Mina Topley-Bird
PFD Report
Partially Responded
Ref: 2021-0100
Coroner's Concerns (AI summary)
Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment processes remained incomplete.
View full coroner's concerns
1. Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form. This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them.
2. It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT. This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments.
3. The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given. One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points.
4. Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust. On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it.
5. The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still ' a work in progress' and further work was required. It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete.
2. It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT. This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments.
3. The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given. One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points.
4. Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust. On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it.
5. The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still ' a work in progress' and further work was required. It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete.
Responses
Action Taken
The Department reports on actions taken by Tees, Esk and Wear Valleys NHS Foundation Trust, including a new protocol for bed transfers, implementation of a checklist for comprehensive risk information, and incorporation of learning into mandatory risk assessment training. A new electronic system for sharing medical notes between trusts is also planned for June 2022. (AI summary)
The Department reports on actions taken by Tees, Esk and Wear Valleys NHS Foundation Trust, including a new protocol for bed transfers, implementation of a checklist for comprehensive risk information, and incorporation of learning into mandatory risk assessment training. A new electronic system for sharing medical notes between trusts is also planned for June 2022. (AI summary)
View full response
Dear Mr Thompson,
Thank you for your correspondence of 9 April 2021 about the death of Mina Topley-Bird. I am responding as Minister responsible for mental health services.
Firstly, I would like to take this opportunity to offer my sincere condolences to the family, friends and loved ones of Ms Topley-Bird. I have noted carefully your concerns about national policy to co-ordinate the transfer of mental health patients back to their 'Home' area, when a person is admitted as an emergency to an NHS Trust outside their normal locality. You also raise concerns about escalation policy when a bed cannot be obtained; and also a process to ‘apply’ for a bed in another NHS Trust area. Your report also notes the ‘ad hoc’ nature of the approach taken by NHS Trusts which may create delays in the transfer of patients. The Government is committed to eliminating inappropriate out of area placements in mental health services for adults in acute inpatient care and in 2016 provided guidance on out of area placements1 to NHS Trusts to support this ambition. The guidance states an out of area placement may be appropriate when: “the person becomes acutely unwell when they are away from home (in such circumstances, the admitting provider should work with the person’s home team to facilitate repatriation to local services as soon as this is safe and clinically appropriate)”. In addition, the guidance advises regular reviews and assessments to enable the patient’s return to their local service as soon as possible.
1 Out of area placements in mental health services for adults in acute inpatient care - GOV.UK (www.gov.uk)
In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSE/I) and the Care Quality Commission (CQC). Your report notes that medical information received from South London and Maudsley NHS Foundation Trust (SLAM) was not sent on to, or requested by, West Park Hospital – part of The Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) – upon Ms Topley-Bird’s admission as an emergency patient. This information would have provided a full understanding of Ms Topley-Bird’s mental health and previous attempts to take her own life. NHSE/I acknowledged to my officials the increased risk to patient safety and the negative impact on experience and outcomes associated with patients being placed out of their usual local network of care for acute mental health treatment. NHSE/I has assured the Department it is working to eliminate all inappropriate acute mental health out of area placements (OAPs) as soon as possible. NHSE/I has told my officials that the decision to admit Ms Topley-Bird to hospital in Darlington was appropriate in the circumstances of her requiring emergency inpatient admission away from home. NHSE/I notes that the decision about when to transfer Ms Topley-Bird back to London should have been clinically-led with clinicians able to access her full medical history during the interim period to ensure her care was as safe and effective as possible. Mental health services provided by TEWV are locally commissioned and therefore operational processes, such as those described, are the responsibility of local NHS providers and their clinical commissioning group (CCG) system partners, which commission the services. However, NHSE/I has noted your concern about an apparent lack of robust information sharing and established transfer protocols and will use the learning from your report to work with its regional teams to consider whether any further guidance or escalation processes should be developed to support local NHS staff to reduce the risk of similar tragic events reoccurring. I understand Tees, Esk and Wear Valleys NHS Foundation Trust are to respond to you directly on the matters raised at the inquest. TEWV has informed NHSE/I of local action taken following Ms Topley-Bird’s death, notably:
• where admission is indicated to a local bed, any information from the home Trust will be forwarded by email directed to the Nurse in Charge of the admitting ward;
• the Trust is exploring compatible electronic solutions to enable staff to print information at non-TEWV sites, with an interim system set up whereby staff follow the Out of Trust Patient Checklist on information sharing; and a new electronic system to be introduced by June 2022 to allow for the printing of medical notes in premises shared with another Trust;
• ongoing work at TEWV to focus on bed management and facilitate patient transfers;
• on admission of a new patient, comprehensive risk profile information is obtained from the admitting team and the home Trust Ward with a checklist to support this,
approved by the Adult Mental Health Speciality Development Group in August 2020 and implemented by all wards during September 2020. The TEWV’s Harm Minimisation Lead has incorporated learning from this case into the Trust’s mandatory risk assessment training, with an emphasis on the importance of ensuring that historical risk information is included in the formulation of risk, risk management and contingency planning. My officials also approached the Care Quality Commission (CQC). The CQC has sought assurances from the Trust in relation to its investigation and has concluded that there is no ongoing risk to service users and that enforcement action was not required. CQC requested, and was provided with, further information from the Trust to assist with its review of the Trust. In light of your report, the CQC has since written to the Trust to request further information in relation to the incident. This information was provided on 4 May 2021 which is I understand is currently being reviewed by the CQC. I hope this information is helpful and explains the actions being taken to address the matters of concern. Thank you for bringing these matters to my attention.
NADINE DORRIES
Thank you for your correspondence of 9 April 2021 about the death of Mina Topley-Bird. I am responding as Minister responsible for mental health services.
Firstly, I would like to take this opportunity to offer my sincere condolences to the family, friends and loved ones of Ms Topley-Bird. I have noted carefully your concerns about national policy to co-ordinate the transfer of mental health patients back to their 'Home' area, when a person is admitted as an emergency to an NHS Trust outside their normal locality. You also raise concerns about escalation policy when a bed cannot be obtained; and also a process to ‘apply’ for a bed in another NHS Trust area. Your report also notes the ‘ad hoc’ nature of the approach taken by NHS Trusts which may create delays in the transfer of patients. The Government is committed to eliminating inappropriate out of area placements in mental health services for adults in acute inpatient care and in 2016 provided guidance on out of area placements1 to NHS Trusts to support this ambition. The guidance states an out of area placement may be appropriate when: “the person becomes acutely unwell when they are away from home (in such circumstances, the admitting provider should work with the person’s home team to facilitate repatriation to local services as soon as this is safe and clinically appropriate)”. In addition, the guidance advises regular reviews and assessments to enable the patient’s return to their local service as soon as possible.
1 Out of area placements in mental health services for adults in acute inpatient care - GOV.UK (www.gov.uk)
In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSE/I) and the Care Quality Commission (CQC). Your report notes that medical information received from South London and Maudsley NHS Foundation Trust (SLAM) was not sent on to, or requested by, West Park Hospital – part of The Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) – upon Ms Topley-Bird’s admission as an emergency patient. This information would have provided a full understanding of Ms Topley-Bird’s mental health and previous attempts to take her own life. NHSE/I acknowledged to my officials the increased risk to patient safety and the negative impact on experience and outcomes associated with patients being placed out of their usual local network of care for acute mental health treatment. NHSE/I has assured the Department it is working to eliminate all inappropriate acute mental health out of area placements (OAPs) as soon as possible. NHSE/I has told my officials that the decision to admit Ms Topley-Bird to hospital in Darlington was appropriate in the circumstances of her requiring emergency inpatient admission away from home. NHSE/I notes that the decision about when to transfer Ms Topley-Bird back to London should have been clinically-led with clinicians able to access her full medical history during the interim period to ensure her care was as safe and effective as possible. Mental health services provided by TEWV are locally commissioned and therefore operational processes, such as those described, are the responsibility of local NHS providers and their clinical commissioning group (CCG) system partners, which commission the services. However, NHSE/I has noted your concern about an apparent lack of robust information sharing and established transfer protocols and will use the learning from your report to work with its regional teams to consider whether any further guidance or escalation processes should be developed to support local NHS staff to reduce the risk of similar tragic events reoccurring. I understand Tees, Esk and Wear Valleys NHS Foundation Trust are to respond to you directly on the matters raised at the inquest. TEWV has informed NHSE/I of local action taken following Ms Topley-Bird’s death, notably:
• where admission is indicated to a local bed, any information from the home Trust will be forwarded by email directed to the Nurse in Charge of the admitting ward;
• the Trust is exploring compatible electronic solutions to enable staff to print information at non-TEWV sites, with an interim system set up whereby staff follow the Out of Trust Patient Checklist on information sharing; and a new electronic system to be introduced by June 2022 to allow for the printing of medical notes in premises shared with another Trust;
• ongoing work at TEWV to focus on bed management and facilitate patient transfers;
• on admission of a new patient, comprehensive risk profile information is obtained from the admitting team and the home Trust Ward with a checklist to support this,
approved by the Adult Mental Health Speciality Development Group in August 2020 and implemented by all wards during September 2020. The TEWV’s Harm Minimisation Lead has incorporated learning from this case into the Trust’s mandatory risk assessment training, with an emphasis on the importance of ensuring that historical risk information is included in the formulation of risk, risk management and contingency planning. My officials also approached the Care Quality Commission (CQC). The CQC has sought assurances from the Trust in relation to its investigation and has concluded that there is no ongoing risk to service users and that enforcement action was not required. CQC requested, and was provided with, further information from the Trust to assist with its review of the Trust. In light of your report, the CQC has since written to the Trust to request further information in relation to the incident. This information was provided on 4 May 2021 which is I understand is currently being reviewed by the CQC. I hope this information is helpful and explains the actions being taken to address the matters of concern. Thank you for bringing these matters to my attention.
NADINE DORRIES
Action Taken
West Park Hospital took immediate action to develop and implement a checklist for A&E patients from outside the area to improve information gathering and sharing. They are also investing in multidisciplinary oversight, staffing, training, and enhancing organisational learning. (AI summary)
West Park Hospital took immediate action to develop and implement a checklist for A&E patients from outside the area to improve information gathering and sharing. They are also investing in multidisciplinary oversight, staffing, training, and enhancing organisational learning. (AI summary)
View full response
Dear Mr Thompson
Dear Mr Thompson
Re: Mina Topley-Bird, deceased Regulation 28 Report
Further to your letter of 09 April 2021, I write to detail the actions the Trust has taken and those that we continue to implement to address the concerns you identified during the inquest into Mina Topley-Bird’s (MTB) death. I would like to reassure you that as an organisation we have taken your concerns very seriously and for ease of reference I will address each of these in turn:
Concern 1
Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form. This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them.
As described at the inquest hearing, immediate action was taken by the Trust to develop and implement a checklist to support the care and treatment of patients presenting at Accident and Emergency departments, who are from outside the area. (please see documents attached at Concern 2 below). This checklist includes:
information gathering from the patient's home Trust sharing information with other teams involved in care ensuring any information received is accurately reflected in the Trust's Safety Summary where admission of the patient is indicated to a local bed, all information from the home Trust will be forwarded by email to the Nurse in Charge of the admitting ward. 28 May 2021 Mr James E Thompson H M Assistant Coroner for County Durham and Darlington H M Coroners Office PO Box 282 Bishop Auckland Co Durham DL14 4FY
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
This issue regarding access to patient information will be fully resolved by the implementation of Cito, which is a full electronic records management solution and allows documents to be scanned in, uploaded or viewed. This solution will be fully implemented by August 2022.
Concern 2
It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT. This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments.
As referenced in the inquest evidence, there is a system in place whereby staff follow the Out of Trust Patient Checklist which details how information is to be shared. In respect of any Mental Health Act documentation, this is shared with the relevant recipients via a secure email route. 1 Out of Trust Liaison Checklist.pdf 4 Referral and Admission OOA Appro
The Trust has also since taken action and increased the staffing establishment of the Liaison Team, increasing the number of staff on duty overnight night to two. This means that if a document does need to be printed urgently, one member of staff can go to our nearby Trust premises to do this.
Again the issues highlighted will be fully resolved by the implementation of Cito, which is described above and planned to be in place by August 2022.
Concern 3
The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given. One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points.
As described at the inquest, the suicide prevention environmental survey and risk assessment was reviewed by the Trust and subsequently changes had been made to improve recording. The revised Suicide Prevention Survey and Risk Assessment now references each bedroom by the actual number (bedroom 1,2,3,4 etc.), rather
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
than the Estates identifier (2.01, 2.93, 2.75 etc) which were used at the time of the incident.
For completeness, MTB was in bedroom 4 (identifier 2.04 previously). The Suicide Prevention Environmental Survey and Risk Assessment, attached below, formed part of the documentary evidence made available to the Coroner. This demonstrated that the survey in place at the time of the incident had included bedroom 4 (2.04).
The Trust has recently undertaken an extensive ligature reduction programme that has included the removal of taps, toilets, shower controls and sinks and replaced with anti-ligature sanitary ware. The Trust is also in the process of installing technology that will assist with the detection of movement of patients in high risk areas such as bedrooms and en-suites. This technology responds to a patients change in vital signs or movements and will send an alert to staff to check on the wellbeing of the patient. This technology is already in place in other areas of the Trust and has been used effectively to maintain patient safety in this way.
Concern 4
Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust. On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it.
In the case of MTB, the issue was there were no beds available to transfer her to her home Trust. Each locality of the Trust has staff who manage patient flow and beds and facilitate patient transfers as part of their daily roles. The Trust has now agreed a plan to implement a bed management team. This will be introduced in the following phased approach: Phase 1 – introduce locality based bed managers (anticipated by October 2021) Phase 2 - implement a central bed management hub (2022)
Suicide prevention environmental survey
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
Concern 5
The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still ' a work in progress' and further work was required. It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete.
Following a CQC inspection in January 2021 where concerns were raised regarding risk assessment and management, a Rapid Process Improvement Workshop (RPIW) was held week commencing 1st February 2021. This was to review, clarify and streamline the process for assessing and managing the clinical risk of patients and to confirm the standards for risk assessment across all services of the organisation. A review of care documentation was undertaken to provide assurance that patient risks were being assessed and each patient had a safety plan in place in line with the agreed standard. Ward to Board governance arrangements were put in place to ensure Executive oversight and the reporting of compliance with the quality standards. An ongoing programme of quality assurance was implemented. This utilises a range of methods such as clinical audit, Matron walkabouts and direct clinical observation to provide assurance to the Trust Board that the actions being taken are having a positive impact and addressing the patient safety concerns. Community assurance processes have included the development of a dashboard to support community caseload reporting and improved clinical supervision processes. In line with the CQC enforcement notice, the Trust had a number of agreed actions to be completed by 3rd May 2021; implementation of these was achieved within timescale. Leading up to this date and beyond, the Trust had recognised the need for further investment in increasing multidisciplinary involvement and oversight, improving staffing establishments, further developing our provision of training and expertise, ensuring sustainable support and clinical supervision as well as providing leadership to our clinical teams as being critical to prioritising a culture of patient safety and continuous quality improvement. In addition, work is underway to enhance and embed organisational learning from a range of internal and external sources. This includes reviewing, strengthening and developing systems and mechanisms for capturing and communicating learning and importantly gaining assurance of the impact of our actions to improve care for services users and their families. A regional Quality Board has been set up by NHS England and Improvement; membership includes key external stakeholders such as CQC and members of the ICS. The Trust provides monthly updates and assurance on its progress. We are also accessing a range of external expertise to support rapid improvement and sustainable changes in practice.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
I trust this provides you with assurance that the appropriate actions are and have ben taken to address the concerns raised. However, should you require any further information please do not hesitate to contact me.
Dear Mr Thompson
Re: Mina Topley-Bird, deceased Regulation 28 Report
Further to your letter of 09 April 2021, I write to detail the actions the Trust has taken and those that we continue to implement to address the concerns you identified during the inquest into Mina Topley-Bird’s (MTB) death. I would like to reassure you that as an organisation we have taken your concerns very seriously and for ease of reference I will address each of these in turn:
Concern 1
Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form. This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them.
As described at the inquest hearing, immediate action was taken by the Trust to develop and implement a checklist to support the care and treatment of patients presenting at Accident and Emergency departments, who are from outside the area. (please see documents attached at Concern 2 below). This checklist includes:
information gathering from the patient's home Trust sharing information with other teams involved in care ensuring any information received is accurately reflected in the Trust's Safety Summary where admission of the patient is indicated to a local bed, all information from the home Trust will be forwarded by email to the Nurse in Charge of the admitting ward. 28 May 2021 Mr James E Thompson H M Assistant Coroner for County Durham and Darlington H M Coroners Office PO Box 282 Bishop Auckland Co Durham DL14 4FY
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
This issue regarding access to patient information will be fully resolved by the implementation of Cito, which is a full electronic records management solution and allows documents to be scanned in, uploaded or viewed. This solution will be fully implemented by August 2022.
Concern 2
It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT. This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments.
As referenced in the inquest evidence, there is a system in place whereby staff follow the Out of Trust Patient Checklist which details how information is to be shared. In respect of any Mental Health Act documentation, this is shared with the relevant recipients via a secure email route. 1 Out of Trust Liaison Checklist.pdf 4 Referral and Admission OOA Appro
The Trust has also since taken action and increased the staffing establishment of the Liaison Team, increasing the number of staff on duty overnight night to two. This means that if a document does need to be printed urgently, one member of staff can go to our nearby Trust premises to do this.
Again the issues highlighted will be fully resolved by the implementation of Cito, which is described above and planned to be in place by August 2022.
Concern 3
The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given. One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points.
As described at the inquest, the suicide prevention environmental survey and risk assessment was reviewed by the Trust and subsequently changes had been made to improve recording. The revised Suicide Prevention Survey and Risk Assessment now references each bedroom by the actual number (bedroom 1,2,3,4 etc.), rather
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
than the Estates identifier (2.01, 2.93, 2.75 etc) which were used at the time of the incident.
For completeness, MTB was in bedroom 4 (identifier 2.04 previously). The Suicide Prevention Environmental Survey and Risk Assessment, attached below, formed part of the documentary evidence made available to the Coroner. This demonstrated that the survey in place at the time of the incident had included bedroom 4 (2.04).
The Trust has recently undertaken an extensive ligature reduction programme that has included the removal of taps, toilets, shower controls and sinks and replaced with anti-ligature sanitary ware. The Trust is also in the process of installing technology that will assist with the detection of movement of patients in high risk areas such as bedrooms and en-suites. This technology responds to a patients change in vital signs or movements and will send an alert to staff to check on the wellbeing of the patient. This technology is already in place in other areas of the Trust and has been used effectively to maintain patient safety in this way.
Concern 4
Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust. On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it.
In the case of MTB, the issue was there were no beds available to transfer her to her home Trust. Each locality of the Trust has staff who manage patient flow and beds and facilitate patient transfers as part of their daily roles. The Trust has now agreed a plan to implement a bed management team. This will be introduced in the following phased approach: Phase 1 – introduce locality based bed managers (anticipated by October 2021) Phase 2 - implement a central bed management hub (2022)
Suicide prevention environmental survey
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
Concern 5
The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still ' a work in progress' and further work was required. It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete.
Following a CQC inspection in January 2021 where concerns were raised regarding risk assessment and management, a Rapid Process Improvement Workshop (RPIW) was held week commencing 1st February 2021. This was to review, clarify and streamline the process for assessing and managing the clinical risk of patients and to confirm the standards for risk assessment across all services of the organisation. A review of care documentation was undertaken to provide assurance that patient risks were being assessed and each patient had a safety plan in place in line with the agreed standard. Ward to Board governance arrangements were put in place to ensure Executive oversight and the reporting of compliance with the quality standards. An ongoing programme of quality assurance was implemented. This utilises a range of methods such as clinical audit, Matron walkabouts and direct clinical observation to provide assurance to the Trust Board that the actions being taken are having a positive impact and addressing the patient safety concerns. Community assurance processes have included the development of a dashboard to support community caseload reporting and improved clinical supervision processes. In line with the CQC enforcement notice, the Trust had a number of agreed actions to be completed by 3rd May 2021; implementation of these was achieved within timescale. Leading up to this date and beyond, the Trust had recognised the need for further investment in increasing multidisciplinary involvement and oversight, improving staffing establishments, further developing our provision of training and expertise, ensuring sustainable support and clinical supervision as well as providing leadership to our clinical teams as being critical to prioritising a culture of patient safety and continuous quality improvement. In addition, work is underway to enhance and embed organisational learning from a range of internal and external sources. This includes reviewing, strengthening and developing systems and mechanisms for capturing and communicating learning and importantly gaining assurance of the impact of our actions to improve care for services users and their families. A regional Quality Board has been set up by NHS England and Improvement; membership includes key external stakeholders such as CQC and members of the ICS. The Trust provides monthly updates and assurance on its progress. We are also accessing a range of external expertise to support rapid improvement and sustainable changes in practice.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS
I trust this provides you with assurance that the appropriate actions are and have ben taken to address the concerns raised. However, should you require any further information please do not hesitate to contact me.
Sent To
- Tees, Esk and Wear Valley NHS Foundation Trust
- Department of Health and Social Care
Response Status
Linked responses
2 of 3
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 Fifteenth May 2019 I commenced an investigation into the death of Mina TOPLEY-BIRD aged
24. The investigation concluded at the end of the inquest on First April 2021. The conclusion of the inquest was Narrative Conclusion - Was there a failure on 8th May 2019 to appreciate that Mina was at increased risk of suicide/self harm following her interaction with a nurse at approximately 2.50pm? YES Was there a failure on the 8th May 2019 to take precautions against that increased risk in particular, further engagement with her and checks on her? YES Did the absence of Mina's historic medical records at West Park Hospital hinder staff from appreciating the nature and extent of Mina's implusive behaviour and the risk of rapid deterioration? YES: I a Hanging I b I c II
24. The investigation concluded at the end of the inquest on First April 2021. The conclusion of the inquest was Narrative Conclusion - Was there a failure on 8th May 2019 to appreciate that Mina was at increased risk of suicide/self harm following her interaction with a nurse at approximately 2.50pm? YES Was there a failure on the 8th May 2019 to take precautions against that increased risk in particular, further engagement with her and checks on her? YES Did the absence of Mina's historic medical records at West Park Hospital hinder staff from appreciating the nature and extent of Mina's implusive behaviour and the risk of rapid deterioration? YES: I a Hanging I b I c II
Circumstances of the Death
The deceased suffered from a severe and enduring mental illness. She lived in London and received treatment from the South London & Maudsley NHS Trust (SLAM) from 2017. She had attempted suicide/self harm on previous occasions. She was prone to impulsive behaviour in terms of her suicide/self harm attempts. She travelled to the North East of England in May 2019 to perform and after an event in Newcastle Upon Tyne she returned to London by train on 5th May 2019. She suffered a mental health episode and left the train at Darlington. She attempted to run in front of moving traffic and was taken to Darlington Memeorial Hospital. Whilst awaiting treatment she attempted to stab herself in the neck with a pen. She was assessed and admitted feeling suicidal. She agreed to be admitted to West Park Hospital (part of the Tees Esk & Wear Valleys NHS Foundation Trust - TEWV) for treatment. Prior to assessment process SLAM on TEWV request sent the deceased's recent medical history and information regarding previous self harm and other safeguarding information. A total of 3 documents were sent attached to an email. Only 1 attachment was read. The information was précised and added to the TEWV medical notes system
- PARIS. The 3 documents were not forwarded to any staff at West Park Hospital. The TEWV staff were unable to print the information they received from SLAM due to the IT system operated by TEWV not being able to allow it to print on other NHS Trusts hardware when they share premises.
When the deceased was a patient at West Park Hospital, attempts were made to locate a bed for the deceased in London, but none were available. On 8th May 2019 at approximately 2.50pm the deceased approached a nurse at West Park Hospital and enquired if a bed had been found for her in London. When informed none was available, the deceased replied words to the effect 'I may as well kill myself'. The deceased was spoken to by the nurse as a result of her statement. The deceased ended the discussion and returned to her room. She was discovered hanging by a scarf secured in the hinge of the bathroom door in her room at approximately 3.55pm and pronounced death at 4.33pm.
- PARIS. The 3 documents were not forwarded to any staff at West Park Hospital. The TEWV staff were unable to print the information they received from SLAM due to the IT system operated by TEWV not being able to allow it to print on other NHS Trusts hardware when they share premises.
When the deceased was a patient at West Park Hospital, attempts were made to locate a bed for the deceased in London, but none were available. On 8th May 2019 at approximately 2.50pm the deceased approached a nurse at West Park Hospital and enquired if a bed had been found for her in London. When informed none was available, the deceased replied words to the effect 'I may as well kill myself'. The deceased was spoken to by the nurse as a result of her statement. The deceased ended the discussion and returned to her room. She was discovered hanging by a scarf secured in the hinge of the bathroom door in her room at approximately 3.55pm and pronounced death at 4.33pm.
Action Should Be Taken
7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 02 June 2021. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Ward Hadaway Solicitors on behalf of Tees, Esk &Wear Valley NHS Foundation Trust Bevan Brittan Solicitors on behalf of South London & Maudsley NHS Foundation Trust DPG Law on behalf of And Rt. Hon Matt Hancock, Secretary of State for Health and Social Care Care Quality Commission who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. James E THOMPSON Assistant Coroner for County Durham and Darlington Dated: 09 April 2021
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Ward Hadaway Solicitors on behalf of Tees, Esk &Wear Valley NHS Foundation Trust Bevan Brittan Solicitors on behalf of South London & Maudsley NHS Foundation Trust DPG Law on behalf of And Rt. Hon Matt Hancock, Secretary of State for Health and Social Care Care Quality Commission who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. James E THOMPSON Assistant Coroner for County Durham and Darlington Dated: 09 April 2021
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Healthcare trust risk information visibility
Southport Inquiry
Inaccurate and inaccessible patient records
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.