Dear Madam

Re: Regulation 28 Report to Prevent Future Deaths – Mr Juan David Martin

We are writing to you following receipt of the Regulation 28: Report to Prevent Future Deaths (PFD) dated 11 June 2024 (received on 13 June 2024), regarding the sad death of Mr Juan David Martin.

You have requested that South West London and St George’s Mental Health NHS Trust (SWLStG) and NHS South West London Integrated Care Board (SWL ICB) respond to the matters of concern that you have detailed in your correspondence.

We have taken a joint approach exploring the matters of concern and provided responses below including actions we are taking and how we will work together to improve.

We thank you for your consideration and commitment to the prevention of future deaths and helping us to learn. We would like to express our deep sympathy to the family and friends of Mr Martin for their loss. While we seek to make improvements within the Trust and local system to help ensure we are able to provide the necessary bed provision, we recognise that this cannot diminish their pain and anguish.

2

The Trust and ICB remains committed to continuous learning and improvement and we are very grateful for all those involved in the Inquest.

Sincerely

Chief Executive Officer South West London and St George’s Mental Health NHS Trust

Chief Executive Officer South West London ICB

3

Bed capacity: Matter of Concerns and Actions

The MATTERS OF CONCERN are as follows:

(1) Juan Martin was held informally on 7 April 2022 and following a mental health assessment on 11 April subsequently became liable for detention. He therefore spent 6 days in the Lotus Assessment Suite. Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.

(2) The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved. The Matron provided one recent example where a patient waited for 7 days in the Accident and Emergency Department for a mental health bed.

(3) The Matron added there was an exceptional process which required a considered decision at a high level to make a bed available through identifying someone currently occupying a bed space to be discharged and that the ‘flow’ of patients being discharged or moving to another setting amplified the bed capacity issue.

Based on the evidence heard, my principal concern is that bed capacity in London remains inadequate. Whilst some action may have been taken by the Trust to better triage the need for beds it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London unless further action is taken.

South West London and St George's Mental Health NHS Trust - Response

The Trust (SWLStG) fully acknowledges the concern regarding insufficient bed capacity in London and the reason why the Coroner has cause to raise these concerns.

SWLStG recognises this as a key risk to patient safety, which is fully captured and articulated within our Board Assurance Framework, and we are working to mitigate the risk as far as possible. We note, as has the Coroner, that this is not fully within our control due to the increasing complexity and level of demand for acute mental health services and the constraints on funding and resources to provide acute mental health beds. Where appropriate and available, we seek acute mental health beds in the private sector, but with a recognition that this is not always in the best interest of the patient as these admissions can be remote from a patient’s local support networks and disconnected from their broader NHS care.

As part of our integrated transformation programme, we have implemented a range of projects aimed to improve acute mental health patient flow and bed access, including:

- Discharge planning best practice implementation in line with NHS guidance (100-day discharge challenge; 10 high impact interventions; ward workflows project).
- Collaborative discharge and flow work with Local Authority partners through the Strategic Operational Interface Programme.

4

- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management.
- Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024.
- Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow.
- Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.

Despite this, we appreciate there is still a risk around patients awaiting admission due to the lack of beds and we are undertaking further work in the following areas:

- Intensive support to our acute ward teams to identify barriers to flow and enhance best practice ways of working, with swift but safe discharges.
- Further transformation of our mental health crisis offer, including developing mental health triage and rapid access services to support our local Emergency departments with patients presenting with mental health needs.
- Review of our rehabilitation and mental health supported living settings in partnership with Local Authorities and the South London Partnership for mental health complex care programme, to support improved access to onward care settings.

We would support any further review of the sufficiency of acute mental health beds in South West London and London-wide to meet the increased and more complex demand for these services.

South West London Integrated Care Board – Response

SWL ICB recognises the demands and pressures on acute mental health inpatient beds. There are a range of reasons including increased demand, increased acuity of patients and delays caused by people who are clinically ready for discharge but are delayed accessing their onward accommodation.

The ICB is working with SWLSTG and other healthcare providers in South West London to address situations where patients experience delay in all parts of the care pathway. This includes work focused on reducing length of stay and minimising the use of out of area placements. As part of the 2024/25 planning process, ongoing investment was made into commissioning additional beds in the private sector to mitigate the current bed pressures while longer term work on improved patient flow continues.

Dear Madam

Re: Regulation 28 Report to Prevent Future Deaths – Mr Juan David Martin

I am writing to you following receipt of the Regulation 28: Report to Prevent Future Deaths dated 11 June 2024 (received on 13 June 2024), regarding the sad death of Mr Juan David Martin.

You have requested that South West London and St George’s Mental Health NHS Trust (SWLStG) respond to the matters of concern that you have detailed in your correspondence.

In order to examine all of the concerns raised, the Prevention of Future Death Report was shared with the clinical leadership team responsible for Mr Martin’s care and treatment and our Trust board quality committee to help the Trust respond to the points of concern you have raised.

I have provided a response to each of your concerns and direction as they were raised in your correspondence:

Fire safety / evacuation

The MATTERS OF CONCERN are as follows:

Chief Executive,

Chair,

(1) There was no policy in place at the time to evacuate those liable for detention and/or at risk of absconding in the fire evacuation policy at the time Juan Martin absconded on 12 April 2022. Witnesses confirmed that the local operational policy was updated on 14 April
2022. The fire evacuation policy was updated in February or March 2024. Notwithstanding the now updated fire evacuation policy, a Health Care Assistant who still works in the Lotus Assessment Unit, confirmed he had not seen the evacuation plans, which form part of the policy.

Based on the evidence heard, my principal concern is that there is a lack of knowledge around the fire evacuation policy on the Lotus Assessment Suite. Whilst some action may have been taken by the Trust to update the policy belatedly and deliver training locally by clinicians; the Health Care Assistant was not familiar with the evacuation plans. It follows there is a genuine risk of future deaths directly connected to a lack of training on the fire evacuation policy and embedded learning and familiarisation around it.

(2) The Fire Safety Advisor in evidence confirmed the findings of the Trust’s Root Cause Analysis (RCA) report were not shared with him, despite the RCA being completed on 18 July 2022. Further the nurse in charge was not made aware of the findings of the report that “it would have been best practice for Lotus staff to consider removing valuable items i.e. bank card and any cash from the patient particularly after he met the criteria for detention”. It is surprising findings from the Trust’s own RCA report were not shared with key staff members, namely the Fire Safety Advisor and the Nurse in Charge on the day Juan Martin absconded from the unit.

As captured during the Inquest, both the Lotus operational policy and fire evacuation procedures had been updated with clear guidance for the variance in procedure of the evacuation of sectioned/detained patients. While this should this have been done sooner, it is now clear that such detained patients should follow the section 136 evacuation procedure and route to ensure they are not able to leave the unit.

Since the Inquest, we have:

▪ Updated the fire training provided as part of the Trust’s corporate induction (for all new staff) to include the consideration to the risk of patients potentially absconding during a fire alarm activation and the importance of consideration of detention status and risk status. ▪ Likewise, the local/team induction information and a focus on the revised evacuation procedures has been established for all inpatient areas and Lotus ▪ Specifically with Lotus, to provide additional assurance, all staff have confirmed they are aware and understand the evacuation procedures and how to legally hold someone under the Mental Health Capacity Act/Common Law. This includes those individuals awaiting a Mental Health Act (MHA) Assessment, or those liable to be detained under the MHA, where staff have material safety concerns considering risk of possible imminent absconding. All Lotus staff (apart from those on leave) have confirmed and signed a local induction sheet to confirm their understanding of the different evacuation procedures. There are plans in place to ensure all staff who are on leave and all new joiners do the same. ▪ Fire warden training has also been updated to cover the same information.

Chief Executive,

Chair,

▪ A real time fire evacuation drill has taken place on Lotus and the Fire Safety Officer confirmed this was very successful and staff were aware of the different evacuation procedures. The Fire Safety Officer produced a written summary of the drill. Further drills will take place and be designed into the routine arrangements for fire drills that will focus on the specific variations to evacuation. ▪ The learning from this situation will be shared and published via our internal Monthly Learning Bulletin (MLB) by September 2024.

Investigation learning

The MATTERS OF CONCERN are as follows:

Based on the evidence heard, my principal concern is that critical learnings from the RCA have not been shared with key individuals. Whilst some action may have been taken by the Fire Safety Advisor following a request for evidence during my investigation, such as updating the fire evacuation policy earlier this year, it is insufficient to resolve the problem of failing to share learning. It follows there is a genuine risk of future deaths directly connected to a failure to share learning from the RCA unless further action is taken.

Since the Inquest, we have:

▪ Provided briefings to the central investigation team to review the process for sharing investigation reports and their key findings and actions at the various stages of the investigation. ▪ Updated our Patient Safety Incident Response Plan (PSIRP) document, adding a new specific section on ‘sharing learning’. This includes the process and guiding principles around engaging and sharing learning with both staff, patients and families. This also recognises that such engagement, following what are often traumatic events can be very upsetting for staff involved, hence the need for a tailored approach (via the key principles) to ensure that the most suitable person engages with the staff involved and best able to provide the necessary pastoral support. ▪ Reviewed the patient safety investigation template to make actions more thoughtful and meaningful. For example, we now include the focus on ‘What does the action intend to achieve’ and ‘How will it be implemented / delivered’. In addition to a firmer focus on assurance and monitoring. ▪ Strengthened the process for capturing actions from investigations into our incident management system, to enable better allocation of actions. ▪ Added more focus on the formal issuing of the final report to the relevant service line with better clarity on the expectations that they properly review within their governance and business meetings to assurance themselves learning is shared and embedded. ▪ Due to national NHS changes that require ‘draft’ investigation reports to be shared with patients and families (as part of meaningful engagement around patient safety), we are reviewing our internal review and sign-off processes which includes the key roles of specific groups and committees. In turn, this will help ensure we have the right learning, with a focus on sharing and improvement.

Chief Executive,

Chair,

Absent without leave (AWOL) and missing persons

The MATTERS OF CONCERN are as follows:

(3) The absent without leave (AWOL) and missing person policy.

(a) The policy in force at the time of Juan Martin’s death and currently in force, confirm the necessity for the engagement of the Security team following a patient absconding and that the hospital and grounds should be searched. This did not happen on 12 April 2022. The Nurse in Charge who still works for the Trust, accepted she did not contact security, nor was there a search. Juan Martin was a high-risk patient.

(b) Furthermore, Trust policy dictates that the police should be called immediately. Despite being in possession of a radio during the fire evacuation, the Nurse in Charge nor any other staff member present telephoned nor asked for the police to be contacted until 11 mins after Juan Martin absconded. CCTV confirmed he was in the vicinity of the hospital grounds for up to 8 mins after absconding.

(c) The London Mental Health Trusts Joint policy dated November 2023 concerning patients who are AWOL or abscond is not in line with the Trust’s current policy dated 22 March 2023, nor does the pan-London policy contain a flow chart for dealing with patients who are high- risk.

Based on the evidence heard, my concerns are that (i) there is a lack of understanding of the AWOL and missing person policy by senior staff; (ii) the pan-London and local policies do not align. Whilst some action may be taken by the Trust to better align the policies and improve knowledge and compliance amongst clinicians of their duties under the policy; this has not yet been undertaken, nor has a clear proposal been provided, such that in my view it is sufficient to resolve the problem. It follows there is a genuine risk of future deaths unless further action is taken, directly connected to (i) a lack of knowledge of procedures following a patient absconding or AWOL and (ii) inconsistency between policy documents.

Prior to the Inquest (and what was then covered during the Inquest proceedings), the Trust had both policies in circulation, although the intention was to have a single policy in place, being the London Mental Health Trust Joint Policy Pan London (‘pan London’). Inevitably this led to a lack of consistency and a lack of alignment, and this was reflective of what was relayed to the Inquest.

The Trust had since removed our internal AWOL policy, replacing with the joint pan-London policy, however the Inquest helped the Trust to identify that there was also key information within our old policy around procedures for missing / AWOL service users that was not reflected in the pan-London policy document.

Chief Executive,

Chair,

Since the inquest, we have:

▪ Reviewed both polices to check what may need to be added into an updated pan-London policy. ▪ As aforementioned, this included adding the flow chart regarding the missing / AWOL procedure to the pan-London policy as an appendix. ▪ Liaised with the pan-London policy owners on the changes we have made, with a view of working together during the formal revision period (July 2024), as other trusts may wish to include a version of what we have since added. ▪ Published the revised policy for all staff to be aware. ▪ Issued the revised policy to the clinical service lines and specifically Lotus service and sought assurance that management to ensure staff are aware and understand the policy requirements and procedures. ▪ Walk-through AWOL drills have been undertaken in Lotus to ensure that staff are aware of the procedure which has resulting in a reassuring understanding and response. ▪ In addition, we will be creating a short scenario video on AWOL and fire, to boaster the awareness and this will be incorporated into both local and corporate induction over the autumn period. ▪ The learning from this situation will be shared and published via our internal Monthly Learning Bulletin (MLB) by September 2024.

A separate letter will follow from the Integrated Care Board (ICB) and myself in connection to the other PFD related to this sad case.

We thank you for your consideration and commitment to the prevention of future deaths and helping us to learn, and I would like to express our deep sympathy to the family and friends of Mr Martin for their loss. While we seek to make significant efforts to ensure that we prevent any similar deaths in the future, I recognise that this cannot diminish their pain and anguish.

The Trust remains committed to continuous learning and improvement and we are very grateful for all those involved in the Inquest.

Dear Mrs Malhotra,

Thank you for your Regulation 28 report to prevent future deaths dated 11 June 2024, about the death of Juan David Martin. I am replying as the recently-appointed Minister with responsibility for mental health and patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Juan’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

Your report raises concerns over the adequacy of mental health bed capacity across London and I recognise the impact that a suitable bed not being available can have on patients, as exemplified in this case.

This government believes that the whole mental health system needs to work together, with efficiency, to reduce the likelihood of inpatient admission. In turn, this will improve bed availability.

I recognise how important it is that people with mental ill health get the level of care that is appropriate for their needs, and we want to ensure that people have access to the right mental health support, in the right place, and at the right time.

1

At national level, as part of our mission to build an NHS fit for the future, we will make sure mental health care is delivered in the community wherever possible - through new models of care and support available for those who are struggling - so that more people are prevented from needing to go into hospital.

The suicide prevention strategy for England, published in 2023, is a five-year strategy which sets out the national ambition for suicide prevention. As part of our commitment to reduce the lives lost to suicide, the 8,500 new mental health workers we will be recruiting across children’s and adult services will be specially trained to support people at risk.

I understand that South West London and St George’s Mental Health NHS Trust and NHS South West London Integrated Care Board will respond to your concerns about local mental health bed capacity directly, reflecting their responsibility to assess bed capacity and the ‘flow’ of patients being discharged or moving to another setting.

I hope this response is helpful. Thank you for bringing these concerns to my attention.