pressures on beds. 

Turning to your concerns around an over-reliance by the NHS on independent providers for mental health beds, private companies have always played a role in the NHS and patients should expect a safe and good quality service regardless of whether their care is delivered by independent sector or public sector providers.  As set out in NHS England’s response to your report, all integrated care boards have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the Independent Sector, as part of NHS England’s mental health, learning disability and autism inpatient quality transformation programme.

I hope this response is helpful. Thank you for bringing these concerns to my attention.