Coventry and Warwickshire Partnership NHS Trust
NHS / Health Body
Action Taken
The Trust has implemented environmental safety improvements, revised language and interpreting procedures, implemented a tear-resistant clothing policy, improved staffing, and strengthened multi-disciplinary team working. (AI summary)
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Dear Sir
I am writing to you in response to the Regulation 28: Prevention of Future Death (PFD) report, which followed the inquest for Mr Henok Zaid Gebrsslasie.
In support of improving the care that we deliver for our patients, the PFD report will likely help us with the challenges we have been working through, including supporting access to funding to complete environmental works.
As you have set out in your report the inquest focussed, in part, on ligature anchor points within inpatient bedroom settings and on our expediency in fitting ‘door top’ alarms to bedroom doors within our male Psychiatric Intensive Care Unit setting.
I am aware that a significant amount of detail was shared with the court, as part of the inquest, and some of this related to our plans to improve the safety of the environment at the Caludon Centre, with a particular focus on using supportive e-technology.
Staff attending the inquest had outlined the challenges of completing work to extensively re- model the Caludon Centre Wards in a building not owned by the Trust. At the time of the death of Mr Gebrsslasie, the Caludon Centre was occupied by the Trust pursuant to a Private Finance Initiative contract with the Coventry and Rugby Hospital Company Plc (“Project Co”) under which Project Co sub-contracted the design and construction of the Caludon Centre to Skanska and the maintenance of the facility to Vinci.
In 2019 the Trust commissioned a series of reports assessing compliance of the Cauldon Centre. These reports identified a number of areas where the design and construction of the centre did not meet the requirements of current guidance.
This process also resulted in a series of test rooms being designed and constructed to identify appropriate solutions to address the areas of improvement required.
Having completed this process, the Trust then sought to engage with Project Co and Vinci to agree the terms of a variation to the PFI contract to implement the solutions identified throughout the Caludon Centre. Unfortunately, the parties to the PFI contract were unable to agree the terms of a contract variation to enable these works to be completed.
Page: 2 of 4 Subsequently the Trust undertook further review of the compliance and maintenance services being provided by the PFI provider at the Caludon Centre and, on reaching the conclusion that these were insufficient instigated the process of terminating the PFI contract in consultation with the Department for Health and Social Care and NHS England. This process is necessarily complex and, in the case of the Caludon Centre required the Trust to engage in formal legal dispute proceedings to enable the Trust to take operational control of the Caludon Centre, a process which was completed in February 2023.
From that point in time the Trust has implemented an extensive programme of remedial works to address fire safety, ligature risk and other areas of incomplete maintenance works within the Caludon Centre. This process has enabled the Trust to improve the standard of the Caludon Centre to reflect changes made to the Trust’s wider estate which as a result of not having been subject to complex PFI arrangements had been completed previously.
In respect of the environmental building works at the Caludon Centre, as detailed above these commenced in February 2023 on termination of the PFI contract with works commenced across all areas of the building to address non-compliance issues with the most recent safety guidance, and this includes supportive e-technology.
The first ward that has been worked on is Westwood Ward, which has had to be emptied of patients in order that work can progress safely. The extensive programme of works being undertaken create a safer ward, including the fitting of new Kingsway doors which incorporate door top alarms. To do this work effectively we have had to strip the ward back to brick. In respect of the replacement doors, they have required us to break into re-enforced concrete in order that we can fit new door frames and run electrical current to them.
When complete, the patients from Sherbourne Ward will be moved to this new safe ward whilst similar works are carried out to Sherbourne Ward.
The works associated with Westwood Ward will be completed by the end of September 2025 and then be ready for Sherbourne patients to move into. We have reviewed our plans to ensure that this the earliest possible date that we can make this series of moves happen safely. Once works have been completed in respect of Westwood Ward, we will then move onto other wards.
The programme of works commenced by the Trust is being progressed in the most effective manner possible within the constraints of the Trust’s capital budget. Since February 2023, the Trust has completed works totalling in excess of £15m, with the total budget for works to be completed anticipated to exceed £40m.
By taking the action detailed above, the Trust has reduced the level of risk present within the building. The Trust has in place appropriate risk mitigation measures in order to manage risk during the on-going works process and minimise the impact on quality of care and continues to monitor these measures risk through the Trust Risk Register and the Board Assurance Framework.
Page: 3 of 4 In undertaking this continuing programme of works, the Trust recognises that new technology, such as door top alarms, will support the reduction in risk of harm to people, however following the death of Mr Gebrsslasie we had also undertaken other improvement activities aimed at minimising risk of harm, and these have included:
• Therapeutic engagement and observations practice
- Our practice has evolved and has been strengthened through a review of policy and training staff on improved practise standards. The change in approach has reduced the predictability of the observations, in line with national guidance and best practice.
- We are monitoring observation practice through routine audit and collate the results on a bespoke internal system (AMaT).
- Observations are discussed daily in safety huddles daily and enhanced observations reviewed daily in line with policy and ensuring least restrictive practices.
- Through our patients experience survey, people report feeling safe on the ward.
• Environment – ligatures
- Windows on all the Acute Mental Health Ward at Caludon centre have been replaced.
- Bedroom door head infill strips (across the top of each door) have been replaced.
- The trust uses the published ligature harm minimisation guidance that was co- produced by the Care Quality Commission and NHS providers in November 2023. The Trust was part of the working group to create the guidance and were part of a group of Trusts identified to pilot the new templates and provided feedback (Sherbourne Ward was part of the pilot).
• Person centred care planning
- We have co-produced guidance ‘Writing a good care plan’ to support staff working with patients.
- Audit standards for care plans and risk assessments now in place and actively being monitored through auditing software (AMaT) the Trust has purchased.
- We were one of ten mental health NHS Trusts to lead work nationally, on co-producing personalised approaches to safety planning in Inpatient Services supported through a ‘culture of care’ programme and best practise guidance produced by NHS England. This demonstrates our ability and willingness to learn continuously improve by working with similar services nationally.
• Therapeutic engagement and ward based care
- Activity Workers are present on the wards and there is an activity timetable in place for patients.
- We have introduced ‘Safewards’ on Sherbourne, which is a framework that targets ‘‘mutual expectations’, ‘bad news mitigation’, ‘positive words’, ‘patient community’ ‘getting to know each other’ and ‘calming down’ methods.
- Other work has focussed on reducing restrictive interventions (seclusion, restraint and rapid tranquilisation) across services. This has been proactively supported by staff on mental health wards and observed by our regulator, the Care Quality Commission in their inspection of services in 2023.
Page: 4 of 4
• Language and Translation
- The Language and Interpreting procedures were reviewed and revised.
- We changed our contract, to a new provider for interpretation and translation services in 2024. Feedback on use of the service is positive and is experienced as responsive by users.
• Tear Resistant Clothing
- A Standard Operating Procedure: Tear Resistant Clothing is in place, with its development and implementation supported by briefings to staff.
• Staffing
- We have worked with Sherbourne Ward to improve supervision and appraisal compliance and training attendance,
- We report our safer staffing data to our public trust board meeting in line with statutory requirements. The ward is adequately staffed for patients’ needs.
- The Mental Health Directorate has a daily system for checking and addressing staffing safety across all wards and taking corrective action.
• Multi-Disciplinary Team (MDT) working
- Sherbourne ward has a substantive Consultant Psychiatrist.
- There is a dedicated weekly MDT meeting.
- The MDT group consists of Medical Team, Nursing Team, Occupational Therapist, Discharge Co-ordinator and Clinical Pharmacist. There is access to a Psychologist.
The safety improvements we have put in place have supported improved safety, and we have not had a similar set of circumstances occur since the events of August 2021.
I trust that this letter sets out a response to the matters that you have raised in your Prevention of Future Death report. I would of course be happy to assist you with any additional questions in respect of this matter.
I am writing to you in response to the Regulation 28: Prevention of Future Death (PFD) report, which followed the inquest for Mr Henok Zaid Gebrsslasie.
In support of improving the care that we deliver for our patients, the PFD report will likely help us with the challenges we have been working through, including supporting access to funding to complete environmental works.
As you have set out in your report the inquest focussed, in part, on ligature anchor points within inpatient bedroom settings and on our expediency in fitting ‘door top’ alarms to bedroom doors within our male Psychiatric Intensive Care Unit setting.
I am aware that a significant amount of detail was shared with the court, as part of the inquest, and some of this related to our plans to improve the safety of the environment at the Caludon Centre, with a particular focus on using supportive e-technology.
Staff attending the inquest had outlined the challenges of completing work to extensively re- model the Caludon Centre Wards in a building not owned by the Trust. At the time of the death of Mr Gebrsslasie, the Caludon Centre was occupied by the Trust pursuant to a Private Finance Initiative contract with the Coventry and Rugby Hospital Company Plc (“Project Co”) under which Project Co sub-contracted the design and construction of the Caludon Centre to Skanska and the maintenance of the facility to Vinci.
In 2019 the Trust commissioned a series of reports assessing compliance of the Cauldon Centre. These reports identified a number of areas where the design and construction of the centre did not meet the requirements of current guidance.
This process also resulted in a series of test rooms being designed and constructed to identify appropriate solutions to address the areas of improvement required.
Having completed this process, the Trust then sought to engage with Project Co and Vinci to agree the terms of a variation to the PFI contract to implement the solutions identified throughout the Caludon Centre. Unfortunately, the parties to the PFI contract were unable to agree the terms of a contract variation to enable these works to be completed.
Page: 2 of 4 Subsequently the Trust undertook further review of the compliance and maintenance services being provided by the PFI provider at the Caludon Centre and, on reaching the conclusion that these were insufficient instigated the process of terminating the PFI contract in consultation with the Department for Health and Social Care and NHS England. This process is necessarily complex and, in the case of the Caludon Centre required the Trust to engage in formal legal dispute proceedings to enable the Trust to take operational control of the Caludon Centre, a process which was completed in February 2023.
From that point in time the Trust has implemented an extensive programme of remedial works to address fire safety, ligature risk and other areas of incomplete maintenance works within the Caludon Centre. This process has enabled the Trust to improve the standard of the Caludon Centre to reflect changes made to the Trust’s wider estate which as a result of not having been subject to complex PFI arrangements had been completed previously.
In respect of the environmental building works at the Caludon Centre, as detailed above these commenced in February 2023 on termination of the PFI contract with works commenced across all areas of the building to address non-compliance issues with the most recent safety guidance, and this includes supportive e-technology.
The first ward that has been worked on is Westwood Ward, which has had to be emptied of patients in order that work can progress safely. The extensive programme of works being undertaken create a safer ward, including the fitting of new Kingsway doors which incorporate door top alarms. To do this work effectively we have had to strip the ward back to brick. In respect of the replacement doors, they have required us to break into re-enforced concrete in order that we can fit new door frames and run electrical current to them.
When complete, the patients from Sherbourne Ward will be moved to this new safe ward whilst similar works are carried out to Sherbourne Ward.
The works associated with Westwood Ward will be completed by the end of September 2025 and then be ready for Sherbourne patients to move into. We have reviewed our plans to ensure that this the earliest possible date that we can make this series of moves happen safely. Once works have been completed in respect of Westwood Ward, we will then move onto other wards.
The programme of works commenced by the Trust is being progressed in the most effective manner possible within the constraints of the Trust’s capital budget. Since February 2023, the Trust has completed works totalling in excess of £15m, with the total budget for works to be completed anticipated to exceed £40m.
By taking the action detailed above, the Trust has reduced the level of risk present within the building. The Trust has in place appropriate risk mitigation measures in order to manage risk during the on-going works process and minimise the impact on quality of care and continues to monitor these measures risk through the Trust Risk Register and the Board Assurance Framework.
Page: 3 of 4 In undertaking this continuing programme of works, the Trust recognises that new technology, such as door top alarms, will support the reduction in risk of harm to people, however following the death of Mr Gebrsslasie we had also undertaken other improvement activities aimed at minimising risk of harm, and these have included:
• Therapeutic engagement and observations practice
- Our practice has evolved and has been strengthened through a review of policy and training staff on improved practise standards. The change in approach has reduced the predictability of the observations, in line with national guidance and best practice.
- We are monitoring observation practice through routine audit and collate the results on a bespoke internal system (AMaT).
- Observations are discussed daily in safety huddles daily and enhanced observations reviewed daily in line with policy and ensuring least restrictive practices.
- Through our patients experience survey, people report feeling safe on the ward.
• Environment – ligatures
- Windows on all the Acute Mental Health Ward at Caludon centre have been replaced.
- Bedroom door head infill strips (across the top of each door) have been replaced.
- The trust uses the published ligature harm minimisation guidance that was co- produced by the Care Quality Commission and NHS providers in November 2023. The Trust was part of the working group to create the guidance and were part of a group of Trusts identified to pilot the new templates and provided feedback (Sherbourne Ward was part of the pilot).
• Person centred care planning
- We have co-produced guidance ‘Writing a good care plan’ to support staff working with patients.
- Audit standards for care plans and risk assessments now in place and actively being monitored through auditing software (AMaT) the Trust has purchased.
- We were one of ten mental health NHS Trusts to lead work nationally, on co-producing personalised approaches to safety planning in Inpatient Services supported through a ‘culture of care’ programme and best practise guidance produced by NHS England. This demonstrates our ability and willingness to learn continuously improve by working with similar services nationally.
• Therapeutic engagement and ward based care
- Activity Workers are present on the wards and there is an activity timetable in place for patients.
- We have introduced ‘Safewards’ on Sherbourne, which is a framework that targets ‘‘mutual expectations’, ‘bad news mitigation’, ‘positive words’, ‘patient community’ ‘getting to know each other’ and ‘calming down’ methods.
- Other work has focussed on reducing restrictive interventions (seclusion, restraint and rapid tranquilisation) across services. This has been proactively supported by staff on mental health wards and observed by our regulator, the Care Quality Commission in their inspection of services in 2023.
Page: 4 of 4
• Language and Translation
- The Language and Interpreting procedures were reviewed and revised.
- We changed our contract, to a new provider for interpretation and translation services in 2024. Feedback on use of the service is positive and is experienced as responsive by users.
• Tear Resistant Clothing
- A Standard Operating Procedure: Tear Resistant Clothing is in place, with its development and implementation supported by briefings to staff.
• Staffing
- We have worked with Sherbourne Ward to improve supervision and appraisal compliance and training attendance,
- We report our safer staffing data to our public trust board meeting in line with statutory requirements. The ward is adequately staffed for patients’ needs.
- The Mental Health Directorate has a daily system for checking and addressing staffing safety across all wards and taking corrective action.
• Multi-Disciplinary Team (MDT) working
- Sherbourne ward has a substantive Consultant Psychiatrist.
- There is a dedicated weekly MDT meeting.
- The MDT group consists of Medical Team, Nursing Team, Occupational Therapist, Discharge Co-ordinator and Clinical Pharmacist. There is access to a Psychologist.
The safety improvements we have put in place have supported improved safety, and we have not had a similar set of circumstances occur since the events of August 2021.
I trust that this letter sets out a response to the matters that you have raised in your Prevention of Future Death report. I would of course be happy to assist you with any additional questions in respect of this matter.