Coventry and Warwickshire Partnership NHS Trust
NHS / Health Body
Action Taken
Coventry and Warwickshire Partnership NHS Trust has amended its Section 17 Leave Policy to ensure patients are collected from and returned to the ward by identified individuals. The Trust is also implementing structured handover meetings at shift changes and introducing competency-based training for staff. (AI summary)
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Dear Mr Henry
Re: The late Ms Katy Samuels
I am writing to you in connection with the Regulation 28: Prevention of Future Deaths Report which was received from your office on 12 December 2020.
I was very grateful for the opportunity to give evidence at the inquest about the work that the Trust have been doing since Ms Samuels death in order to make improvements for our patients at the Trust. Although you were satisfied that the Trust were making good progress in many areas there were two areas of concern that you wanted the Trust to respond to you on. Your report focussed on our arrangements for managing the safety of patients who are prescribed leave whilst detained in accordance with the Mental Health Act 1983, and the second concern focussed on the length of time available for staff to participate in a robust ‘handover’ between the incoming and outgoing ward shifts.
1. Managing Section 17 Leave (Mental Health Act, 1983)
Following conclusion of the inquest, immediate action was taken to ensure that patients going on leave under the care of family or friends, would be collected from and returned to the ward, by the identified person and not permitted to leave the ward unaccompanied to meet family or friends in the reception area or hospital grounds.
To strengthen and formalise our Section 17 leave arrangements across the Trusts inpatient services, we have consulted with our staff and amended our Section 17 Leave Policy. The changes to this policy include clear definitions of the types of leave:
- Chair
- Chief Executive
Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949
• Escorted leave is defined when the Responsible Clinician (RC) directs that their patient remains in the care of a staff member or any person authorised, in writing, by hospital management.
• Accompanied leave is defined when the Responsible Clinician directs leave subject to the condition that a patient is accompanied by a friend or relative (e.g. on a pre-arranged day out from the hospital).
• Unescorted leave is defined when the Responsible Clinician directs leave that does not require the patient to be escorted or accompanied.
Two existing reporting forms have been revised and improved and one additional reporting form has been developed [Enc: Section 17 Leave Policy, the forms are contained in the appendices]. Each form is required to be completed as part of the process of agreeing and enabling leave to commence safely:
• The revised “Leave of Absence (Section 17) – Patients detained under the Mental Health Act 1983” form has been amended to include space for the Responsible Clinician to detail the name(s) of the friend/family/carer identified as responsible for the patient when on accompanied leave.
• The new ‘Accompanied Leave Checklist’ form requires the accompanying person to sign to confirm that they are aware of their responsibilities for the patient’s safety and wellbeing whilst on leave when they arrive on the ward to collect the patient for the leave. The policy requires that ‘When a patient is to be accompanied, staff must ensure that the persons identified to accompany the patient, on the s17 leave form, is the person the patient goes on leave with.’ The form requires certain information to be discussed including risk.
• The revised ‘Leave off the Ward’ form has been revised to record the time the patient is due to return as this will act as an escalation trigger if the patient has not returned. A designated member of staff will be appointed on each shift to monitor the activity at the entrance to the ward including ensuring that patients have returned on time or escalating to senior staff if the patient has not.
Our Section 17 Leave Policy has been approved through the Trust’s governance process with oversight from senior clinicians and operational staff as well executive and non-executive director members of the Trust’s Mental Health Act Committee.
To embed our revised arrangements for the management of Section 17 leave and to ensure that staff are aware of their responsibilities in respect of the revised policy, staff engagement events have been held as well as a series of briefings disseminated.
A consequence of the Covid 19 pandemic has seen a reduction in escorted and accompanied leave being utilised, and this has impacted on our ability to fully appraise ourselves of the impact of these changes. As we make plans to exit the pandemic, we anticipate an increase in levels of leave for patients that we experienced pre-pandemic. To ensure our focus remains on patient safety, we will continue to monitor the safe use of leave thereby providing the organisation and its commissioners with assurance.
- Chair
- Chief Executive
Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949 Once levels of leave are restored and to support assurance, we will commission an independent audit in the 2021/22 audit programme to ensure our arrangements are embedded.
2. Handover between ward shifts
The inquest heard evidence that the time set aside for shift handover was considered insufficient by some staff.
The Trust has identified that there is mixed practice across Mental Health providers, with Trusts operating handovers of different duration and taking different approaches. The Trust is using this intelligence to inform its own work in respect of its handover arrangements. The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation to ensure this takes place in accordance with Trust policy.
The Trust has reflected on the inquest and used this information to review our handover arrangements across the spectrum of clinical care, rather an individual focus on the ward handover from one shift to another.
A working group was established that consulted with staff in respect of the role and function of the handover process to strengthen and ensure patient safety and wellbeing. The working group have developed a Standard Operating Procedure to both standardise the handover content and the way in which a handover functions and operates. The Standard Operating Procedure applies to all clinical handover situations including:
• Shift handover
• Transfer of care (between wards or organisations)
• Handovers to professionals attending emergency situations
• Discharge/leave processes
• Handovers between inpatient and community clinicians
• Handovers to other team members outside of main shift handovers
• Handovers between inpatient wards and the bed management Clinical Coordination Centre.
The working group reviewed best practice for handover methodologies and tools across other NHS Trusts and have adopted the ‘Situation, Background, Assessment and Recommendation’ (SBAR) tool, which is a nationally recognised communication tool that facilitates the effective and efficient handover of concise, accurate and relevant information between clinicians and clinical teams. SBAR supports the timely and effective handover of pertinent information which includes, but is not limited to, all
- Chair
- Chief Executive
Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949 safeguarding issues or risks, feedback from periods of leave from the ward, the patients current physical health and feedback from the patient in respect of what they would wish the incoming staff team to be aware of. SBAR is the tool that will be used for all handover situations as identified above.
As an area of recognised good practice, supported by staff, the Trust is continuing to use ‘safety huddles’. Safety huddles bring staff together each day to discuss important clinical events affecting patients and is targeted at immediate risks to patient and staff safety. Safety huddles complement the formal handover that is in place.
To embed our revised arrangements for the management of handover and to ensure that staff are aware of their responsibilities in respect of the Standard Operating Procedure, staff engagement events have been held as well as a series of briefings disseminated. This work will also form part of future local staff induction and preceptorship for new staff. Working with our staff I believe that the revised arrangements will strengthen handover and provide staff with a clear focus and safe handover practice.
The Trust will continue to establish a consistent time frame for handover after the required consultation process, however the Trust are confident handovers are currently more effective based on the work already undertaken.
3. Further key actions
Patient safety is a priority for the Trust. In responding to the Regulation 28 PFD report, I also wanted to take the opportunity to inform you about other work that I am keen to progress and complete, which was touched upon during the inquest.
I have requested that a dedicated Quality Improvement project be undertaken to focus on drilling down and addressing the key areas for improvement identified through our internal investigation of the tragic set of circumstances surrounding this incident, as well as those factors highlighted throughout the coronial process. The scoping for this work has commenced.
I have also requested and made provision for a full staffing establishment review across all in-patient settings, which will include review of the safer staffing levels and the required skill mix with the aim of introducing new clinical focused roles across our wards to enhance patient safety and wellbeing.
You will recall that you requested that the ward which had provided care to Ms Katy Samuels, confirm to the family that they have been successful with achieving the Accreditation for Inpatient Mental Health Services (AIMS). I will confirm the outcome of this process and I am expecting to receive confirmation by end of March 2021.
- Chair
- Chief Executive
Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949 I confirmed at the inquest that I and my Trust Board colleagues have taken this matter extremely seriously and continue to do so. I trust that this letter provides you with an appropriate level of assurance regarding the actions taken, and those to be taken, to continue improving patient care.
I would be grateful if you could share a copy of my response to you, with the family of Ms Samuels.
Re: The late Ms Katy Samuels
I am writing to you in connection with the Regulation 28: Prevention of Future Deaths Report which was received from your office on 12 December 2020.
I was very grateful for the opportunity to give evidence at the inquest about the work that the Trust have been doing since Ms Samuels death in order to make improvements for our patients at the Trust. Although you were satisfied that the Trust were making good progress in many areas there were two areas of concern that you wanted the Trust to respond to you on. Your report focussed on our arrangements for managing the safety of patients who are prescribed leave whilst detained in accordance with the Mental Health Act 1983, and the second concern focussed on the length of time available for staff to participate in a robust ‘handover’ between the incoming and outgoing ward shifts.
1. Managing Section 17 Leave (Mental Health Act, 1983)
Following conclusion of the inquest, immediate action was taken to ensure that patients going on leave under the care of family or friends, would be collected from and returned to the ward, by the identified person and not permitted to leave the ward unaccompanied to meet family or friends in the reception area or hospital grounds.
To strengthen and formalise our Section 17 leave arrangements across the Trusts inpatient services, we have consulted with our staff and amended our Section 17 Leave Policy. The changes to this policy include clear definitions of the types of leave:
- Chair
- Chief Executive
Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949
• Escorted leave is defined when the Responsible Clinician (RC) directs that their patient remains in the care of a staff member or any person authorised, in writing, by hospital management.
• Accompanied leave is defined when the Responsible Clinician directs leave subject to the condition that a patient is accompanied by a friend or relative (e.g. on a pre-arranged day out from the hospital).
• Unescorted leave is defined when the Responsible Clinician directs leave that does not require the patient to be escorted or accompanied.
Two existing reporting forms have been revised and improved and one additional reporting form has been developed [Enc: Section 17 Leave Policy, the forms are contained in the appendices]. Each form is required to be completed as part of the process of agreeing and enabling leave to commence safely:
• The revised “Leave of Absence (Section 17) – Patients detained under the Mental Health Act 1983” form has been amended to include space for the Responsible Clinician to detail the name(s) of the friend/family/carer identified as responsible for the patient when on accompanied leave.
• The new ‘Accompanied Leave Checklist’ form requires the accompanying person to sign to confirm that they are aware of their responsibilities for the patient’s safety and wellbeing whilst on leave when they arrive on the ward to collect the patient for the leave. The policy requires that ‘When a patient is to be accompanied, staff must ensure that the persons identified to accompany the patient, on the s17 leave form, is the person the patient goes on leave with.’ The form requires certain information to be discussed including risk.
• The revised ‘Leave off the Ward’ form has been revised to record the time the patient is due to return as this will act as an escalation trigger if the patient has not returned. A designated member of staff will be appointed on each shift to monitor the activity at the entrance to the ward including ensuring that patients have returned on time or escalating to senior staff if the patient has not.
Our Section 17 Leave Policy has been approved through the Trust’s governance process with oversight from senior clinicians and operational staff as well executive and non-executive director members of the Trust’s Mental Health Act Committee.
To embed our revised arrangements for the management of Section 17 leave and to ensure that staff are aware of their responsibilities in respect of the revised policy, staff engagement events have been held as well as a series of briefings disseminated.
A consequence of the Covid 19 pandemic has seen a reduction in escorted and accompanied leave being utilised, and this has impacted on our ability to fully appraise ourselves of the impact of these changes. As we make plans to exit the pandemic, we anticipate an increase in levels of leave for patients that we experienced pre-pandemic. To ensure our focus remains on patient safety, we will continue to monitor the safe use of leave thereby providing the organisation and its commissioners with assurance.
- Chair
- Chief Executive
Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949 Once levels of leave are restored and to support assurance, we will commission an independent audit in the 2021/22 audit programme to ensure our arrangements are embedded.
2. Handover between ward shifts
The inquest heard evidence that the time set aside for shift handover was considered insufficient by some staff.
The Trust has identified that there is mixed practice across Mental Health providers, with Trusts operating handovers of different duration and taking different approaches. The Trust is using this intelligence to inform its own work in respect of its handover arrangements. The Trust has identified that extending the time for staff to handover, from one shift to the next, will require a thorough review of the roster and supporting processes that the Trust operates to generate staff shift patterns. This work, ultimately leading to an increase in the protected time for handover from ten minutes will impact on current shift patterns. The Trust cannot change shift patterns without a robust consultative process and is, therefore, working with union and staff side representation to ensure this takes place in accordance with Trust policy.
The Trust has reflected on the inquest and used this information to review our handover arrangements across the spectrum of clinical care, rather an individual focus on the ward handover from one shift to another.
A working group was established that consulted with staff in respect of the role and function of the handover process to strengthen and ensure patient safety and wellbeing. The working group have developed a Standard Operating Procedure to both standardise the handover content and the way in which a handover functions and operates. The Standard Operating Procedure applies to all clinical handover situations including:
• Shift handover
• Transfer of care (between wards or organisations)
• Handovers to professionals attending emergency situations
• Discharge/leave processes
• Handovers between inpatient and community clinicians
• Handovers to other team members outside of main shift handovers
• Handovers between inpatient wards and the bed management Clinical Coordination Centre.
The working group reviewed best practice for handover methodologies and tools across other NHS Trusts and have adopted the ‘Situation, Background, Assessment and Recommendation’ (SBAR) tool, which is a nationally recognised communication tool that facilitates the effective and efficient handover of concise, accurate and relevant information between clinicians and clinical teams. SBAR supports the timely and effective handover of pertinent information which includes, but is not limited to, all
- Chair
- Chief Executive
Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949 safeguarding issues or risks, feedback from periods of leave from the ward, the patients current physical health and feedback from the patient in respect of what they would wish the incoming staff team to be aware of. SBAR is the tool that will be used for all handover situations as identified above.
As an area of recognised good practice, supported by staff, the Trust is continuing to use ‘safety huddles’. Safety huddles bring staff together each day to discuss important clinical events affecting patients and is targeted at immediate risks to patient and staff safety. Safety huddles complement the formal handover that is in place.
To embed our revised arrangements for the management of handover and to ensure that staff are aware of their responsibilities in respect of the Standard Operating Procedure, staff engagement events have been held as well as a series of briefings disseminated. This work will also form part of future local staff induction and preceptorship for new staff. Working with our staff I believe that the revised arrangements will strengthen handover and provide staff with a clear focus and safe handover practice.
The Trust will continue to establish a consistent time frame for handover after the required consultation process, however the Trust are confident handovers are currently more effective based on the work already undertaken.
3. Further key actions
Patient safety is a priority for the Trust. In responding to the Regulation 28 PFD report, I also wanted to take the opportunity to inform you about other work that I am keen to progress and complete, which was touched upon during the inquest.
I have requested that a dedicated Quality Improvement project be undertaken to focus on drilling down and addressing the key areas for improvement identified through our internal investigation of the tragic set of circumstances surrounding this incident, as well as those factors highlighted throughout the coronial process. The scoping for this work has commenced.
I have also requested and made provision for a full staffing establishment review across all in-patient settings, which will include review of the safer staffing levels and the required skill mix with the aim of introducing new clinical focused roles across our wards to enhance patient safety and wellbeing.
You will recall that you requested that the ward which had provided care to Ms Katy Samuels, confirm to the family that they have been successful with achieving the Accreditation for Inpatient Mental Health Services (AIMS). I will confirm the outcome of this process and I am expecting to receive confirmation by end of March 2021.
- Chair
- Chief Executive
Coventry & Warwickshire Partnership NHS Trust Wayside House, Wilsons Lane, Coventry, CV6 6NY Tel: 024 7636 2100 Fax: 024 7636 8949 I confirmed at the inquest that I and my Trust Board colleagues have taken this matter extremely seriously and continue to do so. I trust that this letter provides you with an appropriate level of assurance regarding the actions taken, and those to be taken, to continue improving patient care.
I would be grateful if you could share a copy of my response to you, with the family of Ms Samuels.