James Booth

Coroner's concerns

AI summary

Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information exchange at shift handovers led to a failure in appreciating emerging patient risks.

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Matter One The inquest heard that the Priory had identified that the garden fence was a risk, in particular the section over the door, in about December 2019. There had been a number of escapes both over the fence and through it, in the months leading up to James’ escape. The number of escapes indicates that garden area was not safe. There was a plan to replace it but there were other priorities. More striking was that there is no national guidance for perimeter fencing and security for the outside areas of mental health ‘locked wards’; unlike that in existence for mental health ‘secure units’. In particular, the height of the fence. While it is accepted that national guidance ought not be necessary to carry out appropriate risk assessments and ensure secure/safe spaces it is clear that such guidance is necessary to ensure the correct level of security for vulnerable patients, whilst benefitting from the therapeutic setting of an outdoor space. Matter Two The evidence showed that there was no appreciation of the emerging pattern of behaviour. A major contributing factor was the lack of exchange and transfer of information at the handover between the consecutive shifts. In particular, the form specifically designed for this with a section for completion – ‘Incidents in last 7 days’ which would have provided an information flow through was not completed. Whilst I heard evidence of steps taken to improve information exchange at a higher level than between ward staff (nurses and HCAs) I was very surprised to hear that no audit of these ‘handover documents’ had been carried out. Given the fundamental importance of the exchange of information between each shift and consecutive shifts I am of the opinion that The Priory have not carried out a sufficiently robust review. Until this failure is addressed there is a significant risk of a breakdown in the communication of adverse events across the shift pattern of several days. The risk of a lack of appreciation of an emerging pattern of behaviour remains.

Responses

2 respondents

Priory Group Private Sector

23 Sep 2022 PDF

Action Taken

Priory reviewed shift handovers and found them satisfactory. Additionally, a detailed handover template is being introduced across Priory Healthcare sites and is currently being trialled on Rivendell ward at Altrincham. Risk assessments have been completed on courtyards/gardens and a programme of works is underway to increase courtyard and garden fencing. (AI summary)

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Dear Mr Bridgman Mr James Booth: date of birth: 26 September 1968; date of death: 14 October 2020 I write in response to the Regulation 28 Report dated Sunday 17 July 2022 issued following the Inquest touching the death of Mr Joseph Booth. You have raised one matter of concern that relates to Priory and one matter of concern that has been raised with the Department of Health. In respect of the Priory matter of concern you have identified that the section of the shift handover form titled: 'Incidents in last 7 days' was not completed and that no audit of the forms had been completed. Upon receipt of your letter, your concerns were brought to the attention of , Altrincham Hospital Director and the senior management team (SMT) at the hospital. A review was undertaken by of the shift handovers that were taking place at the hospital during July and August 2022 and these were identified as being satisfactory in that they captured for each patient, their current mental state, recent incidents and emerging issues that may affect their safety and well-being. Furthermore we are assured that has continued to have oversight of the shift handover process and where concerns have been identified these have been immediately raised and reflected back to the ward team and to the SMT and during the hospital governance meetings. Both and the Altrincham Hospital Director of Clinical Services, will continue to attend shift handovers on each of the wards on at least a weekly basis and continue to check the content, accuracy and detail of those handovers. Your concern and the matter of conducting robust shift handovers has also been raised across the wider Priory Healthcare portfolio via safety bulletins issued to hospital staff reminding them to ensure that shift handovers make sufficient reference to previous incidents. Our internal compliance team and the divisional quality team have also continued to monitor the quality of handovers during their inspections. Again, where matters of concern have been identified these have been brought to the immediate attention of the hospital SMT. Additionally, a detailed handover template is being introduced across the Priory Healthcare sites (and this is currently being trialled on Rivendell ward at Altrincham in response to your Regulation 28 report). The handover template has the capacity to download information from different applications including the electronic patient record (CareNotes) and the incident reporting system (Datix). This will give a detailed picture of the patient's current health and Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 BUD Tel: 020 7605 0910 Fax: 020 7605 0911 info@priorygroup.com www.priorygroup.com Registered In England No. 09057543

inform colleagues as to the current level of risk. The handover template, being electronic, will enable detailed and contemporaneous audits to be undertaken of the content. We anticipate that the handover template will be formally introduced across Priory Healthcare on or before Monday 1 November 2022. We note that you have directed one of your matters of concern to the Department of Health. This matter of concern relates to considering the need for having in place national guidance to ensure the correct level of security for vulnerable patients while also benefitting from the therapeutic setting of an outdoor space. In respect of this matter of concern, please be assured that Priory has responded to the risk of patients absconding by completing a series of courtyard/garden risk assessments across all Priory hospitals. There is also an ongoing programme of works at our Priory acute units to increase courtyard and garden fencing (including anti-climb roller bars) to a standard height of 3.2m. I trust that the actions outlined above will provide the assurances you seek in respect of this matter.

Department of Health and Social Care Central Government

3 Feb 2023 PDF

Noted

The Department acknowledges concerns about the security of outside areas in mental health wards and notes actions taken by the Priory Group to improve security around the garden area of Tatton Ward. The response also provides information about national guidance and regulations related to security levels and reporting of unauthorised absences. (AI summary)

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Dear Mr Bridgman,

Thank you for your letter of 17 July 2022 about the death of James John Jude Booth. I am replying as Minister with responsibility for Mental Health.

Firstly, I would like to say how saddened I was to read of Mr Booth’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. I share your concerns about patient safety in inpatient mental health settings. Patient safety remains our top priority and it is vitally important we learn from any mistakes made to improve care across the NHS and protect patients in the future.

I note that your regulation 28 report to prevent future deaths was issued to the Department to respond to the matters of concern raised around the security of outside areas of mental health wards, and to the Priory Group to respond to your concerns around information sharing and exchanging in its services. I therefore write specifically on those concerns addressed to the Department.

In preparing this response, Department officials have made enquiries with NHS England. It informs me, with information gathered via Greater Manchester Integrated Care Board (now responsible for health care commissioning in Altrincham), that the Priory Group has taken a range of actions in response to Mr Booth’s death. This includes improving security around access to the garden area of Tatton Ward. I hope that, in its reply to your regulation 28 report, the Priory has been able to, or will be able to, assure you of the steps it has taken already to improve safe access to the Tatton Ward Garden.

With regard to patient safety broadly, it is important that patients are treated in settings that are therapeutic and as unrestrictive as possible, with due consideration given to individual patient risk.

Physical security measures such as internal and external perimeters are one of a range of measures that can ensure the safety of patients in mental health settings. The others being procedural measures, such as the timely, correct and consistent application of effective

operational procedures and policies; and relational measures, i.e., the understanding and use of knowledge about individual patients, as well as the environment and population dynamic. Ensuring individual patient safety should therefore include an assessment of individual risk and the appropriate and timely keeping of patient notes that are shared with those involved in the individual’s care. It is crucial that services utilise the full range of patient safety measures to prevent patients harming themselves and/or others.

The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), which is funded in part by NHS England, has been collecting in-depth information on all suicides in the UK since 1996, with the overall aim of improving safety for all mental health patients. Based on evidence from studies of mental health services, primary care and accident and emergency departments NCISH has developed a list of ten key elements for safer care for patients. Recommendations that are strongly associated with reducing suicide rates includes creating safer wards, such as by:

• Implementing effective procedures and staff training to ensure in-patient observations are carried out in a skilled way;
• reducing leave from the ward without agreement though CCTV monitoring of entry and exit points, effective staffing and observation points, standard response for patients who do go absent without leave; and
• acknowledging the importance of balancing patient experience and risk of patients leaving the ward.

NCISH has published a toolkit to be used as a basis for self-assessment by mental health care providers. All mental health trusts in England have downloaded a copy of the tool. It can be found at:

Turning to perimeter fence/wall height and its role in patient safety, I understand that the Department received a Prevention of Future Death report last year from another coroner, who raised similar concerns. In response to this, officials worked with a range of stakeholders, including NCISH, to explore expanding the evidence base around the role those physical barriers play in patient safety and from this explore approaches to reducing the risk of such absconding. NCISH has updated its patient suicide questionnaire to include information about whether a patient who has died by suicide was able to leave the ward by scaling a physical barrier – a perimeter fence is provided as an example.

With regard to guidance, acute mental health wards, such as Priory Altrincham, are the least restrictive of inpatient mental health settings. They accommodate voluntary patients as well as people detained under section of the Mental Health Act, and therefore current guidance in Health Building Note 03-01: Adult acute mental health units1 (HBN 03-01), whilst mute on the specifics of fence height, states that:

3.51 The physical security requirements for the design of an adult acute unit are determined by the need to minimise the likelihood of unauthorised entry and exit […] The location of the service and its layout will also help to determine appropriate safety measures.

1 https://www.england.nhs.uk/wp-content/uploads/2021/05/HBN_03-01_Final.pdf

More broadly, consideration of a patient’s safety may extend to considering whether they are in the correct level setting to ensure their safe treatment and recovery. In terms of acuity levels, the next step on from an adult acute mental health unit is a Psychiatric Intensive Care Unit (PICU). There is no Health Building Note covering this, but in 2017 the National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU) published design guidance2 and recommendations for commissioners - the minimum height should be three meters.

As you move up the acuity levels in mental health into secure accommodation there are prescriptive standards for fence heights that must be met on the basis of:

• Low secure services provide care and treatment for patients who present a significant risk of harm to others and whose escape from hospital must be impeded (three meter tall fence);
• Medium secure services provide care and treatment to those adults who present a serious risk of harm to others and whose escape from hospital must be prevented (5.2m fence); and
• High Secure services provide care and treatment to those adults who present a grave and immediate risk to the public and who must not be able to escape from hospital.

Therefore, services with increased security levels are available if there is clinical indication that the person needs to be supported in a more restrictive and secure setting. However, acute mental health wards remain the least restrictive inpatient setting for a person to be supported in.

More generally, Under Regulation 17 of the Care Quality Commission (Registration) Regulations 2009, services must, without delay, notify the Care Quality Commission (CQC) of the unauthorised absence of a person in any location who is liable to be detained under the Mental Health Act 1983. The CQC considers the unauthorised absence of service users as part of its assessment of when and where to inspect services.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Kind regards,

MARIA CAULFIELD MP

2 https://napicu.org.uk/wp-content/uploads/2017/05/Design-Guidance-for-Psychiatric-Intensive-Care-Units-
2017.pdf

Report sections

Investigation and inquest

On 15th October 2020 an investigation commenced into the death of James John Jude Booth who died on 14th October 2020. The inquest concluded on 26th May 2022. The medical cause of death was: 1a) Hanging The conclusion of the jury was: James Booth took his own life by hanging. James was found at 11.09am on the 14th October 2020 at following his absconsion from the Priory, Altrincham on 7th October 2020, where he was being detained under Section 3 of the Mental Health Act. There was a delay in the police response time, however this not causative of his death. Factors that contributed are as follows: Security of Tatton Ward Inadequate security of the garden, including fence height and nearby ledges Risk management Failure to follow communication procedures and associated documentation highlighting essential handover information. Inadequate risk assessments. Possible contributing factors: Failure to implement adequate risk management procedures. Failure to increase observations based on patient’s perception.

Circumstances of the death

At the time of his death James Booth was 52 years of age. James suffered with longstanding mental ill-health. In 2006 he was a detained patient for some 18 months, followed by rehabilitation in the community over 2-3 years to 2010. His chronic diagnosis was anxious avoidant personality disorder. Towards the end of June 2020, probably as a consequence of the restrictions imposed by Covid, James suffered a breakdown in his mental health. He was admitted (under Section 2 of the MHA) on 3rd July 2020 and discharged on 10th July 2020. On 18th July 2020 James made an unsuccessful attempt to hang himself. James was admitted to The Priory, Altrincham. There were no local NHS acute beds available. The plan was for repatriation at the earliest opportunity. The diagnosis was anxious avoidant personality disorder, with severe depression and some symptoms of psychosis. On 14th August 2020 James made an attempt to abscond. James made a number of references to his wish to escape and to end his life. James was on Level 2 observations (2 per hour) from 30th July 2020 Period from 01.10.20 to James absconding on 07.10.20. 01.10.20: James had to be persuaded to come back on to the ward on return from breakfast at the Grange (off Ward). This matter was noted on the Ward Round later that morning. A Risk Assessment was carried as per routine for the Ward Round. 04.10.20: James made an attempt to push past a member of staff when they were coming through the main door to the Ward. This event was noted in the Care Notes with the note “wanted to run away and commit suicide”. It was not recorded in the Datix system. The Responsible Clinician was not informed. No risk assessment was carried out. The event was recorded on the handover sheet from the 04.10 Dayshift (DS) to the 04.10 Nightshift (NS) within the Clinical Risk section. It was not noted in box ‘Incidents in last 7 days’. The event was not recorded in the Clinical Risk section of the 04.10 NS to the 05.10 DS. It was not noted in the box Incidents in last 7 days’, and did not appear in that Box for any of the subsequent handovers. 05.10.20 At around breakfast time James was seen walking up the main drive of the hospital towards the main entrance. When James realised he had been seen he ran away out of the grounds but was eventually caught up with and brought back to the Ward. He would not say how he escaped from the Ward but from his position when first seen it was likely to have been from the garden area of the Ward. This event was noted in the Care Notes. It was recorded in the Datix system – but the report was closed with ‘no lessons to be learned’. The Responsible Clinician was not informed. No risk assessment was carried out. The event was recorded on the handover sheet from the 05.10 DS to the 05.10 NS within the Clinical Risk section. It was not noted in box ‘Incidents in last 7 days’. The event was not recorded in the Clinical Risk section of the 05.10 NS to the 06 DS. It was not noted in the box Incidents in last 7 days’, and did not appear in that Box for any of the subsequent handovers. 06.10.20 During an escorted walk within the hospital grounds James made attempts to divert the walk away from the planned route, one of them towards the adjoining golf club. When near to the main entrance James tried to run away but staff blocked his way. This event was noted in the Care Notes. It was not recorded in the Datix system. The Responsible Clinician was not informed. No risk assessment was carried out. The event was recorded on the handover sheet from the 06.10 DS to the 06.10 NS within the Clinical Risk section. It was not noted in box ‘Incidents in last 7 days’. The event was not recorded in the Clinical Risk section of the 06.10 NS to the 07.10 DS. It was not noted in the box Incidents in last 7 days’. 07.10.20 James absconded at around 13.15 to 13.30 hrs. He was last seen in the vicinity of the door leading out on the garden. The probable route of escape was over the garden fencing. 14.10.20 James’ body was found as above.

Inquest conclusion

Security of Tatton Ward Inadequate security of the garden, including fence height and nearby ledges Risk management Failure to follow communication procedures and associated documentation highlighting essential handover information. Inadequate risk assessments. Possible contributing factors: Failure to implement adequate risk management procedures. Failure to increase observations based on patient’s perception.

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