Source · Prevention of Future Deaths

Stephanie Cave

Ref: 2017-0361 Date: 16 Nov 2017 Coroner: Philip Spinney Area: South Wales Central Responses identified: 2 / 2 View PDF

Inconsistent application and recording of enhanced observations for at-risk mental health patients, coupled with a lack of training and written guidelines, compromised suicide and self-harm prevention.

Date 16 Nov 2017

56-day deadline 30 Jan 2018

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Miss May The

(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep_ (2) The evidence also revealed that there was no training provided and no written guidelines on how such observations should be completed and how they should be recorded in the observation forms_ (3) The evidence also revealed that precise times of such observations were not routinely being recorded

Responses

2 respondents

Response

6 Dec 2017 PDF

Action Planned

Heatherwood Court Hospital will review and update its Levels of Observation Policy and current enhanced observation recording documentation. They will introduce amended documentation for a 2-week trial and update the current training package to include video and exemplar copies of completed documentation. (AI summary)

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Ludlow Street Healthcare & Heatherwood Court Hospital Response to Regulation 28: Report To Prevent Future Deaths Issued by Mr Philip C Spinney, HM Area Coroner, 6 December 2017

Action required by Coroner Action Rationale Person responsible for action Date for completion Consideration should be given to reviewing the process of conducting and recording enhanced observations of patients detained under the mental Health Act and at risk of self-harm or suicide Review and update Levels of Observation Policy for ratification by the Policy Committee

Circulate and implement new policy

Review current enhanced observation recording documentation

Introduce amended recording documentation for 2 week trial commencing 22 January, 2018 with provision for coaching of staff, monitoring and evaluation

Introduce evaluated amended documentation

To consider current policy in relation to the matters of concern raised by the Coroner e.g. by clearly outlining training provided to staff , Registered Manager, with Operational and Board involvement

Policy Committee

, Registered Manager, with Operational involvement

, Registered Manager, , Clinical Lead Manager with Unit Manager support

with administrative support 31 January 2018

12 February 2018

26 January 2018

4 February 2018

5 February 2018

Consideration should be given to introducing training and written guidance on how to conduct and record enhanced observations of patients detained under the mental health Act and at risk of self-harm or suicide Amend documentation form used for recording enhanced observations to include additional guidance on conducting and recording enhanced observations & additional requirement to record actual time that observation is undertaken

Update current training package to include: video that clearly shows the correct way to complete the documentation exemplar copies of completed for the finalised documentation record

To promote more consistent approach by staff in their conducting and recording of enhanced observations and to increase the amount of information recorded

To provide more specific training and guidelines for staff in respect of completing and recording their observations , Registered Manager

, Clinical Lead Manager

19 January 2018

12 February 2018

Welsh Government Devolved Administration

PDF

Action Taken

Healthcare Inspectorate Wales (HIW) completed an inspection of Heatherwood Court and raised concerns about observation of patients. In response, Heatherwood Court reviewed training and amended observation recording sheets. The Welsh government sent copies of the Code of Practice on the Mental Health Act to Heatherwood Court and all units managed by Ludlow Street Healthcare. (AI summary)

View full response

Dear Mr Spinney

Regulation 28 Report to Prevent Future Deaths – Stephanie Monica Cave

Thank you for your letter enclosing your Regulation 28 report following your investigation into the death of Stephanie Monica Cave.

You will wish to be aware that Healthcare Inspectorate Wales (HIW) completed an unannounced focussed inspection of Heatherwood Court on 24 and 25 September 2017. The purpose of the visit was to assess whether Heatherwood Court Hospital is appropriately managing risk, specifically in relation to self harm and suicide. This inspection was in response to HIW being notified of the death of a detained patient (Stephanie Monica Cave).

As with your investigation, HIW raised a number of concerns in regards to the observation of patients detained under the mental health act. In response to HIW’s concerns Heatherwood Court provided an implementation plan of actions they have taken/would take. These actions included –

 A review of training materials and an update to enhanced observation practice.  An amendment to observation recording sheets to explain to staff what action is required in relation to the patients required level of observation.

In addition the NHS Wales Quality Assurance Improvement Team (QAIT) undertook an immediate assessment of the clinical observation procedure within the hospital through an unannounced inspection on 9 January 2018. QAIT were informed of concerns raised through your Regulation 28 report and deployed clinical members to assess the site.

Concerns were again raised in relation to observations which included gaps in observation and enhanced observation records and the sign off of day shift forms which highlight any action required/completed addressed. QAIT will continue to work with the provider to ensure these concerns are addressed and appropriate action is taken.

The statutory Code of Practice (for Wales) 2016 to the Mental Health Act 1983 sets out specific guidance in relation to the practice of clinical observation given in chapter 26 and applies to Independent as well as NHS mental health hospitals/units in Wales. The overarching clinical imperative is that there should be a clear local policy on the clinical observation of patients as an integral aspect of patient engagement and the assessment and management of safety concerns. The Code addresses specific points of relevance to the matters of concern you raise regarding the process of conducting and recording the clinical observation of patients and staff training. In addition, the Code references relevant guidance issued by the National Institute of Clinical Excellence’s (NICE).

We have sent copies of the Code of Practice on the Mental Health Act to the Operational Manager of Heatherwood Court and all units in Wales under the management of Ludlow Street Healthcare.

I hope you find this response helpful.

Report sections

Investigation and inquest

On 18 August 2016 an investigation was commenced into the death of Stephanie Cave: The investigation concluded at the end of the inquest held on 6 November to 16 November 2017. The conclusion of the inquest was the answers t0 a series of questions raised by me and answered by the Jury: In summary the Jury concluded that Cave intended to take her own life. They further concluded that there were no acts or omissions in the overall care and treatment given to Miss Cave that probably contributed to her death

Circumstances of the death

Stephanie Cave first started t0 experience a deterioration in her mental health in 2013 when she first started restricting her diet; later there was a significant deterioration in her functioning with self-harming; obsessional compulsive behaviour and speaking of hearing a derogatory voice associated with self-harming behaviour: She made a number of attempts to end her life. She had two periods of admission to hospital the second in September 2015 when she was admitted to the Dorothy Pattison Hospital under the provisions of the Mental Health Act In January 2016 she was transferred to Heatherwood Court; a private hospital operated by Ludlow Street Healthcare as her needs could not be met on an acute ward. Miss Cave initially appeared to show improvement in her clinical state with her mood and affect improved. However, there were regular incidents of self-harm and of tying ligatures around her neck: In the months of and June there were multiple incidents which required intervention by staff Following this there was a sustained improvement commencing from the July: However on the 17 August 2017 she was discovered with a ligature around her neck which sadly led to her death:

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Report details

Reference: 2017-0361
Date of report: 16 November 2017
Coroner: Philip Spinney
Coroner area: South Wales Central

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 30 Jan 2018.

Sent to

Welsh Government

Ludlow Street Healthcare

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.