Stephanie Daniels
PFD Report
All Responded
Ref: 2013-0353
All 3 responses received
· Deadline: 7 Feb 2014
Coroner's Concerns (AI summary)
Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.
View full coroner's concerns
the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. _ _ Internal NHS SUL Investigation_ v Independent Investigation am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires prompt; thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken: This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin) In this case there were significant errors and omissions in the SUI investigation: Important witnesses were not interviewed. The in finding the deceased a bed was not a central issue and no specific findings were made about it: The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as They During delay other steps in compliance with the Trusts Rapid Tranquilisation Policy: It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented_ Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that significant failures in the investigative process have occurred: The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March: This is not the first time that the Trust SUI investigations have been found wanting and have experience of other Trusts' investigations also significantly flawed: In conclusion in this sort of case am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved; flawed SUI investigation reports may continue to be produced: This is a policy decision for the NHS but strongly urge consideration of this_
2. Handover AIl the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but have a concern that simple issues may be overlooked: For new patients being admitted or transferred; there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policiesprotocols but experience has shown that what may be delivered on paper is not done in practice. Consequently am concerned that without appropriate audit and clinicalnursing leadership this may prove to be ineffective.
3. Bed Availability MHSC say that following the death of the deceased, a new policy has been introduced s0 that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As understood the evidence from the CCG in the case this should have occurred in any event However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that are not having the appropriate nursing and clinical input; as well as medication review_ In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be: am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health trusts_ Clerking _In The failure to properly clerk in the patient is a matter of serious concern,_especially as many such patients will have physical [1 very being being they health problems MHSC had clear policies requiring the clerking in of a patient; but these were simply not adhered to_ It is common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment; It seems that despite the existence of appropriate policies, in practice these were not complied with_ Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. repeat what have said earlier. MHSC have produced new or updated policieslprotocols but experience has shown that what be delivered on paper is not being done in practice. Consequently , am concerned that without appropriate audit and clinicalnursing leadership this may prove to be ineffective_ Supervision of_Junior Medical Staff am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff: Two junior doctors were asked t0 attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication It is appreciated that they are with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen: They did not notice that the patient had not been clerked in: Medication was being prescribed without adequate consideration of the relevant clinical did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved:
6. Prescribing of Medication bY_Junior Medical Staff am concerned by the circumstances in this case where medication came to be prescribed: There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here: Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. simply prescribed the medication. had no recollection of reviewing the deceased's records but understood that was essential when considering prescribing any medication, and in particular PRN tranquilisation: In this case , the patient was already taking a number of drugs which had sedative effects Two further medications were introduced that have similar properties and that also could potentially affect heart function very being may busy history. They They They rapid
Mechanism by which the Consultant in charge of the patient would learn of thepatient's admission It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken: It would seem that there could be a number of simple solutions for this problem.
8. Pertorming and recording observations on other patients was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during course of the inquest and was brought to the attention of MHSC so that could carry out their own investigations_
2. Handover AIl the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but have a concern that simple issues may be overlooked: For new patients being admitted or transferred; there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policiesprotocols but experience has shown that what may be delivered on paper is not done in practice. Consequently am concerned that without appropriate audit and clinicalnursing leadership this may prove to be ineffective.
3. Bed Availability MHSC say that following the death of the deceased, a new policy has been introduced s0 that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As understood the evidence from the CCG in the case this should have occurred in any event However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that are not having the appropriate nursing and clinical input; as well as medication review_ In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be: am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health trusts_ Clerking _In The failure to properly clerk in the patient is a matter of serious concern,_especially as many such patients will have physical [1 very being being they health problems MHSC had clear policies requiring the clerking in of a patient; but these were simply not adhered to_ It is common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment; It seems that despite the existence of appropriate policies, in practice these were not complied with_ Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. repeat what have said earlier. MHSC have produced new or updated policieslprotocols but experience has shown that what be delivered on paper is not being done in practice. Consequently , am concerned that without appropriate audit and clinicalnursing leadership this may prove to be ineffective_ Supervision of_Junior Medical Staff am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff: Two junior doctors were asked t0 attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication It is appreciated that they are with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen: They did not notice that the patient had not been clerked in: Medication was being prescribed without adequate consideration of the relevant clinical did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust involved:
6. Prescribing of Medication bY_Junior Medical Staff am concerned by the circumstances in this case where medication came to be prescribed: There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here: Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. simply prescribed the medication. had no recollection of reviewing the deceased's records but understood that was essential when considering prescribing any medication, and in particular PRN tranquilisation: In this case , the patient was already taking a number of drugs which had sedative effects Two further medications were introduced that have similar properties and that also could potentially affect heart function very being may busy history. They They They rapid
Mechanism by which the Consultant in charge of the patient would learn of thepatient's admission It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken: It would seem that there could be a number of simple solutions for this problem.
8. Pertorming and recording observations on other patients was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during course of the inquest and was brought to the attention of MHSC so that could carry out their own investigations_
Responses
Action Planned
Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning from this case. Matrons will carry out weekly checks on compliance with the quality of documentation on handover forms. The Head of Nursing is writing to all Ward Managers to instruct nursing staff to read recent admission records and risk information and compliance with this system will be monitored through audit. (AI summary)
Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning from this case. Matrons will carry out weekly checks on compliance with the quality of documentation on handover forms. The Head of Nursing is writing to all Ward Managers to instruct nursing staff to read recent admission records and risk information and compliance with this system will be monitored through audit. (AI summary)
View full response
Dear Mr Meadows Re: Stephanie Daniels (deceased) Inquest hearing concluded 29 November 2013. Regulation 28: Report to Prevent Future Deaths Thank you for your Regulation 28 Report following the Inquest Hearing at Manchester Crown Court into the death of Stephanie Daniels_ have provided a response to your concerns, as detailed in your report of 13 December 2013, as follows Serious Untoward Incident / Serious Incident Requiring Investigation (SIRI) Following the concerns raised in your report about the Serious Untoward Incident the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases_ The Trust will also develop further guidance for investigators regarding the learning from this case_ As part of the review, the Trust will look at identifying resource to carry out such independent investigations: Received FES 24
2 Handover process As you are aware, the Trust has a handover of care policy, which sets out the arrangements for the handover of care, and the documentation of information handed over: The Matrons will carry out weekly checks on compliance with the quality of the documentation on the handover forms. To address your concern that issues may be overlooked, the Head of Nursing is writing to all Ward Managers to instruct all registered nursing staff that they must read the recent admission records and risk information relating to all patients who are not known to them or have not been known during the current period of admission. Ward Managers will be required to ensure their registered nursing staffhave received and understood the instruction, which will be monitored through management supervision 3_ Bed availability understand that you have raised this concern in your Regulation 28 Report as a national issue. However, as you are aware, followingh evidence at the inquest, this Trust implemented change to how inpatient beds are accessed in January 2013 and we do not have a waiting list of service users requiring admission: Clerking In The Trust acknowledges the importance of clerking in service users upon admission. In order to strengthen our processes the admission checklist requires the nurse to sign that have contacted the doctor to clerk in a new service user, and an additional sign-off once the doctor has clerked the service user in; It also incorporates the action to inform the consultant by email of hospital admissions_ This will be monitored through audits_ 5_ Supervision of junior doctors appreciate you have also sent your Regulation 28 Report to the Deanery at Manchester University. From a Trust perspective, all trainees graded CT1-3 and StR 4-6 have weekly supervision: Trainees and Consultants have been reminded of the importance of this and a discussion has taken place with the Deanery: This will be additionally monitored through the annual handover and supervision survey data completed by junior medical staff. 6_ Prescribing of medication by junior doctors Interim Medical Director, will ensure that all trainees will be informed about the Rapid Tranquillisation protocol through the induction process_ In addition, consultants will be made aware of their responsibilities in respect of supervision of junior doctors prescribing_ The Trust has amended the prescription card to ensure that Rapid Tranquillisation is clearly identifiable and not confused with PRN (as necessary) medication. The Trust incident reporting system is being adapted to record whether Rapid Tranquillisation was administered intramuscularly or orally and whether physical safe observations were maintained in line with Trust policy This is be monitored through induction attendance records, pharmacy daily monitoring of prescriptions and Datix incident reporting: 7 Mechanism by which the Consultant in charge of the patient would learn of the patient's admission As referred to under point four; the admission checklist system incorporates contacting of consultants by the nursing staff: The compliance with this system will be monitored through audit they
8 Performing and recording of observations on other patients share your concern about incomplete observation forms and the Head of Nursing has instructed staff that observation record forms must be completed contemporaneously and without any gaps: In addition, the nurse in charge must review the observations records during and at the end of the shift and ensure any gaps are addressed and reported through the Datix incident reporting system: The Matrons will monitor the recording of observations and the Trust will audit the compliance with the Safe and Supportive Observation policy: have attached the action plan detailing the timetable for actions to be undertaken in line with the requirements of the Regulation 28 Report. hope this response provides you with assurance that the Trust has taken action in response to your Regulation 28 Report.
2 Handover process As you are aware, the Trust has a handover of care policy, which sets out the arrangements for the handover of care, and the documentation of information handed over: The Matrons will carry out weekly checks on compliance with the quality of the documentation on the handover forms. To address your concern that issues may be overlooked, the Head of Nursing is writing to all Ward Managers to instruct all registered nursing staff that they must read the recent admission records and risk information relating to all patients who are not known to them or have not been known during the current period of admission. Ward Managers will be required to ensure their registered nursing staffhave received and understood the instruction, which will be monitored through management supervision 3_ Bed availability understand that you have raised this concern in your Regulation 28 Report as a national issue. However, as you are aware, followingh evidence at the inquest, this Trust implemented change to how inpatient beds are accessed in January 2013 and we do not have a waiting list of service users requiring admission: Clerking In The Trust acknowledges the importance of clerking in service users upon admission. In order to strengthen our processes the admission checklist requires the nurse to sign that have contacted the doctor to clerk in a new service user, and an additional sign-off once the doctor has clerked the service user in; It also incorporates the action to inform the consultant by email of hospital admissions_ This will be monitored through audits_ 5_ Supervision of junior doctors appreciate you have also sent your Regulation 28 Report to the Deanery at Manchester University. From a Trust perspective, all trainees graded CT1-3 and StR 4-6 have weekly supervision: Trainees and Consultants have been reminded of the importance of this and a discussion has taken place with the Deanery: This will be additionally monitored through the annual handover and supervision survey data completed by junior medical staff. 6_ Prescribing of medication by junior doctors Interim Medical Director, will ensure that all trainees will be informed about the Rapid Tranquillisation protocol through the induction process_ In addition, consultants will be made aware of their responsibilities in respect of supervision of junior doctors prescribing_ The Trust has amended the prescription card to ensure that Rapid Tranquillisation is clearly identifiable and not confused with PRN (as necessary) medication. The Trust incident reporting system is being adapted to record whether Rapid Tranquillisation was administered intramuscularly or orally and whether physical safe observations were maintained in line with Trust policy This is be monitored through induction attendance records, pharmacy daily monitoring of prescriptions and Datix incident reporting: 7 Mechanism by which the Consultant in charge of the patient would learn of the patient's admission As referred to under point four; the admission checklist system incorporates contacting of consultants by the nursing staff: The compliance with this system will be monitored through audit they
8 Performing and recording of observations on other patients share your concern about incomplete observation forms and the Head of Nursing has instructed staff that observation record forms must be completed contemporaneously and without any gaps: In addition, the nurse in charge must review the observations records during and at the end of the shift and ensure any gaps are addressed and reported through the Datix incident reporting system: The Matrons will monitor the recording of observations and the Trust will audit the compliance with the Safe and Supportive Observation policy: have attached the action plan detailing the timetable for actions to be undertaken in line with the requirements of the Regulation 28 Report. hope this response provides you with assurance that the Trust has taken action in response to your Regulation 28 Report.
Action Taken
The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has been developed and implemented. The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly. (AI summary)
The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has been developed and implemented. The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly. (AI summary)
View full response
Dear Mr Meadows
Re: Regulation 28; Prevention of Future Deaths Report (Stephanie Daniels - deceased)
Thank you for your report under Regulation 28, Prevention of Future Deaths following the inquest into the death of Ms Stephanie Daniels. As requested this is the response from the Citywide Commissioning, Quality and Safeguarding Team on behalf of the CCG.
I respond to two concerns raised by your report; number 1 regarding the Serious Untoward Incident investigation and number 3 with regards to bed availability. I deal with them separately below. I am unable to respond specifically in relation to the other issues you raise but have noted your comments.
By way of an introductory comment I provided a detailed statement to you during the inquest into Ms Daniel's death about the manner in which the CCG commissions inpatient beds and the steps it has taken to ensure that there is sufficient mental health inpatient capacity within the Manchester area and the steps it has taken to monitor inpatient capacity (amongst other things) within the Manchester Mental Health and Social Care Trust ("the Trust"). I also provided comments in my statement about the CCG's input into the Serious Untoward Incident investigation carried out into the death of Ms Daniels and I will therefore confine my response to your first concern to a more general explanation of the CCG's overview of untoward incidents occurring within NHS Trusts from which it commissions services.
Concern No 1 - Internal NHS Serious Untoward Incident Investigation
A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.
Lessons learnt from the Serious Untoward Incident investigations carried out by the Trust are shared at this meeting and are cascaded to the three CCG’s within the City via their Quality Leads who also attend. Lessons identified from Serious Untoward Incidents that occur in other NHS Providers are also shared at this Committee with Manchester Mental Health and Social Care Trust.
The City Wide Commissioning, Quality and Safeguarding Team are represented at all High Level Investigation Panels (HLIP) held by the Trust. The HLIP’s were established by the Trust in order to allow scrutiny of their investigations and reports. Prior to the HLIP the Trust provides the City Wide Commissioning, Quality and Safeguarding Team with a draft copy of their investigation report. This allows the City Wide Commissioning, Quality and Safeguarding Team representative to review the report and challenge its robustness, contents and findings. Following the HLIP the Trust develops an action plan and the City Wide Commissioning, Quality and Safeguarding Team representative reviews this to ensure that the actions identified are Specific, Measurable, Achievable, Realistic and Time based (SMART) to reduce the likelihood of a recurrence of the incident.
Challenges into the investigation report and its findings regularly take place at HLIP’s and should concerns regarding the investigation and its robustness be identified further higher level actions would be taken via Executive to Executive discussions.
The Trust's response to the Prevention of Future Deaths Report in this case will be scrutinised by the CCG and assurances will be sought from the Trust in relation to any actions it proposes to take to ensure that they are appropriate and robust and that they are implemented.
Concern No 2 - Bed Availability The commissioning of beds is based on evidence of past need and emerging needs from commissioning intelligence. The CCG does not directly instruct Manchester Mental Health and Social Care Trust, or any other NHS Trust about how its beds should be utilised and although it monitors the Trust's bed utilisation decisions on patient management are solely the responsibility of the Trust as the provider of NHS care.
Commissioners can, by negotiation, influence a Trust's use of resources and can shift resources around the system but decisions about admitting and discharging patients rest with the provider NHS Trust.
As a result of the CCG's concerns relating to out of area placements the following process has been set up and has been operational since August 2013: There are daily bed management conference calls between the CCG and representatives of the Trust to review admissions, discharges, patients waiting for assessment (who may then need a bed) and out of area placements There is a weekly teleconference where delayed discharges are discussed with Manchester City Council. Representatives of the CCG and the Trust attend this conference call.
There are weekly mental health inpatient capacity meetings with representatives from the Trust. Additional capacity has been purchased in neighbouring NHS facilities and via the charitable sector.
The number of out of area placements utilised by the Trust is significant and the CCG monitors usage on a daily and weekly basis (as above) to ensure that patients are either allocated a bed quickly or are repatriated as quickly as possible when a bed is available within the Trust.
An escalation protocol was agreed with the Trust in the financial year of 2011/12 which enabled the Trust to utilise private sector beds when it did not have the capacity to accommodate a patient in need of an inpatient bed. This protocol was reviewed following the inquest into the death of patient FK and has been reviewed again in July 2013 to ensure it remains robust. The CCG is confident that the protocol is appropriate and robust.
An inpatient capacity management plan has been developed and implemented by the CCG. The overall aims of this plan are: To address the financial pressure within the Manchester health economy resulting from out-of-area placements To improve patient experience To maintain bed flows most effectively and efficiently To promote an effective and joint working approach across the stakeholder organisations
The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly as part of quality and performance monitoring processes that are in place within the Citywide Commissioning, Quality and Safeguarding Team.
Conclusion To summarise: the City Wide Commissioning, Quality and Safeguarding Team on behalf of the CCG’s has robust monitoring processes in place to monitor action taken by the Trust in response to this incident and other serious incidents requiring investigation reported by the Trust. Assurance is sought with regards to progress on a monthly basis.
The Team also monitors bed availability on a daily and weekly basis to ensure that patients are not waiting unnecessarily for a bed or that they are not placed out of area for extended periods of time (which can impact on patient experience and also NHS budgets).
Re: Regulation 28; Prevention of Future Deaths Report (Stephanie Daniels - deceased)
Thank you for your report under Regulation 28, Prevention of Future Deaths following the inquest into the death of Ms Stephanie Daniels. As requested this is the response from the Citywide Commissioning, Quality and Safeguarding Team on behalf of the CCG.
I respond to two concerns raised by your report; number 1 regarding the Serious Untoward Incident investigation and number 3 with regards to bed availability. I deal with them separately below. I am unable to respond specifically in relation to the other issues you raise but have noted your comments.
By way of an introductory comment I provided a detailed statement to you during the inquest into Ms Daniel's death about the manner in which the CCG commissions inpatient beds and the steps it has taken to ensure that there is sufficient mental health inpatient capacity within the Manchester area and the steps it has taken to monitor inpatient capacity (amongst other things) within the Manchester Mental Health and Social Care Trust ("the Trust"). I also provided comments in my statement about the CCG's input into the Serious Untoward Incident investigation carried out into the death of Ms Daniels and I will therefore confine my response to your first concern to a more general explanation of the CCG's overview of untoward incidents occurring within NHS Trusts from which it commissions services.
Concern No 1 - Internal NHS Serious Untoward Incident Investigation
A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.
Lessons learnt from the Serious Untoward Incident investigations carried out by the Trust are shared at this meeting and are cascaded to the three CCG’s within the City via their Quality Leads who also attend. Lessons identified from Serious Untoward Incidents that occur in other NHS Providers are also shared at this Committee with Manchester Mental Health and Social Care Trust.
The City Wide Commissioning, Quality and Safeguarding Team are represented at all High Level Investigation Panels (HLIP) held by the Trust. The HLIP’s were established by the Trust in order to allow scrutiny of their investigations and reports. Prior to the HLIP the Trust provides the City Wide Commissioning, Quality and Safeguarding Team with a draft copy of their investigation report. This allows the City Wide Commissioning, Quality and Safeguarding Team representative to review the report and challenge its robustness, contents and findings. Following the HLIP the Trust develops an action plan and the City Wide Commissioning, Quality and Safeguarding Team representative reviews this to ensure that the actions identified are Specific, Measurable, Achievable, Realistic and Time based (SMART) to reduce the likelihood of a recurrence of the incident.
Challenges into the investigation report and its findings regularly take place at HLIP’s and should concerns regarding the investigation and its robustness be identified further higher level actions would be taken via Executive to Executive discussions.
The Trust's response to the Prevention of Future Deaths Report in this case will be scrutinised by the CCG and assurances will be sought from the Trust in relation to any actions it proposes to take to ensure that they are appropriate and robust and that they are implemented.
Concern No 2 - Bed Availability The commissioning of beds is based on evidence of past need and emerging needs from commissioning intelligence. The CCG does not directly instruct Manchester Mental Health and Social Care Trust, or any other NHS Trust about how its beds should be utilised and although it monitors the Trust's bed utilisation decisions on patient management are solely the responsibility of the Trust as the provider of NHS care.
Commissioners can, by negotiation, influence a Trust's use of resources and can shift resources around the system but decisions about admitting and discharging patients rest with the provider NHS Trust.
As a result of the CCG's concerns relating to out of area placements the following process has been set up and has been operational since August 2013: There are daily bed management conference calls between the CCG and representatives of the Trust to review admissions, discharges, patients waiting for assessment (who may then need a bed) and out of area placements There is a weekly teleconference where delayed discharges are discussed with Manchester City Council. Representatives of the CCG and the Trust attend this conference call.
There are weekly mental health inpatient capacity meetings with representatives from the Trust. Additional capacity has been purchased in neighbouring NHS facilities and via the charitable sector.
The number of out of area placements utilised by the Trust is significant and the CCG monitors usage on a daily and weekly basis (as above) to ensure that patients are either allocated a bed quickly or are repatriated as quickly as possible when a bed is available within the Trust.
An escalation protocol was agreed with the Trust in the financial year of 2011/12 which enabled the Trust to utilise private sector beds when it did not have the capacity to accommodate a patient in need of an inpatient bed. This protocol was reviewed following the inquest into the death of patient FK and has been reviewed again in July 2013 to ensure it remains robust. The CCG is confident that the protocol is appropriate and robust.
An inpatient capacity management plan has been developed and implemented by the CCG. The overall aims of this plan are: To address the financial pressure within the Manchester health economy resulting from out-of-area placements To improve patient experience To maintain bed flows most effectively and efficiently To promote an effective and joint working approach across the stakeholder organisations
The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly as part of quality and performance monitoring processes that are in place within the Citywide Commissioning, Quality and Safeguarding Team.
Conclusion To summarise: the City Wide Commissioning, Quality and Safeguarding Team on behalf of the CCG’s has robust monitoring processes in place to monitor action taken by the Trust in response to this incident and other serious incidents requiring investigation reported by the Trust. Assurance is sought with regards to progress on a monthly basis.
The Team also monitors bed availability on a daily and weekly basis to ensure that patients are not waiting unnecessarily for a bed or that they are not placed out of area for extended periods of time (which can impact on patient experience and also NHS budgets).
Noted
The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the National Trust Development Authority (NTDA) which is in contact with MHSC Trust and has received an action plan. (AI summary)
The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the National Trust Development Authority (NTDA) which is in contact with MHSC Trust and has received an action plan. (AI summary)
View full response
From the Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London POC1829620 SWIA 2NS Tel: 020 7210 3000 Nigel Meadows Mb-sofs@dhgsi-govuk Senior Coroner Manchester (City) District The Coroners Court Crown Square Manchester 1 3 FER 2014 M6o [PR Je L_ MuAe+ Thank you for_ letter about the inquest into the death of Stephanie Daniels. Your report gives a comprehensive account of the circumstances surrounding Ms Daniel's death by suicide and highlighted a number of policy and procedural issues for the Manchester Health and Social Care Trust (MHSC) to address, including supervision ofjunior staff; handover and the performing and recording of observations on patients at risk of suicide: [ expect all healthcare professionals working in local Trusts to be fully trained and aware of the existing protocols in their local Trust. It is for local healthcare organisations to ensure that all staff are trained to the appropriate standard. As many of the concerns you raise are issues to be dealt with at Trust level, I have ensured that your concerns have been sent to the National Trust Development Authority (NTDA) which provides support, oversight and governance for all NHS Trusts. The NTDA is in contact with MHSC Trust and has received an action plan which seeks to address the points you have raised. Your report stated that there should be no waiting time for the allocation of a bed in the case ofa patient who is clinically deemed to need one. As the evidence given by the Clinical Commissioning Group in this case stated, this should already be the case. We are clear that acute beds must always be available for people who need them_ your"
The total number of designated mental health beds in England is around 22,000. This includes many different types of mental health bed: from high secure beds in special hospitals to psychiatric intensive care, open rehabilitation beds and recovery houses_ Providers also have a responsibility to listen to patients and offer care in the community as well as in hospitals when appropriate. The right mix of these beds, and of services that can be delivered in out-patient and non-residential community settings or in people's homes will vary by area and population In-patient beds are not always the best place for people with an acute mental health problem. There is a general move in mental health services to provide safe; evidence-based alternatives to in-patient beds in the form of intensive community treatment teams. This has led to reductions in admissions; and, most importantly, enabled patients to be treated closer to home where most want to be. Ido that this response is helpful and I am grateful to you for bringing this issue to my attention: Yv ,nw JEREMY HUNT hope
The total number of designated mental health beds in England is around 22,000. This includes many different types of mental health bed: from high secure beds in special hospitals to psychiatric intensive care, open rehabilitation beds and recovery houses_ Providers also have a responsibility to listen to patients and offer care in the community as well as in hospitals when appropriate. The right mix of these beds, and of services that can be delivered in out-patient and non-residential community settings or in people's homes will vary by area and population In-patient beds are not always the best place for people with an acute mental health problem. There is a general move in mental health services to provide safe; evidence-based alternatives to in-patient beds in the form of intensive community treatment teams. This has led to reductions in admissions; and, most importantly, enabled patients to be treated closer to home where most want to be. Ido that this response is helpful and I am grateful to you for bringing this issue to my attention: Yv ,nw JEREMY HUNT hope
Sent To
- Care Quality Commission
- Department of Health and Social Care
- Greater Manchester Mental Health NHS Foundation Trust
- NHS England
- NHS Manchester Clinical Commissioning Group
- Manchester Mental Health and Social Care Trust
Response Status
Linked responses
3 of 8
56-Day Deadline
7 Feb 2014
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 26 March 2012 commenced an investigation into the death of STEPHANIE DANIELS, aged 32. The investigation concluded at the end of an 19 day jury inquest on 29 November 2013. The cause of death was found to be: Ja Asphyxia due t0 combination of ligature strangulation and obstruction of the airway The conclusion of the inquest was that: The deceased killed herself whilst the balance of her mind was disturbed by suffering from schizophrenia and auditory hallucinations and that her death was contributed to by neglect The jury answered some additional specific questions as follows: Upon the deceased's admission to the Safire unit on 221 March 2012,_what level of observations should she have been subject t0
according to the policy in force at the time and her behaviour; history and presentation? Continuous within eye sight Should she have remained upon that level of observations throughout her stay on the unit until the disclosure about the surrender of the ligature and the lighter on the morning of _ March 20122 Yes Was the deceased admitted to Safire were before or after the handover from the late to night shift took place on 22nd March 20122 We were unable to determine this Was & noose surrendered by the deceased on March 2012 but not recorded by the mental health staff in Amigos records? No Had the deceased actually been subject to any 'discreet 1:1' continuous within sight observations from the time she surrendered the ligature and the lighter on the morning of_ March 2012 to the start of the late shift at about 13.30hrs? No Was the nurse in charge of the early shift present and did they participate in the handover of the deceased'S care to the late shift at about 13.30hrs on 24h March 2013? Present: Yes Participated: No Was the nurse in charge of the late shift present and did they participate in the handover of the deceased"s care to the late shift at about 13.30hrs on March 2013? Present: The nurse in charge arrived late to the handover: Participated: No What information was verbally handed over from the early shift to the late shift from about 13.30 hrs on 24h March 2012? Chaotic Came in via CRHT On general observations, risk of self harm, scars on arms Ligature handed in to staff
according to the policy in force at the time and her behaviour; history and presentation? Continuous within eye sight Should she have remained upon that level of observations throughout her stay on the unit until the disclosure about the surrender of the ligature and the lighter on the morning of _ March 20122 Yes Was the deceased admitted to Safire were before or after the handover from the late to night shift took place on 22nd March 20122 We were unable to determine this Was & noose surrendered by the deceased on March 2012 but not recorded by the mental health staff in Amigos records? No Had the deceased actually been subject to any 'discreet 1:1' continuous within sight observations from the time she surrendered the ligature and the lighter on the morning of_ March 2012 to the start of the late shift at about 13.30hrs? No Was the nurse in charge of the early shift present and did they participate in the handover of the deceased'S care to the late shift at about 13.30hrs on 24h March 2013? Present: Yes Participated: No Was the nurse in charge of the late shift present and did they participate in the handover of the deceased"s care to the late shift at about 13.30hrs on March 2013? Present: The nurse in charge arrived late to the handover: Participated: No What information was verbally handed over from the early shift to the late shift from about 13.30 hrs on 24h March 2012? Chaotic Came in via CRHT On general observations, risk of self harm, scars on arms Ligature handed in to staff
Circumstances of the Death
1. Stephanie Daniels ("the deceased") was born on 16 April 1979 and was 32 years of age when she died on 24 March 2012. This was only some 4 months after had conducted a lengthy and detailed Article 2 inquest into the self inflicted death of a detained patient who had absconded from a different unit but run by MHSC_ had written a comprehensive Rule 43 report letter (Re: Feisal King; deceased) and a number of similar themes and issues that emerged in that case were repeated in this oneNamely: 24th 23d 24h 24th communication, record keeping; handover; clinical leadership, the physical clerking in process and bed availability: In addition, had identitied significant failings in the Serious Untoward Incident Panel Investigation Report ("SUI report") into that death_
2. The deceased had a troubled and unsettled childhood and was placed with foster parents and whilst there was abused: At the age of 13 she took her first overdose and was seen by a child Psychiatrist and was in contact with mental health services for some time Not long after this she first reported hearing "voices" in her head. She had a baby when aged 16 and with whom by 2012 she enjoyed supervised contact about once a fortnight: Unfortunately, apart from her mental health problems she also abused illicit drugs, particularly heroin and cocaine. She suffered physical health problems primarily of a respiratory nature and had recurrent chest infections. She was also obese.
3. In 2001 she came into contact with the criminal justice system and was remanded into custody at HMP Styal. She repeatedly self harmed and is reported to have made one serious attempt to kill herself: She used various items as ligatures: Her first contact with MHSC was in September 2003 and she had contact with mental health services from then right up until her death: Stephanie was diagnosed with suffering mental disorder when she was in her early twenties_
4. From 2004 she spent long periods in hospital either as a voluntary patient or compulsorily detained under the Mental Health Act 1983,as amended ("MHA") . She also had a significant history of numerous attempts at suicide and self harm. She had a diagnoses of schizophrenia, and an emotionally unstable personality disorder plus substance dependence. In addition she was being treated by the Community Drugs Team and was prescribed methadone. She had been treated with a wide range of medication including anti-psychotics, mood stabilizers and anti-depressants_
5. The pattern of her illness was that between hospital admissions she seemed to function with a reasonable quality of life for periods of time. However, these episodes were relatively short The nature of her illness was one of a relapsing and remitting condition: Most of these relapses appeared to occur without any obvious precipitant: When unwell she presented with auditory hallucinations telling her that she was a bad person and that she should kill herself. These voices made her teel distressed and agitated: She was often acutely suicidal and regularly attempted self harm by overdosing or cutting herself: Whilst an inpatient she would often require one to one nursing to try to prevent self harm and her self harm attempts had included the use of a ligature. Sadly, she had a history of using forms of ligature whilst on the ward and also in her 24 hour a supported community accommodation_ 6_ Her most recent admission to hospital was between 29 July and 5 December 2011 and she was formally detained under the MHA_ Her_poor physical health was exacerbated by_recreational drug_use_ from day and a chaotic life style. She had been assessed as suifering from drug resistant schizophrenia and therefore treated with Clozapine, which is only licensed for that use. Treatment with such drug requires regular blood tests and monitoring of heart function. it was noted that she was developing abnormal heart rhythms and this medication had to be stopped. During her various admissions a number of different anti-psychotic drugs were tried but she was eventually discharged on a drug known as Quetiapine, plus a number f other medications including mood stabilisers, anti-depressants and substance misuse treatment opiates. 7 . Following her discharge from hospital she was regularly reviewed by her CPN and she was moved to different accommodation at a place called Clifton House on 9 January 2012 because of the increased level of supervision she required: This provided 24 hour residential care for adults with significant mental health problems. She was also seen by her Psychiatrist at outpatient clinic appointments: Initially she was positive about the future but by the end of January 2012 the CPN began to notice signs of deterioration in her mental state At the beginning of February 2012 she began to self harm again: On 20 February she disclosed that she was having increasing suicidal thoughts. She was taken to A&E and reviewed but seen the following day by her CPN when she reported low mood, intrusive thoughts and voices asking her to kill herself and her 15 year old daughter in a suicide pact by jumping from bridge. Due to these increased risks she was referred to the CRHT. She was seen and reviewed once again by her Psychiatrist who increased her medication: This resulted in some improvement in her condition and she now felt able to resist the voices, especially with the help of the staff at Clifton House and she consequently did not want a hospital admission.
9. However; on 6 March 2012 a member of staff at Clifton House reported that she had attempted to strangle herself by ligature and she was taken to the Manchester Royal Infirmary for assessment; following which she was discharged back to Clifton House with levels of supervision increased. The deceased was anxious to avoid a hospital admission and thought she could cope with the help afforded by the extra supervision: Despite this on 12 March 2012 she rang the CRHT from a bridge saying that she intended to jump_ alerted the Police who were able to intervene and take her back to Clifton House where yet again offered to provide additional support:
10. Her Psychiatrist reviewed her again on 14 March and she presented as agitated and depressed with escalating suicidal ideas. This resulted in a CRHT team meeting at which it was agreed that she now presented simply too high a risk to manage in the community and she required an urgent inpatient admission_ Unfortunately; no inpatient bed was available to her, although she was given the highest priority for a bed when one became available. In the meantime another medication, namely Sodium Valproate_was introduced and her risks were reviewed and using They they managed_ Her medication also included a drug called MXL slow release. This is an opiate drug t replace Methadone: Her AMIGOS electronic medical records ("AMIGOS") had repeatedly noted that she was at risk of postural hypoxia and a number of her medications would have sedative side effects
11. On the 22 March she phoned the CRHT from Clifton House telling them she was barricading herself in her room and attempting to hang herself. in tum alerted the staff at Clifton House who ensured her safety and a bed was found at the Safire Short Stay Assessment unit ("Safire") based at Park House Psychiatric Unit located in the grounds of North Manchester General Hospital but run by MHSC. There was a of 8 days in securing her admission which should not have occurred as MHSC should have found her a bed, private or NHS, in any event: This assurance was given after the Feisal King inquest Rule 43 letter and what the CCG understood to be the position. She agreed to the admission and to receive treatment and so compulsory detention under the MHA was regarded as unnecessary: She arrived at about 21,00 hours and was commenced on what is known as general observations on that ward which was every 30 minutes, but the records suggest only from 21.30 hours at the earliest.
12. The relevant MHSC observation policy then in force defined general observations as once every hour: A greater frequency than that (for example in 30 or in 15) was defined as intermittent observations and there was a requirement to complete particular form of written record. The next level of observation was defined as continuous within sight at all times and the highest level was continuous within arm's length at all times. Safire ward had been operating a general observation policy of in 30 and the records kept of that were not in accordance with the MHSC policy then in force. The policy also defined the sort of behaviour or presentation that would justify each level of observation:
13. The nurse in charge of the shift maintained that the deceased had been admitted t0 the ward before he arrived and took the hand over and was therefore a patient already on the ward and had been assessed by his colleagues_ The documentary evidence did not support this contention but the jury were unable to determine whether she was admitted before or after the handover_
14. instructed two independent court appointed expert witnesses (a Professor of Mental Health Nursing and a Consultant Forensic Psychiatrist) to give evidence about the standard of her mental health nursing care and her psychiatric management: both agreed that the deceased presented as a very difficult patient to deal with and that it would have been a challenge for any mental health team: The only criticism made of her pre-admission care was the delay in finding her a bed when she plainly was ill and in need of admission:
15. Safire usually catered for up to 8 patients but could accommodate 10 and their usual complement of staff was 2 registered mental health nurses ""RMN" and 2 support workers They delay being They they very
("SW"). At weekends and evenings the RMNs would have additional responsibilities of answering a crisis line and also trying to secure beds for urgent patients. These duties took up a lot of time. The shift pattern involved an early shift starting at 07.15, then a late shift starting at 13.30 and finally a night shift starting at 20.45 There would be a hand over from one shift to another and someone from the incoming shift would make written record of what they considered the main highlights: There was no requirement for any of the patients records to be read and considered, even for new or recent admissions
16. Some time after 21.30 hours on 22 March 2012 the on call junior doctor attended the ward and prescribed the deceased her regular medications. There was no record made in AMIGOS of why he was called; by whom or when or if he had actually read any of the deceased's records. Nor was there any record of him seeing the deceased When giving evidence he accepted he should have done so and the absence of any record supported that fact that he did not: He did not clerk the patient in and did not notice that she had not been clerked in order to pass on the responsibility to a colleague_ The MHSC protocol was that a patient must be clerked in (which involves taking a history, reviewing the records, assessing and prescribing appropriate medication, completing a physical assessment and a treatmentlmanagement risk plan) within 6 hours and in any event within 24 hours:
17. The nurse in charge of the night shift on 22 March 2012 recollected having had some contact with the deceased during & previous admission on a different ward. He had a few brief interactions with her but began to complete nursing records at about 00.50 on 23 March 2012 _ He told the court that he did read the last 24 hours' records and considered at the time the level of observations (1 in 30) as appropriate: It seems that overnight there were no incidents or developments of note save that it was recorded by him at 01.20 hours that the deceased would not cooperate with something called a risk follow up assessment:
18. The following morning she was assessed and it seems that she continued to have thoughts of self harm/suicide. She received what is known as PRN (as and when required) medication and this seemed to help. This had actually been recorded in error in the medication chart as the injectable form of Haloperidol whereas it was the oral form. When giving evidence the Nurse who made the error admitted it, This had been prescribed by another junior Doctor who had attended the ward. There was no record made in AMIGOS of why he was called, by whom or when or if he had actually read any of the deceased's records Nor was there any record of him seeing the deceased There was no review of her observation regime which remained the same: When giving evidence he said that his usual practice was to read the recent records, but he accepted that had he done s0 he should have noted that he deceased had not been clerked in and he would have reviewed her observations status and management plan: He also accepted that had he properly checked the records he would have noted the_risk of_postural hypoxia and the_ recent cardiac the history. This would be bound to be a consideration of two further medications which can have sedative and cardiac side effects.
19. The Consultant under whose name the deceased had been admitted never knew that the deceased had been actually admitted as a patient and therefore had not taken any steps t0 check or review the deceased's condition_ No steps were taken to inform him by any staff member on Safire ward.
20. The nurse in charge of the late shift on 23 March 2012 recorded a part of the handover information given to him that the deceased had surrendered a ligature that morning: The jury actually found that no ligature had been surrendered: However, it did not occur to him that in the light of this the observations should have been reviewed by the previous shift as well by himself_ When giving evidence he agreed that he should have done so. On the handover to the night shift he related the history of a noose being handed in and this was recorded, but once again it did not occur to the nurse in charge of the new shift to enquire about the deceased's observations being reviewed nor do so herself. She made a similar concession when giving evidence_
21. On the morning of 24 March; a Support Worker on the unit spoke to the deceased, who disclosed that she had hidden a ligature in her and that she had a lighter and she planned to burn her room down, and she had a male voice in her head telling her to kill herself: She was persuaded to surrender both but said I'IIjust make another if you take it away" . This was brought to the attention of the nurse in charge of the shift straight away and she supervised a "risk follow up entry" being recorded in AMIGOS
22. PRN medication was administered and the nurse in charge advised. Once again oral Haloperidol was given but not recorded at all: The nurse admitted the error when giving evidence. The ligature (which could also be used as a weapon) and the lighter which were surrendered by the deceased were then apparently left in the office_ The deceased returned to the office several times t0 ask for a cigarette thereafter but no consideration was given to searching the deceased or her room_ Her level of observations remained the same: The SW said that the nurse in charge said that should commence what was described as "discreet to 1 continuous within sight observations" _ No clinical record was made of this and no ongoing observation records were kept This would not have been in accordance with the MHSC observation policy. The SW was not asked for a statement by the SUI investigation panel although he made a significant clinical risk follow up entry:
23. The nurse in charge never mentioned this in any statement she made after the incident and nor when she was interviewed by the Chair of the SUI investigation. However, when giving evidence she accepted that she had not seen a copy of the statement the SW had made to the Police and the first time she knew what he was going to say was when he got into the witness box. She gave evidence immediately thereafter and agreed that the substance of what the SW said was correct but thejury did not tind this_ bra they very happened as a fact
24. There was a significant difference in recollection between the nurses in charge of the early and late shifts concerning the information handed over between the shifts on the 24 March: She maintained that the fact the deceased was on "Discreet continuous observations" was handed over and that would need to be reviewed: The late shift staff and in particular the nurse in charge denied this. The jury tound that the "Discreet continuous observations" had not been handed over although they did find that the surrender of a ligature had been mentioned This itself should have prompted a review and according to the MHSC observation policy at least continuous within sight observations should have been commenced, 25_ It is recorded that the deceased was seen at 16.00 as part of the general observations check but one of the staff thinks she may have spoken to the deceased at about 16.15 in the garden: At any rate at about 16.30 she could not be found in the main areas of the unit when the next general observations were due and she was then [ocated in a locked toilet and shower room with a ligature tied around her neck and apparently unconscious_ The alarm was raised and assistance summoned,
26. Unfortunately, a number of issues then arose. There was a large degree of panic and confusion: A specific ligature cutting tool which was meant to be on the ward could not be found; the ligature could then not be cut until some scissors were found; an oxygen cylinder had a missing part and could not be used; staff believed that the suction machine could not be plugged in because it did not reach the nearest socket; what is known as the "crash team" (the emergency cardiac arrest team) were not contacted: Basic life support measures were initiated once the ligature had been cut and a 999 call was made. Records have established that this was actually made at 16.40 hours and 50 seconds and the call lasted for some 3 minutes and 40 seconds. A further call was made at 16.48 which lasted for 42 seconds. The NWAS (Northwest Ambulance Service) personnel arrived at 16.50 and took over care of the patient and carried on CPR: The NWAS defibrillator was used and this showed that the deceased had no shockable rhythm 27 . They left at 17.03 and she was conveyed to the A&E department in the main part of the hospital site a short distance away, arriving at 17.06 and handing over to triage at 17.10. Efforts continued to resuscitate the deceased but these proved unsuccessful and she was pronounced dead at 17.25 hours: authorised a Forensic Post Mortem examination during which it was discovered that the deceased had been wearing a partial upper denture and this had been found lodged in her windpipe. obtained evidence from experts in both ambulance service care and emergency medical treatment who said that actions of both the NWAS and the treating emergency Doctors could not be criticised, nor would it have been apparent that she had an obstruction in the airway: Furthermore, whilst there were failings in the_immediate emergency response when she was found these they the would not have been contributory to or causative of death_
28. Following the death the Police carried out an investigation and examined the deceased's room. did not discover any other ligatures nor any torn sheeting: It could not be established from where or when the ligature that the deceased actually used came from but it had the appearance of being from NHS hospital sheeting were provided with copies of the relevant medical and hand over records. The original hand over records could not be produced by MHSC at the hearing and had either been mislaid or lost: However, the court had good quality photocopies to work from_
29. No one could explain where the surrendered ligature had gone and there remained the possibility that the deceased could have recovered that ligature and used it or may have had another one, but no search or her room or her person was made_
30. MHSC initiated quickly after the incident a Serious Untoward Incident Panel Investigation Report ("SUI report") which was chaired by the Trust's Chief Nurse and had four ther members_ These included a senior Consultant Psychiatrist; his Specialist Registrar plus two other senior health professionals. They had access to all the records and obtained statements from a number of the staff involved and spoke to several of them The SUI report was completed by the end of June 2012. The Chair of the panel gave evidence and accepted that there were significant failures and omissions in the report produced: For example, they had not obtained a statement from the Nurse in charge of the night shift on 22 March; nor a statement from the Nurse in charge of the late shift on 23 March who records the handing in that morning of a ligature; nor a statement from the SW on duty on the early shift who the deceased surrendered the ligature and lighter to and made a significant risk follow up nor had found out why there was delay in the deceased getting a bed: failed to note or record the medication recording errors, despite the fact that if an injection of Haloperidol was administered as the records suggest, then the Trust's Rapid Tranquilisation Policy should have been followed, That required the deceased to have close observations for up to 2 hours post administration but there was no record of that done: 31 _ The Police, as part of my investigation did obtain a statement from the SW on the early shift: It revealed that his recollection was that some form of "discreet" to continuous within eyesight observations was initiated by the nurse in charge, on the basis that she said that the deceased had a history of reacting adversely to increased observations When challenged to substantiate this in giving evidence she could only say that is what she understood from her other nursing colleague but he did not give the same account when he gave evidence_
32. The SUI report concluded that from admission a greater level of observations than in 30 but less than continuous within sight was the appropriate level up to the morning of 24 March. Both expert witnesses were firmly of the view that continuous within sight They They very entry; they They being should have been the observation regime from the time of admission: Importantly, that the deceased's death was both predictable and preventable. The SUI panel did agree that the deceased had not been clerked in at all despite some six shifts of staff being involved_ Nor did she have any psychiatric input; concluded that from the morning of 24 March continuous within arms length observations would have been appropriate although both expert witnesses said the risks could have been managed with the lesser within eyesight status
33. Finally, during the course of the inquest it became apparent that another patient who was seriously unwell had her observations increased t0 the intermittent in 15 level from the late afternoon of the 22 March level and the records suggested that this was done whilst of Safire ward. She was then moved to another ward and her observation levels remained the same for several days but there were gaps in the observation records: Her observation levels were increased to continuous within sight but again there were gaps in the records where nothing was recorded. This raises the possibility that important observations were not being done or certainly not recorded: Whether this is an isolated issue or represents something more systemic would be for MHSC to investigate_
2. The deceased had a troubled and unsettled childhood and was placed with foster parents and whilst there was abused: At the age of 13 she took her first overdose and was seen by a child Psychiatrist and was in contact with mental health services for some time Not long after this she first reported hearing "voices" in her head. She had a baby when aged 16 and with whom by 2012 she enjoyed supervised contact about once a fortnight: Unfortunately, apart from her mental health problems she also abused illicit drugs, particularly heroin and cocaine. She suffered physical health problems primarily of a respiratory nature and had recurrent chest infections. She was also obese.
3. In 2001 she came into contact with the criminal justice system and was remanded into custody at HMP Styal. She repeatedly self harmed and is reported to have made one serious attempt to kill herself: She used various items as ligatures: Her first contact with MHSC was in September 2003 and she had contact with mental health services from then right up until her death: Stephanie was diagnosed with suffering mental disorder when she was in her early twenties_
4. From 2004 she spent long periods in hospital either as a voluntary patient or compulsorily detained under the Mental Health Act 1983,as amended ("MHA") . She also had a significant history of numerous attempts at suicide and self harm. She had a diagnoses of schizophrenia, and an emotionally unstable personality disorder plus substance dependence. In addition she was being treated by the Community Drugs Team and was prescribed methadone. She had been treated with a wide range of medication including anti-psychotics, mood stabilizers and anti-depressants_
5. The pattern of her illness was that between hospital admissions she seemed to function with a reasonable quality of life for periods of time. However, these episodes were relatively short The nature of her illness was one of a relapsing and remitting condition: Most of these relapses appeared to occur without any obvious precipitant: When unwell she presented with auditory hallucinations telling her that she was a bad person and that she should kill herself. These voices made her teel distressed and agitated: She was often acutely suicidal and regularly attempted self harm by overdosing or cutting herself: Whilst an inpatient she would often require one to one nursing to try to prevent self harm and her self harm attempts had included the use of a ligature. Sadly, she had a history of using forms of ligature whilst on the ward and also in her 24 hour a supported community accommodation_ 6_ Her most recent admission to hospital was between 29 July and 5 December 2011 and she was formally detained under the MHA_ Her_poor physical health was exacerbated by_recreational drug_use_ from day and a chaotic life style. She had been assessed as suifering from drug resistant schizophrenia and therefore treated with Clozapine, which is only licensed for that use. Treatment with such drug requires regular blood tests and monitoring of heart function. it was noted that she was developing abnormal heart rhythms and this medication had to be stopped. During her various admissions a number of different anti-psychotic drugs were tried but she was eventually discharged on a drug known as Quetiapine, plus a number f other medications including mood stabilisers, anti-depressants and substance misuse treatment opiates. 7 . Following her discharge from hospital she was regularly reviewed by her CPN and she was moved to different accommodation at a place called Clifton House on 9 January 2012 because of the increased level of supervision she required: This provided 24 hour residential care for adults with significant mental health problems. She was also seen by her Psychiatrist at outpatient clinic appointments: Initially she was positive about the future but by the end of January 2012 the CPN began to notice signs of deterioration in her mental state At the beginning of February 2012 she began to self harm again: On 20 February she disclosed that she was having increasing suicidal thoughts. She was taken to A&E and reviewed but seen the following day by her CPN when she reported low mood, intrusive thoughts and voices asking her to kill herself and her 15 year old daughter in a suicide pact by jumping from bridge. Due to these increased risks she was referred to the CRHT. She was seen and reviewed once again by her Psychiatrist who increased her medication: This resulted in some improvement in her condition and she now felt able to resist the voices, especially with the help of the staff at Clifton House and she consequently did not want a hospital admission.
9. However; on 6 March 2012 a member of staff at Clifton House reported that she had attempted to strangle herself by ligature and she was taken to the Manchester Royal Infirmary for assessment; following which she was discharged back to Clifton House with levels of supervision increased. The deceased was anxious to avoid a hospital admission and thought she could cope with the help afforded by the extra supervision: Despite this on 12 March 2012 she rang the CRHT from a bridge saying that she intended to jump_ alerted the Police who were able to intervene and take her back to Clifton House where yet again offered to provide additional support:
10. Her Psychiatrist reviewed her again on 14 March and she presented as agitated and depressed with escalating suicidal ideas. This resulted in a CRHT team meeting at which it was agreed that she now presented simply too high a risk to manage in the community and she required an urgent inpatient admission_ Unfortunately; no inpatient bed was available to her, although she was given the highest priority for a bed when one became available. In the meantime another medication, namely Sodium Valproate_was introduced and her risks were reviewed and using They they managed_ Her medication also included a drug called MXL slow release. This is an opiate drug t replace Methadone: Her AMIGOS electronic medical records ("AMIGOS") had repeatedly noted that she was at risk of postural hypoxia and a number of her medications would have sedative side effects
11. On the 22 March she phoned the CRHT from Clifton House telling them she was barricading herself in her room and attempting to hang herself. in tum alerted the staff at Clifton House who ensured her safety and a bed was found at the Safire Short Stay Assessment unit ("Safire") based at Park House Psychiatric Unit located in the grounds of North Manchester General Hospital but run by MHSC. There was a of 8 days in securing her admission which should not have occurred as MHSC should have found her a bed, private or NHS, in any event: This assurance was given after the Feisal King inquest Rule 43 letter and what the CCG understood to be the position. She agreed to the admission and to receive treatment and so compulsory detention under the MHA was regarded as unnecessary: She arrived at about 21,00 hours and was commenced on what is known as general observations on that ward which was every 30 minutes, but the records suggest only from 21.30 hours at the earliest.
12. The relevant MHSC observation policy then in force defined general observations as once every hour: A greater frequency than that (for example in 30 or in 15) was defined as intermittent observations and there was a requirement to complete particular form of written record. The next level of observation was defined as continuous within sight at all times and the highest level was continuous within arm's length at all times. Safire ward had been operating a general observation policy of in 30 and the records kept of that were not in accordance with the MHSC policy then in force. The policy also defined the sort of behaviour or presentation that would justify each level of observation:
13. The nurse in charge of the shift maintained that the deceased had been admitted t0 the ward before he arrived and took the hand over and was therefore a patient already on the ward and had been assessed by his colleagues_ The documentary evidence did not support this contention but the jury were unable to determine whether she was admitted before or after the handover_
14. instructed two independent court appointed expert witnesses (a Professor of Mental Health Nursing and a Consultant Forensic Psychiatrist) to give evidence about the standard of her mental health nursing care and her psychiatric management: both agreed that the deceased presented as a very difficult patient to deal with and that it would have been a challenge for any mental health team: The only criticism made of her pre-admission care was the delay in finding her a bed when she plainly was ill and in need of admission:
15. Safire usually catered for up to 8 patients but could accommodate 10 and their usual complement of staff was 2 registered mental health nurses ""RMN" and 2 support workers They delay being They they very
("SW"). At weekends and evenings the RMNs would have additional responsibilities of answering a crisis line and also trying to secure beds for urgent patients. These duties took up a lot of time. The shift pattern involved an early shift starting at 07.15, then a late shift starting at 13.30 and finally a night shift starting at 20.45 There would be a hand over from one shift to another and someone from the incoming shift would make written record of what they considered the main highlights: There was no requirement for any of the patients records to be read and considered, even for new or recent admissions
16. Some time after 21.30 hours on 22 March 2012 the on call junior doctor attended the ward and prescribed the deceased her regular medications. There was no record made in AMIGOS of why he was called; by whom or when or if he had actually read any of the deceased's records. Nor was there any record of him seeing the deceased When giving evidence he accepted he should have done so and the absence of any record supported that fact that he did not: He did not clerk the patient in and did not notice that she had not been clerked in order to pass on the responsibility to a colleague_ The MHSC protocol was that a patient must be clerked in (which involves taking a history, reviewing the records, assessing and prescribing appropriate medication, completing a physical assessment and a treatmentlmanagement risk plan) within 6 hours and in any event within 24 hours:
17. The nurse in charge of the night shift on 22 March 2012 recollected having had some contact with the deceased during & previous admission on a different ward. He had a few brief interactions with her but began to complete nursing records at about 00.50 on 23 March 2012 _ He told the court that he did read the last 24 hours' records and considered at the time the level of observations (1 in 30) as appropriate: It seems that overnight there were no incidents or developments of note save that it was recorded by him at 01.20 hours that the deceased would not cooperate with something called a risk follow up assessment:
18. The following morning she was assessed and it seems that she continued to have thoughts of self harm/suicide. She received what is known as PRN (as and when required) medication and this seemed to help. This had actually been recorded in error in the medication chart as the injectable form of Haloperidol whereas it was the oral form. When giving evidence the Nurse who made the error admitted it, This had been prescribed by another junior Doctor who had attended the ward. There was no record made in AMIGOS of why he was called, by whom or when or if he had actually read any of the deceased's records Nor was there any record of him seeing the deceased There was no review of her observation regime which remained the same: When giving evidence he said that his usual practice was to read the recent records, but he accepted that had he done s0 he should have noted that he deceased had not been clerked in and he would have reviewed her observations status and management plan: He also accepted that had he properly checked the records he would have noted the_risk of_postural hypoxia and the_ recent cardiac the history. This would be bound to be a consideration of two further medications which can have sedative and cardiac side effects.
19. The Consultant under whose name the deceased had been admitted never knew that the deceased had been actually admitted as a patient and therefore had not taken any steps t0 check or review the deceased's condition_ No steps were taken to inform him by any staff member on Safire ward.
20. The nurse in charge of the late shift on 23 March 2012 recorded a part of the handover information given to him that the deceased had surrendered a ligature that morning: The jury actually found that no ligature had been surrendered: However, it did not occur to him that in the light of this the observations should have been reviewed by the previous shift as well by himself_ When giving evidence he agreed that he should have done so. On the handover to the night shift he related the history of a noose being handed in and this was recorded, but once again it did not occur to the nurse in charge of the new shift to enquire about the deceased's observations being reviewed nor do so herself. She made a similar concession when giving evidence_
21. On the morning of 24 March; a Support Worker on the unit spoke to the deceased, who disclosed that she had hidden a ligature in her and that she had a lighter and she planned to burn her room down, and she had a male voice in her head telling her to kill herself: She was persuaded to surrender both but said I'IIjust make another if you take it away" . This was brought to the attention of the nurse in charge of the shift straight away and she supervised a "risk follow up entry" being recorded in AMIGOS
22. PRN medication was administered and the nurse in charge advised. Once again oral Haloperidol was given but not recorded at all: The nurse admitted the error when giving evidence. The ligature (which could also be used as a weapon) and the lighter which were surrendered by the deceased were then apparently left in the office_ The deceased returned to the office several times t0 ask for a cigarette thereafter but no consideration was given to searching the deceased or her room_ Her level of observations remained the same: The SW said that the nurse in charge said that should commence what was described as "discreet to 1 continuous within sight observations" _ No clinical record was made of this and no ongoing observation records were kept This would not have been in accordance with the MHSC observation policy. The SW was not asked for a statement by the SUI investigation panel although he made a significant clinical risk follow up entry:
23. The nurse in charge never mentioned this in any statement she made after the incident and nor when she was interviewed by the Chair of the SUI investigation. However, when giving evidence she accepted that she had not seen a copy of the statement the SW had made to the Police and the first time she knew what he was going to say was when he got into the witness box. She gave evidence immediately thereafter and agreed that the substance of what the SW said was correct but thejury did not tind this_ bra they very happened as a fact
24. There was a significant difference in recollection between the nurses in charge of the early and late shifts concerning the information handed over between the shifts on the 24 March: She maintained that the fact the deceased was on "Discreet continuous observations" was handed over and that would need to be reviewed: The late shift staff and in particular the nurse in charge denied this. The jury tound that the "Discreet continuous observations" had not been handed over although they did find that the surrender of a ligature had been mentioned This itself should have prompted a review and according to the MHSC observation policy at least continuous within sight observations should have been commenced, 25_ It is recorded that the deceased was seen at 16.00 as part of the general observations check but one of the staff thinks she may have spoken to the deceased at about 16.15 in the garden: At any rate at about 16.30 she could not be found in the main areas of the unit when the next general observations were due and she was then [ocated in a locked toilet and shower room with a ligature tied around her neck and apparently unconscious_ The alarm was raised and assistance summoned,
26. Unfortunately, a number of issues then arose. There was a large degree of panic and confusion: A specific ligature cutting tool which was meant to be on the ward could not be found; the ligature could then not be cut until some scissors were found; an oxygen cylinder had a missing part and could not be used; staff believed that the suction machine could not be plugged in because it did not reach the nearest socket; what is known as the "crash team" (the emergency cardiac arrest team) were not contacted: Basic life support measures were initiated once the ligature had been cut and a 999 call was made. Records have established that this was actually made at 16.40 hours and 50 seconds and the call lasted for some 3 minutes and 40 seconds. A further call was made at 16.48 which lasted for 42 seconds. The NWAS (Northwest Ambulance Service) personnel arrived at 16.50 and took over care of the patient and carried on CPR: The NWAS defibrillator was used and this showed that the deceased had no shockable rhythm 27 . They left at 17.03 and she was conveyed to the A&E department in the main part of the hospital site a short distance away, arriving at 17.06 and handing over to triage at 17.10. Efforts continued to resuscitate the deceased but these proved unsuccessful and she was pronounced dead at 17.25 hours: authorised a Forensic Post Mortem examination during which it was discovered that the deceased had been wearing a partial upper denture and this had been found lodged in her windpipe. obtained evidence from experts in both ambulance service care and emergency medical treatment who said that actions of both the NWAS and the treating emergency Doctors could not be criticised, nor would it have been apparent that she had an obstruction in the airway: Furthermore, whilst there were failings in the_immediate emergency response when she was found these they the would not have been contributory to or causative of death_
28. Following the death the Police carried out an investigation and examined the deceased's room. did not discover any other ligatures nor any torn sheeting: It could not be established from where or when the ligature that the deceased actually used came from but it had the appearance of being from NHS hospital sheeting were provided with copies of the relevant medical and hand over records. The original hand over records could not be produced by MHSC at the hearing and had either been mislaid or lost: However, the court had good quality photocopies to work from_
29. No one could explain where the surrendered ligature had gone and there remained the possibility that the deceased could have recovered that ligature and used it or may have had another one, but no search or her room or her person was made_
30. MHSC initiated quickly after the incident a Serious Untoward Incident Panel Investigation Report ("SUI report") which was chaired by the Trust's Chief Nurse and had four ther members_ These included a senior Consultant Psychiatrist; his Specialist Registrar plus two other senior health professionals. They had access to all the records and obtained statements from a number of the staff involved and spoke to several of them The SUI report was completed by the end of June 2012. The Chair of the panel gave evidence and accepted that there were significant failures and omissions in the report produced: For example, they had not obtained a statement from the Nurse in charge of the night shift on 22 March; nor a statement from the Nurse in charge of the late shift on 23 March who records the handing in that morning of a ligature; nor a statement from the SW on duty on the early shift who the deceased surrendered the ligature and lighter to and made a significant risk follow up nor had found out why there was delay in the deceased getting a bed: failed to note or record the medication recording errors, despite the fact that if an injection of Haloperidol was administered as the records suggest, then the Trust's Rapid Tranquilisation Policy should have been followed, That required the deceased to have close observations for up to 2 hours post administration but there was no record of that done: 31 _ The Police, as part of my investigation did obtain a statement from the SW on the early shift: It revealed that his recollection was that some form of "discreet" to continuous within eyesight observations was initiated by the nurse in charge, on the basis that she said that the deceased had a history of reacting adversely to increased observations When challenged to substantiate this in giving evidence she could only say that is what she understood from her other nursing colleague but he did not give the same account when he gave evidence_
32. The SUI report concluded that from admission a greater level of observations than in 30 but less than continuous within sight was the appropriate level up to the morning of 24 March. Both expert witnesses were firmly of the view that continuous within sight They They very entry; they They being should have been the observation regime from the time of admission: Importantly, that the deceased's death was both predictable and preventable. The SUI panel did agree that the deceased had not been clerked in at all despite some six shifts of staff being involved_ Nor did she have any psychiatric input; concluded that from the morning of 24 March continuous within arms length observations would have been appropriate although both expert witnesses said the risks could have been managed with the lesser within eyesight status
33. Finally, during the course of the inquest it became apparent that another patient who was seriously unwell had her observations increased t0 the intermittent in 15 level from the late afternoon of the 22 March level and the records suggested that this was done whilst of Safire ward. She was then moved to another ward and her observation levels remained the same for several days but there were gaps in the observation records: Her observation levels were increased to continuous within sight but again there were gaps in the records where nothing was recorded. This raises the possibility that important observations were not being done or certainly not recorded: Whether this is an isolated issue or represents something more systemic would be for MHSC to investigate_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.
Inquest Conclusion
Upon the deceased's admission to the Safire unit on 221 March 2012,_what level of observations should she have been subject t0
according to the policy in force at the time and her behaviour; history and presentation? Continuous within eye sight Should she have remained upon that level of observations throughout her stay on the unit until the disclosure about the surrender of the ligature and the lighter on the morning of _ March 20122 Yes Was the deceased admitted to Safire were before or after the handover from the late to night shift took place on 22nd March 20122 We were unable to determine this Was & noose surrendered by the deceased on March 2012 but not recorded by the mental health staff in Amigos records? No Had the deceased actually been subject to any 'discreet 1:1' continuous within sight observations from the time she surrendered the ligature and the lighter on the morning of_ March 2012 to the start of the late shift at about 13.30hrs? No Was the nurse in charge of the early shift present and did they participate in the handover of the deceased'S care to the late shift at about 13.30hrs on 24h March 2013? Present: Yes Participated: No Was the nurse in charge of the late shift present and did they participate in the handover of the deceased"s care to the late shift at about 13.30hrs on March 2013? Present: The nurse in charge arrived late to the handover: Participated: No What information was verbally handed over from the early shift to the late shift from about 13.30 hrs on 24h March 2012? Chaotic Came in via CRHT On general observations, risk of self harm, scars on arms Ligature handed in to staff
according to the policy in force at the time and her behaviour; history and presentation? Continuous within eye sight Should she have remained upon that level of observations throughout her stay on the unit until the disclosure about the surrender of the ligature and the lighter on the morning of _ March 20122 Yes Was the deceased admitted to Safire were before or after the handover from the late to night shift took place on 22nd March 20122 We were unable to determine this Was & noose surrendered by the deceased on March 2012 but not recorded by the mental health staff in Amigos records? No Had the deceased actually been subject to any 'discreet 1:1' continuous within sight observations from the time she surrendered the ligature and the lighter on the morning of_ March 2012 to the start of the late shift at about 13.30hrs? No Was the nurse in charge of the early shift present and did they participate in the handover of the deceased'S care to the late shift at about 13.30hrs on 24h March 2013? Present: Yes Participated: No Was the nurse in charge of the late shift present and did they participate in the handover of the deceased"s care to the late shift at about 13.30hrs on March 2013? Present: The nurse in charge arrived late to the handover: Participated: No What information was verbally handed over from the early shift to the late shift from about 13.30 hrs on 24h March 2012? Chaotic Came in via CRHT On general observations, risk of self harm, scars on arms Ligature handed in to staff
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
London Fire Brigade to establish lessons learned process
Grenfell Tower Inquiry
No open learning culture
Ensure Home Office staff presence and visibility in IRCs
Brook House Inquiry
No open learning culture
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.