Henry Holcombe

Dear Ms Schofield We write in response to Ms Hamilton-Deeley's Regulation 28 Report, dated 15 July 2021, following the Inquest into the death of Mr Henry Holcombe. We were saddened by Mr Holcombe's death and have extended our sincere condolences to his family. We fully agree with Ms Hamilton-Deeley's concerns regarding the need to ensure that observations are appropriately completed, in accordance with the Trust's Therapeutic Engagement and Observation Policy (the 'Policy'), especially at night. We are strengthening our clinical practices in the light of Mr Holcombe's death and the broader learning from Serious Incidents where full adherence to our Policy has been identified as a factor. The Trust's actions, to date, in relation to this issue, have focused on staff training, competency and understanding of our Policy. This stipulates that: ‘If a member of staff is not able to observe the patient move or breath they must ensure the patient is conscious which will require entering the bedroom’ and staff competency and understanding of the Policy is assessed through competency checks. However, it is clear that further, sustained action is required to ensure that this requirement is fully understood and adhered to by all clinical staff. Specifically, in response to the findings of our investigation into Mr Holcombe's death, we have strengthened our internal monitoring arrangements to ensure the Office of the Chief Executive Trust Headquarters Swandean Arundel Road Worthing West Sussex BN13 3EP

requirements of the Policy are effectively embedded in clinical practice. Additionally, the training provision has been enhanced - including assessment of agency and bank staff - and Policy compliance is now reviewed on a weekly basis by the Ward Manager and on a monthly basis by the Matron.

Also, although Ms Hamilton-Deeley's concerns related particularly to safety at night, we have recognised that a systemic quality improvement approach is needed to ensure that therapeutic observations are of an appropriate standard. As a result, we are undertaking a robust programme of therapeutic observation Quality Improvement ('QI') work. The aim of this work is to improve the quality of therapeutic observations in terms of safety, effectiveness and experience; specifically, to ensure observations are a therapeutic, individualised and skilled intervention that is responsive to a patient's needs, are least restrictive, and aimed at recovery. This QI work will give specific attention to:

• the competencies of individuals' undertaking therapeutic observations;
• the need for an individualised approach to care;
• proactive exploration of the patient experience and a focused review of night- time observations, including seclusion and physical observations.

Additionally, consideration is being given to the potential use of technological aids to support patient safety and enhanced physical observation, which includes an electronic system to remotely monitor a patient’s respiration, movement and heart rate and flags immediate changes to the patient’s physical presentation.

The QI work will be completed by 31st December 2021. We anticipate that you would want to be updated on the results, so we will write with an update by 1 February 2022. In the meantime, if further information of clarification would be of assistance to you, please do not hesitate to contact either one of us.

Your sincerely

Dr

Chief Executive

Chief Nursing Officer