“(brief summary of matters of concern) NHS England Jack moved from Shropshire to Hampshire…”

The coroner’s concerns

(brief summary of matters of concern) NHS England Jack moved from Shropshire to Hampshire in the year leading up to his death. He had been under the care of the Midlands Partnership NHS Foundation Trust for many years in relation to his mental health difficulties and they held significant Regulation 28 – After Inquest Document Template Updated 30/07/2021 records. He was assessed as stable in 2019 when he moved to Hampshire and was discharged from their service. When Jack became unwell again neither the community mental health team nor the in-patient mental health team of Solent NHS Trust were able to access Jack's records from the Midlands and a copy had to be requested. For a number of reasons this was not available prior to Jack's death and this may have impacted the decision making ability of the staff caring for Jack. I heard evidence that there is no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas and the Care and Health Information Exchange (CHIE) operating in the local area contains limited information. I also received evidence that the new NHS England National Record Locator system only acts as a flag to show who holds records rather than allowing access to clinicians. This fragmentation of patient records means that medical and mental health practitioners do not have quick access to relevant information about their patients. In Jack’s case he was detained under the Mental Health Act on New Years Eve and at the start of a bank holiday weekend. As such the staff of the mental health unit did not have any way to obtain his records during the out of hours period. Solent NHS Trust I am pleased to hear that since Jack’s death and the subsequent inquest Solent NHS Trust have updated their training and guidance to staff members who are escorting detained patients. Additionally they are introducing an alert system within SystmOne for patients at increased risk of absconding and/or self-harm. There remain 2 areas of concern: 1. Handovers I heard evidence that the staff within the secure mental health unit rely very heavily on information given at handovers at the start of a shift and they do not have time to review the patient records in detail. At the time of Jack’s death records of these handovers were not stored in the same way as other patient records and, in Jack’s case, were missing entirely. This significantly hampered the investigation and inquest. I am pleased to hear that Solent NHS Trust have now changed their document storage policy in this regard and these records will now be added to and stored on SystmOne. However the handover records are not currently completed within SystmOne. This gives rise to the continuing risk of this information not being correctly recorded or correctly stored. I understand that this requires a change to SystmOne which is not yet complete. Regulation 28 – After Inquest Document Template Updated 30/07/2021 2. Paper & electronic records Solent NHS Trust still relies on paper forms for some observations and record keeping within the mental health unit. In Jack’s case these were not scanned and stored which hampered the investigation and inquest. There remains a risk that where paper records are kept information is not properly recorded, stored or audited. Portsmouth Hospitals University NSH Trust 1. Handover on arrival I heard that there is no specific structure in place at Queen Alexandra Hospital Emergency Department for ensuring the full and accurate handover of information about a patient who arrives whilst subject to detention under the Mental Health Act. I heard evidence that the receiving staff are not required to ask about a patients history of absconding or self harm. This gives rise to the possibility of a patient’s risk not being properly assessed. It was accepted in evidence at inquest that the hospital has a duty of care for all persons on it’s premises and not just those who have been formally admitted as patients. In written submissions after the inquest hearing the hospital have stated that risks of absconding and self-harm are managed by the escorting mental health team. This does not, in my view, absolve them of responsibility for managing these risks whilst the patient is present at their site. 2. Flagging of risk I heard in evidence that it is possible for patient risks to be ‘flagged’ within the Oceana records system to ensure that all staff are made aware of these. This was not done in Jack’s case and that this was not done as a matter of course, The Acting Medical Director was not aware of an established policy or procedure about using this existing functionality. 3. Risk assessment tool A ‘Mental Health Primary Disturbance Survey’ tool was used to assess Jack on his arrival at ED. This indicated that his risk level was ‘level 5+ black’ and this in turn set out a requirement of the mandatory presence of security guards. However when Jack absconded there was evidence that no security guards were present. There was evidence that clinicians made risk based decisions that such guards were not necessary. However I heard evidence that the hospital board were not aware of this tool mandating a security presence and that the tool outcomes were not reflected in trust policies about the risk of absconding. The Acting Medical Director has stated that this tool requires assessment as to whether it is fit for purpose. 4. Paper and electronic records There were records kept during Jack’s presence at Queen Alexandra Hospital which were either not stored or had been lost prior to the inquest. This Regulation 28 – After Inquest Document Template Updated 30/07/2021 significantly hampered the investigation and restricted the information available to the jury. I accept that the location of patients with mental health issues whilst awaiting transfer to a mental health unit has changed since Jack’s death. I also understand that mental health nursing

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2023-0436

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0