Helen Kerr

Dear Ms Topping

Helen Kerr (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 18 September 2024, in relation to the inquest touching the death of Helen Kerr. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues from the relevant divisions.

In the PFD report, you highlighted that a considerable amount of evidence has been provided by the Trust of the changes around processing referrals into our services. In particular, the PFD report notes that referrals into the Single Point of Access (“SPA”) can now be made by voluntary agencies and new protocols require more senior oversight of triaging decisions and recording of collateral information from referrers.

In addition to the above improvements, the Trust website was updated to provide detail to external professionals on the different routes for emergency, urgent and routine referrals. There is now greater collaboration with family and referrers, supported by changes to the SBAR (a structured tool for communicating and sharing information which requires recording of the Situation, Background, Assessment and Recommendation) to now include carer/family views which are factored into decision making.

The implementation of the new SPA procedures is currently subject to testing in line with our quality improvement approach. The aim of this is to provide assurance that the new processes are applied consistently and are embedded. We have introduced a quality control process within SPA and the ongoing testing and review will allow us to identify other ways in which the service can be optimised As part of this work, we are taking additional steps to enhance the out of hours offer.

11 November 2024

Private and Confidential

During the inquest, the Trust also provided written evidence of improvements that had been implemented in the Psychiatric Liaison Service (“PLS”), particularly in relation to ensuring that collateral information is obtained. The PLS Standard Operational Policy (“SOP”) has now been updated to reflect these changes. This document was ratified and disseminated to all PLS teams in September 2024. The improvements include an emphasis on identifying relevant sources of collateral information and the process that should be followed when a clinician is unable to access relevant collateral information. It outlines that, in these circumstances, consideration should be given to delaying discharge to allow further attempts to obtain collateral and formulate a safe discharge plan. Further changes to the SOP include greater emphasis on staff utilising support of other practitioners when lone working to assist decision making.

A random dip audit of assessments across our five PLS services in September 2024 confirms a trajectory of improvement in that collateral information was sought in 90% of cases, as compared to 80% when the same audit was conducted in June 2024.

Further progress has been made in the development a digital solution which will more robustly support the obtaining and recording of collateral information. A collateral history section has been added to the new PLS assessment template as a mandatory field. There is also a section where a reason must be provided if collateral information has not been obtained. The roll out of the new assessment template has been expedited to the Psychiatric Liaison Services and is currently being tested in two of our PLS services as part of our quality improvement approach and in order to trial clinical effectiveness. Full roll out is anticipated to be completed by the end of 2024.

Alongside the changes to the SOP and the digital assessment template, a case formulation and presentation outlining the learning from Ms Kerr’s inquest has been developed by one of the divisional Nurse Consultants. This provides a forum for reflection and learning to ensure that clinicians understand the factors that were relevant to Ms Kerr’s sad death, and their responsibilities in implementing the improvements that the Trust has made. The case formulation supports the translation of the learning into changes in practice and will have been presented to all PLS teams by the end of November 2024.

Further learning is reflected in the production of training which has been developed and rolled out across our i-access services. This focuses on recognising signs and symptoms of psychosis and the importance of a timely referral to mental health services for assessment. To date, 86% of relevant staff have viewed this training and it is planned that the remaining staff (who have been unable to do so due to absence from work) will have viewed this by 15 November 2024.

The PFD Report also outlines a concern that the Single Combined Assessment of Risk Form, known as a SCARF, does not enable information sharing between organisations out of hours. The purpose of a SCARF is to help police officers to record and raise safeguarding concerns and observations about the needs, vulnerabilities and risk issues relating to those who come into contact with the police. A SCARF is not designed to be used to access crisis support or obtain emergency assistance. If the police have concerns which require urgent attention or advice, there is a dedicated Professionals Line which operates 365 days a year, 24 hours a day.

The Professionals Line number is published on the Trust’s website and can also be accessed by any healthcare professional, or voluntary or statutory agency where an urgent discussion is required. This allows professionals, including from the police or social services, to share or request critical information in an immediate timeframe to help inform decisions about people they have come into contact with. Furthermore, the Trust has a Crisis Line that anyone with concerns about their own mental health or someone else’s may use. This also operates 365 days a year, 24 hours a day.

The SCARF process is therefore only a way of sharing information between organisations and, where there is an urgent need, the crisis referral pathway should be used.

The other matters within the PFD Report relate solely to Surrey Police and I will therefore allow that organisation to address those issues directly.

On behalf of the Trust, I would like to offer our sincere condolences to Ms Kerr’s family for their loss.

Dear Mr Travers, In response to the Regulation 28 notice following the inquest of Ms Helen Kerr, I write to you to provide updates to each matter of concern.

The matters of concern, relevant to Surrey Police, are as follows. –
2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk. As a point of learning, all officers are being reminded to ensure that research is undertaken as soon as practicable when dealing with members of the public, including asking the Force Control Room to do so on their behalf when it is impracticable to do so themselves. In this instance, by asking the Force Control Room, this would have enabled an alternative Surrey Police employee to assess previous information held on Surrey Police systems whilst they were engaging with Ms Kerr. This message will be conveyed by force emails and a reminder on the daily briefing to response officers. We fully accept that this research should have been conducted in order to inform the officer’s decision making. This incident was reviewed as part of the inquest and the officer who saw Ms Kerr explained her rationale as to why she did not use her section 136 powers under the Mental Health Act. The officer did undertake research following Ms Kerr’s departure from the police station and submitted a SCARF (see point 3 below). This decision, which was also based on the research, was supported by a supervisor at the time of the incident and reviewed by the force mental health lead as part of the inquest proceedings.

Surrey Police, PO Box 101, Guildford, Surrey, GU1 9PE | surrey.police.uk Although Ms Kerr did previously carry a nail file for her own protection, the officer would have required grounds to search Ms Kerr. Although some forces are operating a pilot allowing them to search a person with a previous conviction of a weapons offence, who has a court order made against them upon conviction, Surrey is not a pilot force, and Ms Kerr was in any case highly unlikely to have met the required threshold for such an order. Therefore, an officer would rely on the powers conveyed in Section 1 of the Police and Criminal Evidence Act to conduct a search, but in order to do so, they would need to have reasonable grounds to suspect that they will find something prohibited (i.e. a weapon). At the relevant time, the officer did not have this suspicion. There was no information at the time to suggest Ms Kerr was a risk to either herself or the public at large.

(3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public. The SCARF is not intended as a crisis management tool, nor is it intended to convey imminent unmitigated risk, which is laid out in the SCARF policy which all officers and staff can access. The SCARF is intended to pass safeguarding information where it has been deemed that there is no requirement for imminent action. In simple terms, Police have left the person safe in the immediate time frame and it is normal and appropriate for the SCARF to be assessed in a timely manner, (but not immediately), and to be screened and assessed by professionals. Although police submit SCARFs 24/7 to the PSPA (Police Single Point of Access), a review and sharing information out of hours by the PSPA is not completed. The PSPA offers coverage 0900- 1700hours Monday to Friday. If we share SCARF outside of these hours, they would only wait in our partners (adult’s or children’s services) mailboxes until business hours. Surrey Police PSPA used to work weekends until recently, but this was removed because referrals processed were not seen by other agencies. There are numerous things that officers can do in terms of informing our partners about more imminent risk. The primary one is the Emergency Duty Team (EDT) – this process is long established for response officers. This is person-to-person communication between agencies, where agreements can be made and issues escalated. Likewise, there are other methods, such as the professionals / crisis line / Accident and Emergency departments etc. All of these are 24/7 where ‘real time’ concerns can be discussed and safety plans formulated. However, although information can be shared via these methods, practically they are designed mainly for organising immediate out of hours response. In these circumstances, those involving Ms Kerr, officers decided that there was nothing that required this level of immediate response, nor the use of section 136 powers which was heard at the inquest. As a result, the SCARF would normally be the correct method of information sharing as was the evidence submitted by during the inquest.

Surrey Police, PO Box 101, Guildford, Surrey, GU1 9PE | surrey.police.uk (4) The refuge was not made aware of Ms Kerr’s presentation on the 31st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger. Information sharing protocols are in place with statutory partners. The refuge is not a statutory partner, so with regard to the sharing of SCARF, there would be no existing process that would include them in Surrey Police’s safeguarding information sharing protocols. Adult Social Care would be responsible and facilitate any onward information sharing if appropriate, based on a multi-agency assessment.

I hope that this response is sufficient. Please advise me if I can be of further assistance.