Dear Madam

Re: Regulation 28 Report to Prevent Future Deaths – Mr Christopher Ryan

I am writing to you following receipt of the Regulation 28: Report to Prevent Future Deaths dated 22nd July 2022, but was not issued to the Trust until 13th February 2023, regarding the sad death of Mr Christopher Ryan. 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 Ryan’s care and treatment, to help the Trust respond to the points of concern you have raised.

I, therefore, respond to each of your concerns and direction as they were raised in your correspondence:

(1) The Consultant Psychiatrist had signed the agreed escorted leave form on the basis that Chris would be accompanied 1:1 with a nurse. The purpose of the leave was therapeutic, to enable Chris to access the community in a supported manner. Evidence was before the court that the leave was only to the adjacent car park, to facilitate a smoking break, and 1 member of staff accompanied up to 6 patients. The Trust's own Root Cause Analysis report confirms that the practise was at this time for 1 staff member to accompany those patients who wished to smoke to the adjacent car park.

The ‘Leave of Absence – section 17’ form that covers the period in question was approved by the Consultant Psychiatrist on 30th September 2020. The form did not include any stipulation around 1:1 escorting; however, we acknowledge that live evidence given to the Inquest by the consultant put forward that it was their expectation this would be 1:1.

We feel it is important to note that at the time of this incident, 23rd December 2020, the country was under Tier 4 National Lockdown, which had the strict government legal restrictions, which included only being able to leave residence for essential activities only and all non-essential retail was not permitted to be open. An individual could only meet one other person in an outside public space and there were rules on support bubbles in place.

These requirements had a significant impact on how escorted leave was carried out. Escorted leave was often carried out in the context of patients being part of a group of six support bubble. There was no leave permitted for anyone outside of the hospital grounds in line with National Covid 19 legislation. The Trust Root Cause Analysis report confirmed escorted leave at the time was not carried out on a 1:1 basis but in a group. The appropriate individual risk assessments were undertaken at the time and there had been no risk incidents with any patients having escorted leave as part of a group up to this point. These were exceptional circumstances to avoid anyone leaving the site to comply with the legislation and keep people safe from the risks of Covid as they were understood at that time.

It is understood that this, along with the requirements to remain in small support bubbles, did result in more group on-site activities, such as walking groups that could have seen one staff member escorting such groups.

We have referred back to our Root Cause Analysis report and cannot find any mention or reference of the practice around one staff member to accompany those patients who wished to smoke to the adjacent car park. Although we acknowledge (especially given the Covid restrictions mentioned above) that patients may have used the car park to smoke and that the family did provide statements that they had witnessed such smoking on the grounds.

We recognise that understanding of Covid and the applicable restrictions have reduced significantly over time. Despite this, we have taken on board the spirit of the concerns raised and will review our leave form / guidance to help ensure we better capture any stipulations around staffing of escorts. Leave will be facilitated in accordance with these stipulations and non-compliance with be addressed accordingly with the applicable members of staff.

(2) The car park is entirely unsecure and open to the road. Evidence given in court was that the hospital site is non-smoking, but the evidence was unclear whether the car park was considered to be part of the hospital site or separate.

The car park is not owned or run by this Trust. This car park is on the Queen Mary’s Hospital site, which is owned and run by St George’s University Hospital NHS Foundation Trust (SGH). I can confirm that the Queen Mary’s Hospital site is a non-smoking site and is covered by the SGH ‘Smokefree Policy’; which specifically mentions the Queen Mary’s Hospital site, where smoking is not permitted and our policy is the same for our sites, where smoking is not permitted anywhere on our grounds (see below).

(3) My concern is that there has been a tolerated blurring of the boundaries between the intentions of escorted leave for individuals under a MHA section, and the ward staff's ability to facilitate this in a meaningful and therapeutic way to benefit the patients, and that the clinical staff were not aware of this. Chris had indicated his desire to access the cash point and buy Christmas presents for his family, but there was no suggestion these requests had been considered by the Trust and either approved or refused. Chris therefore made the decision to leave the ward, with catastrophic consequences. Has the Trust given any consideration to the provision of a "safe" smoking area that patients can access without the need to be accompanied or to use their restricted escorted leave for this purpose alone?

Mr Ryan mentioned to nursing staff that his wish to go shopping once he received his benefit payment. At the time, the ability for him to do this would have been very limited due to the Covid Restrictions, as patients were not permitted to leave the hospital grounds and non-essential shops were closed. This impacted on the ability of ward staff to consider and design a plan with Mr Ryan for him to go shopping.

From a holistic perspective, ward staff have conversations with patients about how they intend to use their leave and how best they can be supported. Being able to complete daily living activities such as going shopping, viewing properties that patients may live in post discharge and attending appointments are seen as part of the patient’s recovery journey; ward staff often support patients through escorted leave to achieve these recovery goals. This is now greatly aided by the relaxation of the Covid Restrictions. Going forward the Trust will continue to observe any further restrictions should they return, in order to protect its service users, its staff and the public. The learning arising from this Inquest has been shared across the service line.

In regard to consideration of safe smoking area, the Trust has a policy titled ‘Completely Smoke Free Policy’ which makes clear that smoking is not permitted anywhere in the Trust’s buildings, including inpatient settings or grounds. This position follows clear national guidance from the Department of Health and Public Health England (now called UK Health Security Agency) and the Trust’s policy is underpinned by studies around links related to morbidity and mortality particularly in smokers with mental health problems and our desire help support their physical

Chief Executive, Vanessa Ford Trust Chair, Ann Beasley health. Leave will be facilitated in accordance with the smoke free policy and compliance with it will be emphasised accordingly with the members of staff.

As aforementioned, the Queen Mary’s Hospital site is also covered by a clear policy where smoking is not permitted in its buildings, car parks, grounds and gardens.

However, the Trust has committed to undertaking a formal and comprehensive review of our ‘Smoke Free’ policy which has commenced and is due to be concluded in July 2023, which will also include how we ensure that practice reflects policy, particularly around leave.

We thank you for your consideration and commitment to prevention of future deaths and helping us and the wider NHS to learn. There are areas in this response which are within our control, and we will ensure are completed. The PFD request for the Trust to essentially consider establishing an area on NHS grounds to smoke would be a breach of the wider NHS smoke free policy, and as such this may require further support from you with senior Department of health NHS policy makers, which we would be happy to discuss.

I would like to express our deep sympathy to the family and friends of Mr Ryan for their loss. Many staff at the Trust who knew Mr Ryan were greatly affected by his death. While we seek to make significant effort 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.