Jean Pike
PFD Report
All Responded
Ref: 2025-0127
Mental Health related deaths
Suicide (from 2015)
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 2 May 2025
Response Status
Responses
1 of 1
56-Day Deadline
2 May 2025
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
During the inquest the evidence revealed matters giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
I am concerned that Jean was discharged from Ward F of Neath Port Talbot Hospital on two occasions shortly before her death by a consultant psychiatrist and that prior to the decision to discharge on both occasions there was no multi-disciplinary meeting between the consultant on Ward F and the professionals directly involved in caring for Jean in the community about Jean’s mental health and the risks she posed to herself in the community. This was in circumstances where the consultant knew before the decisions to discharge that these professionals, which included Jean’s care co-ordinator, were clearly stating that they were extremely concerned about Jean’s mental health and that they did not consider that they could keep Jean safe in the community and that they thought that Jean would hang herself in the community – which is in fact what happened in this case. I am particularly concerned by the evidence I heard from Jean’s care co-ordinator that care co-ordinators are rarely if ever consulted by consultant psychiatrists in Ward F of Neath Port Talbot Hospital before a decision is made to discharge a patient/person under secondary mental health care. This issue was not identified by Swansea University Bay Health Board (‘SUBHB’) in their internal investigation into Jean’s death. This investigation found that “there is evidence of regular and effective communication between support staff, community staff and hospital staff”.
The above finding of SUBHB’s internal investigation raises a concern that critical lessons have not being identified and learnt by SUBHB from Jean’s death about the importance of multi-disciplinary decision making in clinical care and risk management and the importance of including care co-ordinators and professionals in the community before a decision is taken to discharge a patient from Ward F. This creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F. I am also concerned that if there is a lack of clarity or a reluctance in Ward F at the consultant level to engage with care co-ordinators and professionals in the community (and before decisions are made to discharge) there is a risk that the concerns of the professionals managing a patient/person under secondary care will not be adequately considered in the decisions made by Ward F clinicians. This also creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F.
I am concerned that Jean was discharged from Ward F of Neath Port Talbot Hospital on two occasions shortly before her death by a consultant psychiatrist and that prior to the decision to discharge on both occasions there was no multi-disciplinary meeting between the consultant on Ward F and the professionals directly involved in caring for Jean in the community about Jean’s mental health and the risks she posed to herself in the community. This was in circumstances where the consultant knew before the decisions to discharge that these professionals, which included Jean’s care co-ordinator, were clearly stating that they were extremely concerned about Jean’s mental health and that they did not consider that they could keep Jean safe in the community and that they thought that Jean would hang herself in the community – which is in fact what happened in this case. I am particularly concerned by the evidence I heard from Jean’s care co-ordinator that care co-ordinators are rarely if ever consulted by consultant psychiatrists in Ward F of Neath Port Talbot Hospital before a decision is made to discharge a patient/person under secondary mental health care. This issue was not identified by Swansea University Bay Health Board (‘SUBHB’) in their internal investigation into Jean’s death. This investigation found that “there is evidence of regular and effective communication between support staff, community staff and hospital staff”.
The above finding of SUBHB’s internal investigation raises a concern that critical lessons have not being identified and learnt by SUBHB from Jean’s death about the importance of multi-disciplinary decision making in clinical care and risk management and the importance of including care co-ordinators and professionals in the community before a decision is taken to discharge a patient from Ward F. This creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F. I am also concerned that if there is a lack of clarity or a reluctance in Ward F at the consultant level to engage with care co-ordinators and professionals in the community (and before decisions are made to discharge) there is a risk that the concerns of the professionals managing a patient/person under secondary care will not be adequately considered in the decisions made by Ward F clinicians. This also creates a continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F.
Responses
Swansea Bay University Health Board has approved and implemented new Standard Operating Procedures for discharge planning requiring mandatory multi-disciplinary team discussions, including the care coordinator, prior to discharge. They have also approved and implemented new guidance on strategy meetings and provided training to serious incident investigators.
AI summary
View full response
Dear Ms Heaven, RESPONSE BY SWANSEA BAY UNIVERSITY HEALTH BOARD TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS ISSUED IN THE INQUEST OF JEAN PIKE This letter is written in response to the Report issued under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations_ Regulations 2013 dated notification dated 7th March 2025 wherein you identified the following concerns and stated that it was your opinion there is a risk that future deaths will occur unless action is taken Swansea Bay University Health Board sets out below the concerns and the action taken which is within the power of the Health Board. CORONER'S CONCERNS Concern That Jean Pike was discharge from Ward F of Neath Port Talbot Hospital on two occasions prior to death by consultant psychiatrist and that prior to the decision on both occasions there was no multi-disciplinary meeting between the consultant on Ward F and the professionals directly involved in caring for Jean in the community about Jean's mental health and the risks she posed to herself in the community: This was in circumstances where the consultant knew before the decisions to discharge that these professionals,; which included Jean's care co-ordinator; were clearly stating that were extremely concerned about Jean's mental health and that did not consider that could keep Jean safe in the community The coroner's expressed a particular concerned by the evidence / heard Jean'$ care cO-ordinator that care cO-ordinators are rarely, if ever; consulted by consultant psychiatrists in Ward F of Neath Port Talbot Hospital before a decision is made to discharge patient person under secondary mental health care: Concerned that if there is a lack of clarity or a reluctance in Ward F at the consultant level to engage with care CO-ordinators and professionals in the community (and before decisions are made to discharge) there is a risk that the concerns of the professionals managing a patientperson under secondary care will not be adequately considered in the Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg: Atebir goheblaeth Gymraeg yn y Gymraeg; ac ni fydd hyn yn arwain at oedi. We welc = = #trarpondence in Welsh or English. Welsh ianguage correspondence will be replied to in Welsh, and this will not lead to delay. Cadeirydd/Chair: Prif WeithredwrIChief Executive; Pencadlys BIP Bae Abertawe; Un Porthfa Talbot; Port Talbot; SA12 7BR Bwrdd lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters One Talbot Gateway; Port Talbot; SA12 7BR Swansea University Health Board is the operational name of Swansea Bay University Locai Health Board her they they they from Bay
decisions made by Ward F clinicians: This also creates continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F Swansea University Health Board Response: Discharge processes within the adult mental health wards have been reviewed over the last three years and Terms of Reference were developed for the Multi-Disciplinary Team (MDT) Ward meetings in April 2022. The MDT meeting is held on a weekly basis, with the focus being to work collaboratively with colleagues in the Community Mental Health Services and other agencieslproviders to provide holistic and patient centred care. The Terms of Reference for the MDT meetings and review process sets out the purpose and expectation of all parties within this process; including collaboration with care coordinators, families, and other agencies_ Prior to each MDT meeting, a communication is sent to all Integrated team managers for CMHTs (this includes the Local Authority and Health manager) , informing them of the MDT meeting agenda_ Care Coordinators are able to attend to participate in the review and discussion of their patient(s) through making an appointment with the ward medical secretary. However, the CMHT representative at the meeting also acts as a conduit to cascade information and MDT decisions back to the team and individual care coordinators. Care coordinators also take opportunity to contact the ward for updates on patients outside of these formal meeting: Within the adult Mental Health services, weekly discharge planning meeting is held, where all inpatients progress and discharge plans are discussed and prioritised. Attendees at this meeting are representatives from each of the inpatient and community teams. The purpose of this meeting is for information sharing; working collaboratively to inform effective patient flow and discharge planning through the service There are going to be times where patients are appropriate for discharge in circumstances outside of the above timeframes; such as a short admission, in this situation and for planned discharged, the utilisation of discharge checklist ensures that there is effective communication and collaboration with all parties The purpose of the Pre-discharge checklist is to provide an overview of the necessary actions required in preparation for a patient discharge. The checklist includes the required stakeholders who need to attend, such as familylcarer or advocacy, care coordinator;, care providers and any other agencies involved, Other aspects of the checklist include social circumstances, occupational therapy needs, safeguarding, follow up from the Crisis resolution and home treatment team, and take-home medication requirements_ The checklist provides a prompt to the ward team to ensure the care coordinator is involved in the patient's discharge In addition to this, there is also a patient discharge pack which is provided, which includes information for the patient; family or care provider on discharge and ongoing support and signposting_ The Pre- discharge Checklist was revised and improved in July 2022. Assurance around the effective implementation and use of the Pre-discharge Checklist is reviewed as part of a weekly audit of clinical records. The findings are shared with the Ward Manager and Clinical Lead and any improvements implemented: Discharge planning has been a focus of a current clinical audit that is undertaken by the Quality Improvement and Practice Development teams_ This audit is looking at Discharges from the Adult inpatient Wards against the guidance identified in NG53 Transition between inpatient Mental Health Settings and Community or Care home settings. This audit commenced in March 2025 and the findings are planned to be presented in July 2025. MHLD Services in SBUHB are actively involved in the National Patient Safety Programme This is a programme of work led by the NHS Wales Executive Team, and includes the safe discharge work stream_ This forum is developing a set of national standards around discharge, and includes the requirement: that all patients discharged from Adult Mental Health wards (this is for Ward F Clyne and Fendrod) receive a 72 hour follow up review_ This has been in place since May 2024 and has been monitored for compliance since September 2024. During this six-month period, Rydym yn croesawu gohebiaeth yn y Gymraeg neur Saesneg Atebir goheblaeth Gymraeg yn y Gymraeg ac ni fydd hyn yn arwain at oedi: We welcome correspondence In Welsh or English: Welsh language correspordence will be repliec to in Welsh and this will nol lead t0 Gelay; Cadeirydd/Chair | Prif Weithredwr/Chief Executive;| Pencadlys BIP Bae Abertawe; Un Porthfa Talbot; Port Talbot; SA12 7BR Bwrdd lechyd Prifysgol Bae Abertawe YW enw gweithredu Bwrdd lechyd Lleol Prifysg , Bae Abertawe Swansea Bay UHB Headquarters One Talbot Gatcway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board Bay being
there has been 230 discharges across adult inpatient wards, of these 90% have received the offer of 72-hour follow-up. Of those who were not offered, the reasons include patient discharged out of area; patient deceased and patients that had received an extended period of home leave as part of transitioning/discharge planning_ There is a focus across Wales for the implementation of Patient Centred Safety planning: SBUHB working with the NHS Wales Executives, were pilot site for this approach within one of our CMHTs. Following the success of this pilot; there is an MDT task and finish group chaired by the Lead Nurse for Adult Community Mental Health Directorate, who will work towards scaling this in phased approach across all adult mental health services over the next year. Patient centred safety planning is patient led approach to managing emotional distress and crisis, through identifying means of support, distraction, contacts and strategies to maintain safety _ This will be led by the patient and centred around them, and therefore consent and engagement be required. For those patients who engage with a Patient Centred Safety plan , will still require a risk assessment, formulation, and plan to be in place. All patients who have been admitted to an inpatient setting, will have a risk assessment completed within 24 hours, and for care coordinated patients, this will form a review of their current risk assessment (as they will already have one from the community) As part of the admission process, the patients Care and Treatment Plan would be reviewed within 72 hours, where the care coordinator attends this meeting where possible in line with the operational hours of the community mental health teams Both of the above criteria are reported to NHS Wales Executives on a monthly basis. The monitoring of this has been in place since September 2024. MDT working requires a shared responsibility and collaborative working: However; where different professionals are involved, this can bring different views and opinions on patient care and treatment_ In these circumstances,' clinicians including care coordinators, can raise concerns: There are a number of forums where this is possible_ Within the CMHTs, there are weekly Community MDT meetings where clinicians raise and discuss patients their case load; there is an item on the agenda 'cases that are escalatinglof concern' This is an opportunity for the care coordinator and the MDT to discuss the case; the care coordinator will receive peer supervision; alternative interventions can be.discussed and a decision if gatekeeping or Mental Health Act Assessment is required. The team consultant has emergency slots within their clinics, and these can be utilised should a patient require an urgent review in the community_ Another area for support and escalation would be caseload supervision; this is a one-to-one meeting 6 weeks with the team manager or deputy_ in line with professional standards It allows the care coordinator to focus on their individual caseloads, it is an opportunity for reflection; support; and development: Outside of these, more formal processes would include escalating any concerns they have via their Team Manager, escalated to the Lead Nurse; Head of Nursing and finally Nurse Director within the Service Group if required: In addition to escalation routes, there is also a monthly community team manager meeting that is held and chaired by the divisional manager for Mental health services_ This meeting allows for team managers to raise any concerns have; to reflect on any trends or patterns that are emerging across all the teams and therefore make changes and review any processes that could improve: This is another opportunity for concerns to be escalated upwards: Since June 2023, the NHS 111 option 2 service has been introduced. This service is accessible for the general public, professionals, and agencies, on a 24/7 basis relating to individuals in mental health crisis or for any urgent support: Calls to this service are answered by Mental Health Professionals, who will assess the call to triage and ensure the appropriate support, response and intervention is provided. Concern 2 Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg: Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English Welsh language correspondence will be replied to in Welsh, and this will not lead to delay: CadeiryddiChair: Prif Weithredwr/Chief Executive: Pencadlys BIP Bae Abertawe_ Un Porthfa Talbot; Port Talbot; SA12 7BR Bwrda lecnyd Prifysgol Bae Abertawe yW enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe Swansea UHB Headquarters, One Talbot Gateway, Port Talbot SA12 7BR Swansea Bay University Health Apard tne operationa name of Swansea Bay University Local Health Board will they the from every they Bay
The decision not to discuss discharge with the care cO-ordinator was not identified by the internal investigation undertaken by SBUHB, rather the investigation' found: 'there is evidence of regular and effective communication between support staff; community staff and hospital staff: This raises & concern that critical lessons have not been identified and learnt by SBUHB from Jean's death about the importance of including care co-ordinators and professions in the community before decision is taken to discharge patient from Ward F This creates continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F Swansea University Health Board Response: The Health Board recognises that through this case, the coroner has identified additional learning for the Mental Health services that was not identified in the original Serious Incident Review and is grateful to the coroner for this Following the inquest; a debrief session was convened to consider the coroners concerns and the required actions that were to be taken, noting that some actions had been implemented prior to the inquest hearing addressing the identified risk to life as outlined in concern
1. In addition to these, the Medical Director and Nurse Director for MH&LD have issued formal correspondence to all clinical areas and teams, reaffirming adherence to Section 3.4: Discharge and Discharge Planning of the Acute Adult Mental Health Inpatient Wards Operational Policy and the Pre-Discharge Planning Checklist and the patientlrelative receives the "Moving on information leaflet: This formal correspondence will also be cascaded through the relevant forums throughout May 2025, such as Ward[Team manager meetings and consultant forums_ In relation to the Serious Incident Review Process, the MH&LD team is continually working towards improving this and in August 2024 a review was commissioned by the MH&LD Nurse Director; requesting that Professor Jason Davies: (RDIIAL Hub Director and Consultant Forensic and Clinical Psychologist) Undertake a review of the purpose and processes related to the SIG (Serious Incident Group) functions and to make recommendations to Serious Incident Group and MHLD: Quality and Safety Committee detailing effective practice and potential changes to process This report was finalised and reported back to MH&LD Quality and Safety Committee in October 2024 with recommendations which the Service Group are embedding: One of these recommendations was around processes of Serious Incident Strategy Meetings Strategy Meeting is held following some fact finding and established contacts with the service , and is chaired by the MHLD Nurse Director or one of the four Heads of Nursing_ The chair acts as the commissioner for the review, ensuring any immediate actions are identified and carried out; identifies the scope of the review and terms of reference. There has been a focus on ensuring that this process includes identification of questions and lines of enquiry which are set out for the investigators. An emphasis has also been placed on the involvement of families, clinical advisors and identification of relevant policies and guidance related to the case. This meeting would identify cases where externality is required for the review, for example inpatient deaths are reviewed by HB Sl investigators and cases where the chajr has identified the need to request a reviewer from neighbouring HB_ A further change has been implemented in the development of a two-stage process for sign off and approval of the learning and findings identified in Serious Incident Review Reports. The initial stage is for a focused group of senior clinicians to scrutinise and critique the outcome report to ensure that it meets the scope, terms of reference and areas of review as commissioned within Rydym yn croesawu gohcbiacth yn y Gymraeg neu'r Saesneg Atebir gohebiaeth Gymraeg yn y Gymraeg; ac ni fydd hyn yn arwain at oedi We welcome correspondence in Welsh or English: Welsh language correspondence will be replied to in Welsh; and this will not lead lo delay- Cadeirydd/Chair: Prif WeithredwrIChief Executive: Pencadlys BIP Bae Abertawe Un Porthfa Talbot; Port Talbot; SA12 7BR bwrod lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters; One Talbot Gateway, Port Talbot; SA12 7BR Swansea University Health Board is the operational name of Swansea Bay University Local Health Baxrd Bay key the the key Bay
the strategy meeting: It also acts as panel to ensure that the review has been thorough and whether there are any further areas that require exploration prior to it signed off: The second stage is a forum to share the findings and learning; identifying improvements and actions required, identifying leads for the improvement plan with a timeframe for return: This stage will support a wider cascade of learning and implementation of improvements. This second stage is currently implemented with the first SIRL (Serious Incident Review Learning) meeting planned for May 2025. This will be evaluated as part of the ongoing SIG Review facilitated by RDIIAL and Prof Davies, and a will be following the 6u SIRL Meeting in November 2025. A series of learning events have been arranged in the Service Group through RDIIAL. RDIIAL (Research, Development, Innovation, Improvement, Audit & Learning) is known as the learning hub and reports into the MH&LD Quality & Safety Committee. There was learning event held on 20th. September 2024, presenting shared learning from an inquest case and thematic links. Further learning events are planned for 6th 2025 on implementation, monitoring and sustaining actionlimprovement plans, 19th May 2025 on Risk planning and safety, relating to policy and process and gth July 2025 on collaboration, CO- production; and family involvement with a particular focus on safety planning: In line . with the above review , further training has been provided to the Serious Incident Investigators within MH&LD Service Group: The Health Board Serious Incident Investigators received training from Consequence UK, an organisation which provides training on techniques and processes to increase the effectiveness of Serious Incident reviews. Following this, training on process mapping in particular; was cascaded to the MH&LD Serious Incident investigator team (October 2024) in line with this_ This way of reviewing, aids the investigator to break down policy and procedures into step-by-step guidance, which in turn can be used by the investigator to map and measure the care provided_ This allows the incident investigators to make more accurate analysis of the clinical input against the specified clinical processes and guidance. As with the change in process for strategy meetings, the Service Group are in a transition period regards the investigation methodology and will be monitoring and reviewing the process. To support this the team are implementing regular team meetings to reflect on the review process, identify themes in the learning and reflect on feedback on the reports_
decisions made by Ward F clinicians: This also creates continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F Swansea University Health Board Response: Discharge processes within the adult mental health wards have been reviewed over the last three years and Terms of Reference were developed for the Multi-Disciplinary Team (MDT) Ward meetings in April 2022. The MDT meeting is held on a weekly basis, with the focus being to work collaboratively with colleagues in the Community Mental Health Services and other agencieslproviders to provide holistic and patient centred care. The Terms of Reference for the MDT meetings and review process sets out the purpose and expectation of all parties within this process; including collaboration with care coordinators, families, and other agencies_ Prior to each MDT meeting, a communication is sent to all Integrated team managers for CMHTs (this includes the Local Authority and Health manager) , informing them of the MDT meeting agenda_ Care Coordinators are able to attend to participate in the review and discussion of their patient(s) through making an appointment with the ward medical secretary. However, the CMHT representative at the meeting also acts as a conduit to cascade information and MDT decisions back to the team and individual care coordinators. Care coordinators also take opportunity to contact the ward for updates on patients outside of these formal meeting: Within the adult Mental Health services, weekly discharge planning meeting is held, where all inpatients progress and discharge plans are discussed and prioritised. Attendees at this meeting are representatives from each of the inpatient and community teams. The purpose of this meeting is for information sharing; working collaboratively to inform effective patient flow and discharge planning through the service There are going to be times where patients are appropriate for discharge in circumstances outside of the above timeframes; such as a short admission, in this situation and for planned discharged, the utilisation of discharge checklist ensures that there is effective communication and collaboration with all parties The purpose of the Pre-discharge checklist is to provide an overview of the necessary actions required in preparation for a patient discharge. The checklist includes the required stakeholders who need to attend, such as familylcarer or advocacy, care coordinator;, care providers and any other agencies involved, Other aspects of the checklist include social circumstances, occupational therapy needs, safeguarding, follow up from the Crisis resolution and home treatment team, and take-home medication requirements_ The checklist provides a prompt to the ward team to ensure the care coordinator is involved in the patient's discharge In addition to this, there is also a patient discharge pack which is provided, which includes information for the patient; family or care provider on discharge and ongoing support and signposting_ The Pre- discharge Checklist was revised and improved in July 2022. Assurance around the effective implementation and use of the Pre-discharge Checklist is reviewed as part of a weekly audit of clinical records. The findings are shared with the Ward Manager and Clinical Lead and any improvements implemented: Discharge planning has been a focus of a current clinical audit that is undertaken by the Quality Improvement and Practice Development teams_ This audit is looking at Discharges from the Adult inpatient Wards against the guidance identified in NG53 Transition between inpatient Mental Health Settings and Community or Care home settings. This audit commenced in March 2025 and the findings are planned to be presented in July 2025. MHLD Services in SBUHB are actively involved in the National Patient Safety Programme This is a programme of work led by the NHS Wales Executive Team, and includes the safe discharge work stream_ This forum is developing a set of national standards around discharge, and includes the requirement: that all patients discharged from Adult Mental Health wards (this is for Ward F Clyne and Fendrod) receive a 72 hour follow up review_ This has been in place since May 2024 and has been monitored for compliance since September 2024. During this six-month period, Rydym yn croesawu gohebiaeth yn y Gymraeg neur Saesneg Atebir goheblaeth Gymraeg yn y Gymraeg ac ni fydd hyn yn arwain at oedi: We welcome correspondence In Welsh or English: Welsh language correspordence will be repliec to in Welsh and this will nol lead t0 Gelay; Cadeirydd/Chair | Prif Weithredwr/Chief Executive;| Pencadlys BIP Bae Abertawe; Un Porthfa Talbot; Port Talbot; SA12 7BR Bwrdd lechyd Prifysgol Bae Abertawe YW enw gweithredu Bwrdd lechyd Lleol Prifysg , Bae Abertawe Swansea Bay UHB Headquarters One Talbot Gatcway, Port Talbot, SA12 7BR Swansea Bay University Health Board is the operational name of Swansea Bay University Local Health Board Bay being
there has been 230 discharges across adult inpatient wards, of these 90% have received the offer of 72-hour follow-up. Of those who were not offered, the reasons include patient discharged out of area; patient deceased and patients that had received an extended period of home leave as part of transitioning/discharge planning_ There is a focus across Wales for the implementation of Patient Centred Safety planning: SBUHB working with the NHS Wales Executives, were pilot site for this approach within one of our CMHTs. Following the success of this pilot; there is an MDT task and finish group chaired by the Lead Nurse for Adult Community Mental Health Directorate, who will work towards scaling this in phased approach across all adult mental health services over the next year. Patient centred safety planning is patient led approach to managing emotional distress and crisis, through identifying means of support, distraction, contacts and strategies to maintain safety _ This will be led by the patient and centred around them, and therefore consent and engagement be required. For those patients who engage with a Patient Centred Safety plan , will still require a risk assessment, formulation, and plan to be in place. All patients who have been admitted to an inpatient setting, will have a risk assessment completed within 24 hours, and for care coordinated patients, this will form a review of their current risk assessment (as they will already have one from the community) As part of the admission process, the patients Care and Treatment Plan would be reviewed within 72 hours, where the care coordinator attends this meeting where possible in line with the operational hours of the community mental health teams Both of the above criteria are reported to NHS Wales Executives on a monthly basis. The monitoring of this has been in place since September 2024. MDT working requires a shared responsibility and collaborative working: However; where different professionals are involved, this can bring different views and opinions on patient care and treatment_ In these circumstances,' clinicians including care coordinators, can raise concerns: There are a number of forums where this is possible_ Within the CMHTs, there are weekly Community MDT meetings where clinicians raise and discuss patients their case load; there is an item on the agenda 'cases that are escalatinglof concern' This is an opportunity for the care coordinator and the MDT to discuss the case; the care coordinator will receive peer supervision; alternative interventions can be.discussed and a decision if gatekeeping or Mental Health Act Assessment is required. The team consultant has emergency slots within their clinics, and these can be utilised should a patient require an urgent review in the community_ Another area for support and escalation would be caseload supervision; this is a one-to-one meeting 6 weeks with the team manager or deputy_ in line with professional standards It allows the care coordinator to focus on their individual caseloads, it is an opportunity for reflection; support; and development: Outside of these, more formal processes would include escalating any concerns they have via their Team Manager, escalated to the Lead Nurse; Head of Nursing and finally Nurse Director within the Service Group if required: In addition to escalation routes, there is also a monthly community team manager meeting that is held and chaired by the divisional manager for Mental health services_ This meeting allows for team managers to raise any concerns have; to reflect on any trends or patterns that are emerging across all the teams and therefore make changes and review any processes that could improve: This is another opportunity for concerns to be escalated upwards: Since June 2023, the NHS 111 option 2 service has been introduced. This service is accessible for the general public, professionals, and agencies, on a 24/7 basis relating to individuals in mental health crisis or for any urgent support: Calls to this service are answered by Mental Health Professionals, who will assess the call to triage and ensure the appropriate support, response and intervention is provided. Concern 2 Rydym yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg: Atebir gohebiaeth Gymraeg yn y Gymraeg, ac ni fydd hyn yn arwain at oedi. We welcome correspondence in Welsh or English Welsh language correspondence will be replied to in Welsh, and this will not lead to delay: CadeiryddiChair: Prif Weithredwr/Chief Executive: Pencadlys BIP Bae Abertawe_ Un Porthfa Talbot; Port Talbot; SA12 7BR Bwrda lecnyd Prifysgol Bae Abertawe yW enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe Swansea UHB Headquarters, One Talbot Gateway, Port Talbot SA12 7BR Swansea Bay University Health Apard tne operationa name of Swansea Bay University Local Health Board will they the from every they Bay
The decision not to discuss discharge with the care cO-ordinator was not identified by the internal investigation undertaken by SBUHB, rather the investigation' found: 'there is evidence of regular and effective communication between support staff; community staff and hospital staff: This raises & concern that critical lessons have not been identified and learnt by SBUHB from Jean's death about the importance of including care co-ordinators and professions in the community before decision is taken to discharge patient from Ward F This creates continuing risk to life as it may lead to risk being ignored or not properly considered by Ward F Swansea University Health Board Response: The Health Board recognises that through this case, the coroner has identified additional learning for the Mental Health services that was not identified in the original Serious Incident Review and is grateful to the coroner for this Following the inquest; a debrief session was convened to consider the coroners concerns and the required actions that were to be taken, noting that some actions had been implemented prior to the inquest hearing addressing the identified risk to life as outlined in concern
1. In addition to these, the Medical Director and Nurse Director for MH&LD have issued formal correspondence to all clinical areas and teams, reaffirming adherence to Section 3.4: Discharge and Discharge Planning of the Acute Adult Mental Health Inpatient Wards Operational Policy and the Pre-Discharge Planning Checklist and the patientlrelative receives the "Moving on information leaflet: This formal correspondence will also be cascaded through the relevant forums throughout May 2025, such as Ward[Team manager meetings and consultant forums_ In relation to the Serious Incident Review Process, the MH&LD team is continually working towards improving this and in August 2024 a review was commissioned by the MH&LD Nurse Director; requesting that Professor Jason Davies: (RDIIAL Hub Director and Consultant Forensic and Clinical Psychologist) Undertake a review of the purpose and processes related to the SIG (Serious Incident Group) functions and to make recommendations to Serious Incident Group and MHLD: Quality and Safety Committee detailing effective practice and potential changes to process This report was finalised and reported back to MH&LD Quality and Safety Committee in October 2024 with recommendations which the Service Group are embedding: One of these recommendations was around processes of Serious Incident Strategy Meetings Strategy Meeting is held following some fact finding and established contacts with the service , and is chaired by the MHLD Nurse Director or one of the four Heads of Nursing_ The chair acts as the commissioner for the review, ensuring any immediate actions are identified and carried out; identifies the scope of the review and terms of reference. There has been a focus on ensuring that this process includes identification of questions and lines of enquiry which are set out for the investigators. An emphasis has also been placed on the involvement of families, clinical advisors and identification of relevant policies and guidance related to the case. This meeting would identify cases where externality is required for the review, for example inpatient deaths are reviewed by HB Sl investigators and cases where the chajr has identified the need to request a reviewer from neighbouring HB_ A further change has been implemented in the development of a two-stage process for sign off and approval of the learning and findings identified in Serious Incident Review Reports. The initial stage is for a focused group of senior clinicians to scrutinise and critique the outcome report to ensure that it meets the scope, terms of reference and areas of review as commissioned within Rydym yn croesawu gohcbiacth yn y Gymraeg neu'r Saesneg Atebir gohebiaeth Gymraeg yn y Gymraeg; ac ni fydd hyn yn arwain at oedi We welcome correspondence in Welsh or English: Welsh language correspondence will be replied to in Welsh; and this will not lead lo delay- Cadeirydd/Chair: Prif WeithredwrIChief Executive: Pencadlys BIP Bae Abertawe Un Porthfa Talbot; Port Talbot; SA12 7BR bwrod lechyd Prifysgol Bae Abertawe yw enw gweithredu Bwrdd lechyd Lleol Prifysgol Bae Abertawe Swansea Bay UHB Headquarters; One Talbot Gateway, Port Talbot; SA12 7BR Swansea University Health Board is the operational name of Swansea Bay University Local Health Baxrd Bay key the the key Bay
the strategy meeting: It also acts as panel to ensure that the review has been thorough and whether there are any further areas that require exploration prior to it signed off: The second stage is a forum to share the findings and learning; identifying improvements and actions required, identifying leads for the improvement plan with a timeframe for return: This stage will support a wider cascade of learning and implementation of improvements. This second stage is currently implemented with the first SIRL (Serious Incident Review Learning) meeting planned for May 2025. This will be evaluated as part of the ongoing SIG Review facilitated by RDIIAL and Prof Davies, and a will be following the 6u SIRL Meeting in November 2025. A series of learning events have been arranged in the Service Group through RDIIAL. RDIIAL (Research, Development, Innovation, Improvement, Audit & Learning) is known as the learning hub and reports into the MH&LD Quality & Safety Committee. There was learning event held on 20th. September 2024, presenting shared learning from an inquest case and thematic links. Further learning events are planned for 6th 2025 on implementation, monitoring and sustaining actionlimprovement plans, 19th May 2025 on Risk planning and safety, relating to policy and process and gth July 2025 on collaboration, CO- production; and family involvement with a particular focus on safety planning: In line . with the above review , further training has been provided to the Serious Incident Investigators within MH&LD Service Group: The Health Board Serious Incident Investigators received training from Consequence UK, an organisation which provides training on techniques and processes to increase the effectiveness of Serious Incident reviews. Following this, training on process mapping in particular; was cascaded to the MH&LD Serious Incident investigator team (October 2024) in line with this_ This way of reviewing, aids the investigator to break down policy and procedures into step-by-step guidance, which in turn can be used by the investigator to map and measure the care provided_ This allows the incident investigators to make more accurate analysis of the clinical input against the specified clinical processes and guidance. As with the change in process for strategy meetings, the Service Group are in a transition period regards the investigation methodology and will be monitoring and reviewing the process. To support this the team are implementing regular team meetings to reflect on the review process, identify themes in the learning and reflect on feedback on the reports_
Report Sections
Investigation and Inquest
On 18th February and 5th March 2025 I heard an inquest into the death of Jean Pike. The investigation concluded at the end of the inquest on 5th March 2025.
The medical cause of death was: 1a Hanging
The conclusion of the inquest was a narrative conclusion as follows:
Jean Pike was a vulnerable women aged 54 at the time of death and had a diagnosis of Emotionally Unstable Personality Disorder and suffered from a depressive illness. Jean resided in supported accommodation and was under secondary mental health care. In the three months prior to her death Jean’s mental health deteriorated and she engaged in serious self-harm to manage her suicidal thoughts. At this time all those involved with Jean knew she was experiencing suicidal thoughts and was expressing an intention to hang herself and was impulsive. Jean had two hospital admissions in the three weeks before her death and during this time support staff at Jean’s accommodation and Jean’s care co-ordinator were clearly communicating to the acute hospital where Jean was admitted on both occasions that they could not keep Jean safe in the community in her supported accommodation and that they were concerned that Jean was going to hang herself. Seven days before Jean’s death a decision was taken by a consultant psychiatrist to discharge Jean from hospital nine hours after she had been admitted and at time when Jean was still actively experiencing suicidal thoughts. This decision was taken without any consultation with the professionals involved with Jean and there was no risk assessment of Jean’s risk of suicide undertaken by the consultant before Jean was discharged. I find that these actions including the decision to discharge Jean from hospital constitute a gross failure to provide Jean with basic medical attention which she obviously needed and that this contributed to Jean’s death. On the day of her death Jean experienced a mental health crisis at her supported accommodation and was threatening to hang herself. This was known to support staff at Jean’s supported accommodation and Jean’s care co-ordinator but despite this an inadequate safety plan was put in place to safeguard Jean. Jean was left unattended for between 20 – 45 minutes during which time Jean took her own life by hanging. I find that the failure to put in place a robust safety plan and leaving Jean unattended constitute a gross failure to provide Jean with basic medical attention which she obviously needed and that this contributed to Jean’s death.
I find that Jean took her own life and that she intended to do so, and that Jean’s death was contributed to by neglect.
The medical cause of death was: 1a Hanging
The conclusion of the inquest was a narrative conclusion as follows:
Jean Pike was a vulnerable women aged 54 at the time of death and had a diagnosis of Emotionally Unstable Personality Disorder and suffered from a depressive illness. Jean resided in supported accommodation and was under secondary mental health care. In the three months prior to her death Jean’s mental health deteriorated and she engaged in serious self-harm to manage her suicidal thoughts. At this time all those involved with Jean knew she was experiencing suicidal thoughts and was expressing an intention to hang herself and was impulsive. Jean had two hospital admissions in the three weeks before her death and during this time support staff at Jean’s accommodation and Jean’s care co-ordinator were clearly communicating to the acute hospital where Jean was admitted on both occasions that they could not keep Jean safe in the community in her supported accommodation and that they were concerned that Jean was going to hang herself. Seven days before Jean’s death a decision was taken by a consultant psychiatrist to discharge Jean from hospital nine hours after she had been admitted and at time when Jean was still actively experiencing suicidal thoughts. This decision was taken without any consultation with the professionals involved with Jean and there was no risk assessment of Jean’s risk of suicide undertaken by the consultant before Jean was discharged. I find that these actions including the decision to discharge Jean from hospital constitute a gross failure to provide Jean with basic medical attention which she obviously needed and that this contributed to Jean’s death. On the day of her death Jean experienced a mental health crisis at her supported accommodation and was threatening to hang herself. This was known to support staff at Jean’s supported accommodation and Jean’s care co-ordinator but despite this an inadequate safety plan was put in place to safeguard Jean. Jean was left unattended for between 20 – 45 minutes during which time Jean took her own life by hanging. I find that the failure to put in place a robust safety plan and leaving Jean unattended constitute a gross failure to provide Jean with basic medical attention which she obviously needed and that this contributed to Jean’s death.
I find that Jean took her own life and that she intended to do so, and that Jean’s death was contributed to by neglect.
Circumstances of the Death
On 18 May 2022 Jean Pike was stating that she was suicidal and intending to hang herself. Jean Pike was left unattended and unobserved for between 20 – 45 minutes. Jean Pike was then found suspended in her supported living accommodation on 18 May 2022 and declared deceased at 14.27.
Inquest Conclusion
Jean Pike was a vulnerable women aged 54 at the time of death and had a diagnosis of Emotionally Unstable Personality Disorder and suffered from a depressive illness. Jean resided in supported accommodation and was under secondary mental health care. In the three months prior to her death Jean’s mental health deteriorated and she engaged in serious self-harm to manage her suicidal thoughts. At this time all those involved with Jean knew she was experiencing suicidal thoughts and was expressing an intention to hang herself and was impulsive. Jean had two hospital admissions in the three weeks before her death and during this time support staff at Jean’s accommodation and Jean’s care co-ordinator were clearly communicating to the acute hospital where Jean was admitted on both occasions that they could not keep Jean safe in the community in her supported accommodation and that they were concerned that Jean was going to hang herself. Seven days before Jean’s death a decision was taken by a consultant psychiatrist to discharge Jean from hospital nine hours after she had been admitted and at time when Jean was still actively experiencing suicidal thoughts. This decision was taken without any consultation with the professionals involved with Jean and there was no risk assessment of Jean’s risk of suicide undertaken by the consultant before Jean was discharged. I find that these actions including the decision to discharge Jean from hospital constitute a gross failure to provide Jean with basic medical attention which she obviously needed and that this contributed to Jean’s death. On the day of her death Jean experienced a mental health crisis at her supported accommodation and was threatening to hang herself. This was known to support staff at Jean’s supported accommodation and Jean’s care co-ordinator but despite this an inadequate safety plan was put in place to safeguard Jean. Jean was left unattended for between 20 – 45 minutes during which time Jean took her own life by hanging. I find that the failure to put in place a robust safety plan and leaving Jean unattended constitute a gross failure to provide Jean with basic medical attention which she obviously needed and that this contributed to Jean’s death.
I find that Jean took her own life and that she intended to do so, and that Jean’s death was contributed to by neglect.
I find that Jean took her own life and that she intended to do so, and that Jean’s death was contributed to by neglect.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.