Dear Ms Pountney

Regulation 28 Response: Ms. Sophie Towle

I write in response to the inquest which was concluded on 24 October 2025 into the death of Ms Sophie Towle. We accept your findings in relation to the received Regulation 28 and offer our sincere apologies to the family of Sophie.

Please find below the Trust response in relation to the relevant matters of concern and actions taken.

Lack of joint agency policy/cross-sector working between physical and mental health Trusts in relation to the insertion of foreign bodies

Staff at Nottinghamshire Healthcare Foundation Trust (NHFT) and Sherwood Forest Hospital Trust (SFHT) have collaborated on creating a joint management policy that provides guidance to staff on the management of patients who have inserted a foreign body. This includes the recommendation of joint meetings to support joined up collaborative care for patients requiring support from both services. This is being trialled for three months, and the impact of its use will be reviewed.

Sherwood Forest Hospitals shared the draft of the policy for the management of insertion of foreign bodies for input from mental health services. We have reviewed from a Liaison Psychiatry and inpatient perspective and agreed interface and actions alongside the need

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for multi-agency joint reviews where indicated. The roles and responsibilities of each agency are outlined in this policy.

VTE risk assessment and associated policy and training at Nottinghamshire Healthcare Foundation Trust

a. The staff do not have a proper working knowledge of the current local VTE policy.

We have worked with our E-learning department to create an electronic link to the policy and competency questions to ensure that people have both read and understand the implications of the policy to their practice. It will be reportable so that there is oversight and assurance that all who need to be aware of the policy have read it. This has been trialled as a pilot to ensure it is effective and functional prior to being fully rolled out and will report into the Urgent Care Improvement Group for ongoing oversight.

b. The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.

E-learning training for medical staff members has recently gone live and uptake will now be monitored for compliance. The e-learning was created as a bespoke module recognising that the modules available on Learning for Healthcare were only relevant to physical acute hospitals and primary care. The locally developed Trust module also places significant focus on the risks of VTE associated with Psychiatry. The development of this module is aligned to the NICE guidance (Venous thromboembolism in over 16s) and the evidence base available through Thrombosis UK online source.

A reflective learning session was facilitated on the 22 July 2024 with the medical team involved in Sophie’s care by a Trust GP and the Associate Director for Physical Health. This learning was also shared via presentation to the Resident Doctors Forum on the 16 July 2024 and shared through the physical health forum for wider consideration across services.

The Electronic Patient Record system RiO was updated in June 2024 to ensure clarity that all inpatients require VTE assessment with a mandatory field of actions to be taken if there are risk factors identified. This also includes a risk alert activation on the patient’s electronic record. Amendments were made to the VTE risk assessment template form within the Electronic Patient Record system RiO in June 2024 to ensure clarity that all inpatients require a VTE risk assessment on admission with the addition of a mandatory field of actions to been taken if there are risk factors identified. This also includes a risk alert activation on the patient’s electronic record.

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Additional training was delivered to Fir Ward staff to support identification of a deteriorating patient, this included simulations and tabletop National Early Warning Scores (NEWS2) reviews.

To increase staff awareness a VTE poster has been developed and is displayed in ward offices and clinic rooms. The Trust VTE policy was reviewed and updated in April 2025 to amend the frequency of re-assessment of VTE risk, provide clarity on which patients require re-assessment of VTE risk and the training expectations of those performing VTE risk assessments.

An E-Learning module for VTE risk prevention and management for medical staff within the trust has been developed, which has been peer reviewed with consultants from other mental health trusts and is now live with the expectation of this being annual essential training.

The ‘Fundamentals of Care’ training package developed for Nursing and Allied Health Professional Staff was updated in May 2025 to include VTE risk assessment alongside recognition, assessment and actions required in relation to other essential physical health conditions. There have been 1084 staff trained to date and further regular sessions as part of the trust training offer.

VTE assessment has been added as a metric in the Trust’s Integrated Performance Report to ensure adequate visibility, governance and assurance.

VTE Assessment is included in the Safe Now Dashboard which ensures weekly Associate Director of Nursing (ADON) oversight and is reported up to the Trust Executive Leadership Team.

c. The current policy has been weakened in its terms, in particular at paragraph
1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.

The revised policy was reviewed in line with NICE guidance (Venous thromboembolism in over 16s; reducing the risk of hospital acquired deep vein thrombosis or pulmonary embolism, 2019)., As part of the review of the policy, policies from 4 other mental health organisations were reviewed for comparison on standards relating to VTE risk re-

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assessment. The review of our policy and subsequent changes are in line with other mental health organisations.

The policy expects that VTE reassessment is carried out at the time of a change in clinical condition or risk. This has been reflected within adult mental health services inpatient areas within the daily board review process which now includes prompts relating to VTE risks and reassessment. This is a daily process to adhere to the requirement to early identification of change rather than a previous focus on re-assessment at least weekly which could have resulted in further missed opportunities. This process ensures timely identification and response to a change in risk factors.

Within the ward based weekly Multi-disciplinary Team (MDT) meetings, a review of VTE risk changes remains within the template to ensure the team are considering any identified new changes that have occurred since the previous MDT which have led to the need for reassessment.

Ward Managers or the nurse in charge of the ward attends daily ‘Safe Care Meetings’. This is a meeting where staffing, clinical needs, acuity and other factors impacting on the wards are raised to the Matrons and Head of Nursing. This reports into a daily Sit-Rep meeting which reviews any issues of concern or unmet needs and either provides, authorises or further escalates unmet needs for action to senior levels in the Trust.

The VTE policy reflects the expected standard across our Trust inpatient services. It is recognised that the local systems, processes and practice need to be included and reflected within the Trust policy. Within the next 3 months, an appendix will be added to the policy outlining the local approach across our inpatient services in delivering practice against this policy standard.

The disbanding of the Personality Disorder Hub at NHCT

In line with wider community mental health service improvements, the Personality Disorder pathway has been reviewed and an associated improvement plan developed. The pathways consist of two parts: a hub, which is senior clinical leads, and the spoke part, which relates to the clinical staffing linked to each local mental health team. As part of the Improvement Plan, the Personality Disorder Hub has not been disbanded. Key clinical leads from within the Hub will remain in place to ensure ongoing oversight of the clinical interventions, development of the clinical pathway and oversee and evaluate clinical effectiveness. Changes to the spoke part of the pathway has been made which is in relation to the line management of the staff within the spoke part of the personality disorder pathway. Further details in relation to this are outlined below.

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Background

The Personality Disorder pathway was implemented in 2021/ 2022 in line with NHS England recommendations (https://www.longtermplan.nhs.uk/publication/nhs-mental-health- implementation-plan-2019-20-2023-24/ with an ambition to create a clear Personality Disorder treatment pathway, improve access to evidence-based psychological therapies, reduce waiting times and increase available staff training on Personality Disorders. The changes aimed to include ensuring equity in the offering of specialist psychological therapies for Personality Disorder, employing specialised Personality Disorder Practitioners placed within Local Mental Health Teams (LMHT) in liaison roles and offering training and guidance to Trust-wide services.

As part of the improvement programme of works for mental health community services, the Personality Disorder Pathway was highlighted as an area of concern. This follows an independent evaluation carried out by the University of Nottingham and the Institute of Mental Health (IMH) and a more recent report in 2024 from Jonathan Warren that consisted of an evaluation of the service and an externally commissioned review of the functioning of community mental health services.

To further assess the current service provision the pathway was reviewed and benchmarked against NHSE Maturity Index for Complex Emotional Needs in March 2025. This is a national tool to support organisations and whole systems of community transformation in assessing their level of service development to deliver transformed services for people with personality difficulties across the breadth of the community and in a way that supports people to access services at the right time and place to meet their needs appropriately.

The maturity index applies to those involved in the leadership, management and delivery of services, in primary care, secondary care, the voluntary sector, local authorities and most importantly those people with lived experience of the system and services. It consists of a series of questions and prompts that are drawn from the ‘Annexes: Guidance to help development of 2021/22 proposals for adult and older adult community mental health transformation funding’, the 3 year community mental health roadmap with supporting annexes, Mental Health Implementation Plan 2019-2024, and the case for change document National Confidential Inquiry into Suicide and Safety in Mental Health Report (NCISH).

The Maturity Index is a benchmarking document based upon The Community Mental Health Roadmap which was developed as part of the national transformation programme to guide systems in considering the key elements required to deliver community transformation at a system wide level.

The roadmap is broken down into both the specifics for complex emotional needs services as well as the critical core elements of service. (see figure 1 below).

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Figure 1

Findings of the Review and Next Steps

Governance & Leadership Of the ten specific core domains three areas were deemed not to be in place and action was required which were a strategic planning and working group in place to meet the core needs of people with a Personality Disorder inclusive of key stake holders from VCSE, third sector and Primary Care, inclusive of joint working with the Trust’s Chief Psychological Professions Officer. A further unmet need was in relation to the wider concept of ‘No Wrong Door’ approach and wider collective responsibility for a patient’s treatment. Two domains were found not to be in place but actions in place to address which was having in place a specific planning meeting, it was recognised there is currently a fortnightly oversight meeting however this was commissioned by the Care Group Nurse, AHP & Quality Director as part of the wider Improvement plan, with aims to agree the longer term planning group and a gap in relation to longer term strategic planning with clear ambitions, outcomes and deliverables with milestones.

Four domains were rated as being in place but need improvement; these were a lead professional being in post, although there is a named individual, issues were found in relation to the resilience of this role, wider strategic and system support needed. Lead professional feeding into pathway steering group, although this was in place initially this was stood down and needs to be recommissioned following the improvement group work. Experts by experience are part of the core model however it was identified that this needs

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to be stronger and more visible and lastly there was very limited provision to measure patient experience. There are no agreed and rolled out patient rated outcome Measures (PROMS) in line with national recommendations although Core 10 (a patient rated outcome measure) is in place. One domain was found to be working well and that was having a dedicated Psychologist with significant clinical expertise within this field of practice.

Establishment & Core Function On review of these 24 domains 13 were rated to be not in place and include access to CAT therapy, a clear clinical model identifies modes of treatment, adopted principles across inpatient and crisis services, training to crisis and inpatient teams alongside governance over longer stay inpatient admissions and interlinked pathway. Eight areas were identified as being in place but required improvement which include the range of evidence based interventions, MBT is available but not part of the Adult Mental Health or clinical pathway, no clear strategy to access Health Education England (HEE) funded training places, wider training with a focus on partner in primary care and subsequent developed relationships, three domains were assessed as working well and this was Dialectical Behaviour Therapy (DBT) being part of the pathway however no current data on demand and no current waiting list, adherence to evidencing criteria for level 2 inpatient rehabilitation but not for acute and wider support for carers growing with the carer support worker roles.

Intervention and Support Across the Core Mental Health Teams This section incorporates ten domains, six domains rated as not being in place and requires action; these include sections such as wider link and scoping with Primary Care, Local Authority, inclusive of GP leads being in place and supporting with work, engagement with Voluntary, Community, Social Enterprise (VCSE) and wider working as a holistic MDT, evidence of culturally sensitive interventions and wider awareness of regulating emotions across pathways. Three domains have been rated as being in place but require improvement and these are Understanding and having VCSE infrastructure as part of the wider patient pathway, a consideration of cultural differences and how these differences could present, integrated core services considering the whole person, which is partly met associated to wider roles within the LMHT. One domain was rated as working well which was having a core assessment which is based upon a biopsychosocial model.

Dedicated Function, Support and Consultation to the Local Authority, VCSE & Primary Care Two domains were rated as not being in place and require action which include having an operational model for training, consultation and support for Local Authority, VCSE, Primary Care to upskill clinicians, and a lack of function for services to reflect, consult and wider reflective thinking. Two areas rated as being in place but require improvement and these are scoping and provision of training and associated training needs, whilst some training is available there is a wider requirement needed to meet these wider core domains.

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Provision to Meet the Needs of Young People, With Alignment to Children & Young People’s Services Many domains within this section were rated as being in place but require improvement. The service does have a transitional protocol with a Young Persons transitions lead however additional improvements are required to evaluate and demonstrate changes to services based on Young People’s experiences of services alongside wider workforce development being evidencable to meet the need of this patient group.

Provision for Older Adults All four domains were rated as not in place and require action.

Embed Experts by Experience in Service Development and Delivery One domain rated as not in place and requires action which was having lived experience as part of pathway governance meetings and operational groups, two domains were rated as not being in place but actions in hand to address which is having some dedicated resource to support coproduction and principles of coproduced commissioning in place. One domain has been rated as in place but requires improvement and this is in relation to Peer Support Worker roles & lived experience roles. Three domains rated as being in place & working well and this is in relation to recruitment of lived experience roles and associated support.

Creating a Service Offer that Supports a Preventative Approach One domain rated as not being in place and requires action which was having a service in place that focuses on prevention and escalation into secondary care services, one domain was in place but needs improvement and this was around support for people waiting for intervention, one domain not in place but action in hand relating to personalised care.

Organisational Change Requirement & Consultation On completion of the maturity index, it was clear there were wider improvements required to the PD pathway for patients. An organisational change was proposed and approved by the Executive Leadership Team, the Mental Health Care Group Senior Leadership Team (SLT) and the Care Unit SLT.

The organisational change case for change stated, whilst it is clear the current Personality Disorder Service has dedicated staff that are passionate about delivering services to people with Personality Disorder, the current service configuration led to a fractured pathway where:
• Core interventions such as MBT are not properly integrated
• Inequitable waits for interventions for people that are not open to the Personality Disorder Pathway
• An inconsistent approach delivered across teams for people with a personality disorder.
• One of the key directives for the Personality Disorder Pathway was to increase access to services including to Psychological Interventions creating a needs-led,

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community-based offer could be developed for patients with the most complex needs. This would have a direct impact on admission rates to acute care which currently has not been supported by clinical data. Service change is required to ensure patient need is met, with measurable clinical outcomes and joined up pathways across the wider system.

The change that was completed integrated key workers from within the PD pathway into core local mental health teams (LMHTs). This change constituted a change in line management, as it was clear from the review that the pathways were fractured, with an inequitable service offer based upon the geographical area.

The PD Hub, which is the overarching strategic lead for Complex Emotional needs remains in place.

The Lived Experience Development Lead moved under the line management of the Associate Director of Nursing, with a broader responsibility to embed lived experience and peer support across all Local Mental Health Services. Supporting our ambition to increase the number of lived experience roles across the community.

The review identified that based on Nottinghamshire prevalence rates for Complex Emotional Needs, having a small, segregated resource was creating not only a health inequality but people with complex emotional needs were not experiencing the same level of intervention as other people with another mental health condition or diagnosis. There was also significant variation in caseload numbers some being as low as 6 for 1.0wte worker and low levels of clinical activity whilst internal community mental health waiting lists for interventions for people with Complex Emotional Needs, who were not open to the PD pathway was growing with the longest wait over 48 weeks. To support wider integration and reduce the clear health inequality, the Mental Health Practitioner (MHP) roles, community support workers and Peer Support Workers were merged into the LMHTs, continuing to work with their patient caseload, however with the same remit as their colleagues within teams.

In line with NHS organisational change processes consultation with staff from the Personality Disorder Pathway occurred from the 13 August 2025 to 24 September 2025 (extension of 2 weeks). Counter proposals were received from some staff however all had cost implications or further risks such as wider segregation and not in line with the NHS Mental Health Community Framework.

As the intention was for no reduction or closure in services, (as described within this paper, all patients open to the Personality Disorder pathway were also open to core LMHT teams) and given the two previous independent reviews and the assessment against the NHSE maturity index, no wider consultation was thought to be required, given the emphasis on improving access and reducing health inequalities.

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Impact on Clinical Activity As part of the review, attempts had been made to quantify clinical activity. The data suggested that across the core service patients accessing the Personality Disorder pathway on average received one contact per week. Clinical staffing activity was also reviewed and data recorded suggested on average that per WTE, 8 clinical contacts are delivered per week. Whilst it is recognised that some staff are currently attending additional training for 2 days per week, we would expect to see a higher level of clinical activity given that this staff group are not conducting a wider series of tasks as seen within Local Mental Health Teams.

92% of CEN (Personality Disordered) patients, were seen by the staff within the LMHTs, with only 8% being supported by the PD Spoke Service.

Due to the configuration of the separate Personality Disorder Pathway, the people that were accessing the Personality Disorder pathway were not part of core LMHT MDT oversight and planning, did not have wider access to roles such Health Improvement Workers and were not part of the daily risk oversight meetings that core LMHT services operate.

This change formed part of a wider programme of work focusing on:
1. Clear communications to all LMHT workforce regarding the expectation for all to work with and treat people with a Personality Disorder / Complex Emotional Needs.
2. Rebranding of the pathway moving away from stigmatising labels of diagnosis.
3. Development of a workforce training plan for all clinical staff within LMHTs to meet the needs of people with Complex Emotional Needs inclusive of SCM training.
4. Review of roles aligned to the Hub alongside development and clarification of key areas of accountability and responsibility.
5. Ensuring that the pathway is psychologically informed and therefore the lead is recommended to be a psychologist by professional registration.
6. Consideration of the wider roles and need for a Nurse Consultant, working part clinically.
7. Identifying key areas of training and wider pathway resilience across core community services.
8. Redesign of the Hub consultation meeting in terms of ToR and attendees.
9. MBT service to be relocated to AMH Community Services. Wider work as part of this is to explore the form and function of this service to ensure fidelity.
10. Patient PROMS to be aligned to national guidance in line with wider LMHT improvement work.
11. Monthly pathway steering group to be initiated that also considers specific Equality, Diversity & Inclusion data and enablement strategies.
12. Clear clinical pathways to be developed across Acute and Crisis services.

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13. Pathway development to be agreed in line with stepped care model considering brief, moderate and intensive treatment with clarity around complexity to aid clinical pathway navigation.

Pathway improvement work to develop in the form of a project plan in line with the Maturity Index.

Overview of PD Pathway Vs Proposed Complex Emotional Needs Pathway

PD Pathway Proposed Complex Emotional Needs Pathway within Core LMHT Comments

Wrap-around MDT No Yes Embedding the newly proposed pathway within core LMHT teams will support wider integration. Embedded within daily Risk meeting No Yes Embedding the newly proposed pathway within core LMHT teams will align to risk and oversight meetings. Access to the service

No change Usual routes for access will remain via internal and system partners. Referral pathway

No change The same referral pathway via the LMHT remains in place.

Location of service

No change

The service offer will continue to be available across all localities. Access to MBT

No Yes This service is currently operated within the forensic care group, the proposal recommends that this is reviewed and considered to be part of the wider clinical pathway. Access to DBT In part Yes There is currently variation in access to this intervention. The proposal includes having access to DBT for all geographical localities.

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Access to Structured clinical management Yes Yes although improved. As part of the wider proposal change and due to prevalence rates for complex emotional needs, the wider core LMHT will work with all patient needs therefore growing access to interventions for people with complex emotional needs. Access to supervision Yes Yes No change has been made to this offer. PD HUB Yes Yes The PD Hub as it is currently known is made up of 3 senior roles that support the oversight of the clinical pathway, training and supervision. There are no plans to change this approach. Patient rated outcome measures No Yes In line with current improvement work patients within the Complex Emotional Needs pathway will be part of the wider PROMS roll out within core LMHT services. Lived Experience Yes Yes There will remain lived experience embedded into the core pathway and no changes proposed to change this. Waiting Time

Yes We will see a positive impact on waiting times for people with complex emotional needs with moving away from a smaller segregated workforce working with a smaller number of patients outside of core community teams. The growth in the pathway expectations will ensure there is the right staff with the right expertise and training to better meet demand.

Next Steps for the Complex Emotional Needs Pathway The Terms of reference, agenda and membership for the Complex Emotional Needs have been developed, the first meeting took place in November 2025. The ICB is a core member of this group, alongside a range of clinicians and service representatives, who will work together to shape the future of treatment provision. The meeting will be chaired by the ADOP

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for Mental Health Community Services, however, the lead for this meeting will be the CEN Senior Psychologist.

Expected Impact

Following the changes being implemented that have been discussed within this paper we envisage the following impact.

• All staff working within mental health community services to work with people with Complex Emotional Needs.
• Community mental health teams training analysis across the workforce to include intervention for people with Complex Emotional Needs.
• The clinical pathway to be clearly developed with a stepped care level of input for people with Complex Emotional Needs.
• Due to the reconfiguration of the Personality Disorder Pathway people with Complex Emotional Needs to not exceed wait times of 18 weeks for treatment.
• People with Complex Emotional Needs that the PD pathway had struggled to engage were discharged to the LMHT service. This caused poor patient outcomes and fractured engagement. Due to the change in configuration people will not be discharged from one worker to another based on engagement. The emphasis will be on therapeutic engagement and personalised care.
• Services that sit outside of core Mental Health community services but see patients with Complex Emotional Needs will be reviewed to consider the patient experience and removal of internal bureaucracy.
• Patients with Complex Emotional needs have the same level of risk oversight, risk management and risk escalation as all patients within community mental health teams.
• Patients being seen with Complex Emotional Need will be offered and encouraged to complete patient rated outcome measures, the same as wider patients within core mental health community teams so that their care and input can be measured and evaluated.
• The level of intervention for people with Complex Emotional needs will available across all geographical localities of Nottinghamshire and removal of a health inequalities such as increased access to CBT which was only available in the North of Nottinghamshire.
• In line with wider community improvement work in relation to working with VCSE, third sector and other organisations, people with Complex Emotional Needs will be part of this and included within this work.
• The Complex Emotional Needs steering group has a bespoke Improvement Plan which incorporates all areas of improvement required in line with the Maturity Index for Complex Emotional Needs.

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Summary An internal review of the Personality Disorder pathway was carried out due to quality and patient experience concerns across wider community mental health services. The review was based upon NHS England Maturity Index for people with Complex Emotional needs and benchmarked against the Personality Disorder pathway and wider community mental health services. Central to the review was patient experience, feedback and health equality. The outcome of the review will ensure services are designed and developed in line with patient need opposed to service need with equitable access to evidence based interventions for people with complex emotional needs regardless of where they live. The review and changes proposed demonstrates a continual commitment to service improvement based on quality, safety and meeting the needs of the local communities in which we serve.

Staffing on mental health wards

As discussed at the Inquest, the safe staffing tool identifies what staffing numbers are needed is set by NHS England via the Mental Health Optimal Staffing Tool, (MHOST). In October 2025, the Trust reviewed the staffing establishment tool (MHOST) which were agreed by the Ward Managers, Matrons and Nurse Directors to be sufficient to meet the clinical demands. This then reports to the board for oversight at the most senior level within the Trust.

Any staffing concerns are raised in the morning ‘safe now’ meeting where staffing for that day and the following few days are reviewed to ensure that there are enough staff on each shift and to authorise additional staff via the trust ‘bank’ of staff if there isn’t adequate staffing. The final state is the authorisation to book agency staff if regular or bank staff are unable to fill the shifts. If observation levels change for patients on the ward which indicates more staff are needed, this will also be reported through this meeting. If the requirement for additional staff occurs outside of this meeting time, direct approval to book additional staff can be sought 24/7 via the out of hours silver on-call manager.

Staffing levels are reviewed in the daily ‘sit-rep’ meetings, which is the point that any concerns are actioned if needed. Within this meeting, the balance between substantive staff and temporary staff is reviewed, this is to ensure there are substantive staff who know the patients and ward environment. There are a number of bank staff that do work regularly on certain sites and also develop this knowledge of the patients and environments. Staffing levels are also discussed with the Chief Nurse and the Nurse Directors of the care group in a senior meeting weekly for Trust oversight.

Within the inpatient environments, the Trust has a high percentage of newly qualified nurses in their preceptorship period. Due to recognising their experience is minimal at this point in their career, the preceptee is not left as the only registered nurse on a ward and will have a more experienced nurse working at the same time, leading the shift.

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The attendance at the Safe Care and Sit-Rep meetings has been streamlined so that the 4 inpatient Matrons take it in turns to attend with the expectation that the other Matrons are attending the board reviews and, on the wards, to review firsthand the staffing levels on the wards and to oversee clinical quality on the ward. Any concerns will also be escalated to the Head of Nursing and Associate Director of Nursing.

To support preceptee nurses there are Practice Development Nurses in post who work on the wards to role model, mentor and coach staff and also deliver direct training. These are directly overseen by the Head of Nursing who also spends time on the wards and with Ward Managers to understand the current ward contexts and senior clinical nursing support.

A review of ward inductions is planned with learning taken from areas of good practice within the Trust. The Head of Nursing will work with Practice Development Nurses to review the inductions, which include assessments of competence for responsibilities such as observations. and support teams to embed them. The observation competencies are completed by all staff prior to them being able to access the electronic observations system. The additional quality work will be completed by March 2026.

The staffing for Fir ward for the past two months is indicated in the table below:

100% equates to the basic MHOST safe staffing rate which for Fir ward is 6 staff on an early shift, 6 staff on a late shift and 5 staff on a night shift for up to 17 patients. 2 of these staff are planned on the rosters to be Registered Nurses.

As seen above the ward is consistently above the 100%. The temporary staffing figures are the percentage of staff that are not working as a substantive member of staff on the shift on

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the ward. This can include substantive staff picking up additional shifts, regular bank staff that work on the ward and also other bank or agency staff. The temporary staffing figures are mostly in line with the increase from baseline of the fill rate.

The Trust has taken the concerns highlighted seriously. I hope that this response provides you, Sophie’s family and the other parties involved with reassurance in terms of changes already made and ongoing plans to improve these important areas of patient care moving forward.

1 Inquest touching the death of Sophie Towle Response of Sherwood Forest Hospitals NHS Foundation Trust to Regulation 28 report to prevent future deaths This is the organisational response from Sherwood Forest Hospitals NHS Foundation Trust (SFH) to the Regulation 28: Report To Prevent Future Deaths issued by HM Coroner, following the conclusion of the inquest touching the death of Miss Sophie Towle. We offer our condolences to Miss Towle’s family, and we hope this response, the new guideline for the management of deliberately inserted foreign bodies and the introduction of a Mental Health Inpatient Transfer to an Acute Hospital – Hospital Passport provides reassurance that the Trust recognises and acknowledges its failings and is committed to ensuring that we learn from this to prevent future deaths. The two matters of concern raised within the report which relate to SFH (points 1 and
4) and responses for each point are as follows:
1) Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies During the Inquest it was acknowledged that there is no embedded mechanism for arranging a multi-disciplinary team (MDT) meeting between the psychiatric team (Nottinghamshire Healthcare NHS Foundation Trust) and the physical health team (Sherwood Forest Hospital). In addition, the inquest highlighted that there was no clinical documentation or guidance for staff which prompts physical health staff to consider an MDT approach. In response to these findings, a series of cross-organisational meetings were convened between Sherwood Forest Hospital and Nottinghamshire Healthcare, facilitated by the Governance Support Unit. The purpose of these meetings was to explore methods by which both organisations could work collaboratively, specifically in relation to patients who have deliberately inserted foreign bodies, as well as other patient cohorts who may require input from both the psychiatric and physical health teams. During these discussions, the implementation of the "Mental Health Inpatient Transfer to an Acute Hospital – Hospital Passport", which was already in development by the Sherwood Forest Hospital’s Mental Health Specialist Nurse, was considered. It was agreed that this passport would be utilised for all inpatient mental health transfers from Nottinghamshire Healthcare to Sherwood Forest Hospital. The aim is to improve communication with Emergency Department colleagues and the discharging team, where appropriate. The Mental Health Inpatient Transfer to an Acute Hospital – Hospital Passport includes contact details for key locations, which staff have identified as beneficial for facilitating

2 effective communication. Both organisations have reaffirmed their commitment to enhancing communication between the Trusts. The Governance Support Unit at Sherwood Forest Hospital have agreed to organise a meeting at the end of February 2026 with Nottinghamshire Healthcare to review implementation of the Mental Health Inpatient Transfer to an Acute Hospital – Hospital Passport. A 3-month review date has been agreed due to the low numbers of mental health patients requiring transfer to acute services. The aim of the review meeting is to collaboratively discuss usability of the passport and provide an opportunity to discuss any challenges which have been identified and identify any further actions or amendments required. In addition to the introduction of the passport, the new guideline for management of patients with deliberately inserted foreign bodies, as detailed in part 2 of the response, has been developed. These procedures provide clear guidance regarding the circumstances in which an MDT is required, specify the team responsible for arranging the meeting, and reflect a shared commitment from both organisations to ensure that MDT discussions are undertaken in order to safeguard our patients.
4) The policy and procedures around the management of insertion of foreign objects for SFH During the Inquest proceedings HM Coroner reported that the standard operating procedure (SOP) for the management of deliberately inserted foreign bodies content was lacking in specificity, had vague language which was open to interpretation and did not provide clear advice to medical professionals accessing it for guidance. HM Coroner also acknowledged that there was no reference to consultation with mental health services. Upon conclusion of the Inquest, a comprehensive review of the SOP for deliberately inserted foreign bodies, as initially presented to HM Coroner, was undertaken. This review was conducted with the support and oversight of the Governance Support Unit to ensure rigorous examination and improvement of the procedure. As a direct outcome of the review process, the previous SOP for the management of deliberately inserted foreign bodies has been archived. In its place, a new, approved guideline has been developed to address the concerns raised by HM Coroner. This guideline provides clear, concise, and practical guidance to clinical staff and incorporates recommendations to ensure specificity and clarity. Furthermore, the guideline incorporates a flowchart designed to assist clinical staff by offering clear advice regarding the minimum circumstances for contacting mental health services. Additionally, Appendix A contains the referenced document entitled "Mental Health Inpatient Transfer to an Acute Hospital – Hospital Passport.” Which will promote communication between physical and psychological health teams. The development of the new guideline was informed by a robust consultation process, which included input from key stakeholders across Trauma and Orthopaedics, the

3 Emergency Department, Safeguarding, and Nottinghamshire Healthcare. This collaborative approach ensured that expert advice and perspectives from all relevant disciplines were considered. In addition, Nottinghamshire Healthcare’s Trust wide Procedure for the Management of Foreign Bodies (2023) was reviewed to ensure there was no discrepancy in advice being provided. On 28th November 2025, the document entitled “Management of Deliberately Inserted Foreign Bodies Guideline” was formally ratified at the Surgery, Anaesthetics and Critical Care Divisional Governance meeting. The final approved guideline is now available on the Trust intranet for clinicians to access and has been disseminated to all staff directly involved in the management of patients presenting with deliberately inserted foreign bodies. The Trust is committed to ongoing improvement of clinical guidance and ensuring the highest standards of patient care. We are confident that the new guideline addresses the issues identified by HM Coroner and provides comprehensive support to clinical teams managing these complex cases.