Daniela Pani
PFD Report
Partially Responded
Ref: 2024-0664
673 days overdue · 1 response outstanding
Response Status
Responses
2 of 3
56-Day Deadline
29 Jan 2025
673 days past deadline — 1 response outstanding
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
Concerns regarding the train station After Daniela’s death British Transport Police (BTP) prepared a ‘Post Incident Site Report’. I understand that this report was undertaken in conjunction with the station operator; in this case South Western Railways, and Network Rail. This report detailed a number of potential problems at and proposed mitigation measures. These included:
1. A lack of Samaritan signs on the platforms or within the stations. The mitigation proposed was conspicuously placed posters and/or additional signage.
2. Car park line side fencing being too low. The proposed mitigation was replacement of the fencing. The report was submitted on the 25th July 2023. Despite the passage of nearly 9 months from submission of the report to the date of the inquest the BTP officer giving evidence could not inform me whether these changes had been actioned. I was advised that this information had been requested from South Western Railways but had not been provided. On the 18th March 2024 I requested an update from BTP about the actions taken and invited them to attend the final hearing on the 25th March 2024. No information was submitted and no-one from BTP attended the final hearing. I am therefore concerned that measures to mitigate the risk of future suicides at the train station have not been implemented. Concerns regarding the 72 hour review meeting I heard evidence from a number of members of the CMHT regarding the policies, procedures and training around the completion of this important review meeting. During the course of this I heard that training and guidance did not specifically address how to deal with service users declining a visit or meeting. This is a complex area with competing demands of the duty of care, mental capacity and the autonomy of an individual to make decisions about their own care and treatment. The evidence from the CMHT Joint Service Manager was that guidance and/or training would be important for staff seeking to deal with this challenging area. This gap had not been identified by the NHS Trust in their Serious Incident Report in 2023. Following the evidence at inquest the matter has been raised internally but no changes have yet been introduced. I am concerned that the staff not being able to carry out face to face assessments in all possible cases gives rise to the risk of future deaths.
1. A lack of Samaritan signs on the platforms or within the stations. The mitigation proposed was conspicuously placed posters and/or additional signage.
2. Car park line side fencing being too low. The proposed mitigation was replacement of the fencing. The report was submitted on the 25th July 2023. Despite the passage of nearly 9 months from submission of the report to the date of the inquest the BTP officer giving evidence could not inform me whether these changes had been actioned. I was advised that this information had been requested from South Western Railways but had not been provided. On the 18th March 2024 I requested an update from BTP about the actions taken and invited them to attend the final hearing on the 25th March 2024. No information was submitted and no-one from BTP attended the final hearing. I am therefore concerned that measures to mitigate the risk of future suicides at the train station have not been implemented. Concerns regarding the 72 hour review meeting I heard evidence from a number of members of the CMHT regarding the policies, procedures and training around the completion of this important review meeting. During the course of this I heard that training and guidance did not specifically address how to deal with service users declining a visit or meeting. This is a complex area with competing demands of the duty of care, mental capacity and the autonomy of an individual to make decisions about their own care and treatment. The evidence from the CMHT Joint Service Manager was that guidance and/or training would be important for staff seeking to deal with this challenging area. This gap had not been identified by the NHS Trust in their Serious Incident Report in 2023. Following the evidence at inquest the matter has been raised internally but no changes have yet been introduced. I am concerned that the staff not being able to carry out face to face assessments in all possible cases gives rise to the risk of future deaths.
Responses
South Western Railways states that Samaritan signs are conspicuously placed at Bracknell station, and 'Managing Suicide Contact' training is now mandatory for all new employees and front-facing third-party staff. The organisation also outlined existing station safety measures and deferred responsibility for lineside fencing to Network Rail, which they have flagged.
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Dear Assistant Coroner Simpson Regulation 28 Report: Daniela Vitalia Pani We refer to your Regulation 28 report dated 28 March 2024 (the “Report”) regarding the death of Daniela Vitalia Pani (“Ms Pani”) on the railway tracks at Bracknell Train Station on 29 June 2023. SWR would like to take this opportunity to express its sincere condolences to Ms Pani’s family and friends. 1 SWR ENGAGEMENT
1.1 Within section 5 of the Report, you have made reference to the difficulties you experienced in seeking confirmation regarding what steps had been taken following the preparation of a ‘Post Incident Site Report’ into Ms Pani’s death undertaken by the British Transport Police (“BTP”). There is reference to SWR failing to provide information about whether recommendations made by the Report had been actioned.
1.2 SWR would like to assure you from the outset that it takes its engagement with Coronial investigations seriously and is committed to assisting Coroners where SWR holds relevant information. SWR would like to start by providing you with an explanation for any confusion or miscommunication which may have impacted your investigation and prevented SWR from assisting you.
1.3 SWR were involved in the immediate response to the incident and fully cooperated with BTP’s post incident investigations. This included having an SWR Representative, RCO Barry Osborne, present at the post incident site visit (the investigation which preceded the post incident site report) conducted by BTP.
1.4 BTP sent the post incident site report to SWR following the investigation, but SWR were not informed of the commencement of the Inquest. It has come to SWR’s attention that BTP tried to contact SWR about the Inquest using an incorrect email address, but due to the error in the contact address used this was not received by SWR. As a result, SWR were unaware of the Inquest and the subsequent request for information.
1.5 SWR has taken steps to make sure that BTP has the correct contact details. We would also ask that if any further contact is needed, correspondence is sent to SWR’s Head of Security and Safety Assurance, Mr O’Riordan, who has provided his contact details to your office separately. Mr O’Riordan will act as a single point of contact and will be able to assist if information is required in any future investigations. 2 THE REPORT
2.1 Within section 5 of the Report, which sets out the basis for your concern that there is a risk that future deaths could occur unless action is taken, you have set out areas of concern regarding Bracknell train station, specifically two areas of concern arising from the post-incident site report prepared by BTP: (a) A lack of Samaritan signage; and (b) Car park line fencing being too low.
2.2 SWR has considered these areas of concern and sets out its response to each of them below. 3 SAMARITAN SIGNAGE
3.1 Signage at the station
3.2 There are 4 Samaritan signs on the platform at Bracknell train station. These are in prominent locations, including on all platform end gates and on a lamppost.
3.3 SWR have included photographs of these signs for your consideration at Annex A.
3.4 There is 1 Samaritan sign situated within the station, which is located near the ticket office. The station itself is staffed by means of a gate line between 06.00 and 22.00 hours, meaning there is a member of either SWR or contracted staff always present at the station between these times.
3.5 Since this incident, no additional signs have been placed at Bracknell station and there is currently no intention to place any additional signs at Bracknell station. The signage has been reviewed and has been assessed as appropriate. SWR have set out the background to that conclusion below to assist you in understanding what steps have been taken following this incident.
3.6 Consultation with the Samaritans
3.7 A risk analysis is undertaken by the Samaritans at every station to determine the level of signage to implement. There are various human and psychological factors which must be measured when considering the number of signs and the placement of the signs across the station. This assessment is necessary to balance the provision of information and support to deter suicide and suicide attempts against the unwanted advertisement of the suicide potential of a site. The risk of deliberate unauthorised access to the tracks must also be balanced against the control measures required to mitigate the risks of unintentional/accidental unauthorised access to the tracks.
3.8 SWR work with the Samaritans to place signage where both parties consider it to have the most effective engagement. SWR cannot, however, unilaterally increase the number of signs at a station without consultation and the consent of the Samaritans.
3.9 As a result, the Samaritan signage is as listed at paragraph 3.1 above and no additional signage has been added. Bracknell train station was not considered a priority location for trespass and welfare concerns. The station has not experienced a prevalence of unauthorised access (either into the confines of the station itself by those not authorised to be in the station or from those within the station gaining access to prohibited areas such as the tracks) nor has it experienced a prevalence of suicide or suicide attempts. Please see paragraph 4 below for more details as to how SWR manages the risk of unauthorised access.
3.10 SWR’s senior security manager, Matthew Smith, has also recently undertaken a full review of Samaritan signage across all stations on the SWR route. This was to check correct placement, wear and tear (fading), and the display of the correct information and phone numbers. Bracknell did not require any replacement signs as their signage in place was sufficient. As set out above, this did not include the provision for new signage as this is an agreed process with the Samaritans themselves. 4 CAR PARK LINE FENCING
4.1 The car park perimeter fencing at Bracknell train station is the responsibility of Network Rail (“NR”), not SWR. Responsibility for management of the station infrastructure is governed by the lease agreement between SWR and
NR. If it assists the Coroner, SWR has provided further detail in the next paragraph on the general delineation of responsibilities between NR and SWR across the rail network.
4.2 NR is responsible for the operation and management of railway infrastructure. They own, operate, maintain and develop the main rail network in Great Britain including the railway tracks, junctions, bridges, tunnels and level crossings. NR is also the landlord for almost all stations on the national network. SWR and other train-operating companies (“TOCs”) lease train stations from NR and manage them in accordance with lease agreements. Each specific agreement determines responsibility for the management of each site, but NR retains responsibility for aspects of the infrastructure (which often includes fencing) at the majority of stations. Bracknell train station is leased to SWR in this way.
4.3 SWR is responsible for site management at the stations it leases from NR, including ticket barriers/ticket office, staffing and security. SWR has the following arrangements in place relevant to both the management of unauthorised access and the risks associated with the platform train interface which are designed to mitigate the risks of both deliberate and accidental unauthorised access to the tracks at Bracknell train station: (a) The station can only be accessed via the ticket office and is staffed from 06:00 – 22:00 seven days a week. (b) Between these hours, there is a staffed gate to access the station. Outside of these hours, there is a night gate which allows passengers to enter and leave the station when their trains arrives or depart. (c) All SWR staff at the station are trained to look out for passengers in distress or who may be a concern for welfare. Managing Suicide Contact is a course delivered both in house and by the Samaritans that is now mandatory for all new employees of SWR, it is also a course that all third-party suppliers contracted to SWR must now deliver to their front facing staff. It is specifically in place to identify those in crisis. (d) The placement of Samaritan signage as set out above at paragraph 3 and Annex A. (e) Tactiles at the platform edge to assist vulnerable passengers in locating the platform edge. (f) The platforms include signage relating to platform/train interface (e.g. the yellow line and the instructions to stand back). (g) There are automated tannoy announcements asking passengers to stand behind the yellow line, announcing scheduled arrivals and warning of through trains (non-stop services). (h) There are electronic timetables indicating the scheduled arrivals and which also display written warnings alongside the tannoy announcements at (g) regarding through trains (non-stop services).
4.4 A representative from NR was present at the post incident site visit and NR were identified by BTP in the post incident site report as the ‘Owner’ of action 6 which relates to car park lineside fencing. NR are therefore best placed to respond to this concern.
4.5 Nevertheless, SWR work closely with NR and have flagged the issue raised by you of the lineside fencing. We trust that the above is of assistance but if you require any further information, please do not hesitate to contact us.
1.1 Within section 5 of the Report, you have made reference to the difficulties you experienced in seeking confirmation regarding what steps had been taken following the preparation of a ‘Post Incident Site Report’ into Ms Pani’s death undertaken by the British Transport Police (“BTP”). There is reference to SWR failing to provide information about whether recommendations made by the Report had been actioned.
1.2 SWR would like to assure you from the outset that it takes its engagement with Coronial investigations seriously and is committed to assisting Coroners where SWR holds relevant information. SWR would like to start by providing you with an explanation for any confusion or miscommunication which may have impacted your investigation and prevented SWR from assisting you.
1.3 SWR were involved in the immediate response to the incident and fully cooperated with BTP’s post incident investigations. This included having an SWR Representative, RCO Barry Osborne, present at the post incident site visit (the investigation which preceded the post incident site report) conducted by BTP.
1.4 BTP sent the post incident site report to SWR following the investigation, but SWR were not informed of the commencement of the Inquest. It has come to SWR’s attention that BTP tried to contact SWR about the Inquest using an incorrect email address, but due to the error in the contact address used this was not received by SWR. As a result, SWR were unaware of the Inquest and the subsequent request for information.
1.5 SWR has taken steps to make sure that BTP has the correct contact details. We would also ask that if any further contact is needed, correspondence is sent to SWR’s Head of Security and Safety Assurance, Mr O’Riordan, who has provided his contact details to your office separately. Mr O’Riordan will act as a single point of contact and will be able to assist if information is required in any future investigations. 2 THE REPORT
2.1 Within section 5 of the Report, which sets out the basis for your concern that there is a risk that future deaths could occur unless action is taken, you have set out areas of concern regarding Bracknell train station, specifically two areas of concern arising from the post-incident site report prepared by BTP: (a) A lack of Samaritan signage; and (b) Car park line fencing being too low.
2.2 SWR has considered these areas of concern and sets out its response to each of them below. 3 SAMARITAN SIGNAGE
3.1 Signage at the station
3.2 There are 4 Samaritan signs on the platform at Bracknell train station. These are in prominent locations, including on all platform end gates and on a lamppost.
3.3 SWR have included photographs of these signs for your consideration at Annex A.
3.4 There is 1 Samaritan sign situated within the station, which is located near the ticket office. The station itself is staffed by means of a gate line between 06.00 and 22.00 hours, meaning there is a member of either SWR or contracted staff always present at the station between these times.
3.5 Since this incident, no additional signs have been placed at Bracknell station and there is currently no intention to place any additional signs at Bracknell station. The signage has been reviewed and has been assessed as appropriate. SWR have set out the background to that conclusion below to assist you in understanding what steps have been taken following this incident.
3.6 Consultation with the Samaritans
3.7 A risk analysis is undertaken by the Samaritans at every station to determine the level of signage to implement. There are various human and psychological factors which must be measured when considering the number of signs and the placement of the signs across the station. This assessment is necessary to balance the provision of information and support to deter suicide and suicide attempts against the unwanted advertisement of the suicide potential of a site. The risk of deliberate unauthorised access to the tracks must also be balanced against the control measures required to mitigate the risks of unintentional/accidental unauthorised access to the tracks.
3.8 SWR work with the Samaritans to place signage where both parties consider it to have the most effective engagement. SWR cannot, however, unilaterally increase the number of signs at a station without consultation and the consent of the Samaritans.
3.9 As a result, the Samaritan signage is as listed at paragraph 3.1 above and no additional signage has been added. Bracknell train station was not considered a priority location for trespass and welfare concerns. The station has not experienced a prevalence of unauthorised access (either into the confines of the station itself by those not authorised to be in the station or from those within the station gaining access to prohibited areas such as the tracks) nor has it experienced a prevalence of suicide or suicide attempts. Please see paragraph 4 below for more details as to how SWR manages the risk of unauthorised access.
3.10 SWR’s senior security manager, Matthew Smith, has also recently undertaken a full review of Samaritan signage across all stations on the SWR route. This was to check correct placement, wear and tear (fading), and the display of the correct information and phone numbers. Bracknell did not require any replacement signs as their signage in place was sufficient. As set out above, this did not include the provision for new signage as this is an agreed process with the Samaritans themselves. 4 CAR PARK LINE FENCING
4.1 The car park perimeter fencing at Bracknell train station is the responsibility of Network Rail (“NR”), not SWR. Responsibility for management of the station infrastructure is governed by the lease agreement between SWR and
NR. If it assists the Coroner, SWR has provided further detail in the next paragraph on the general delineation of responsibilities between NR and SWR across the rail network.
4.2 NR is responsible for the operation and management of railway infrastructure. They own, operate, maintain and develop the main rail network in Great Britain including the railway tracks, junctions, bridges, tunnels and level crossings. NR is also the landlord for almost all stations on the national network. SWR and other train-operating companies (“TOCs”) lease train stations from NR and manage them in accordance with lease agreements. Each specific agreement determines responsibility for the management of each site, but NR retains responsibility for aspects of the infrastructure (which often includes fencing) at the majority of stations. Bracknell train station is leased to SWR in this way.
4.3 SWR is responsible for site management at the stations it leases from NR, including ticket barriers/ticket office, staffing and security. SWR has the following arrangements in place relevant to both the management of unauthorised access and the risks associated with the platform train interface which are designed to mitigate the risks of both deliberate and accidental unauthorised access to the tracks at Bracknell train station: (a) The station can only be accessed via the ticket office and is staffed from 06:00 – 22:00 seven days a week. (b) Between these hours, there is a staffed gate to access the station. Outside of these hours, there is a night gate which allows passengers to enter and leave the station when their trains arrives or depart. (c) All SWR staff at the station are trained to look out for passengers in distress or who may be a concern for welfare. Managing Suicide Contact is a course delivered both in house and by the Samaritans that is now mandatory for all new employees of SWR, it is also a course that all third-party suppliers contracted to SWR must now deliver to their front facing staff. It is specifically in place to identify those in crisis. (d) The placement of Samaritan signage as set out above at paragraph 3 and Annex A. (e) Tactiles at the platform edge to assist vulnerable passengers in locating the platform edge. (f) The platforms include signage relating to platform/train interface (e.g. the yellow line and the instructions to stand back). (g) There are automated tannoy announcements asking passengers to stand behind the yellow line, announcing scheduled arrivals and warning of through trains (non-stop services). (h) There are electronic timetables indicating the scheduled arrivals and which also display written warnings alongside the tannoy announcements at (g) regarding through trains (non-stop services).
4.4 A representative from NR was present at the post incident site visit and NR were identified by BTP in the post incident site report as the ‘Owner’ of action 6 which relates to car park lineside fencing. NR are therefore best placed to respond to this concern.
4.5 Nevertheless, SWR work closely with NR and have flagged the issue raised by you of the lineside fencing. We trust that the above is of assistance but if you require any further information, please do not hesitate to contact us.
Berkshire Healthcare NHS has reviewed its training and guidance, developing a new algorithm for staff to follow when a service user declines a 72-hour review meeting. The Trust has also implemented additional pre-discharge guidance, developed a targeted risk audit for complex cases, and updated its peer review process to focus on post-discharge follow-up.
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Dear Sir
I write in relation to the above inquest which concluded on 28 March 2024.
On 28 March 2024 you made 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. Your report was sent to:
– CEO Berkshire Healthcare NHS Foundation Trust British Transport Police
– Interim Managing Director South-Western Railway
I am writing to provide you with the Berkshire Healthcare response which relates to your concerns about training and guidance for staff on how to deal with service users declining a 72-hour review meeting. Specifically, staff not being able to carry our face-to-face assessments in all possible cases.
The Trust recognise how challenging it is for clinicians when a patient prefers not to have a face-to-face review within the expected 72-hour period. Our existing training and guidance focused on staff making a clinical decision based on their knowledge of the patient, input from family/carer where possible and the current risk assessment. There is national guidance available, and this informed our approach. This NICE1 guidance states:
1. Ensure the aim of care and support of people in transition is person-centred and focused on recovery.
2. Work with people as active partners in their own care and transition planning.
3. Support people in transition in the least restrictive setting available (in line with the Mental Health Act Code of Practice).
4. Record the needs and wishes of the person at each stage of transition planning and review.
1 Overview | TransiƟon between inpaƟent mental health seƫngs and community or care home seƫngs | Guidance | NICE London House London Road Bracknell Berkshire RG12 2UT Tel:
5. Identify the person's support networks. Work with the person to explore ways in which the people who support them can be involved throughout their admission and discharge. This guidance goes on to say:
"Health and social care practitioners in the hospital and community should plan discharge with the person and their family, carers or advocate. They should ensure that it is collaborative, person- centred and suitably paced, so the person does not feel their discharge is sudden or premature".
In light of the guidance and also our clinical experience the Trust do not feel having a blanket rule about enforcing a face-to-face meeting in all possible cases would be helpful for the patient/practitioner relationship, nor would this approach prevent a future death, it may even increase the risk of suicide by adversely impacting the therapeutic relationship and increasing feelings of hopelessness.
Therefore, the approach the Trust has taken focuses on enhancing the existing clinical risk training and guidance for staff to include an increased focus on a collaborative risk formulation and safety planning. This includes a specific skills component on:
1. Engaging with the patient to understand why they do not want the face-to-face review.
2. Escalating to supervisor to consider decision making collaboratively.
3. Involving the family/carer if possible. In addition to this we have provided additional guidance for 72-hour follow up and a short film clip for staff on how to deal with a person refusing or postponing the face-to-face appointment (this approach would still require a clinical judgement).
Trust Guidance for 72-hour follow up:
1. Establish the reason why the person cannot/prefers not to attend. Do this by engaging with the person, asking specifically about the following:
• What is the reason they cannot attend?
• What can we do to support them to attend?
• Explain why this follow up is important (it can be a time of increased risk/need for some people, we want to help and it is an opportunity to see how they are getting on having been recently discharged)
2. Explain the importance of the appointment and attempt to be as flexible as possible with the 72-hour window. Offer a choice of location to overcome practical barriers.
3. Refer to the safety plan and the recent discharge plan.
4. Rule out imminent risks associated with withheld suicidal intent or ambivalence.
5. Involve family/carers if possible (see film clip).
6. Involve your manager or supervisor.
7. Options if you are concerned the person may be concealing their intent or they are at risk of harming themselves or others:
• Cold calling anyway (see guidance on how to approach this),
• Arranging a Mental Health Act assessment, the family/carer if possible and MDT should be involved in the decision making to request this.
8. If you feel there is a legitimate practical reason to postpone the face to face and you have determined it is safe to do so, you must discuss this and seek support from service manager or their deputy and the patient's family/carer if possible. If all agree you can then arrange a telephone or video call with the face to face to follow asap (see guidance on what to cover in the follow up if you are unsure).
9. Always clearly record all steps taken in RiO. In addition to the above, we have also provided additional pre discharge guidance for staff in the inpatient setting on including the detail, expectations and importance of 72-hour reviews within the discharge safety plan. During this conversation any barrier to attending the 72-hour review will also be explored.
To ensure the new training and guidance is impactful the Trust has developed a targeted risk audit that focuses on more complex cases where refusal may be more likely. A peer review process was already in place, and it now includes a focus on post discharge follow up and the safety planning process. We are also using the NCISH2 safer wards audit tool which focuses on 72-hour follow up. The Trust Quality and Safety meetings at service and executive level already monitor 72-hour follow up as it is a tracker metric, the compliance is high (100% in March 24).
As a Trust, the safety and wellbeing of those we provide services to is paramount and despite the unfortunate circumstances in which this query has arisen, we welcome the opportunity HM Assistant Coroner has provided for us to review and enhance the training and guidance for staff on how to deal with service users declining a 72-hour review meeting.
I write in relation to the above inquest which concluded on 28 March 2024.
On 28 March 2024 you made 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. Your report was sent to:
– CEO Berkshire Healthcare NHS Foundation Trust British Transport Police
– Interim Managing Director South-Western Railway
I am writing to provide you with the Berkshire Healthcare response which relates to your concerns about training and guidance for staff on how to deal with service users declining a 72-hour review meeting. Specifically, staff not being able to carry our face-to-face assessments in all possible cases.
The Trust recognise how challenging it is for clinicians when a patient prefers not to have a face-to-face review within the expected 72-hour period. Our existing training and guidance focused on staff making a clinical decision based on their knowledge of the patient, input from family/carer where possible and the current risk assessment. There is national guidance available, and this informed our approach. This NICE1 guidance states:
1. Ensure the aim of care and support of people in transition is person-centred and focused on recovery.
2. Work with people as active partners in their own care and transition planning.
3. Support people in transition in the least restrictive setting available (in line with the Mental Health Act Code of Practice).
4. Record the needs and wishes of the person at each stage of transition planning and review.
1 Overview | TransiƟon between inpaƟent mental health seƫngs and community or care home seƫngs | Guidance | NICE London House London Road Bracknell Berkshire RG12 2UT Tel:
5. Identify the person's support networks. Work with the person to explore ways in which the people who support them can be involved throughout their admission and discharge. This guidance goes on to say:
"Health and social care practitioners in the hospital and community should plan discharge with the person and their family, carers or advocate. They should ensure that it is collaborative, person- centred and suitably paced, so the person does not feel their discharge is sudden or premature".
In light of the guidance and also our clinical experience the Trust do not feel having a blanket rule about enforcing a face-to-face meeting in all possible cases would be helpful for the patient/practitioner relationship, nor would this approach prevent a future death, it may even increase the risk of suicide by adversely impacting the therapeutic relationship and increasing feelings of hopelessness.
Therefore, the approach the Trust has taken focuses on enhancing the existing clinical risk training and guidance for staff to include an increased focus on a collaborative risk formulation and safety planning. This includes a specific skills component on:
1. Engaging with the patient to understand why they do not want the face-to-face review.
2. Escalating to supervisor to consider decision making collaboratively.
3. Involving the family/carer if possible. In addition to this we have provided additional guidance for 72-hour follow up and a short film clip for staff on how to deal with a person refusing or postponing the face-to-face appointment (this approach would still require a clinical judgement).
Trust Guidance for 72-hour follow up:
1. Establish the reason why the person cannot/prefers not to attend. Do this by engaging with the person, asking specifically about the following:
• What is the reason they cannot attend?
• What can we do to support them to attend?
• Explain why this follow up is important (it can be a time of increased risk/need for some people, we want to help and it is an opportunity to see how they are getting on having been recently discharged)
2. Explain the importance of the appointment and attempt to be as flexible as possible with the 72-hour window. Offer a choice of location to overcome practical barriers.
3. Refer to the safety plan and the recent discharge plan.
4. Rule out imminent risks associated with withheld suicidal intent or ambivalence.
5. Involve family/carers if possible (see film clip).
6. Involve your manager or supervisor.
7. Options if you are concerned the person may be concealing their intent or they are at risk of harming themselves or others:
• Cold calling anyway (see guidance on how to approach this),
• Arranging a Mental Health Act assessment, the family/carer if possible and MDT should be involved in the decision making to request this.
8. If you feel there is a legitimate practical reason to postpone the face to face and you have determined it is safe to do so, you must discuss this and seek support from service manager or their deputy and the patient's family/carer if possible. If all agree you can then arrange a telephone or video call with the face to face to follow asap (see guidance on what to cover in the follow up if you are unsure).
9. Always clearly record all steps taken in RiO. In addition to the above, we have also provided additional pre discharge guidance for staff in the inpatient setting on including the detail, expectations and importance of 72-hour reviews within the discharge safety plan. During this conversation any barrier to attending the 72-hour review will also be explored.
To ensure the new training and guidance is impactful the Trust has developed a targeted risk audit that focuses on more complex cases where refusal may be more likely. A peer review process was already in place, and it now includes a focus on post discharge follow up and the safety planning process. We are also using the NCISH2 safer wards audit tool which focuses on 72-hour follow up. The Trust Quality and Safety meetings at service and executive level already monitor 72-hour follow up as it is a tracker metric, the compliance is high (100% in March 24).
As a Trust, the safety and wellbeing of those we provide services to is paramount and despite the unfortunate circumstances in which this query has arisen, we welcome the opportunity HM Assistant Coroner has provided for us to review and enhance the training and guidance for staff on how to deal with service users declining a 72-hour review meeting.
Report Sections
Investigation and Inquest
On 04 July 2023 I commenced an investigation into the death of Daniela Vitalia PANI aged 57. The investigation concluded at the end of the inquest on 28 March 2024. The conclusion of the inquest was that: On the 29th June 2023 Daniela Vitalia Pani died at after deliberately leaving the platform as a train approached and remaining on the tracks until she was struck by the train. She had suffered from a serious and enduring mental health problem for most of her adult life and was under the care of the mental health services at the time of her death.
Circumstances of the Death
Daniela had suffered from bi-polar affective disorder for many years. Over the course of 2022 her mental health deteriorated and she then came under the care of the Community Mental Health Team (CMHT) and Crisis Resolution Home Treatment Team (CRHTT); which are services provided by the Berkshire Healthcare NHS Foundation Trust. In May 2023 this culminated in her admission, as a voluntary patient, to an in-patient ward at Prospect Park Hospital. Daniela was discharged from Prospect Park Hospital on the 26th June 2023 after her condition appeared to have stabilised. There was a care package in place for her in the community involving the CMHT and a care agency. On the 28th June 2023 Daniela was due to have a review meeting with a member of the CMHT. This is known as a 72 hour review and is required due to the knowledge that there is a heightened risk to persons at periods of transition; such as discharge from an in-patient unit. Daniela telephoned the CMHT on that morning to say that she was unwell and to cancel the visit to her. The CMHT best practice guidance states that a 72 hour review should take place face to face and that telephone reviews should only be used as a rare exception once all avenues to arrange a face to face meeting have been exhausted. After speaking to her manager, the CMHT member undertook the 72 hour review meeting with Daniela via telephone on the 28th June 2023. During this review Daniela denied that she had any intent to harm herself. Later that day Daniela twice called the CRHTT Crisis Line. The CRHTT nurse on duty reassured Daniela, carried out some safety planning and assessed Daniela as not posing an imminent risk to herself such that required an immediate intervention. On the 29th June 2023 Daniela got a taxi to and entered the station. As a train approached the platform shortly after 9.00am Daniela jumped onto the tracks and was struck by the train. The impact caused a severe head injury and Daniela was sadly declared deceased at the scene.
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