Dear Mr Holden Re: Prevention of Future Death Report Following Inquest into the Death of Maziellie MacKenzie Further to the inquest of Maziellie MacKenzie, which concluded on 15 December 2021, I am providing you with a response to your concerns detailed in the Prevention of Regulation 28 Notice, dated 31 December 2021. Please be assured the Trust has taken this extremely seriously. We are disappointed that we did not deliver care and treatment to the level expected for Maziellie at the time of her death and I reiterate the Trust’s apologies regarding this. I hope my response provides you with the assurance that we have implemented improvements that prevents similar incidents from occurring.
1. The circumstances in which group leave from the Cove (and other tier 4 units) is granted and who is responsible for the granting of such leave. The Trust have developed a written procedure (enclosed), which identifies the circumstances in which group leave from The Cove is granted. The Cove is the only Tier 4 CAMHS unit within the Trust. The procedure was approved at the Specialist Network Governance Group on 3 February 2022 and has been subsequently shared with staff. Until the procedure was ratified, group leave at The Cove was temporarily suspended, following receipt of your Regulation 28 notification. Whilst the procedure has been shared with staff, there are further engagement events planned, which includes ensuring every member of staff has this discussed with them as part of their supervision and also ensuring that this procedure is part of the unit’s induction programme, so this is highlighted to new starters also in the unit going forward. PRIVATE AND CONFIDENTIAL Mr Philip Holden Assistant Coroner

Safety Department Lancashire & South Cumbria NHS Foundation Trust 2nd Floor Lingmell House Water Street Chorley PR7 1EE

21 February 2022

2. That a mandatory risk assessment is required and setting out a list of factors/criteria that must be considered before any group leave is granted.

The enclosed procedure (section 5.15) sets out that young people with approved escorted group leave must have a pre-leave risk assessment completed prior and documented as a narrative entry on RIO (the Trust’s clinical record system). This is to make sure that any potential risks or changes in a young person’s presentation are acknowledged and so that the necessary safeguards are put in place. The procedure states that “risk assessment should consider the presenting level of risk and the care plan (including the number of escorts where identified).”

Prior to the risk assessment being completed, any period of group leave must be discussed and agreed by the multi-disciplinary (MDT) meeting and be included as part of each individualised care plan and have an identified therapeutic purpose. The MDT discussion should capture the risk mitigation factors and the risk aggravating factors in relation to the mix of the group, irrespective of the legal status of the young person.

The procedure also identifies that young people will only be eligible for group leave if they are being nursed on general observation levels and any change in observation that occurs after the decision to grant group leave, but before the planned group leave will result in the individual being unable to access group leave.

The procedure also includes that an individual young person’s participation in the MDT agreed group leave can be cancelled by the shift leader if there are concerns about individual or group risks which were not previously known or have changed since the decision was made by the MDT. In the event a young person does not agree to the conditions of group leave, the individual’s participation in the intervention should be reviewed by the shift leader, in conjunction with the MDT as necessary.

3. Setting out the staff to patient ratios for any group leave and identifying the criteria to be considered.

The procedure specifies that the MDT must agree in advance on the specific staffing requirements to safely support a period of group leave and this should be based on the combined dependency needs of individuals in the group. In the event that the required staffing levels cannot be achieved, leave should be cancelled and an incident form completed. The mandated pre-leave risk assessment is also to include the number of escorts needed.

We have shared this procedure with other North West of England Tier 4 CAMHS providers, in the interests of shared learning.

The Trust would like to once again apologise to the family of Miss MacKenzie for her tragic death.

I would also like to re-affirm our commitment as a Trust, to continually develop and improve our services for the young people in Lancashire.

Please let me know if you require any further information in relation to this matter.