Source · Prevention of Future Deaths

Amy Henderson

Ref: 2023-0129 Date: 21 Apr 2023 Coroner: Caroline Topping Area: Surrey Responses identified: 1 / 2 View PDF

Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. There was also staff confusion regarding responsibility for removing banned items on admission.

Date 21 Apr 2023

56-day deadline 16 Jun 2023 est.

Responses identified 1 of 2

Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

1. The information that Miss Henderson had practised tying a ligature was divulged by her at Kingston Hospital but not repeated on admission to the Priory Woking. The evidence given at the inquest was that there is no quick method to obtain NHS records on admission to a private hospital. A request could have been made but the records would have taken over a week to be released. The records were not sought. An ability to obtain the NHS records quickly would have been of assistance to the Priory clinicians.

2. The Priory Woking has a policy in relation to the removal of banned and restricted items but there was a lack of clarity and confusion among the clinicians as to who was responsible for ensuring that such items are identified and removed from the patient at admission.

Responses

1 respondent

NHS England NHS / Health Body

21 Apr 2023 PDF

Action Planned

NHS England states that Shared Care Records programme, implemented by Integrated Care Boards (ICBs), will improve access to patient records in private hospitals. National guidance around risk assessments is being reviewed, and regional colleagues have been asked to confirm whether Priory Woking now has access to GP records. All reports received are discussed by the Regulation 28 Working Group. (AI summary)

View full response

Dear Coroner

Re: Regulation 28 Report to Prevent Future Deaths – Amy Henderson who died on 21 March 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 April 2023 concerning the death of Amy Henderson on 21 March 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Amy’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Amy’s care have been listened to and reflected upon.

In your report, you raised a concern that there was no quick method to obtain NHS records on admission to a private hospital. It is hoped that improvement will be made to issues such as this through the NHS England Shared Care Records programme, which seeks to bring together information from a range of healthcare providers in support of the provision of direct care. The focus is on the person receiving the care, rather than the provider and supports the safe and secure sharing of individuals’ health and care information. A shared care record joins up information based on the individual, from across different organisations. For patients, shared care records will include information such as care plans, previous appointments, inpatient stays, clinical contacts and medications, and is anticipated to bring:

• Safer, more coordinated services
• Reduction in time by avoiding the need to repeat medical or social care history
• Fewer repeats of tests, appointments and admissions
• Preferences and needs observed
• Improved experience and continuity of care
• Improved confidence in services

Implementation and operation of shared care records is the responsibility of Integrated Care Boards (ICBs). Initially, public sector connectivity is being prioritised but the forward programme plan for the Shared Care Record programme for 2023/25 acknowledges the important role that independent sector providers of care play. NHS England are aware that some ICBs are already engaging with Voluntary, Community and Social Enterprise organisations, recognising the important role that they play in the provision of care to their population. The Shared Care Record programme is also National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

14 June 2023

prioritising national interoperability, pertinent to this case where there were two separate Care Record locations (South West London ICB, where Kingston Hospital is located, being part of the London Care Record, and Surrey Heartlands ICB, where this site of the Priory is located, being covered by the Surrey Care Record). Further information on the Shared Care Record programme can be found here.

Regarding your second concern that at The Priory Woking there was a lack of clarity and confusion among clinicians as to who was responsible for ensuring that banned and restricted items are identified and removed from a patient at admission, this is outside of NHS England’s remit and I note that you have also addressed your Report to Priory Group who are the appropriate organisation to respond to this concern.

NHS England has, however, been sighted on Priory Group’s Serious Incident Report regarding this matter and the resulting Action Plan and recommendations. I would like to provide some additional assurance that national guidance around risk assessments is currently being reviewed. I have also asked my regional colleagues to confirm whether Priory Woking now has access to GP records. NHS England is happy to provide further updates to the coroner in due course.

I would also like to provide further assurances on national NHSE 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.

Report sections

Investigation and inquest

An inquest into the death of Miss Amy Henderson was opened on the 26th April 2022 and resumed with a jury on the 6th February 2023. The inquest was concluded on the 23rd February 2023. Evidence in respect of matters pertaining to this report was heard on the 20th March 2023. The jury concluded that Miss Henderson died on the 21st March 2022 at the Priory Hospital, Woking and the medical cause of her death was: 1a Suspension They concluded with a narrative conclusion and found that:
1. The Priory staff knew Amy had suicidal ideation, but they did not know any details concerning plans, or that she had practised tying a ligature.
2. No-one at the Priory asked her family about her suicide plans.
3. It is not possible to determine what Amy would have said to her consultant if she had been asked about suicide plans. Amy denied having any plans when asked by an HCA and she denied having thoughts of suicide in her 1:1 with a SHCA.
4. If Amy’s mother had been asked, she would have shown the screen shots from Amy’s phone and given details of Amy practising tying ligatures. Amy’s mother has no recollection of volunteering the information.
5. Despite the notes from the therapy sessions being uploaded at 16.06, there was no formal request for Amy to be reviewed. There is evidence from professionals that Amy should have been reviewed urgently on the basis of the notes, if they had been scrutinised.
6. If information about Amy practising tying a ligature had been known, there would have been more consideration given bearing in mind the balance of risk and least restrictive practice. 21st March. Amy was generally compliant with staff,

.
7. After the identification of the disabled toilet as a high-risk area in 2021, the ligature risk of the disabled toilet was not effectively managed although the Priory considered that it was.
8. Amy had unrestricted access to the disabled toilet, which was accessible to all patients, staff and visitors.
9. The Jury was not able to make a finding as to whether Amy was alive between 19.35 and 19.47. In summary the following facts, on the balance of probabilities, made a material contribution to Amy Henderson’s death:
a. Risk Assessments were not performed in line with Priory policy.
b. There was no Key Worker present throughout Amy’s stay.
c. There were incomplete observations and little evidence of engagement with Amy during observations. Boxes were not ticked on Observation and Engagement Records.
d. The family was not consulted or questioned about Amy’s Suicide Plans.
e. Therapy notes were not acted upon.
f. There was a lack of staff training in Postnatal depression.
g. There was a lack of continuity of care.
h. The disabled toilet was not locked.
i. Staff knowledge of the ligature footprint was inconsistent.

Amy committed suicide. She used a ligature and intended to kill herself. She is shown on CCTV entering the disabled toilet and no-one else entered it until Amy’s body was discovered. The death was contributed to by Neglect

Circumstances of the death

Miss Henderson had a baby in 2021. When her baby was 11 months old she returned to work, but was signed off sick suffering from anxiety and depression. On the evening of the 14th March 2022 she was taken by her family to Kingston Hospital and assessed by the liaison psychiatric team. She expressed suicidal thoughts and plans

She was diagnosed with post partum depression. She was advised to become an informal patient in the NHS but there was no bed available so she would have had to wait in the hospital until a bed could be found. She decided to seek a private admission the following day.

On the 15th March 2022 she sought treatment at the Priory Hospital, Woking. She had a preadmission assessment with a consultant psychiatrist who accepted her as a patient. She told him that she had a suicide plan but did not provide details of what it was. He assessed her as a high risk of suicide and set observations at four times an hour. She was allocated a Key Worker who was not due to be in the hospital until 22nd March 2022, and a Co-worker, who had a one-to-one with her on 19th March 2022. Her overall mental health appeared to have improved when she was reviewed by on March 18th 2022. The observation level was reduced to twice an hour on the 16th March 2022, and then further to once an hour on the morning of March 21st 2022, on each occasion without a risk assessment being performed as specified in the Priory policy.

Later on the morning of the 21st March 2022 Miss Henderson made comments during a therapy session which indicated that her mental health was deteriorating. The therapists recorded what she had said in her notes, but the concerns were not considered to be serious enough to be escalated to the nursing team. Evidence presented to the inquest suggests that Amy’s observations should have been increased at this stage. Amy was not reviewed by the nursing team when the therapists’ notes were uploaded onto the system at 16.06 on 21st March 2022. The information was not reviewed and therefore not acted upon.

Miss Henderson was last seen in person at 18.02 in the dining room. At 18.12. she entered the downstairs disabled toilet. The disabled toilet had been identified in risk assessments as a high-risk area but it was not locked. She wrote a farewell note to her parents at 18.14. She was found in the disabled toilet on the ground floor at 20.01. She had taken her own life by suspension,

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Care Quality Commission

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Report details

Reference: 2023-0129
Date of report: 21 April 2023
Coroner: Caroline Topping
Coroner area: Surrey

Responses identified

Responses identified 1 of 2

1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 16 Jun 2023 (estimated).

Sent to

NHS England

Priority Group

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.