Inmind Healthcare Group
Private Sector
Action Taken
Following the death, an emergency bag is now in every ward in all Inmind hospitals. Regular training and competency assessments are now undertaken regarding observations, and a new radio protocol has been implemented for staff to communicate effectively in emergencies. (AI summary)
View full response
_____________________________________________________________ _____________________________________________________________ BEFORE HIS REGULATION 28 REPORT TO PREVENT DEATHS INQUEST TOUCHING UPON THE DEATH OF SAMANTHA JANE BOAZMAN amantha
I, c/o the Inmind Healthcare Group, Unit 7 The Quadrant, Upper Culham Farm, Cockpole Green, Berkshire, RG10 8NR will say as follows:
1. I am the Group Medical Advisor at Inmind Healthcare Group. I took over this role in January 2023.
2. The following information is provided, to the best of my knowledge, to assist HM Coroner, Miss Butler, in relation to concerns raised by her about the hospitals run by Inmind Healthcare Group ( ), as set out in the under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (the ). 1
HM CO
3. As a result of her inquisitorial proceedings, HM Coroner has raised concerns in policy and practice regarding:
a. The emergency response to alarms sounded by Health Care Assistants ( ) or other members of staff;
b. Observations of patients undertaken by HCAs. EMERGENCY RESPONSE TO ALARMS
4. HM Coroner heard evidence that at the time of Samantha death there was only one emergency bag for the entire hospital which caused a delay in the . , Chairman of Inmind and , Hospital Director of Sturdee Community Hospital, gave evidence that, as a result of Inmind Root Cause Analysis into the circumstances of Samantha death, there is now an emergency bag in every ward in all Inmind hospitals.
5. HM Coroner expressed concern that the emergency protocol at Sturdee Community Hospital, and throughout all hospitals, remained that staff would respond to an alarm by attending immediately, without first collecting the emergency bag, rather than taking the emergency bag to respond to such an alarm. HM Coroner is concerned that this approach may delay the use of life 2
saving equipment and could lead to future deaths. HM Coroner therefore recommended that staff should collect the emergency bag before attending the location of every alarm.
6. HM Coroner heard submissions by Counsel for Inmind, , that there was a practical risk-assessed element to responding to an alarm without the emergency bag, namely to attend as quickly as possible to ensure the safety and wellbeing of hospital staff who are regularly assaulted or threatened by patients. HM Coroner was concerned that this did not balance the risk presented to patients, who may have seriously self-harmed, and might require the immediate use of life-saving equipment.
7. Inmind immediately implemented HM C across Sturdee Community Hospital, ensuring that staff attending alarms always collected the emergency bag first. Regrettably this change in procedure has already caused significant difficulties and prompted further review:
a. Observing the emergency bag repeatedly being carried through the ward in undesirable behaviours by such patients;
b. The arrival of the emergency bag at the location where the alarm has been sounded has behaviour, the exact opposite of what usually occurs when a second member of 3
staff arrives to assist the first member of staff, thereby putting staff and patients at greater risk;
c. Patients sometimes carry out deliberately orchestrated disruptive behaviour in tandem at different locations, resulting in more than one alarm sounding at a time. This can cause the emergency bag to be taken to one patient who does not require any emergency equipment, making the bag harder to locate when it needs to be taken in response to the other alarm. (No such emergency equipment has yet been required to be used for a life-threatening event, but a real conundrum does arise in these foreseen circumstances.)
8. Inmind has informed the Care Quality Commission about the development. Inmind has also perused national and NHS Trusts policies and protocols. Based on these and the best evidence available, Inmind has implemented the following:
a. Staff have been provided with two-way radios and given training in the use of these radios. As a result, the response to an alarm has substantially changed;
b. The approach to hearing an alarm sound is now encapsulated in the new Medical Emergency Response Local Protocol (MV1) and Press to Talk Radios Protocol (MV2), appended to this statement. 4
9. Inmind has trialled the above and I am satisfied we have found an effective solution to the problem presented. The use of radios and designated first responders is recognised practice in NHS Mental Health hospitals and is deemed to be an effective response to emergency scenarios.
10.Practice emergency scenarios have been carried out every two weeks to test these changes. These tests demonstrate that this system should work well in the event of a real emergency (MV3). It has been observed that there are swift responses to alarms to de-escalate patients as well as less triggering of patients . This has now become part of internal Basic Life Support training.
11.Training of all staff in the use of radios has been undertaken, please see appended training record (MV4). Further emergency response training has been provided to all staff underlining the importance of protecting both staff and patients in the various scenarios that may arise. OBSERVATION POLICY
12.HM Coroner reviewed evidence provided by Sturdee Community Hospital of the observations made by HCAs since changes implemented following the RCA . HM Coroner was satisfied that the observations are now undertaken in a less predictable manner, for example 5
being done within one hour rather than on the hour. HM Coroner has, however, raised concerns that:
a. despite effective observations being recognised as a vital tool to assess and manage the risk to patients Policy, detailed observations are not always recorded by healthcare staff and often merely state where the patient was and/or what the patient was doing, rather than other aspects of the presentation of patients, such as their apparent mood, distress or agitation;
b. the forms used to record observations are not as clear as they should be in terms of what HCAs are expected to do (for example the title of ed with the subtitle saying hourly observations ) and that a systematic review of these forms should be undertaken to ensure they are optimised.
13.Inmind immediately reviewed the forms used at Sturdee Community Hospital and in the other hospitals run by Inmind and found staff had been using a variety of forms rather than one centralised document. All pre-existing forms have been systematically deleted from computers in the hospitals and replaced with two forms which are now available on the shared drive and used by all Inmind Hospitals. Copies of these two forms are appended: Intermittent observations (MV5) and Continuous Observations (MV6). 6
14.The Inmind Observations Policy has been updated to ensure these centralised forms are used and ensure that observations are made in line with national NHS standards.
15.Further training has been provided to HCAs and other staff to ensure the completion of these observation forms is optimised so that the entries are meaningful and assist others in gathering information about the patient and any potentially escalating scenarios. After training, staff undergo a competency assessment.
16.In addition to the further training provided to staff, I confirm that regular audits of the quality of the entries in observation records will be carried out by the Hospital Directors (or Deputy Hospital Directors) across all the Inmind hospitals. These audits will be overseen by the Medical Director of the Inmind Healthcare Group. Any HCA who fails to make appropriate observation entries will be spoken to and further training provided, if necessary.
17.Inmind is currently piloting a system of electronic patient records where each member of staff has a tablet upon which they can enter observations, read updated care plans etc. The plan is that this system, or a similar one, will be rolled out to all Inmind hospitals within the next six months. This would mean that information entered on one tablet can immediately be seen by others and that any changes to observation levels or restricted items can easily be implemented and the information updated on every tablet simultaneously. 7
18. procedure and training. Statement of Truth I confirm that the facts stated in this statement are true to the best of my knowledge and belief. I am duly authorised to make this Statement. Name:
Position within Inmind Group: Group Medical Advisor Signed: Date: 03 March 2023 8
Press To Talk Radio Protocol Sturdee Community Hospital Press to Talk Radios Protocol This protocol is to guide the use of Press to Talk Radios (PTTR) by staff at Sturdee Hospital. This is only in reference to the radios used by Sturdee Hospital Staff, not those used by domestic services or by on-site contractors (i.e., maintenance, cleaners). The purpose is to ensure that in the event of an emergency within the Hospital, staff can respond appropriately. For example, ensuring that in the event of a medical emergency staff who are responding MUST be BLS trained. In the event of a patient going AWOL, staff may be directed in the direction of the patient, rather than directly to a ward. Use of the radios is also to facilitate communication between staff members when they are in an isolated part of the hospital, such as a patients bedroom, and they require non urgent assistance, e.g. they need to use the toilet. Aylestone ward is supplied with two batteries operated (PTTR). Rutland ward is supplied with eight (PTTR’s) Foxton ward has 4 (PTTRs) The radios should be worn by a nurse and staff on observationson each ward, the others should remain on the charger in the nursing office. At all times, all radios should be;
1. Turned on
2. Tuned to channel 1
3. Have the volume turned up so audible to the wearer. At night, staff should be especially mindful of the volume of the radio in patient areas so not to wake or startle our patients. In the nursing office, the radios that are not in use should be always left on the charger (docking station). The radios make a beeping sound when it is running out of battery power. It should be wopped immediately for one on the docking station Testing Radios will be call tested each shift at: 08:00 AM 20:00 PM The NIC for Rutland will be responsible for actioning these checks and document this on the report. If a ward fails to respond to the test, the NIC must contact the ward in question either by phone or in person and re-test.
Press To Talk Radio Protocol Sturdee Community Hospital Tests are as follows: RADIO CHECK RADIO CHECK NIC to *Aylestone*
*Aylestone* Responding
* each ward in turn Minimising Feedback Use following alarm activation. Call Codes
- Medical Emergency – “Medical Emergency … (say location)” Only staff who are BLS trained can respond. Personal Alarm/ Violence and Aggression incident
- Aggression/violence/absconsion - “Assistance required on …. (say location)”. (Staff may be required to repeat the command over the radio). Personal alarms must still be used in any urgent situation. Responding When responding to an emergency call over the radio, you must say which ward you are from and responding. For example, “RUTLAND Responding”. This is to allow the ward requesting assistance know that support is coming. Cancellation If no further assistance is required, you must say clearly over the radio. For example “No further assistance required on treatment I repeat no further assistance required on treatment” “FALSE ALARM ON RUTLAND WARD. DO NOT RESPOND. I REPEAT, FALSE ALARM ON RUTLAND WARD DO NOT RESPOND.” Fire If the fire alarm sounds, check the fire panel and if it is your ward the fire warden should check the area and if it is a false alarm, the NIC must call that it is a false alarm over the radio by saying “False alarm on… (say location).” Further instructions
Press To Talk Radio Protocol Sturdee Community Hospital It may be the case that staff need to relay instructions to responding staff before entry. These should be kept to a minimum and only be to ensure staff safety when they enter the ward. Basic Radio Etiquette Rules
• The international radio language is English.
• When using a two-way radio, you cannot speak and listen at the same time, as you can with a phone.
• Do not interrupt if you hear other people talking.
• Never transmit sensitive, confidential, information. Use room numbers where possible, if you need to mention the patient, say initials only.
• Perform radio checks to ensure your radio is in good working condition.
• Do not allow patients to use the radio. THINK BEFORE YOU SPEAK: Decide what you are going say and to whom it is meant for. Make your conversations as concise, precise, and clear as possible. Avoid long and complicated sentences. If your message is long, divide it into
• separate shorter messages. Do not use abbreviations unless they are well understood by your group. Golden Rules of Radio Communication
1. Clarity: Your voice should be clear. Speak a little slower than normal. Speak in a normal tone, do not shout.
2. Simplicity: Keep your message simple enough for intended listeners to understand.
3. Brevity: Be precise and to the point.
4. Security: Do not transmit confidential information on a radio. Remember, frequencies are shared, you do not have exclusive use of the frequency. Making a Call Follow these easy steps to make a call:
1. First listen to ensure the channel is clear for you.
2. Press the PTT (Push-To-Talk) button.
3. After 2 seconds:
4. Say "recipient's name"
5. Followed by "this" and "your name"
6. Once the person replies, convey your message. Two-Way Radio Protocol
Press To Talk Radio Protocol Sturdee Community Hospital Sample Dialog: Below is a sample dialog that puts these standards to use. Doris: Betty, this is Doris. Over. Betty: Doris, this is Betty, Stand By. Over. Betty: Doris, this is Betty, Go Ahead. Over. Doris: Betty, Asisstance required in bedroom 1. Over. Betty: Doris, this is Betty, confirming assistance is required, staff on their way. Over. Doris: Betty, this is Doris, thanks for the help. Over and Out. Radio Communication Tips
• Leave a second or two between "hand-offs" to give others a chance to break in.
• It is always best to speak in short simple phrases on the radio and toss the conversion back and forth with the word "OVER."
• Don't speak immediately when you press the PTT (push to talk), wait 2-3 seconds.
• If you speak as soon you press the PTT button, it can chop off your the first syllable or word, making you hard to understand. If that word doesn't make it, you will just have to say it again and run down your batteries faster. Radio User’s Language Go Ahead – Resume transmission Say Again – Re-transmit your message Stand-by – Transmission has been acknowledged, but I am unable to respond now. Roger – Message received and understood. Affirmative – Yes – Avoid yup, nope, etc. Negative – No Over – Transmission finished. Out – Communication is over and the channel is available for others. Standard NATO Alphabet Used to spell out letters over the radio.
I, c/o the Inmind Healthcare Group, Unit 7 The Quadrant, Upper Culham Farm, Cockpole Green, Berkshire, RG10 8NR will say as follows:
1. I am the Group Medical Advisor at Inmind Healthcare Group. I took over this role in January 2023.
2. The following information is provided, to the best of my knowledge, to assist HM Coroner, Miss Butler, in relation to concerns raised by her about the hospitals run by Inmind Healthcare Group ( ), as set out in the under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (the ). 1
HM CO
3. As a result of her inquisitorial proceedings, HM Coroner has raised concerns in policy and practice regarding:
a. The emergency response to alarms sounded by Health Care Assistants ( ) or other members of staff;
b. Observations of patients undertaken by HCAs. EMERGENCY RESPONSE TO ALARMS
4. HM Coroner heard evidence that at the time of Samantha death there was only one emergency bag for the entire hospital which caused a delay in the . , Chairman of Inmind and , Hospital Director of Sturdee Community Hospital, gave evidence that, as a result of Inmind Root Cause Analysis into the circumstances of Samantha death, there is now an emergency bag in every ward in all Inmind hospitals.
5. HM Coroner expressed concern that the emergency protocol at Sturdee Community Hospital, and throughout all hospitals, remained that staff would respond to an alarm by attending immediately, without first collecting the emergency bag, rather than taking the emergency bag to respond to such an alarm. HM Coroner is concerned that this approach may delay the use of life 2
saving equipment and could lead to future deaths. HM Coroner therefore recommended that staff should collect the emergency bag before attending the location of every alarm.
6. HM Coroner heard submissions by Counsel for Inmind, , that there was a practical risk-assessed element to responding to an alarm without the emergency bag, namely to attend as quickly as possible to ensure the safety and wellbeing of hospital staff who are regularly assaulted or threatened by patients. HM Coroner was concerned that this did not balance the risk presented to patients, who may have seriously self-harmed, and might require the immediate use of life-saving equipment.
7. Inmind immediately implemented HM C across Sturdee Community Hospital, ensuring that staff attending alarms always collected the emergency bag first. Regrettably this change in procedure has already caused significant difficulties and prompted further review:
a. Observing the emergency bag repeatedly being carried through the ward in undesirable behaviours by such patients;
b. The arrival of the emergency bag at the location where the alarm has been sounded has behaviour, the exact opposite of what usually occurs when a second member of 3
staff arrives to assist the first member of staff, thereby putting staff and patients at greater risk;
c. Patients sometimes carry out deliberately orchestrated disruptive behaviour in tandem at different locations, resulting in more than one alarm sounding at a time. This can cause the emergency bag to be taken to one patient who does not require any emergency equipment, making the bag harder to locate when it needs to be taken in response to the other alarm. (No such emergency equipment has yet been required to be used for a life-threatening event, but a real conundrum does arise in these foreseen circumstances.)
8. Inmind has informed the Care Quality Commission about the development. Inmind has also perused national and NHS Trusts policies and protocols. Based on these and the best evidence available, Inmind has implemented the following:
a. Staff have been provided with two-way radios and given training in the use of these radios. As a result, the response to an alarm has substantially changed;
b. The approach to hearing an alarm sound is now encapsulated in the new Medical Emergency Response Local Protocol (MV1) and Press to Talk Radios Protocol (MV2), appended to this statement. 4
9. Inmind has trialled the above and I am satisfied we have found an effective solution to the problem presented. The use of radios and designated first responders is recognised practice in NHS Mental Health hospitals and is deemed to be an effective response to emergency scenarios.
10.Practice emergency scenarios have been carried out every two weeks to test these changes. These tests demonstrate that this system should work well in the event of a real emergency (MV3). It has been observed that there are swift responses to alarms to de-escalate patients as well as less triggering of patients . This has now become part of internal Basic Life Support training.
11.Training of all staff in the use of radios has been undertaken, please see appended training record (MV4). Further emergency response training has been provided to all staff underlining the importance of protecting both staff and patients in the various scenarios that may arise. OBSERVATION POLICY
12.HM Coroner reviewed evidence provided by Sturdee Community Hospital of the observations made by HCAs since changes implemented following the RCA . HM Coroner was satisfied that the observations are now undertaken in a less predictable manner, for example 5
being done within one hour rather than on the hour. HM Coroner has, however, raised concerns that:
a. despite effective observations being recognised as a vital tool to assess and manage the risk to patients Policy, detailed observations are not always recorded by healthcare staff and often merely state where the patient was and/or what the patient was doing, rather than other aspects of the presentation of patients, such as their apparent mood, distress or agitation;
b. the forms used to record observations are not as clear as they should be in terms of what HCAs are expected to do (for example the title of ed with the subtitle saying hourly observations ) and that a systematic review of these forms should be undertaken to ensure they are optimised.
13.Inmind immediately reviewed the forms used at Sturdee Community Hospital and in the other hospitals run by Inmind and found staff had been using a variety of forms rather than one centralised document. All pre-existing forms have been systematically deleted from computers in the hospitals and replaced with two forms which are now available on the shared drive and used by all Inmind Hospitals. Copies of these two forms are appended: Intermittent observations (MV5) and Continuous Observations (MV6). 6
14.The Inmind Observations Policy has been updated to ensure these centralised forms are used and ensure that observations are made in line with national NHS standards.
15.Further training has been provided to HCAs and other staff to ensure the completion of these observation forms is optimised so that the entries are meaningful and assist others in gathering information about the patient and any potentially escalating scenarios. After training, staff undergo a competency assessment.
16.In addition to the further training provided to staff, I confirm that regular audits of the quality of the entries in observation records will be carried out by the Hospital Directors (or Deputy Hospital Directors) across all the Inmind hospitals. These audits will be overseen by the Medical Director of the Inmind Healthcare Group. Any HCA who fails to make appropriate observation entries will be spoken to and further training provided, if necessary.
17.Inmind is currently piloting a system of electronic patient records where each member of staff has a tablet upon which they can enter observations, read updated care plans etc. The plan is that this system, or a similar one, will be rolled out to all Inmind hospitals within the next six months. This would mean that information entered on one tablet can immediately be seen by others and that any changes to observation levels or restricted items can easily be implemented and the information updated on every tablet simultaneously. 7
18. procedure and training. Statement of Truth I confirm that the facts stated in this statement are true to the best of my knowledge and belief. I am duly authorised to make this Statement. Name:
Position within Inmind Group: Group Medical Advisor Signed: Date: 03 March 2023 8
Press To Talk Radio Protocol Sturdee Community Hospital Press to Talk Radios Protocol This protocol is to guide the use of Press to Talk Radios (PTTR) by staff at Sturdee Hospital. This is only in reference to the radios used by Sturdee Hospital Staff, not those used by domestic services or by on-site contractors (i.e., maintenance, cleaners). The purpose is to ensure that in the event of an emergency within the Hospital, staff can respond appropriately. For example, ensuring that in the event of a medical emergency staff who are responding MUST be BLS trained. In the event of a patient going AWOL, staff may be directed in the direction of the patient, rather than directly to a ward. Use of the radios is also to facilitate communication between staff members when they are in an isolated part of the hospital, such as a patients bedroom, and they require non urgent assistance, e.g. they need to use the toilet. Aylestone ward is supplied with two batteries operated (PTTR). Rutland ward is supplied with eight (PTTR’s) Foxton ward has 4 (PTTRs) The radios should be worn by a nurse and staff on observationson each ward, the others should remain on the charger in the nursing office. At all times, all radios should be;
1. Turned on
2. Tuned to channel 1
3. Have the volume turned up so audible to the wearer. At night, staff should be especially mindful of the volume of the radio in patient areas so not to wake or startle our patients. In the nursing office, the radios that are not in use should be always left on the charger (docking station). The radios make a beeping sound when it is running out of battery power. It should be wopped immediately for one on the docking station Testing Radios will be call tested each shift at: 08:00 AM 20:00 PM The NIC for Rutland will be responsible for actioning these checks and document this on the report. If a ward fails to respond to the test, the NIC must contact the ward in question either by phone or in person and re-test.
Press To Talk Radio Protocol Sturdee Community Hospital Tests are as follows: RADIO CHECK RADIO CHECK NIC to *Aylestone*
*Aylestone* Responding
* each ward in turn Minimising Feedback Use following alarm activation. Call Codes
- Medical Emergency – “Medical Emergency … (say location)” Only staff who are BLS trained can respond. Personal Alarm/ Violence and Aggression incident
- Aggression/violence/absconsion - “Assistance required on …. (say location)”. (Staff may be required to repeat the command over the radio). Personal alarms must still be used in any urgent situation. Responding When responding to an emergency call over the radio, you must say which ward you are from and responding. For example, “RUTLAND Responding”. This is to allow the ward requesting assistance know that support is coming. Cancellation If no further assistance is required, you must say clearly over the radio. For example “No further assistance required on treatment I repeat no further assistance required on treatment” “FALSE ALARM ON RUTLAND WARD. DO NOT RESPOND. I REPEAT, FALSE ALARM ON RUTLAND WARD DO NOT RESPOND.” Fire If the fire alarm sounds, check the fire panel and if it is your ward the fire warden should check the area and if it is a false alarm, the NIC must call that it is a false alarm over the radio by saying “False alarm on… (say location).” Further instructions
Press To Talk Radio Protocol Sturdee Community Hospital It may be the case that staff need to relay instructions to responding staff before entry. These should be kept to a minimum and only be to ensure staff safety when they enter the ward. Basic Radio Etiquette Rules
• The international radio language is English.
• When using a two-way radio, you cannot speak and listen at the same time, as you can with a phone.
• Do not interrupt if you hear other people talking.
• Never transmit sensitive, confidential, information. Use room numbers where possible, if you need to mention the patient, say initials only.
• Perform radio checks to ensure your radio is in good working condition.
• Do not allow patients to use the radio. THINK BEFORE YOU SPEAK: Decide what you are going say and to whom it is meant for. Make your conversations as concise, precise, and clear as possible. Avoid long and complicated sentences. If your message is long, divide it into
• separate shorter messages. Do not use abbreviations unless they are well understood by your group. Golden Rules of Radio Communication
1. Clarity: Your voice should be clear. Speak a little slower than normal. Speak in a normal tone, do not shout.
2. Simplicity: Keep your message simple enough for intended listeners to understand.
3. Brevity: Be precise and to the point.
4. Security: Do not transmit confidential information on a radio. Remember, frequencies are shared, you do not have exclusive use of the frequency. Making a Call Follow these easy steps to make a call:
1. First listen to ensure the channel is clear for you.
2. Press the PTT (Push-To-Talk) button.
3. After 2 seconds:
4. Say "recipient's name"
5. Followed by "this" and "your name"
6. Once the person replies, convey your message. Two-Way Radio Protocol
Press To Talk Radio Protocol Sturdee Community Hospital Sample Dialog: Below is a sample dialog that puts these standards to use. Doris: Betty, this is Doris. Over. Betty: Doris, this is Betty, Stand By. Over. Betty: Doris, this is Betty, Go Ahead. Over. Doris: Betty, Asisstance required in bedroom 1. Over. Betty: Doris, this is Betty, confirming assistance is required, staff on their way. Over. Doris: Betty, this is Doris, thanks for the help. Over and Out. Radio Communication Tips
• Leave a second or two between "hand-offs" to give others a chance to break in.
• It is always best to speak in short simple phrases on the radio and toss the conversion back and forth with the word "OVER."
• Don't speak immediately when you press the PTT (push to talk), wait 2-3 seconds.
• If you speak as soon you press the PTT button, it can chop off your the first syllable or word, making you hard to understand. If that word doesn't make it, you will just have to say it again and run down your batteries faster. Radio User’s Language Go Ahead – Resume transmission Say Again – Re-transmit your message Stand-by – Transmission has been acknowledged, but I am unable to respond now. Roger – Message received and understood. Affirmative – Yes – Avoid yup, nope, etc. Negative – No Over – Transmission finished. Out – Communication is over and the channel is available for others. Standard NATO Alphabet Used to spell out letters over the radio.