Sian Witheridge
PFD Report
Partially Responded
Ref: 2017-0305
Coroner's Concerns (AI summary)
Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding of suicide risk coupled with disjointed care between services.
View full coroner's concerns
1. While Ms Witheridge was staying in Crisis House, her mental health records were not available to the OneHousing staff there.
2. I was told that the written risk assessment provided to Highbury Grove Crisis House was not as detailed as it should have been.
I was unable to make a judgement about this myself because no member of the treating teams or those advising them brought the records to court.
(This is especially disappointing given that it is a specific instruction contained within every witness summons that was signed and returned.)
3. The crisis team staff (as opposed to the crisis house staff) did have access to Ms Witheridge’s mental health records, but they did not read them any further back than the date of her first call to crisis house during that last episode, i.e. 25 May 2017, despite her very extensive past medical history.
There seemed a lack of recognition of the importance of the notes, particularly the older notes. This may explain why no member of the team thought to bring the notes to court for the inquest.
4. One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms Witheridge took any leave.
However, this was an unenforceable plan, because Highbury Grove is an open facility.
If the crisis team nurse had considered this, he might have decided that Ms Witheridge in fact needed an assessment under the Mental Health Act when she sought to self discharge on 27 May.
5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.
False reassurance appeared to have been drawn from the latter. No arrangement was made for the crisis team to meet Ms Witheridge on 30 May.
6. The care offered to service users of Highbury Grove Crisis House and the Islington Crisis Team seemed disjointed and not dovetailed between OneHousing and Camden & Islington NHS Trust.
For example, the crisis team members who gave evidence did not have any knowledge of the crisis house procedure for risk assessing before allowing leave.
I found it difficult to make further assessment of this because of the lack of medical records, and the presentation to me of the serious incident investigation report only the day before inquest.
2. I was told that the written risk assessment provided to Highbury Grove Crisis House was not as detailed as it should have been.
I was unable to make a judgement about this myself because no member of the treating teams or those advising them brought the records to court.
(This is especially disappointing given that it is a specific instruction contained within every witness summons that was signed and returned.)
3. The crisis team staff (as opposed to the crisis house staff) did have access to Ms Witheridge’s mental health records, but they did not read them any further back than the date of her first call to crisis house during that last episode, i.e. 25 May 2017, despite her very extensive past medical history.
There seemed a lack of recognition of the importance of the notes, particularly the older notes. This may explain why no member of the team thought to bring the notes to court for the inquest.
4. One of the crisis team nurses made a plan for a risk assessment to be carried out before Ms Witheridge took any leave.
However, this was an unenforceable plan, because Highbury Grove is an open facility.
If the crisis team nurse had considered this, he might have decided that Ms Witheridge in fact needed an assessment under the Mental Health Act when she sought to self discharge on 27 May.
5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan.
False reassurance appeared to have been drawn from the latter. No arrangement was made for the crisis team to meet Ms Witheridge on 30 May.
6. The care offered to service users of Highbury Grove Crisis House and the Islington Crisis Team seemed disjointed and not dovetailed between OneHousing and Camden & Islington NHS Trust.
For example, the crisis team members who gave evidence did not have any knowledge of the crisis house procedure for risk assessing before allowing leave.
I found it difficult to make further assessment of this because of the lack of medical records, and the presentation to me of the serious incident investigation report only the day before inquest.
Responses
Action Planned
The organisation plans to provide Highbury Grove Crisis House staff with access to their IT system in early 2018, following training and checks. It has also agreed to jointly investigate all deaths connected to the Crisis House. (AI summary)
The organisation plans to provide Highbury Grove Crisis House staff with access to their IT system in early 2018, following training and checks. It has also agreed to jointly investigate all deaths connected to the Crisis House. (AI summary)
View full response
Dear Madam Prevention of future deaths report ~ Sian Witheridge write further to your Regulation 28 Prevention of Future Deaths report dated 23 October 2017 in which you highlighted concerns about the care provided to Ms Witheridge You have brought to our attention a number of concerns which will address below.
1. While Ms Witheridge was staying in Highbury Grove Crisis House her mental health records were not available to the OneHousing staff there: We agree that Highbury Grove Crisis House staff should have access to our clinical records: To this end, we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks_
2. You were told that the written risk assessment provided to Highbury Grove Crisis House was not as detailed as it should have been_ We have reviewed our risk assessment and have enclosed a copy for your information. We are satisfied that it contains a comprehensive risk history and that it includes sufficient detail about previous suicide attempts and risk factors_ This risk assessment would have been provided to Highbury Grove as Highbury Grove does not accept referrals without first reading the risk assessment: As above, going forward, Highbury Grove staff will be able to access our risk assessments and obtain all the relevant information about a patient's previous risk history and current risk factors_ Chair; Leisha Fullick Your partner in Chief Executive: Angela McNab care & improvement Camden ISLINGTON Cei NHS Foundation Trust providing mental health and substance misuse services I0 people living Camden and Islington and substance mnsuse J psychological therapies service t0 resldents Knastan Wing IJn
NHS We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&l staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&l staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient; We are sorry that we did not bring medical records to the inquest We will ensure that we do so in future.
3. The Crisis Team Assistant Practitioner who saw Ms Witheridge on 29 2017 did not read any further back than the date of her first call to the crisis house i.e. 25 May 2017 despite her very extensive past medical history The Assistant Practitioner acknowledged at the inquest that she should have read further back in the clinical records than she did, To ensure that the learning from this case is embedded within the teams, the operational manager and team manager of the crisis team have reinforced the importance of undertaking comprehensive review of the clinical records, including reading the risk assessment, before seeing a patient: The practice of reading the history will be checked in regular supervisions
4. One of the Crisis Team nurses made a plan for a risk assessment to be carried out before Ms Witheridge took any leave. However, this was unenforceable because Highbury Grove is an open facility. If the crisis team nurse had considered this he might have decided that Ms Witheridge in fact needed an assessment under the Mental Health Act when she sought to self-discharge on 27 May: The nurse in question was unable to attend the inquest to explain his plan. However _ he was certainly aware that Highbury Grove is an open facility and that Ms Witheridge could not have forcibly been prevented leaving the premises_ The nurse's intention in asking Highbury Grove staff to check in with Ms Witheridge before she took any leave was for them to obtain an impression of her mental state and to make an assessment as to whether she was safe to leave_ If staff considered that Witheridge was at immediate risk of self-harm before leaving the premises then immediate action could have been taken such as trying to persuade Ms Witheridge to stay or calling emergency services. As such, whilst the nurse was aware that Ms Witheridge could not be detained at Highbury Grove_ he was ensuring that an additional check was undertaken before she left the premises This is not dissimilar to the assessment which would take place with an informal patient before they leave a ward_ We do not consider that the nurse's action in this instance was inappropriate _ A mental health assessment was an option that the crisis team was actively considering_ However did not consider it was needed when Ms Witheridge sought to self-discharge on 27 May_ CR the the May from Ms they
NHS 5_ seemed to be a lack of between a patient bes Verirgf posieivelndiag by the staff of the difference patient positively that no suicide reassurance to answer a question about plan and appeared to have been drawn suicide plan: False atrangement was made for the ceigis the latter. No team to meet Ms Witheridge on 30 urdergtspoken with the Assistant Practitioner, understands the difference betaveen we are satisfied that she have no suicide plan and patient positively that suicide planc (reheaevidenceatiene siapey to answer a question about she was concerned aNtitteeinquest; the Assistant Practitioner about about Ms Witheridge's mental state said that suicidal ideation was minimal; and that her response consider that Ms Witheridge was THowever the Assistant Practitiones odgot Witheridge was to at immediate risk of her life. Ms her; she was engage in her treatment plan after her treatment. compliant with her medication, and she was with to pursue herethosgte bPracttioner agreed with Ms Witheridge thoughts on paper and pass this on ts that she would write down struggling to engage verbally with theo, Highbury Grove staff as she wes returned to her she verbally When the Assistant Practitioner mental state to senior staff fechback her concerns about Ms Witheridge's member of staff to on shift; The plan which was agreed was for review her on 31 and a referral for aissessment continued to be an ongoing mental health act disengaged from the service andlogo consideration if Ms Witheridge consider that a member of the her risk to self-escalated. In hindsight; we However, on 29 crisis team should have visited on 30 to self because Ms itherdd not consider there to be an immediate risk Of harm hereleeeirgusehMVne Vibssicge Pactiling t0 engage in henmeatatent af &ier medication, Assistant Practitioner; she was complianawilehep and she was to pursue treatment 6_ The care offered to service users of Highbury Grove Crisis Islington Crisis Team seemed disjointed and House and the OneHousing and Camden & not dover tailed between Islington NHS Trust: OUe hce aware that Highbury Grove has sent you our 'Working Protocol' setting out how our teams work together As set out earlier; we accept that there been challenges with information sharing: We are confident howeverhezt thiy has been rectified and Highbury Grove and staff will in the future have ready access to all the relevant clinical information; We would like to assure you that we have good channels of communication with Highbury Grove, and our senior operational staff meet with the Highbury Grove team regularly to discuss how the service is working, and to identify whether there are problems in particular areas CRI There they simply have refusing from May. answering they refusing taking willing meeting willing team May May. May, willing have
NHS Folloectecthis inquest we have also agreed to jointly connected to the Highbury Grove Crisis investigate all deaths taken so that all service House to ensure that a holistic approach is problems are identified. that the information in this letter assures that learning from this case, and our you we have taken forward the our patients safe. ongoing commitment and determination oo keep aei sincerely Angela McNab Chief Executive Enc: CRI delivery hope Yours Kjutub
1. While Ms Witheridge was staying in Highbury Grove Crisis House her mental health records were not available to the OneHousing staff there: We agree that Highbury Grove Crisis House staff should have access to our clinical records: To this end, we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks_
2. You were told that the written risk assessment provided to Highbury Grove Crisis House was not as detailed as it should have been_ We have reviewed our risk assessment and have enclosed a copy for your information. We are satisfied that it contains a comprehensive risk history and that it includes sufficient detail about previous suicide attempts and risk factors_ This risk assessment would have been provided to Highbury Grove as Highbury Grove does not accept referrals without first reading the risk assessment: As above, going forward, Highbury Grove staff will be able to access our risk assessments and obtain all the relevant information about a patient's previous risk history and current risk factors_ Chair; Leisha Fullick Your partner in Chief Executive: Angela McNab care & improvement Camden ISLINGTON Cei NHS Foundation Trust providing mental health and substance misuse services I0 people living Camden and Islington and substance mnsuse J psychological therapies service t0 resldents Knastan Wing IJn
NHS We are also going to move to undertaking joint risk assessments which will be completed by One Housing and C&l staff members. This will ensure that all risk factors as identified by all the staff caring for the patient are taken into account when formulating risk assessments and next steps. In cases where C&l staff conduct the risk assessment themselves, the Operations Manager and Team Manager for the crisis teams have reinforced to the teams the importance of providing detailed feedback to One Housing staff and agreeing a written plan of action for each patient; We are sorry that we did not bring medical records to the inquest We will ensure that we do so in future.
3. The Crisis Team Assistant Practitioner who saw Ms Witheridge on 29 2017 did not read any further back than the date of her first call to the crisis house i.e. 25 May 2017 despite her very extensive past medical history The Assistant Practitioner acknowledged at the inquest that she should have read further back in the clinical records than she did, To ensure that the learning from this case is embedded within the teams, the operational manager and team manager of the crisis team have reinforced the importance of undertaking comprehensive review of the clinical records, including reading the risk assessment, before seeing a patient: The practice of reading the history will be checked in regular supervisions
4. One of the Crisis Team nurses made a plan for a risk assessment to be carried out before Ms Witheridge took any leave. However, this was unenforceable because Highbury Grove is an open facility. If the crisis team nurse had considered this he might have decided that Ms Witheridge in fact needed an assessment under the Mental Health Act when she sought to self-discharge on 27 May: The nurse in question was unable to attend the inquest to explain his plan. However _ he was certainly aware that Highbury Grove is an open facility and that Ms Witheridge could not have forcibly been prevented leaving the premises_ The nurse's intention in asking Highbury Grove staff to check in with Ms Witheridge before she took any leave was for them to obtain an impression of her mental state and to make an assessment as to whether she was safe to leave_ If staff considered that Witheridge was at immediate risk of self-harm before leaving the premises then immediate action could have been taken such as trying to persuade Ms Witheridge to stay or calling emergency services. As such, whilst the nurse was aware that Ms Witheridge could not be detained at Highbury Grove_ he was ensuring that an additional check was undertaken before she left the premises This is not dissimilar to the assessment which would take place with an informal patient before they leave a ward_ We do not consider that the nurse's action in this instance was inappropriate _ A mental health assessment was an option that the crisis team was actively considering_ However did not consider it was needed when Ms Witheridge sought to self-discharge on 27 May_ CR the the May from Ms they
NHS 5_ seemed to be a lack of between a patient bes Verirgf posieivelndiag by the staff of the difference patient positively that no suicide reassurance to answer a question about plan and appeared to have been drawn suicide plan: False atrangement was made for the ceigis the latter. No team to meet Ms Witheridge on 30 urdergtspoken with the Assistant Practitioner, understands the difference betaveen we are satisfied that she have no suicide plan and patient positively that suicide planc (reheaevidenceatiene siapey to answer a question about she was concerned aNtitteeinquest; the Assistant Practitioner about about Ms Witheridge's mental state said that suicidal ideation was minimal; and that her response consider that Ms Witheridge was THowever the Assistant Practitiones odgot Witheridge was to at immediate risk of her life. Ms her; she was engage in her treatment plan after her treatment. compliant with her medication, and she was with to pursue herethosgte bPracttioner agreed with Ms Witheridge thoughts on paper and pass this on ts that she would write down struggling to engage verbally with theo, Highbury Grove staff as she wes returned to her she verbally When the Assistant Practitioner mental state to senior staff fechback her concerns about Ms Witheridge's member of staff to on shift; The plan which was agreed was for review her on 31 and a referral for aissessment continued to be an ongoing mental health act disengaged from the service andlogo consideration if Ms Witheridge consider that a member of the her risk to self-escalated. In hindsight; we However, on 29 crisis team should have visited on 30 to self because Ms itherdd not consider there to be an immediate risk Of harm hereleeeirgusehMVne Vibssicge Pactiling t0 engage in henmeatatent af &ier medication, Assistant Practitioner; she was complianawilehep and she was to pursue treatment 6_ The care offered to service users of Highbury Grove Crisis Islington Crisis Team seemed disjointed and House and the OneHousing and Camden & not dover tailed between Islington NHS Trust: OUe hce aware that Highbury Grove has sent you our 'Working Protocol' setting out how our teams work together As set out earlier; we accept that there been challenges with information sharing: We are confident howeverhezt thiy has been rectified and Highbury Grove and staff will in the future have ready access to all the relevant clinical information; We would like to assure you that we have good channels of communication with Highbury Grove, and our senior operational staff meet with the Highbury Grove team regularly to discuss how the service is working, and to identify whether there are problems in particular areas CRI There they simply have refusing from May. answering they refusing taking willing meeting willing team May May. May, willing have
NHS Folloectecthis inquest we have also agreed to jointly connected to the Highbury Grove Crisis investigate all deaths taken so that all service House to ensure that a holistic approach is problems are identified. that the information in this letter assures that learning from this case, and our you we have taken forward the our patients safe. ongoing commitment and determination oo keep aei sincerely Angela McNab Chief Executive Enc: CRI delivery hope Yours Kjutub
Sent To
- Camden & Islington NHS Trust
- One Housing Group
Response Status
Linked responses
1 of 2
56-Day Deadline
22 Jan 2018
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 5 June 2017, I commenced an investigation into the death of Siân Louise Witheridge, aged 36 years. The investigation concluded at the end of the inquest on 10 October 2017. I made a determination at inquest of death by suicide.
Circumstances of the Death
Ms Witheridge hanged herself at home on 30 May 2017.
She had been detained in hospital under a section of the Mental Health Act on several occasions. She then contacted the crisis team on 20 May, attended an emergency unit on 22 May and, at her crisis team assessment on 24 May, reported staring at traffic for hours considering jumping into it. She also told her care co-ordinator that she had a rope to use to hang herself.
She was admitted to Highbury Grove Crisis House (operated by OneHousing) on 25 May.
She wanted to self discharge on Saturday the 27th but, having spoken to a member of the crisis team at some length, agreed to stay. The plan was for the crisis team to visit each day, for her to have a session with Highbury Grove staff twice a day, and for her risk to self to be reviewed prior to any leave being granted. She saw an advanced practitioner at crisis house on Monday, 29 May.
She was planned for crisis team review next on 31 May, but on 30 May she left Crisis House in the morning and was found by police at her home that evening.
She had been detained in hospital under a section of the Mental Health Act on several occasions. She then contacted the crisis team on 20 May, attended an emergency unit on 22 May and, at her crisis team assessment on 24 May, reported staring at traffic for hours considering jumping into it. She also told her care co-ordinator that she had a rope to use to hang herself.
She was admitted to Highbury Grove Crisis House (operated by OneHousing) on 25 May.
She wanted to self discharge on Saturday the 27th but, having spoken to a member of the crisis team at some length, agreed to stay. The plan was for the crisis team to visit each day, for her to have a session with Highbury Grove staff twice a day, and for her risk to self to be reviewed prior to any leave being granted. She saw an advanced practitioner at crisis house on Monday, 29 May.
She was planned for crisis team review next on 31 May, but on 30 May she left Crisis House in the morning and was found by police at her home that evening.
Copies Sent To
Care Quality Commission for England
, adult social care, Camden, Islington & Enfield
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.