Natalie Gray
PFD Report
All Responded
Ref: 2017-0003
All 1 response received
· Deadline: 16 Apr 2017
Coroner's Concerns (AI summary)
Concerns included an unfinalized discharge pathway for personality disorder patients, inadequate risk assessment forms and subjective terminology leading to inaccurate assessments. Crucially, significant third-party information was not consistently recorded.
View full coroner's concerns
In the circumstances it is my statutory duly to report to Ou. day-ward daugr her, live aunt fine:
Whilst it is recognised that a significant number of changes have bean made by both the Mental Health Trust and Kent Police t0 procedures and protocols that were in place at the time of the death of Natalie a number of matters remain outstanding, are subject of continuing work or require clarification and as a result the following matters are Of concern: (1) The approach t0 discharge planning has been addressed on a general basis but the pathway for those with a diagnosis of personality disorder is currently under review and has not been fnalised: It remains a concern that a patient with an emotionally unstable personality disorder will meet the current criteria for discharge but shortly thereafter be at risk particularly where specialist therapies are planned but have not been approvedlstarted (2) The risk assessment form has not yet been addressed and is under review; there remains an issue a8 t0 whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose t0 historic risk: Although risk is discussed at handovers and rounds there is no evidence that the risk rating is communicated or signed Off by the doctor when the record is completed by nurseljunior doctor (3) Kent Police and Kent & Medway NHS & Social Care Partnerahip Trust have agreed Missing Person Procedure implemented 1 December 2015. There is a concem about the terminology for use in the risk assessment that Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented or the risk at the time the patient left the facility which may be less clear: Additionally the use of the tem 'significant' is highly subjective, is It intended to mean a likely risk of self ham or something more. It is not clear how the Trust should deal with those likely t0 place themselves in danger and therefore at medium risk of self harm; in terms of the timescales involved and whether 999 should be used or not By way of example, Natalie'8 documented risk was inaccurately recorded a8 Jw; when it should have been medium and on leaving the facility medium to high, this could lead t0 an underestimation of the risk of self ham depending on how the form is interpreted by staff: (4) Significant infomation from third parties was not recorded in the Rio notes when received or at all
Whilst it is recognised that a significant number of changes have bean made by both the Mental Health Trust and Kent Police t0 procedures and protocols that were in place at the time of the death of Natalie a number of matters remain outstanding, are subject of continuing work or require clarification and as a result the following matters are Of concern: (1) The approach t0 discharge planning has been addressed on a general basis but the pathway for those with a diagnosis of personality disorder is currently under review and has not been fnalised: It remains a concern that a patient with an emotionally unstable personality disorder will meet the current criteria for discharge but shortly thereafter be at risk particularly where specialist therapies are planned but have not been approvedlstarted (2) The risk assessment form has not yet been addressed and is under review; there remains an issue a8 t0 whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose t0 historic risk: Although risk is discussed at handovers and rounds there is no evidence that the risk rating is communicated or signed Off by the doctor when the record is completed by nurseljunior doctor (3) Kent Police and Kent & Medway NHS & Social Care Partnerahip Trust have agreed Missing Person Procedure implemented 1 December 2015. There is a concem about the terminology for use in the risk assessment that Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented or the risk at the time the patient left the facility which may be less clear: Additionally the use of the tem 'significant' is highly subjective, is It intended to mean a likely risk of self ham or something more. It is not clear how the Trust should deal with those likely t0 place themselves in danger and therefore at medium risk of self harm; in terms of the timescales involved and whether 999 should be used or not By way of example, Natalie'8 documented risk was inaccurately recorded a8 Jw; when it should have been medium and on leaving the facility medium to high, this could lead t0 an underestimation of the risk of self ham depending on how the form is interpreted by staff: (4) Significant infomation from third parties was not recorded in the Rio notes when received or at all
Responses
Action Taken
The Trust has implemented steps to support discharge from in-patient services, including using a countdown to discharge tool and strengthening links between CMHT and CRHT teams. The Trust is improving relationships with Kent Police by designating a third police officer to the acute service line and holding quarterly executive liaison meetings. (AI summary)
The Trust has implemented steps to support discharge from in-patient services, including using a countdown to discharge tool and strengthening links between CMHT and CRHT teams. The Trust is improving relationships with Kent Police by designating a third police officer to the acute service line and holding quarterly executive liaison meetings. (AI summary)
View full response
Dear Madam
Re: Preventing Future Death; The Inquest in to Natalie Gray’s death Response
I joined Kent and Medway NHS and Social Care Partnership Trust (the Trust) in June 2016. Soon after joining I was made aware of the tragic circumstances surrounding Natalie’s death on 21st April 2015. I received regular updates in relation to the inquest which concluded on 1st November 2016. Following its conclusion (Acute Service Line Director), who attended the entirety of the inquest, briefed myself and the Board on the inquest’s findings.
I have carefully considered the three areas you have highlighted as being of particular concern. My response is set out against each of your points.
1. The approach to discharge planning has been addressed on a general basis but the pathway for those with a diagnosis of personality disorder is currently under review and has not been finalised. It remains a concern that a patient with an emotionally unstable personality disorder will meet the current criteria for discharge but shortly thereafter be at risk particularly where specialist therapies are planned but have not been approved/started.
My response in relation to this is twofold. It consists of steps already put in place to support discharge from in-patient services including those with a diagnosis of Personality Disorder in line with NICE guidance. The second part, outlining our longer term plans as part of the ongoing Personality Disorder Review being over seen by our Executive Medical Director.
Dealing with the former first, the countdown to discharge tool about which I understand you received oral evidence on during the course of the inquest is key to this. In addition to this, links between Community Mental Health teams (CMHT) and the Crisis Resolution Home Treatment (CRHT) team have been strengthened. A daily Crisis Call (Monday to Friday) has been implemented Trust-wide. This allows for a patient focused discussion to occur and for the CMHT to be fully involved in any decision to discharge a patient from either a ward or the CRHT. Patricia Harding H M Senior Coroner for Mid Kent and Medway Archbishops Palace Maidstone Kent
Your reference My reference HG/366
Date 14 March 2017 Chairman – Andrew Ling Chief Executive – Helen Greatorex
The Trust Patient Flow Board provides a further means by which services can closely monitor the input that service users have, by ensuring that once admitted to the inpatient setting a care coordinator is allocated through the process of patient flow meetings, using the Board as a guide and reference point.
The Medical Psychotherapist and Lead Consultant for Personality Disorder unit is providing specialist advice and training to the acute wards on the management and discharge planning for their patients with Personality Disorders. In February 2017, he started training staff at Priority House on a ward by ward basis. This includes risk management formulation and mindfulness. By the end of April all staff at Priority House should have received this training. This will then be rolled out Trust-wide across the Acute Service Line.
A Trust-wide Personality Disorder Panel is being established. Complex and high risk patients will be discussed and support provided to access appropriate interventions. The Panel will consist of a Consultant Medical Psychotherapist/Psychiatrist, Director of Specialist Services, Assistant Director of Acute Service Line, Clinical Lead for specialist psychological practice and Clinical Lead for Community and Recovery services.
The first meeting to establish the panel and approve terms of reference is on 1st May
2017. It is proposed it will meet every two weeks. The Panel will initially focus on our top 50 frequent attenders of acute services to provide support and offer guidance to Care Coordinators in managing these complex cases and assisting with access to the appropriate specialist psychological interventions.
The Trust’s Personality Disorder review concludes in May. The issue of safe transition between acute and community services is a central part of this review. A key aim is for all appropriate patients to be able to access specialist psychological therapies. The Trust Board will be presented with plans for a new integrated care pathway for Personality Disorder to consider at the end of May.
As part of the development of the new Personality Disorder pathway we have been considering the stepdown from the acute pathway and into the community and support that is available to patients including psycho-educational groups, service user network support groups which may be provided by voluntary organisations and specialised therapy appropriate for the patients needs, additional training for Care Coordinators and approved care planning for newly admitted Personality Disorder patients.
It is a key component of our suicide prevention strategy (launched in September 2016) and sets out the Trust’s strategy over a three year period.
The strategy recognised that those with a diagnosed Personality Disorder are at a higher risk, and therefore require priority due to being in this high risk group. There is work underway in line with this to transform clinical risk assessment and management, both in practice and recording, with new training in place, and new risk assessment documentation about to come onto our electronic clinical record system for general 2
use. As an organisation we are committing ourselves to achieve greater engagement of patients, families and carers and work jointly with them to achieve effective “safety planning”. .
2. The risk assessment form has not yet been addressed and is under review, there remains an issue as to whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose to historic risk. Although risk is discussed at handover and ward rounds there is no evidence that the risk rating is communicated or signed off by the doctor when the record is completed by a nurse/junior doctor.
In January 2017 the Trust launched a newly reviewed risk policy and risk summary form, this is currently being implemented Trust-wide.
We have taken a number of steps to highlight how the points of transition of care are an area of risk for those with a diagnosis of Personality Disorder. Changes have been made to our Clinical Risk Policy to reflect this. There is a flow diagram in the policy providing guidance on when to assess and reassess clinical risk and it highlights transition periods.
I am aware that its development was informed by learning from Serious Incidents and near misses. Natalie’s was a case where the grading of risk was key as there was always a chronic risk which would fluctuate. Updated mandatory training focuses on the critically high risk period as well as other transitions in care. The updated training explains how the period is often referred to as the ‘Low Risk Paradox’ with risk assessed as low in one environment yet high or escalating in another
We are using learning from real case examples with our clinicians to ensure that the multidisciplinary teams understand risk, its importance and variability in a more sophisticated sense.
We have changed our approach to testing practice in relation to risk assessment. As part of the programme for implementation of the new Risk Summary, auditing is focused on quality of the risk assessment rather than just the percentage of risk assessments completed.
We recognise the importance of the communication of risk both between members of the multidisciplinary team and from shift to shift and this is recognised in training.
The importance of clearly recording the Consultant’s review of risk has been discussed and action taken to ensure this happens. Changes are being made to our electronic patient record to make it easier to record and review.
Shift patterns and handovers are being reviewed so that they can be structured in such a way as to ensure that the key information is passed onto the next shift. We are considering standardising shift times across all sites and wards and to cost this accordingly. This would be with a view to an extended handover time. 3
3. Kent Police and Kent & Medway NHS Social Care Partnership Trust have agreed a Missing person Procedure implemented 1st December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to weather the risk is that formally documented or the risk at the time the 'significant' is highly subjective, is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie's documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff.
We have taken a series of steps to resolve this. They include
• Jointly agreed Adverse Incident Process shared by Kent Police and the Trust.
• A compliance bulletin and reminders across the whole Trust, specifying terminology to be used.
• From April 2017 there will be a third specifically designated Police Officer to the acute service line, these are already in situ in North and East and from April this will extend to West Kent, this Officer will be based at Priority House. This supports improvements to communications, joint working, joint learning, and ultimately reduction in risk of harm.
• We continue to work closely with Kent Police on a number of joint projects, including Operation Sotor which has been recognised as an item of good practice nationally.
• Since September 2016 the Trust has established a KMPT and Kent Police Executive Liaison Meeting which takes place quarterly and is attended by KMPT CEO, Exec Lead, Assistant Chief Constable and Strategic Lead Superintendent from Kent Police, Kent Police and Crime Commissioner and the Accountable Officer from West Kent CCG. This is an executive steering group for joint strategic planning and to support the delivery of Crisis Care Concordat. Building on the positive relationships with Kent Police is helping identify and address similar risk to those found in Natalie’s case.
As I conclude this letter, I am struck by how much has or is changing since the tragedy of Natalie’s death. As Chief Executive I take full and personal responsibility to make sure that we are doing everything we possibly can to avoid such a tragedy being repeated. I offer you as H. M. Senior Coroner my assurance that I believe we are addressing the serious concerns that you raise. I recognise that we have a significant amount of work to do in order to create truly patient focused, high quality services.
4
I would with your agreement, like to provide you with a further update in the autumn. By then, I believe our service for people with Natalie’s diagnosis will be transformed.
Re: Preventing Future Death; The Inquest in to Natalie Gray’s death Response
I joined Kent and Medway NHS and Social Care Partnership Trust (the Trust) in June 2016. Soon after joining I was made aware of the tragic circumstances surrounding Natalie’s death on 21st April 2015. I received regular updates in relation to the inquest which concluded on 1st November 2016. Following its conclusion (Acute Service Line Director), who attended the entirety of the inquest, briefed myself and the Board on the inquest’s findings.
I have carefully considered the three areas you have highlighted as being of particular concern. My response is set out against each of your points.
1. The approach to discharge planning has been addressed on a general basis but the pathway for those with a diagnosis of personality disorder is currently under review and has not been finalised. It remains a concern that a patient with an emotionally unstable personality disorder will meet the current criteria for discharge but shortly thereafter be at risk particularly where specialist therapies are planned but have not been approved/started.
My response in relation to this is twofold. It consists of steps already put in place to support discharge from in-patient services including those with a diagnosis of Personality Disorder in line with NICE guidance. The second part, outlining our longer term plans as part of the ongoing Personality Disorder Review being over seen by our Executive Medical Director.
Dealing with the former first, the countdown to discharge tool about which I understand you received oral evidence on during the course of the inquest is key to this. In addition to this, links between Community Mental Health teams (CMHT) and the Crisis Resolution Home Treatment (CRHT) team have been strengthened. A daily Crisis Call (Monday to Friday) has been implemented Trust-wide. This allows for a patient focused discussion to occur and for the CMHT to be fully involved in any decision to discharge a patient from either a ward or the CRHT. Patricia Harding H M Senior Coroner for Mid Kent and Medway Archbishops Palace Maidstone Kent
Your reference My reference HG/366
Date 14 March 2017 Chairman – Andrew Ling Chief Executive – Helen Greatorex
The Trust Patient Flow Board provides a further means by which services can closely monitor the input that service users have, by ensuring that once admitted to the inpatient setting a care coordinator is allocated through the process of patient flow meetings, using the Board as a guide and reference point.
The Medical Psychotherapist and Lead Consultant for Personality Disorder unit is providing specialist advice and training to the acute wards on the management and discharge planning for their patients with Personality Disorders. In February 2017, he started training staff at Priority House on a ward by ward basis. This includes risk management formulation and mindfulness. By the end of April all staff at Priority House should have received this training. This will then be rolled out Trust-wide across the Acute Service Line.
A Trust-wide Personality Disorder Panel is being established. Complex and high risk patients will be discussed and support provided to access appropriate interventions. The Panel will consist of a Consultant Medical Psychotherapist/Psychiatrist, Director of Specialist Services, Assistant Director of Acute Service Line, Clinical Lead for specialist psychological practice and Clinical Lead for Community and Recovery services.
The first meeting to establish the panel and approve terms of reference is on 1st May
2017. It is proposed it will meet every two weeks. The Panel will initially focus on our top 50 frequent attenders of acute services to provide support and offer guidance to Care Coordinators in managing these complex cases and assisting with access to the appropriate specialist psychological interventions.
The Trust’s Personality Disorder review concludes in May. The issue of safe transition between acute and community services is a central part of this review. A key aim is for all appropriate patients to be able to access specialist psychological therapies. The Trust Board will be presented with plans for a new integrated care pathway for Personality Disorder to consider at the end of May.
As part of the development of the new Personality Disorder pathway we have been considering the stepdown from the acute pathway and into the community and support that is available to patients including psycho-educational groups, service user network support groups which may be provided by voluntary organisations and specialised therapy appropriate for the patients needs, additional training for Care Coordinators and approved care planning for newly admitted Personality Disorder patients.
It is a key component of our suicide prevention strategy (launched in September 2016) and sets out the Trust’s strategy over a three year period.
The strategy recognised that those with a diagnosed Personality Disorder are at a higher risk, and therefore require priority due to being in this high risk group. There is work underway in line with this to transform clinical risk assessment and management, both in practice and recording, with new training in place, and new risk assessment documentation about to come onto our electronic clinical record system for general 2
use. As an organisation we are committing ourselves to achieve greater engagement of patients, families and carers and work jointly with them to achieve effective “safety planning”. .
2. The risk assessment form has not yet been addressed and is under review, there remains an issue as to whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose to historic risk. Although risk is discussed at handover and ward rounds there is no evidence that the risk rating is communicated or signed off by the doctor when the record is completed by a nurse/junior doctor.
In January 2017 the Trust launched a newly reviewed risk policy and risk summary form, this is currently being implemented Trust-wide.
We have taken a number of steps to highlight how the points of transition of care are an area of risk for those with a diagnosis of Personality Disorder. Changes have been made to our Clinical Risk Policy to reflect this. There is a flow diagram in the policy providing guidance on when to assess and reassess clinical risk and it highlights transition periods.
I am aware that its development was informed by learning from Serious Incidents and near misses. Natalie’s was a case where the grading of risk was key as there was always a chronic risk which would fluctuate. Updated mandatory training focuses on the critically high risk period as well as other transitions in care. The updated training explains how the period is often referred to as the ‘Low Risk Paradox’ with risk assessed as low in one environment yet high or escalating in another
We are using learning from real case examples with our clinicians to ensure that the multidisciplinary teams understand risk, its importance and variability in a more sophisticated sense.
We have changed our approach to testing practice in relation to risk assessment. As part of the programme for implementation of the new Risk Summary, auditing is focused on quality of the risk assessment rather than just the percentage of risk assessments completed.
We recognise the importance of the communication of risk both between members of the multidisciplinary team and from shift to shift and this is recognised in training.
The importance of clearly recording the Consultant’s review of risk has been discussed and action taken to ensure this happens. Changes are being made to our electronic patient record to make it easier to record and review.
Shift patterns and handovers are being reviewed so that they can be structured in such a way as to ensure that the key information is passed onto the next shift. We are considering standardising shift times across all sites and wards and to cost this accordingly. This would be with a view to an extended handover time. 3
3. Kent Police and Kent & Medway NHS Social Care Partnership Trust have agreed a Missing person Procedure implemented 1st December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to weather the risk is that formally documented or the risk at the time the 'significant' is highly subjective, is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie's documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff.
We have taken a series of steps to resolve this. They include
• Jointly agreed Adverse Incident Process shared by Kent Police and the Trust.
• A compliance bulletin and reminders across the whole Trust, specifying terminology to be used.
• From April 2017 there will be a third specifically designated Police Officer to the acute service line, these are already in situ in North and East and from April this will extend to West Kent, this Officer will be based at Priority House. This supports improvements to communications, joint working, joint learning, and ultimately reduction in risk of harm.
• We continue to work closely with Kent Police on a number of joint projects, including Operation Sotor which has been recognised as an item of good practice nationally.
• Since September 2016 the Trust has established a KMPT and Kent Police Executive Liaison Meeting which takes place quarterly and is attended by KMPT CEO, Exec Lead, Assistant Chief Constable and Strategic Lead Superintendent from Kent Police, Kent Police and Crime Commissioner and the Accountable Officer from West Kent CCG. This is an executive steering group for joint strategic planning and to support the delivery of Crisis Care Concordat. Building on the positive relationships with Kent Police is helping identify and address similar risk to those found in Natalie’s case.
As I conclude this letter, I am struck by how much has or is changing since the tragedy of Natalie’s death. As Chief Executive I take full and personal responsibility to make sure that we are doing everything we possibly can to avoid such a tragedy being repeated. I offer you as H. M. Senior Coroner my assurance that I believe we are addressing the serious concerns that you raise. I recognise that we have a significant amount of work to do in order to create truly patient focused, high quality services.
4
I would with your agreement, like to provide you with a further update in the autumn. By then, I believe our service for people with Natalie’s diagnosis will be transformed.
Sent To
- Kent and Medway NHS
Response Status
Linked responses
1 of 1
56-Day Deadline
16 Apr 2017
All responses received
About PFD responses
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On April 2015 commenced an investigation into the death of Natalie years: The investigation concluded at the end of the inquest on 1" November 2016, The conclusion of the inquest was suicide contributed to by neglect where there were gross tailures resulting from; 1Insufficient risk assessments on 17"h , 20th and 21* April 2015 t highlight the risk of self harm
2. Inadequate MDT and nursing handovers on 21" April 2015 including omission of the requirement t0 reassess Natalie's informal status should her presentation change or should she attempt to self diecharge
3. Failure to convey and enforce the correct procedures for infomal patient leave t OT support workers
4. Failure by OT support workers t0 follow the leave procedure The following failures were found to have possibly contributed t0 the death:
1.A by staff at Priority House on confirming that it was Natalie who left Priority House and commencing a search
2. An unnecessary delay in the deputy ward manager reporting that Natalie was missing to Kent Police
3. A failure by deputy ward manager t0 provide Kent Police with relevant information
4. A failure by the deputy ward manager t0 follow Trust policy by not contacting Natalie's next of kin The following matters were found t0 be relevant t0 the circumstances of the death;
1.A failure by the Mental Health Trust to record third party information on and 21" April 2015
2. By a majority of 9.2 a failure by the call taker and back UP dispatch officer t0 elicit relevant information from the infomant
2. Inadequate MDT and nursing handovers on 21" April 2015 including omission of the requirement t0 reassess Natalie's informal status should her presentation change or should she attempt to self diecharge
3. Failure to convey and enforce the correct procedures for infomal patient leave t OT support workers
4. Failure by OT support workers t0 follow the leave procedure The following failures were found to have possibly contributed t0 the death:
1.A by staff at Priority House on confirming that it was Natalie who left Priority House and commencing a search
2. An unnecessary delay in the deputy ward manager reporting that Natalie was missing to Kent Police
3. A failure by deputy ward manager t0 provide Kent Police with relevant information
4. A failure by the deputy ward manager t0 follow Trust policy by not contacting Natalie's next of kin The following matters were found t0 be relevant t0 the circumstances of the death;
1.A failure by the Mental Health Trust to record third party information on and 21" April 2015
2. By a majority of 9.2 a failure by the call taker and back UP dispatch officer t0 elicit relevant information from the infomant
Circumstances of the Death
Natalie was 24 years Of age at the time of her death. On 21 April 2015 she leit Priority House where she was an informal patient and made her way to Barming railway station where she remained on the station platform for two hours until a non-stopping train approached at which point she jumped in front of it causing multiple injuries from which she died: Natalie was diagnosed with an emotionally unstable personality disorder and had a number of previous admissions to mental health hospitals following attempts to take her life: Although her mental illness was longstanding; in 2015 Natalie'8 father was gravely ill, her daughter was removed from her care as Natalie was subject of a police investigation and her relationship with her partner with whom her daughter was living;, ended: These individuals were all major protective features in Natalie $ Iife. Natalie had 270 _ Gray = delay the 17th Gray attempted to kill herself wlthin a very short period of being discharged or self-discharging from hospital during the course of these events. On 9 April 2015 she was admitted as an informal patient to Priority House after attempting to gas herself:. On 15 April 2015 she attended the funeral of her father and the following was repeatedly heard t0 express quasi-psychotic thoughts and statements that she wanted to end her life On 17 April 2015 she left the facility and travelled to Maidstone Hospital where she expressed the same thoughts to a hospital chaplain: The chaplain reported the visit to staff at Priority House who failed to record the matter: Natalie was seen on a round after retuming to the facility at which time she was told that her discharge was being planned, Although Natalie acknowledged that she had a good relationship with her care coordinator and was willing to engage with psychological therapy which had been planned for her some months before and was awalting funding; it was evident that she was dlstressed about the proposed discharge and felt let down. She continued to express quasi psychotic thoughts_ On the evening of 20 April 2015 Natalie was found to be very agitated and demanded t0 see a doctor a8 she wanted to discharge herself having learned that her discharge was imminent: She told a psychiatrist that she wanted to leave before she was kicked out; that she felt abandoned as & result of her Jhter being taken away from her partner not wanting to know and her father having died, she was a burden and couldnt see a way forward but wanted to g0 home t0 die. As with previous occasions Natalie gradually calmed down: The psychiatrist recorded that Natalie's informal status should be reassessed if she further became agitated and wanted to leave the facility: A short while later Natalie became agitated again asking t0 eave and stating she didn't want to anymore: On this occasion she accepted medication and her observations were increased. She appeared settled throughout the night and the following morning: Shortly after 15.00 on 21st of April 2015 Natalie was heard to be shouting and screaming in the ward corridor: She could not get into her room and was punching and kicking the door: After being let into her room by a nurse Natalie continued to be agitated. It was established that she wanted t0 speak to social services to arrange contact with her daughter: She eventually calmed down after the nurse spent some 20 minutes talking to her; Natalie's had telephoned the facility around this time as she was concerned for Natalie following a communication from her the previous evening: She was told that Natalie was The telephone contact was not recorded The nurse returned to her office leaving Natalie In her room and some 10 to 15 minutes later saw an OT support worker letting Natalie off the ward: It was another 5 t0 8 minutes before the nuree went to make enquiries with the OT support worker as she was on the telephone with the relatives of another patient The OT support worker was not aware that an informal patient had to be signed out by a nurse. It had become common practice for OT support workers t0 let informal patients off the ward to smoke in contravention of Trust policy: As a result of insufficlent and inaccurately recorded risk assessments and inadequate nursing and MDT handovers none Of the staff working on 21 April 2015 save the deputy ward manager were aware that Natalie was a medium risk of self-harm which became high if she left the ward, nor were they aware that her informal status should have been reassessed in the circumstances under which she left the hospital: Once it had been established that it was Natalia who left the facility a local search was conducted by two members of staff but that Natalie was missing was not reported to the police for some 30 t0 40 minutes: When the police were contacted by the deputy ward manager he did not adequately convey relevant infomation about Natalie or her risk of self-har andthe call takers from Kent Police did not seek to elicit relevant infomation which would have assisted in the classification of the call and the police response.
Action Should Be Taken
In my opinion action should be taken t0 prevent future deaths and believe your organisation has the power to take such action.
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