Locket Williams
PFD Report
All Responded
Ref: 2024-0543
All 1 response received
· Deadline: 9 Dec 2024
Response Status
Responses
1 of 1
56-Day Deadline
9 Dec 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
Coroner’s Concerns
The evidence received at the prevention of future deaths hearing showed that a number of the issues and concerns raised at and following the inquest hearing have been addressed.
However, in my opinion the following concerns remain and give rise to a continuing risk that future deaths could occur unless action is taken. Concern 1
The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all. At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening, (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time, and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care.
Concern 2
On the basis of the evidence I heard at the inquest hearing, I found that Locket’s death was contributed to by the Trust’s underestimation of their risk of suicide.
At the prevention of future deaths hearing, I was told that the Trust has introduced a new risk assessment system. The new system is in accordance with NICE guidelines and relies on a fuller description of the nature and level of the risk rather than its classification as low, medium, or high.
It is clear from the evidence that there is good reason to move away from the three-tier classification, but I am concerned that the new system does not include any clear and obvious alert, on the medical records, that there is a risk of suicide in relation to the child in question. Although the intention of the new system is to encourage each clinician to read the narrative of the fuller risk assessment, there is currently a risk that, if they do not do so (and it is foreseeable that they will not always do so or be able to do so), they will be unaware of the risk of suicide.
It was accepted in the evidence that an alert for a risk of suicide could be included in a child’s record without undermining the move away from the three-tier classification of that risk as low, medium or high.
Concern 3
I also heard that a child at risk of suicide may now be provided with a document, called “My Safety Plan”, one purpose of which is to help the child to communicate with others (including for example family members, teachers, and social workers) about their condition and risk. I was told that, if a child does not want to refer in the document to the risk of suicide, other terms such as “distress” may be used.
To the extent that part of the purpose of the My Safety Plan is to enable the child to communicate their risk of suicide and thereby receive help to stay safe, I am concerned that by substituting the word “distress” for “suicide”, some plans may not refer to suicide and may not therefore ensure that the nature of the risk is clearly conveyed to those from whom the child may seek support, and to the responsible adults in their life.
Concern 4
From the evidence I heard at the inquest hearing, it was apparent that staff within CAMHS did not always attend or engage with Core Group Meetings to which they were invited by children’s services.
At the prevention of future deaths hearing, it was accepted that, for those children under Children’s Services, active involvement in Core Group Meetings by all agencies involved with the child was of real importance. This was so, because the meetings were the means by which information was shared by different agencies and an informed plan was made to protect the child’s life (including from suicide) and welfare. Failure by Trust staff to attend or otherwise to engage with the meetings, and the other agencies involved with the child, may therefore raise the risk to the child and undermine their protection.
I was also told that there is an expectation that Trust staff should prioritise attendance / involvement in Core Group Meetings but, it seems, that no monitoring takes place to assess compliance with that expectation, including no systematic recording of the receipt of invitations to attend Core Group Meetings and no systematic recording of the response by the staff who have been invited, or otherwise.
However, in my opinion the following concerns remain and give rise to a continuing risk that future deaths could occur unless action is taken. Concern 1
The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all. At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening, (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time, and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care.
Concern 2
On the basis of the evidence I heard at the inquest hearing, I found that Locket’s death was contributed to by the Trust’s underestimation of their risk of suicide.
At the prevention of future deaths hearing, I was told that the Trust has introduced a new risk assessment system. The new system is in accordance with NICE guidelines and relies on a fuller description of the nature and level of the risk rather than its classification as low, medium, or high.
It is clear from the evidence that there is good reason to move away from the three-tier classification, but I am concerned that the new system does not include any clear and obvious alert, on the medical records, that there is a risk of suicide in relation to the child in question. Although the intention of the new system is to encourage each clinician to read the narrative of the fuller risk assessment, there is currently a risk that, if they do not do so (and it is foreseeable that they will not always do so or be able to do so), they will be unaware of the risk of suicide.
It was accepted in the evidence that an alert for a risk of suicide could be included in a child’s record without undermining the move away from the three-tier classification of that risk as low, medium or high.
Concern 3
I also heard that a child at risk of suicide may now be provided with a document, called “My Safety Plan”, one purpose of which is to help the child to communicate with others (including for example family members, teachers, and social workers) about their condition and risk. I was told that, if a child does not want to refer in the document to the risk of suicide, other terms such as “distress” may be used.
To the extent that part of the purpose of the My Safety Plan is to enable the child to communicate their risk of suicide and thereby receive help to stay safe, I am concerned that by substituting the word “distress” for “suicide”, some plans may not refer to suicide and may not therefore ensure that the nature of the risk is clearly conveyed to those from whom the child may seek support, and to the responsible adults in their life.
Concern 4
From the evidence I heard at the inquest hearing, it was apparent that staff within CAMHS did not always attend or engage with Core Group Meetings to which they were invited by children’s services.
At the prevention of future deaths hearing, it was accepted that, for those children under Children’s Services, active involvement in Core Group Meetings by all agencies involved with the child was of real importance. This was so, because the meetings were the means by which information was shared by different agencies and an informed plan was made to protect the child’s life (including from suicide) and welfare. Failure by Trust staff to attend or otherwise to engage with the meetings, and the other agencies involved with the child, may therefore raise the risk to the child and undermine their protection.
I was also told that there is an expectation that Trust staff should prioritise attendance / involvement in Core Group Meetings but, it seems, that no monitoring takes place to assess compliance with that expectation, including no systematic recording of the receipt of invitations to attend Core Group Meetings and no systematic recording of the response by the staff who have been invited, or otherwise.
Responses
The Trust opened Emerald Place in March 2024, a new inpatient unit with sufficient bed capacity for General Adolescent Unit needs in Surrey, and is currently accessing beds via independent providers while admissions are temporarily paused. They have also emphasized the importance of engaging with Core Group Meetings to managers and requested Children’s Services to copy invitations to their central Safeguarding team for better oversight.
AI summary
View full response
Dear Mr Travers
Locket Ure Williams (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”)
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 14 October 2024, in relation to the inquest touching upon the death of Locket Ure Williams. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues.
I have addressed each of your concerns in turn below.
1. Inpatient mental health beds for children in Surrey Typically, 6-8 General Adolescent Unit inpatient beds are required at any given time within Surrey. Emerald Place was opened by the Trust in partnership with a private provider, Elysium Healthcare, in March 2024. Emerald Place has sufficient bed capacity to meet the demand for GAU inpatient beds within Surrey.
In line with best practice for a new service, admissions have been staggered to allow the new team to develop and embed a safe and therapeutic culture on the ward. As part of our ongoing quality review process, a decision was made to pause further admissions. The Surrey Heartlands CAMHS Tier 4 Provider Collaborative is working at pace with NHS England, Elysium Healthcare and the Trust to support quality improvements at the unit with a current expectation that the unit can resume admissions from January 2025. In the meantime, the Trust is accessing GAU beds through independent providers.
5 December 2024
Private and Confidential
2. System alerts for risk relating to suicide
It is recognised that risk prediction in suicide has been shown repeatedly to be ineffective1. As recognised in your letter to us, the Trust has recently revised its risk assessment approach to align with NICE Guidelines2 and NHS England’s recommendations. This approach emphasises addressing patient needs rather than predicting future risk through the previously used ‘low/medium/high’ categorisation.
Risks are identified and mitigated through a comprehensive risk reduction plan, tailored to the individual, and incorporated into every risk assessment and formulation. The needs-based, patient- centred methodology provides a robust, evidence-based approach to managing risks which complies with national guidance. The suggested binary ‘suicidal/not suicidal’ flag system would force clinicians into an overly simplistic model of risk prediction inconsistent with the nuanced and individualised approach recommended by NICE and now implemented by the Trust. As a result, and having carefully considered this, we will not be introducing a binary flag system.
The Trust’s risk assessment process is designed on the basis that clinicians are acting in accordance with their professional and regulatory responsibilities. As per the NHS Constitution for England3, our staff have a duty to accept professional accountability and maintain the standards of professional practice as set by the appropriate regulatory body applicable to their profession or role. The Trust works in accordance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 20144 in deploying suitably qualified, competent, skilled and experienced persons and ensuring that they receive support, training, professional development, supervision and appraisal.
Through induction and training processes, all staff are aware that our Electronic Patient Record, SystmOne is the single source of all written information and that the risk formulation, care plan, and My Safety Plan must all be kept up to date and stored in specific locations of the patient record so that they are readily available. The MDT process enables clinicians to seek additional support, guidance or reflection where these are required to enable them to properly assess and manage risk.
All of the above are core activities and expectations for all of our clinicians. During clinical supervision, managers review sample cases with each clinician to support effective risk management and clinical reflection.
3. My Safety Plan
My Safety Plan is not a tool for assessing or recording risk of suicide. The document is not written in clinical terms, and it not intended to be a means of sharing information about risk between organisations. Instead, formal documentation of clinical risk (including clear and correct clinical terminology around suicide) is recorded in the Risk Formulation and Care Plan documents which, along with My Safety Plan, form an interlinked suite of documents which are held within a person’s Electronic Patient Record.
Clinical risk information is shared with the network around the child including their school and Children’s Services. Information sharing and safeguarding procedures ensure that relevant clinical information including around risk of suicide is shared with other organisations where appropriate regardless of whether a child or young person decides to share their My Safety Plan.
1 Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation and risk management, Hawton et al, The Lancet, published 8 August 2022 2 NICE Guidance NG225 Overview | Self-harm: assessment, management and preventing recurrence | Guidance | NICE 28056 3 The NHS Constitution for England - GOV.UK 4 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Designed in collaboration with Surrey County Council’s Consulting Youth Advisers team, My Safety Plan empowers a child or young person to communicate with the network around them about their concerns or triggers. A child or young person is encouraged to use their own choice of words within their My Safety Plan to express how they are feeling, enabling them take ownership of this document. The document is compiled in discussion between the clinician and the child or young person and their family/carer, primarily for the child or young person to hold, and to share with adults around them, if and when they choose. Equally, they may choose not to share it at all. We might share it on their behalf if we are given consent or are requested to do so.
It is also incumbent on other agencies around the child or young person to raise concerns of suicidality, for example, teachers and social workers must independently assess their level of concern and seek advice or link with Trust services if they feel this is necessary.
4. Core Group Meetings Attendance at Core Group meetings in respect of those supported by Children’s Services is mandatory. There is also an expectation that clinicians contribute to other safeguarding meetings, and local authority reviews of Education Health and Care Plans (“EHCP”). The Standard Operating Procedure (“SOP”) for our community teams requires that Care Plans include actions flowing from these meetings. Care Plans are recorded on SystmOne and accessible to any Trust clinician involved in the care of the child or young person.
This was discussed at the monthly divisional Quality Operations Board on 19 November 2024 attended by managers and senior clinicians where the importance of engagement with Core Group Meetings was emphasised. Managers were tasked with cascading this to their teams and confirmation that this has been actioned will be provided to the Quality Operations Board.
The Trust is only able to monitor responses to invitations that are received and we are reliant on those invites being sent to us in a timely manner to enable arrangements for attendance to be made. We have therefore requested that Children’s Services copy each invite into our central Safeguarding team in order to have a greater oversight of these invitations and our responses/attendance.
On behalf of the Trust, I would like to offer our sincere condolences to Locket’s family for their loss.
Locket Ure Williams (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”)
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 14 October 2024, in relation to the inquest touching upon the death of Locket Ure Williams. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues.
I have addressed each of your concerns in turn below.
1. Inpatient mental health beds for children in Surrey Typically, 6-8 General Adolescent Unit inpatient beds are required at any given time within Surrey. Emerald Place was opened by the Trust in partnership with a private provider, Elysium Healthcare, in March 2024. Emerald Place has sufficient bed capacity to meet the demand for GAU inpatient beds within Surrey.
In line with best practice for a new service, admissions have been staggered to allow the new team to develop and embed a safe and therapeutic culture on the ward. As part of our ongoing quality review process, a decision was made to pause further admissions. The Surrey Heartlands CAMHS Tier 4 Provider Collaborative is working at pace with NHS England, Elysium Healthcare and the Trust to support quality improvements at the unit with a current expectation that the unit can resume admissions from January 2025. In the meantime, the Trust is accessing GAU beds through independent providers.
5 December 2024
Private and Confidential
2. System alerts for risk relating to suicide
It is recognised that risk prediction in suicide has been shown repeatedly to be ineffective1. As recognised in your letter to us, the Trust has recently revised its risk assessment approach to align with NICE Guidelines2 and NHS England’s recommendations. This approach emphasises addressing patient needs rather than predicting future risk through the previously used ‘low/medium/high’ categorisation.
Risks are identified and mitigated through a comprehensive risk reduction plan, tailored to the individual, and incorporated into every risk assessment and formulation. The needs-based, patient- centred methodology provides a robust, evidence-based approach to managing risks which complies with national guidance. The suggested binary ‘suicidal/not suicidal’ flag system would force clinicians into an overly simplistic model of risk prediction inconsistent with the nuanced and individualised approach recommended by NICE and now implemented by the Trust. As a result, and having carefully considered this, we will not be introducing a binary flag system.
The Trust’s risk assessment process is designed on the basis that clinicians are acting in accordance with their professional and regulatory responsibilities. As per the NHS Constitution for England3, our staff have a duty to accept professional accountability and maintain the standards of professional practice as set by the appropriate regulatory body applicable to their profession or role. The Trust works in accordance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 20144 in deploying suitably qualified, competent, skilled and experienced persons and ensuring that they receive support, training, professional development, supervision and appraisal.
Through induction and training processes, all staff are aware that our Electronic Patient Record, SystmOne is the single source of all written information and that the risk formulation, care plan, and My Safety Plan must all be kept up to date and stored in specific locations of the patient record so that they are readily available. The MDT process enables clinicians to seek additional support, guidance or reflection where these are required to enable them to properly assess and manage risk.
All of the above are core activities and expectations for all of our clinicians. During clinical supervision, managers review sample cases with each clinician to support effective risk management and clinical reflection.
3. My Safety Plan
My Safety Plan is not a tool for assessing or recording risk of suicide. The document is not written in clinical terms, and it not intended to be a means of sharing information about risk between organisations. Instead, formal documentation of clinical risk (including clear and correct clinical terminology around suicide) is recorded in the Risk Formulation and Care Plan documents which, along with My Safety Plan, form an interlinked suite of documents which are held within a person’s Electronic Patient Record.
Clinical risk information is shared with the network around the child including their school and Children’s Services. Information sharing and safeguarding procedures ensure that relevant clinical information including around risk of suicide is shared with other organisations where appropriate regardless of whether a child or young person decides to share their My Safety Plan.
1 Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation and risk management, Hawton et al, The Lancet, published 8 August 2022 2 NICE Guidance NG225 Overview | Self-harm: assessment, management and preventing recurrence | Guidance | NICE 28056 3 The NHS Constitution for England - GOV.UK 4 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Designed in collaboration with Surrey County Council’s Consulting Youth Advisers team, My Safety Plan empowers a child or young person to communicate with the network around them about their concerns or triggers. A child or young person is encouraged to use their own choice of words within their My Safety Plan to express how they are feeling, enabling them take ownership of this document. The document is compiled in discussion between the clinician and the child or young person and their family/carer, primarily for the child or young person to hold, and to share with adults around them, if and when they choose. Equally, they may choose not to share it at all. We might share it on their behalf if we are given consent or are requested to do so.
It is also incumbent on other agencies around the child or young person to raise concerns of suicidality, for example, teachers and social workers must independently assess their level of concern and seek advice or link with Trust services if they feel this is necessary.
4. Core Group Meetings Attendance at Core Group meetings in respect of those supported by Children’s Services is mandatory. There is also an expectation that clinicians contribute to other safeguarding meetings, and local authority reviews of Education Health and Care Plans (“EHCP”). The Standard Operating Procedure (“SOP”) for our community teams requires that Care Plans include actions flowing from these meetings. Care Plans are recorded on SystmOne and accessible to any Trust clinician involved in the care of the child or young person.
This was discussed at the monthly divisional Quality Operations Board on 19 November 2024 attended by managers and senior clinicians where the importance of engagement with Core Group Meetings was emphasised. Managers were tasked with cascading this to their teams and confirmation that this has been actioned will be provided to the Quality Operations Board.
The Trust is only able to monitor responses to invitations that are received and we are reliant on those invites being sent to us in a timely manner to enable arrangements for attendance to be made. We have therefore requested that Children’s Services copy each invite into our central Safeguarding team in order to have a greater oversight of these invitations and our responses/attendance.
On behalf of the Trust, I would like to offer our sincere condolences to Locket’s family for their loss.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths by addressing the concerns set out above and I believe your organisation has the power to take such action.
Report Sections
Investigation and Inquest
I commenced an investigation into the death of Locket Ure Williams. The inquest concluded on the 31st May 2024 when I found that the medical cause of death was:
Ia Multiple Injuries and my conclusion as to the death was that:
Locket Ure Williams died as a result of Suicide. Their death was more than minimally contributed to by Surrey and Borders Partnership NHS Foundation Trust’s Children and Adolescent Mental Health Service’s: (i) delay in assessing Locket’s condition and needs, (ii) underestimation of Locket’s risk of suicide, and (iii) failure to deliver necessary therapeutic treatment to Locket in a timely manner.
I subsequently held a hearing to receive evidence relating to the prevention of future deaths and this was concluded on the 26th September 2024.
Ia Multiple Injuries and my conclusion as to the death was that:
Locket Ure Williams died as a result of Suicide. Their death was more than minimally contributed to by Surrey and Borders Partnership NHS Foundation Trust’s Children and Adolescent Mental Health Service’s: (i) delay in assessing Locket’s condition and needs, (ii) underestimation of Locket’s risk of suicide, and (iii) failure to deliver necessary therapeutic treatment to Locket in a timely manner.
I subsequently held a hearing to receive evidence relating to the prevention of future deaths and this was concluded on the 26th September 2024.
Circumstances of the Death
Locket Williams was 15 years of age when they died. They had a history of self-harm, suicidal ideation, and suicide attempts. This history included a referral to Surrey and Borders Partnership NHS Foundation Trust’s Children and Adolescent Mental Health Service, with a report of self-harm and suicidal ideation, in October 2020, and three subsequent suicide attempts, in February, June and July 2021. Locket was suffering a Depressive Disorder and Emotional Dysregulation and, in April 2021, they were placed on the waiting list for Cognitive Behaviour Therapy, which was expected to be effective in treating their conditions and controlling their suicidal ideation. Although Locket was prescribed medication and received some monitoring and support from the Children and Adolescent Mental Health Service, the Cognitive Behaviour Therapy did not commence until very shortly before their death, and no effective treatment had been provided prior to their death.
On the night of the 27th September 2021, Locket left their home and walked to , from where they jumped to the road below. Locket’s death, from consequential injuries, was recognised at 00:01 hours on the 28th September 2021.
Full details of the events and failings which lead to Locket Ure Williams’ death are set out in my “Findings and Conclusions” document, a copy of which is sent with this report.
On the night of the 27th September 2021, Locket left their home and walked to , from where they jumped to the road below. Locket’s death, from consequential injuries, was recognised at 00:01 hours on the 28th September 2021.
Full details of the events and failings which lead to Locket Ure Williams’ death are set out in my “Findings and Conclusions” document, a copy of which is sent with this report.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.