Rianna Poiana-Lazarec

Dear Mr Burge, Re: Regulation 28 Report to Prevent Future Deaths – Rianna Poiana-Lazarec who died on 4th January 2025. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2nd July 2026 concerning the death of Rianna Poiana-Lazarec on 4th January 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Rianna’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Rianna’s care have been listened to and reflected upon. Your report raises concerns about the ease with which the towelling provided in a mental health facility was capable of being torn by hand and the absence of a system to control a patient's access to material which can be adapted for self-harming purposes. NHS England published the Staying Safe from Suicide: Best Practice Guidance for Safety Assessment, Formulation and Management on 4th April 2025. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing their safety. The purpose of this guidance is to enable mental health practitioners to adopt best practice principles in working with people of all ages to stay safe from suicide. Training has been made available to all mental health practitioners to incorporate the principles of this guidance into their practice. This complements existing local training on suicide prevention, and a number of other national e-learning products that are already available. NHS England also commissioned The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) through the National Culture of Care programme to support every provider of NHS commissioned inpatient services to move to personalised safety planning in line with the latest evidence.

[Page 2] In addition to this, NHS England will be publishing guidance in response to the Health Services Safety Investigations Body (HSSIB) recommendations following their investigation into creating conditions for learning from deaths in mental health inpatient services on the importance on defining the therapeutic relationship and guidance on responding to the use of non-anchored ligature points. Anti-tear products, including , are available within NHS healthcare settings, although they are not typically supplied through standard laundry providers due to their specialised nature. Decisions regarding the use of strengthened or specialist linen are primarily clinical matters and should be informed by an assessment of an individual patient’s risks, needs and care requirements. There is no single national specification that mandates a minimum tear-resistance standard for all strengthened bedding, towels or similar products. Requirements are typically determined at a local level, informed by clinical risk assessments, service needs, and procurement decisions. In practice, such products would not generally form part of routine provision within a standard adult mental health unit and would only be considered where an individual’s assessed clinical risks and needs indicate that their use is appropriate. Regional response Nottinghamshire Healthcare NHS Foundation Trust remains subject to significant NHS England oversight due to ongoing quality and patient safety concerns and the Nottingham Inquiry. The Trust is currently subject to national oversight arrangements, with regular engagement between the Trust and NHS England Midlands regional colleagues to monitor delivery of improvement plans and provide assurance regarding the effectiveness and sustainability of improvement activity. Midlands regional colleagues have advised that regional oversight has, since 2024, been via a monthly Improvement Oversight and Assurance Group which included routine review of patient safety, quality, governance and leadership issues though established assurance mechanisms, including oversight meetings, escalation processes and monitoring of key improvement actions. Ongoing escalated oversight is now managed via a monthly Provider Review Meeting. As part of the oversight structure, the Trust is required to demonstrate progress against identified areas of concerns, including the quality of clinical risk assessment, observation practices, and implementation of learning from patient safety events. Midland regional colleagues are discussing this Report with the Trust to ensure that enhanced observations compliance is captured and escalated as appropriately through their quality monitoring processes. In response to the concerns raised by the Coroner, NHS England Midlands regional colleagues will continue to seek assurance that learning has been embedded across inpatient mental health services and that actions to reduce the risk of recurrence are being implemented and monitored effectively. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical

[Page 3] Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Rianna, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mr Burge Regulation 28 Response: Rianna Poiana-Lazarec I write in response to the inquest which was concluded on 15 June 2026 into the death of Ms Rianna Poiana-Lazarec. We accept your findings in relation to the received Regulation 28 and offer our sincere apologies to the family of Rianna. Please find below the Trust response in relation to the relevant matters of concern and actions taken. The ease with which the was capable of being torn by hand We are very sorry that Rianna died whilst she was an inpatient, and we are, and will continue to improve individualised safety planning. The Trust is committed to preventing and minimising risks in relation to ligature from going forward. We have therefore considered national guidance and the relevant legislation in providing this response. Highbur Hos ital Hi hbur Road Nottin ham NG6 9DR

[Page 2] The prevention of self-harm and suicide, alongside the assessment and treatment of mental health, is one of the key aims and primary roles of ward staff in mental health settings. The challenge between minimising harm and adhering to the least restrictive practice as defined in the Code of Practice (Mental Health Act 2025) is a core ethical and legal dilemma in mental health care. It requires balancing the person’s right to freedom against the duty to keep them safe. The need is to minimise harm within legal and ethical requirements to achieve a positive outcome using minimal possible restrictions on a patient’s liberty, rights and choices. The CQC guidance for staff in reducing harm from ligatures in mental health wards appreciates that removing or reducing the means and opportunity for people to harm themselves is one aspect of managing risks. This is in addition to a therapeutic environment, expert staff who have the requisite skills, and the use of technology. The need is to balance each person’s risk and respond proportionately by focusing on therapeutic and individual approaches to care and safety planning. We appreciate that a patient’s risks need to be managed dependent on their specific needs, however a standardised approach is not always possible. We need to consider managing the therapeutic environment, including the building, and its contents. The availability of specific equipment needs to be based on individual patient risks, be care- planned and proportionate. We have therefore arranged to purchase non-tear-able towels, these could be utilised for patients following bespoke risk assessment and with detailed care planning. The use of these will be supported by learning sessions, guidance and team discussions prior to them becoming available. The complete absence of any system for controlling a vulnerable patient’s access to material which can easily be adapted for self-harming purposes. The Trust recognises the sad circumstances of Rianna’s death and is committed to minimising the risk of such events happening. However, the AMH inpatient wards are not secure services and as such, patients will have access to certain items which can unfortunately be used to self-harm. The removal or restriction of such items does not always mitigate the risk to the patient, as they will often find alternative ways to enable them to continue to display self-injurious behaviour. Due to this, the therapeutic relationship that staff build with patients is often the key to keeping patients safe. To support this the Trust uses care planning and risk assessment tools to guide staff as to how to support patients appropriately. To support with this, the Trust has implemented the Dialog+ informed care planning system for AMH Inpatient Services. This pro-forma makes it easier for the level of patient involvement in their care plan to be evidenced, with a focus on collaborative working with Highbur Hos ital Hi hbur Road Nottin ham NG6 9DR

[Page 3] both patients, families and carers where appropriate. These care plans were implemented from November 2025, with each new admission using the new template. If patients have not been involved in the development of their care plan, clear justification as to why and what steps have been taken to enable this must be clearly documented before the care plan can be saved. The Care Plan and Risk Assessment Tool are used by the clinical teams to inform them how to deliver care to patients, including access to risk items, which in this case included towels. In October 2025 the Trust Ratified the Delivery of Personalised Care Policy. This policy is designed to ensure that adults with mental health conditions are supported in a way that is personalised and meaningful for them. The policy and framework have been developed in line with Guidance from NHS England. Key areas of focus in the policy are care planning, safety planning and family. Co-produced training has been designed for the delivery of personalised care, and this training is now available for staff to book onto. To support this, changes were made to the Supervision Policy in January 2026 to stipulate that Care Plans and Risk Assessments must be reviewed as a part of supervision to ensure that the Care Plans are compliant with the standards. Additionally, the Care Unit has developed an Internal Working Instruction which details the roles of responsibilities of the Ward Manager, Named Nurse and Allocated Worker. The allocated worker is a member of staff who is identified for each patient on each shift as the main point of contact. This is especially important if the Named Nurse is not on shift. The allocated worker will support with ensuring that care is delivered in line with the patient’s care plan, support the patient with any queries or concerns and speak to the patient following any periods of leave to assess how the leave went and escalate any concerns. The Trust introduced Clinical Risk and Safety Training in March 2025. This is made up of two modules. The first module is an e-learning module, and the second module is a face- to-face training session. This training has been incorporated into the ‘Fundamentals of Care’ Block Training that all staff undertake yearly, and the Care Unit is also running ad hoc sessions to ensure all staff are trained in a timely manner. This training helps the staff to recognise what risk is, how to recognise how a patient’s presentation may be an indication of an increase in risk, and what to do with this information to try and ensure that the patient remains safe. The Trust has also reviewed Crisis and Safety Planning with a focus on self-harm and/or suicide and the known impact that social media can have on the people we support. A ‘guide on a page’ has been produced and has been signed off at Trust level and has been approved by the External Evidence and Assurance Group. Alongside this, co-produced training is also being designed to ensure the voice and experience of people with lived Highbur Hos ital Hi hbur Road Nottin ham NG6 9DR

[Page 4] experience is captured within the Crisis and Safety Planning Training. This training will be co-produced and co-delivered by people with lived experience. This training will complement the Clinical Risk and Safety training to ensure that staff consider all aspects of a person’s risk. This would include access to towels, and whether these can be used independently or under supervision. Alongside this, AMH Inpatient Wards complete daily Environmental checks. All communal areas and patient bedrooms are assessed and risk items removed as necessary. These checks are documented and reviewed by the senior leadership team. Patients and their bedrooms are searched as required based on their risk presentation at the time. The Nursing team are able to conduct searches if they feel that the patient is at higher risk of harming themselves. The Nursing team are also empowered to use Enhanced Observations or remove items from the patient to limit the risk, however these are extremely restrictive interventions that do not address the root cause of the behaviour.