Dear Ms Schofield,

Re: Regulation 28 Report to Prevent Future Deaths – Caroline Victoria Forte who died on 20 February 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11 May 2023 concerning the death of Caroline Forte on 20 February 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Caroline’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Caroline’s care have been listened to and reflected upon.

I note that Sussex Partnership NHS Foundation Trust has written a comprehensive response to you reviewing the concerns highlighted by you in a separate Report addressed to them, raising concerns about Caroline’s care. It is clear they have reflected upon and taken actions and learnings from the concerns raised. I note that there is now new documentation at the Trust; the ‘Record of patient leaving ward’ which staff complete before a patient’s Section 17 leave is approved. The completion of the document requires collaborative consideration of the leave safety plan with, not only the patient, but also any relevant family/carer/friend. If the plan lacks any detail this would be identified before the patient leaves the ward and should help avoid any reoccurrence of the issues you have highlighted regarding Caroline’s death.

The Trust has also shared with us a helpful learning briefing on Section 17 leave from inpatient wards. This will be shared with the national Regulation 28 Working Group regional representatives for dissemination across the seven NHS regions, to raise awareness of the issue with their Trusts and to encourage best practice.

Your concern at the lack of national guidance regarding help and support for families in similar situations to that experienced by Caroline’s family has also been raised with NHS England’s national Mental Health Team. In 2022, NHS England committed £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. The Mental Health team have advised that these improvements will include developing a culture of care improvement programme which, importantly, is being co-produced with patients, carers, and families with lived experience of mental health illness. The programme, which should come to completion in 2025, addresses the concerns you raise, identifying opportunities to strengthen family/carer voice in patient care, including the risk management of suicide and self- harm and safety planning. This will drive forward improvements in quality and safety National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

3 July 2023

across the board nationally, so that all patients experience excellent and meaningful care.

I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Schofield Inquest into the Death of Caroline Forte, Regulation 28: Report to Prevent Future Deaths I write in response to your Regulation 28 Report dated 27 April 2023, addressed to my predecessor,

I was so sorry to read the details of the circumstances leading to Caroline's death and I extend my sincerest condolences to her family. I acknowledge and understand the concerns that you have raised and want to assure you that, following the Inquest, the Trust took immediate steps to seek to learn from the Inquest's findings and make improvements, not just specifically relating to Amberley ward but trust-wide. To do that, the Trust set up a working Group, of senior clinicians, to identify what action was needed to prevent recurrence of the contributory factors identified in Caroline's Inquest. That working Group was led by the Trust's Deputy Chief Nurse (Quality, Safety & Improvement) and met fortnightly to formulate the necessary improvements and enable trust-wide implementation. Additionally, in parallel, the Trust's Legal Director led a piece of work to create new leave documentation, process and policy. I will describe the outcomes of the improvements in turn, utilising and thus responding to each of the seven concerns you raise in your Regulation 28 Report: Office of the Chair & Chief Executive Trust Headquarters Swandean Arundel Road Worthing West Sussex BN13 3EP

a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted and to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of it's consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum. That Forum is a meeting of trust-wide clinicians as well as service users, and the new documentation was collaboratively formulated within that Forum to seek to ensure that it would best meet the needs of staff, patients and families/carers.

b) There was no record to show which nurse carried out a risk assessment before she left The new 'Record of patient leaving ward' document requires a Registered Nurse (or another registered professional, such as Medic or OT) to sign the patient out. Moreover, and specifically, the new document makes it clear that, by signing the form, the nurse/medic/OT has collaboratively considered the patient's leave safety plan with them and any relevant family/carer/friend etc and, furthermore, that the leave safety-plan has been collaboratively re-affirmed by all.

c) There was no overnight care plan As referred to above, completion of the new 'Record of patient leaving ward' document requires consideration of the leave safety plan which, if a patient were going on overnight leave, would require consideration of the overnight care plan and would thus identify if it were missing. Overnight care plans are used by Amberley ward, as a local initiative, and the ward Matron is now doing monthly spot checks to confirm that these are being completed and uploaded for patients going on overnight leave. Further, the Trust has an ongoing trust-wide audit programme whereby it is qualitatively auditing in-

patient records to ensure care plans are appropriately completed. This audit, once complete, will be presented to and monitored by the Trust's Effectiveness Committee, to ensure care plans are of an appropriate standard trust-wide.

d) The “My care and safety plan” had not been updated with regards to “My family will do” section As referred to above, completion of the new 'Record of patient leaving ward' document requires collaborative consideration of the leave safety plan with, not only the patient, but also any relevant family/carer/friend etc. So, any lack of detail in the 'My care and safety plan' would be identified before a patient were permitted to leave the ward.

e) The family were not provided with a copy of the Section 17 leave form When the new 'Record of patient leaving ward' document is completed there is now a specific prompt to ensure that the patient (if detained) has a copy of the s.17 leave form then there is the aforementioned collaborative consideration of the leave safety plan with the patient and the family/carer/friend etc. This will enable family/carer/friend etc to have knowledge of the contents of both the s.17 leave form and the safety plan. That collaborative conversation would enable further documents to be copied and provided, as appropriate.

f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly, there was no communication with the hospital as to how to minimise Caroline’s risk. As indicated above, safety planning ought to be a collaborative process and I was truly saddened to hear that Caroline's family were left without strategies to support them to minimise Caroline's risks. Amberley ward have, of course, reflected, at length, on the sequence of events that led to Caroline's death. The Matron is overseeing monthly audits to check that family have either participated in ward

reviews, or been contacted after, to be given an update. The ward's aim is to invite a relevant family member to their loved ones' MDT review meetings, so the family member can participate in the review and have an opportunity to give their own views. If they have not been able to attend then a call to the relevant family member is made after the meeting to ensure they are aware of the plan. Additionally, the ward is considering employing a "Carers Lead", who would provide a primary point of contact for all family members. Further, the aforementioned trust-wide care plan and risk assessment auditing includes qualitatively auditing to ensure meaningful, appropriate family/carer engagement, as part of the Trust's ongoing 2023/4 improvement plan. The new 'Record of patient leaving ward' document will also ensure a further collaborative conversation takes place and the leave safety plan is re-affirmed before the patient leaves the hospital.

g) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure. The s.17 leave policy is being updated, so that it incorporates the new form, as well as some other modifications. Once ratified, there will be corresponding training which is delivered by the Trust's Mental Health Act team which is overseen by the Trust's Legal Director. Regarding, the ward's understanding of the Safe and Effective Assessment & Management of Clinical risk: Risk Management policy, I understand that this specifically centred on the aforementioned assessment of risk prior to
s.17 leave and corresponding sharing of information within the ward and with the family. The Amberley ward Matron led the ward's discussions about the improvements needed following the Inquest which, in addition to those already mentioned, has involved on-going monitoring of the quality of concise and precise handover of information (both verbal and written) from shift to shift, and to MDT, during MDT daily handovers. Additionally, the Matron has been working with the Trust's lead trainer for clinical risk and the Trust's suicide prevention lead, to fully understand early indicators of risk to ensure his ward is capturing and fully understanding these warning signs. The Matron has also been actively involved in the formulation of the new 'Record of patient leaving ward' document which Amberley ward will be using from the trust-wide implementation date of 1 July.

By way of further assurance, and for completeness, I have also enclosed the Patient Safety Learning briefing that the Trust circulated, following the Inquest, to all its acute care teams, for learning from the matters that arose in the Inquest.

I hope that the aforementioned actions are of assurance to you. We believe that these actions will lead to a substantial improvement in the experience of patients and the families/carers/friends who support them when they are on leave from our hospitals. As indicated, we will be monitoring the effectiveness of these improvements to ensure they meet the needs of our patients and their families/carers/friends and will write to you with an update in 6 months' time. In the meantime, if you have any questions regarding the content of this response or if I can further assist please do not hesitate to contact me.

Dear Ms Schofield Inquest into the Death of Caroline Forte - Letter of Concern Thank you for your letter dated 5 May 2023, addressed to my predecessor, . I was sorry to learn of the concerns relating to the Serious Incident (SI) investigation into Caroline's death and I'm grateful to you for affording the Trust the opportunity to review matters and provide you with this response. I understand that this response, along with the letter I sent you last week, responding to the Regulation 28 Report, will be shared with Caroline's family. As such, I would also like to extend, through this letter, my sincere apologises to them regarding the quality of the Trust's SI report. I am truly sorry that it did not fully consider all matters relating to Caroline's death and thus enable the comprehensive learning that should have happened following Caroline's death. I sincerely hope this this letter, coupled with the response to the Regulation 28 report, provides assurance. I understand that, during the Inquest, three areas of concern regarding the quality of the SI arose, namely, that the:
1. SI investigation did not identify the four issues that the Jury found contributed to Caroline's death and, indeed, found that 'all care provided was responsive and appropriate';
2. SI reviewer did not record or consider, within the SI, the important issue of Caroline ligature tying on the ward; and Office of the Chair & Chief Executive Trust Headquarters Swandean Arundel Road Worthing West Sussex BN13 3EP

3. 'Lessons learnt' were not captured within an action plan, so there was no evidence that they were actually actioned.

I am particularly disappointed to read of these concerns as, when I first joined the Trust, as Chief Nurse, nearly 2 years ago now, I quickly recognised that our internal incident investigation processes required improvements. That being said, any significant change, of course, takes time and I recognise that the SI report into Caroline's death was completed in August 2022. The improvements specific to the SI investigation process have been taking place over the course of the last 18 months and have led to the Trust's central investigation team undergoing significant and ongoing change. A number of senior personnel changes, coupled with the need to prepare for the forthcoming national change from the SI framework to the Patient Safety Incident Response Framework (PSIRF) has meant that the SI team has required significant support to enable the necessary changes to occur, whilst also continuing to operate. Whilst this does not in any way excuse any SI's being below the standard we expect, and the SI into Caroline's death was certainly below that standard, I feel the aforementioned context is important to share with you to enable me to provide you with the assurances you, and Caroline's family, understandably, seek as to the quality of other and future SI/PSII reports.

Turning to your specific concerns, I will address the first two concerns jointly as they relate to the intrinsic quality of the SI review itself. The most significant change the Trust has made since last year is the way in which SI reports are quality assured. Specifically, now, SIs are subject to a higher level and layered quality review process, including, ultimately, sign-off by either the Trust's Chief Nursing Officer or the Chief Medical Officer. Additionally, multi-disciplinary panel sign-off approaches are now used so that quality can be assessed and discussed with the benefit of a range of expertise to provider richer scrutiny and thus learning. This multi-disciplinary/panel approach is also now being used during earlier stages of investigations by the use of subject-matter experts, in more complex cases, as well as wider use of independent chairs. These new wider multi-disciplinary approaches are also key as the Trust transitions to PSIRF.

PSIRF provides the Trust with a clear and welcome opportunity to affect the nationally recognised need to change from the SI framework to a more effective model of responding to incidents. So, this is where the Trust has invested in and is focusing upon, to ensure we have robust processes in place to sustain meaningful improvements to the way we respond to incidents. The Trust is aiming to transition to PSIRF at the end of August 2023. Prior to that transitioning the Trust's Legal Director would welcome the opportunity to meet with you to discuss the transition and the Trust's key priorities for future investigations, to ensure that they are in line with those matters that you feel ought to be prioritised in the forthcoming year. I understand that the Legal Director has a planned meeting with you, on other matters, in a few weeks' time, and I will ask that she takes the opportunity to initiate the conversation with you in relation to PSIRF.

Regarding your third concern, I confirm that, earlier this year, the SI team adapted their processes to enhance the 'lessons learnt' section, within all SI reports, to seek to widen the scope, for capturing learning. It is right to say that, initially, this learning, particularly if already effected, did not always have an action plan. However, since our new Chief Nursing Officer has been overseeing SIs, all 'lessons learnt' have had a corresponding action within a monitored action plan. I can also confirm that all action plans are overseen by the central SI team and their monitoring feeds into the governance structures within the clinical directorates, who are then responsible for ensuring completion of the actions. We have a newly established Quality and Risk Management Committee, co-chaired by the Chief Medical Officer and Chief Nursing officer, where assurance and risks relating to the learning from SIs and the action plans are overseen.

I hope that the aforementioned actions are of assurance to you. We believe that the current Executive led governance of SI reports, followed by the implementation of PSIRF has and will continue to lead to sustainable improvements in the quality of the learning we extract from SIs, to reduce incident recurrence and thus improve patient safety. As indicated, this is an ongoing piece of work, with national change being implemented, and the Trust welcomes your involvement. We will, of course, continue to monitor both the effectiveness of the recent improvements and how we achieve the best future improvements, as we transition to PSIRF. I will add an update on the

transition when I write to you in 6 months' time to update you on the Regulation 28 related improvements. In the meantime, if you have any questions regarding the content of this response or if I can further assist please do not hesitate to contact me.