Mid South Essex NHS Foundation Trust
NHS Trust
Disputed
AI-generated response summary
• The Trust provided an updated Policy for Enhanced Supervision and Engagement, which strengthens assessment and guidance for patients requiring enhanced supervision. • The Trust provided an updated Policy for Ligature and Self Harm Awareness, which requires ligature risk assessments and documentation of mitigating actions. • The Trust uses Hospital Passports and its specialist Learning Disabilities Team to support communication adjustments for patients with Autism and learning difficulties.
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Dear Ms Hayes
Regulation 28 Report to Prevent Future Deaths- Ms Abbigail Smith
I write further to your Regulation 28 Report to Prevent Future Deaths (‘PFDR’) dated 27 May 2026, relating to the Inquest of Ms Abbigail Smith (‘Abbi’).
We have considered your concerns and set out our formal response to each matter using your numbering as follows.
Matters of Concern
1. There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life.
Upon review of the relevant rotas, we can confirm that staffing on the night of 26.01.22 was adequate with 15 Registered Nurses and 9 Health care assistants and one registered Nurse that worked a twilight shift 1500-0300. The optimum staffing levels at that time for a night shift was 16 Registered Nurses and 9 Healthcare Assistants.
We acknowledge the concerns of HM Coroner that lack of staffing led to the provision of a security guard in order to support the Mental Health Team. We have not identified any evidence of a Trust-employed security staff being allocated to patients that night, as would usually be documented. In any event, we are not able to comment on staffing of the mental health team which would fall within the remit of Essex Partnership University Foundation Trust (EPUT).
2. For a period of time Abbi was left under the observation of staff that were security personnel and were not appropriate or trained to undertake this work. Male security staff were informed that Abbi should use a commode due to her presenting risks and there were not sufficient trained female staff available. There had been a previous incident where actions taken to restrain Abbi by security personnel caused her trauma and there had been an allegation of assault, this was not considered in this admission.
I understand that the Court has been provided with an updated copy of the Trust’s Policy for Enhanced Supervision and Engagement. This policy strengthens our assessment and guidance for patients requiring enhanced supervision as per the attached tool.
Under the terms of the policy, where a patient meets the threshold for Enhanced Supervision, the patient’s views should be considered when determining the appropriate member of staff to conduct the observation. Staff should also engage with the relevant family member/ carer/ key professional/ Lasting Power of Attorney and keep them informed about the care plan and the enhanced supervision which is in place.
In Abbi’s case, there should have been discussion about Abbi’s previous history regarding restraint, and discussions should have taken place as to how enhanced supervision could have been put in place in a manner which was supportive to Abbi.
3. Abbi at times had to be physically and chemically restrained due to the level of distress and harm to herself. During her admissions Abbi was able to access ligature material that she tied around her neck on multiple occasions over multiple days including her socks, cords from her clothing and pull cords in the bathroom. There were no appropriate care plan and risk assessments to mitigate a significant known risk.
I am aware that the Court has been provided with an updated copy of the Trust’s Policy for Ligature and Self Harm Awareness.
This policy requires the performance of ligature risk assessments and recognises the potential use of clothing items as a ligature. Where it is identified that clothing could present a ligature risk, this will be assessed on a case-by-case basis with regards to the need to balance the patient’s dignity. Where a ligature item is not removed, the rationale for not removing the item and any mitigating actions should be documented and communicated with staff.
4. Abbi was a complex mental health patient awaiting assessment under the Mental Health Act and was being cared for in a part of the hospital that was not suitable for a patient who was actively attempting to take her life.
Our Policy for Ligature and Self Harm Awareness require environmental risk assessments to be performed in regard to clinical and non-clinical areas. These risk assessments are considered by staff before placing a potentially at-risk patient within the area.
5. Staff left Abbi unsupervised during the admission to attend to other patients that permitted her to tie ligatures.
Our Policy for Enhanced Supervision and Engagement, risk assesses patients at five different levels. As Abbi was risk assessed as Level 4 Enhanced Supervision, she should not have been left unsupervised due to the severity of her behaviours.
Enhanced Supervision is part of mandatory training for all staff who are involved with providing enhanced supervision to patients.
6. No adjustments or plans were made for communication for Abbi as a patient with Autism and learning difficulty.
For patients with Learning Disabilities, a Hospital Passport should be completed which includes questions such as ‘How I communicate and how you communicate with me’ and any sensory issues which may impact communication.
For patients with Autism and or learning difficulties such as Abbi, the Trust uses the Autism Health Passport which has been created by the National Autistic Society. This includes questions such as ‘How I would like you to communicate with me’ and ‘How I communicate.’
Our specialist Learning Disabilities (‘LD’) Team is trained to support and advise staff on patient communication needs; any sensory needs or sensitivities; pain recognition; interaction with medical history and any medication regimens; and to ensure reasonable adjustments are considered in line with the Equality Act 2010 and the Mental Capacity Act 2005. For example, this may be facilitating a patient being placed in a quiet area away from populated waiting rooms and information being given that is free of jargon and medical terminology.
In addition to the above, our LD Team and Autism Lead are available to support clinical teams with devising individual care plans and responding to learning difficulty support queries. Our clinical teams work collaboratively with the LD team ensuring as far as possible that appropriate adjustments are made for patients, providing the most therapeutic environment for their care. Our teams have reflected deeply on Abbi’s experience as evidence by the changes and improvements detailed above. We hope that these actions will assure the Court we have made changes to our practice within the Trust, and we are committed to ongoing learning from this case.
If I can assist further with these matters, please do not hesitate to contact me.
Regulation 28 Report to Prevent Future Deaths- Ms Abbigail Smith
I write further to your Regulation 28 Report to Prevent Future Deaths (‘PFDR’) dated 27 May 2026, relating to the Inquest of Ms Abbigail Smith (‘Abbi’).
We have considered your concerns and set out our formal response to each matter using your numbering as follows.
Matters of Concern
1. There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life.
Upon review of the relevant rotas, we can confirm that staffing on the night of 26.01.22 was adequate with 15 Registered Nurses and 9 Health care assistants and one registered Nurse that worked a twilight shift 1500-0300. The optimum staffing levels at that time for a night shift was 16 Registered Nurses and 9 Healthcare Assistants.
We acknowledge the concerns of HM Coroner that lack of staffing led to the provision of a security guard in order to support the Mental Health Team. We have not identified any evidence of a Trust-employed security staff being allocated to patients that night, as would usually be documented. In any event, we are not able to comment on staffing of the mental health team which would fall within the remit of Essex Partnership University Foundation Trust (EPUT).
2. For a period of time Abbi was left under the observation of staff that were security personnel and were not appropriate or trained to undertake this work. Male security staff were informed that Abbi should use a commode due to her presenting risks and there were not sufficient trained female staff available. There had been a previous incident where actions taken to restrain Abbi by security personnel caused her trauma and there had been an allegation of assault, this was not considered in this admission.
I understand that the Court has been provided with an updated copy of the Trust’s Policy for Enhanced Supervision and Engagement. This policy strengthens our assessment and guidance for patients requiring enhanced supervision as per the attached tool.
Under the terms of the policy, where a patient meets the threshold for Enhanced Supervision, the patient’s views should be considered when determining the appropriate member of staff to conduct the observation. Staff should also engage with the relevant family member/ carer/ key professional/ Lasting Power of Attorney and keep them informed about the care plan and the enhanced supervision which is in place.
In Abbi’s case, there should have been discussion about Abbi’s previous history regarding restraint, and discussions should have taken place as to how enhanced supervision could have been put in place in a manner which was supportive to Abbi.
3. Abbi at times had to be physically and chemically restrained due to the level of distress and harm to herself. During her admissions Abbi was able to access ligature material that she tied around her neck on multiple occasions over multiple days including her socks, cords from her clothing and pull cords in the bathroom. There were no appropriate care plan and risk assessments to mitigate a significant known risk.
I am aware that the Court has been provided with an updated copy of the Trust’s Policy for Ligature and Self Harm Awareness.
This policy requires the performance of ligature risk assessments and recognises the potential use of clothing items as a ligature. Where it is identified that clothing could present a ligature risk, this will be assessed on a case-by-case basis with regards to the need to balance the patient’s dignity. Where a ligature item is not removed, the rationale for not removing the item and any mitigating actions should be documented and communicated with staff.
4. Abbi was a complex mental health patient awaiting assessment under the Mental Health Act and was being cared for in a part of the hospital that was not suitable for a patient who was actively attempting to take her life.
Our Policy for Ligature and Self Harm Awareness require environmental risk assessments to be performed in regard to clinical and non-clinical areas. These risk assessments are considered by staff before placing a potentially at-risk patient within the area.
5. Staff left Abbi unsupervised during the admission to attend to other patients that permitted her to tie ligatures.
Our Policy for Enhanced Supervision and Engagement, risk assesses patients at five different levels. As Abbi was risk assessed as Level 4 Enhanced Supervision, she should not have been left unsupervised due to the severity of her behaviours.
Enhanced Supervision is part of mandatory training for all staff who are involved with providing enhanced supervision to patients.
6. No adjustments or plans were made for communication for Abbi as a patient with Autism and learning difficulty.
For patients with Learning Disabilities, a Hospital Passport should be completed which includes questions such as ‘How I communicate and how you communicate with me’ and any sensory issues which may impact communication.
For patients with Autism and or learning difficulties such as Abbi, the Trust uses the Autism Health Passport which has been created by the National Autistic Society. This includes questions such as ‘How I would like you to communicate with me’ and ‘How I communicate.’
Our specialist Learning Disabilities (‘LD’) Team is trained to support and advise staff on patient communication needs; any sensory needs or sensitivities; pain recognition; interaction with medical history and any medication regimens; and to ensure reasonable adjustments are considered in line with the Equality Act 2010 and the Mental Capacity Act 2005. For example, this may be facilitating a patient being placed in a quiet area away from populated waiting rooms and information being given that is free of jargon and medical terminology.
In addition to the above, our LD Team and Autism Lead are available to support clinical teams with devising individual care plans and responding to learning difficulty support queries. Our clinical teams work collaboratively with the LD team ensuring as far as possible that appropriate adjustments are made for patients, providing the most therapeutic environment for their care. Our teams have reflected deeply on Abbi’s experience as evidence by the changes and improvements detailed above. We hope that these actions will assure the Court we have made changes to our practice within the Trust, and we are committed to ongoing learning from this case.
If I can assist further with these matters, please do not hesitate to contact me.