Samantha Boazman
PFD Report
All Responded
Ref: 2023-0034Deceased
All 1 response received
· Deadline: 28 Mar 2023
Coroner's Concerns (AI summary)
The report raises concerns that emergency response protocols at the hospital involved staff assessing a situation and then collecting equipment, rather than bringing it immediately, and observations were recorded in a predictable manner, not therapeutically.
View full coroner's concerns
1. Emergency Response I heard during the course of the inquest that when an alarm sounded staff would attend the location of the alarm, assess the situation and then go and collect what equipment may be necessary to deal with the emergency. At the time of Samantha’s death there was only 1 emergency bag for the entire hospital (which had 2 wards and separate self-contained flats on the site). This has now been rectified and there is an emergency bag for every ward. Staff partake in a drill and evidence provided to me for the purposes of Regulation 28 showed that response times of staff remain at 2 minutes to a patient’s side. However, I was told that the emergency response still has staff attend a patient, assess and then go and collect the emergency bag, rather than taking it immediately to the patient’s side. I was provided with evidence for the purposes of Regulation 28 by Inmind Healthcare Group which showed, for example, that in December of 2022 there were 64 incidents, 45 of which were self-harm, 2 of which were clinical incidents. 16 resulted in actual harm and a large number of those incidents concerned patients ligating. To continue with an emergency response which delays the provision of life saving equipment to the patients’ side is unsafe and in my opinion could lead to future deaths. The delay in providing CPR to Samantha on balance had no causative effect on her death, but it could for another patient.
2. Observation Policy At the time of Samantha’s death observations were conducted and recorded in a predictable and prescriptive way by healthcare staff. The quality of observations recorded at the time of Samantha’s death were such that they did not accord with the expectation of the policy and merely recorded where the patient was and what they were doing. Effective observations were acknowledged as being a vital tool to assess and manage the risk of a patient. Inmind Healthcare Group’s new observation Policy states: ‘Observations are a therapeutic intervention aimed at reducing factors which contribute to increased risk and promoting recovery. The use of enhanced observation levels should never be regarded as routine practice……. Observation practice must focus on engaging the person therapeutically and enabling them to address their difficulties constructively. Our interactions must seek to create rapport which allows those in our care to feel valued and safe to share their experiences with us’. Since Samantha’s death changes have been made by Inmind Healthcare Group to their policy and practice, in that observations are now recorded at the precise time they are conducted and are infrequent in their predictability (eg: hourly observation should be conducted once hourly rather than on the hour every hour). Evidence of recent observation records demonstrated that this was now practice. However, there was a disconnect between the new policy and the pre-printed forms being used to record observations; what staff were being instructed to do and what they were recording. This was confusing and the evidence produced did not support the expectations of the new policy or demonstrate it had become embedded practice. The evidence produced did not support a change in staff recording quality observations, so that whilst precise and intermittent timings were evidenced, beyond the location of the patient or what they were doing, the actual presentation of the patient was not being recorded.
2. Observation Policy At the time of Samantha’s death observations were conducted and recorded in a predictable and prescriptive way by healthcare staff. The quality of observations recorded at the time of Samantha’s death were such that they did not accord with the expectation of the policy and merely recorded where the patient was and what they were doing. Effective observations were acknowledged as being a vital tool to assess and manage the risk of a patient. Inmind Healthcare Group’s new observation Policy states: ‘Observations are a therapeutic intervention aimed at reducing factors which contribute to increased risk and promoting recovery. The use of enhanced observation levels should never be regarded as routine practice……. Observation practice must focus on engaging the person therapeutically and enabling them to address their difficulties constructively. Our interactions must seek to create rapport which allows those in our care to feel valued and safe to share their experiences with us’. Since Samantha’s death changes have been made by Inmind Healthcare Group to their policy and practice, in that observations are now recorded at the precise time they are conducted and are infrequent in their predictability (eg: hourly observation should be conducted once hourly rather than on the hour every hour). Evidence of recent observation records demonstrated that this was now practice. However, there was a disconnect between the new policy and the pre-printed forms being used to record observations; what staff were being instructed to do and what they were recording. This was confusing and the evidence produced did not support the expectations of the new policy or demonstrate it had become embedded practice. The evidence produced did not support a change in staff recording quality observations, so that whilst precise and intermittent timings were evidenced, beyond the location of the patient or what they were doing, the actual presentation of the patient was not being recorded.
Responses
Action Taken
Following the death, an emergency bag is now in every ward in all Inmind hospitals. Regular training and competency assessments are now undertaken regarding observations, and a new radio protocol has been implemented for staff to communicate effectively in emergencies. (AI summary)
Following the death, an emergency bag is now in every ward in all Inmind hospitals. Regular training and competency assessments are now undertaken regarding observations, and a new radio protocol has been implemented for staff to communicate effectively in emergencies. (AI summary)
View full response
_____________________________________________________________ _____________________________________________________________ BEFORE HIS REGULATION 28 REPORT TO PREVENT DEATHS INQUEST TOUCHING UPON THE DEATH OF SAMANTHA JANE BOAZMAN amantha
I, c/o the Inmind Healthcare Group, Unit 7 The Quadrant, Upper Culham Farm, Cockpole Green, Berkshire, RG10 8NR will say as follows:
1. I am the Group Medical Advisor at Inmind Healthcare Group. I took over this role in January 2023.
2. The following information is provided, to the best of my knowledge, to assist HM Coroner, Miss Butler, in relation to concerns raised by her about the hospitals run by Inmind Healthcare Group ( ), as set out in the under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (the ). 1
HM CO
3. As a result of her inquisitorial proceedings, HM Coroner has raised concerns in policy and practice regarding:
a. The emergency response to alarms sounded by Health Care Assistants ( ) or other members of staff;
b. Observations of patients undertaken by HCAs. EMERGENCY RESPONSE TO ALARMS
4. HM Coroner heard evidence that at the time of Samantha death there was only one emergency bag for the entire hospital which caused a delay in the . , Chairman of Inmind and , Hospital Director of Sturdee Community Hospital, gave evidence that, as a result of Inmind Root Cause Analysis into the circumstances of Samantha death, there is now an emergency bag in every ward in all Inmind hospitals.
5. HM Coroner expressed concern that the emergency protocol at Sturdee Community Hospital, and throughout all hospitals, remained that staff would respond to an alarm by attending immediately, without first collecting the emergency bag, rather than taking the emergency bag to respond to such an alarm. HM Coroner is concerned that this approach may delay the use of life 2
saving equipment and could lead to future deaths. HM Coroner therefore recommended that staff should collect the emergency bag before attending the location of every alarm.
6. HM Coroner heard submissions by Counsel for Inmind, , that there was a practical risk-assessed element to responding to an alarm without the emergency bag, namely to attend as quickly as possible to ensure the safety and wellbeing of hospital staff who are regularly assaulted or threatened by patients. HM Coroner was concerned that this did not balance the risk presented to patients, who may have seriously self-harmed, and might require the immediate use of life-saving equipment.
7. Inmind immediately implemented HM C across Sturdee Community Hospital, ensuring that staff attending alarms always collected the emergency bag first. Regrettably this change in procedure has already caused significant difficulties and prompted further review:
a. Observing the emergency bag repeatedly being carried through the ward in undesirable behaviours by such patients;
b. The arrival of the emergency bag at the location where the alarm has been sounded has behaviour, the exact opposite of what usually occurs when a second member of 3
staff arrives to assist the first member of staff, thereby putting staff and patients at greater risk;
c. Patients sometimes carry out deliberately orchestrated disruptive behaviour in tandem at different locations, resulting in more than one alarm sounding at a time. This can cause the emergency bag to be taken to one patient who does not require any emergency equipment, making the bag harder to locate when it needs to be taken in response to the other alarm. (No such emergency equipment has yet been required to be used for a life-threatening event, but a real conundrum does arise in these foreseen circumstances.)
8. Inmind has informed the Care Quality Commission about the development. Inmind has also perused national and NHS Trusts policies and protocols. Based on these and the best evidence available, Inmind has implemented the following:
a. Staff have been provided with two-way radios and given training in the use of these radios. As a result, the response to an alarm has substantially changed;
b. The approach to hearing an alarm sound is now encapsulated in the new Medical Emergency Response Local Protocol (MV1) and Press to Talk Radios Protocol (MV2), appended to this statement. 4
9. Inmind has trialled the above and I am satisfied we have found an effective solution to the problem presented. The use of radios and designated first responders is recognised practice in NHS Mental Health hospitals and is deemed to be an effective response to emergency scenarios.
10.Practice emergency scenarios have been carried out every two weeks to test these changes. These tests demonstrate that this system should work well in the event of a real emergency (MV3). It has been observed that there are swift responses to alarms to de-escalate patients as well as less triggering of patients . This has now become part of internal Basic Life Support training.
11.Training of all staff in the use of radios has been undertaken, please see appended training record (MV4). Further emergency response training has been provided to all staff underlining the importance of protecting both staff and patients in the various scenarios that may arise. OBSERVATION POLICY
12.HM Coroner reviewed evidence provided by Sturdee Community Hospital of the observations made by HCAs since changes implemented following the RCA . HM Coroner was satisfied that the observations are now undertaken in a less predictable manner, for example 5
being done within one hour rather than on the hour. HM Coroner has, however, raised concerns that:
a. despite effective observations being recognised as a vital tool to assess and manage the risk to patients Policy, detailed observations are not always recorded by healthcare staff and often merely state where the patient was and/or what the patient was doing, rather than other aspects of the presentation of patients, such as their apparent mood, distress or agitation;
b. the forms used to record observations are not as clear as they should be in terms of what HCAs are expected to do (for example the title of ed with the subtitle saying hourly observations ) and that a systematic review of these forms should be undertaken to ensure they are optimised.
13.Inmind immediately reviewed the forms used at Sturdee Community Hospital and in the other hospitals run by Inmind and found staff had been using a variety of forms rather than one centralised document. All pre-existing forms have been systematically deleted from computers in the hospitals and replaced with two forms which are now available on the shared drive and used by all Inmind Hospitals. Copies of these two forms are appended: Intermittent observations (MV5) and Continuous Observations (MV6). 6
14.The Inmind Observations Policy has been updated to ensure these centralised forms are used and ensure that observations are made in line with national NHS standards.
15.Further training has been provided to HCAs and other staff to ensure the completion of these observation forms is optimised so that the entries are meaningful and assist others in gathering information about the patient and any potentially escalating scenarios. After training, staff undergo a competency assessment.
16.In addition to the further training provided to staff, I confirm that regular audits of the quality of the entries in observation records will be carried out by the Hospital Directors (or Deputy Hospital Directors) across all the Inmind hospitals. These audits will be overseen by the Medical Director of the Inmind Healthcare Group. Any HCA who fails to make appropriate observation entries will be spoken to and further training provided, if necessary.
17.Inmind is currently piloting a system of electronic patient records where each member of staff has a tablet upon which they can enter observations, read updated care plans etc. The plan is that this system, or a similar one, will be rolled out to all Inmind hospitals within the next six months. This would mean that information entered on one tablet can immediately be seen by others and that any changes to observation levels or restricted items can easily be implemented and the information updated on every tablet simultaneously. 7
18. procedure and training. Statement of Truth I confirm that the facts stated in this statement are true to the best of my knowledge and belief. I am duly authorised to make this Statement. Name:
Position within Inmind Group: Group Medical Advisor Signed: Date: 03 March 2023 8
Press To Talk Radio Protocol Sturdee Community Hospital Press to Talk Radios Protocol This protocol is to guide the use of Press to Talk Radios (PTTR) by staff at Sturdee Hospital. This is only in reference to the radios used by Sturdee Hospital Staff, not those used by domestic services or by on-site contractors (i.e., maintenance, cleaners). The purpose is to ensure that in the event of an emergency within the Hospital, staff can respond appropriately. For example, ensuring that in the event of a medical emergency staff who are responding MUST be BLS trained. In the event of a patient going AWOL, staff may be directed in the direction of the patient, rather than directly to a ward. Use of the radios is also to facilitate communication between staff members when they are in an isolated part of the hospital, such as a patients bedroom, and they require non urgent assistance, e.g. they need to use the toilet. Aylestone ward is supplied with two batteries operated (PTTR). Rutland ward is supplied with eight (PTTR’s) Foxton ward has 4 (PTTRs) The radios should be worn by a nurse and staff on observationson each ward, the others should remain on the charger in the nursing office. At all times, all radios should be;
1. Turned on
2. Tuned to channel 1
3. Have the volume turned up so audible to the wearer. At night, staff should be especially mindful of the volume of the radio in patient areas so not to wake or startle our patients. In the nursing office, the radios that are not in use should be always left on the charger (docking station). The radios make a beeping sound when it is running out of battery power. It should be wopped immediately for one on the docking station Testing Radios will be call tested each shift at: 08:00 AM 20:00 PM The NIC for Rutland will be responsible for actioning these checks and document this on the report. If a ward fails to respond to the test, the NIC must contact the ward in question either by phone or in person and re-test.
Press To Talk Radio Protocol Sturdee Community Hospital Tests are as follows: RADIO CHECK RADIO CHECK NIC to *Aylestone*
*Aylestone* Responding
* each ward in turn Minimising Feedback Use following alarm activation. Call Codes
- Medical Emergency – “Medical Emergency … (say location)” Only staff who are BLS trained can respond. Personal Alarm/ Violence and Aggression incident
- Aggression/violence/absconsion - “Assistance required on …. (say location)”. (Staff may be required to repeat the command over the radio). Personal alarms must still be used in any urgent situation. Responding When responding to an emergency call over the radio, you must say which ward you are from and responding. For example, “RUTLAND Responding”. This is to allow the ward requesting assistance know that support is coming. Cancellation If no further assistance is required, you must say clearly over the radio. For example “No further assistance required on treatment I repeat no further assistance required on treatment” “FALSE ALARM ON RUTLAND WARD. DO NOT RESPOND. I REPEAT, FALSE ALARM ON RUTLAND WARD DO NOT RESPOND.” Fire If the fire alarm sounds, check the fire panel and if it is your ward the fire warden should check the area and if it is a false alarm, the NIC must call that it is a false alarm over the radio by saying “False alarm on… (say location).” Further instructions
Press To Talk Radio Protocol Sturdee Community Hospital It may be the case that staff need to relay instructions to responding staff before entry. These should be kept to a minimum and only be to ensure staff safety when they enter the ward. Basic Radio Etiquette Rules
• The international radio language is English.
• When using a two-way radio, you cannot speak and listen at the same time, as you can with a phone.
• Do not interrupt if you hear other people talking.
• Never transmit sensitive, confidential, information. Use room numbers where possible, if you need to mention the patient, say initials only.
• Perform radio checks to ensure your radio is in good working condition.
• Do not allow patients to use the radio. THINK BEFORE YOU SPEAK: Decide what you are going say and to whom it is meant for. Make your conversations as concise, precise, and clear as possible. Avoid long and complicated sentences. If your message is long, divide it into
• separate shorter messages. Do not use abbreviations unless they are well understood by your group. Golden Rules of Radio Communication
1. Clarity: Your voice should be clear. Speak a little slower than normal. Speak in a normal tone, do not shout.
2. Simplicity: Keep your message simple enough for intended listeners to understand.
3. Brevity: Be precise and to the point.
4. Security: Do not transmit confidential information on a radio. Remember, frequencies are shared, you do not have exclusive use of the frequency. Making a Call Follow these easy steps to make a call:
1. First listen to ensure the channel is clear for you.
2. Press the PTT (Push-To-Talk) button.
3. After 2 seconds:
4. Say "recipient's name"
5. Followed by "this" and "your name"
6. Once the person replies, convey your message. Two-Way Radio Protocol
Press To Talk Radio Protocol Sturdee Community Hospital Sample Dialog: Below is a sample dialog that puts these standards to use. Doris: Betty, this is Doris. Over. Betty: Doris, this is Betty, Stand By. Over. Betty: Doris, this is Betty, Go Ahead. Over. Doris: Betty, Asisstance required in bedroom 1. Over. Betty: Doris, this is Betty, confirming assistance is required, staff on their way. Over. Doris: Betty, this is Doris, thanks for the help. Over and Out. Radio Communication Tips
• Leave a second or two between "hand-offs" to give others a chance to break in.
• It is always best to speak in short simple phrases on the radio and toss the conversion back and forth with the word "OVER."
• Don't speak immediately when you press the PTT (push to talk), wait 2-3 seconds.
• If you speak as soon you press the PTT button, it can chop off your the first syllable or word, making you hard to understand. If that word doesn't make it, you will just have to say it again and run down your batteries faster. Radio User’s Language Go Ahead – Resume transmission Say Again – Re-transmit your message Stand-by – Transmission has been acknowledged, but I am unable to respond now. Roger – Message received and understood. Affirmative – Yes – Avoid yup, nope, etc. Negative – No Over – Transmission finished. Out – Communication is over and the channel is available for others. Standard NATO Alphabet Used to spell out letters over the radio.
I, c/o the Inmind Healthcare Group, Unit 7 The Quadrant, Upper Culham Farm, Cockpole Green, Berkshire, RG10 8NR will say as follows:
1. I am the Group Medical Advisor at Inmind Healthcare Group. I took over this role in January 2023.
2. The following information is provided, to the best of my knowledge, to assist HM Coroner, Miss Butler, in relation to concerns raised by her about the hospitals run by Inmind Healthcare Group ( ), as set out in the under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (the ). 1
HM CO
3. As a result of her inquisitorial proceedings, HM Coroner has raised concerns in policy and practice regarding:
a. The emergency response to alarms sounded by Health Care Assistants ( ) or other members of staff;
b. Observations of patients undertaken by HCAs. EMERGENCY RESPONSE TO ALARMS
4. HM Coroner heard evidence that at the time of Samantha death there was only one emergency bag for the entire hospital which caused a delay in the . , Chairman of Inmind and , Hospital Director of Sturdee Community Hospital, gave evidence that, as a result of Inmind Root Cause Analysis into the circumstances of Samantha death, there is now an emergency bag in every ward in all Inmind hospitals.
5. HM Coroner expressed concern that the emergency protocol at Sturdee Community Hospital, and throughout all hospitals, remained that staff would respond to an alarm by attending immediately, without first collecting the emergency bag, rather than taking the emergency bag to respond to such an alarm. HM Coroner is concerned that this approach may delay the use of life 2
saving equipment and could lead to future deaths. HM Coroner therefore recommended that staff should collect the emergency bag before attending the location of every alarm.
6. HM Coroner heard submissions by Counsel for Inmind, , that there was a practical risk-assessed element to responding to an alarm without the emergency bag, namely to attend as quickly as possible to ensure the safety and wellbeing of hospital staff who are regularly assaulted or threatened by patients. HM Coroner was concerned that this did not balance the risk presented to patients, who may have seriously self-harmed, and might require the immediate use of life-saving equipment.
7. Inmind immediately implemented HM C across Sturdee Community Hospital, ensuring that staff attending alarms always collected the emergency bag first. Regrettably this change in procedure has already caused significant difficulties and prompted further review:
a. Observing the emergency bag repeatedly being carried through the ward in undesirable behaviours by such patients;
b. The arrival of the emergency bag at the location where the alarm has been sounded has behaviour, the exact opposite of what usually occurs when a second member of 3
staff arrives to assist the first member of staff, thereby putting staff and patients at greater risk;
c. Patients sometimes carry out deliberately orchestrated disruptive behaviour in tandem at different locations, resulting in more than one alarm sounding at a time. This can cause the emergency bag to be taken to one patient who does not require any emergency equipment, making the bag harder to locate when it needs to be taken in response to the other alarm. (No such emergency equipment has yet been required to be used for a life-threatening event, but a real conundrum does arise in these foreseen circumstances.)
8. Inmind has informed the Care Quality Commission about the development. Inmind has also perused national and NHS Trusts policies and protocols. Based on these and the best evidence available, Inmind has implemented the following:
a. Staff have been provided with two-way radios and given training in the use of these radios. As a result, the response to an alarm has substantially changed;
b. The approach to hearing an alarm sound is now encapsulated in the new Medical Emergency Response Local Protocol (MV1) and Press to Talk Radios Protocol (MV2), appended to this statement. 4
9. Inmind has trialled the above and I am satisfied we have found an effective solution to the problem presented. The use of radios and designated first responders is recognised practice in NHS Mental Health hospitals and is deemed to be an effective response to emergency scenarios.
10.Practice emergency scenarios have been carried out every two weeks to test these changes. These tests demonstrate that this system should work well in the event of a real emergency (MV3). It has been observed that there are swift responses to alarms to de-escalate patients as well as less triggering of patients . This has now become part of internal Basic Life Support training.
11.Training of all staff in the use of radios has been undertaken, please see appended training record (MV4). Further emergency response training has been provided to all staff underlining the importance of protecting both staff and patients in the various scenarios that may arise. OBSERVATION POLICY
12.HM Coroner reviewed evidence provided by Sturdee Community Hospital of the observations made by HCAs since changes implemented following the RCA . HM Coroner was satisfied that the observations are now undertaken in a less predictable manner, for example 5
being done within one hour rather than on the hour. HM Coroner has, however, raised concerns that:
a. despite effective observations being recognised as a vital tool to assess and manage the risk to patients Policy, detailed observations are not always recorded by healthcare staff and often merely state where the patient was and/or what the patient was doing, rather than other aspects of the presentation of patients, such as their apparent mood, distress or agitation;
b. the forms used to record observations are not as clear as they should be in terms of what HCAs are expected to do (for example the title of ed with the subtitle saying hourly observations ) and that a systematic review of these forms should be undertaken to ensure they are optimised.
13.Inmind immediately reviewed the forms used at Sturdee Community Hospital and in the other hospitals run by Inmind and found staff had been using a variety of forms rather than one centralised document. All pre-existing forms have been systematically deleted from computers in the hospitals and replaced with two forms which are now available on the shared drive and used by all Inmind Hospitals. Copies of these two forms are appended: Intermittent observations (MV5) and Continuous Observations (MV6). 6
14.The Inmind Observations Policy has been updated to ensure these centralised forms are used and ensure that observations are made in line with national NHS standards.
15.Further training has been provided to HCAs and other staff to ensure the completion of these observation forms is optimised so that the entries are meaningful and assist others in gathering information about the patient and any potentially escalating scenarios. After training, staff undergo a competency assessment.
16.In addition to the further training provided to staff, I confirm that regular audits of the quality of the entries in observation records will be carried out by the Hospital Directors (or Deputy Hospital Directors) across all the Inmind hospitals. These audits will be overseen by the Medical Director of the Inmind Healthcare Group. Any HCA who fails to make appropriate observation entries will be spoken to and further training provided, if necessary.
17.Inmind is currently piloting a system of electronic patient records where each member of staff has a tablet upon which they can enter observations, read updated care plans etc. The plan is that this system, or a similar one, will be rolled out to all Inmind hospitals within the next six months. This would mean that information entered on one tablet can immediately be seen by others and that any changes to observation levels or restricted items can easily be implemented and the information updated on every tablet simultaneously. 7
18. procedure and training. Statement of Truth I confirm that the facts stated in this statement are true to the best of my knowledge and belief. I am duly authorised to make this Statement. Name:
Position within Inmind Group: Group Medical Advisor Signed: Date: 03 March 2023 8
Press To Talk Radio Protocol Sturdee Community Hospital Press to Talk Radios Protocol This protocol is to guide the use of Press to Talk Radios (PTTR) by staff at Sturdee Hospital. This is only in reference to the radios used by Sturdee Hospital Staff, not those used by domestic services or by on-site contractors (i.e., maintenance, cleaners). The purpose is to ensure that in the event of an emergency within the Hospital, staff can respond appropriately. For example, ensuring that in the event of a medical emergency staff who are responding MUST be BLS trained. In the event of a patient going AWOL, staff may be directed in the direction of the patient, rather than directly to a ward. Use of the radios is also to facilitate communication between staff members when they are in an isolated part of the hospital, such as a patients bedroom, and they require non urgent assistance, e.g. they need to use the toilet. Aylestone ward is supplied with two batteries operated (PTTR). Rutland ward is supplied with eight (PTTR’s) Foxton ward has 4 (PTTRs) The radios should be worn by a nurse and staff on observationson each ward, the others should remain on the charger in the nursing office. At all times, all radios should be;
1. Turned on
2. Tuned to channel 1
3. Have the volume turned up so audible to the wearer. At night, staff should be especially mindful of the volume of the radio in patient areas so not to wake or startle our patients. In the nursing office, the radios that are not in use should be always left on the charger (docking station). The radios make a beeping sound when it is running out of battery power. It should be wopped immediately for one on the docking station Testing Radios will be call tested each shift at: 08:00 AM 20:00 PM The NIC for Rutland will be responsible for actioning these checks and document this on the report. If a ward fails to respond to the test, the NIC must contact the ward in question either by phone or in person and re-test.
Press To Talk Radio Protocol Sturdee Community Hospital Tests are as follows: RADIO CHECK RADIO CHECK NIC to *Aylestone*
*Aylestone* Responding
* each ward in turn Minimising Feedback Use following alarm activation. Call Codes
- Medical Emergency – “Medical Emergency … (say location)” Only staff who are BLS trained can respond. Personal Alarm/ Violence and Aggression incident
- Aggression/violence/absconsion - “Assistance required on …. (say location)”. (Staff may be required to repeat the command over the radio). Personal alarms must still be used in any urgent situation. Responding When responding to an emergency call over the radio, you must say which ward you are from and responding. For example, “RUTLAND Responding”. This is to allow the ward requesting assistance know that support is coming. Cancellation If no further assistance is required, you must say clearly over the radio. For example “No further assistance required on treatment I repeat no further assistance required on treatment” “FALSE ALARM ON RUTLAND WARD. DO NOT RESPOND. I REPEAT, FALSE ALARM ON RUTLAND WARD DO NOT RESPOND.” Fire If the fire alarm sounds, check the fire panel and if it is your ward the fire warden should check the area and if it is a false alarm, the NIC must call that it is a false alarm over the radio by saying “False alarm on… (say location).” Further instructions
Press To Talk Radio Protocol Sturdee Community Hospital It may be the case that staff need to relay instructions to responding staff before entry. These should be kept to a minimum and only be to ensure staff safety when they enter the ward. Basic Radio Etiquette Rules
• The international radio language is English.
• When using a two-way radio, you cannot speak and listen at the same time, as you can with a phone.
• Do not interrupt if you hear other people talking.
• Never transmit sensitive, confidential, information. Use room numbers where possible, if you need to mention the patient, say initials only.
• Perform radio checks to ensure your radio is in good working condition.
• Do not allow patients to use the radio. THINK BEFORE YOU SPEAK: Decide what you are going say and to whom it is meant for. Make your conversations as concise, precise, and clear as possible. Avoid long and complicated sentences. If your message is long, divide it into
• separate shorter messages. Do not use abbreviations unless they are well understood by your group. Golden Rules of Radio Communication
1. Clarity: Your voice should be clear. Speak a little slower than normal. Speak in a normal tone, do not shout.
2. Simplicity: Keep your message simple enough for intended listeners to understand.
3. Brevity: Be precise and to the point.
4. Security: Do not transmit confidential information on a radio. Remember, frequencies are shared, you do not have exclusive use of the frequency. Making a Call Follow these easy steps to make a call:
1. First listen to ensure the channel is clear for you.
2. Press the PTT (Push-To-Talk) button.
3. After 2 seconds:
4. Say "recipient's name"
5. Followed by "this" and "your name"
6. Once the person replies, convey your message. Two-Way Radio Protocol
Press To Talk Radio Protocol Sturdee Community Hospital Sample Dialog: Below is a sample dialog that puts these standards to use. Doris: Betty, this is Doris. Over. Betty: Doris, this is Betty, Stand By. Over. Betty: Doris, this is Betty, Go Ahead. Over. Doris: Betty, Asisstance required in bedroom 1. Over. Betty: Doris, this is Betty, confirming assistance is required, staff on their way. Over. Doris: Betty, this is Doris, thanks for the help. Over and Out. Radio Communication Tips
• Leave a second or two between "hand-offs" to give others a chance to break in.
• It is always best to speak in short simple phrases on the radio and toss the conversion back and forth with the word "OVER."
• Don't speak immediately when you press the PTT (push to talk), wait 2-3 seconds.
• If you speak as soon you press the PTT button, it can chop off your the first syllable or word, making you hard to understand. If that word doesn't make it, you will just have to say it again and run down your batteries faster. Radio User’s Language Go Ahead – Resume transmission Say Again – Re-transmit your message Stand-by – Transmission has been acknowledged, but I am unable to respond now. Roger – Message received and understood. Affirmative – Yes – Avoid yup, nope, etc. Negative – No Over – Transmission finished. Out – Communication is over and the channel is available for others. Standard NATO Alphabet Used to spell out letters over the radio.
Sent To
Response Status
Linked responses
1 of 1
56-Day Deadline
28 Mar 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 29 October 2021, I commenced an investigation into the death of Samantha Jane BOAZMAN aged 54. The investigation concluded at the end of a 10 day inquest on 27 January 2023. The conclusion of the jury was: ‘Death by misadventure. We find that there was gross neglect due to a continuous sequence of shortcomings, including a lack of adequate training on the risks and triggers of patients. Failure to remove ligature risks from bedrooms. Inadequate induction and training of temporary staff’.
Circumstances of the Death
Samantha Boazman had a diagnosis of Emotionally Unstable Personality Disorder and Dissocial Personality Disorder. She had had a 35 year history with mental health services. Samantha arrived at Sturdee Community Hospital (a locked female rehabilitation ward) in June of 2020, when her community placement had broken down and she could no longer be safely managed within the community. At the time of her death, Samantha was detained under s.3 of the Mental Health Act. On 17th September 2021 whilst on s.17 leave Samantha walked in front of a slow-moving vehicle, she was admitted to A&E with a minor injury to her knee and head injury where she had fallen backwards. She was discharged the same day. On return to Sturdee Community Hospital Samantha was placed on 15 minute observations but was found in her bathroom
Samantha was moved to a safety room. On 14th October 2021 Samantha returned to her normal bedroom, room 5. Observation levels were reduced from 15 minutes to 30 minutes on 21st and 22nd September, and then reduced to hourly observations on 23rd September 2021. The RAG rating records Samantha as being on hourly observations from 23rd September to the date of her death. On 20th September 2021, Samantha was denied access to ‘cables/chargers’. The Jury heard evidence that something coloured red on the RAG rating was a ‘high risk’. Cables/chargers were highlighted red and remained contraband items from 20th September to the point of Samantha’s death. Samantha found transitions difficult to go somewhere she didn’t know. On 21st October 2021 Samantha was informed that she would be moving to Aylestone Flats within the ground of Sturdee Community Hospital in preparation for moving to the community in the future. A Senior Registered MHN told the Jury that the thought of moving destabilised Samantha. Samantha had heightened sensitivity as part of her Emotionally Unstable Personality Disorder, so a small thing (not receiving a text message) would be felt more strongly. Her Psychologist saw Samantha on the 21st October and described Samantha as anxious and the reasons for this were not receiving responses to her text messages and also leaving the hospital for a future placement (yet to be identified). Samantha had been more agitated than usual over the course of the previous week and seeking staff support quite a lot. No one could recall a discussion about Samantha’s risk at the risk management meeting of 22nd October 2021 and if there was a discussion about Samantha’s risk, her risk rating wasn’t changed on the RAG document. Various staff gave evidence as to Samantha’s presentation on the 22nd October 2021, for example: Samantha was at around 3pm almost irritable; very unsettled and had been more agitated in the days prior to her death and seeking more 1-1 interactions. Samantha was described as unsettled, kept pacing and crying, this was different to what Samantha was like before. Samantha was said to be ‘very very’ anxious walking up and down asking for the doctor or the nurse in charge. The CCTV evidence of Samantha on 22 October 2021 between 15.57 hours and 17.33 hours (when Samantha was last seen) showed that between 15.57 and 16.29 hours Samantha can be seen pacing the corridor 27 times within the 32 minute period, and between 16.29 and 17.33, a 64 minutes period, she can be seen pacing the corridor 70 times – more than 1 x per minute. Health care assistants who were allocated general observations would be allocated these within a 1-hour period, for example 4pm to 5pm. The Jury heard how healthcare assistants had to observe and record the hourly observation for a patient on the hour every hour, none were told to record the actual time they observed the patient, nor was that the Inmind Healthcare Group Policy for Sturdee Community Hospital in place at the time. Healthcare assistants would locate the patient 5 minutes before the hour period was up and then record their observation on the hour and then move to their next patient. As far as the purpose of conducting observations, the evidence of the healthcare assistants was that they needed to observe that the patient was safe and if the patient was sleeping, to check if the patient was breathing. Health care assistants were to record the location and what the patient was doing and also to record if the healthcare assistant interacted with the patient and anything else meaningful. If a patient was engaged with something (eg: watching tv) there wasn’t an expectation to disturb the patient to interact with them. There was a period of 1 hour and 12 minutes between Samantha closing her bedroom door and it being opened by a healthcare assistant and no was seen entering Samantha’s room during that time. No one observed her. Samantha was found at 18.45 hours in her bathroom on 22nd of October 2021
A nurse and healthcare assistant answered the alarm at 18.47, just under 2 minutes. There were difficulties in entering Samantha’s bathroom because she was behind the door. The 999 call to East Midlands Ambulance Service was received at 18.53 hrs, 8 minutes after the alarm was raised. A trained paramedic co-incidentally arrived at the hospital to work in a different capacity and went to assist, arriving at Samantha’s bedroom at 18.53 hours, the same time as the 999 call was being made. The Jury hard in evidence that there was no CPR in progress when she arrived. The paramedic said that ILS training was that you should commence early CPR. The emergency response bag was delayed in being brought to the scene due to being situated on a different ward which required access to another building through locked doors. The defibrillator was being attached during the 999 call and at the point the trained paramedic arrived at the scene. CPR was commenced at a time at least 8 minutes after the alarm was raised, and at a time at least 6 minutes after the alarm was answered. The defibrillator advised no shock indicating that there was no electrical activity within Samantha’s heart (asystole). A second round of CPR as advised by the defibrillator, was commenced, but Samantha’s pupils were fixed and dilated, she had mottled skin, which she described was a bruising effect when the body has been lying for some time and as advised by the Resuscitation Council UK, CPR was ceased to preserve Samantha’s dignity. Paramedics attended and Samantha was pronounced dead at 19:15 hours.
Samantha was moved to a safety room. On 14th October 2021 Samantha returned to her normal bedroom, room 5. Observation levels were reduced from 15 minutes to 30 minutes on 21st and 22nd September, and then reduced to hourly observations on 23rd September 2021. The RAG rating records Samantha as being on hourly observations from 23rd September to the date of her death. On 20th September 2021, Samantha was denied access to ‘cables/chargers’. The Jury heard evidence that something coloured red on the RAG rating was a ‘high risk’. Cables/chargers were highlighted red and remained contraband items from 20th September to the point of Samantha’s death. Samantha found transitions difficult to go somewhere she didn’t know. On 21st October 2021 Samantha was informed that she would be moving to Aylestone Flats within the ground of Sturdee Community Hospital in preparation for moving to the community in the future. A Senior Registered MHN told the Jury that the thought of moving destabilised Samantha. Samantha had heightened sensitivity as part of her Emotionally Unstable Personality Disorder, so a small thing (not receiving a text message) would be felt more strongly. Her Psychologist saw Samantha on the 21st October and described Samantha as anxious and the reasons for this were not receiving responses to her text messages and also leaving the hospital for a future placement (yet to be identified). Samantha had been more agitated than usual over the course of the previous week and seeking staff support quite a lot. No one could recall a discussion about Samantha’s risk at the risk management meeting of 22nd October 2021 and if there was a discussion about Samantha’s risk, her risk rating wasn’t changed on the RAG document. Various staff gave evidence as to Samantha’s presentation on the 22nd October 2021, for example: Samantha was at around 3pm almost irritable; very unsettled and had been more agitated in the days prior to her death and seeking more 1-1 interactions. Samantha was described as unsettled, kept pacing and crying, this was different to what Samantha was like before. Samantha was said to be ‘very very’ anxious walking up and down asking for the doctor or the nurse in charge. The CCTV evidence of Samantha on 22 October 2021 between 15.57 hours and 17.33 hours (when Samantha was last seen) showed that between 15.57 and 16.29 hours Samantha can be seen pacing the corridor 27 times within the 32 minute period, and between 16.29 and 17.33, a 64 minutes period, she can be seen pacing the corridor 70 times – more than 1 x per minute. Health care assistants who were allocated general observations would be allocated these within a 1-hour period, for example 4pm to 5pm. The Jury heard how healthcare assistants had to observe and record the hourly observation for a patient on the hour every hour, none were told to record the actual time they observed the patient, nor was that the Inmind Healthcare Group Policy for Sturdee Community Hospital in place at the time. Healthcare assistants would locate the patient 5 minutes before the hour period was up and then record their observation on the hour and then move to their next patient. As far as the purpose of conducting observations, the evidence of the healthcare assistants was that they needed to observe that the patient was safe and if the patient was sleeping, to check if the patient was breathing. Health care assistants were to record the location and what the patient was doing and also to record if the healthcare assistant interacted with the patient and anything else meaningful. If a patient was engaged with something (eg: watching tv) there wasn’t an expectation to disturb the patient to interact with them. There was a period of 1 hour and 12 minutes between Samantha closing her bedroom door and it being opened by a healthcare assistant and no was seen entering Samantha’s room during that time. No one observed her. Samantha was found at 18.45 hours in her bathroom on 22nd of October 2021
A nurse and healthcare assistant answered the alarm at 18.47, just under 2 minutes. There were difficulties in entering Samantha’s bathroom because she was behind the door. The 999 call to East Midlands Ambulance Service was received at 18.53 hrs, 8 minutes after the alarm was raised. A trained paramedic co-incidentally arrived at the hospital to work in a different capacity and went to assist, arriving at Samantha’s bedroom at 18.53 hours, the same time as the 999 call was being made. The Jury hard in evidence that there was no CPR in progress when she arrived. The paramedic said that ILS training was that you should commence early CPR. The emergency response bag was delayed in being brought to the scene due to being situated on a different ward which required access to another building through locked doors. The defibrillator was being attached during the 999 call and at the point the trained paramedic arrived at the scene. CPR was commenced at a time at least 8 minutes after the alarm was raised, and at a time at least 6 minutes after the alarm was answered. The defibrillator advised no shock indicating that there was no electrical activity within Samantha’s heart (asystole). A second round of CPR as advised by the defibrillator, was commenced, but Samantha’s pupils were fixed and dilated, she had mottled skin, which she described was a bruising effect when the body has been lying for some time and as advised by the Resuscitation Council UK, CPR was ceased to preserve Samantha’s dignity. Paramedics attended and Samantha was pronounced dead at 19:15 hours.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Police-ambulance terminology interoperability
Southport Inquiry
Emergency responder equipment training
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.