Bedfordshire Hospital NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust updated its Transfer Policy in collaboration with ELFT, adding a section on patient transfers for those at risk of absconding. The Emergency Department and Safeguarding Team reviewed MCA and restraint training, updating it for junior doctors, and implemented monthly shared learning forums. (AI summary)
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Dear Mrs Whitting
Re: Yuksel Bedri Ismail – Regulation 28 Report to Prevent Future Deaths
I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued on 26th August 2022, following the Inquest into the death of Mr Ismail, which concluded on 24th August 2022.
I would like to begin by extending my sincere condolences to the family of Mr Ismail for their loss. I appreciate this will still be a very difficult time for the family.
In response to evidence heard at the Inquest you raised some concerns around the policy for transferring patients within the hospital and also the knowledge of our Emergency Department staff in respect of the powers available to them under the Mental Capacity Act 2005.
This letter sets out the Trust’s formal response.
We acknowledge that our SI decision panel, PEARL, did not declare this an SI. On reflection we agree this was not the correct decision and have taken steps to ensure that in future greater consideration as to investigation requirements is given to incidents of a similar nature. The most appropriate criteria in this case would have been a joint investigation between ELFT and BHFT, and we will take this learning forward for the future.
We note that at the SI decision panel, PEARL, whilst we did identify that immediate improvements were required to our Transfer Policy, these had not been fully actioned by the time of the inquest. For this we apologise and have included a copy of the revised policy. The policy has been updated in collaboration with colleagues at ELFT and now more fully addresses patient needs. We have added Section 4.7 around patient transfers for those identified at risk of absconding, and Appendices 6, 7 and 8 now support this addition to the policy.
Cont…..
Collaborative work between the Trust and ELFT will also be ongoing to ensure embedding of protocols and increased safety when it is necessary for mental health patients to be transferred.
In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.
I hope that this response provides assurance to Mr Ismail’s family and to you that the Trust has taken the learning from the Inquest very seriously and continues to improve its policies and procedures, and has put in place measures to ensure safe and effective services.
Re: Yuksel Bedri Ismail – Regulation 28 Report to Prevent Future Deaths
I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued on 26th August 2022, following the Inquest into the death of Mr Ismail, which concluded on 24th August 2022.
I would like to begin by extending my sincere condolences to the family of Mr Ismail for their loss. I appreciate this will still be a very difficult time for the family.
In response to evidence heard at the Inquest you raised some concerns around the policy for transferring patients within the hospital and also the knowledge of our Emergency Department staff in respect of the powers available to them under the Mental Capacity Act 2005.
This letter sets out the Trust’s formal response.
We acknowledge that our SI decision panel, PEARL, did not declare this an SI. On reflection we agree this was not the correct decision and have taken steps to ensure that in future greater consideration as to investigation requirements is given to incidents of a similar nature. The most appropriate criteria in this case would have been a joint investigation between ELFT and BHFT, and we will take this learning forward for the future.
We note that at the SI decision panel, PEARL, whilst we did identify that immediate improvements were required to our Transfer Policy, these had not been fully actioned by the time of the inquest. For this we apologise and have included a copy of the revised policy. The policy has been updated in collaboration with colleagues at ELFT and now more fully addresses patient needs. We have added Section 4.7 around patient transfers for those identified at risk of absconding, and Appendices 6, 7 and 8 now support this addition to the policy.
Cont…..
Collaborative work between the Trust and ELFT will also be ongoing to ensure embedding of protocols and increased safety when it is necessary for mental health patients to be transferred.
In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.
I hope that this response provides assurance to Mr Ismail’s family and to you that the Trust has taken the learning from the Inquest very seriously and continues to improve its policies and procedures, and has put in place measures to ensure safe and effective services.