Sandra Kirk
PFD Report
All Responded
Ref: 2022-0298
All 2 responses received
· Deadline: 21 Nov 2022
Coroner's Concerns (AI summary)
Ligature risk policies inadequately address potential ligature items like clothing, focusing instead on anchor points and avoiding 'blanket restrictions' without sufficiently identifying actual risks to vulnerable patients.
View full coroner's concerns
The evidence in this inquest was that Cygnet’s Ligature Risk Reduction Policy and the Ligature Audit Tool/Ligature Risk Assessment are standard documents used by Mental Health inpatient providers, including NHS Psychiatric Trusts.
- The Ligature Risk Reduction Policy quotes the CQC guidance of 2015, that “Three-quarters of people who kill themselves whilst on a psychiatric ward do so by hanging or strangulation”.
- Whilst these documents provide detailed guidance in respect of minimising ligature anchor points, they do not give guidance as to minimising potential ligatures themselves, which are defined as “Any item which can be used to make a loop or noose with the intention of limiting the supply of oxygen to an individual by hanging or asphyxiation”.
- Rather than emphasising the very real risk that specific items of clothing, , can pose to vulnerable patients, the document places emphasis on avoiding ‘blanket restrictions’ which does not assist in identifying where the real risks lie.
- Death by the use of a ligature is likely to occur within a few minutes, whereas observations for a high-risk patient not assessed
- The Ligature Risk Reduction Policy quotes the CQC guidance of 2015, that “Three-quarters of people who kill themselves whilst on a psychiatric ward do so by hanging or strangulation”.
- Whilst these documents provide detailed guidance in respect of minimising ligature anchor points, they do not give guidance as to minimising potential ligatures themselves, which are defined as “Any item which can be used to make a loop or noose with the intention of limiting the supply of oxygen to an individual by hanging or asphyxiation”.
- Rather than emphasising the very real risk that specific items of clothing, , can pose to vulnerable patients, the document places emphasis on avoiding ‘blanket restrictions’ which does not assist in identifying where the real risks lie.
- Death by the use of a ligature is likely to occur within a few minutes, whereas observations for a high-risk patient not assessed
Responses
Action Planned
NHS England is reviewing national guidance around risk assessments and working towards a more personalised safety planning approach. They are supporting units in urgent need of support, redesigning the model of care, and driving cultural change through leadership development. (AI summary)
NHS England is reviewing national guidance around risk assessments and working towards a more personalised safety planning approach. They are supporting units in urgent need of support, redesigning the model of care, and driving cultural change through leadership development. (AI summary)
View full response
Dear Ms Loxton,
Re: Regulation 28 Report to Prevent Future Deaths – Sandra Kirk who died on 2 August 2021
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26 September 2022 concerning the death of Sandra Kirk on 2 August 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sandra’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Sandra’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise to the family for the delay, as I appreciate this will have been an incredibly difficult time for them. Following the inquest, you raised concerns in your Report regarding the relevant Ligature Risk Reduction Policy which was in place, which does not give guidance on minimising potential ligatures themselves (only ligature anchor points) and does not emphasise the very real risk that specific items of clothing, such as belts and shoelaces, can pose to vulnerable patients. Further, there is only a limited degree of risk reduction with observations taking place 4 times per hour for high-risk patients not in immediate crisis, as death by ligature can occur within a few minutes. You therefore directed that the efficacy of the policy should be considered, including whether it can be improved.
Suicide Prevention
• Integrated care systems (ICSs) are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. NHS England » What are integrated care systems? As part of the £2.3 billion settlement for mental health in the NHS Long Term Plan, NHSE are providing targeted and ring fenced funding to ICSs so they can deliver their multi-agency plans. This includes suicide prevention activities such as Zero Suicide Plans in inpatient services, National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
12 January 2023
initiatives to prevent self-harm and putting in place postvention bereavement support.
• With the publication of the Long Term Plan (LTP), we committed that, from 2019/20, every area of the country would receive funding for suicide prevention and bereavement services by 2023/24, from the total pot of money of £57 million allocated through the Long Term Plan. Local areas are required to prioritise groups at high risk of suicide in their multi-agency plans, including mental health inpatients.
• Key components will include supporting services with safety planning, using resources such as The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) ‘Safer services: A toolkit for specialist mental health services and primary care’
Quality Programme
• NHS England has established a new programme to support the sector with tackling significant quality and safety concerns within Mental Health, Learning Disabilities and Autism (MHLDA) inpatient services.
• The establishment of this new programme has been co-produced with local systems, providers, regions and clinicians and people with lived experience.
• The programme will focus both on helping systems to transform their current service offer, so that only those models of inpatient care which can deliver safe, high quality, therapeutic care are commissioned with community alternatives stood up, and to ensure effective quality improvement support is in place for appropriate models of inpatient care.
• In the aftermath of recent incidents of patient safety and quality failures, NHS England asked every MHLDA provider to review their oversight of patient safety, mitigation for closed cultures, safeguards for patients and patient advocacy arrangements. The outcomes of their reviews have been made publicly available by each Trust at the end of December 2022 in their Trust Board papers.
• In addition to this, NHS England is working to drive longer-term improvements in the following key areas:
• Providing support to those units across the NHS and independent sector in urgent need of support today.
• Expediting our work to redesign the model of care more in line with the latest evidence – including addressing risk factors which are more likely to lead to poor outcomes.
• Driving cultural change and improvement through leadership development, inpatient workforce redesign and change programmes.
• Change the way we oversee the quality of MHLDA inpatient settings so that the metrics we collect are based upon the known risk factors.
• We are also working with the sector to agree the most impactful immediate actions they can take to improve lived experience oversight of quality and local quality improvement
I would also like to provide further assurances on the 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 events, such as the sad death of Sandra, are shared across the NHS at both a national and regional level, and helps us to 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.
Re: Regulation 28 Report to Prevent Future Deaths – Sandra Kirk who died on 2 August 2021
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26 September 2022 concerning the death of Sandra Kirk on 2 August 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sandra’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Sandra’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise to the family for the delay, as I appreciate this will have been an incredibly difficult time for them. Following the inquest, you raised concerns in your Report regarding the relevant Ligature Risk Reduction Policy which was in place, which does not give guidance on minimising potential ligatures themselves (only ligature anchor points) and does not emphasise the very real risk that specific items of clothing, such as belts and shoelaces, can pose to vulnerable patients. Further, there is only a limited degree of risk reduction with observations taking place 4 times per hour for high-risk patients not in immediate crisis, as death by ligature can occur within a few minutes. You therefore directed that the efficacy of the policy should be considered, including whether it can be improved.
Suicide Prevention
• Integrated care systems (ICSs) are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. NHS England » What are integrated care systems? As part of the £2.3 billion settlement for mental health in the NHS Long Term Plan, NHSE are providing targeted and ring fenced funding to ICSs so they can deliver their multi-agency plans. This includes suicide prevention activities such as Zero Suicide Plans in inpatient services, National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
12 January 2023
initiatives to prevent self-harm and putting in place postvention bereavement support.
• With the publication of the Long Term Plan (LTP), we committed that, from 2019/20, every area of the country would receive funding for suicide prevention and bereavement services by 2023/24, from the total pot of money of £57 million allocated through the Long Term Plan. Local areas are required to prioritise groups at high risk of suicide in their multi-agency plans, including mental health inpatients.
• Key components will include supporting services with safety planning, using resources such as The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) ‘Safer services: A toolkit for specialist mental health services and primary care’
Quality Programme
• NHS England has established a new programme to support the sector with tackling significant quality and safety concerns within Mental Health, Learning Disabilities and Autism (MHLDA) inpatient services.
• The establishment of this new programme has been co-produced with local systems, providers, regions and clinicians and people with lived experience.
• The programme will focus both on helping systems to transform their current service offer, so that only those models of inpatient care which can deliver safe, high quality, therapeutic care are commissioned with community alternatives stood up, and to ensure effective quality improvement support is in place for appropriate models of inpatient care.
• In the aftermath of recent incidents of patient safety and quality failures, NHS England asked every MHLDA provider to review their oversight of patient safety, mitigation for closed cultures, safeguards for patients and patient advocacy arrangements. The outcomes of their reviews have been made publicly available by each Trust at the end of December 2022 in their Trust Board papers.
• In addition to this, NHS England is working to drive longer-term improvements in the following key areas:
• Providing support to those units across the NHS and independent sector in urgent need of support today.
• Expediting our work to redesign the model of care more in line with the latest evidence – including addressing risk factors which are more likely to lead to poor outcomes.
• Driving cultural change and improvement through leadership development, inpatient workforce redesign and change programmes.
• Change the way we oversee the quality of MHLDA inpatient settings so that the metrics we collect are based upon the known risk factors.
• We are also working with the sector to agree the most impactful immediate actions they can take to improve lived experience oversight of quality and local quality improvement
I would also like to provide further assurances on the 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 events, such as the sad death of Sandra, are shared across the NHS at both a national and regional level, and helps us to 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.
Action Planned
NHS England acknowledges the concerns regarding ligature risk reduction policies and guidance. They state that Cygnet is providing ligature training and enhancing their ligature risk reduction policy. They are also reviewing national guidance around risk assessments. (AI summary)
NHS England acknowledges the concerns regarding ligature risk reduction policies and guidance. They state that Cygnet is providing ligature training and enhancing their ligature risk reduction policy. They are also reviewing national guidance around risk assessments. (AI summary)
View full response
Dear Ms Loxton,
Re: Regulation 28 Report to Prevent Future Deaths – Sandra Kirk who died on 2 August 2021.
I write in response to the email received from your colleague , dated 25 January 2023, regarding Ms Sandra Kirk.
As per my previous correspondence dated 12 January 2023, I wish to reiterate my condolences to Sandra’s family and loved ones. I appreciate this will have been an incredibly difficult time for them, and I want to stress that NHS England takes the concerns and issues raised in every PFD report very seriously. I therefore apologise that both yourself and Sandra’s family do not feel that NHS England’s initial response to your Report dated 26 September 2022 adequately addressed the specific concerns raised, particularly around the risk of ligatures in the inpatient mental health unit setting, and the guidance provided to staff in mitigating this risk (as per the Ligature Risk Reduction Policy and the Ligature Audit Tool / Risk Assessment). I also sincerely apologise that the previous response provided by NHS England has come across as a “very general response to reducing the risk of suicide”, rather than addressing your matters of concern. In your Report dated 26 September 2022, you raised concerns regarding the relevant Ligature Risk Reduction Policy which was in place, which does not give guidance on minimising potential ligatures themselves (only ligature anchor points) and does not emphasise the very real risk that specific items of clothing, such as belts and shoelaces, can pose to vulnerable patients. Further, there is only a limited degree of risk reduction with observations taking place four times per hour for high-risk patients not in immediate crisis, as death by ligature can occur within a few minutes. You therefore directed that the efficacy of the policy should be considered, including whether it can be improved. In respect of the specific concerns in your Report regarding Cygnet’s Ligature Risk Reduction Policy and Ligature Audit Tool / Risk Assessment, these are outside of NHS England’s remit and are more matters for Cygnet to action, which is why our previous response did not fully address the same. However, I can confirm that NHS England National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
6 February 2023
has had sight of the full Root Cause Analysis (RCA) report dated 4 January 2022 and we note that the main learning points which were identified included contemporaneous record keeping, named nurse practice and a review of general observation practice. Our regional team have liaised further with Cygnet, who have advised that they are providing ligature training as part of the induction process for all new staff, and they have a contraband list in place across all in-patient areas. They are also planning on enhancing their ligature risk reduction policy, which will include associated awareness training and identifying risk in their patients. Regarding the national guidance around risk assessments (relevant to your comments around observations and risk reduction), I would like to provide my assurance that this is currently being reviewed and work is underway to assess a move to a more personalised safety planning approach, in line with an evidence base. The concerns raised in PFD reports, including your Report dated 26 September 2022, are communicated to the national policy and programme teams to help inform their work around this. We hope to have further updates on the above, as well as the quality programme for Mental Health, Learning Disabilities and Autism (MHLDA) inpatient services referenced in my last letter, in due course. We are more than happy to provide you and/or Sandra’s family with another update once these developments have taken place, if this would assist? I would also like to provide further assurances that the Regulation 28 Working Group, who closely monitor and share learnings and commitments arising from or linked to PFD reports, will continue to do so in this case. I hope that the above sufficiently addresses your previous concerns, and I am very sorry that you have had to request a further response from NHS England on this occasion. Please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Sandra Kirk who died on 2 August 2021.
I write in response to the email received from your colleague , dated 25 January 2023, regarding Ms Sandra Kirk.
As per my previous correspondence dated 12 January 2023, I wish to reiterate my condolences to Sandra’s family and loved ones. I appreciate this will have been an incredibly difficult time for them, and I want to stress that NHS England takes the concerns and issues raised in every PFD report very seriously. I therefore apologise that both yourself and Sandra’s family do not feel that NHS England’s initial response to your Report dated 26 September 2022 adequately addressed the specific concerns raised, particularly around the risk of ligatures in the inpatient mental health unit setting, and the guidance provided to staff in mitigating this risk (as per the Ligature Risk Reduction Policy and the Ligature Audit Tool / Risk Assessment). I also sincerely apologise that the previous response provided by NHS England has come across as a “very general response to reducing the risk of suicide”, rather than addressing your matters of concern. In your Report dated 26 September 2022, you raised concerns regarding the relevant Ligature Risk Reduction Policy which was in place, which does not give guidance on minimising potential ligatures themselves (only ligature anchor points) and does not emphasise the very real risk that specific items of clothing, such as belts and shoelaces, can pose to vulnerable patients. Further, there is only a limited degree of risk reduction with observations taking place four times per hour for high-risk patients not in immediate crisis, as death by ligature can occur within a few minutes. You therefore directed that the efficacy of the policy should be considered, including whether it can be improved. In respect of the specific concerns in your Report regarding Cygnet’s Ligature Risk Reduction Policy and Ligature Audit Tool / Risk Assessment, these are outside of NHS England’s remit and are more matters for Cygnet to action, which is why our previous response did not fully address the same. However, I can confirm that NHS England National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
6 February 2023
has had sight of the full Root Cause Analysis (RCA) report dated 4 January 2022 and we note that the main learning points which were identified included contemporaneous record keeping, named nurse practice and a review of general observation practice. Our regional team have liaised further with Cygnet, who have advised that they are providing ligature training as part of the induction process for all new staff, and they have a contraband list in place across all in-patient areas. They are also planning on enhancing their ligature risk reduction policy, which will include associated awareness training and identifying risk in their patients. Regarding the national guidance around risk assessments (relevant to your comments around observations and risk reduction), I would like to provide my assurance that this is currently being reviewed and work is underway to assess a move to a more personalised safety planning approach, in line with an evidence base. The concerns raised in PFD reports, including your Report dated 26 September 2022, are communicated to the national policy and programme teams to help inform their work around this. We hope to have further updates on the above, as well as the quality programme for Mental Health, Learning Disabilities and Autism (MHLDA) inpatient services referenced in my last letter, in due course. We are more than happy to provide you and/or Sandra’s family with another update once these developments have taken place, if this would assist? I would also like to provide further assurances that the Regulation 28 Working Group, who closely monitor and share learnings and commitments arising from or linked to PFD reports, will continue to do so in this case. I hope that the above sufficiently addresses your previous concerns, and I am very sorry that you have had to request a further response from NHS England on this occasion. Please do not hesitate to contact me should you need any further information.
Sent To
- NHS England
- NHS Improvement
Response Status
Linked responses
2 of 2
56-Day Deadline
21 Nov 2022
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
The inquest into the death of Sandra Kirk was opened on 5th November 2021. It was resumed on 5th September and concluded on 15th September 2022 before a Jury. The Jury found the medical cause of death to be: 1a. Asphyxia due to ligature around her neck
The jury returned a narrative conclusion, recording that Sandra had no mental health history until after she contracted Covid-19 in November 2020. Whilst she appeared to make a full physical recovery, she became increasingly preoccupied by the delusional belief that she had sustained a permanent degenerative brain disorder as a result of Covid, which was progressive and terminal. They recorded that as a result of this fixed belief, she attempted suicide on 23rd February 2021 with a carefully planned overdose and carbon monoxide poisoning, leading to a diagnosis of psychotic depression and
The jury returned a narrative conclusion, recording that Sandra had no mental health history until after she contracted Covid-19 in November 2020. Whilst she appeared to make a full physical recovery, she became increasingly preoccupied by the delusional belief that she had sustained a permanent degenerative brain disorder as a result of Covid, which was progressive and terminal. They recorded that as a result of this fixed belief, she attempted suicide on 23rd February 2021 with a carefully planned overdose and carbon monoxide poisoning, leading to a diagnosis of psychotic depression and
Circumstances of the Death
Sandra Kirk was found unresponsive on the floor of the ensuite bathroom of her bedroom at Cygnet Hospital at 7.55am on the morning of 2nd August 2021 . She could not be resuscitated and was declared deceased by attending paramedics at 8.53am.
Copies Sent To
1. See names in paragraph 1 above
3. Cygnet Healthcare, , DAC Beachcroft
5. Care Quality Commission
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.