Surrey and Borders Partnership NHS
NHS / Health Body
Action Taken
The Trust opened Emerald Place to meet demand for inpatient beds, although admissions are currently paused for quality improvements. They have also requested that Children’s Services copy each invite into their central Safeguarding team to have a greater oversight of these invitations and responses/attendance. (AI summary)
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Dear Mr Travers
Locket Ure Williams (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”)
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 14 October 2024, in relation to the inquest touching upon the death of Locket Ure Williams. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues.
I have addressed each of your concerns in turn below.
1. Inpatient mental health beds for children in Surrey Typically, 6-8 General Adolescent Unit inpatient beds are required at any given time within Surrey. Emerald Place was opened by the Trust in partnership with a private provider, Elysium Healthcare, in March 2024. Emerald Place has sufficient bed capacity to meet the demand for GAU inpatient beds within Surrey.
In line with best practice for a new service, admissions have been staggered to allow the new team to develop and embed a safe and therapeutic culture on the ward. As part of our ongoing quality review process, a decision was made to pause further admissions. The Surrey Heartlands CAMHS Tier 4 Provider Collaborative is working at pace with NHS England, Elysium Healthcare and the Trust to support quality improvements at the unit with a current expectation that the unit can resume admissions from January 2025. In the meantime, the Trust is accessing GAU beds through independent providers.
5 December 2024
Private and Confidential
2. System alerts for risk relating to suicide
It is recognised that risk prediction in suicide has been shown repeatedly to be ineffective1. As recognised in your letter to us, the Trust has recently revised its risk assessment approach to align with NICE Guidelines2 and NHS England’s recommendations. This approach emphasises addressing patient needs rather than predicting future risk through the previously used ‘low/medium/high’ categorisation.
Risks are identified and mitigated through a comprehensive risk reduction plan, tailored to the individual, and incorporated into every risk assessment and formulation. The needs-based, patient- centred methodology provides a robust, evidence-based approach to managing risks which complies with national guidance. The suggested binary ‘suicidal/not suicidal’ flag system would force clinicians into an overly simplistic model of risk prediction inconsistent with the nuanced and individualised approach recommended by NICE and now implemented by the Trust. As a result, and having carefully considered this, we will not be introducing a binary flag system.
The Trust’s risk assessment process is designed on the basis that clinicians are acting in accordance with their professional and regulatory responsibilities. As per the NHS Constitution for England3, our staff have a duty to accept professional accountability and maintain the standards of professional practice as set by the appropriate regulatory body applicable to their profession or role. The Trust works in accordance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 20144 in deploying suitably qualified, competent, skilled and experienced persons and ensuring that they receive support, training, professional development, supervision and appraisal.
Through induction and training processes, all staff are aware that our Electronic Patient Record, SystmOne is the single source of all written information and that the risk formulation, care plan, and My Safety Plan must all be kept up to date and stored in specific locations of the patient record so that they are readily available. The MDT process enables clinicians to seek additional support, guidance or reflection where these are required to enable them to properly assess and manage risk.
All of the above are core activities and expectations for all of our clinicians. During clinical supervision, managers review sample cases with each clinician to support effective risk management and clinical reflection.
3. My Safety Plan
My Safety Plan is not a tool for assessing or recording risk of suicide. The document is not written in clinical terms, and it not intended to be a means of sharing information about risk between organisations. Instead, formal documentation of clinical risk (including clear and correct clinical terminology around suicide) is recorded in the Risk Formulation and Care Plan documents which, along with My Safety Plan, form an interlinked suite of documents which are held within a person’s Electronic Patient Record.
Clinical risk information is shared with the network around the child including their school and Children’s Services. Information sharing and safeguarding procedures ensure that relevant clinical information including around risk of suicide is shared with other organisations where appropriate regardless of whether a child or young person decides to share their My Safety Plan.
1 Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation and risk management, Hawton et al, The Lancet, published 8 August 2022 2 NICE Guidance NG225 Overview | Self-harm: assessment, management and preventing recurrence | Guidance | NICE 28056 3 The NHS Constitution for England - GOV.UK 4 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Designed in collaboration with Surrey County Council’s Consulting Youth Advisers team, My Safety Plan empowers a child or young person to communicate with the network around them about their concerns or triggers. A child or young person is encouraged to use their own choice of words within their My Safety Plan to express how they are feeling, enabling them take ownership of this document. The document is compiled in discussion between the clinician and the child or young person and their family/carer, primarily for the child or young person to hold, and to share with adults around them, if and when they choose. Equally, they may choose not to share it at all. We might share it on their behalf if we are given consent or are requested to do so.
It is also incumbent on other agencies around the child or young person to raise concerns of suicidality, for example, teachers and social workers must independently assess their level of concern and seek advice or link with Trust services if they feel this is necessary.
4. Core Group Meetings Attendance at Core Group meetings in respect of those supported by Children’s Services is mandatory. There is also an expectation that clinicians contribute to other safeguarding meetings, and local authority reviews of Education Health and Care Plans (“EHCP”). The Standard Operating Procedure (“SOP”) for our community teams requires that Care Plans include actions flowing from these meetings. Care Plans are recorded on SystmOne and accessible to any Trust clinician involved in the care of the child or young person.
This was discussed at the monthly divisional Quality Operations Board on 19 November 2024 attended by managers and senior clinicians where the importance of engagement with Core Group Meetings was emphasised. Managers were tasked with cascading this to their teams and confirmation that this has been actioned will be provided to the Quality Operations Board.
The Trust is only able to monitor responses to invitations that are received and we are reliant on those invites being sent to us in a timely manner to enable arrangements for attendance to be made. We have therefore requested that Children’s Services copy each invite into our central Safeguarding team in order to have a greater oversight of these invitations and our responses/attendance.
On behalf of the Trust, I would like to offer our sincere condolences to Locket’s family for their loss.
Locket Ure Williams (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”)
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 14 October 2024, in relation to the inquest touching upon the death of Locket Ure Williams. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues.
I have addressed each of your concerns in turn below.
1. Inpatient mental health beds for children in Surrey Typically, 6-8 General Adolescent Unit inpatient beds are required at any given time within Surrey. Emerald Place was opened by the Trust in partnership with a private provider, Elysium Healthcare, in March 2024. Emerald Place has sufficient bed capacity to meet the demand for GAU inpatient beds within Surrey.
In line with best practice for a new service, admissions have been staggered to allow the new team to develop and embed a safe and therapeutic culture on the ward. As part of our ongoing quality review process, a decision was made to pause further admissions. The Surrey Heartlands CAMHS Tier 4 Provider Collaborative is working at pace with NHS England, Elysium Healthcare and the Trust to support quality improvements at the unit with a current expectation that the unit can resume admissions from January 2025. In the meantime, the Trust is accessing GAU beds through independent providers.
5 December 2024
Private and Confidential
2. System alerts for risk relating to suicide
It is recognised that risk prediction in suicide has been shown repeatedly to be ineffective1. As recognised in your letter to us, the Trust has recently revised its risk assessment approach to align with NICE Guidelines2 and NHS England’s recommendations. This approach emphasises addressing patient needs rather than predicting future risk through the previously used ‘low/medium/high’ categorisation.
Risks are identified and mitigated through a comprehensive risk reduction plan, tailored to the individual, and incorporated into every risk assessment and formulation. The needs-based, patient- centred methodology provides a robust, evidence-based approach to managing risks which complies with national guidance. The suggested binary ‘suicidal/not suicidal’ flag system would force clinicians into an overly simplistic model of risk prediction inconsistent with the nuanced and individualised approach recommended by NICE and now implemented by the Trust. As a result, and having carefully considered this, we will not be introducing a binary flag system.
The Trust’s risk assessment process is designed on the basis that clinicians are acting in accordance with their professional and regulatory responsibilities. As per the NHS Constitution for England3, our staff have a duty to accept professional accountability and maintain the standards of professional practice as set by the appropriate regulatory body applicable to their profession or role. The Trust works in accordance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 20144 in deploying suitably qualified, competent, skilled and experienced persons and ensuring that they receive support, training, professional development, supervision and appraisal.
Through induction and training processes, all staff are aware that our Electronic Patient Record, SystmOne is the single source of all written information and that the risk formulation, care plan, and My Safety Plan must all be kept up to date and stored in specific locations of the patient record so that they are readily available. The MDT process enables clinicians to seek additional support, guidance or reflection where these are required to enable them to properly assess and manage risk.
All of the above are core activities and expectations for all of our clinicians. During clinical supervision, managers review sample cases with each clinician to support effective risk management and clinical reflection.
3. My Safety Plan
My Safety Plan is not a tool for assessing or recording risk of suicide. The document is not written in clinical terms, and it not intended to be a means of sharing information about risk between organisations. Instead, formal documentation of clinical risk (including clear and correct clinical terminology around suicide) is recorded in the Risk Formulation and Care Plan documents which, along with My Safety Plan, form an interlinked suite of documents which are held within a person’s Electronic Patient Record.
Clinical risk information is shared with the network around the child including their school and Children’s Services. Information sharing and safeguarding procedures ensure that relevant clinical information including around risk of suicide is shared with other organisations where appropriate regardless of whether a child or young person decides to share their My Safety Plan.
1 Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation and risk management, Hawton et al, The Lancet, published 8 August 2022 2 NICE Guidance NG225 Overview | Self-harm: assessment, management and preventing recurrence | Guidance | NICE 28056 3 The NHS Constitution for England - GOV.UK 4 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Designed in collaboration with Surrey County Council’s Consulting Youth Advisers team, My Safety Plan empowers a child or young person to communicate with the network around them about their concerns or triggers. A child or young person is encouraged to use their own choice of words within their My Safety Plan to express how they are feeling, enabling them take ownership of this document. The document is compiled in discussion between the clinician and the child or young person and their family/carer, primarily for the child or young person to hold, and to share with adults around them, if and when they choose. Equally, they may choose not to share it at all. We might share it on their behalf if we are given consent or are requested to do so.
It is also incumbent on other agencies around the child or young person to raise concerns of suicidality, for example, teachers and social workers must independently assess their level of concern and seek advice or link with Trust services if they feel this is necessary.
4. Core Group Meetings Attendance at Core Group meetings in respect of those supported by Children’s Services is mandatory. There is also an expectation that clinicians contribute to other safeguarding meetings, and local authority reviews of Education Health and Care Plans (“EHCP”). The Standard Operating Procedure (“SOP”) for our community teams requires that Care Plans include actions flowing from these meetings. Care Plans are recorded on SystmOne and accessible to any Trust clinician involved in the care of the child or young person.
This was discussed at the monthly divisional Quality Operations Board on 19 November 2024 attended by managers and senior clinicians where the importance of engagement with Core Group Meetings was emphasised. Managers were tasked with cascading this to their teams and confirmation that this has been actioned will be provided to the Quality Operations Board.
The Trust is only able to monitor responses to invitations that are received and we are reliant on those invites being sent to us in a timely manner to enable arrangements for attendance to be made. We have therefore requested that Children’s Services copy each invite into our central Safeguarding team in order to have a greater oversight of these invitations and our responses/attendance.
On behalf of the Trust, I would like to offer our sincere condolences to Locket’s family for their loss.