Surrey NHS
Action Planned
The Trust is working with other acute NHS Trusts within Surrey as part of the Surrey Heartlands Mind & Body Programme. A mental health skills module for nurses working at Frimley began last year, and there is space for 30 students for the next cohort starting in March 2024. (AI summary)
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Dear Mr Stewart
Ryan Evans (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”)
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 20 December 2023, in relation to the inquest touching the death of Ryan Evans. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues from the relevant divisions.
In the PFD report, you highlighted a concern relevant to the Trust and Frimley Health NHS Foundation Trust (“Frimley”). In particular, you outline the additional evidence provided at the inquest by Frimley Health NHS Foundation Trust. We believe that the Trust did have adequate measures in place at the time of Mr Evans’ admission to Frimley Park Hospital and that, had we received a referral, we would have responded in a timely manner.
We were not present at the inquest to hear the additional evidence referred to as the Trust was not an Interested Person, nor was any member of staff asked to provide oral evidence. We were not therefore advised of the date of the inquest or aware of these concerns until receipt of the PFD Report. Had we been aware of your concerns at the time that the Prevention of Future Deaths evidence was heard (which we understand both Frimley and Southern Health NHS Foundation Trust were invited to provide), we would have been very willing to seek to provide you with assurance as to the processes for referral from the Emergency Department (“ED”) to our Psychiatric Liaison Services (“PLS”) based in the ED.
The Trust is commissioned to provide the PLS within Frimley Park Hospital. This includes all wards within the hospital, of which the Emergency Department is one. The PLS team has developed close working relationships with the clinicians operating across the hospital.
We are confident that the Trust has a robust process for referral and assessment of people presenting with mental health needs at Frimley Park Hospital. The PLS Standard Operating Policy also sets out guidance to assist those working at Frimley Park Hospital determine when a referral may be appropriate. This includes where a person presents with self-harm and suicidal ideation. We are aware 28 February 2024
Private and Confidential
that the Emergency Department at Frimley Park Hospital has introduced changes to their triage system in accordance with NICE and Royal College of Emergency Medicine (RCEM) guidelines, which we support.
As part of our continuous improvement work, we are constantly reviewing the PLS referral criteria. The Standard Operating Policy (dated February 2019) was most recently updated and ratified in October
2023. The Mental Health Lead at Frimley Park Hospital provided input as part of this process. The referral criteria provides guidance to clinicians but cannot prescribe for every scenario that may be presented. This is attached, as an aide memoir, to the referral form. The referral form allows for sufficient information to be shared with the PLS clinician assessing the referral. There is a low threshold for acceptance of referrals. Exercise of clinical judgment and relationships between the PLS and clinicians at Frimley Park Hospital are important aspects of decision making in this context.
PLS clinicians attend a monthly meeting with Emergency Department clinicians and Surrey Police which is an opportunity to discuss complex referrals and other issues such as identification of training needs. This collaborative working has enabled better understanding of mental health needs and the role of PLS as part of this.
Recognising the challenges presented by people attending the Emergency Department with physical and mental health needs, the Trust is also currently working with Frimley (as well as all four other acute NHS Trusts within Surrey) as part of the Surrey Heartlands Mind & Body Programme. This includes current work on the Enhanced Clinical Framework which is designed to promote a culture of excellence, continuous learning, and patient-centred care relating to people presenting with mental health needs in acute hospitals. The framework provides guiding principles and the bedrock to help improve access, experience and outcomes.
We are aware that a mental health skills module for nurses working at Frimley began last year, facilitated by New Buckinghamshire University. Twenty students completed the 12 week level 7 training and they will work as mental health champions in their respective areas. There is space for 30 students for the next cohort which will start in March 2024.
On behalf of the Trust, I would like to offer our sincere condolences to Mr Evans’ family for their loss.
Ryan Evans (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”)
Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 20 December 2023, in relation to the inquest touching the death of Ryan Evans. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues from the relevant divisions.
In the PFD report, you highlighted a concern relevant to the Trust and Frimley Health NHS Foundation Trust (“Frimley”). In particular, you outline the additional evidence provided at the inquest by Frimley Health NHS Foundation Trust. We believe that the Trust did have adequate measures in place at the time of Mr Evans’ admission to Frimley Park Hospital and that, had we received a referral, we would have responded in a timely manner.
We were not present at the inquest to hear the additional evidence referred to as the Trust was not an Interested Person, nor was any member of staff asked to provide oral evidence. We were not therefore advised of the date of the inquest or aware of these concerns until receipt of the PFD Report. Had we been aware of your concerns at the time that the Prevention of Future Deaths evidence was heard (which we understand both Frimley and Southern Health NHS Foundation Trust were invited to provide), we would have been very willing to seek to provide you with assurance as to the processes for referral from the Emergency Department (“ED”) to our Psychiatric Liaison Services (“PLS”) based in the ED.
The Trust is commissioned to provide the PLS within Frimley Park Hospital. This includes all wards within the hospital, of which the Emergency Department is one. The PLS team has developed close working relationships with the clinicians operating across the hospital.
We are confident that the Trust has a robust process for referral and assessment of people presenting with mental health needs at Frimley Park Hospital. The PLS Standard Operating Policy also sets out guidance to assist those working at Frimley Park Hospital determine when a referral may be appropriate. This includes where a person presents with self-harm and suicidal ideation. We are aware 28 February 2024
Private and Confidential
that the Emergency Department at Frimley Park Hospital has introduced changes to their triage system in accordance with NICE and Royal College of Emergency Medicine (RCEM) guidelines, which we support.
As part of our continuous improvement work, we are constantly reviewing the PLS referral criteria. The Standard Operating Policy (dated February 2019) was most recently updated and ratified in October
2023. The Mental Health Lead at Frimley Park Hospital provided input as part of this process. The referral criteria provides guidance to clinicians but cannot prescribe for every scenario that may be presented. This is attached, as an aide memoir, to the referral form. The referral form allows for sufficient information to be shared with the PLS clinician assessing the referral. There is a low threshold for acceptance of referrals. Exercise of clinical judgment and relationships between the PLS and clinicians at Frimley Park Hospital are important aspects of decision making in this context.
PLS clinicians attend a monthly meeting with Emergency Department clinicians and Surrey Police which is an opportunity to discuss complex referrals and other issues such as identification of training needs. This collaborative working has enabled better understanding of mental health needs and the role of PLS as part of this.
Recognising the challenges presented by people attending the Emergency Department with physical and mental health needs, the Trust is also currently working with Frimley (as well as all four other acute NHS Trusts within Surrey) as part of the Surrey Heartlands Mind & Body Programme. This includes current work on the Enhanced Clinical Framework which is designed to promote a culture of excellence, continuous learning, and patient-centred care relating to people presenting with mental health needs in acute hospitals. The framework provides guiding principles and the bedrock to help improve access, experience and outcomes.
We are aware that a mental health skills module for nurses working at Frimley began last year, facilitated by New Buckinghamshire University. Twenty students completed the 12 week level 7 training and they will work as mental health champions in their respective areas. There is space for 30 students for the next cohort which will start in March 2024.
On behalf of the Trust, I would like to offer our sincere condolences to Mr Evans’ family for their loss.