Mina Topley-Bird

Dear Mr Thompson,

Thank you for your correspondence of 9 April 2021 about the death of Mina Topley-Bird. I am responding as Minister responsible for mental health services.

Firstly, I would like to take this opportunity to offer my sincere condolences to the family, friends and loved ones of Ms Topley-Bird. I have noted carefully your concerns about national policy to co-ordinate the transfer of mental health patients back to their 'Home' area, when a person is admitted as an emergency to an NHS Trust outside their normal locality. You also raise concerns about escalation policy when a bed cannot be obtained; and also a process to ‘apply’ for a bed in another NHS Trust area. Your report also notes the ‘ad hoc’ nature of the approach taken by NHS Trusts which may create delays in the transfer of patients. The Government is committed to eliminating inappropriate out of area placements in mental health services for adults in acute inpatient care and in 2016 provided guidance on out of area placements1 to NHS Trusts to support this ambition. The guidance states an out of area placement may be appropriate when: “the person becomes acutely unwell when they are away from home (in such circumstances, the admitting provider should work with the person’s home team to facilitate repatriation to local services as soon as this is safe and clinically appropriate)”. In addition, the guidance advises regular reviews and assessments to enable the patient’s return to their local service as soon as possible.

1 Out of area placements in mental health services for adults in acute inpatient care - GOV.UK (www.gov.uk)

In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSE/I) and the Care Quality Commission (CQC). Your report notes that medical information received from South London and Maudsley NHS Foundation Trust (SLAM) was not sent on to, or requested by, West Park Hospital – part of The Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) – upon Ms Topley-Bird’s admission as an emergency patient. This information would have provided a full understanding of Ms Topley-Bird’s mental health and previous attempts to take her own life. NHSE/I acknowledged to my officials the increased risk to patient safety and the negative impact on experience and outcomes associated with patients being placed out of their usual local network of care for acute mental health treatment. NHSE/I has assured the Department it is working to eliminate all inappropriate acute mental health out of area placements (OAPs) as soon as possible. NHSE/I has told my officials that the decision to admit Ms Topley-Bird to hospital in Darlington was appropriate in the circumstances of her requiring emergency inpatient admission away from home. NHSE/I notes that the decision about when to transfer Ms Topley-Bird back to London should have been clinically-led with clinicians able to access her full medical history during the interim period to ensure her care was as safe and effective as possible. Mental health services provided by TEWV are locally commissioned and therefore operational processes, such as those described, are the responsibility of local NHS providers and their clinical commissioning group (CCG) system partners, which commission the services. However, NHSE/I has noted your concern about an apparent lack of robust information sharing and established transfer protocols and will use the learning from your report to work with its regional teams to consider whether any further guidance or escalation processes should be developed to support local NHS staff to reduce the risk of similar tragic events reoccurring. I understand Tees, Esk and Wear Valleys NHS Foundation Trust are to respond to you directly on the matters raised at the inquest. TEWV has informed NHSE/I of local action taken following Ms Topley-Bird’s death, notably:
• where admission is indicated to a local bed, any information from the home Trust will be forwarded by email directed to the Nurse in Charge of the admitting ward;
• the Trust is exploring compatible electronic solutions to enable staff to print information at non-TEWV sites, with an interim system set up whereby staff follow the Out of Trust Patient Checklist on information sharing; and a new electronic system to be introduced by June 2022 to allow for the printing of medical notes in premises shared with another Trust;
• ongoing work at TEWV to focus on bed management and facilitate patient transfers;
• on admission of a new patient, comprehensive risk profile information is obtained from the admitting team and the home Trust Ward with a checklist to support this,

approved by the Adult Mental Health Speciality Development Group in August 2020 and implemented by all wards during September 2020. The TEWV’s Harm Minimisation Lead has incorporated learning from this case into the Trust’s mandatory risk assessment training, with an emphasis on the importance of ensuring that historical risk information is included in the formulation of risk, risk management and contingency planning. My officials also approached the Care Quality Commission (CQC). The CQC has sought assurances from the Trust in relation to its investigation and has concluded that there is no ongoing risk to service users and that enforcement action was not required. CQC requested, and was provided with, further information from the Trust to assist with its review of the Trust. In light of your report, the CQC has since written to the Trust to request further information in relation to the incident. This information was provided on 4 May 2021 which is I understand is currently being reviewed by the CQC. I hope this information is helpful and explains the actions being taken to address the matters of concern. Thank you for bringing these matters to my attention.

NADINE DORRIES

Dear Mr Thompson

Dear Mr Thompson

Re: Mina Topley-Bird, deceased Regulation 28 Report

Further to your letter of 09 April 2021, I write to detail the actions the Trust has taken and those that we continue to implement to address the concerns you identified during the inquest into Mina Topley-Bird’s (MTB) death. I would like to reassure you that as an organisation we have taken your concerns very seriously and for ease of reference I will address each of these in turn:

Concern 1

Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form. This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them.

As described at the inquest hearing, immediate action was taken by the Trust to develop and implement a checklist to support the care and treatment of patients presenting at Accident and Emergency departments, who are from outside the area. (please see documents attached at Concern 2 below). This checklist includes:

 information gathering from the patient's home Trust  sharing information with other teams involved in care  ensuring any information received is accurately reflected in the Trust's Safety Summary  where admission of the patient is indicated to a local bed, all information from the home Trust will be forwarded by email to the Nurse in Charge of the admitting ward. 28 May 2021 Mr James E Thompson H M Assistant Coroner for County Durham and Darlington H M Coroners Office PO Box 282 Bishop Auckland Co Durham DL14 4FY

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Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS

This issue regarding access to patient information will be fully resolved by the implementation of Cito, which is a full electronic records management solution and allows documents to be scanned in, uploaded or viewed. This solution will be fully implemented by August 2022.

Concern 2

It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT. This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments.

As referenced in the inquest evidence, there is a system in place whereby staff follow the Out of Trust Patient Checklist which details how information is to be shared. In respect of any Mental Health Act documentation, this is shared with the relevant recipients via a secure email route. 1 Out of Trust Liaison Checklist.pdf 4 Referral and Admission OOA Appro

The Trust has also since taken action and increased the staffing establishment of the Liaison Team, increasing the number of staff on duty overnight night to two. This means that if a document does need to be printed urgently, one member of staff can go to our nearby Trust premises to do this.

Again the issues highlighted will be fully resolved by the implementation of Cito, which is described above and planned to be in place by August 2022.

Concern 3

The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given. One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points.

As described at the inquest, the suicide prevention environmental survey and risk assessment was reviewed by the Trust and subsequently changes had been made to improve recording. The revised Suicide Prevention Survey and Risk Assessment now references each bedroom by the actual number (bedroom 1,2,3,4 etc.), rather

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Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS

than the Estates identifier (2.01, 2.93, 2.75 etc) which were used at the time of the incident.

For completeness, MTB was in bedroom 4 (identifier 2.04 previously). The Suicide Prevention Environmental Survey and Risk Assessment, attached below, formed part of the documentary evidence made available to the Coroner. This demonstrated that the survey in place at the time of the incident had included bedroom 4 (2.04).

The Trust has recently undertaken an extensive ligature reduction programme that has included the removal of taps, toilets, shower controls and sinks and replaced with anti-ligature sanitary ware. The Trust is also in the process of installing technology that will assist with the detection of movement of patients in high risk areas such as bedrooms and en-suites. This technology responds to a patients change in vital signs or movements and will send an alert to staff to check on the wellbeing of the patient. This technology is already in place in other areas of the Trust and has been used effectively to maintain patient safety in this way.

Concern 4

Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust. On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it.

In the case of MTB, the issue was there were no beds available to transfer her to her home Trust. Each locality of the Trust has staff who manage patient flow and beds and facilitate patient transfers as part of their daily roles. The Trust has now agreed a plan to implement a bed management team. This will be introduced in the following phased approach:  Phase 1 – introduce locality based bed managers (anticipated by October 2021)  Phase 2 - implement a central bed management hub (2022)

Suicide prevention environmental survey

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Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS

Concern 5

The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still ' a work in progress' and further work was required. It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete.

Following a CQC inspection in January 2021 where concerns were raised regarding risk assessment and management, a Rapid Process Improvement Workshop (RPIW) was held week commencing 1st February 2021. This was to review, clarify and streamline the process for assessing and managing the clinical risk of patients and to confirm the standards for risk assessment across all services of the organisation. A review of care documentation was undertaken to provide assurance that patient risks were being assessed and each patient had a safety plan in place in line with the agreed standard. Ward to Board governance arrangements were put in place to ensure Executive oversight and the reporting of compliance with the quality standards. An ongoing programme of quality assurance was implemented. This utilises a range of methods such as clinical audit, Matron walkabouts and direct clinical observation to provide assurance to the Trust Board that the actions being taken are having a positive impact and addressing the patient safety concerns. Community assurance processes have included the development of a dashboard to support community caseload reporting and improved clinical supervision processes. In line with the CQC enforcement notice, the Trust had a number of agreed actions to be completed by 3rd May 2021; implementation of these was achieved within timescale. Leading up to this date and beyond, the Trust had recognised the need for further investment in increasing multidisciplinary involvement and oversight, improving staffing establishments, further developing our provision of training and expertise, ensuring sustainable support and clinical supervision as well as providing leadership to our clinical teams as being critical to prioritising a culture of patient safety and continuous quality improvement. In addition, work is underway to enhance and embed organisational learning from a range of internal and external sources. This includes reviewing, strengthening and developing systems and mechanisms for capturing and communicating learning and importantly gaining assurance of the impact of our actions to improve care for services users and their families. A regional Quality Board has been set up by NHS England and Improvement; membership includes key external stakeholders such as CQC and members of the ICS. The Trust provides monthly updates and assurance on its progress. We are also accessing a range of external expertise to support rapid improvement and sustainable changes in practice.

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Trust headquarters West Park Hospital, Edward Pease Way, Darlington, DL2 2TS

I trust this provides you with assurance that the appropriate actions are and have ben taken to address the concerns raised. However, should you require any further information please do not hesitate to contact me.