Lajos Mandrik

Dear Sir

Management of Contraband Items: Response to the Concern Raised at the Inquest of Mr Mandrik

Background

This letter sets out the Trust’s response to the concern raised by the Learned Coroner at Mr Mandrik’s inquest that contraband items issued to patients are not routinely recorded as returned.

A Contraband Item Form was in use on Ellis Ward at the time of Mr Mandrik’s admission; however, it was applied inconsistently and there was no clear Trust-wide policy or procedure governing the signing in and out of contraband items issued to patients. As a result, items given to patients were not reliably recorded as returned. The Trust acknowledges this gap and has taken immediate action to address it while the wider policy is updated. On behalf of South West London and St George's Mental Health NHS Trust (the “Trust”), we would like to reiterate our apology to the family of Mr Mandrik.

Summary of Actions

The Trust’s response has three components: (1) a revised Contraband Item Form with a mandatory return field, to be implemented across all inpatient wards (Appendix 1);

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(2) an interim Standard Operating Procedure (SOP) to ensure immediate compliance while the wider policy is updated (Appendix 2); and (3) a formal update to the Trust’s Searching of Environment, Property, Service Users and Visitors and Managing Contraband Policy through the Quality Governance Group (QGG).

1. Revised Contraband Item Form (Appendix 1)

The existing form has been revised to establish clear expectations of responsibility and accountability in the management of contraband items in the inpatient setting.

The revised form includes:

• a mandatory return field requiring the date and time of return and the signature of the receiving staff member, so that every issued contraband item has a documented return entry;
• a requirement that the risk assessment of the contraband is conducted by the nurse in charge;
• a clear requirement that any staff member issuing a contraband item must ensure its return, or formally hand over responsibility to a named colleague if they are unavailable; and
• completed forms to be uploaded to a shared drive by administrative staff to support monthly compliance audits.

Implementation: the revised form will be tested on all acute inpatient wards as an immediate interim measure, ahead of formal approval of the updated policy. [Lead: Head of Nursing, AUC. Target rollout: end of April.

2. Standard Operating Procedure (Appendix 2)

An interim SOP has been created to accompany the revised Contraband Item Form. It sets out the key guidance points, staff responsibilities and audit requirements, and serves as an interim protocol until the Trust-wide policy is updated. The SOP provides ward staff with unambiguous instructions on the issue, tracking, return and escalation of contraband items.

Implementation: the SOP will be used in conjunction with the daily contraband item form on all acute inpatient wards during the trial period. As above, the Head of Nursing, Acute and Urgent Care Service Line, will lead on this, with a target rollout date of the end of April 2026.

3. Integration with Trust Policy

The Trust Searching of Environment, Property, Service Users and Visitors and Managing Contraband Policy will be formally updated to incorporate the revised Contraband Item Form and the SOP. The new process will be inserted into the policy under ‘Management of Contraband Items’, immediately before section 16.1, with the form and SOP included as appendices.

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This amendment has been discussed with the Head of Security Management Team and the Deputy Director of Nursing, who are the joint authors of the policy. The revised form and SOP will next be shared with all service lines Head of Nursing, and the updated policy will be taken through the Trust approval process via the Quality Governance Group (QGG). Completion is anticipated by the end of June 2026. This project will be led by the Deputy Director of Nursing.

4. Communication and Staff Adoption

A communication plan will ensure all inpatient staff are briefed on the revised form and SOP, the expectations on them, and the compliance requirements. Briefings will be delivered through ward handovers, ward-based meetings and clinical supervision. Staff will be required to sign a register to confirm their understanding and adoption of the new process. Ward managers will retain the register as evidence of local compliance.

5. Training

All inpatient staff receive training on the management of contraband items, including risk assessment, search processes and escalation procedures. This is embedded within the Proactive Physical Intervention (PPI) Training package, which includes guidance on identifying, managing and responding to contraband and ligature risks. Staff are required to complete the full PPI induction training and attend annual refresher updates to maintain competence. The revised form and SOP will be incorporated into the PPI refresher content at the next update cycle.

6. Assurance, Audit and Escalation

Compliance with the revised process is monitored through monthly snapshot audits of the completed Contraband Item Forms held on the shared drive. The target is 100% of issued items having a documented return entry. Audit outcomes, including both good practice and areas of concern, are shared with ward teams and reported to the Ward Quality Meeting. Performance below 95% triggers escalation to the Head of Nursing for action, with progress tracked to ensure learning and sustained improvement. Trust-wide assurance will be provided through the Quality Governance Group. A baseline audit will be undertaken at the point of rollout to establish the current position and measure subsequent improvement

7. Shared Learning

The learning from Mr Mandrik’s inquest and the revised contraband management process will be shared across the inpatient wards through the Senior Nurses’ Forum, ward managers’ meetings and a Patient Safety bulletin, to ensure that the changes are understood and embedded Trust-wide.

Dear Sir,

Re: Regulation 28 Report to Prevent Future Deaths – Lajos Mandrik

On behalf of South West London and St George’s Mental Health NHS Trust, I wish first to express our sincere and unreserved condolences to the family of Mr Lajos Mandrik. We recognise the profound impact of his death and the importance of responding fully, transparently, and with urgency to the concerns identified at inquest.

We are grateful for the matters raised in your Regulation 28 Report dated 1 April 2026, and we accept the findings made. We are committed to ensuring that the learning from this case results in sustained and measurable improvements in care.

In order to examine all of the concerns raised, the Prevention of Future Death Report was shared with the clinical leadership team responsible for Mr Mandrik’s care and treatment and our Trust board quality committee to ensure a thorough organisational response and appropriate oversight.

We acknowledge the serious concerns raised regarding observation and engagement and the importance of ensuring that observation practices are safe, therapeutic, and compliant with Trust policy at all times. As you are aware the Trust made immediate changes post the death of Mr Mandrik and has continued to work on improving compliance with Observation and Engagement through daily checks of completion by

the Nurse in Charge as well as weekly assurance Audits. There was continuous work done on revising the policy and adjustments made in line with the existing training package to include an agreed code of conduct that clearly lays out expectation on roles and responsibility by staff who undertake observation.

In September 2024, NHS England launched the Enhanced Therapeutic Observation and Care (ETOC) programme, which supports trusts to make local, clinically led, and patient centred approaches that improve their care provision.

The Trust joined cohort 2 of this project in May 2025 and began working on a number workstreams from September 2025, across all three-service line inpatient wards. The focus of this work was on improving compliance with observation as well as to revise current Trust Policy.

In October 2025 as part of the ETOC project the Trust began a comprehensive review of the Observation and Engagement Policy to provide greater clarity regarding expectations for all levels of observation.

Following receipt of your Regulation 28 report, the Trust conducted a structured Walkthrough under the Patient Safety Incident Response Framework (PSIRF). This exercise mapped the processes and workflow associated with observation practices, identifying the gap between “work as imagined” (policy) and “work as done” (practice). This has enabled us to identify operational pressures, variations in staff understanding, and inconsistencies in application. Findings from this review have also directly informed the policy revision and identified further improvement actions.

I therefore provide a response to your concerns and direction as they were raised in your correspondence:

The MATTERS OF CONCERN are as follows:

1. ‘The Trust's policy - in common with that of other Trusts - is that all observations should include an attempt, at least, at engagement. The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations, in September 2023 or now. Intermittent observations may be recorded as, for example, 'Corridor - pacing' because the HCA has seen the patient but not attempted to engage with the patient. General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now).

1. Trust Policy – Clarification of the observation model The Trust has undertaken a comprehensive review of the Observation and Engagement Policy in line with NICE guidelines with an increased focus on quality of observations to improve patient’s experience as well as to provide greater clarity regarding expectations for all levels of observation. Specifically, the revised policy outlines the expectation for staff carrying out General and Intermittent Observation stating: General observations are the baseline observation applied within the trust, these low-level observations are performed hourly with the intention of locating a patient and visually checking their wellbeing. Intermittent observation is intended to be used for patients who are potentially but not immediately at risk of seriously harming themselves or others, or there are concerns about their physical health which requires them to be monitored and supported at specific times through a well-being check and supported with a meaningful engagement.

The governance process to support implementation of the revised policy will ensure a smooth transition for the implementation and the actions are as follows:
- The revised policy was presented in the Quality Governance Group in May 2026, this will be ratified at the June 2026 meeting.
- Webinars are scheduled for the launching of the policy from July through to September. This is across all inpatient services and includes both substantive and bank/agency staff.
- The e-learning package has been updated to include the changes made in the policy and all staff will be expected to compete this with a new competency framework to demonstrate understanding and compliance with Observation. This will be reviewed by 30 December 2026 to ensure staff are compliant

The Trust has an existing digital system that supports recording Constant and Enhanced Observation. To improve consistency, transparency and auditability of observations, the Trust will move general and intermittent observations to the same digital format. To enable this process, there is a plan to pilot the use of digital technology, ‘e-obs’ in 6 inpatient wards across the organisation, to ensure a collaborative approach to change in practice. This digital system will support a more detailed documentation which will include a safety and wellbeing check on patients during both general and intermittent observation. A set of PDSA cycles will be undertaken to ensure the change is supported and understood by staff. With a final evaluation of the pilot completed by 31 July 2026, with a planned phased roll-out across all inpatient wards by 31 October 2026, subject to evaluation findings.

In addition, a new credit card sized memory Card has been created as an aid- memoir that can be kept on staff’s lanyard that will support staff at a glance to

differentiate between each level of observation as well as a minimum expectation of engagement under each observation level.

The MATTERS OF CONCERN are as follows

2.This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest. It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust's policy. If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward).

We acknowledge that HCAs were specifically referenced in HM Coroner’s concerns and recognising that sustainable improvement requires cultural as well as procedural change, the Trust is implementing a programme of workforce development for all disciplines across all inpatient wards including:
• Mandatory competency-based assessment for all staff across the organisation undertaking observations; and
• Reinforcement of roles, responsibilities and expectations through training as well as monitoring through regular supervision. We will also increase visibility of leadership by regular ward visits to support staff in safe management of patients on observation and better oversight on whether the Observation Policy is being followed by staff. This oversight will:
• Strengthen quality of engagement (not just compliance);
• Track patient experience and outcomes (e.g. reduction in incidents, improved feedback); and
• Reduce prolonged restrictive practice via robust step-down planning. The Trust also has a Nursing Optimisation & Workforce Programme that is focusing on compliance with observation and the quality of these. Having learned from the death of Mr Mandrik, the programme has reviewed the quality of observations and aims to ensure that all observations are supportive of the patient and are a therapeutic intervention. A dashboard to understand the quality of observation is being created and aim to be in use and visible to clinical staff in June 2026.

Delivery of these actions will be overseen through the Trust’s established governance structures, including the Board Quality Committee. This programme of work is designed not only to address the specific concerns highlighted in your report, but to ensure sustained improvement in patient safety, therapeutic engagement, and quality of care across all inpatient services.

Formal review will be undertaken in June 2027 to evaluate the implementation plan, and whether there has been an improvement in practice in line with observation.

On behalf of the Trust, I extend my deepest and sincerest condolences to Mr Mandrik’s family. We are committed to learning from this tragic event and to implementing the necessary improvements to reduce the risk of future harm.

We will continue to monitor the effectiveness of these actions and ensure that they are embedded into routine practice.

Please do not hesitate to contact me should you require any further information.