Philip Taylor

Coroner's concerns

AI summary

Insufficient information sharing, poor discharge planning, and delayed documentation transfer between the Health Board and private out-of-area psychiatric units were identified. The absence of written agreements for minimum standards and communication protocols creates a significant risk of future deaths.

View full coroner's concerns

|

a. The Health Board utilises facilities out of area for acute psychiatric care when there are no available beds in the NHS in North Wales. I was informed that the patients, however, remain the responsibility of the Health Board. During the deceased’s time at Ty Grosvenor it does not appear that any/all relevant information was shared between the two organisations e.g. deceased’s progress, medication, treatment etc, except for few telephone conversations.

b. There was no joined up planning or joint meeting between the Health Board and Ty Grosvenor prior to the deceased’s discharge.

c. The prescription and administration record together with a copy of the pre-admission paperwork were only sent to the Health Board two days after the deceased was discharged.

d. The discharge summary was emailed to the Health Board three days after discharge, but this was either not received by the Health Board or received and not acted upon. In fact, it is the deceased’s wife who had informed the Home Treatment Team that the deceased had been discharged. On knowing this, no one sought to request the discharge summary from Ty Grosvenor, even where there was a change in medication dosage.

e. There was no evidence at Inquest of any written agreement or standard operating procedure or similar between the Health Board and private facility as to minimum standard requirements or expectations between both organisations
e.g. what documentation should be shared, how it is to be shared, when documentation should be shared, the timeliness of sharing documentation etc.

f. It is concerning that such minimum standards are not set out and agreed between the Health Board and this private psychiatric unit in a situation where many patients are likely to be treated there. It is not known whether or not such minimum standards or Agreement exists with other out of area private units.

g. In the event that patients are to be treated in private units out of the area then there will be a risk of future deaths if such minimum standards regarding sharing of information and communication are not set and agreed between the Health Board and private facility. There had been no consideration of this as part of the actions arising from the Health Board’s own investigation.

Responses

2 respondents

Betsi Cadwaladr University Health Board NHS / Health Body

20 Mar 2024 PDF

Action Planned

Following an inquest a memorandum/alert was shared with MHLD staff as an immediate “make safe” notice. A fully ratified Standard Operating Procedure (SoP) will be implemented to provide clear direction for health board staff and providers, ensuring a coordinated approach to out of area placement management and optimize communication. The Health Board is reviewing completed proportionate reviews and action plans to identify and address issues and expect this review to be fully completed towards the latter end of summer 2024. (AI summary)

View full response

Dear Ms Robertson, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Philip David Taylor I write in response to the Regulation 28 Report to Prevent Future Deaths dated 02 February 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Phillip David Taylor. I would like to begin by offering my deepest condolences to the family and friends of Mr Taylor, and to apologise to them for the failures that were identified during the inquest that led to your notice. In the notice, you highlighted your concerns about the management of patients placed Out of Area by the Health Board for acute care when there are no available beds within North Wales. You specifically noted a lack of sharing of information, joined up planning meetings, the timely sharing of key documentation and lack of a standard operating procedure defining the standard requirements and expectations between the Health Board and independent providers. The Health Board recognises that the use of out of area acute beds is a necessity in the current climate and is a nationally recognised issue for all NHS providers. However, the Health Board is committed to ensuring that the safety and experience of those patients is not compromised. In response to the Notice, I requested our Mental Health and Learning Disabilities Division (MHLD) to consider your concerns and provide details of their plans to make our services as safe as possible, taking into account the learning from the inquest. After the inquest a memorandum/alert was shared with MHLD staff as an immediate “make safe” notice. This memorandum reinforced the requirements for the monitoring of out of area patients and key responsibilities for roles and wider teams. This memorandum was presented in each area of mental health through the established daily safety huddles, ensuring all staff understood the context of the communication, responsibilities and action. This was disseminated on 08 February 2024 and I can confirm that mental health A1 Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk

services in East, Centre and West are directly overseeing acute out of area patients within their services. All areas have stood up a formal weekly out of area monitoring meeting. The purpose of this meeting is to promote timely repatriation where possible, assurance that key clinical activity and standards are being met and that discharge plans are being implemented and actioned. These meetings are underpinned by terms of reference, agenda, minutes and a log of actions to be completed. Membership includes the multidisciplinary team, including Health and Social Care, Consultant and Medical staffing, Occupational Therapy, Home Treatment Team and Care Coordinators. Outcomes from the meetings are provided to Divisional Putting Things Right meetings and the weekly Divisional Senior Leadership meeting to ensure appropriate escalation arrangements can be put in place where required. The learning from the inquest of Mr Taylor has identified that a standard operating procedure is required (SoP) and must include the requirements for sharing information, joined up planning for repatriation and/or discharge and standards for the development and sharing of key documentation. A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024. For out of area acute placements, the health board uses providers’ identifed as part of the All Wales Commissioning Care Assurance and Performance framework, commissioned by the National Collaborative Commissioning Unit. These providers have qualified to be on the framework by undergoing a robust due diligence process including provision of evidence to demonstrate they are meeting required quality standards with regard to patient safety, quality and experience. The Health board currently uses 3 of the identified providers, including Elysium. Implementation of the fully ratified SoP, will provide clear direction for health board staff and providers on the framework and will ensure a coordinated approach to the management of out of area placement and optimise communication between all parties. I share your disappointment that the action plan presented at the inquest of Mr Taylor did not identify the need for stronger governance in relation to the management of acute out of area patients and I would like to advise you that the Health Board is currently reviewing completed proportionate reviews and action plans to identify and address issues such as this. We expect this review to be fully completed towards the latter end of summer 2024. A2

I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed. We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to the family and friends of Mr Taylor for their loss and I reiterate my sincere apologies to them for the concerns identified at inquest.

Elysium Healthcare Private Sector

25 Mar 2024 PDF

Disputed

Elysium Healthcare disputes the coroner's concerns regarding information sharing and the existence of a standard operating procedure, stating that information was shared and a framework agreement with information sharing requirements was in place. They highlight Betsi's lack of attendance at MDT meetings and assert that there is no risk of future deaths if their processes are properly followed. (AI summary)

View full response

Dear Madam

Report for the Prevention of Future Deaths (PFD) Inquest of Philip David Taylor

I refer to the letter from Mr Gittins, HM Senior Coroner for North Wales (East and Central) enclosing your Regulation 28 report dated 2 February 2024.

This letter comprises the response on behalf of Elysium Healthcare Limited, which operates Ty Grosvenor Hospital, Wrexham where Mr Taylor was an informal patient (that is, he was not detained under the Mental Health Act (MHA) (and his status is of particular relevance here)).

Elysium takes inquests very seriously. These are managed by our in-house legal team (with assistance from external solicitors where appropriate) to ensure courts have all the documentation and evidence requested, and families therefore have the closure of an inquest that is as full and effective as possible. Further, we support our staff attending as witnesses and send legal representation whenever this is required. Unfortunately, I regret, for the reasons set out below, that something seems to have gone wrong in this particular instance as the inference behind and basis upon which the report has been issued does not properly reflect the factual position. For some reason, none of our staff were called to attend the

inquest, or asked in advance about these matters, and thus we were not given the opportunity to address the issues to which the PFD report refers.

I am sorry that it has thus appeared necessary to address a report to Elysium but I will deal with the matters of concern that you have raised as follows:

Not sharing information except a few telephone calls That is not a fair reflection of the factual position. The reality is:-
1. There were three ward rounds during Mr Taylor’s stay at the hospital on 31 July, 7 August and 14 August 2023. Betsi Cadwaladr University Health Board (“Betsi”) were invited to all of them (via a Teams invitation) but did not attend any.

Under the terms of the NHS Wales Framework Agreement (see further below), to which Elysium is a party, Elysium enters ward round details through the informatics system in use by NHS Wales (the Commissioning Care Assurance and Performance System or “CCAPS”) live during a ward round but Betsi do not avail themselves of this facility (unlike other Welsh Commissioners) because they do not enter their patients into that electronic system. NHS Wales are frustrated by this and have apparently provided training to Betsi but, as they failed to register Mr Taylor, their lack of use of the system meant they did not have that ward round information live.

2. The third ward round took place on 14 August. Mr Taylor wished to leave. He was an informal patient. He did not meet the criteria for detention under the MHA. Nor did he lack capacity so a deprivation of liberty under the Mental Capacity Act was not available. He had to be discharged as there was accordingly no lawful basis to refuse this. It was agreed that to enable this to take place in an orderly fashion he would leave the next day. Elysium had no alternative but to proceed with this.

3. On 15 August, before Mr Taylor left the hospital, Elysium’s charge nurse at Ty Grosvenor phoned the Betsi home treatment team (HTT) to inform them of the discharge. They said they would not be seeing Mr Taylor until the following day, so on the next day the hospital followed up by emailing to the HTT the requisite risk matrix and care notes. These documents would serve to provide a full brief to the HTT. No request for additional information was forthcoming from the HTT.

4. On 17 August Elysium received a telephone call from Betsi who stated they were assessing Mr Taylor at 11 o’clock that day (not the previous day as they had previously assured Elysium they would be doing). The documents referred to above had not been received so these were re- sent immediately.

5. This is, therefore, as far as Elysium is concerned, not a case where the facts suggest a risk of future deaths in relation to the role of Elysium. Mr Taylor was an informal patient and was assessed as low risk. His details were already well known to Betsi who had summarised his position when referring him to Elysium in the first place. They had been informed by

telephone of the discharge and provided with the information set out above before their post- discharge visit. There was ample time for an assessment and any intervention to take place based on the information circulated prior to the date of Mr Taylor’s sad death on 23 August.

There was no joint discharge meeting.

That is factually correct but the context is important because:-

i. Betsi did not attend the multi-disciplinary team (MDT) meetings to which they were invited
ii. Betsi did not have the live ward round information because of their failure to register the patient through CCAPS
iii. Mr Taylor was a voluntary patient who wanted to leave. There was no legal basis to detain him, and therefore no basis to delay that discharge to seek to arrange a joint discharge meeting
iv. This is not a case where the facts indicate that the lack of a discharge meeting gives rise to a risk of future deaths because relevant information was passed on to Betsi, Mr Taylor was assessed as a low risk informal patient who had the right to leave anyway, and the Betsi HTT had ample time to intervene (if indeed that was necessary, foreseeable or reasonable) prior to his death.

The prescription, pre-admission and admission paperwork was only sent to Betsi after the death and The discharge letter was only sent after the death This is also factually correct. However, as is apparent from what is set out above, Mr Taylor was a voluntary patient who wished to leave. There was no legal basis to detain him and his departure therefore took place quickly. There was no legal framework to insist to the contrary. Information was sent to Betsi by email and telephone as set out above. The discharge letter was not sent at the point of discharge as this is almost always not possible except with a long-planned discharge or transfer. Discharge letters have to be prepared, typed and checked carefully before they can be sent and that almost invariably takes at least 48-72 hours. The Elysium internal policy is to ensure the relevant information is given to home teams so that they can follow up within 72 hours (as was done here). In case it is of assistance to put the issue in context, the contract we have with Surrey requires that information only within 5 days of discharge.

It was Mr Taylor’s wife who informed the HTT of discharge. This is factually incorrect. As is apparent from the information above, the HTT were informed of the discharge by telephone on 15 August before Mr Taylor left the hospital.

In addition, it should be noted that Mr Taylor was discharged with two weeks of medication to take out. There is no standard operating procedure or agreement regarding sharing information. This is incorrect. Following a formal procurement exercise, a framework agreement of 138 pages was put in place with Elysium for Welsh NHS patients by Velindre University NHS Trust dated 1 April 2022. Betsi is one of several Welsh Authorities that expressly have the benefit of this Framework Agreement. The agreement sets out at length at paragraph 14 and schedule 6 the information sharing requirements. It should be noted that despite the careful procurement exercise by the qualified NHS professionals who led this, there is no contractual requirement for discharge letters to be sent concurrently with the discharge of the patient. It should also be noted that schedule 2 of the contract has a detailed service specification. At paragraph 1.4 this provides that all professionals involved in a patient’s care should attend the MDT. Sadly, as is apparent from what is set out above, Betsi did not attend the three MDT meetings for Mr Taylor.

I hope that this information provides helpful background evidence to this matter which I infer was not available at the inquest. As I have indicated above, given what is set out in this letter, as far as Elysium is concerned, there is no risk of future deaths created by the processes outlined above if they are properly followed.

Report sections

Investigation and inquest

On 1 September 2023 an investigation was commenced into the death of Philip David Taylor (DOB 12/6/55) who died on 23 August 2023. The investigation concluded at the end of the inquest on 30 January 2024. The conclusion of the inquest was suicide.

Circumstances of the death

The circumstances of the death are as follows :-

Philip David Taylor had a short history of mental health difficulties from April 2023 for which he was receiving support from the Community Mental Health Team and Home Treatment Team, part of the Betsi Cadwaladr University Local Health Board. On 28 July 2023 he was admitted as an informal patient to a private psychiatric unit at Elysium Ty Grosvenor Hospital, Wrexham. He was admitted to there as there were no beds available within the NHS North Wales area. He was discharged on 15 August 2023 to the care of the Home Treatment Team. On 23 August 2023 Philip Taylor died by suicide at his home address.

Similar PFD reports

Shared signals

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Part of a series

Source links