Kingsley Burrell

Dear Mrs Hunt KINGSLEY BURRELL (DECEASED) Thank you for your Regulation 28 Report to prevent future deaths, dated 20 May 2015, bringing to my attention the Coroners concerns arising from the inquest into the death of Kingsley Burrell: The Association of Ambulance Chief Executives (AACE) provides ambulance services with central organisation that supports, coordinates and implements nationally agreed policy. It also provides the general public and other stakeholders with a central resource of information about NHS ambulance services: The primary focus of the AACE is the ongoing development of the English ambulance services and the improvement of patient care. We have given careful consideration to your concerns and have consulted with the mental health leads and senior clinicians in the NHS ambulance trusts: Taking the concerns in turn; set ut the actions we have taken and response: Medical evidence at the inquest confirmed that Mr Burrell was suffering from acute behavioural disturbance. As result he continued to struggle against restraint; Patients with this condition are at risk of death through prolonged restraint and struggle against restraint: Most training in relation to restraint deaths focuses on positional asphyxia: Position in this case was not a major consideration: It was clear from the inquest that there was a lack of understanding of how to treat someone with an acute behavioural disturbance. Minimising the period of restraint is West Midlands police have undertaken considerable work and training of staff concerning this condition. My concern is that this has not been rolled out nationally and therefore many other forces will not understand the implications of this condition and how best to treat it. suggest contact is made with Chief Inspector at WMP for full information on the changes made in the West Midlands area: We sent a survey to the mental health leads of NHS ambulance trusts asking if they had a restraint policy and what training and education is currently provided to front staff around acute behavioural disturbance_ We established that ambulance trusts currently do not have specific policies regarding restraint: Some trusts are currently developing a restraint policy or have wording around restraint in other trust policies such as capacity and consent to treatment: We also established that not all trusts comprehensively incorporate education to their staff around ABD_ The National Ambulance Mental Health Leads group that reports to the National Ambulance Service Medical Director group (NASMeD) have been asked to develop the principles and Chairman: Dr Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc FASI Managing Director: Martin Flaherty OBE key: line

recommend what should be part of policies around conveyance of mental health patients, highlighting the principles of restraint and awareness of acute behavioural disturbance. This will include an awareness of the impact that prolonged restraint can have on an individual and the importance of performing physical observations during and after physical intervention/restraining_ Also the importance of documenting that any physical intervention has been used on a person_ This group will then share these principles with ambulance trusts for them to consider implementation: This action will be completed by November 2015_ We have made a recommendation to the National Education Network for Ambulance Services leads (NENAS) that each trust considers including; if not completed already, the education of front line staff and control room staff in acute behavioural disturbance to raise awareness of the condition and how it can present in a patient: We have approached the leads of the two systems used in ambulance control rooms that triage 999 calls and asked them to review their triage pathways to ensure that ABD is included or referred to in the questions that are asked (AMPDS and NHS pathways) An ambulance guideline development group is currently working on revising the UK ambulance services clinical practice guidance around the management of mental health patients. This will include aspects of restraint and include recognition and management of patients with ABD. This work will be completed in 2016 and will be incorporated into the guidance used to inform the clinical practice of ambulance clinicians across the UK: Ambulance clinicians are legally authorised and obliged under the Mental Capacity Act to act in the best interests of, and provide treatment for, patients who lack capacity, even where the patient refuses treatment or are abusivve , threatening or violent: The Mental Capacity Act also supports the use of reasonable force to ensure that patients lacking capacity receive care that is in their best interests or are protected from further harm: However ambulance clinicians are neither trained nor expected to restrain patients who are acting in threatening or violent manner, Ambulance staff are trained t0 provide minimal restraint and use soft control techniquelphysical intervention in cases where patients lack capacity and there is no perceived risk of harm to them or the patient: In the event of restraint required for a violent patient ambulance staff will continue to rely on the Police to provide that restraint as their officers have been specifically trained to do so. In these instances ambulance staff are required to monitor the patient to ensure their continued safety. 2 The West Midlands area now have a crisis team that works with people who are in a mental health crisis. This involves mental health worker and ambulance crew working together with the police to try to help patients with acute mental_health disorders_ My concern is that this is not a national system. Chief Inspector West Midlands Police can provide full details of the scheme_ 3_ This case has resulted in multi-agency review of how patients are managed between the services when crisis occurs_ new conveying of patients policy has been devised Critically police now only attend a mental health ward if there was a patient who is threatening staff or if there is disorder on the ward: My concern is that this is not reflected nationally. Chief Inspector at West Midiands police can provide full details of the policy. In the survey we sent to trusts, we asked what schemes were in existence around multi agency working: We found that there were a variety of schemes, some in pilot stage and still reviewed in terms of effectiveness and efficiency, others in planning: Some of them had paramedics working as part of joint team, others had pathways where paramedics could refer to mental health teams Chairman: Dr Anthony C Marsh QAM SBStJ DSci (Hon) MBA MSc FASI Managing Director: Marlin Flaherty OBE being being

Due to a now recognised national shortage of paramedics, being able to provide a paramedic to specifically work as part of a team to respond t0 patients with acute mental health disorders will be difficult for some trusts; and will depend on local commissioning arrangements. We recognise that these schemes are likely to continue to develop: Ambulance trusts do work closely with their local Police Forces, and we found that most trusts have at least three police forces within their region Therefore it is important to ensure that collaborative arrangements are in place to jointly manage a range of incidents including the multi- agency response to patients experiencing mental health crisis_ At a national level the AACE and the National Police Chiefs Council (NPCC) have been working closely together to improve arrangements for inter-agency working and the demand that ambulance trusts and police forces generate for one another; the aim being to improve the response to the public whilst also operating together as efficiently as possible. Particular efforts have been expended in relation to offering better care to patients experiencing mental health crisis and the Crisis Care Concordat, supported by local declarations, have given added impetus to this work: As a consequence ambulance trusts in England introduced new protocols in April 2014 designed to improve the speed of response to patients detained under Section 136 of the Mental Health Act in order to offer a clinical assessment more quickly and to arrange subsequent conveyance to a place of safety more efficiently. Data for 2014/15 indicates that there have been encouraging improvements with 74% of incidents where the police requested an ambulance receiving response within 30 minutes. AACE continue to work with the NPCC , Home Office and the Department of Health to drive further improvements in both the speed of ambulance response and the proportion of patients conveyed by ambulance rather than police vehicles. In the respect of the latter recent Home Office data indicates that for Section 136 where patients were conveyed by the Police 43% of cases were due to risk or behavioural issues and in 32% of cases no ambulance had been requested by the police. AACE continue to work with the NPCC to ensure that an ambulance is always requested and that police conveyance is reduced to as low a rate as possible _ The College of Policing, Health and Ambulance Service representatives are currently working together to devise a national protocol for the management of ABD in the pre-hospital setting: This is a complex piece of work but the impetus certainly exists to ensure a suitable outcome is reached that will be both manageable and of course beneficial to the patients concerned hope that you will agree that we have dealt comprehensively with the concerns that you have raised. We will continue to ensure CO-ordination between ambulance trusts who have shown themselves to be absolutely committed to learning from this tragic event and do everything within our power to prevent it happening in the future.

Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whilehall London SWIA 2NS POC3000948033 Mrs L Hunt Senior Coroner 50 Newton Street Birmingham B4 6NE 2 0 JUL 2015 Dw Mt Iut Thank you for your letter of 20 2015 following the inquest into the death of Kingsley Burrell in March 2011. I was very sorry to hear of Mr Burrell's death and wish to extend my sincere condolences to his family: You note that Mr Burrell was restrained for a total oftwo and a half hours during period of detention under the Mental Health Act: The inquest jury found that this was an unreasonable period of restraint which, together with the covering applied to his head, the delay in instigating resuscitation and neglect; contributed to his death: You raise a number of concers, some of which are for our response: Mr Burrell struggled against his restraint as a result of suffering an acute behaviour disturbance. The West Midlands area now has a crisis team that work with people in mental health crisis this involves mental health workers and ambulance crew working together with Police to help patients with acute mental health disorders. You are concered this is not national This case has resulted in a local multi agency review ofhow mental health crisis patients are managed between services and a new policy for conveying patients has been devised. This means that police only attend a mental health ward if patient is threatening staff or disorder on the ward: You are concerned that this policy is not reflected nationally: On restraint; both statutory and non-statutory guidance exists The Mental Health Act 1983 Code of Practice (the Code) was revised in 2015 and provides statutory guidance on the appropriate use of restrictive practices that protect the dignity and safety of patients The Code is clear that any restraint should be the least restrictive, May system

proportionate to the risk ofharm to the person and others, and used for the least amount of time appropriate to manage the risk The Code states that there should be Iocal policies in place between NHS bodies and the police which should have a clear protocol about the circumstances when, very exceptionally, police may be asked to use physical restraint in a health-based place of safety. The Department of Health has also published guidance on the reduction of restrictive practices which sets out the appropriate use of restraint: The Department' $ Positive ond Proactive Care: reducing the need for_restrictive interventions (2014) guidance echoes the requirements of the Code and sets out guidance in more detail around the use of restraint. During restraint; people must not have their mouths andlor noses covered: The use of mechanical restraint must be exceptional, as a response to extreme violent behaviour; to ensure the safety of the person and professionals. The guidance also states that; when confronted with acute behavioural disturbance, the choice of restrictive intervention must always represent the least restrictive option to meet the immediate need. It should always be informed by any particular risks associated with the individual'$ general health and an appraisal of the immediate environment. Factors which suggest a person is at increased risk of physical and/ or emotional trauma must be taken into account when applying restrictive interventions: Both the Code and the guidance make clear that all types of restraint should be used for the least amount of time needed to manage risks to the individual and others Department officials continue to work with the police, the Royal Colleges of Nurses and Psychiatrists, and Mental Health Trusts to develop further guidance and training to support local protocols, so that all partners are clear about what should happen in these circumstances The Department published Positive and Safe" in April 2014. This is a two-year programme which aims to end unnecessary use of restrictive interventions across all health and adult social care. The programme incorporates two pieces of guidance the Positive and Proactive Care mentioned above and Positive and Proactive Workforce: Whilst we aim to reduce restrictive practices, there will always be circumstances in which it is necessary to use restraint. When restraint is used on patients who are suffering of conflict or disturbed behaviour; their physical responses to stress and anxiety may be heightened and a worsening of pre-existing medical conditions can occUr. It is therefore vital to observe the patient to monitor for deterioration in health: key guide period

Department of Health NHS England has responsibility for patient safety and is aware of the importance of performing physical observations and after physical intervention Or restraint: Discussions are currently focusing on the risks posed to patients in mental health care where continued physical observations are not undertaken during and following of restraint: NHS England shared the details of Kingsley Burrell 's death with the Expert Safety Group for Mental Health (a group with representation from the health and voluntary sector) on 29th June 2015. discussed the wider issues this case highlights for all care settings across the NHS. The Expert Group has helped support the development of a "Mental Health Patient Safety Thermometer" . This measures the prevalence of specific types of harm for every patient including use of restraint: This helps local teams to develop and implement improvements to restraint practice. Teams using the tool can access data from other teams to provide wider picture of the prevalence of restraint across NHS organisations. The National Reporting and Learning System NRLS) is a comprehensive database of patient safety information. From April 2015 it became a requirement to report all incidents where harm has been caused by restraint as separate patient safety incidents. In this way, important patient safety issues can be identified and tackled at the root cause. You highlight the need for cross-agency working to safely manage people moved between services when a mental health crisis occurs and when police attend a health setting: The Code states local policies should be in place between providers, the and other agencies with protocols covering all aspects of the use of section 135 and 136 powers. Sections 135 and 136 give the police powers to temporarily move people, who appear to be suffering from a mental disorder, and who need urgent care, to a "place of safety' so that a mental health assessment can be carried out and appropriate arrangements made for care. Local policies should include arrangements for police attend a health-based setting and transporting people between places of safety. The Department published the Crisis Care Concordat in 2014 to ensure that anyone experiencing a mental health crisis receives the right support in the right place The Concordat is a crOSs-sector agreement which ensures that local areas provide the during period They survey being police

appropriate response to people in mental health crisis. Every local area in England now has a local mental health crisis plan in place to ensure this happens. The Department has also funded a number of street triage pilot schemes where mental health professionals provide on the spot advice to police when dealing with people with possible mental health problems. These pilots are currently evaluated so that this approach can be rolled out more widely. The Association of Ambulance Chief Executives (AACE) is developing principles and policies for the conveyance of mental health patients and restraint which will cover the importance of physical observations during and after physical intervention. AACE recommends that awareness of acute behavioural disturbance is raised with front line and control room staff at all ambulance trusts_ AACE reports that there are a number of schemes for multi-agency working at ambulance trusts AACE has worked nationally with the National Police Chiefs Council (NPCC) to improve inter- agency working and the efficiency of responses to the public, particularly to those patients experiencing mental health crisis AACE will be responding separately to your concerns and will no doubt provide you with further detail about their work hope that you find this reply helpful and I am grateful to you for bringing the circumstances of Mr Burrell's death to my attention. Youn $mec5J (kt ALISTAIR BURT being (9-