Dear Mr Winter Inquest into the death of Paige Bell Response to Regulation 28 Report to Prevent Future Deaths write in response to your Regulation 28 Report following your investigation into the death of Paige Louise Bell. As you are no doubt aware, the Trust takes all patient deaths very seriously and investigates them very thoroughly to establish if lessons can be learned or services improved. This case was no exception. The Trust carried out a detailed Serious Incident Review and addressed the recommendations which were identified. understand that you heard detailed evidence about those recommendations and the implementation of them at the inquest: am informed that the group nursing director at the relevant time, provided a statement and addressed these issues in some detail at the inquest have asked relevant staff to consider the issues identified again and respond as follows: Engagement and Observation Policy While the Trust must and does accept conclusion of the jury, believe it is important for me to express concern that our staff present throughout the proceedings were confused by the finding that there were contradictions and ambiguities in the Observation Policy: am informed that the primary issue of concern at the inquest related to the choice made by the relevant clinicians regarding the level of observation (which is of course a complex and challenging clinical issue for patients with Emotionally Unstable Personality Disorder) rather than the policy or its implementation_ As set out in evidence of Trust has already invested a significant amount of time and resource into developing the new Engagement and Observation Policy: This has included consultation amongst internal senior clinical staff; obtaining external expertise from national leading figures, looking carefully at the approach of other Trusts and considering available research into the usefulness of the NICE observation guidelines: Floor Jhdor Jja '3e 44ott City AR 235 the the the

The Trust have carefully considered the changes made to the policy and with expert input have decided to put greater emphasis on clinical assessments and engagement with patients rather than time based observations_ It is believed this will reduce risk t0 patients_ As you heard in some detail in the evidence the Engagement and Observation Policy clearly sets out the different categories of observation availabie and gives guidance as to when each of these categories should be considered: Having already invested significant time and both internal and external expertise in the revision of this policy, we do not feel that it is ambiguous. As explained at the inquest, all staff are aware of what each category requires of them: The policy sets out guidance as to when a particular level of observation should be used: However; this is no more than guidance and will need to be considered in conjunction with other factors: Ultimately, observation is a clinical decision and must be specific to the patient and the circumstances_ This is particularly important in the context of patients with Emotionally Unstable Personality Disorder as they are always at significant risk: If a risk based observation policy was applied without any flexibility, such patients would always be on "within eyesight" observations and would never leave hospital. That would have significant negative implications for their mental health and ability to integrate into society. The policy therefore takes this into account and acknowledges that if a higher level of observation is going to increase the risk to a patient; other options can be considered. Record Keeping In relation to the concerns about space on the new observation record, staff are aware that can write in the box below if necessary: The RiO number (on our electronic patient record system) is not required on the front sheet, as unlike the continuation sheets, the front sheet has the patients name and hospital number written on it which will enable the patient to be found on RiO. With regard to the concerns about the lack of completion of the observation record, staff acknowledged at inquest that this was not done on this occasion but were aware that it should have been. Staff are aware that all parts of the document shouid be completed and this should include a rationale as to why a level of observation is changed. As discussed in evidence, the importance of record keeping has been reiterated to staff, Furthermore, Iconfirmed that as the revised policy is rolled out across the Trust; staff will receive training on the policy which will include appropriate completion of the new observation record. In [elation ta ahservation records and incident report forms being completed electronically, as (explained, this is something which the Trust has considered and will continue to do S0 for observation records. As you will appreciate, introducing such an electronic system is complex. In relation to electronic incident reporting; can confirm the web based incident reporting project has commenced, with the first site reporting on April 2015,,a potential for Hopewood Park to report electronically in June 2015, and the full organisation reporting electronic incidents by October 2015. It is worthy to note that this project has been planned for a number of years, and pre-project planning commenced in 2014 This project was unrelated to this incident; but the Trust acknowledges the benefits that timely reporting and escalation of incidents brings to improve the quality and safety of care_ In respect to the stated over the presentation of written copies of RiO records explained that this is something which was identified in the Serious Incident Review. He explained that the RiO records are used by staff electronically, and a printed version does not properly reflect how would be seen or used by staff. In particular the date and time of a meeting or incident is recorded in addition to when the record was made: This allows the entries to be recorded chronologically in relation to the date and time of the meeting or incident: As you heard in evidence_ in a and demanding mental health ward 2 they the they July " they busy very

environment staff have to prioritise dealing with patients first and it would be impossible for every decision or action to be recorded immediately. Information can be and is shared in other ways such as through team meetings and handovers. am informed that staff in this case gave evidence that information was shared and was available to decision makers throughout the relevant timeline. As Imade clear_ we acknowledge that entries should be detailed and always made as soon as practically possible and we provide regular staff training to this effect hope that the information provided offers you the assurance that the Trust have invested significant time, effort and resource in investigating the issues have highlighted with a view to improving patient care and safety and reducing the risk of any adverse incidents or outcomes in the future. Paige Bells death was a tragedy and we will continue to strive to make improvements wherever possible to minimise the risk of further such tragic incidents.

Dear Mr Winter Thank you for your letter following the inquest into the death of Paige Bell: was very SOITY to hear of Ms Bell's death and wish to extend my sincere condolences to her family. Matters revealed at the inquest have led yOu to raise the following concerns: That case notes were not held in one place and not all transferred with the patient: You ask if there are plans to allow medical personnel to have immediate access to all notes electronically rather than notes following the patient; as they contain essential information for patient care and treatment The Trust concemed is due to implement & new Engagement and Observation Policy: You ask if there are plans for a National policy or template to ensure consistency between Trusts. You ask if there are plans to update guidance on the treatment and management of patients with Borderline Personality Disorder you are aware that National Institute for Health and Care Excellence (NICE) guidelines were published in 2009. The benefits of electronic patient records have long been known: Such electronic systems help healthcare staff to treat patients more effectively by giving quicker ad easier access to up-to-date inforation about medical treatment and history: The Summary Care Record (SCR) was introduced to improve the safety and quality of patient care: The SCR is an electronic record which gives healthcare staff access to essential information about patients, and ensures patients receive safe treatment during an emergency or when GP surgery is closed. An SCR contains information about prescription medications a patient is including allergies and reactions to medicines prescribed in the past: The information is derived from GP records. By August 2014, 40 million patients had a SCR and the number is constantly increasing: Only the healthcare staff directly involved in a patients care can see that patient'$ SCR. Information is obtained by use of a smartcard with a chip and pass code, similar to bank card and PIN. taking;

Healthcare staff only see the information need to do their job, and need to ask permission of the to read the SCR. If the patient' $ permission cannot be obtained because, for example; the patient is unconscious, staff are able to read the SCR without permission. However; if this happens, the system records the access and a note would have to be made on the SCR to show why the record has been accessed without permission from the patient: In addition, there are & number of versions of electronic patient record and health record systems being used in many hospitals across the UK . These systems are being used to provide accurate; up to-date, and complete information about patients at the of care. However; the choice and implementation of these systems is a matter for individual NHS Trusts. You ask if there is national policy 0 patient engagement and observation NHS England is planning to update its Suicide Prevention Audit Tool for Emergency Care, in light of leaming from suicides in acute care settings This stresses the importance of engagement with the patient; the recording of observations and timeliness of mental health assessment. Further guidelines for patient observation are contained in the Mental Health Act 1983 Code of Practice: This has recently been reviewed by the Department of Health and the revised edition came into effect on 1st April 2015. Within this code is a section which advises on enhanced observation for patients in hospital wards and services The Code of Practice provides a legal framework for the NHS. Individual NHS Trusts are expected to develop and implement their own patient observation policies that are appropriate to the needs of their patients and in line with this statutory guidance: Lastly, you refer to NICE publication on the treatment and management of patients with Borderline Personality Disorder. We assume you are referring to NICE guideline CG78, Borderline personality disorder: Treatment and management which was published in January
2009. NICE very recently reviewed this guidance. In January 2015 it concluded that the guideline did not need to be updated at present; and will next review the guideline in March 2017. NICE would be happy to answer any further questions you might have about this: that this response is helpful and am grateful to you for bringing the circumstances of Ms Bell 's death to my attention.