Source · Prevention of Future Deaths

Adam Withers

Ref: 2016-0059 Date: 15 Feb 2016 Coroner: Alison Hewitt Area: Surrey Responses identified: 3 / 3 View PDF

Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient assessment and care.

Date 15 Feb 2016

56-day deadline 12 Apr 2016

Responses identified 3 of 3

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

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in respect of the matters which have not yet been addressed or sufficiently addressed. A. To the Surrey and Borders Partnership NHS Foundation Trust

(1) It was apparent from the evidence that periodic observations of psychiatric patients are conducted not only to check that each is present, but also in order to observe and assess their current state of mind and presentation, by means of a meaningful interaction, if possible. The importance of nursing staff (Registered Nurses and Health Care Assistants) making a sufficient written record of these observations was acknowledged. Regular notes of a patient’s condition are important for the purposes of diagnosis and they provide the information which is needed for a reliable assessment of the patient’s progress and current level of risk of harm or death. It was accepted in evidence that this is especially so in relation to any patient whose condition fluctuates.

It was clear from the evidence that the nursing staff involved in Adam Withers’ care failed to record sufficiently his presentation and their interactions with him. For example, on the day of his death Adam Withers was subject to four observations per hour but no entries were made on his RIO notes or elsewhere about his state of mind or presentation at these observation points and no record was made about the conversation a nurse conducted with him that afternoon.

Some of the nursing staff who gave evidence appeared to have little understanding of the need to make such written records and/or their importance.

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If permitted to continue, the insufficient recording of observations and events could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives.

(2) It was clear from the evidence that any note made in a patient’s record should be made contemporaneously or, if made later, should be timed, dated and labelled as retrospective. This is necessary to ensure that all notes are accurate and reliable.

The evidence at the inquest revealed that at least one member of nursing staff made entries on Adam Withers’ manuscript observation record after he had died, without marking the entries as retrospective. When giving evidence, the member of staff in question did not appear to understand that he ought not to have done so.

If permitted to continue, this practice could result in current and future patients’ notes containing inaccurate and unreliable, and potentially misleading, information and this could have an adverse impact on their assessment, treatment and care and upon the protection of their lives.

B. To : The Surrey and Borders Partnership NHS Foundation Trust, and

To : The Secretary of State for Health

The MATTER OF CONCERN is as follows :

(1) At the inquest an issue arose as to when the manuscript observation record for Adam Withers for the 9th May 2014 was completed and I asked to see the original document. I was provided with a witness statement from the Trust’s Medical Records Manager indicating that, after Adam Withers’ death, the original record had been scanned in to his electronic records and then destroyed. The Trust considers that this is permitted by the NHS Code of Practice on Record Management. It is not clear to me whether that is a correct analysis of the Code or not. No clear guidance appears to exist.

Whilst I understand that paper records may now routinely be scanned in to a patient’s electronic record and then destroyed, my concern relates to that taking place after a patient has died and it is apparent that the death must be reported to the police and/or coroner. The destruction of any original document which is still in existence at the time of death could undermine the efficacy of the police investigation and/or the coroner’s investigation. In turn, this could adversely affect the coroner’s ability to establish the facts of how the deceased person came by his death and to report concerns for the prevention of future deaths.

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C. To : The Secretary of State for Health

To : NHS England

The MATTER OF CONCERN is as follows :

(1) At the inquest the number of nursing staff (Registered Nurses and Health Care Assistants) on duty on Elgar Ward was considered. It was apparent from the evidence that the nursing staff levels could result in patients on the ward being insufficiently supervised at meal times and staff stated in evidence that they did not always have time to read patients’ notes as they should.

Further, Elgar Ward is an acute psychiatric ward with both detained and voluntary patients. It is foreseeable that reactive and unplanned interventions will be required at times and that the level of observation needed by each patient will fluctuate. The staffing levels on Elgar Ward were deemed sufficient for only a fixed number of patients to be subject to increased observation levels, and only one patient to be under constant observation, at any one time. I was informed that if more patients required increased or constant observation, additional staff would be needed but may not be readily available.

I have been told by the Trust that no nationally prescribed safe staffing levels are in place for an acute psychiatric ward (whether based on patient to staff ratios or otherwise) and that the Trust considers its staffing levels to be in accordance with such guidelines as do exist. The Mental Health Taskforce’s recently published report entitled “The Five Year Forward View For Mental Health” does not appear to address this issue.

It does seem that the absence of prescribed safe nursing staff levels for acute psychiatric wards could leave such wards unable to provide, throughout each shift, the level of patient supervision, observation and intervention needed. This could adversely affect the staff’s ability to protect their patients’ lives.

Responses

3 respondents

Department of Health Central Government

17 Feb 2016 PDF

Noted

The Department of Health states that original paper records should not be destroyed after a patient's death where the death may be subject to investigation. They state that the NHS Records Management Code of Practice is currently under review. (AI summary)

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Philip Dunne MP Minister of State for Health Department of Health Richmond House 79 Whitehall London SWIA 2NS Ms Alison Hewitt Tel: 020 7210 4850 Assistant Coroner HM Coroner for Surrey HM. Coroner' s Court Station Approach Woking Surrey GU22 TAP K Heile Thank you for your letter of 17 February 2016, following the inquest into the death of Adam Withers. I was sorry to hear of his death and wish to extend my condolences to his family and I apologise for delay in providing this response. There are two concerns for the Department's attention. The first concerns the destruction of original paper patient records after have been transferred to electronic format following a patient's death. You are concerned that such practice, when it is apparent that the death must be reported to either or coroner; could undermine any police or coroner investigation. The Trust considered it was adhering to the NHS Code of Practice on Records Management when the paper record was destroyed after converting it to electronic format. You are unsure whether this was correct interpretation of the Code and consider that no clear guidance on this issue exists_ Our view is that original paper records should not be destroyed after a patient's death where the death may be subject to investigation. I fully support the view that the NHS must be totally candid in its dealings with coroner or police investigations. This raises a question about whether the Trust acted appropriately in destroying the paper record following Mr Withers' death: It is not clear from the information available whether the Trust was aware that a coroner'$ investigation was going to take place. Destroying the paper record might have been justifiable if that took place before the Trust was aware of the possibility of an investigation. Destruction would have been much less justifiable where an investigation was already underway. they police

The NHS Records Management Code of Practice is currently under review and a revised Code is due to be published when the review is complete: Clear guidance on the point you raise will be added to the revised Code before publication Your second concern relates to insufficient staffing levels both on Elgar Ward at Epsom General and in acute psychiatric wards in general. The Trust informed you at the inquest that there are no nationally set "safe staffing levels" for acute psychiatric wards. You are concerned that this could leave patients in such wards at risk due to inadequate supervision, observation and intervention As set out in the NHS Constitution, patients have the right to be treated to a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality. Reports on the failings at Mid Staffs highlighted the importance of the appropriate staffing levels to the delivery of safe and effective care: The Care Quality Commission's (CQC) Fundamental Standards require care and treatment to be provided in a safe way, and that includes safe levels of staffing Responsibility for staffing rests (as it has always done) with Trust boards. Trusts ` staffing arrangements should enable the right numbers and skill mix of staff at the right time to deliver quality care and patient safety while s0 efficiently, taking into account local factors such as acuity, case mix and how to respond to fluctuations in workload. This was underlined by: recent correspondence a letter on safe staffing and efficiency was sent to NHS Trusts in October 2015 from NHS Improvement; CQC, NHSE, the Chief Nursing Officer and the National Institute for Health and Care Excellence; underlined by a letter in January 2016 from the Chief Executive-designate of NHS Improvement; Jim Mackey, and the Care Quality Commission'$ Chief Inspector of Hospitals, Professor Sir Mike Richards. Copies of theseletters_are enclosed: Lord Carter's review highlighted the importance of getting staffing right as a means of increasing the productivity and efficiency of the health service while providing quality, safe care; and publication in July 2016 ofrefreshed National Quality Board (NQB) guidance on Safe and Sustainable Staffing: https/LwwwenglandnhsukJwp-contentLuploads/2013/04/ngb-guidance pdf This refreshed guidance acts as a resource to support the decisions that trust Boards need to make; bringing together judgements about eg casemix and patterns of demand doing good

Department of Health to ensure their arrangements underpin safety while still affordable and sustainable. It emphasises that Trusts' focus should be on patient outcomes rather than relying on input measures such as crude numbers or ratios of staff; We do not agree that a minimum staffing level for services would be a 'guarantee for safety" : the evidence base is lacking and minimum staffing numbers and ratios would not take account of local circumstances, skill mix or case mix: Following publication of the revised guidance by NQB, further outputs will be developed by the national programme for individual settings including mental health and learning disability settings hope that this reply is helpful and I am grateful to you for bringing the circumstances of Mr Withers' death to my attention. fuA Vx~ PHILIP DUNNE being &xs

Adam WITHERS

11 Apr 2016 PDF

Action Taken

The Trust has instigated work to improve the quality of engagement with adult inpatient services using a process of purposeful engagement and revised their Observation Policy to include clearer guidance on recording all clinical interventions. (AI summary)

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Dear Ms Hewitt Inquest into the death of Adam Withers REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Further to the recent conclusion of the inquest into Adam Wither's death on 9 2014, you wrote to Surrey and Borders Partnership NHS Foundation Trust in accordance with the Regulation 28 report to prevent future deaths, stating that during the course of the inquest the evidence revealed matters giving rise to concern: would Iike start our response, by offering our sincere condolences to the Withers' family for their loss. The areas of concern you raised that relate to our Trust and our responses are detailed below: It was clear from the evidence that nursing staff involved in Adam Wither's care failed to record sufficiently his presentation and their interactions with him: We acknowledge that our record keeping practice did not meet our desired and expected quality levels in this instance and we have learnt from these identified deficiencies We have already instigated work to further improve the quality of our engagement with people using our adult inpatient services by ensuring that all interactions are meaningful; using process of purposeful engagement (a modified form of intentional rounding); The purposeful engagement process assists our staff in ensuring continuous assessment of individuals SO timely interventions can be undertaken when necessary As part of this process we expect all staff in these services to record interactions in the person's clinical records in a timely way. We have also revised our Observation Policy to include much clearer guidance on how when and where people should record all clinical interventions_ This includes a review of the assessment section of this policy, which clearly states that all people that use our inpatient services will have comprehensive Risk Assessment. This will include For abetter Ilfe Tust Headquarters, 18 Mole Business Park; Lea#herhead, Surrey KT22 7AD 10300 55 55 222 F_01372 217111 Wwvv sahp nls,uk May We

looking at risk of suicide, absconding, self-harm, violence , vulnerability to exploitation and self-neglect: It is further outlined that this assessment will be recorded in the person's multidisciplinary clinical records, along with the joint decision regarding the level of observations assessed, as being most appropriate. This record will include details about specific elements of risk, including any relevant trigger factors to be considered when carrying out the observations_ There is also clear expectation that where specific risks have been identified by the referrer, those people awaiting assessment should be kept within eyesight observation To ensure wider understanding of the observation expectations, we have issued Trust-wide Clinical Risk Alert clearly outlining our expectations in this regard 2 It was clear from the evidence that any note made In a patient's record should be made contemporaneously if made later, should be timed; dated and labelled as retrospective. This is necessary to ensure all notes are accurate and reliable. We have since reviewed our Records Management Policy which has a section outlining the 'Standards for Record Keeping' . Under these standards there is clear expectation that: a) All records will be factual, consistent, accurate and evidence-based , Where records are professional opinions, this must be clearly stated b) Records will be written as soon as possible after contact has occurred, providing current information on the care and condition of the person who uses our services (within 24 hours). It is also our expectation that all our registered staff work within their relevant professional codes of practice. The NMC state that; in line with local policy, staff should put the date and time on all records_ This should be in real time and chronological order, and be as close to the actual time as possible (the contemporaneous record) In an emergency where staff are unable to record the times we would expect them to highlight that the recordlentry is retrospective, but should still follow chronological format of proceedings. Our use of the electronic patient record system in our Acute Services now removes any doubt about record entry time as every now leaves clear audit trail which can be reviewed as required. Quality is further maintained when we share learning from our record keeping audits which we undertake as part of our clinical audit program_ We have added the issues identified in the Regulation 28 report and our resulting actions to our corporate action plan, which we share with commissioners to ensure we continue to embed leaming from issues raised: We would like to offer our sincere condolences again to the Withers family for their loss. We hope that the steps we have taken as outlined above assure you and Adam's family that we have learnt and or, entry

continue to learn from his death. Please do not hesitate to contact me or Jo Young; Director of Quality and Deputy Chief Executive (Nurse Director), if you require any further information:

CQC Regulator / Inspectorate

PDF

Noted

This is a joint strategic statement from NHS Improvement and the CQC about working together to ensure financial rigour while improving quality outcomes for patients. It describes how the two organisations will work together in the future. (AI summary)

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Dear Colleague, We are all aware that the NHS, and providers specifically , have been under great pressure as we seek to improve quality outcomes for patients within the financial resources available. However, the size of this year's provider sector deficit makes it clear that; collectively, we need to focus more on financial rigour as one of the routes to excellent quality. We recognise that both our organisations NHS Improvement and the CQC have an important role in enabling every trust to deliver that balance. We also recognise that how we do our work; the signals we send and how we work together, are an important influence on whether you can deliver that balance or not: We have therefore been discussing between ourselves, and with senior provider colleagues, what more we can do to help and support you and we wanted to share the early outcomes of that work 'Early outcomes because, at this point, this is strategic statement of intent and we want you to tell us what we have to do differently to secure the right financelquality balance that we all need: Success is delivering the right quality outcomes within the resources available We want to start off by being clear that; from our perspective, quality and financial objectives cannot trump one another_ We know that; in the past; there was perception that delivering financial targets was more important than delivering the right quality outcomes; and that, more recently, improving quality was more important than staying in financial surplus. We want to clearly and unequivocally state, with the full support of our other arms' length body colleagues, that your task as provider leaders is to deliver the right quality outcomes within the resources available: That is how we will both measure success and that is how the NHS Improvement regulatory framework and the CQC inspection regime will be framed going forward. Some changes will be needed to make this happen in exactly the way we now want

We will involve you in how we make' those changes for example through the consultations that we will shortly be launching on the CQC's future strategy and single new NHS Improvement regulatory framework for providers CQC and NHS Improvement working together on single national framework We recognise that it is particularly important that you single clear, consistent message from both of us on this issue_ There has been perception in the past that our organisations had greater focuses on different sides of the qualitylfinance balance, potentially creating unhelpful mixed messages_ So, we will jointly design the approach the CQC will use to assess trusts' use of resources_ We are also looking at how the CQC can use the financial data NHS Improvement holds and use the expertise of NHS Improvement staff in reaching its judgements on use of resources. Similarly, as NHS Improvement develops its view of the role of quality in the new; single, provider regulatory framework, we will do this jointly with the CQC and NHS England_ We will also be sharing revised National Quality Board staffing guidance and a new metric looking at care hours per patient that will both use in looking at how trusts manage staffing resources_ In practical terms, we want regulators and commissioners to rely on each other's work, rather than duplicating effort; and we want to create a single unified framework with single way of measuring success that we all use_ We want this to greater clarity and consistency and reduce the regulatory burden, as you have asked for: NHS Improvement and CQC working together on turnarounds One of NHS Improvement's early priorities will be to work with organisations with large deficits to help them return to surplus There is an incorrect assumption that this can only be done at the expense of quality So we will, again , be working together closely so that we can all be sure that; even in the trusts facing some of the biggest financial challenges, it is possible to balance finance and quality. We this gives you a clear statement of our joint intent success is delivering the right quality outcomes within the resources available and how we want to translate that intent into the way we work in future. Please provide us with any comments you have on this letter and tell uS what more we can do our email addresses are below. It would help if you used JOINT NHSIICQC LETTER" as the subject of any email you send us de Lui_Pag Jim Mackey Professor Sir Mike Richards Chief Executive Chief Inspector of Hospitals NHS Improvement Care Quality Commission Jim Mackey@monitor gv uk Mike Richards@cqcorg uk get have day- we bring hope

Report sections

Investigation and inquest

I commenced an investigation into the death of Adam James Withers aged 20 years. The investigation concluded at the end of the inquest on 22nd January 2016.

The jury’s conclusion as to the death was that :

“Whilst suffering an acute psychotic illness, Adam Withers climbed to the top of a 130 foot chimney and fell from it unintentionally.

Adam Withers’ death was caused or more than minimally contributed to by :

(1) A failure by the Surrey and Borders Partnership NHS Foundation Trust to take effective steps to address the known risk of detained patients absconding from the Elgar Ward courtyard via its flat roof.

(2) A failure by the Surrey and Borders Partnership NHS Foundation Trust on 9th May 2014 to reassess Adam’s risk levels after his comment in relation to climbing the ladder on the chimney.

(3) A failure by the Surrey and Borders Partnership NHS Foundation Trust on 9th May 2014 to take effective steps to prevent Adam from absconding from Elgar Ward pending RT4724

reassessment of his risk levels after his comment in relation to climbing the ladder on the chimney.

(4) A failure by Epsom and St Helier University Hospitals NHS Trust to take effective steps to prevent access to the ladder on the chimney.

(5) In view of the healthcare requirements for the patients detained in the Langley Unit, there was a systemic failure by both Surrey and Borders Partnership NHS Foundation Trust and Epsom and St Helier University Hospitals NHS Trust to effectively communicate changes to the environment and take remedial action to address identified risks.”

At the conclusion of the inquest the Interested Persons were given time to make, and respond to, written submissions concerning my duty to make a report to prevent future deaths. I have received written submissions from all the Interested Persons save for the Health and Safety Executive, the last being received on the 5th February 2016.

Circumstances of the death

The circumstances of Adam Withers’ death are set out in the jury’s full findings of fact which were as follows :

“Adam Withers was admitted to the Elgar Ward of the Epsom General Hospital as a voluntary patient on 14th April 2014 suffering from acute psychotic illness.

Elgar Ward had a documented history between 2012 and 2014 of numerous patients absconding by climbing from its courtyard on to its flat roof and on 22nd April 2014 Adam Withers climbed from the courtyard on to its flat roof after being detained under section 3 of the Mental Health Act. As a result, Adam Withers was transferred to the Psychiatric Intensive Care Unit where on 23rd April 2014 he was further detained under section 2 of the Mental Health Act.

On 2nd May 2014 there was a ladder attached to the full height of a 130 foot high chimney within the grounds of the Epsom General Hospital which was partly visible from the courtyard and bedrooms off the female corridor of Elgar Ward. This was for a maintenance inspection for the expected duration of one day and to be taken down on the same day. During the inspection, further remedial work was identified and at this point it was agreed that the ladder would be left in place until quotations had been received and the work carried out.

On 5th May 2014 Adam Withers was transferred back to Elgar Ward from the Psychiatric Intensive Care Unit but his medical records do not indicate his risk of absconding being reviewed.

On the morning of 9th May 2014 Adam Withers was placed on a 15 minute observation regime because of the risk of absconding. It was also observed but not logged that he was in an agitated state.

During the afternoon, prior to 3.00pm, Adam was in the courtyard of Elgar Ward. In conversation with a member of staff he stated that he could see a ladder attached to the RT4724

chimney and that he felt it was a message from God who wanted him to climb it. The member of staff subsequently passed this information to a member of nursing staff on the Elgar Ward. However, this was not effectively communicated in full to all staff on duty and neither was a further assessment taken as to Adam Withers’ risk of absconsion and the need for increased supervision.

Shortly after 6.00pm, Adam Withers was in the courtyard of Elgar Ward. Despite the risk assessment Item 35 of the RAI Form stating patients should be supervised whilst in the courtyard, there were no members of staff present. He absconded by climbing, via the conservatory, on to Elgar Ward’s flat roof with ease and speed. A member of staff entered the courtyard when Adam Withers was on the roof of the conservatory and raised the alarm. From the flat roof of Elgar Ward, Adam Withers made his way without effective restriction to the base of the chimney where he overcame the security measures that had been put in place at the base of the ladder. Adam Withers climbed the ladder to the top of the chimney and fell to the ground and suffered fatal injuries as a result.”

Action should be taken

In my opinion action should be taken to prevent future deaths by addressing the concerns set out above and I believe you have the power to take such action.

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Shared signals

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Report details

Reference: 2016-0059
Date of report: 15 February 2016
Coroner: Alison Hewitt
Coroner area: Surrey

Responses identified

Responses identified 3 of 3

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Apr 2016.

Sent to

Department of Health and Social Care

NHS England

Surrey and Borders Partnership NHS Trust

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