Unnamed respondent
Form 6.2 Response SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH SHERIFF COURT Procurator Fiscal ref: EP14006807 RESPONSE to the DETERMINATION OF SHERIFF SHEEHAN UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC. (SCOTLAND) ACT 2016 IN THE INQUIRY INTO THE DEATH OF CLARE SHANNON To: the Scottish Courts and …
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Form 6.2 Response
SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH SHERIFF
COURT
Procurator Fiscal ref: EP14006807
RESPONSE
to the
DETERMINATION OF SHERIFF SHEEHAN
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS
ETC. (SCOTLAND) ACT 2016
IN THE
INQUIRY INTO THE DEATH OF CLARE SHANNON
To: the Scottish Courts and Tribunals Service
1. Lothian Health Board, Waverley Gate, 2-4 Waterloo Pl, Edinburgh EH1 3EG
being a person to whom a recommendation under section 26(1)(b) was
addressed, do respond as follows.
2. Lothian Health Board was a participant in the inquiry.
3. It was recommended that:-
(i) Lothian Health Board should ensure that the Royal Edinburgh Hospital (or
one of its associated services) is in a position to offer adult psychiatric in
patient care for patents diagnosed with EUPD who require admission
(beyond the average 10-14 day period of stabilisation and assessment which
is offered on acute wards) in a safe, secure and therapeutic environment with
access to the specialist clinical psychology treatments which are recognised
as the appropriate clinical pathway for their condition.
As part of the planned renovation of the Royal Edinburgh Hospital site,
Lothian Health Board has now completed the construction of a facility known
as the Margaret Duguid Unit. This unit will provide an expanded range of in-
patient options. It was designed as an alternative to out of area low secure
care. It offers an enhanced level of staff support, which allows the unit to
accommodate patients who require additional support, such as those with
EUPD. It is designed to accommodate patients who require longer than
average admissions. As at the 17th July 2020 four beds are now accessible.
The Margaret Duguid Unit operates as part of the expanded rehabilitation
service at REH. It has substantial psychological input on its own, with a
dedicated Consultant Clinical Psychologist one day per week. That
psychologist operates as part of a team on the REH site, which will provide
cover for that post during periods of absence.
In addition to the input of a dedicated Consultant Clinical Psychologist,
funding can be accessed for treatment which is otherwise not available. This
was previously under the control of the Out of Area Group overseen by
Public Health. Now, if additional psychological input is required, a referral can
be made directly to the Director of Psychology at REH. The Director of
Clinical Psychology is a member of both the Senior Management Team and
the new Management Out of Area Group at REH. If a particular specialist
psychological therapy is available within the Board area, she can approve
that treatment directly. If the desired therapy is not available within the Board
area, or is only available from a private provider within the Board area, she
may refer to the MOOAG, which meets every six to eight weeks. The group
can convene remotely for discussion of urgent cases. The group has a
dedicated administrator at REH If these options are not suitable the group
can authorise funding for patients to facilitate access to specialist
inpatient treatment.
Both these responses are set out in the attached REAS Action Plan.
(ii) NHS Lothian should fully implement the 2019 Health Care Improvement
Scotland Guidance “From observation to intervention – a proactive response
and personalised care and treatment framework for acutely unwell people in
mental health care” in all inpatient adult psychiatric wards as soon as
practically possible.
Lothian Health Board has put in place a working group to complete the plan
and a competency frame work for the implementation of the Health Care
Improvement Scotland Guidance. A test phase of that project will be
completed between August and December of 2020 and if successful will be
rolled out across all Mental Health Facilities within NHS Lothian’s Board area
in 2021 per the attached action plan.
The first locations in which the test phase of this project is being
implemented are the adult acute wards at REH.
NOTES
(Please refer to section 28 of the Act. A person to whom a recommendation has
been addressed under section 26(1) of the Act, if they were also a participant in the
inquiry, is under a legal duty to respond to those recommendations in writing.
Persons who were not participants but to whom recommendations have been
directed are encouraged to respond, though they are not obliged to.
The response must set out–
(a) details of what the respondent has done or proposes to do in response to the
recommendation, or
(b) if the respondent has not done, and does not intend to do, anything in
response to the recommendation, the reasons for that.
A response must be given to the Scottish Courts and Tribunals Service within the
period of 8 weeks beginning with the day on which the respondent receives a copy of
the determination in which the recommendation is made.
The response may be published, though you may make representations to SCTS as
to the withholding of all or part of the response from publication.
A response made under section 28(1) is not admissible in evidence, and may not be
founded on, in any judicial proceedings of any nature).
PAPER APART
FAI RECOMMENDATIONS - REAS ACTION PLAN
FAI determination
Recommendations
Level of Actions to
Recommendation Address
Factors Resource Evidence of Completion
Recommendation (Individual, Lead(s) Area
Team, Service Date of Requirements Completion Sign-off
Directorate, expected
Organisation) completion
NHS Lothian should ensure Construction and
that the Royal Edinburgh opening of a
facility (Margaret
Hospital (or one of its Further
Duguid Unit) Executive
purpose built
associated services) is in a that can Director
Organisation areas as part
position to offer adult accommodate Nursing, NHSL
of Part of
low secure Midwifery
psychiatric inpatient care Phase 2
patients now & REAS
for patients diagnosed with business case
complete and 4
EUPD who require beds accessible
from 17th July.
REAS June 2020 CS FAI Action Plan v0.1
admission (beyond the Ensure funding
average 10 to 14 day & organisation
structure is in MOAOG
period of stabilisation and
place to facilitate meeting
assessment which is meets
timely access to Services
offered on acute wards) in Service specialist MOAG funding regularly and T McKigen
Director REAS
Directorate inpatient in place urgent 22.07.2020
a safe, secure and REAS
treatment via requests can
therapeutic environment be made out
MOOAG
with access to the pathway with
specialist clinical In place
psychology treatments
Develop
which are recognised as
Margaret Duguid Will be funded
the appropriate clinical Unit (up to 8 General Adult
from patients
pathway for their condition. Team bedded unit) Manager Mental
returning from
REAS Health
out of area
Dec 2020
Working group Adult
NHS Lothian should fully
to complete plan Acute
implement the 2019 (Associate
Team & Competency Mental
Medical
Healthcare Scotland Framework for Health
Director)/
Guidance 2019 ‘From implementation Wards
(Deputy
of ‘From
REAS June 2020 CS FAI Action Plan v0.1
Observation to Intervention Observation to Chief
– A proactive responsive Intervention’ – Nurse)
this is to be
and personalised care and
presented for
treatment framework for approval at
acutely unwell people in REAS SMT (July
2020)
mental health care’ in all
Testing
inpatient adult psychiatric
Implementation
wards as soon as is August to Dec
practicably possible. 2020 then roll
out 2021
Where
appropriate, use
Adult Acute Plan
& Competency
Framework as
Service basis for Services
REAS
Directorate implementation Director
in other relevant
areas across
REAS.
Implementation
August to Dec
REAS June 2020 CS FAI Action Plan v0.1
2020 then roll
out 2021
Where
appropriate, use
REAS Plan &
Competency
Framework as
basis for Executive
implementation Director
in other relevant
Organisation Nursing, NHSL
areas across Midwifery
NHS Lothian. & REAS
Through NHSL
Policy Group
implementation
2021
Other Actions Identified from the FAI Report Plan
REAS June 2020 CS FAI Action Plan v0.1
Level of
Recommendation
(Individual, Actions to Resource Evidence of Completion
Comment in FAI Report Lead(s) Area
Team, Service Address Factors Requirements Completion Sign-off
Directorate,
Organisation)
The independent expert
opinion concurred that
Ms S’s treatment was
unduly focussed on Ensure equitable
medication and nursing access to clinical
psychology
care and lacked the full
Service resource across
General
multi-disciplinary REAS using
Directorate Managers REAS
consideration that the available
REAS
severity of her condition, resources
symptoms and chronicity July 2021
required. In particular,
there was a lack of
comprehensive
psychological
REAS June 2020 CS FAI Action Plan v0.1
assessment and
psychological treatment
offered during her
admission
Dr M. did not have
access to any clinical
psychology resource for
patients in his care at
that point in time.
NHS Lothian Clinical Review
Psychologists do not appropriate
clinical
work collegiately to cover
psychology for General
each other’s wards acute wards within
Manager Adult
during absences. Team available REAS Acute
resources
Recruiting and retaining
April 2021
clinical psychologists to
REAS June 2020 CS FAI Action Plan v0.1
acute wards has proved Ensure robust
very challenging process for
covering absence
is embedded into (Director of
Team REAS
psychologist job Psychology)
plan and practice.
April 2021
As part of this process,
we have determined that
it would be worthwhile to Summarise all General
themes and Manager
review Action Plans for Team REAS
recommendations. REAS
all SAER of suicides – for
October 2020
the period from 2014 to
present.
REAS June 2020 CS FAI Action Plan v0.1
Improvement Plan from Initial SAER
Level of
Recommendation
Actions to Evidence
(Individual, Resource Completion
Recommendation Address Lead(s) Area of
Team, Service Requirements Sign-off
Factors Completion
Directorate,
Organisation)
MOAG
Meetings in
Process for
place and
application of out
there is a
of area has been Executive
mechanism
The process for accessing simplified and is Director NHSL whereby
out of area care was Organisation more robust and Nursing, complete
urgent
delayed and complex managed through Midwifery
applications
REAS which is a & REAS
can be
change since
agreed out
2014
with
meeting
REAS June 2020 CS FAI Action Plan v0.1
Even though staff were Audit completed
trained in basic first aid and to ensure all staff
have updated
CPR they were unable to
BLS & CPR
dislodge lid Training
Use of McGills
forceps is a All staff
specialist skill have had Mandatory
and staff are not Services
update training
Directorate trained to use – Director REAS
training – above 80%
mainly due to the REAS empower consistently
fact that they report
would rarely have
to use and would
be unable to
maintain
competencies
therefore No
action
Care planning not updated
regularly Need for care Audit of
plans to be General
observation Ongoing
Directorate recorded/updated Managers REAS
care plans monitoring
timeously and REAS
monthly
communicated
REAS June 2020 CS FAI Action Plan v0.1
with patient, staff
and relatives.
Improvement at
handover
required.
Observation
nurse must check
updated care
plan prior to
taking on
observation
duties
Staff attitudes and Targeted training
responses for staff around Adult SMT
behaviours and
attitudes. Rolling
programme
Involve known General
Service family members Manager Joy in
and Carers REAS Work
council OD support
Started June to cultural
2020 ongoing change
programme
REAS June 2020 CS FAI Action Plan v0.1
SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH SHERIFF
COURT
Procurator Fiscal ref: EP14006807
RESPONSE
to the
DETERMINATION OF SHERIFF SHEEHAN
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS
ETC. (SCOTLAND) ACT 2016
IN THE
INQUIRY INTO THE DEATH OF CLARE SHANNON
To: the Scottish Courts and Tribunals Service
1. Lothian Health Board, Waverley Gate, 2-4 Waterloo Pl, Edinburgh EH1 3EG
being a person to whom a recommendation under section 26(1)(b) was
addressed, do respond as follows.
2. Lothian Health Board was a participant in the inquiry.
3. It was recommended that:-
(i) Lothian Health Board should ensure that the Royal Edinburgh Hospital (or
one of its associated services) is in a position to offer adult psychiatric in
patient care for patents diagnosed with EUPD who require admission
(beyond the average 10-14 day period of stabilisation and assessment which
is offered on acute wards) in a safe, secure and therapeutic environment with
access to the specialist clinical psychology treatments which are recognised
as the appropriate clinical pathway for their condition.
As part of the planned renovation of the Royal Edinburgh Hospital site,
Lothian Health Board has now completed the construction of a facility known
as the Margaret Duguid Unit. This unit will provide an expanded range of in-
patient options. It was designed as an alternative to out of area low secure
care. It offers an enhanced level of staff support, which allows the unit to
accommodate patients who require additional support, such as those with
EUPD. It is designed to accommodate patients who require longer than
average admissions. As at the 17th July 2020 four beds are now accessible.
The Margaret Duguid Unit operates as part of the expanded rehabilitation
service at REH. It has substantial psychological input on its own, with a
dedicated Consultant Clinical Psychologist one day per week. That
psychologist operates as part of a team on the REH site, which will provide
cover for that post during periods of absence.
In addition to the input of a dedicated Consultant Clinical Psychologist,
funding can be accessed for treatment which is otherwise not available. This
was previously under the control of the Out of Area Group overseen by
Public Health. Now, if additional psychological input is required, a referral can
be made directly to the Director of Psychology at REH. The Director of
Clinical Psychology is a member of both the Senior Management Team and
the new Management Out of Area Group at REH. If a particular specialist
psychological therapy is available within the Board area, she can approve
that treatment directly. If the desired therapy is not available within the Board
area, or is only available from a private provider within the Board area, she
may refer to the MOOAG, which meets every six to eight weeks. The group
can convene remotely for discussion of urgent cases. The group has a
dedicated administrator at REH If these options are not suitable the group
can authorise funding for patients to facilitate access to specialist
inpatient treatment.
Both these responses are set out in the attached REAS Action Plan.
(ii) NHS Lothian should fully implement the 2019 Health Care Improvement
Scotland Guidance “From observation to intervention – a proactive response
and personalised care and treatment framework for acutely unwell people in
mental health care” in all inpatient adult psychiatric wards as soon as
practically possible.
Lothian Health Board has put in place a working group to complete the plan
and a competency frame work for the implementation of the Health Care
Improvement Scotland Guidance. A test phase of that project will be
completed between August and December of 2020 and if successful will be
rolled out across all Mental Health Facilities within NHS Lothian’s Board area
in 2021 per the attached action plan.
The first locations in which the test phase of this project is being
implemented are the adult acute wards at REH.
NOTES
(Please refer to section 28 of the Act. A person to whom a recommendation has
been addressed under section 26(1) of the Act, if they were also a participant in the
inquiry, is under a legal duty to respond to those recommendations in writing.
Persons who were not participants but to whom recommendations have been
directed are encouraged to respond, though they are not obliged to.
The response must set out–
(a) details of what the respondent has done or proposes to do in response to the
recommendation, or
(b) if the respondent has not done, and does not intend to do, anything in
response to the recommendation, the reasons for that.
A response must be given to the Scottish Courts and Tribunals Service within the
period of 8 weeks beginning with the day on which the respondent receives a copy of
the determination in which the recommendation is made.
The response may be published, though you may make representations to SCTS as
to the withholding of all or part of the response from publication.
A response made under section 28(1) is not admissible in evidence, and may not be
founded on, in any judicial proceedings of any nature).
PAPER APART
FAI RECOMMENDATIONS - REAS ACTION PLAN
FAI determination
Recommendations
Level of Actions to
Recommendation Address
Factors Resource Evidence of Completion
Recommendation (Individual, Lead(s) Area
Team, Service Date of Requirements Completion Sign-off
Directorate, expected
Organisation) completion
NHS Lothian should ensure Construction and
that the Royal Edinburgh opening of a
facility (Margaret
Hospital (or one of its Further
Duguid Unit) Executive
purpose built
associated services) is in a that can Director
Organisation areas as part
position to offer adult accommodate Nursing, NHSL
of Part of
low secure Midwifery
psychiatric inpatient care Phase 2
patients now & REAS
for patients diagnosed with business case
complete and 4
EUPD who require beds accessible
from 17th July.
REAS June 2020 CS FAI Action Plan v0.1
admission (beyond the Ensure funding
average 10 to 14 day & organisation
structure is in MOAOG
period of stabilisation and
place to facilitate meeting
assessment which is meets
timely access to Services
offered on acute wards) in Service specialist MOAG funding regularly and T McKigen
Director REAS
Directorate inpatient in place urgent 22.07.2020
a safe, secure and REAS
treatment via requests can
therapeutic environment be made out
MOOAG
with access to the pathway with
specialist clinical In place
psychology treatments
Develop
which are recognised as
Margaret Duguid Will be funded
the appropriate clinical Unit (up to 8 General Adult
from patients
pathway for their condition. Team bedded unit) Manager Mental
returning from
REAS Health
out of area
Dec 2020
Working group Adult
NHS Lothian should fully
to complete plan Acute
implement the 2019 (Associate
Team & Competency Mental
Medical
Healthcare Scotland Framework for Health
Director)/
Guidance 2019 ‘From implementation Wards
(Deputy
of ‘From
REAS June 2020 CS FAI Action Plan v0.1
Observation to Intervention Observation to Chief
– A proactive responsive Intervention’ – Nurse)
this is to be
and personalised care and
presented for
treatment framework for approval at
acutely unwell people in REAS SMT (July
2020)
mental health care’ in all
Testing
inpatient adult psychiatric
Implementation
wards as soon as is August to Dec
practicably possible. 2020 then roll
out 2021
Where
appropriate, use
Adult Acute Plan
& Competency
Framework as
Service basis for Services
REAS
Directorate implementation Director
in other relevant
areas across
REAS.
Implementation
August to Dec
REAS June 2020 CS FAI Action Plan v0.1
2020 then roll
out 2021
Where
appropriate, use
REAS Plan &
Competency
Framework as
basis for Executive
implementation Director
in other relevant
Organisation Nursing, NHSL
areas across Midwifery
NHS Lothian. & REAS
Through NHSL
Policy Group
implementation
2021
Other Actions Identified from the FAI Report Plan
REAS June 2020 CS FAI Action Plan v0.1
Level of
Recommendation
(Individual, Actions to Resource Evidence of Completion
Comment in FAI Report Lead(s) Area
Team, Service Address Factors Requirements Completion Sign-off
Directorate,
Organisation)
The independent expert
opinion concurred that
Ms S’s treatment was
unduly focussed on Ensure equitable
medication and nursing access to clinical
psychology
care and lacked the full
Service resource across
General
multi-disciplinary REAS using
Directorate Managers REAS
consideration that the available
REAS
severity of her condition, resources
symptoms and chronicity July 2021
required. In particular,
there was a lack of
comprehensive
psychological
REAS June 2020 CS FAI Action Plan v0.1
assessment and
psychological treatment
offered during her
admission
Dr M. did not have
access to any clinical
psychology resource for
patients in his care at
that point in time.
NHS Lothian Clinical Review
Psychologists do not appropriate
clinical
work collegiately to cover
psychology for General
each other’s wards acute wards within
Manager Adult
during absences. Team available REAS Acute
resources
Recruiting and retaining
April 2021
clinical psychologists to
REAS June 2020 CS FAI Action Plan v0.1
acute wards has proved Ensure robust
very challenging process for
covering absence
is embedded into (Director of
Team REAS
psychologist job Psychology)
plan and practice.
April 2021
As part of this process,
we have determined that
it would be worthwhile to Summarise all General
themes and Manager
review Action Plans for Team REAS
recommendations. REAS
all SAER of suicides – for
October 2020
the period from 2014 to
present.
REAS June 2020 CS FAI Action Plan v0.1
Improvement Plan from Initial SAER
Level of
Recommendation
Actions to Evidence
(Individual, Resource Completion
Recommendation Address Lead(s) Area of
Team, Service Requirements Sign-off
Factors Completion
Directorate,
Organisation)
MOAG
Meetings in
Process for
place and
application of out
there is a
of area has been Executive
mechanism
The process for accessing simplified and is Director NHSL whereby
out of area care was Organisation more robust and Nursing, complete
urgent
delayed and complex managed through Midwifery
applications
REAS which is a & REAS
can be
change since
agreed out
2014
with
meeting
REAS June 2020 CS FAI Action Plan v0.1
Even though staff were Audit completed
trained in basic first aid and to ensure all staff
have updated
CPR they were unable to
BLS & CPR
dislodge lid Training
Use of McGills
forceps is a All staff
specialist skill have had Mandatory
and staff are not Services
update training
Directorate trained to use – Director REAS
training – above 80%
mainly due to the REAS empower consistently
fact that they report
would rarely have
to use and would
be unable to
maintain
competencies
therefore No
action
Care planning not updated
regularly Need for care Audit of
plans to be General
observation Ongoing
Directorate recorded/updated Managers REAS
care plans monitoring
timeously and REAS
monthly
communicated
REAS June 2020 CS FAI Action Plan v0.1
with patient, staff
and relatives.
Improvement at
handover
required.
Observation
nurse must check
updated care
plan prior to
taking on
observation
duties
Staff attitudes and Targeted training
responses for staff around Adult SMT
behaviours and
attitudes. Rolling
programme
Involve known General
Service family members Manager Joy in
and Carers REAS Work
council OD support
Started June to cultural
2020 ongoing change
programme
REAS June 2020 CS FAI Action Plan v0.1