Dear Ms Saunders Regulation 28 report following the inquest into the death of Huw Erasmus Thank you for your Report dated 12 December 2024. I understand that the concerns to which this Report relates are the requirements for post-leave assessment when a patient has Ground Leave, and the documentation of those assessments. Elysium Healthcare’s Leave (including Section 17) Policy, to which reference was made at the inquest, is that which was current in November 2022. Even before the inquest, Elysium Healthcare had been reviewing this policy and l would like to reassure you that the issues you have raised will be incorporated into this review. The new policy will meet the operational needs of all our units (currently we have over 90). We are looking at a range of issues around leave generally, including issues of risk assessment, documentation and post-leave feedback. The new policy will be adopted and rolled out across all our units. Part of the policy review is to distinguish between leave under Section 17 Mental Health Act and Ground Leave. As you will appreciate, Ground Leave is not Section 17 leave1. Some of the “confusion” to which the Report refers relates to the requirement in the old policy for a “similar” approach for Section 17 leave and Ground Leave. The new policy will ensure there is clear guidance around the process for S17 leave (assessment, documentation and post-leave review) and the process for Ground Leave (assessment, documentation and post-leave review) as distinct entities. In the interim, whilst the new policy is being developed, we have implemented the following changes in respect of Ground Leave at Aderyn:
1. All ward staff have been reminded of the need for the security ‘nurse’ to ascertain that there is no reason for the Ground Leave granted by the Responsible Clinician not to go ahead when they sign a patient out of the unit;
2. Although the Ground Leave is commonly summarised in carenotes (our electronic patient records system) at the end of each shift, all ward staff have been reminded of the need for a record to be made that expressly addresses any issues that have arisen in relation to an episode of Ground Leave, and that they record feedback in relation to any specific conditions of that Ground Leave;
3. The Hospital Director for Aderyn will be auditing a specimen number of carenotes weekly to ensure that these records are being made. 1 See paragraph 27.5 of the Code of Practice to the Mental Health Act: “Except for certain restricted patients (see paragraphs 27.39 – 27.42 and 22.53 – 22.60) no formal procedure is required to allow patients to move within a hospital or its grounds. Such ‘ground leave’ within a hospital may be encouraged or, where necessary, restricted, as part of each patient’s care plan.”

Finally, you have raised the issue as to “whether in fact these assessments had taken place at all”. As others may have sight of this response, it is therefore right that I cite the oral evidence that I understand was given at the inquest both by the patient’s Responsible Clinician, Dr Jones, and the Ward Manager, which confirmed that the patient’s Leave was indeed assessed in MDT and other staff meetings. As a result, the patient had had some 84 episodes of Leave at Aderyn without any issues arising in relation to the ingestion of vegetation. This included five episodes of unescorted Ground Leave, which were all the subject of an entry in carenotes providing a comment on the utilisation of that Leave.