Aaron Deeley

Dear Ms Hayes

Aaron James Deeley (RIP)

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 19th June 2024 in respect of the above, which was issued following the inquest into the death of Mr Deeley.

I would like to begin by extending my deepest condolences to Mr Deeley’s family. The Trust sympathises with their very sad loss.

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to these concerns in the hope that this provides both yourself and Aaron Deeley’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised, whilst noting that some of the concerns raised are best answered by Mid & South Essex University Hospital (MSE / the Acute Trust) and / or NHSE.

Concern a)

While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.

Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.

Response:

In order for an application for detention under the Mental Health Act 1983 to be made the application needs to be addressed to the managers of the specific hospital where the person is being detained to for purpose of admission. The application then needs to be formally accepted by the hospital managers (or nominated person on behalf of) for the named specific

hospital stated on the application. Patients in Accident and Emergency departments are not formally admitted for treatment nor assessment within the hospital inpatient wards, therefore the use of detention under Mental Health Act 2007can not be applied in this setting.

All patients above age 18 years old both in Accident & Emergency department and those admitted to Southend University Hospital who require support with their mental health needs and referred to Mental Health Liaison Team (MHLT) are supported by this team regardless of their legal status. In the event of a patient aged 18 years old or over admitted to Southend University Hospital requiring the allocation of a Responsible Clinician in order to execute duties under the Mental Health Act EPUT will allocate a nominated professional to fulfil this role, in general practise (but not exclusively) this tends to be allocated to a consultant psychiatrist of the MHLT based within Southend University Hospital.

EPUT and MSE have a Service Level Agreement, ref number: MSE-558-A Mental Health Act Administration in place in order to support MSE in compliance with the Mental Health Act and achieve best practise for service uses in relation to Mental Health Act. The allocation of Responsible Clinician by EPUT is confirmed by point 3.5.2 page 15 of this document.

Concern b)

Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental Health Act.

Response:

The Mental Health Act 1983 Code of Practice at paragraph 36.1 refers to the identification of Responsible Clinician for patients being assessed and treated under the Act (i.e. section 2 for assessment and treatment, section 3 for treatment). There is no mention of the need for the identification of a Responsible Clinician requirement for patients who are subject to a holding power under section 5 (2). It is therefore respectfully submitted that the Trust adhered to the above provisions when applying the requirements of the Mental Health Act 1983 to the care and treatment of Mr Deeley.

As set out in evidence by EPUT during the course of this Inquest; a patient is placed on a section 5(2) MHA by the Acute Trust, there is a requirement for the mental health liaison team at EPUT to be informed to ensure that appropriate mental health support is in place.

In order to strengthen collaborative working across the two Trusts, a project group for development of the ‘joint protocol’ is being put into place. The first meeting with attendees from both Trusts has been arranged for 23rd September 2024

Further, whilst the project group takes forward the joint protocol work, EPUT’s Mental Health Act office continues to deliver training to MSE which includes the support available and role of the Mental Health Liaison team.

The service matron is currently review this training package in order to ensure there that clear and specific information is cascaded in relation to roles and responsibilities of the Acute Trust as well as the role of the Mental Health Liaison team.

We are advised that MSE leads are in the process of reviewing the ‘Admission and treatment of Mental Health Patients with a Mental Health Disorder in an acute hospital setting’ policy.

In support of the collaborative approach that both Trusts are taking forward, the service matron has confirmed with MSE leads that EPUT will be supportive of an active role in the ratification of this policy. Further, the EPUT Mental Health Liaison Service Operational Policy has been updated to include the support and advice to acute providers regarding risk management of patient’s presenting as requiring assessment under the Mental Health Act 2007. A Standard Operating Procedure (SOP) was presented at the Liaison Services steering group on the 30th July 2024, final copy for comments has been circulated for comments by 5th August 2024; the Policy is now due for final ratification.

By way of information, this SOP contains the following provisions:

- Where a referral is made to the Mental Health Liaison Team; there is a requirement that they respond within the following timeframes:  Emergency: 1 hour  Urgent: 4 hours  Routine: 24 hours.

The SOP will be shared with the Acute Trust once it has been ratified; and on request, with your Court.

Concern c)

During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm.

Response:

In line with the above assurances, training has been tightened in respect of the awareness of the need for Mental Health Liaison to be promptly be made aware by the Acute Trust of all patients that have been placed on a section of the Mental Health Act to ensure appropriate support is in place for the patient as well as our Acute colleagues. Where urgent immediate attendance is required this will be facilitated in line with the protocols detailed above.

Further, as set out above a joint working protocol that clearly outlines the responsibilities of the Acute Trust when placing a person on a section of the Mental Health Act is being put into place.

Concern d)

The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.

Response:

Where there is a concern relating to a person’s mental health, Acute clinicians are required to ensure that there is a prompt referral made to Mental Health Liaison team, who will respond in line with the above provisions. The Mental Health Liaison Team will duly attend to assess and provide support to the patient and Acute colleagues to ensure risks are managed within the environment that they are being treated.

The above provision will be included with the MSE mental health lead is reviewing the Admission and Treatment of Patients with a Mental health Disorder in an Acute Hospital

Setting again EPUT’s Senior Management Team will provide in-put and support in terms of the ratification of this Policy

Concern e)

There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.

Response:

With respect to the Learned Coroner, the answer to this particular concern will be for the Acute Trust to respond to. However, by way of completeness, the planned updates to the Mental Health Liaison Service Operational Policy will include provisions around support and advice to Acute providers regarding care planning and risk management.

Concern f)

There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety

Response:

There is a Mental Health Act Service Level Agreement (SLA) is in place between EPUT and MSE. EPUT provides an administration service that supports MSE in the administration of the Mental Health Act. The SLA supports MSE by undertaking a robust scrutiny of the section documentation to ensure that the patients are detained lawfully and where amendments which can be amended under the Act are done so within the required timelines. The SLA supports the MSE staff when a patient appeals to the Mental Health Tribunal or Hospital Managers against detention under the Act to ensure appropriate reports are requested and submitted in a timely manner. The SLA provides each detained patient with a Responsible Clinician.

Again a Joint Working Protocol is also being put into place.

In light of this Regulation 28 Report, a review of the Mental Health Liaison SOP has been undertaken. The SOP now provides a clearer direction for the Mental Health Liaison Team staff to support and assist patients and acute colleagues in the management of patients who are awaiting formal assessment under the Mental Health Act. With Mental Health Liaison Staff particularly supporting in the identification and management of risk. The recent review of this SOP is being shared with all MHLT staff in order to ensure awareness and consistency throughout the service.

The SLA between MSE and EPUT, as well as the management and responsibility of the Mental Health Act assessments is being addressed at a senior level – with all escalations and concerns now having the benefit of senior oversight.

I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We appreciate that there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care.

Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above.

We Trust that your Court will share, as standard, a copy of this reply with Mr Aaron Deeley’s family

Dear Ms Hayes

Regulation 28 Report to Prevent Future Deaths- Aaron Deeley

I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 19th June 2024, relating to the Inquest of Mr Aaron James Deeley

Thank you for this opportunity to share the improvements we have made since the tragic death of Mr Deeley. We know that sadly, increasing numbers of our acutely unwell patients also face mental health challenges, and this is an important area of focus for us.

We have carefully considered the specific areas of concern arising from Mr Deeley’s Inquest and I have set out below our response to each matter raised.

Matters of Concern

While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours.

a) Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team.

If a clinician is concerned about a patient's mental health whilst in the Emergency Department (ED), the Mental Health Liaison Team (MHLT) is available 24 hours a day and 7 days a week to provide support. The MHLT are responsible for prioritising referrals as they receive them, and there are escalation routes in place for the ED team if required.

We have recently reviewed our policy ‘MSEPO-21231 Admission & Treatment of Patients with a Mental Health Disorder in an Acute Hospital Setting’ which reinforces the mental health support available to patients whilst in ED and inpatient wards.

The policy includes clear and practical guidance for staff setting out how to access the MHLT and when to escalate concerns.

b) Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental Health Act. &

c) During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self- harm. We recognise the legislation does not require a patient to have a ‘responsible clinician’ allocated whilst they await assessment. During this time, it is the ward's responsibility to risk assess the patient and maintain their safety. We know this can be challenging, especially when both acuity and patient flow is high. The wards are advised to refer to the MHLT when they have concerns about a patient’s mental health and associated risk(s). We are encouraging staff to have early conversations with the MHLT, and where possible, a discussion with a psychiatrist before the application of a Section 5(2), working towards holistic and collaborative risk assessments. I am advised that the MHLT are routinely advising ward staff on how best to support patients. A key management tool for staff caring for acute patients with mental health needs is our ‘MSEPO-21228 Policy for Enhanced Supervision and Engagement’. We have therefore made several improvements to this policy to provide more practical guidance and support for staff during this important time while patents await assessment. We have also delivered training to nursing colleagues in relation to the updated policy and refreshers on record keeping standards so that staff are appropriately skilled in how to complete the supervision paperwork correctly. All ward managers are empowered to escalate to senior managers if a patient requires additional mental health support. We are accessing Registered Mental Health Nurses where needed to maintain patient safety, and we are confident that managers are escalating these patients appropriately.

We acknowledge that our pathway documentation for patients detained under Section 5(2) needed reform. We have therefore added a new flowchart to our ‘Admission & Treatment of Patients with a Mental Health Disorder in an Acute Hospital Setting’ Policy. A copy of the flowchart is attached for reference. Our new training sessions cover the practical application of this flowchart with worked examples for staff to understand the correct route to treatment for patients. We are confident that staff attending the training are clear on the steps they should take to maintain patient wellbeing and safety, whilst awaiting formal assessment. We share your concerns that the MHLT may not attend the acute ward or make assessments of the presenting risks of self-harm. There may of course be instances where it would be inappropriate to attend upon an acutely unwell patient and conduct such formal mental health assessments. For example, when a patient is unconscious or intoxicated. However, there are instances when our team feel MHLT support would benefit the patient prior to them being ‘medically fit.’

We have listened to this concern, and we feel this is a key topic for us to take forward with EPUT in our future working arrangements. As you will be aware, the MHLT service is commissioned by our local Integrated Care Board (ICB), and there exists a contractual arrangement between the ICB and Essex Partnership University Trust (EPUT).

We have taken the lead with organising a joint working group with the ICB, EPUT and ourselves to discuss this issue as well as the mental health services provided to us, as a whole, to make sure we are getting this service right for our patients.

The joint working group will meet for the first time on 23 September 2024, and senior colleagues will set out terms of reference including the sequencing of assessments for patients with both a mental and physical health need; a written service level agreement so that staff are clear on when to ask for support, and when to expect it; a document setting our clear roles and responsibilities for staff at both trusts.

We are confident we have the right colleagues attending this meeting to make important decisions about improving the standard of mental health care for patients in our hospitals.

d) The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.

As an acute trust we cannot expect all staff to be able to conduct comprehensive mental health assessments and associated risk assessments, this is a service that EPUT are contracted to provide. However, staff must be trained to identify when mental health assessments are required, and all staff should know when a patient is at risk of harm, to themselves or others. We have therefore employed a Mental Health Lead Nurse tasked to review our current policies, processes, and training needs. They are already working closely with partner agencies to strengthen current practice and increase staff knowledge. Training has been delivered to Heath Care Assistants by the Mental Health Lead Nurse targeted on enhanced supervision skills, how to gain greater awareness of mental health issues, and how to engage meaningfully with patients and offer support. We have also recently developed a rolling training programme with EPUT so that our staff can learn from the experts, and develop their skills and confidence delivering de- escalation techniques, therapeutic engagement, risk assessment, awareness of warning signs, triggers and environmental hazards and risk management. The training is delivered by EPUT on a three-weekly basis to cohorts of MSE staff and this will continue indefinitely. In addition to staff training, improvements have already been made to policies as discussed above, and we are keeping our training needs under review.

e) There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley.

Section 5 of our Policy for Enhanced Supervision and Engagement has been re-written in collaboration with the Mental Health Lead Nurse to clearly set out the criteria that should be met for a patient to trigger for enhanced supervision.

Appendix 4 of our ‘Admission & Treatment of Patients with a Mental Health Disorder in an Acute Hospital Setting’ provides further guidance on assessing individuals with a decision-making flowchart included (attached).

f) There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations.

It is a key priority for us to develop a robust joint protocol with EPUT, and this will be the first order of business at our meeting in September 2024.

Our vision is that patients in our hospital should have access to appropriate and timely mental health care in parallel with their acute treatment; many patients may not be medically fit, but they are well enough to receive mental health support, and we know the sooner they have this, the better. We are committed to working with EPUT to develop a collaborative patient centered approach.

There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety.

We have delivered training so that staff are able to identify patients such as this, and we have improved our policies and guidance to make sure patients are carefully supervised when needed. We would be happy to supply full copies of the new policies if this would provide further assurance.

We now have clear escalation routes to senior colleagues who can access external support, for example Registered Mental Health Nurses, when the ward team are unable to meet the patient’s needs, or the risks mean that extra help is needed. I am aware these practices are happening, and we are appropriately managing and mitigating risks.

Further, we have important work to do with our colleagues at EPUT to develop a clear joint working protocol. We have a plan, and the right colleagues involved in this project to make this happen. We hope that the action we have taken, and the plans we have in place have provided assurance that your concerns are being addressed. However, if you have any further concerns or you would like to discuss this case further, please do not hesitate to contact me.