Agnes Lambert
PFD Report
All Responded
Ref: 2018-0410
All 1 response received
· Deadline: 11 Feb 2019
Coroner's Concerns (AI summary)
Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
View full coroner's concerns
1. Two weeks before the allegations were made and the investigation began (i.e. two weeks before the occasion of Nurse Lambert entering the patient’s room), the patient in question argued with another patient whom he thought was stealing his fiancée. He and Nurse Lambert were not engaged. They were not in a romantic relationship.
The more senior member of staff who dealt with the matter, recognised the patient’s fixation and thought that Agnes Lambert should move to work on another ward. However, when Nurse Lambert declined because she did not regard the matter as serious, the manager, who had seniority and more experience, did not insist.
The service manager who gave evidence in court accepted that the move should have been made regardless of the staff nurse’s wishes. If it had been, Nurse Lambert would not have been in a position to enter the patient’s room a fortnight later.
2. Following the allegations, it then took the trust four months (rather than the expected four weeks) to interview eight witnesses in order to progress to a disciplinary hearing. This was a distressing time for Ms Lambert and she finally went on sick leave.
The service manager who gave evidence in court agreed that this was an unacceptable delay.
The more senior member of staff who dealt with the matter, recognised the patient’s fixation and thought that Agnes Lambert should move to work on another ward. However, when Nurse Lambert declined because she did not regard the matter as serious, the manager, who had seniority and more experience, did not insist.
The service manager who gave evidence in court accepted that the move should have been made regardless of the staff nurse’s wishes. If it had been, Nurse Lambert would not have been in a position to enter the patient’s room a fortnight later.
2. Following the allegations, it then took the trust four months (rather than the expected four weeks) to interview eight witnesses in order to progress to a disciplinary hearing. This was a distressing time for Ms Lambert and she finally went on sick leave.
The service manager who gave evidence in court agreed that this was an unacceptable delay.
Responses
Action Planned
The Trust is rolling out 'vital conversations' training for managers and reviewing its disciplinary policy to include clearer criteria for investigations. A specially-trained staff member will review cases to challenge whether a formal hearing is required, and the refreshed policy is expected to be complete in March 2019. (AI summary)
The Trust is rolling out 'vital conversations' training for managers and reviewing its disciplinary policy to include clearer criteria for investigations. A specially-trained staff member will review cases to challenge whether a formal hearing is required, and the refreshed policy is expected to be complete in March 2019. (AI summary)
View full response
Dear Coroner Hassell Re: Prevention offuture deaths report inquest concerning the death of Agnes Stephanie Lambert am writing further to the conclusion of this inquest that took place on 17 December 2018 and the subsequent Prevention of Future Deaths report that was issued to the Trust. Agnes Lambert was employed by the Trust as mental health nurse based at Highgate Mental Health Centre: In the months prior to her death, an issue had arisen in regard to a patient who had become fixated on her and it was alleged that she had entered his room at night without telling other members of staff: A disciplinary investigation was commissioned and Ms Lambert was informed on 12 April that the case would proceed to a formal hearing At this point, Lambert went on sick leave, returning to work on 19 June, following the disciplinary hearing which took place on 29 May 2018. Ms Lambert'$ death was reported to the Trust on 2 July 2018_ The matters of concern that arose from the inquest were as follows: Prior to the allegations of Ms Lambert entering the patient's room, a more senior staff member recognised the patient's fixation and requested that she be temporarily redeployed to work on another ward: She declined and the manager did not insist on this redeployment: At the hearing, the Senior Service Manager who gave evidence, Chair: Lelsha Fullick Your partner in C Chief Executive: Angela McNab care & improvement Camden ISLINGTON Celian NNS Founcaton Trust providimg tental healin and substance misuse serices t0 people Camden and Itington subftance risuse Jnd Dsycnologica therapies serice i0 residents in Kingson Reoeeswr Ms Inng Fnd
NHS accepted that the temporary redeployment to another ward should have been made regardless of Ms Lambert's wishes If this had been executed, she would not have been in a position to enter the patient's room later_ 2 Following the allegations, the investigation process took four months to interview eight witnesses in order to progress to a disciplinary hearing: This was obviously a distressing time for Ms Lambert and at the point that the decision was made to progress to hearing, she went on sick leave: The Senior Service Manager who gave evidence in court agreed that the lengthy process was unacceptable_ You requested that we respond by 18 February 2019 to inform you of our intended actions. Thank you for highlighting these issues which have subsequently been discussed and reflected on at a number of forums between the operational teams involved and HR & OD_ We are committed to learning from Ms Lambert'$ tragic death and promote to staff that the Trust is a just and fair place to work: Firstly, it is recognised that at the time that these events began, the ward where Ms Lambert worked did not have permanent ward manager in post and the overall management and supervision structure on the ward was not as robust as it should have been. Significant steps have since been taken to address this and there is now a permanent ward manager_ Further, we have recognised that there is a general need among managers for further support around how to have challenging conversations with staff, particularly in situations such as this, where the intention is not to punish the staff member, but to ensure their safety, whilst making it clear that are expected to follow reasonable management instructions_ To support this, we are in the process of out 'vital conversations' training which will form part of the professional requirements for all line managers in the Trust, though nursing managers will initially be prioritised. We absolutely recognise that unnecessary and lengthy disciplinary processes can have serious detrimental impact on staff mental health and wellbeing: With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby specially-trained member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the CR staff rolling lay
NHS Vital Conversations training, will facilitate more issues being resolved informally through the supervision process: For those investigations that do proceed formally, there will be greater focus on managers' responsibility to minimise delay/keep to timeframes, and monitoring to ensure that managers have offered/referred staff to occupational health for support and also made them aware of our Employee Assist Programme: The refreshed policy is expected to complete in March 2019. The risks posed by unnecessary and lengthy disciplinary processes have been added to the HR & OD department risk register to monitor and ensure progress is made_ hope that my response provides you with the necessary assurance: If you need any further information please do not hesitate to contact me.
NHS accepted that the temporary redeployment to another ward should have been made regardless of Ms Lambert's wishes If this had been executed, she would not have been in a position to enter the patient's room later_ 2 Following the allegations, the investigation process took four months to interview eight witnesses in order to progress to a disciplinary hearing: This was obviously a distressing time for Ms Lambert and at the point that the decision was made to progress to hearing, she went on sick leave: The Senior Service Manager who gave evidence in court agreed that the lengthy process was unacceptable_ You requested that we respond by 18 February 2019 to inform you of our intended actions. Thank you for highlighting these issues which have subsequently been discussed and reflected on at a number of forums between the operational teams involved and HR & OD_ We are committed to learning from Ms Lambert'$ tragic death and promote to staff that the Trust is a just and fair place to work: Firstly, it is recognised that at the time that these events began, the ward where Ms Lambert worked did not have permanent ward manager in post and the overall management and supervision structure on the ward was not as robust as it should have been. Significant steps have since been taken to address this and there is now a permanent ward manager_ Further, we have recognised that there is a general need among managers for further support around how to have challenging conversations with staff, particularly in situations such as this, where the intention is not to punish the staff member, but to ensure their safety, whilst making it clear that are expected to follow reasonable management instructions_ To support this, we are in the process of out 'vital conversations' training which will form part of the professional requirements for all line managers in the Trust, though nursing managers will initially be prioritised. We absolutely recognise that unnecessary and lengthy disciplinary processes can have serious detrimental impact on staff mental health and wellbeing: With this in mind, the disciplinary policy is currently being reviewed to include clearer criteria as to what does or does not warrant a full investigation. We also have an added step in our disciplinary process whereby specially-trained member of staff reviews cases to gain assurance or indeed challenge that a formal hearing is required. It is expected that this change along with the CR staff rolling lay
NHS Vital Conversations training, will facilitate more issues being resolved informally through the supervision process: For those investigations that do proceed formally, there will be greater focus on managers' responsibility to minimise delay/keep to timeframes, and monitoring to ensure that managers have offered/referred staff to occupational health for support and also made them aware of our Employee Assist Programme: The refreshed policy is expected to complete in March 2019. The risks posed by unnecessary and lengthy disciplinary processes have been added to the HR & OD department risk register to monitor and ensure progress is made_ hope that my response provides you with the necessary assurance: If you need any further information please do not hesitate to contact me.
Sent To
- Camden & Islington NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
11 Feb 2019
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 3 July 2018, I commenced an investigation into the death Agnes Stephanie LAMBERT. The investigation concluded at the end of the inquest earlier today. I made a determination of suicide at inquest. The medical cause of death was 1a) suspension by ligature.
Circumstances of the Death
Agnes Lambert was a mental health nurse working at Highgate Mental Health Centre. Following allegations that she had failed to follow a direct instruction not to engage with a patient who was fixated on her, and that she had entered his room at night without telling other members of staff, she was investigated by the trust in the six months preceding her death. The investigation had been concluded by the time of Ms Lambert’s death and she was just about to return to work, but a day or two before she died she was very upset by a colleague’s remark that everyone at Highgate knew of the allegations and believed them.
Copies Sent To
Care Quality Commission for England
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.