Source · Prevention of Future Deaths

Sarah Holmes

Ref: 2023-0383 Date: 11 Oct 2023 Coroner: Janine Richards Area: County Durham and Darlington Responses identified: 5 / 2 View PDF

The Trust routinely experienced substantial and prolonged delays in completing serious incident investigations, far exceeding national guidelines, potentially allowing lethal hazards to persist longer than necessary.

Date 11 Oct 2023

56-day deadline 25 Dec 2023 est.

Responses identified 5 of 2

Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

(1) The serious incident investigation by the Trust has been substantially delayed. Sarah died on the 10th of July 2022 and the Trust confirmed to the Coroner’s service that there was to be a serious incident investigation on the 26th July 2022. The serious incident investigation remained unallocated and with no timeframe for completion for over 7 months and on the 13th of March 2023 as this remained the position I listed this case for Inquest on the 24th of April 2023. On the 17th April 2023 I was alerted by deceased’s family to possible progress in respect of the serious incident investigation in this case, subsequent to their formal complaint to the Trust. After making enquiries of the Trust I was informed that the report would be available at the end of May 2023 and I therefore acceded to a family request to adjourn the final hearing given the short delay this would cause. On the 25th of April 2023 the Coronial service was informed that in fact that it was unlikely that the report would be finalised by May and would be’ likely end of July/August time’. On the 26th of June I was informed that the report would now not be available until the ‘end of September/beginning of October’ and that the initial dates given were “too ambitious”. The case was listed to commence on the 16th of November 2023 on that basis. On the 28th of July the deceased’s family notified me of a likely further delay in the report being available due to the author’s sick leave from work. The Trust offered reassurance that the report remained due ‘end of September/beginning of October’. On the 28th of September a Pre Inquest Review Hearing was held in relation to a separate discrete issue and I was informed that the report was to be further delayed and would not be available until the end of October.

(2) The NHS framework sets out clearly a timescale of 60 working days for the completion of investigation reports and highlights the importance of working in an open, honest and transparent way. One of the key underpinning principles in the management of all serious incidents is that they should be timely and responsive. The purpose of the investigation is to ensure that weaknesses in a system or process are identified to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again.

(3) If the final version report is received by the end of October it will be some 15 months since Sarah’s death and some 13 months outside the NHS framework. This is neither timely nor responsive.

(4) I have previously issued a PFD report in relation to this issue as has the Senior Coroner for Durham and Darlington, Mr Chipperfield, who stated that Tees Esk and Wear Valleys NHS Foundation Trust routinely fails, to employ, in a timely way, nationally recognised process and procedure designed to prevent avoidable death. In permitting delay of “serious incident” investigations, TEWV may: (i) permit lethal hazard to persist for longer than necessary; and (ii) compromise the quality of such investigations and hence their value in preventing avoidable deaths.   (5) I am concerned that these dangers persist, despite the Trust’s response to previous PFD reports and their assurances that remedial action was being taken to eradicate the delays, and as a result it is my statutory duty to make this further report.

Responses

5 respondents

Independent Office for Police Conduct Regulator / Inspectorate

16 Jan 2024 PDF

Noted

The IOPC expresses condolences and explains its role in the police complaints system. It details the recommendations made to Durham Constabulary, their response, and the IOPC's follow-up actions to seek further clarity on the acceptance of recommendations. (AI summary)

View full response

Dear Madam,

Re: Inquest of Sarah Holmes

I am writing with regards to the inquest of Sarah Holmes, and thank you for your report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.

Thanks also to your office for providing information subsequent to that report.

This is a tragic set of circumstances, and I extend my most sincere condolences to Sarah’s family and friends.

1. I am grateful for the opportunity to consider and respond to matters raised in your report which go towards the work of the IOPC.

2. You will know that the IOPC has a significant role to play in the Police Complaints System. And you will know of course that the “police complaints system” is about more than complaints against the Police, also covering “recordable conduct” relating to persons serving with the police and as in this case, Deaths and Serious Injuries which occur following contact with the police.

3. It is the duty of a Chief Officer to refer a Death and Serious Injury (DSI) matter to the IOPC. Having received a referral, we may thereafter determine that it is necessary for the matter to be investigated. Where that arises, we will go on to determine the form which the investigation should take. We may determine that it is appropriate for the investigation to take the form of an investigation by the appropriate authority on its own behalf. This is often referred to as a “local investigation”.

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4. Where a person conducting a “local investigation” does not identify an indication that a person serving with the police may have a) committed a criminal offence, or b) behaved in a manner which would justify the bringing of disciplinary proceedings, the person investigating shall submit a copy of the investigation report to us.

5. That describes some of the relevant statutory responsibilities in instances such as this. There are of course responsibilities that the we continue to have, such as deciding whether we agree (or not) that the investigation gives an indication of those things that I have detailed in paragraph 4. I am conscious however that your report raises several specific concerns which I should turn to, and that the purpose here is to identify action that can be taken to prevent future deaths.

6. Paragraphs 5 and 7 of your Report involve issues which would appear to relate to the work of the IOPC to which I shall now respond.

Paragraph (5) “I am concerned that there was a lack of reflection on the part of the Police and there is no formal procedure by which lessons can be learnt from such serious incidents, the professional standards department and IOPC having a limited remit in this regard.”

7. “Learning”, at an individual departmental and Force level, is an important part of the police complaints system. At a departmental and Force level (in fact, at a national level), learning is formally “built into” the complaints system via Section 10 and Paragraph 28A of Schedule 3, Police Reform Act 2002.

8. “Leading Improvement”, of which “learning” is a vital part, is a key area of focus for the IOPC. We are mindful that there are opportunities for learning not just around the behaviour of individuals, but also around issues such as policy, training, practice, leadership and culture.

9. Please consider the following data to be provisional, in the sense that it may yet change, but currently, our data suggests that in the last full reporting year, 1 April 2022 to 31 March 2023, we made 176 organisational learning recommendations. of which 134 were made under Paragraph 28A of the Police Reform Act, where recipients have a legal obligation to respond. 117 were accepted, 9 not accepted and responses are awaited for 8 recommendations.

10. I appreciate that the volume of recommendations may not appear to be overwhelming, but this is generally an area of growth where we tend to be making more recommendations for learning, year on year, certainly in cases which we have not investigated ourselves.

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11. It is worth reiterating that our recommendations are not mandatory. They may be refused by the person or organisation to whom they are made. We cannot require any person to accept a learning recommendation. An IOPC learning recommendation should be practicable and meaningful, but the recipient is entitled to hold a differing view as to whether the learning recommendation is both justified, and thereafter practicable and meaningful.

12. While a recipient is not obliged to accept a recommendation, they are legally obliged to respond to a recommendation made under Paragraph 28A (as here), and responses will generally be published. This includes where a recipient does not accept a recommendation, as an explanation as to why it is not accepted is also required.

13. Where a recommendation is made by the IOPC, and rejected by the recipient, it still has importance, as it can contribute to an evidence base for future conversations and future learning opportunities.

14. I think it could be said that there is therefore, a formal procedure by which learning can be identified from such serious events. If a matter is defined as a Death or Serious Injury incident, it will often have to be investigated. The terms of reference for such an investigation will usually include, among other things, whether there is an opportunity for learning. In cases involving the IOPC, as here, we will expressly consider the opportunities for learning.

15. I think this shows that learning is an important area for the IOPC. But I fully accept that our role could be considered to be of “limited remit”, in that we do not of course see all cases, and that our recommendations are simply that – recommendations.

16. We did have a statutory and formal involvement in this tragic case, and we would hope that the formal involvement of the Professional Standards Department and the IOPC would help precipitate some reflection. “The system” itself does encourage reflection. I would add here, that this matter was formally investigated by the Professional Standards Department, and the Investigating Officer, the IOPC and thereafter the Appropriate Authority, were all relatively aligned as to the opportunities and need for learning.

17. Regarding any lack of refection in respect of individuals, forgive me but I do not believe it would be appropriate for me to comment further, beyond the findings that we reached on the case. I believe that such matters should better be addressed by the Appropriate Authority and the Police and Crime Commissioner.

Paragraph 7 “I am concerned that IOPC recommendation 3 in this case, namely that the messaging from senior management to the control room was a

4 negative factor in this case, and should be revisited, was not accepted by senior officers who gave evidence at the Inquest.”

18. I understand that the evidence from officers at the Inquest was that they did not agree with our recommendation, asserting that policing decisions were not influenced by SMT messaging, and instead were entirely based upon risk. Our determination was not that policing decisions here were not risk based. But our view is still, without being determinative, that there is evidence which could suggest that the messaging from the SMT did negatively influence the decision making of control room staff.

19. The substance of that messaging features in the FIM’s statement, provided during the investigation, and it is difficult to understand why it would feature in that way if the officer did not think it was relevant.

20. We have not taken a definitive position on whether policing decisions in this matter were entirely appropriate and properly reflective of the risk that presented at the time, and so it would not be appropriate for me to do so at this stage. However we are on record as acknowledging that police staff, applying a THRIVE assessment, had tried to deploy Police at 14:37 on 11 July 2022, and that this decision was reversed by the FIM.

21. It is also appropriate to point out that the investigation conducted by the Professional Standards Department did consider that log in particular. It is understandable that each officer must conduct their own assessment of the presenting risk and reach their own conclusions as to the available options. But to be clear, the investigation by the Professional Standards Department expressed the opinion of the Investigating Officer, that there had been sufficient grounds at that time for police officers to enter Ms Holmes’ address under Section 17 PACE.

22. We issued some contextual narrative around the recommendations that we made in this case. That narrative said,

“The comments made by the FIM and supervisor could suggest that the message passed by the Senior Management Team had negatively influenced the FIM and Supervisor’s decision making in respect of this incident…”.

23. Our view was that there was evidence which could suggest that the messaging from the Senior Management Team had negatively influenced the FIM and Supervisor’s decision making. We did not definitely conclude that that was the case, as our role is not to be that determinative on matters which would ordinarily be decided by a Court or other tribunal.

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24. We did receive a reply from the appropriate authority to our recommendation on 21 April 2023. That reply said,

“Durham Constabulary acknowledges that messaging from Senior Management has influenced the Force Incident Manager’s decision making in this case. This was discussed at a recent development day for Force Incident Managers with a view to clarifying the force position and ensuring that operational decisions are always based on an objective assessment of threat, harm, and risk. The implementation of RCRP/Op Accelerate (see response to 22/172495/001, above) will further clarify the force position and will support staff in making future risk-based decisions”.

25. We have taken the appropriate authority’s acceptance of our recommendations at face value and having been assured of the quick time resolution to our recommendations, that would ordinarily be an end to our involvement in the area of learning in a matter such as this.

26. The evidence provided by the officers at the inquest does not sit entirely squarely with the acceptance of our recommendation by the appropriate authority, and we will be seeking some further clarity from them in this regard.

27. We understand that officers are expected to provide their own accounts and express their own views when giving evidence, and that this will not always align with how those things have been viewed by the appropriate authority. But it is difficult to see how learning can truly be successful if, at the end of the process, it does not encourage introspection and reflection at an individual level.

Please do not hesitate to contact me if there is anything else that we may help with or clarify.

Department for Work and Pensions Central Government

8 Feb 2024 PDF

Noted

DWP expresses condolences and states that existing guidance and support are adequate for vulnerable customers. They describe the call-back procedure followed and note that the ESA agent did not stop Ms Holmes’ benefit pending receipt of a PW1 form, indicating recognition of her vulnerabilities. (AI summary)

View full response

Dear Ms Richards,

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS I write on behalf of the Department for Work and Pensions’ (“DWP”) in response to your Prevention of Future Deaths Report made under Regulation 28 of the Coroners (Investigations) Regulations
2013. I would like to take this opportunity to express my condolences, both personally and on behalf of DWP, to Ms Holmes’ family. You raised the following concerns in your report: (1) The central cause of Sarah’s mental health deterioration was her concerns in relation to a difficulty that had arisen in respect of her benefits, and the prospective actions she feared would be taken by the Department of Work and Pensions as a result. (2) The DWP were aware that Sarah had mental illness and that she was “very distressed” about the difficulty which had arisen, namely that she had earnt very slightly above, for a very short period of time, the permitted level for the benefit she was in receipt of. (3) I have a concern about how the DWP interact with the vulnerable when there has been a difficulty in relation to benefits. (4) Although the recordings of the calls were not available to me, I am satisfied that Sarah was made aware of the possible actions available to the DWP. These actions

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included the possibility of closing her claim, referring the overpayment, and requiring Sarah to make a new claim for Universal credit, in place of the ESA benefit which had been payable to her as an individual with a disability or health condition that affects how much they can work. No new claim for ESA could be made in this eventuality. I am concerned about both the availability of disproportionate action and the communication of this. (5) I understand that the DWP are undertaking an internal investigation into this case, and that they consider all correct procedures were followed in terms of call handling, but I remain concerned that greater care needs to be taken in relation to how such prospective actions are communicated to those the Department knows to be vulnerable and distressed. DWP interaction with vulnerable customers The department supports millions of people every year and its top priority is that they get the benefits to which they are entitled at the right time, and to ensure they receive a supportive and compassionate service. The department is bound by laws which dictate how the benefit system is delivered and clearly define a person’s entitlement to benefit. The Social Security Administration Act 1992 is the main piece of legislation dealing with the administration of social security benefits in the United Kingdom. Under this legislation, DWP can only pay benefits to those who are legally entitled. However, partly because of processes it has in place to support vulnerable claimants, the department continued to pay Ms Holmes’ benefit even when a question arose about her entitlement. If a decision had been made to close Ms Holmes’ Employment and Support Allowance (ESA) claim due to her earnings exceeding the permitted work (PW) limits, she would have had to make a new benefit claim. Relevantly, Ms Holmes’ claim was for Income Related ESA which no longer accepts applications. In usual circumstances, Ms Holmes would have been directed to make a new claim to Universal Credit. To support the application of this legislation the department has robust policies and guidance in place to support colleagues dealing with customers it identifies as vulnerable. I describe some of these below. Customer Experience Directorate The Customer Experience Directorate was created in 2019 to co-ordinate policy development, guidance, and learning, as well as monitoring the implementation of change. Through this directorate the department is examining how it listens and learns as an organisation using customer experiences, insight and data to improve the service it offers to its customers. The Customer Experience Advanced Support Team The Customer Experience Advanced Support Team (CEAST) for Working Age (WA, the business area ESA sits under) was established in January 2021. Its function is to support DWP colleagues and external partners who identify customers who are vulnerable, or have complex needs, and who therefore need more advanced support in order to comply with the statutory requirements of the benefit. WA CEAST work with Vulnerable Customer Champions (further details provided below) to provide specialist support to vulnerable customers and work closely with colleagues across DWP to resolve any complaints raised. Additional checks before withdrawal of benefits from vulnerable customers

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The department has reviewed the processes in place where existing benefits are suspended or stopped and has put in place additional steps to check on the wellbeing and support needs of customers it identifies as vulnerable. For example, Stopping Payments guidance introduced in 2020 ensures that payments are not stopped or suspended while the department considers a customer’s vulnerability. Measures in place to support vulnerable customers DWP looks to maximise opportunities to signpost vulnerable customers towards support. The department wants to ensure that chances to flag concerns to agencies with statutory safeguarding responsibilities are not missed. DWP frequently collaborates with these agencies. For individual customers, the department can liaise with health and social services to consider next steps, contact GPs for evidence for disability benefits decisions, or offer a voluntary referral to local authority housing teams (in England) for people who may be homeless or threatened with homelessness. The role of the Vulnerable Customer Champion (VCC) was implemented to provide additional support to customers. VCCs help support Decision Makers to make more informed decisions when dealing with vulnerable customers, particularly those that fail to attend Work Capability Assessments or do not engage with DWP as required under the terms of their benefit entitlement. The department’s national network of Visiting Officers allows DWP to meet the needs of customers with complex requirements who may be unable to access its services. This includes vulnerable customers and those needing additional support. Disability Employment Advisers have extensive knowledge of the support available enabling customers with health conditions and disabilities to prepare for work and move into and remain in employment. They work with stakeholders and healthcare professionals meeting customer needs. The department also has a detailed mental health training package which all customer facing colleagues undertake. This provides colleagues with learning that they can then apply to the different scenarios with which they may be faced. The training includes modules on appropriate actions to take to support customers with vulnerabilities including mental health issues. The package is constantly evolving, and work is ongoing to further strengthen guidance and training as part of continuous improvement activities. These activities benefit all our customers, especially the many vulnerable people who rely upon us. One of these improvements is the introduction of the Serious Case Panel, which was set up in late 2019. The Serious Case Panel meets quarterly considering themes and issues that have arisen across DWP service lines, in order to agree changes and improvements. It does not investigate individual cases but considers themes arising from a range of sources, including Internal Process Reviews, frontline feedback and Independent Case Examiner reports. The minutes of its meetings are published on the GOV.UK website. DWP communication with Ms Holmes regarding the possible effects of her work on her Employment and Support Allowance claim Departmental guidance on supporting vulnerable ESA customers requires details of any incapacity to be recorded on a customer’s account. When a call handler accesses the customer’s account, details of the incapacity are available on screen as primary and secondary disabilities. The purpose of this is to ensure that call handlers are aware of any health conditions which may impact a customer and require them to tailor their communication accordingly.

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DWP provides call handlers with training that helps them understand some of the issues that people with mental health conditions might face. However, they are not medically trained and DWP does not expect call handlers to have a detailed understanding of individual mental health conditions. The existing service assurance process includes the requirement for call handlers to check customer records for any additional needs each time a customer contacts the department. This, alongside the incapacity banner and tailored training, enables colleagues to identify and be mindful of a customer’s vulnerability or additional needs. This means that each interaction will be assessed against the information known at that time, allowing us to adapt to the individual’s circumstances. As you are aware, Ms Holmes was in receipt of both ESA and Personal Independence Payment (PIP) at the time of her death. Neither of these benefits required Ms Holmes to routinely attend her local Jobcentre, nor did she have regular interactions with DWP once she had been assessed as eligible to receive each benefit. Ms Holmes’ entitlement to PIP began on 21 March 2017 and remained until her death. DWP were not aware of Ms Holmes’ worries regarding exaggerating her health conditions on her PIP application, nor the impact it was having on her mental health as stated by the NHS and Police at the inquest. Her payments continued until her death. Similarly, her entitlement to ESA began on 5 April 2017 and remained until her death. ESA payments continued despite the doubt of entitlement in relation to Ms Holmes’ permitted work, which I will come to next. Ms Holmes telephoned the ESA enquiry line at 11:20 on 4 July 2023 as she thought she might have earned over the permitted work limit. The primary incapacities listed on Ms Holmes’ account were, “debility (other)” and “mental illness”. The note of the initial call from Ms Holmes stated that she was “very distressed”, however there was no mention of her expressing suicidal thoughts or any intention to harm herself. The telephony agent recognised that Ms Holmes was distressed, as demonstrated by the note they recorded on the computer system, which meant that the distress would be known to future colleagues. The telephony agent also arranged for a 3-hour call-back because they were unable to fully answer her query. The call back procedure involves an electronic message being sent to the site to which the customer is attached in order for a processing agent to make contact. Arranging for someone to contact the customer within 3 hours is the correct procedure in circumstances where a customer appears distressed but does not indicate that they are suicidal or at risk of harming themselves. A telephone call was made to Ms Holmes later that day at 14:04, in accordance with DWP guidance. The call notes confirm that “earning over the limit was discussed” and that Ms Holmes “advise[d] she will be reducing her hours to earn under PW limit and will send in PW1 form”. There is no mention of suicidal thoughts or an intention to harm, therefore no further action would have been required following this call. The ESA agent did not stop Ms Holmes’ benefit pending the receipt of a PW1 form even though her benefit entitlement was in doubt. This action indicates that Ms Holmes’ vulnerabilities were recognised, and the department’s Stopping Payment guidance had been followed. Ms Holmes’ PW1 form, along with proof of earnings, was received by the department on 14 July 2023. No further action was taken by DWP in relation to Ms Holmes’ ESA claim at that time and payments continued to be made to Ms Holmes until her death. Conclusion The full circumstances of this case have been reviewed, and the department is satisfied that there is appropriate guidance and support in place to allow vulnerable customers with complex needs access to benefits. In addition, the department is continually looking at ways to support vulnerable

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customers and to build on the support it currently provides. I trust that my response addresses your concerns and helps to assure you of the measures DWP currently has in place and the department’s commitment to developing such measures.

Tees Esk and Wear Valleys NHS / Health Body

9 Feb 2024 PDF

Action Taken

TEWV acknowledges concerns and details actions taken including confirming assessment methods, developing an interim policy to address disputes between police and mental health services, and preparing a patient safety briefing on actions to take when disputes arise with partner agencies. (AI summary)

View full response

Dear Ms Richards,

Re: Response to Report to Prevent Future Deaths issued on 08.12.2023 in relation to Sarah Holmes

I am writing to you in response to the Prevention of Future Death (PFD) Report issued to Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV, or the Trust) on 08.12.2023 following the inquest touching the death of Sarah Holmes. I note that the PFD Report issued has been directed to both TEWV and Durham Constabulary, on the basis you have concerns in respect of both organisations. I have provided a response below in respect of concerns 5(1) and 5(2) of your PFD Report as it appears those are the matters where your concerns are directed to TEWV (with the second of those also being a matter for the Police to respond to). I set out below your concerns, as well as the response from TEWV in respect of each matter:

1. The escalation in risks that Sarah presented with which included highly dangerous and impulsive thoughts of harming herself were not appropriately reflected in a robust safety plan, and it was not thought appropriate to liaise with family and friends who may have provided an essential safety net when Sarah was alone, and at obvious risk of the impulsive thoughts of self harming returning, in the absence of any ongoing professional support. Although evidence was heard about further training and improvements that have been made in respect of safety planning and around issues of confidentiality, I remained concerned that such issues could arise again.

The Trust acknowledges HM Assistant Coroner's concerns in respect of robust safety planning and this is a key priority across all Trust services.

To provide some context to our response in respect of Sarah's care, as confirmed at the inquest, the mental health worker(s) who assessed Sarah on 10 July 2022, acknowledged the varying methods of self harm that Sarah undertook in the days leading to her death, and took this into account as part of their assessment. It was heard that the plan for Sarah to return Office of the Chief Executive West Park Hospital Edward Pease Way Darlington Co Durham DL2 2TS

home was very much made in collaboration with her. The mental health worker had considered the safety plan that Sarah had written with her community team and all options for treatment, including hospital admission were explored with Sarah. It was confirmed that, as would be expected by the Trust, the clinicians tried to go with the least restrictive options that would be the most beneficial for the patient. It is not accepted by the Trust that there was an absence of any ongoing professional support; a plan was in place for the crisis team to contact Sarah on the evening of 10 July 2022, and for her Care Co-ordinator to continue to engage and support after the weekend, on 11 July 2022.

At the time the plan was formulated, Sarah was reported to be no longer feeling distressed, was future planning, positive, bright, chatty and talking spontaneously. She wanted to resolve the issues around her benefits and move forward, and was not having ongoing suicidal thoughts. She remained calm and engaging, with plans to see a friend later that afternoon.

It is acknowledged that the mental health workers asked Sarah if they could contact her family or friends, and she asked that they didn’t, as she did not want to worry her family when the crisis was felt to have passed. The inquest heard that the mental health workers felt they could not break confidentiality as there was not considered to be any immediate risk to Sarah, or others, and it was felt that Sarah had the capacity to make that decision. The mental health workers considered breaching confidentiality and weighed up the risk of Sarah going home without the support of a friend, against the risk of losing the strong therapeutic trusting relationship that Sarah had built up with services that would come with beaching her confidentiality. They felt that as Sarah had always worked with services, she would engage with the plan that she had collaboratively created on this occasion. The inquest heard how the mental health worker had reflected on this difficulty where patients have capacity to decline that family and friends are contacted, and has taken this on board in their future practice.

The Trust Serious Incident Investigation found that there was potentially a missed opportunity to contact Sarah's family or friends following the assessment, although this was a finding made with the benefit of hindsight.

Clinicians have a common law duty of confidentiality to patients such that personal information provided in confidence, such as between a patient and a healthcare professional, can only be disclosed with a legal authority or justification. Often, that legal authority will come from a patient's consent, but where that isn’t forthcoming, clinicians have to consider whether or not there is sufficient justification to breach a patient's confidentiality. The Trust recognises the difficult position clinicians are faced with when considering this, particularly where the patient is considered to have capacity, and the risks are not felt to be sufficiently high at that moment in time, to justify a breach.

In addition, clinicians also have their professional codes to adhere to. For nursing staff, the relevant section on the Nursing and Midwifery code provides:

"5. Respect people’s right to privacy and confidentiality

As a nurse, midwife or nursing associate, you owe a duty of confidentiality to all those who are receiving care. This includes making sure that they are informed about their care and that information about them is shared appropriately. To achieve this, you must:

5.1 respect a person’s right to privacy in all aspects of their care

5.2 make sure that people are informed about how and why information is used and shared by those who will be providing care

5.3 respect that a person’s right to privacy and confidentiality continues after they have died

5.4 share necessary information with other health and care professionals and agencies only when the interests of patient safety and public protection override the need for confidentiality

5.5 share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand."

The Trust has in place Common Sense Confidentiality guidance which considers how we work with carers where a service user states we cannot share information with their family / people close to them. This useful guidance is currently under review to provide further clarity to staff. In addition, discussions have already taken place at the Trust Fundamental Standards Group on 22 November 2023, to consider how this guidance can be further improved. Although plans are early in development, the intention is to create an updated guidance document to inform carers and support staff with decision making around confidentiality and information sharing. In addition, the Trust intends to develop a Trust-wide communication plan to disseminate the updated guidance. More information can be provided on this if required, as the information is collated and shared. However, in Sarah’s case this guidance is not likely to have led to a different decision being made by the clinicians who clearly thought this through.

It is noted that HM Assistant Coroner has acknowledged that evidence was heard at the inquest about the implementation of training and improvements around safety planning and confidentiality. To reiterate, in accordance with the action plan developed as a result of the Trust investigation, the Trust has already;

 Re-shared the safety summary and plan information from the Intouch page on the Trust Intranet with all team members to improve the knowledge and quality of safety summaries and plans. A copy of the first page of the 3 sections covered has been provided, however, the full documents can be shared if required – particularly that which relates to 'Creating and Updating a Safety Plan'.  A video providing a presentation on Safety Plans has been reshared with staff (https://vimeo.com/819417803/e915314e18?share=copy).

 Reflective practice sessions have now taken place to discuss the learning from this incident. There has also been discussion in huddles regarding safety planning and also on using the 'need to know' section to ensure core information is included in the safety plan. There has also been individual practitioner reflection around discussing risks with families, maintaining the trust in a therapeutic relationship and the circumstances where confidence has to be broken, to mitigate risk.  Literature is being developed and disseminated across the Trust in relation to key learning from the patient's journey. In addition, the Patient Safety Team will be undertaking Teams meetings to discuss the same.  Supervision sessions are carried out monthly to evidence that learning has been embedded.
• Carer awareness training has been carried out.  Consent and confidentiality has been discussed in Team meetings and supervision.

Separately to the learning identified as a result of the Trust investigation, HM Assistant Coroner is aware that the Trust has ongoing assurance around assessment and management of risk via the Quality Assurance Schedule (QAS). Senior Clinical Staff complete monthly audits to monitor the quality of narrative risk assessment and risk formulations and safety plans being produced by staff, the audits also consider evidence of co production with the service user and involvement of families / carers. The findings from these audits are then discussed and scrutinised at the Specialty Governance Group to identify whether any further action is required. Anything that remains a concern following the monthly audit is added to team meeting agendas for discussion to ensure that improvements can be implemented on a rolling basis. These actions also inform the overarching Adult Mental Health Action Plan which is reviewed and implemented by the governance action planning sub-group. The Quality Assurance Schedule is monitored by the Trust's Fundamental Standards Group and reports into the Care Group Board and Executive Board to ensure monitoring through the Trust's governance structures. NHS England, the ICS, the CQC and our partners see the audit results at the Quality Board which is a part of mandated support and focusses on the quality of care at TEWV. These results are showing an improving picture and identify the teams that require more support to improve.

2. There remains no policy in place between Mental Health Services and the Police as to the appropriate agency to undertake welfare checks and in particular there is no formal procedure to escalate matters when Mental Health professionals are concerned that life or limb is at risk and the Police do not agree and decline to assist. The College of Policing authorised guide to professional practice is clear that forces should ensure they have a policy on mental health and that although certain issues are required to be subject to local operating protocols with mental health, ambulance and other providers, there are other issues that should be determined by policy which would also ensure that services which operate across multiple health commissioners and providers to establish basic minimum requirements to determine police contribution to any local agreement with other providers.

At the time of Sarah's involvement with services, there was no specific policy in place between TEWV and Durham Constabulary as to the appropriate agency to undertake welfare checks, however, the agencies have worked together to develop an Interim Policy pending implementation of 'Right Care, Right Person' (RCRP). This Interim Policy will be entitled 'Interim Concern for Safety Escalation Policy' and has been collaboratively created between Durham Constabulary and the Trust. The Interim Policy 'provides a process to support decision making in relation to Police attendance at concern for safety incidents'. The aim of the Interim Policy is to provide 'a framework for escalating incidents of concern for safety and welfare checks, in which a decision is made for Police not to attend and partner agencies disagree'.

The position remains that only the Police have the power to force entry into a property under section 17 Police and Criminal Evidence Act 1984 (PACE) in circumstances to save life or limb, or prevent serious damage to property. TEWV staff are encouraged to always use their best endeavours to make enquiries by telephone and in person to establish the wellbeing of a patient where concerns have been raised.

I can reiterate the position that was explained at the inquest, that TEWV is currently working very closely with Durham Constabulary (along with other relevant stakeholders) with regard to the introduction of 'Right Care, Right Person' (RCRP). This will supersede the Interim Policy that has been developed and provide a more detailed Policy and framework for TEWV, Durham Constabulary and other partner organisations to work within in carrying out welfare checks. The Trust has attended an event in October and December 2023 with Durham Constabulary to establish work streams to implement the model, and is actively working with all partner agencies to progress this.

With regards to the concerns around escalation, the Interim Policy confirms that if there is a situation whereby Police and mental health services disagree on which agency should take primacy for the concern of welfare report, the Interim Policy will be triggered. It sets out the roles and responsibilities of each level of Police command and details of who concerns should be escalated to within each organisation where such disagreements arise. The Interim Policy also includes an out of hours provision.

In addition, prior to the implementation of the Interim Policy, the Trust committed to preparing a patient safety briefing regarding actions to be taken when a dispute arises with partner agencies. This has been completed and circulated to all clinical teams. I understand a copy was also provided to HM Assistant Coroner. The briefing provides a clear message to staff in respect of communication and escalation in circumstances where it is apparent that 'opinions of the level and immediacy of risk posted to an individual differs between organisations and that this may result in a delay in response'. Pending the introduction of RCRP, this provides staff with practical and appropriate guidance to so far as possible, manage patients in a safe and consistent manner.

I trust that this provides assurance that these concerns have been taken very seriously by the Trust and we will continue to strive to improve the service that we offer.

Our Chief Nurse, Medical Director and I have made repeated offers to meet with the Coroners in the Durham and Darlington jurisdiction and all offers have been declined. We do meet with other Coroners, and we are aware of some of our partners who meet with Coroners in this jurisdiction. I would like to repeat our sincere offer to meet at your convenience and discuss the developments at TEWV and how we are working with our partners and the people who use our services to improve care.

Durham Constabulary Police / Law Enforcement

20 Feb 2024 PDF

Noted

The Police and Crime Commissioner acknowledges receipt of the report and expresses condolences. They state they have discussed the concerns with the Chief Constable, who has implemented an interim escalation policy with TEWV pending the roll-out of the national ‘Right Care Right Person’ approach. (AI summary)

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Dear HMAC Richards

I write to acknowledge receipt of the Regulation 28 report dated 8th December 2023 which was safely received in my office on 15th December 2023. I note that a copy of this correspondence has also been sent to Brent Kilmurray, Chief Executive of Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), Chief Constable of Durham Constabulary and the Independent Office of Police Conduct (IOPC).

From the outset, I would like to take this opportunity to express my sincere condolences to Sarah’s family following her untimely death. I can understand the distress Sarah’s family and friends have endured during this difficult and emotional time.

The matters highlighted in the Assistant Coroner’s report received my priority attention and I have consequently discussed these matters with the Chief Constable and Force Executive Team. I have also been sighted on the Chief Constable’s response sent to you.

As part of my ‘holding the force to account’ responsibility, I have been given assurances that organisational learning following this incident has been reflected upon, to mitigate any future risks. It is vital to me as the Police and Crime Commissioner for County Durham and Darlington for the force to demonstrate that appropriate training for police officers and staff is in place, robust safety plans exist, and effective policies and practices are regularly discussed and reviewed with TEWV to respond to calls acknowledging that such a response should be a partnership conversation.

Following this report, I have been reassured that the force swiftly implemented an interim escalation policy with TEWV, and this is pending progress on the roll-out of the national ‘Right Care Right Person’ approach which includes a clear escalation plan through strategic, tactical, and operational levels. This interim approach supports the principles of ‘Right Care Right Person’ and my office is supporting the force and relevant partners in adopting this protocol in due course.

In conclusion, I am fully supportive that every person in crisis or nearing that point receives the best care and support from the right partner agency. Effective communication between partners is key to achieving this.

2

I trust this response addresses the issues you have brought to my attention and I will continue to monitor the progress of Right Care Right Person being adopted across County Durham and Darlington, particularly the role of the Force.

Police Police / Law Enforcement

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Action Planned

The constabulary has worked with TEWV to develop a strong partnership plan, implemented an interim escalation policy, and will train frontline officers with a national training package and local guidance. (AI summary)

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Response to RegulaƟon 28 Report for HM Coroner RelaƟng to the Inquest Touching upon the Death of Ms Sarah Holmes

CORONER’S CONCERNS During the course of the inquest the evidence revealed maters giving rise to concern. In my opinion there is a risk that future deaths could occur unless acƟon is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:-

(1) The escalaƟon in risks that Sarah presented with which included highly dangerous and impulsive thoughts of harming herself were not appropriately reﬂected in a robust safety plan, and it was not thought appropriate to liaise with family and friends who may have provided an essenƟal safety net when Sarah was alone, and at obvious risk of the impulsive thoughts of self harming returning, in the absence of any ongoing professional support. Although evidence was heard about further training and improvements that have been made in respect of safety planning and around issues of conﬁdenƟality, I remained concerned that such issues could arise again.

Durham Constabulary Response The overall responsibility in respect of safety planning for Ms Holmes lies with the health provider, in this case for Tees, Esk and Wear Valley Mental Health Trust (TEWV). Durham Constabulary have subsequently worked closely with TEWV to develop a strong partnership plan to respond to calls in the future, acknowledging that such a response should be a partnership conversaƟon.

(2) There remains no policy in place between Mental Health services and the Police as to the appropriate agency to undertake welfare checks and in parƟcular there is no formal procedure to escalate maters when Mental Health professionals are concerned that life or limb is at risk and the Police do not agree and decline to assist. The College of Policing authorised guide to professional pracƟce is clear that forces should ensure they have a policy on mental health

and that although certain issues are required to be subject to local operaƟng protocols with mental health, ambulance and other providers, there are other issues that should be determined by policy which would also ensure that services which operate across mulƟple health commissioners and providers to establish basic minimum requirements to determine police contribuƟon to any local agreement with other providers.

Durham Constabulary Response Durham Constabulary recognises the addiƟonal value of a documented escalaƟon approach to provide clarity for operaƟonal staﬀ and has progressed priority acƟvity in this regard. Following the Coroner’s raised concerns, the force has swiŌly implemented an interim escalaƟon policy, pending progress on the roll out of the naƟonal ‘Right Care, Right Person’ approach, which includes a clear escalaƟon plan through operaƟonal, tacƟcal and strategic level command bands. TEWV has been engaged throughout and consulted with in the development of this policy. Force Incident Managers, CriƟcal Incident Managers and Force Silver Commanders have been trained in relaƟon to the policy. The Force has also liaised with Street Triage MH PracƟƟoners based in the Force Control Room who are a crucial partner when dealing with the response to incidents involving mental health. HM Coroner will be aware that there is naƟonal work being undertaken to standardise the approach to incidents where an individual’s mental health is a factor. The naƟonal project is known under the Ɵtle ‘Right Care, Right Person’ (RCRP) and is aimed at ensuring a person in crisis or nearing that point receives the best care from the right agency. Durham Constabulary has not yet implemented this policy approach, but the interim escalaƟon approach acts to support those principles. A Force Project Team has been established to progress the naƟonal approach locally. (By means of context, RCRP provides Police Forces with a consistent approach supported by legal advice and training support. Each Force is reviewing the naƟonal package.) Durham Constabulary is engaging with all relevant partners and held a strategic meeƟng in December 2023 as part of an extensive consultaƟve approach. Durham Constabulary will conƟnue to work with partners in a joint mulƟ-agency governance structure for developing, implemenƟng, and monitoring the RCRP approach locally. The project is led by the Assistant Chief Constable supported by a dedicated Superintendent.

This project will develop policies and procedures relaƟng to concerns for welfare, dealing with persons detained under the Mental Health Act, the transportaƟon of persons detained under the Mental Health Act and persons reported missing from health care faciliƟes. The force is conﬁdent that these policies and procedures will build on exisƟng good pracƟce and further improve the service to those in crisis or nearing that point.

(3) The Police did not accept the concerns of the Mental Health professionals in this case and placed undue reliance upon the Mental Health teams earlier decision to send Sarah home and that her car was back at her home address, and failed to take suﬃcient account of the highly unusual and uncharacterisƟc presentaƟon thereaŌer in her not engaging with mental health staﬀ, and the conƟnuing passage of Ɵme when no one had been assured that Sarah was safe and well, in the context of numerous highly dangerous impulsive acts in the proceeding hours. No comprehensive evaluaƟon seems to have taken place as to the increasing concerns for Sarah’s welfare and whether the threshold for police acƟon, including whether to force entry was met.

Durham Constabulary Response The force accepts HM Coroner’s observaƟon, and it is now more clearly deﬁned in the interim Force EscalaƟon Policy the requirement to document clear raƟonale for decision making on the Force Command and Control system. This has been highlighted in the training to support policy implementaƟon. This speciﬁcally extends to recommended quesƟons to be asked of mental health professionals or other third parƟes to beter understand their relaƟonship with the person in crisis and therefore inform subsequent acƟons. The Joint Decision Model (JDM) and Risk Principles as deﬁned by naƟonal Approved Professional PracƟce (APP) will be uƟlised by all commanders to support decision making. This will be underpinned by THRIVE assessment which is used for all incidents reported to Durham Constabulary. (For informaƟon, the JDM is the recognised decision model for all emergency services responders.) THRIVE is a structured framework to evaluate and manage a policing response. The acronym stands for Threat – the threat posed to oneself or others; Harm - the potenƟal consequences or damage that may occur from the threat; Risk – this relates to the risk assessment quanƟfying the likelihood and severity of the potenƟal harm occurring; InvesƟgaƟon – this component focuses on idenƟfying and gathering the relevant informaƟon as appropriate to the incident; Vulnerability – an assessment of the individual’s

vulnerabiliƟes or factors which increase their risk of harm and Engagement – which emphasises the importance of partners in our response and involves developing a response plan which idenƟﬁes from the outset the importance of collaboraƟon.

(4) I am concerned that poliƟcal arguments were at play in terms of “who should assume the risk” in this case and a push back against third party agencies requesƟng police assistance were implicated in the decision not to deploy oﬃcers rather than a comprehensive evaluaƟon of risk and an appreciaƟon of what Mental Health professionals were atempƟng to convey which was that Sarah’s life was at risk. I am concerned that I heard evidence that there have been other occasions where Mental Health professionals believed someone was at serious risk of harm (life or limb) and the Police have declined to act.

Durham Constabulary Response The escalaƟon policy makes clear when the police will atend in relaƟon to relevant legislaƟon to support agencies reporƟng a concern for a person’s welfare where there is a life at risk or there is a risk of serious harm. Policing powers have been deﬁned within the escalaƟon policy. This has been developed in conjuncƟon with mental health partners and will be reviewed in more detail as part of the RCRP project and further developed in consultaƟon with partner agencies.

(5) I am concerned that there was a lack of reﬂecƟon on the part of the Police and there is no formal procedure by which lessons can be learnt from such serious incidents, the professional standards department and IOPC having a limited remit in this regard.

Durham Constabulary Response To supplement the escalaƟon policy there will be a review procedure which will occur monthly to review any lessons learned. This will be co-ordinated by the Force Mental Health Lead, and builds on exisƟng review approaches relaƟng to other incident types that have been seen as good pracƟce by His Majesty’s Inspectorate. There is already a review procedure in place in relaƟon to SecƟon 136 detenƟons and persons reported as missing from Health Care FaciliƟes, whereby Police and TEWV convene to discuss issues/concerns and this will be expanded to include concern for safety type incidents involving concerns for

a person’s welfare. Any lessons learned will be communicated to Force Incident Managers, CriƟcal Incident Managers, Silver and Gold Commanders via structured training sessions co- ordinated by OperaƟonal Planning who are responsible for command level training and CPD. The Force is using the ﬁndings of this inquest as part of the training material to support the new escalaƟon policy.

(6) There is no speciﬁc guidance in place for the Police as to how to assess the level of risk when requested to undertake a welfare check and to assist other agencies who have no power to force entry, no clear raƟonale was recorded for the Police decision not to uƟlise their powers under s17 of PACE, and given the poliƟcal pressures at play that there may sƟll be a reluctance, pending the implementaƟon of ‘Right care, Right person’ and any other appropriate local policies between various services, to ensure operaƟonal decisions are evidence based on an objecƟve evaluaƟon of the risks, aided and assisted by other professionals such as mental health professionals, who may be able to give crucial informaƟon to inform the assessment of vulnerable persons who may be at serious risk.

Durham Constabulary Response The escalaƟon policy does now deﬁne the policing powers to support the assessment of risk when dealing with welfare checks. Decision making is guided by the Joint Decision Model and APP risk principles. The policy speciﬁcally highlights the need to consistently review and assess the risks when there is a change in informaƟon or intelligence. The policy also mandates the requirement to record and document decisions taken in relaƟon to deployment of police resources. RCRP will ensure that all frontline oﬃcers and commanders will be trained with a naƟonal training package and local guidance. RCRP is a naƟonal policing approach and the Force will adopt that protocol in due course. It’s important to highlight that we aren’t simply waiƟng for the implementaƟon of Right Care Right Person, and the implementaƟon of the escalaƟon policy now will provide structure, guidance and governance to future decisions.

(7) I am concerned that IOPC recommendaƟon 3 in this case, namely that the messaging from senior management to the control room was a negaƟve factor in this case, and should be revisited, was not accepted by senior oﬃcers who gave evidence at the Inquest.

Durham Constabulary Response Durham Constabulary does accept the IOPC recommendaƟon. The escalaƟon policy clearly outlines the powers and legislaƟon to inform the response to requests for welfare checks. For the avoidance of doubt, the refreshed training input has paid special atenƟon to this area to ensure there is no doubt among operaƟonal staﬀ and decision makers as to any negaƟve aspects that were highlighted by HM Coroner.

Report sections

Investigation and inquest

On 25th of July 2022 an investigation was commenced into the death of Sarah Elizabeth Holmes, aged 32. The investigation has not yet concluded and the Inquest has not been heard, and is currently listed to commence on the 16th of November 2023.

Circumstances of the death

The deceased had a history of mental health difficulties and self harm and was found dead after a discharge home, subsequent to a mental health assessment,

. The medical cause of death is Asphyxia

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2023-0383
Date of report: 11 October 2023
Coroner: Janine Richards
Coroner area: County Durham and Darlington

Responses identified

Responses identified 5 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Dec 2023 (estimated).

Sent to

Care Quality Commission

Tees, Esk and Wear Valleys NHS

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.