Surrey and Borders Partnership NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust has developed guidance regarding alcohol detoxification for people admitted to inpatient wards and are developing new guidelines for managing people with Alcohol Use Disorders (AuDs). They have also completed a retrospective baseline audit and will complete a second audit to check for improvements. (AI summary)
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Dear Miss Crawford
Re: Regulation 28 Report to Prevent Future Deaths Surrey and Borders Partnership NHS Foundation Trust Response
I am writing in response to your Regulation 28 Report to Prevent Future Deaths, hereafter referred to as ‘PFD’, issued on the 9th December 2020 following the inquest touching upon the death of Kimberley Smith. I would like to thank you for investigating this matter so thoroughly and for bringing the matters of concern you have to my attention.
In the PFD, you identified four key matters of concern that had arisen from the inquest, and I will address each one in turn below, with details of action we have taken or plan to take to address the issues.
1. Policy/procedure on leave for informal patients
In the PFD report, you identified that the Trust has no clear written policy/procedure on the following:
• The carrying out of risk assessments when informal patients request to leave the unit;
• The relevance of an informal patient being on intermittent observations when they request to leave the unit;
• The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
• The risk management plans to put in place when informal patients do leave the unit;
• The recording of assessments and decisions in relation to requests made by informal patients to leave the unit;
• The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
February 4th, 2021
Private and Confidential
Our response: Guidance in relation to leave for informal patients is currently set out in the Trust’s Section 17 Leave Policy. The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients. The policy will aim to ensure that the right balance is struck between respecting the rights of informal patients and the need to protect people who may be vulnerable and at risk of harm to themselves. The policy will also require all leave for informal patients to be supported by the patient’s risk assessment and care plan. I have had sight of the new draft policy and am confident that it will cover all the issues that you have highlighted (as outlined above).
2. Policy/procedure on reporting patients as missing In the PFD, you identified that there is no clear written policy/procedure on the timeframe for reporting patients to the police as missing persons if they fail to return at the agreed time.
Our response: This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.
3. Introducing written policies In the PFD, you identified that there is no clear written policy/procedure on the above matters [Policy/procedure on leave for informal patients; Policy/procedure on reporting patients as missing] and said that consideration should be given to introducing such policies and ensuring staff are fully trained and competent in relation to these matters.
Our response: Please see our above responses to (1) and (2).
Once the new and updated policies have been finalised and approved, a structured roll out of a competency framework will begin, to support our staff in understanding the new policy and the updated policies and how to put them into practice.
In addition to staff training through competency frameworks, we will also be adding the existing eLearning module regarding “Alcohol Identification and Brief Advice” to the mandatory training list for all inpatient staff.
4. Protocol for managing alcohol detoxification on mental health wards In the PFD, you said that consideration should be given to implementing the recommendation arising from the Serious Incident investigation to develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.
Our response: The Trust has now completed its guidance regarding “Alcohol detoxification for people admitted to inpatient wards”.
We are also developing new guidelines for “Management of People with Alcohol Use Disorders (AuDs) Admitted to Mental Health Wards”. The new guidelines cover the following: monitoring of patients during withdrawal and detoxification (both physical and mental health), leave, risk assessments and care planning.
Once complete, i-access detoxification nurses will work with the inpatient Advanced Clinical Practitioners to train and support inpatient staff to put the guidelines into practice.
A retrospective baseline audit is also underway, looking back over a three month period between 1.8.2019 – 31.10.2019 to consider whether the Working Age Adult division identified and managed alcohol dependence appropriately. Once the improvements have been embedded, a second audit will be completed to check for improvements in our practices.
I attach the Trust’s action plan that has been devised, to monitor and track our improvement work. The delivery of the plan will be monitored through our established Inpatient Improvement Board, chaired by the Chief Operating Officer and Chief Nursing Officer. Regular briefings will be made to myself, as Chief Executive and the Executive Directors.
On behalf of the Trust, I would like to offer our sincere condolences to Miss Smith’s family for their loss and hope that our actions outlined above assures you and them that we have learnt and continue to learn from her death.
Re: Regulation 28 Report to Prevent Future Deaths Surrey and Borders Partnership NHS Foundation Trust Response
I am writing in response to your Regulation 28 Report to Prevent Future Deaths, hereafter referred to as ‘PFD’, issued on the 9th December 2020 following the inquest touching upon the death of Kimberley Smith. I would like to thank you for investigating this matter so thoroughly and for bringing the matters of concern you have to my attention.
In the PFD, you identified four key matters of concern that had arisen from the inquest, and I will address each one in turn below, with details of action we have taken or plan to take to address the issues.
1. Policy/procedure on leave for informal patients
In the PFD report, you identified that the Trust has no clear written policy/procedure on the following:
• The carrying out of risk assessments when informal patients request to leave the unit;
• The relevance of an informal patient being on intermittent observations when they request to leave the unit;
• The processes to follow if informal patients are risk assessed as too high risk to themselves to leave the unit;
• The risk management plans to put in place when informal patients do leave the unit;
• The recording of assessments and decisions in relation to requests made by informal patients to leave the unit;
• The timeframe for reporting informal patients to the police as missing persons if they fail to return at the agreed time.
February 4th, 2021
Private and Confidential
Our response: Guidance in relation to leave for informal patients is currently set out in the Trust’s Section 17 Leave Policy. The Trust has decided to build and strengthen upon this by developing a separate, standalone written policy regarding leave for informal patients. The policy will aim to ensure that the right balance is struck between respecting the rights of informal patients and the need to protect people who may be vulnerable and at risk of harm to themselves. The policy will also require all leave for informal patients to be supported by the patient’s risk assessment and care plan. I have had sight of the new draft policy and am confident that it will cover all the issues that you have highlighted (as outlined above).
2. Policy/procedure on reporting patients as missing In the PFD, you identified that there is no clear written policy/procedure on the timeframe for reporting patients to the police as missing persons if they fail to return at the agreed time.
Our response: This issue is going to be covered in the new policy regarding leave for informal patients, as outlined above. We are also going to update our Section 17 Leave policy (for detained patients) and our Absent Without Leave policy with the same guidance.
3. Introducing written policies In the PFD, you identified that there is no clear written policy/procedure on the above matters [Policy/procedure on leave for informal patients; Policy/procedure on reporting patients as missing] and said that consideration should be given to introducing such policies and ensuring staff are fully trained and competent in relation to these matters.
Our response: Please see our above responses to (1) and (2).
Once the new and updated policies have been finalised and approved, a structured roll out of a competency framework will begin, to support our staff in understanding the new policy and the updated policies and how to put them into practice.
In addition to staff training through competency frameworks, we will also be adding the existing eLearning module regarding “Alcohol Identification and Brief Advice” to the mandatory training list for all inpatient staff.
4. Protocol for managing alcohol detoxification on mental health wards In the PFD, you said that consideration should be given to implementing the recommendation arising from the Serious Incident investigation to develop a protocol for managing alcohol detoxification on mental health wards, including specific care plans, minimum monitoring and how to manage leave requests during treatment.
Our response: The Trust has now completed its guidance regarding “Alcohol detoxification for people admitted to inpatient wards”.
We are also developing new guidelines for “Management of People with Alcohol Use Disorders (AuDs) Admitted to Mental Health Wards”. The new guidelines cover the following: monitoring of patients during withdrawal and detoxification (both physical and mental health), leave, risk assessments and care planning.
Once complete, i-access detoxification nurses will work with the inpatient Advanced Clinical Practitioners to train and support inpatient staff to put the guidelines into practice.
A retrospective baseline audit is also underway, looking back over a three month period between 1.8.2019 – 31.10.2019 to consider whether the Working Age Adult division identified and managed alcohol dependence appropriately. Once the improvements have been embedded, a second audit will be completed to check for improvements in our practices.
I attach the Trust’s action plan that has been devised, to monitor and track our improvement work. The delivery of the plan will be monitored through our established Inpatient Improvement Board, chaired by the Chief Operating Officer and Chief Nursing Officer. Regular briefings will be made to myself, as Chief Executive and the Executive Directors.
On behalf of the Trust, I would like to offer our sincere condolences to Miss Smith’s family for their loss and hope that our actions outlined above assures you and them that we have learnt and continue to learn from her death.