Priory Hospital
Private Sector
Action Taken
The Priory Hospital Roehampton details environmental and health and safety risk assessments undertaken and coordinated with Policy H43 Observation and Engagement throughout the ward. The Incident Management; Reporting and Investigation Policy (OP4) has been updated to include a requirement that serious self-harm incidents will require an SBAR notification to be made and further investigation will be commissioned. (AI summary)
View full response
Dear Ms Monaghan; ReMs Francesca Whyatt (deceased) dated Monday 21 the Regulation 28 Report to Prevercthincturre Deettf ctevs Fancesca Iwrite to you in response to to the Inquest Touching the August t2017 that YoU issued irnaseopon are set out below; Agyatt ?he matters of concern and responses over four of the East Wing ward no risk assessment of the configuration There has been floors: that patients are unable to would respectfully ask vou to please note without being escorted; As preliminary issue, ebeewhole of the basement (Floor U patients with mental access the rooms on Floor or that many units in the UK for and Fcceher; Jewould wish to make the gereral will inform the main risk assessment risk are multi-level and that layout In addition, to support clinical health issues the clinical risk assessment fora health and safety risk assessments management tool i.e; environmental and assessments, there will be more which are summarised below. and management ward patients have a current clinical rishtsssesspeans_ on day-to-day Clinical Risk_assessnents: All aeuitements of these assessmeahs ar/plansexperierced ward place. In order to meet the with oversight from an plan in core staff team in place that the group are basis the ward has Systems in place to ensure team: All baanager and hospital teanageetentbervationts undertaken by fully trained It subject to co-ordinated erafetaccodenctionth Policr H43 Observatioduandhergpgeengroughoord observations are undertaken in_ patients are in individual therapy in the also be noted that during the the ots te ward (or other areas of the Hospital) areas and will therefore occupy presence of staff. an ongoing basis, there to the opening of a service and on blind audits: Environmental risk_assessmentsspior which wili include ligature and Quality Walk will be an environmental riskrassefeasentwicei Additionally thereateet eckStarusafety and Thesee audits wilil be refreshed at least these include reference to; and risk being completed by senior nursing staff_ obstruction; areas that present a Rounds to corridors being kept free of available: The documents make reference emergency equipment being effectively and 12th point ward patient: general patient regular are staff should occupied day, particular spot point year. patient are completed managed
THE PRIOY HOSPITAL reviewed by the relevant hospital director and are also subject to review by the ROEHAMPTON divisional quality team: Health_and_safety_risk_assessments: these will include the Potential Violence Risk Assessment has recently been updated and scrutinised by our Director of Risk and Safetvwho has found (heichsessmere t beeeccuratetanarsitable). SThe assessment document is completed prior to ay the ward opening and also in: response to any serious incident of violence and aggression or new in patient profile: The assessment assists staff in identifying any actions that sieedficantechakee t0 DatierthPredilecinghehestieetifood o violent incident: Additional health and need to and audits that assist in ensuring and staff safety include fire risk safety risk assessments assessments, infection control and anti-barricade door audits. There is no written or other formal guidance on the frequency with which ad-hoc agency staff should complete the observation competency checklist We would wish to make the general point that ward staff will have access to agency training recordon ar ongoing basis to enable a check to be made of when the observation competencvtfor partic laramember of staff was Iast completed, However, we can see the benefits of this practice codified in our existing Policy H43 Observation and Engagement and the following being requirement has now been added: 'Where bank or agency member of staff has a break in service of over one month then H Form: 99 Observation Competency Checklist must be completed again' This additional requirement will be communicated to divisional during week commencing Monday 16 October 2017 via the weekly divisional newsletter and as part of the ongoing observation and engagement staff training webinars that are delivered on monthly basis_ Ligature incidents are not automatically treated as SUIs (though the evidence suggests that death can occur within seconds of a ligature being applied) We wish to make the general that self-harm incidents both generally and those ligature will vary in their nature and degree and it would not be appropriate for all iigvolyieg incideats to be treated as SUIs. It will depend on the patient and the particular ligature in each case: Accordingly, it is for the staff who deal with the incident on the ward to cirkenstadetermireatroncaise partictdargthe twarar manager, as to how such an incident should be make graded: However; all ligature incidents will be recorded on our e-compliance system within 48 hourst ofethe incident and all e-compliance incident reports are reviewed by the hospital management team within 72 hours of the incident report being made: will check the accuracy of the report and the incident grading; Where necessary the incident grade will be amended; Incident reports are ialso reviewed on daily basis by the central risk and audit team and where appropriate; there wiltbe follow-ups with the Hospital to check on how the incident is managed and what changes to patient's risk assessment are needed. More serious ligature incidents resulting in medical intervention will be the subject of tedetailed incident report (called an SBAR) which will be sent to the central risk and audit teameand eeridlated toehe senior levels of management for review with an SUI report being commissionedin circumstances: Again; though this happens in practice, we can see the benefits of this appropriate patient staff staff point would they being
THE PRIORY HosPITAL being expressly set out in our Incident Management; Reporting and Investigation ROEHAMPTON Policy (OP4) and the following requirement has been added to the policy: "Serious self-harm incidents involving ligature or self-mutilation of such severity that the service user was at risk of death andjor life changing injuries and which necessitated medical treatment" will require an SBAR notification to be made and further investigation be commissioned to enable an understanding of the actual incident and identification of any improvements that need to be made to assist in preventing a repeat of similar incidents in the future. This requirement will be communicated to divisional staff during week commencing Monday 16 October 2017 via the weekly divisional newsletter There is no clear guidance or criteria on the circumstances in which ligature incident/incident/s or other self harming incident/s) should be treated as an SUI such as to trigger an SUI investigation: As with point 3 above, we have identified that any self-harm incident which requires medical attendance and medical intervention will be recorded as serious incident and will require escalation with serious incident investigation being commissioned by the divisional management team in appropriate circumstances: The report arising from that investigation will be shared and any lessons learnt and improvements will be rolled-out across the division as required. I do hope that these actions will provide you with the reassurance that you require: If I can be of further assistance then please do not hesitate to contact me;
THE PRIOY HOSPITAL reviewed by the relevant hospital director and are also subject to review by the ROEHAMPTON divisional quality team: Health_and_safety_risk_assessments: these will include the Potential Violence Risk Assessment has recently been updated and scrutinised by our Director of Risk and Safetvwho has found (heichsessmere t beeeccuratetanarsitable). SThe assessment document is completed prior to ay the ward opening and also in: response to any serious incident of violence and aggression or new in patient profile: The assessment assists staff in identifying any actions that sieedficantechakee t0 DatierthPredilecinghehestieetifood o violent incident: Additional health and need to and audits that assist in ensuring and staff safety include fire risk safety risk assessments assessments, infection control and anti-barricade door audits. There is no written or other formal guidance on the frequency with which ad-hoc agency staff should complete the observation competency checklist We would wish to make the general point that ward staff will have access to agency training recordon ar ongoing basis to enable a check to be made of when the observation competencvtfor partic laramember of staff was Iast completed, However, we can see the benefits of this practice codified in our existing Policy H43 Observation and Engagement and the following being requirement has now been added: 'Where bank or agency member of staff has a break in service of over one month then H Form: 99 Observation Competency Checklist must be completed again' This additional requirement will be communicated to divisional during week commencing Monday 16 October 2017 via the weekly divisional newsletter and as part of the ongoing observation and engagement staff training webinars that are delivered on monthly basis_ Ligature incidents are not automatically treated as SUIs (though the evidence suggests that death can occur within seconds of a ligature being applied) We wish to make the general that self-harm incidents both generally and those ligature will vary in their nature and degree and it would not be appropriate for all iigvolyieg incideats to be treated as SUIs. It will depend on the patient and the particular ligature in each case: Accordingly, it is for the staff who deal with the incident on the ward to cirkenstadetermireatroncaise partictdargthe twarar manager, as to how such an incident should be make graded: However; all ligature incidents will be recorded on our e-compliance system within 48 hourst ofethe incident and all e-compliance incident reports are reviewed by the hospital management team within 72 hours of the incident report being made: will check the accuracy of the report and the incident grading; Where necessary the incident grade will be amended; Incident reports are ialso reviewed on daily basis by the central risk and audit team and where appropriate; there wiltbe follow-ups with the Hospital to check on how the incident is managed and what changes to patient's risk assessment are needed. More serious ligature incidents resulting in medical intervention will be the subject of tedetailed incident report (called an SBAR) which will be sent to the central risk and audit teameand eeridlated toehe senior levels of management for review with an SUI report being commissionedin circumstances: Again; though this happens in practice, we can see the benefits of this appropriate patient staff staff point would they being
THE PRIORY HosPITAL being expressly set out in our Incident Management; Reporting and Investigation ROEHAMPTON Policy (OP4) and the following requirement has been added to the policy: "Serious self-harm incidents involving ligature or self-mutilation of such severity that the service user was at risk of death andjor life changing injuries and which necessitated medical treatment" will require an SBAR notification to be made and further investigation be commissioned to enable an understanding of the actual incident and identification of any improvements that need to be made to assist in preventing a repeat of similar incidents in the future. This requirement will be communicated to divisional staff during week commencing Monday 16 October 2017 via the weekly divisional newsletter There is no clear guidance or criteria on the circumstances in which ligature incident/incident/s or other self harming incident/s) should be treated as an SUI such as to trigger an SUI investigation: As with point 3 above, we have identified that any self-harm incident which requires medical attendance and medical intervention will be recorded as serious incident and will require escalation with serious incident investigation being commissioned by the divisional management team in appropriate circumstances: The report arising from that investigation will be shared and any lessons learnt and improvements will be rolled-out across the division as required. I do hope that these actions will provide you with the reassurance that you require: If I can be of further assistance then please do not hesitate to contact me;