Source · Prevention of Future Deaths

Daniel Tucker

Ref: 2024-0115 Date: 29 Feb 2024 Coroner: Michael Wall Area: Nottingham City and Nottinghamshire Responses identified: 4 / 4 View PDF

Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective named nurse sessions was also inadequate.

Date 29 Feb 2024

56-day deadline 27 Apr 2024

Responses identified 4 of 4

Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

The following directed to NHCT for response
1. A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan I am concerned that, notwithstanding the existence of a clear, appropriate policy and significant commendable actions by the Trust since Daniel’s death to address this issue, there remain clinical and nursing staff who do not fully recognise or accept the importance of completing and utilising the required risk assessment and care plan. This suggests there may be a persisting training or cultural issue. The inquest heard evidence that there was (and remains) a clear and robust policy in place which most staff were aware of. This requires a care plan and risk assessment be initiated upon a patient’s admission, completed within 72 hours of admission and updated as necessary during admission. Further, since Dan’s death, the Trust has gone to considerable and commendable lengths to ensure that care plans and risks assessments are in place in every case and to reinforce the requirements of this guidance within the Nursing team; that team hold primary (but not sole) responsibility for creating and updating the risk assessment and care plan document. I also heard that a recent audit found that all current patients had an appropriate care plan in place. The Ward Manager agreed this is “a basic and fundamental part” of any patient’s care. In spite of all of this, an experienced ward nurse and two psychiatrists (a consultant and a registrar) involved in Dan’s care seemed to minimise the practical importance of the required process and documentation, the latter both suggesting they would not routinely consult it.
2. Inadequate system of allocating a named nurse to patients and recording the same I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises. The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed.
3. Inadequate skills/knowledge/training on how to encourage patients to engage I am concerned that clinical, nursing and/or support staff may not currently have sufficient skills or knowledge in dealing with patients who appear unable or unwilling to engage with staff and/or treatment. A psychiatrist not involved in Dan’s care gave evidence about the advice he would have given to colleagues on how to seek to assist a patient who, like Dan, was unwilling or unable to engage with staff: first, identify the likely reasons for the patient’s lack of engagement; second, having regard to those reasons, develop plans and strategies to address the specific barriers identified. I heard little evidence that either of these steps was followed by any of the staff involved in Dan’s care. One barrier was identified (his previous negative experiences on the ward and wish to be transferred to another ward or hospital) but seemingly forgotten after an initial transfer request to the Bed Management team, which was not then followed up. Even with the benefit of hindsight, the doctors, nurses and healthcare assistants involved in Dan’s care seemed unable to offer any insight into the reasons for his difficulties engaging beyond his diagnosis of EUPD or articulate any strategies or techniques that might have helped him overcome them. The following addressed to Secretary of State for Health and Social Care & NHS England
1. I am concerned that confirmed ingestion of during a 999 call does not trigger a category 1 response from the Ambulance Service / Dan ingested at around 20:30 on 22 April 2022. His friend informed the 999 call handler that he had done so during a first 999 call at 20:39. That call was correctly graded as requiring a category 2 response, as Dan was both conscious and awake. 14 minutes later, at 20:53, Dan collapsed. His friend’s second 999 call was correctly graded as requiring a category 1 response, as Dan had become unconscious, his breathing agonal. The first ambulance crew arrived at 21:04. Dan went into cardiac arrest at approximately 21:24. Consideration was given by the ambulance crew to scoop and run ‘ ’ to arrange a rendezvous to administer the necessary “drugs to counter ”, but this was no considered longer feasible once Dan had gone into cardiac arrest. evidence expressed deep concern at its easy availability and growing popularity for vulnerable people seeking to end their own lives. The expert toxicological evidence indicated that its acute toxic effects can be rapid (as short as 20 minutes after ingestion, depending on dose) and can quickly become irreversible. The inquest heard evidence from a consultant toxicologist that even in very small quantities (or ) is lethal; it is a potent poison. I understand it is also, tragically, an increasingly common means of suicide. Mental health professionals who gave This suggests that almost any case involving the ingestion of or is likely to be a time critical life-threatening event. Yet it is does not currently fall within that category for the purposes of grading 999 calls, unless the patient is unconscious or not breathing. While there was no evidence that a category 1 response would have prevented Dan’s death, I believe there is a risk that other deaths will occur if ingestion of continues to require a category 2 response. The following addressed to the Secretary of State for Health and Social Care and the Chief Executive of OFCOM
1. Continuing accessibility of Dan was using an online suicide forum, Through that forum he was able to engage in discussions with other members and obtain information

Notwithstanding the provisions of the Online Safety Act 2023, and apparent attempts to block access to the website, I heard evidence that it remains easily accessible to vulnerable people in the UK. I am concerned that further deaths will occur while this remains the case.

Responses

4 respondents

NHS England NHS / Health Body

29 Feb 2024 PDF

Action Taken

NHS England detailed updates to overdose guidance, implemented in November 2023, to include callers who reach a Category 5 disposition. Additionally, TOXBASE is to be viewed for each overdose/accidental ingestion incident, and the initial clinical review should consider any ongoing suicidal ideation with a specific plan/means. (AI summary)

View full response

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Daniel Mark Edward Tucker who died on 22 April 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 February 2024 concerning the death of Daniel Mark Edward Tucker on 22 April 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Dan’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Dan’s care have been listened to and reflected upon. 

In your Report, you addressed a concern to NHS England that confirmed ingestion of during a 999 call does not trigger a Category 1 ambulance response.

Ambulance Emergency Operation Centres (EOCs) use one of two approved triage tools to take 999 emergency calls – Medical Priority Dispatch System (MPDS) or NHS Pathways. At the time of the calls being made to East Midlands Ambulance Service NHS Trust (EMAS) in Dan’s case, EMAS were users of the protocols within the MPDS, for which there is a protocol. This protocol generates a specific ‘Determinant Code’ for overdose, following the initial assessment of the patient. This then allows the relevant Ambulance Emergency Operation Centre (EOC), in this case that of EMAS, to consider the Determinant Code and locally determine and apply a local response mode or ‘Category’. The response modes are underwritten by the UK Government Emergency Call Prioritisation Ambulance Group (ECPAG) and sent to NHS Ambulance Service Trusts in England for implementation.

While ingestion of can lead to fatality, this can unfortunately be said of an array of substances, ranging from prescription medicines to over-the-counter household products and other agents available commercially or over the internet. The MPDS does specifically code some common overdose/poisoning agents, but this is for the provision of specific therapies and information for responders rather than for specific response assignment.1 The listing of all possible fatal agents would likely lead

1 NHS Pathways, the alternative triaging system, also has a disposition code to facilitate improved visibility of overdose and suicide attempt cases within the ambulance dispatch code. It also provides a

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

26th April 2024

to significant over-triage and delay as many of these patients are asymptomatic and do not represent pre-arrival emergencies. Additionally, the type and amount of substance taken is not always reliably obtained as patients attempting suicide can mislead responders. Therefore, listing specific agents and amounts with the expectation that non-clinician Emergency Dispatchers make response assignment decisions based on what may well be inaccurate information would likely result in significant and potentially dangerous triage practice. The BRAVO-Level code assigned to intentional overdose (intent to harm self) cases, specifically patients without priority symptoms, is intentionally isolated so that agencies can prioritise intentional acts and respond appropriately, regardless of the substance information offered by the caller.

Due to the broad spectrum of potentially dangerous substances that can be ingested by members of the public, either intentionally or accidentally, coupled with the urgent and emergency care (UEC) challenges and delayed response times currently faced by the NHS, it is recommended by the MPDS (and NHS England, please see below) that ambulance trusts utilise trained clinicians in the control center to advise further on the potential effect of ingestions and upgrade responses if deemed necessary. The MPDS also has protocols for overdose patients as well as those patients with mental health conditions that are suffering any self-harm or suicidal thoughts. Since the time of this call, specific training and a new protocol have been developed specifically for first party callers in crisis.

EOCs follow specific principles to ensure clinical oversight for patients calling and presenting with overdose and suicidal ideations. These principles have been reviewed and strengthened through several national recommendations since 2019, see below. Firstly, on 2 April 2019,
– then National Clinical Director for Urgent and Emergency Care at NHS England – wrote to ambulance trusts and NHS 111 providers to mandate that robust clinical oversight was in place in control rooms and call centres to monitor self-harm and suicidal patients safely and effectively. Secondly, in 2020, the Healthcare Safety Investigation Branch (HSIB), investigated the potentially under-recognised risk of harm from the use of propranolol. They made a safety recommendation for NHS England to evaluate current approaches to clinical oversight of overdose calls within ambulance control rooms, and to develop a national framework to describe requirements for appropriate clinical oversight of overdose calls. NHS England issued guidance for Ambulance Services relating to overdoses and suicidal intent in April 2021. The guidance highlights the critical importance of clinical oversight and review and sets out that:
• where an overdose is declared, further clinical intervention should take place, or the case should be automatically upgraded if this does not occur within a specified time (30 minutes).

telephone consultation tool called Pathways Clinical Consultation Support System (PaCCS). This is for use by experienced clinicians and lends itself more to a consultation-led assessment rather than triage

• it is good practice for TOXBASE® (clinical toxicology database) to be viewed for each overdose / accidental ingestion incident, despite the familiarity of the reviewing clinician with that particular toxicity profile, which includes . It is noted that management practices often change in relation to specific toxins, therefore guidance around the use of TOXBASE ® was issued instead.
• the initial clinical review should also consider any ongoing suicidal ideation with a specific plan / means.

Most recently, the overdose guidance was updated in November 2023 to include callers who reach a Category 5 disposition (hear and treat). This followed a review by the Emergency Call Prioritisation Advisory Group (ECPAG, NHS England) and the National Ambulance Service Medical Director’s Group (NASMeD, Association of Ambulance Chief Executives) to ensure it remained clinically fit for purpose.

I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Ofcom Regulator / Inspectorate

26 Apr 2024 PDF

Action Planned

Ofcom acknowledges the concerns and outlines its plans to implement the Online Safety Act, including consulting on draft codes of practice and taking enforcement action against non-compliant services regarding harmful suicide content. (AI summary)

View full response

Dear Mr Wall, We write in response to the Regulation 28 report to Prevent Future Deaths, received 1st March 2024, which was issued to Ofcom following the death of Daniel Tucker (‘the Report’). Firstly, I would like to offer my deepest condolences to Mr Tucker’s family and loved ones on behalf of Ofcom. I understand that a loss in such troubling circumstances must be incredibly difficult. Our response will necessarily focus only on the issues raised in the report which are within Ofcom’s remit, namely, the ‘continuing accessibility of the pro suicide web-forum, with reference to new legal requirements under the Online Safety Act 2023 (‘the Act’). We thank the coroner’s office for bringing our attention to the role of online services in the tragic circumstances of Mr Tucker’s death. Intelligence about the real-world effects of online harms and their links to specific services will be crucial as we develop our approach to the Online Safety regime. I wish to assure you and the family of the deceased that Ofcom is committed to taking action to ensure that all online services in scope of the Act fulfil their duties in regard to harmful suicide content, as we press forward in our implementation of the Act’s provisions.

i. Response to Regulation 28 report following inquest into the death of Daniel Tucker

In the response below, we set out our proposed actions in relation to the issues raised by the Report, where these fall within the scope of the Online Safety regime, and the timetable for these actions. These actions are pursuant to the new duties and powers assigned to Ofcom by the Act and relate to Ofcom’s plans for implementation of the Act as the UK’s regulator for online safety. The report outlines a number of detailed matters of concern and our response below highlights the steps we are taking to promote compliance with the requirements of the regime across all relevant regulated services. We are currently in the process of putting in place regulation to implement the Online Safety regime, following the Act coming into force on 26 October 2023. Until the relevant procedural steps outlined below are completed, the duties on regulated services are not yet fully in force. As Ofcom’s enforcement powers are tied to non-compliance with these duties, we will only be able to pursue enforcement action against online services once our Codes of Practice are finalised in 2025. Once

Classification: HIGHLY SENSITIVE the duties are in force, we won’t hesitate to exercise our enforcement powers where appropriate and effective to protect Internet users. Following reports1 of alleged illegal and harmful suicide content on , Ofcom contacted the service on 7 November 2023, which subsequently announced via its website that UK users would be blocked. On January 8 2024, we contacted the service again to note we were aware that the restrictions appeared to no longer be in place. At the time of writing, we are aware that the site is accessible by UK users. This is a situation which we will continue to monitor, but as noted above, Ofcom does not have powers to enforce these duties until the relevant guidance and Codes have been finalised and come into force. As a provider of a service that allows user-to-user sharing of content and that is accessible in the UK, is likely to be in scope and subject, in particular, to the illegal content duties found in sections 9 and 10 of the Act, which we outline in further detail below. This means that if the site is still accessible to UK users in its current form when these duties take effect, we would then be able to carry out an initial assessment to explore whether the available evidence merits opening an investigation, whether the issue can be resolved through other means, and whether it should be prioritised. Our published enforcement guidance sets out the framework within which we will make these decisions. If, following a formal investigation, we are satisfied that the company concerned has contravened one or more of its obligations under the Act, Ofcom may issue a notice of contravention, impose a financial penalty and/or require steps to be taken to remedy the harm or come into compliance. Should the service fail to comply with these remedial steps (or pay the financial penalty), we can apply to the court for business disruption measures, which include service restriction orders or access restriction orders. In exceptional circumstances, we may consider it appropriate to apply for a business disruption measure before taking formal enforcement action. Below we set out in more detail the steps and approach we are taking to implement the Act, estimated timelines, and in-scope services’ legal duties to comply with the Act. The Online Safety Act 2023 The Online Safety Act 2023 (‘the Act’) makes persons that operate a wide range of online services legally responsible for keeping people safer online. The Act covers certain categories of internet services that have links with the UK including what are known as user-to-user services and search services. The Act defines a user-to-user or search service as having links to the UK if it meets any one or more of the following criteria:
• Has a significant number of UK users; or
• Has UK users as one of its target markets; or
• Is capable of being used by UK users, and there are reasonable grounds to believe that there is a material risk of significant harm to UK users. Any service which meets one more or the above criteria, and which is not exempt2, will be expected to comply with the relevant duties under the Act.

1 BBC News, ‘“Failure to act” on suicide websites linked to 50 UK deaths’, 24 October 2023 2 A number of exemptions also apply as set out in Schedule 1 to the Act. See: Vol 1, Section 3 of our Illegal Harms Consultation

Classification: HIGHLY SENSITIVE

Provisions of the Act: legal duties on services Among other things, the Act:
• Appoints Ofcom as the regulator for online safety and confers upon us a number of powers and duties (set out in detail below).
• Imposes a number of duties on those regulated services which focus on improving the systems and processes online services operate to ensure the safety of their users, rather than on the presence of individual pieces of content. These include: o duties on user-to-user services to swiftly take down illegal content (including illegal suicide and illegal self-harm content) when it is identified, and to prevent children from encountering content that is harmful to them (including content which encourages, promotes or provides instructions for suicide or self-injury); o duties on search services to minimise the risk of individuals encountering illegal content (including illegal suicide and self-harm content) and children from encountering content that is harmful to them (including content that encourages, promotes or provides instruction for suicide or deliberate self-harm) in search results; and o additional duties for the largest and highest-risk services allowing their users to increase control over the content they encounter on those services.
• Requires regulated services to assess the risks their services pose to users in relation to illegal content and content that is harmful to children and take steps to mitigate and manage those risks.
• Requires Ofcom to issue a number of regulatory publications to help regulated services understand how they can comply with their legal duties. These include Codes of Practice setting our recommended measures services can take to mitigate risks of harm in compliance with their duties, and resources to help companies assess, understand and manage risk. Specifically, the duties on all regulated user-to-user services relating to protecting their users from illegal harms will require those services to understand and take steps to manage and mitigate the risks of users encountering illegal suicide content, or their services being used for the commission or facilitation of this offence. User-to-user services will also have to swiftly take down illegal suicide and illegal self-harm content when it is identified. Where regulated services are likely to be accessed by children, they will also have to take steps to prevent child users from encountering content that encourages, promotes or provides instructions for suicide or deliberate self-injury. There are also additional duties which apply to certain user-to-user services which will be ‘categorised’ based on user numbers and functionalities (these services will be known as ‘Category 1 services’3). These duties are designed to make these services more transparent and accountable to their users about the steps they take to protect them from harm; and enable adult users to have

3 ‘Category 1’ refers to certain user-to-user services categorised based on user numbers and functionalities. Services in this category are subject to additional duties related to transparency, user empowerment and protection of democratic and journalistic content. ‘Category 1 threshold conditions’ are set the Secretary of State, with advice provided by Ofcom. Ofcom will then be responsible for designating services into categories according to these thresholds. See our advice on categorisation: Categorisation Research and advice (ofcom.org.uk)

Classification: HIGHLY SENSITIVE more control over the type of content they encounter, including by having access to tools to reduce their potential exposure to suicide and self-harm content. A set of separate duties apply to regulated search services. These duties focus on those services understanding the risks of harm and focus on services taking steps to minimise the risk of individuals encountering illegal suicide and self-harm content and content that encourages, promotes or provides instruction for suicide or deliberate self-harm to children in search results. Timeline for duties under the Act coming into force Although the Act is now law, there are numerous procedural steps needed for the new regime to be fully implemented, and these steps need to be completed before services’ legal duties under the regime – and Ofcom’s ability to enforce those duties – come into force. These steps include: the completion of public consultations (the first, on illegal harms, closed on 23rd February 2024); services completing Risk Assessments designed to help them understand and managing the risks of harm to their users; and Parliament approving Ofcom’s final Codes of Practices. We explain our plans to implement the regime below. In the meantime, we are already encouraging in-scope service providers to take meaningful steps to improve safety on their platforms. To this end, we are committed to driving industry improvements by engaging with the largest and riskiest services via continuous ‘regulatory supervision.’

ii. Ofcom’s implementation of the Online Safety Act To coincide with Royal Assent, we set out our approach to implementing the Act on our website – this included an implementation road map setting out our three key phases of work over the next three years. We set out in summary below our intended plans for implementation, and in diagram form in Figure 1. This timeline shows our key milestones and documentation but is not a comprehensive guide to everything we will produce over the first three years of the regime. Figure 1: Ofcom’s timeline for Online Safety implementation

As part of our preparatory work for implementation, we have been actively engaging with a range of expert stakeholders including government, law enforcement, and charities such as the Samaritans to develop our understanding, expertise and evidence base in relation to suicide and self-harm, and to ensure that we are aware of developing areas of risk. We have also been concentrating on growing

Classification: HIGHLY SENSITIVE our internal expertise in relation to this complex and important harms area, including by commissioning research.4 We will continue our programme of engagement with relevant experts as we consult on our initial proposals on how services can comply with their duties. Phase One: Illegal Harms Ofcom’s illegal harms consultation: assessing risks The Act requires Ofcom to produce a register of risks for illegal harms, and guidance to assist services in conducting their own risk assessment. Our draft guidance sets out a four-step risk assessment process which we propose as the best way to ensure that a service’s assessments meet their obligations. We have also consulted on our ’Risk Profiles’, which set out an explanation of factors in service design and operation that increase risk of harm. Services will be required to take account of our Risk Profiles when conducting their risk assessments. The information contained in the Risk Profiles is sourced from Ofcom’s own Register of Risks. For illegal suicide and self-harm content, we set out risk factors relating to:
• service type;
• user base;
• functionalities of the service; and
• recommender systems. We are using the consultation process to help us finalise this work. Ofcom’s illegal harms consultation: Codes of Practice The Act requires Ofcom to produce Codes of Practice setting out the measures that in-scope services may take to comply with their duties under the Act.5 The Codes will recommend proportionate systems and processes across a number of areas, including: moderation, governance, and user complaints. While services are not required to implement all measures in our Codes of Practice, in the event that they choose not to take the steps recommended, they will need to be able to explain how their chosen approach allows them to be compliant with their legal duties. We published our illegal content Codes of Practice in draft form alongside our illegal harms consultation.6 The proposed measures in our Codes of Practice would require services to, among other things:
• have a named person, who is accountable to the most senior governance body, for compliance with illegal content safety duties, and reporting and complaints duties;

4 See, for example, our recent research on suicide content and search services: ‘One Click Away: a study on the prevalence of non-suicidal self injury, suicide, and eating disorder content accessible by search engines’. See also our research into children’s experience of suicide, self-harm and eating disorders content: ‘Experiences of children encountering online content relating to eating disorders, self-harm and suicide’ 5 Section 41 of the Act 6 Ofcom, ‘Consultation: Protecting people from illegal harm online’, November 2023. See: Volume 4: How to mitigate the risk of illegal harms – the illegal Content Codes of Practice, Annex 7: Illegal Content Codes of Practice for user-to-user services and Annex 8: Illegal Content Codes of Practice for search services.

Classification: HIGHLY SENSITIVE
• have in place effective and easy-to-find content reporting and complaint mechanisms, so that users that encounter illegal content (including illegal suicide and, if the offence is brought into force, self-harm content) can report it and see action taken;
• in the case of medium or high-risk services that use algorithms to recommend content to users, measure the risk that changes to algorithms increase the chance of users' exposure to illegal content (including illegal suicide and self-harm content);
• in the case of user-to-user services: have in place content moderation systems or processes that are designed to take down known illegal content (including illegal suicide and self-harm content) swiftly; and
• in the case of search services: have systems and processes in place that are designed so that search content that is illegal content is deprioritised or deindexed for UK users. In addition, our draft Codes of Practice include a proposal that search services should provide crisis prevention information in response to search requests that contain general queries regarding suicide and queries seeking specific, practical or instructive information regarding suicide methods. This information should include a helpline and links to freely available supportive information provided by a reputable mental health or suicide prevention organisation. It should also be prominently displayed to users in the search results. Ofcom’s illegal harms consultation: Illegal Content Judgements Guidance Our illegal harms consultation includes a draft version of Ofcom’s Illegal Content Judgements Guidance.7 This document provides guidance to in-scope services on how they may identify illegal content (content which may be reasonably inferred to amount to a relevant offence) including under Section 2 of the Suicide Act 1961. In our draft guidance, we note the intentional act of encouraging or assisting the suicide (or attempted suicide) of another person is an offence and have proposed that, in certain contexts, the provision of specific, practical or instructive information on suicide methods – for example about how to take one’s life, and content inducing someone to enter into a ‘suicide pact’, are likely to be able to be inferred to be illegal content. Our draft guidance therefore suggests that content of this type should be removed from services in order for providers to be compliant with their illegal content safety duties. The Illegal Harms consolation closed on 23rd February 2024. We are now reviewing responses to our consultation and working towards our Illegal Harms Statement, in which we will outline our final policy decisions. After Ofcom’s illegal harms consultation and statement Once we have completed our illegal harms consultation, we are required to publish a statement setting out our response to issues raised by stakeholders, and our final policy decisions. The Act requires Ofcom to submit our Codes of Practice on illegal harms to the Secretary of State and to publish associated guidance within 18 months of Royal Assent. Once we issue our statement, services will have three months to undertake their illegal content risk assessments. At this point we

7 Ofcom, ‘Consultation: Protecting people from illegal harm online’, November 2023. See: Volume 5: How to judge whether content is illegal or not? (Illegal Content Judgements Guidance) and Annex 10: Online Safety Guidance on Judgement for Illegal Content.

Classification: HIGHLY SENSITIVE will also submit the Codes of Practice to the Secretary of State, which, subject to their approval, are to be laid in Parliament for 40 days. Following approval by Parliament, the Codes will come into force 21 days after they have been issued. At this time the illegal harms safety duties become enforceable, and we can begin investigations and – following the conclusion of those – impose sanctions if we find that services are not compliant with these duties. Phase Two: Child Safety As stated above, services that are likely to be accessed by children are required to protect children from legal content which may harm them. As part of Phase Two, we will publish a consultation on protecting children, to be published in May 2024, which will include our proposals for:
• Draft guidance for services on carrying out their Children’s Access Assessments
• Ofcom’s analysis of the causes and impacts of harms to children
• Draft guidance on carrying out Children’s Risk Assessments
• Draft Codes of Practice setting out recommended measures to protect children online. After publication of our final guidance on Children’s Risk Assessments (Spring 2025), relevant services will have three months to carry out a Children’s Risk Assessment. At the same time, we will submit the children’s Codes of Practice to the Secretary of State. Subject to the Secretary of State’s approval, they will then be laid in Parliament for 40 days. Following approval by Parliament, the codes will come into force 21 days after they have been issued. At this time the children’s safety duties become enforceable, and we can begin investigations and impose sanctions for non-compliance. Assuming Parliament immediately approves the codes, we expect the duties to become enforceable in Summer 2025. Phase Three: transparency, user empowerment, and other duties on categorised services Phase Three of online safety focuses on transparency, user empowerment, and other duties which will apply to Category 1 services. The user empowerment duties will contain a duty to include, to the extent that it is proportionate to do so, features which adult users may use or apply if they wish to increase their control over certain kinds of content including content which encourages, promotes or provides instructions for suicide or an act of deliberate self-injury. We issued a Call for Evidence regarding our approach to phase three on 25 March 2024.

iii. Conclusion We thank the Coroner again for bringing to our attention the role that access to online services had in Mr Tucker’s death. His story highlights the pressing importance of tackling the harm from services which provide ready access to suicide content. Government and Parliament have signalled the importance of tackling such content by designating illegal suicide content as a priority offence and legal suicide content as primary priority content that is harmful to children, and our strategic priorities reflect this. As we have set out in our approach to implementing the Online Safety Act, once the regime is in force we expect change.

Classification: HIGHLY SENSITIVE Specifically, we anticipate implementation of the Act will ensure people in the UK are safer online by delivering four outcomes:
• stronger safety governance in online firms;
• online services designed and operated with safety in mind;
• choice for users so they can have meaningful control over their online experiences; and
• transparency regarding the safety measures services use, and the action Ofcom is taking to improve them, in order to build trust. We have set out that we will expect all in-scope services to have appropriate trust and safety measures tackling the full range of harms listed in the Act. In particular, we want to see wider deployment and improvements in services’ measures to address areas which pose the greatest risk to people, including illegal and harmful suicide content, to protect UK users, especially children and vulnerable users. We are committed to working with industry to ensure compliance with these duties, and to this end our draft illegal harms Codes of Practice include specific measures which we propose would allow services to meet their duties in an effective and proportionate manner. We will ensure that through consulting on our proposals we seek input and engagement with external experts. We will also work directly with services to promote compliance, including – where appropriate – through targeted supervision. And where we identify non-compliance, we will not hesitate to take appropriate enforcement action to protect users from harm. Evidence included in reports from coroners and other experts will play an important role in our policy proposals and response as we implement the regime, and we will of course take the evidence in your report into account as we continue our policy development. We hope that this response provides helpful information about the significant steps Ofcom is taking as we continue to work through the implementation of the Act. If further information or clarification is required, we would be happy to provide this.

Department of Health and Social Care Central Government

7 Jun 2024 PDF

Action Taken

The Department of Health and Social Care references actions taken to address harmful online content such as the Online Safety Act and states that the multi-sector and cross-government suicide prevention strategy for England was published in September 2023. (AI summary)

View full response

Dear Mr Wall,

Thank you for the Regulation 28 report to prevent future deaths dated 29 February 2024 about the death of Daniel Mark Edward Tucker. I am replying as Minister with responsibility for Mental Health and Women’s Health Strategy.

Firstly, I would like to say how deeply saddened I was to read of the circumstances of Daniel Tucker’s death, and I offer my sincere condolences to their family and loved ones. I can only begin to imagine the effect that this will have had on his loved ones and, whilst I know that it will come as little comfort to them, I nevertheless hope they will accept my heartfelt condolences.

In preparing this response, Departmental officials have made enquiries with NHS England.

On your concern regarding ingestion of , Ambulance Emergency Operation Centres (EOCs) use one of two approved triage tools to take 999 emergency calls – Medical Priority Dispatch System (MPDS) or NHS Pathways. At the time of the calls being made to East Midlands Ambulance Service NHS Trust (EMAS) in Mr Tucker’s case, EMAS were users of the protocols within the MPDS. This protocol generates a specific ‘Determinant Code’ for overdose, following the initial assessment of the patient. This then allows the relevant Ambulance Emergency Operation Centre (EOC), in this case that of EMAS, to locally determine and apply a local response mode or ‘Category’. The response modes are underwritten by the NHS England Emergency Call Prioritisation Advisory Group (ECPAG) and sent to NHS Ambulance Service Trusts in England for implementation.

The MPDS does specifically code some common overdose/poisoning agents, but this is for the provision of specific therapies and information for responders rather than for specific

response assignment. The listing of all possible fatal agents would likely lead to significant over-triage and delay as many of these patients are asymptomatic and do not represent pre-arrival emergencies.

The code assigned to intentional overdose (intent to harm self) cases, specifically patients without priority symptoms, is intentionally isolated so that agencies can prioritise intentional acts and respond appropriately, regardless of the substance information offered by the caller. Due to the broad spectrum of potentially dangerous substances that can be ingested by members of the public, either intentionally or accidentally, coupled with the urgent and emergency care (UEC) challenges and delayed response times currently faced by the NHS, it is recommended by the MPDS (and NHS England) that ambulance trusts utilise trained clinicians in the control centre to advise further on the potential effect of ingestions and upgrade responses if deemed necessary. The MPDS also has protocols for overdose patients as well as those patients with mental health conditions that are suffering any self-harm or suicidal thoughts. Since the time of this call, specific training and a new protocol have been developed specifically for first party callers in crisis.

EOCs follow specific principles to ensure clinical oversight for patients calling and presenting with overdose and suicidal ideations. These principles have been reviewed and strengthened through several national recommendations since 2019.

NHS England issued guidance for Ambulance Services relating to overdoses and suicidal intent in April 2021. The guidance highlights the critical importance of clinical oversight and review and sets out that where an overdose is declared, further clinical intervention should take place, or the case should be automatically upgraded if this does not occur within a specified time (30 minutes). This is for use by experienced clinicians and lends itself more to a consultation-led assessment rather than triage. Most recently, the overdose guidance was updated in November 2023 to include callers who reach a Category 5 disposition (hear and treat). This followed a review by the Emergency Call Prioritisation Advisory Group (ECPAG, NHS England) and the National Ambulance Service Medical Director’s Group (NASMeD, Association of Ambulance Chief Executives) to ensure it remained clinically fit for purpose.

I also understand that Joint Royal Colleges Ambulance Liaison Committee (JRCALC) who produce clinical guidelines for UK paramedics is currently working with the National Poisons Information Service (NPIS) colleagues/experts to update the JRCALC overdose and poisoning guidance.

The Government has taken steps to reduce access to and awareness of this substance. DHSC has led an emerging methods working group to prevent awareness and access to substances such as this one. This involves close working across government and with others to ensure rapid, targeted action has been taken to prioritise tackling the substance in question. The working group involves representatives from the voluntary, community and social enterprises sector, police as well as government departments including the Home Office and The Department for Science, Innovation and Technology as well as academics and the NHS. There are currently over 30 live actions and interventions that collectively are reducing public access to methods, including by reducing the sale and importation of

methods where appropriate as well as reducing references to, and limiting awareness of, emerging methods.

The group has worked with business, including online suppliers and manufacturers of the substance, to significantly reduce access. We have also worked with major online suppliers also remove it from sale to individuals in its pure form. We continue to work operationally with our broader partners, including Border Force and the police on interventions to reduce access to this specific substance for the purpose of suicide. These actions are kept under operational review.

I would also like to assure you that the Government has also taken action to address the prevalence of harmful suicide and self-harm content online such as the website you highlighted. For example, as you will be aware, the Online Safety Act, when fully in force, will require all services in scope to rapidly remove regulated content that meets the criminal threshold once they become aware of it, this includes illegal suicide and self-harm content. Under the Act, search services also have targeted duties that require them to minimise the risk of users encountering illegal search content, such as those found on this specific website. There is also a requirement for search services to take or use, where proportionate, user support measures. The regulator now responsible for online safety, Ofcom, will recommend measures that search services can put in place to achieve these objectives. These could include removing results for sites that are known to host illegal suicide and self-harm content, as well as signposting users towards sources of support.

The Act provides Ofcom with a robust suite of enforcement powers, including business disruptions measures and significant fines for use in the case of non-compliance. The Government has also worked with internet service providers, tech companies and social media platforms, as well as expert advisors such as the Samaritans, to tackle harmful pro-suicide forums such as this one.

In addition, in September 2023 the multi-sector and cross-government suicide prevention strategy for England was published. The five-year strategy set out over 130 actions aimed at reducing the rates of suicide in England.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Nottinghamshire Healthcare NHS Foundation Trust NHS / Health Body

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Action Taken

Nottinghamshire Healthcare NHS Foundation Trust stated that care plans and risk assessments are individualised and updated, with monthly audits to ensure compliance. They have also invested in additional self-harm and suicide prevention training and additional training commenced to support staff and suicide awareness. (AI summary)

View full response

Dear Mr. Wall

Regulation 28 Response – Mr. Daniel Tucker – April 2022

Please find below the Organisational response to the received Regulation 28 Report to Prevent Deaths following the death of Mr. Daniel Tucker, the inquest of which was concluded on the 6 February 2024. We offer our continued sincere condolences to Mr. Tucker’s family.

1. A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan. I am concerned that, notwithstanding the existence of a clear, appropriate policy and significant commendable actions by the Trust since Daniel’s death to address this issue, there remain clinical and nursing staff who do not fully recognise or accept the importance of completing and utilising the required risk assessment and care plan. This suggests there may be a persisting training or cultural issue.

Response:

The Trust expectation remains that care plans and risk assessments are individualised and fully updated following the 72-hour assessment period. Throughout a person’s admission care plans and risk assessments are expected to be kept contemporaneous and accessible to all staff to support a patients care. At the inquest evidence was provided about how an improvement in care planning had been demonstrated and the oversight of this is a continual process to ensure this is maintained. A monthly audit is completed which is shared within

26 April 2024

Private and Confidential

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

the clinical team to ensure any discrepancy for expectations is addressed and updated. The latest figure for this from March 2024 was 81% compliance with care planning expectations.

The oversight of care planning is a feature of the Trust rapid improvement programme. This is a Trust board supported priority focus to improve the quality within adult mental health (AMH) service inpatients wards. With regards care planning the emphasis of this work has been the engagement of our patients regarding their experience of care planning. Secondly the Trust is looking to move to an alternative care planning tool through the Dialog+ model. This is an evidence-based tool which has received positive feedback in their evaluations. AMH’s Head of Nursing colleagues are involved in supporting the implementation plans. Additionally, an allocated worker model is in the implementation phased at Highbury Hospital. This sets a key expectation of allocated staff members to have a deep understanding of individual care plans on each clinical shift to ensure effective and meaningful care is offered in line with said care plan. This will be in addition to a named nursing team.

Regarding risk assessments this is also a feature of the rapid improvement work with clear emphasis in the understanding of risk within the clinical areas. A key element of this is the introduction of safety huddles which is within the pilot stage within AMH before role out to all wards. These safety huddles support the team to reflect on the dynamic risks within the ward ensuring risk is well understood and shared amongst the team to ensure effective robust plans are in place.

Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and literature. Nottinghamshire Healthcare’s Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with NHSE and other leaders in suicide prevention to scope good practice and share learning. Updated guidance is reflected in the Trust’s new Clinical Risk and Safety Policy (due to be ratified early May 2024) and guidance documents relating to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self-harm have been developed. Audits, and risk and safety forms within healthcare records (including risk and safety assessments, formulation and care and safety planning forms) are being reviewed and updated to reflect the latest guidance, and support improvement and safety. In April 2024, the Trust also commenced development of a Trust Clinical Risk and Safety Panel, to provide governance and guidance relating to clinical risk and safety, including policy, training, and support for complex cases.

Suicide prevention and self-harm training was reviewed and enhanced in early 2024, to provide assurance re quality and oversight, and include updated self-harm awareness and response training in addition to suicide prevention awareness and response training for compliance with NICE guidelines and to support consistent language, content, and approach. This training continues to be supported by Learning and Organisational

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

Development but is now coordinated and assurance provided by the Trust Lead for Self- harm and Suicide Prevention and the suicide prevention training team regarding quality and consistency of training. The Suicide Prevention team also work with clinical teams to support implementation of good practice and guidance in relation to self-harm and suicide prevention with a further 8 colleagues from within the Care Groups becoming licenced Train the Trainers in March 2024 with supervision and support (including co-delivery) from the training team to support further implementation.

Mandatory training for risk is at 85% for Redwood 1 at Highbury Hospital. This is monitored by senior leads to support staff to attended to this training. Additional training that may support staff’s confidence with regards risk is being considered to augment existing risk assessment training.

The need for clear risk assessment and care planning lead to the review of MDT records and an improved template to capture discussions and plans in a more meaningful manner has been completed by AMH Clinical Directors. This has been launched and is due for full evaluation in July 2024.

2. Inadequate system of allocating a named nurse to patients and recording the same I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises.

Response:

It was recognised within the inquest that an urgent review was needed for the system of named nursing within AMH inpatient acute wards. This work is being led by the Head of Nursing at Highbury Hospital. The expectation would be for named nurses to be allocated on admission and wherever possible this should be the admitting nurse due to continuity of care. Where this is not possible for example where a staff member will be taking some annual leave, an alternative nurse anticipated to be working within the 72 hours will be allocated. This is current work in progress and in the engagement phase with the ward teams.

To ensure that all patients know of their named nurses and that there is a clear record of this an interim measure has been agreed for the named nurse to be cleared detailed within the care plan. For the patients experience this will mean that upon receipt of their care plan they will have this detail to hand and will be confident of who their named nurse is. This will also provide a record should the identification of the named nurse be required for

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

governance processes such as an investigation. Audits will now be ongoing to support oversight and compliance.

Longer term the allocated worker, as detailed in point 1, and the named nurse work will feature as part of the nurse’s development through training, coaching and support to fully understand the roles and the importance this has for high quality and safe patient care.

3. Inadequate skills/knowledge/training on how to encourage patients to engage I am concerned that clinical, nursing and/or support staff may not currently have sufficient skills or knowledge in dealing with patients who appear unable or unwilling to engage with staff and/or treatment.

Response:

Mr. Tucker had very clear reasons for seeking an alternative bed which may have supported his engagement with the team. Whilst Mr. Tucker was recorded on a transfer list seeking an alternative bed this process was no robust enough. The process has since been reviewed which saw the transfer procedure reviewed to ensure the full MDT was explicitly clear of the need for transfer and rationale for this. In addition, our bed management recording has been amended to hold a single bed list to include all admissions and transfers. This now offers a clear oversight and allows for prioritisation based on all known factors.

To further support clinical training oversight, the Trust has a newly formed Clinical education steering group which is a strategically led group with representation from senior staff within learning and development and clinical practice. The remit for this group is to carry out a comprehensive review of all training, both mandatory, essential and desirable, across the whole of the trust to align with the needs of each care group. The group will carry our mapping exercises on current provision and sign off new training to ensure it meets the quality and safety requirements for the staff attending. The review will align with the NHSE optimize, rationalize and reform plan. The group has clear governance procedures which will guide the review and implementation. It will allow clear data to be produced so that the care group needs can be met in a timely manner, by adapting the training delivered according to the needs of the service.

More specifically, additional training has commenced to support staff which has included additional suicide awareness through formal training over January 2024 – 78% of Redwood 1 staff attended during this month, additional training is being arranged for those unable to attend in January and new starters that have joined the team since. Alongside this bitesize training sessions were made available, and training is in development regarding positive behavioural support. The Trust have invested in additional self-harm and suicide prevention training – Storm which is due to start to roll out in June 2024.

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

I would once again express our deepest condolences to Mr. Tucker’s family.

Report sections

Investigation and inquest

On 11 May 2022 I commenced an investigation into the death of Daniel Mark Edward TUCKER aged 24. The investigation concluded at the end of the inquest, conducted before a jury, on 06 February 2024. The jury returned a narrative conclusion.

Circumstances of the death

Daniel (referred to as Dan at the request of his family) was detained pursuant to s.2 of the Mental Health Act 1983 on Saturday 9th April 2022 and admitted to Redwood 1, Highbury Hospital, Nottingham the following day. He had a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and a long history of mental ill health, including multiple instances of self-harm and suicidal thoughts and behaviour. Following a period of relative stability, he presented at A&E on 5th April 2022 after an episode of deliberate self-harm. He disclosed suicidal thoughts. He was referred to the Crisis Resolution Home Treatment Team that day but was detained on 9th April after disclosing that he had not only an intention but a plan to end his life, details of which he declined to disclose. Due to previous negative experiences on Redwood 1, Dan requested a move to another ward. He declined nearly all attempts by staff to engage with him and was consistently described as low in mood, very withdrawn and largely confining himself to his bedroom. He was physically (though not formally) discharged following a Ward Round on 22nd April 2022. A clinical psychologist present at that Ward Round gave evidence that she raised concerns that his mental state and demeanour were not conducive to imminent discharge. Dan left Highbury Hospital at around 17:55 that day. At approximately 20:30, he ingested a lethal quantity of which he purchased prior to his detention and admission to Redwood 1. The jury found the following failings in Dan’s care (the first four of which were admitted) contributed to his death:  More should have been done to try and effect the move from Redwood 1 to another hospital/ward in line with Dan’s wishes.  There was a failure to allocate a Named Nurse and/or a failure of the allocated named nurse to carry out a 1:1 session with Dan during his admission.  There was a lack of exploration in the Ward Round on 22 April 2022 and/or a lack of documentation of an exploration in the Ward Round of the “plan” that Dan had to end his life before his admission.  There was a failure by ward staff to hand over information regarding a threat to ligate (noted in the handover sheet from 20 April 2022) to the Ward Round on the 22 April 2022.  A failure to record and take appropriate action following significant risk-related incidents (Daniel expressing an intention to self-harm) which occurred during Dan’s admission.  A failure to take proper account of all available relevant information concerning Dan’s risk when assessing his risk prior to discharge. The jury also found the following failings (the first three of which were admitted) but did not find these to have contributed to Dan’s death:  A failure to update Dan’s ward specific Care Plan and Risk Assessment documentation in RIO during his admission.  Dan had a Crisis Care Plan developed in August 2018 and updated in January 2019. There was a failure to update it in preparation for his discharge on 22 April 2022.  A failure to adequately discuss Dan's risk with Dan's carer prior to discharge.  A failure by the Trust to engage adequately with Dan’s family and/or carers either during his admission on Redwood 1 and/or at the point of discharge. The inquest heard evidence that Dan had openly discussed his plans to end his own life on a chat forum of the while detained at Highbury Hospital. It appears he also obtained information on as a method of suicide and where to source it, from that site.

Copies sent to

2. East Midlands Ambulance Service3. CQC

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2024-0115
Date of report: 29 February 2024
Coroner: Michael Wall
Coroner area: Nottingham City and Nottinghamshire

Responses identified

Responses identified 4 of 4

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Apr 2024.

Sent to

Department of Health and Social Care

NHS England

Nottinghamshire Healthcare NHS Foundation Trust

OFCOM

Source links

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Data: judiciary.uk under OGL.