Andrew Bowles
PFD Report
All Responded
Ref: 2023-0423
All 1 response received
· Deadline: 27 Dec 2023
Coroner's Concerns (AI summary)
A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.
View full coroner's concerns
1. Mr Bowles had an extensive mental health history with incidents of self-harm and suicidal intent.
2. On 15th May 2023 Mr Bowles had told attending paramedics and the triage nurse at Birmingham City hospital that over the last 24 hours he had been hearing voices that were telling him to hurt himself and others. When he was seen, post triage, by the doctor (SHO)
Having been deemed to have no physical health needs a referral was made to the psychiatric liaison team.
3. The mental health liaison nurse from Birmingham and Solihull mental health NHS foundation trust did not have a log in to be able to directly access City Hospital records, but rather relied on a colleague to access any notes and provide a verbal handover. Further, she stated in evidence that her assessment may have taken place prior to the A&E notes being put onto the system, as she was unaware that Mr Bowles had been experiencing command hallucinations and had thoughts of self-harm, the same being denied when she saw him less than an hour later. Her evidence was clear, that had she been privy to this information, it would have put a different angle on the assessment and would have led down the route of psychiatric review for potential admission.
4. I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment. I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment. The situation may well be the same at University Hospitals Birmingham, given that Birmingham and Solihull Mental Health NHS foundation Trust also run a mental health liaison service in the A&E department.
2. On 15th May 2023 Mr Bowles had told attending paramedics and the triage nurse at Birmingham City hospital that over the last 24 hours he had been hearing voices that were telling him to hurt himself and others. When he was seen, post triage, by the doctor (SHO)
Having been deemed to have no physical health needs a referral was made to the psychiatric liaison team.
3. The mental health liaison nurse from Birmingham and Solihull mental health NHS foundation trust did not have a log in to be able to directly access City Hospital records, but rather relied on a colleague to access any notes and provide a verbal handover. Further, she stated in evidence that her assessment may have taken place prior to the A&E notes being put onto the system, as she was unaware that Mr Bowles had been experiencing command hallucinations and had thoughts of self-harm, the same being denied when she saw him less than an hour later. Her evidence was clear, that had she been privy to this information, it would have put a different angle on the assessment and would have led down the route of psychiatric review for potential admission.
4. I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment. I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment. The situation may well be the same at University Hospitals Birmingham, given that Birmingham and Solihull Mental Health NHS foundation Trust also run a mental health liaison service in the A&E department.
Responses
Action Planned
The two Trusts have agreed to allocate access to hospital records for bank staff who regularly work shifts within the Psychiatric Liaison Team to improve information sharing. Issues will be monitored through clinical governance at BSMHFT. (AI summary)
The two Trusts have agreed to allocate access to hospital records for bank staff who regularly work shifts within the Psychiatric Liaison Team to improve information sharing. Issues will be monitored through clinical governance at BSMHFT. (AI summary)
View full response
Dear Mrs Samuel, RE: Andrew Bowles Thank you for your Prevention of Future Deaths letter of the 31 October 2023 raising the concerns you have around the sharing of information between the two trusts on the front line, specifically in relation to the accessing of electronic patient records. We have worked together to try and address your concerns and therefore felt that it would be beneficial to provide a joint response in regard to the matters arising from your PFD. We would like to begin by assuring you that the staff in Accident and Emergency do work closely with the Psychiatric Liaison Team to ensure the safe care of patients. For some time the permanent staff in the Psychiatric Liaison Team (PLT) based at City Hospital Accident and Emergency Department (A&E) have been able to access the electronic records and also contribute to the records of the Sandwell and West Birmingham NHS Trust. This has been crucial in keeping not just the A&E and PLT staff up to date but also the Ward staff, if a patient is admitted. In the past any “bank staff” (temporary staff) who were on shift would ask a member of the permanent team to access the records, so that they could review them prior to seeing a patient and would also ask permanent staff to update the records, following their review. Following the PFD, a joint meeting has taken place between the two trusts, and we have been able to identify that a number of the bank staff are regularly working bank shifts within the PLT. Therefore these staff will now be allocated access to hospital records. This will improve matters considerably in this area. There are a small number of staff who may be called in from agencies when there are no other staff available. As these staff may be new to the team and/or to both trusts and only working one shift, it is unlikely that an account is set up immediately for them with the Hospital. In these exceptional circumstance, when the local induction takes place, they will be advised of the processes in place for them to speak with other permanent team members to access the City Hospital notes. They will review them prior to speaking with the patient and also update the records with their assessment after. Now that BSMHFT bank staff also have access to the │ Website: www.bsmhft.nhs.uk Customer Relations: Mon–Fri, 8am–6pm │ Tel: 0800 953 0045 │ Email: bsmhft.customerrelations@nhs.net
notes, there will be more staff with access to the records available to support this. They will also be able to update hospital staff with their reviews and fully support staff through joint working. Any issues will be monitored through clinical governance at BSMHFT. Please be assured, we did explore all possible options including providing a generic log on for agency only staff who may be carrying out one shift. However from an information governance perspective it would not be possible to ascertain who had inputted the information and therefore there would be no traceability or accountability in place, if any problem arose. This is contra to the lawful processing of confidential information. Therefore the only option available was to strengthen the number of PLT staff who have access to the City Hospital records to address any concerns going forward and ensure smooth working. We would like to assure you that we are working very closely together to ensure that all patients receive the right care at the right time. We appreciate that sharing of information is crucial for this to take place and so are working to resolve this problem as a matter of urgency. We hope this offers you full reassurance in respect of the issues you have raised.
notes, there will be more staff with access to the records available to support this. They will also be able to update hospital staff with their reviews and fully support staff through joint working. Any issues will be monitored through clinical governance at BSMHFT. Please be assured, we did explore all possible options including providing a generic log on for agency only staff who may be carrying out one shift. However from an information governance perspective it would not be possible to ascertain who had inputted the information and therefore there would be no traceability or accountability in place, if any problem arose. This is contra to the lawful processing of confidential information. Therefore the only option available was to strengthen the number of PLT staff who have access to the City Hospital records to address any concerns going forward and ensure smooth working. We would like to assure you that we are working very closely together to ensure that all patients receive the right care at the right time. We appreciate that sharing of information is crucial for this to take place and so are working to resolve this problem as a matter of urgency. We hope this offers you full reassurance in respect of the issues you have raised.
Sent To
- Birmingham and Solihull Mental Health NHS Foundation Trust
- Sandwell and West Birmingham NHS Trust
Response Status
Linked responses
1 of 2
56-Day Deadline
27 Dec 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 1 June 2023 I commenced an investigation into the death of Andrew BOWLES. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Drowned in a canal, having recently attended hospital suffering with a deterioration in mental health. It is unknown how he entered the water nor his intent at the time.
Circumstances of the Death
On 15th May 2023 the deceased, who had an extensive mental health background including self-harm, was taken to Birmingham City Hospital, concerns having been raised after he had been seen running in and out of traffic. He was deemed medically fit and was referred for psychiatric assessment. Following assessment referrals were made to the home treatment team and the homeless pathway team, there being no undue concerns noted by psychiatric liaison. Discharge was documented at 23.30, with an expectation that the deceased would remain in A&E until the following morning. CCTV footage showed the deceased leaving the hospital grounds at 23.28. The deceased was found face down in the canal under the road bridge of Dudley Road at 6.34 on the 16th May 2023, it being unclear how and when he entered the water. Following a post mortem the medical cause of death was determined to be: 1a Drowning 1b 1c II
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