An independent investigation into the
circumstances surrounding two separate but
related incidents involving Norbury patients on
Spring Ward on the night of 1st October 2012
Commissioned by South London and
Maudsley NHS Foundation Trust
FINAL REPORT - SUMMARY
10th MAY 2013
1 Independent Report - Norbury incidents, night of 1st October 2012
This is the report of an Independent investigation commissioned by South London and Maudsley
NHS Foundation Trust, following two separate but related patient incidents on the night of 1st
October 2012, involving Norbury patients on Spring Ward.
This report refers to ten patients, whom for the purposes of confidentiality have been anonymised
(referred to as patients A to J), as have staff and other individuals referred to in this report.
The Independent investigation was guided by the Terms of reference, agreed in November 2012, the
Trust’s Incident Policy, September 2011 (including Management and Reporting Processes for
Incidents and Near Misses), the Policy for Investigation of Incidents, Complaints and Claims,
September 2011, and other relevant policies listed in the appendices to this report.
2. Executive Summary
On the night of the 1st October 2012, two days after Norbury Ward had moved to Spring Ward, two
separate but patient-related disturbances occurred on Spring Ward, where Norbury patients had
been temporarily relocated as part of a phased programmed of planned ward moves, to facilitate
essential health and safety works being carried out in River House (RH).
In the first incident, four patients besieged the nursing station where staff had retreated, causing
damage to property, whilst at the same time making threats to kill and rape staff. This necessitated
intervention from the RH Rapid Response team, The Bethlem Royal Hospital (BRH) Emergency Team,
various on-call managers from the Behavioural and Developmental Psychiatry (BDP) Clinical
Academic Group (CAG), an On-Call Executive Director, three divisions of the Metropolitan Police, the
London Ambulance Service, and the presence of the London Fire Brigade.
The first incident began at approximately 2200, when one patient, as part of his recurrent delusional
state, accused the designated ward-based security nurse on the night shift of stealing designer wear
and trainers which he believed his mother had brought to RH for him.
Attempts to deescalate this incident were unsuccessful. Although a decision was taken to offer the
patient prn medication, a second patient destabilised the intervention and two other patients
subsequently became involved. Staff considered the situation to be unsafe and retreated to the
Assistance from the Metropolitan Police was first requested at 2244 and the first police officer from
Bromley Police Station arrived promptly at 2247.
The police contend that on arrival they were unable to access key information about the patients
involved in the first disturbance which frustrated their ability to risk assess the situation.
The Unit Coordinator (UC), along with other nursing staff, were trapped in the nursing station where
grab packs were located which contained vital information to be used in specific situations. This
2 Independent Report - Norbury incidents, night of 1st October 2012
information was available on the hard drive and could have been accessed in RH Reception, albeit
there was no senior clinician present in this area to govern release of this confidential material,
which formed part of an agreed protocol between the Trust and the Metropolitan Police.
In the course of approximately three and a half hours, somewhere in the region of forty police
officers were on-site, comprising the entire Bromley Borough Night Response team, the Territorial
Support Group (TSS) – Commissioner’s reserve, three police dog units and Trojan (specially trained
With the assistance of the Metropolitan Police and the first on-call CAG manager, three of the four
patients were, after several hours, placed in supervised confinement (SC) on other wards. The
clinical environment was restored at approximately 0230.
In the second incident which occurred at approximately 0250, one patient challenged staff with
regard to decisions which had been taken about the management of the four patients involved in
the first incident. He accused them of discrimination, believing that there had been a racist motive
and that staff had assisted the police to pursue this line of action. He threatened to kill staff and one
of the white perpetrators, who he declared had been treated differently to the black perpetrators.
This resulted in nursing staff losing control of the ward for a second time when they retreated to the
This incident also required intervention from on-call managers and the Metropolitan Police. The
clinical environment was finally restored at 0500.
Staff that had been trapped in the nursing station and in the intensive care area (ICA) involved in the
incident were emotionally and physically shaken by the first incident, however, they returned to
duty following time spent in RH Reception, where they were seen by paramedics from the London
One patient sustained injury to his hand during the second incident. No physical injuries were
sustained by staff.
The care and treatment of ten patients, five of whom were identified as perpetrators and five who
were referred to during examination of events was examined specifically for the month of
September 2012, leading up to incident 1 and incident 2 on the night of 1st October 2012. The time
frame was extended either side when it was considered to be relevant to do so.
The Independent team found that for all ten patients there was a completed ePJS risk assessment in
place that ranged from satisfactory to excellent, completed by a range of disciplines. As at 1 October
2012, the average age of those ten patients' risk assessments was 40 days exactly.
In contrast, it is of note that no 'risk event' entry was made for the night of 1 October for any of the
ten patients identified as being involved.
Of the ten patients, seven had HCR20 risk assessments. The three patients that did not have HCR20
risk assessments had been admitted to hospital for less than three months.
The Independent team was very impressed with the scope and depth of the HCR20s and with the
risk scenarios. They went well beyond the standard and rather categorical approach.
3 Independent Report - Norbury incidents, night of 1st October 2012
There was quite a range of ages of HCR20s, with the oldest (on 1 October 2012) being 435 days old.
The average age of the seven completed HCR20 risk assessments was 244 days, or eight months and
The Forensic Inpatient Emergency Transfer protocol recommends the inclusion of a current and
complete HCR20 at the time of patients transferring between wards. The Independent team found
that transfers went ahead more often than not without transfer forms (i.e. clinical summaries) in
place. It found also that HCR20s are not updated for this purpose and did not accompany
The Independent team was impressed with the good intention behind the running of the HCR group
and the principle that lay behind it - the involvement of the patient in risk management.
Of the clinical notes examined, the Independent team was impressed with the quality of the OT
entries in particular, by the thorough and regular CT-grade doctor entries for secluded patients, and
by the contribution made to the record by gym instructors.
One of the features that really stood out, however, was the reduced amount of senior medical
entries on ePJS and the reliance instead on Ward Round minutes to record clinical changes and
decisions that had been made. The Independent team is clear in its finding that during the
timeframe when care and treatment was reviewed there were fewer entries made by senior doctors
setting out clinical information relevant to treatment than would be expected.
The Mental Health Act Code of Practice states that If the patient is secluded for more than 8 hours
consecutively or for 12 hours or over a period of 48 hours, then a multi-disciplinary review should be
completed by a senior doctor or suitably qualified approved clinician, and nurses and other
professionals who were not involved in the incident which led to the seclusion. In a number of cases
there was significant deviation from the Mental Health Act Code of Practice.
Care planning practice was variable. The Independent team was impressed by the OT care plans in
particular but found that there was an inconsistent overall picture.
The prescribing practice on Norbury Ward is up-to-date and is evidence-based. However, the
Independent team did not find good evidence of mediation changes always being discussed with
patients and recorded and that is of note.
The Independent team was impressed with the reliable pattern of consent always being obtained at
the three-month point for newly admitted patients as Section 58 of the Mental Health Act requires it
to be. However, the situation concerning valid Consent to Treatment procedures for patients who
were already in River House but had moved on to Norbury Ward needs attention.
One hugely impressive feature of Norbury Ward is the Family Surgery which the RC operates (and
which is a feature of a very busy Monday, alongside the Management Round). The Independent
team was very impressed that the Management Round was used as an opportunity to ensure that
invitations were made to others to attend this.
While substance misuse groups are available in the central therapies department in RH, in practice
Norbury Ward patients have restricted access. However, the ward-based assistant psychologist runs
4 Independent Report - Norbury incidents, night of 1st October 2012
a substance misuse group. There is no dual diagnosis practitioner as part of the RH establishment.
Given the prevalence of substance misuse, support to clinical teams with regard to dual diagnosis
and access to substance misuse groups should be reviewed.
As part of the security review a rage of policies were reviewed to examine quality, with reference to
their contribution to the overall security envelope of River House, and the translation of these
policies into practice.
The operational policies for both RH and Norbury Ward offer a clear vision and structure for the
service. They are aspirational in nature, realistic and achievable. They are presented clearly and
concisely, and provide a logical progression; setting out appropriate objectives for the care and
management of patients within a Medium Secure Service. The policies offer a baseline for service
audit through which organisational assurance can be tested.
Despite the comments above, there is serious disconnection between excellence in policy and
translation of policy into practice and serious concern on the part of the Independent team that
assurance testing of agreed polices is not rigorously and consistently applied.
Relational security is poorly understood by some staff. The attitude and behaviour on the part of
some of the nursing staff, observed during this Independent investigation is counterproductive to
safe clinical practice.
It is clear from interviews with staff, particularly the UC on the night in question that a problem
arose with following the Emergency Response Protocol.
The Lock Down procedure was implemented on instruction of the first CAG on-call manager at some
point after her arrival, having been advised to do so by the second CAG on-call manger. The Lock
Down policy stipulates that for a major incident the Bronze, Silver and Gold command structure
should be established.
The police adopted this modus operandus, but despite the fact that several managers became
involved throughout the night, four of whom came on-site at various times, there is no evidence that
the Bronze, Silver or Gold command roles were assigned to Trust staff to work with the police
Staff entering clinical areas are expected to collect and return Ascoms communication devices from
RH Reception, although in the case of the Rapid Response Ascoms, these are kept on the wards, for
which charging units are available. Ascoms are tested by reception staff on every occasion prior to
Ascom is a global positioning system providing staff with a means of summoning help in an
emergency from colleagues working in the same location or from the wider RH Rapid Response
Team drawn from each of the wards, where there is a designated member of staff on each shift.
Some staff told the Independent team that they had little confidence in the Ascom system and that
it was not uncommon for there to be systems failure, as opposed to incorrect usage by staff.
However, when the Independent team met with the Security Team Leader and Risk Management
Portfolio Lead, the Clinical Service Leader – Service Line One, the RH Customer Services Manager and
5 Independent Report - Norbury incidents, night of 1st October 2012
representatives from Ascom it became clear that the main problem lay with staff, as opposed to
systems failure (soft or hardware).
At interview and during visits to Norbury Ward, there was a surprising number of staff who gave
incorrect information, when asked to explain how the Ascom units worked, especially with regard to
the means by which they could summon help in an emergency. This is something which has been
identified previously in a number of internal investigations, but not addressed sufficiently to secure a
high level of compliance and confidence in the system.
There were examples of user failure on the night of 1st October 2012. Some of this may have been
the result of human error arising from ‘panic- scramble’ on the part of individuals. However, even
allowing for this as a factor, the evidence presented to the Independent team indicates serious
failings across RH as well as Norbury Ward. The root cause appears to be a culture of no confidence
in the Ascom system, with ineffective controls assurance.
There is evidence of very good and consistent training for staff on security and particularly the use of
See Think Act – Your guide to relational security, published by the Department of Health 2010, was
used as marker, with specific reference to team functioning, boundary setting, therapy, patient mix,
patient Dynamic and physical environment.
The Chair of the Independent Investigation spent most of one day in RH Reception, shadowing
different members of the team in the execution of their duties and responsibilities. This
demonstrated a high level of policy being delivered in practice.
The Independent team visited Norbury Ward on three occasions and Spring Ward twice. During the
first visit to Norbury Ward (a planned visit), the SC rooms, in the opinion of the Independent team,
were unfit for clinical purpose. The Trust took immediate steps to decommission the two SC room on
Norbury Ward, whilst remedial works took place before the SC rooms were put back into clinical use.
In addition, new measures with regard to monitoring the safety of SC rooms were immediately
The poor design of the SC rooms on Norbury, their constant use and fabric, present on-going and
costly problems for the Trust. The constant destruction of these rooms contributes to reduced
confidence on the part of ward staff that patients with severely challenging behaviour cannot be
safely nursed within them.
The lack of awareness of the risks outlined above and the ease with which these were quickly
identified by the Independent team, suggests a less than optimal grip on environmental security in
which safe clinical practice takes place.
The Independent Team understand that the Trust is planning a further review and reprovision of
supervised confinement facilities in RH.
The daily ward-based security checks on Norbury Ward were not up to date; the last one available
was from June 2012.
6 Independent Report - Norbury incidents, night of 1st October 2012
Two impromptu visits to Spring Ward were made on 10/12/12 and 28/01/13. The first visit examined
the exact location where the incidents on the night of the 1st October 2012 had taken place.
The second visit examined the lay-out of the ICA and access to the fire-road (the position the police
adopted to monitor the ward before making a decision as to when to go in.
The internal door leading from the ICA into the airlock, through which access to the fire road is
possible, was found to be unlocked, as was the outer door from the airlock to the fire road. This door
can only be opened from the fire road and is controlled by RH Reception.
In the course of five visits, the Independent team found on three occasions, at best perfunctory
attitudes and practice towards physical, procedural and relational security.
The importance of shared understanding and mutual respect between patients and staff is vital in
the maintenance of relational security, as advocated in See Think Act.
Some of the evidence associated with this Independent Investigation demonstrates that there are
times when control of the shift passes from the nursing team to some of the most challenging
patients on Norbury ward, rendering the clinical environment to a level of suboptimal safety.
It is important to recognise the impact of change in circumstances which effect how people feel.
Although the Independent team found one example of a one-to-one session with one patient with
reference to their move from Norbury to Spring Ward, this was not consistently the case across the
cohort of patients considered as part of this investigation.
Norbury Ward requires their patient mix to be fully appreciated at all levels in the service and
subjected to continual impact and risk assessment. The very nature of Norbury ward means that
patient mix is a continual challenge and something which requires robust clinical and managerial
leadership to secure, as far as is possible, a clinical environment which is within the competency of
staff allocated to work on this ward across all shifts, including nights and at weekends.
There is no documentary evidence to demonstrate that in the period leading up to Norbury patients
moving to Spring Ward that patient mix was adequately assessed, either at ward level, Pathways or
by the Senior Management Team.
Although there is a weekly Pathways meeting, usually chaired by the Clinical Service Leader - Line
One Forensic Services, the record of such meetings is produced in such a way that concerns with
regard to patient mix are not identifiable. For this reason, and from what some staff have said about
Pathways meetings, the Independent team is concerned that the clinical implications of decision
making, both admissions and internal transfers, is not given a consistent level of priority.
See Think Act captures the very essence of why patient dynamics are a critical feature in safe and
effective service provision: ‘The mix of patients and the dynamic that exists between them has a
fundamental effect on our ability to provide safe and effective services – the whole group can be
affected by the arrival or departure of just one patient’.
During September 2012, three patients arrived on Norbury Ward, two of whom played a part in the
incidents on the night of 1st October 2012, namely: Patient C, who transferred from BDU on
07/09/12, and Patient A, who transferred from Thames Ward on 24/09/12; having perpetrated a
7 Independent Report - Norbury incidents, night of 1st October 2012
serious assault on a member of staff. It is also worth noting that Norbury Ward received three other
patients during late August 2012, whilst the RC was on annual leave.
There were known dynamics between named patients, for example, between patient B and patient
D. However, there is no documentary evidence that patient dynamics were fully assessed in
preparation for Norbury patients moving to Spring Ward on 29/09/12.
The physical environment on Norbury Ward is such that there is no separation of the ward
immediately between the main airlock and the main ward. This could be easily rectified. There is no
safe egress from the nursing station which has, on more than one occasion, led to nursing staff being
trapped in this area, requiring police assistance. This requires urgent resolution. The staff room and
the staff toilet are not adjacent to each other which means that if staff go on break in the staff room,
they have to re-enter the ward to go to the toilet. The acoustic is such that the noise factor is
significant. Noise is a well- known exacerbating trigger, adversely affecting people’s mental
wellbeing. This too is resolvable. Internal investigations have raised concerns about ward design but
to date a definitive course of action has not been agreed.
Very considerable resources were consumed both on the part of the Trust and the emergency
services, especially the Metropolitan Police.
Whilst the management on-call arrangements were successfully and appropriately initiated, the on-
call arrangements, with regard to the on-call RC were not.
There was significant service disruption from 02/10/12. Norbury Ward, in particular, faced difficulty
in covering shifts. This was exacerbated further by other bank staff cancelling shifts.
There was a constellation of factors which, to a greater or lesser extent, played their part in some of
the patients gaining control of the ward on two separate but linked occasions on the night of 1st
October 2012, namely:
Disengaged staff from the process of management
Sub-optimal senior clinical involvement in the planning process with reference to Norbury
patients moving to Spring Ward, despite there being provision for this.
Insufficient management oversight.
Imperceptible clinical leadership.
Linked together, these factors represent systemic failure, which on the night of 1st October 2012,
resulted in the destabilisation of the care environment which could have had catastrophic
Systems and safety culture are the root cause of the majority of incidents and no less so in relation
to what took place on the night in question.
8 Independent Report - Norbury incidents, night of 1st October 2012
There was a departure from risk management protocols in fully assessing the risks of Norbury
patients moving to Spring Ward and this too had a direct bearing on the night of the 1st October
Once the incidents took hold, there was impulsive and deliberate intention to harm on the part of
the perpetrators, three of whom (Patients B, C and D), were very unwell. There is no evidence that
either incident was premeditated.
The Independent team considered whether substance misuse, at least in the form of cannabis, may
have played its part with some of the perpetrators. However, the RC is of the view that the patients
did not require cannabis to be disinhibited. Patient B at the time, according to the RC, had been very
unwell, but was improving mentally. His significant mood disorder would account for his
disinhibition. Moreover, when urine samples from the perpetrators were tested for cannabis they
proved to be negative. Nevertheless, Patient B is known to be a dealer. His nursing management
plan written by patient B’s Primary Nurse to manage his physical aggression and his drug
taking/dealing activities dated 11/08/12, does not contain any specific therapeutic intervention,
distraction techniques or focused work around drug issues. It does, however, insist that he must not
have any access to private calls, other than his solicitor and benefit agency.
The RH management and service culture appears to place less than optimal emphasis on standards
of professional practice, practice development, clinical leadership, risk management and impact
assessment, which creates anxiety and stress amongst some staff. Some of the nursing staff have
adopted ‘distancing’ as a means of coping.
Seven out of the twelve factors cited in the Contributory Factor Taxonomy (National Patient Safety
Agency, Root cause analysis – 2004) feature generally in this investigation, namely: patient factors,
individual factors, task factors, communication factors, team and social factors, working condition
factors and organisational and management factors.
Recurrent factors, previously identified as areas of concern by internal investigations carried out by
the Trust and cited in an Organisation with a Memory (Department of Health, June 2000), are also
relevant to this investigation, namely: institutional context, organisational and management factors,
work environment, team factors, individual (staff) factors, task factors, patient characteristics.
This Independent investigation raises a number factors highlighted in the Francis Inquiry (Final
Report February 2013) with specific reference to:
A lack of impact assessment.
Staff disengagement from the process of management.
The appointment of a new BDP CAG Service Director creates a fresh opportunity for
transformational leadership of forensic services. The Independent team suggest there are three
9 Independent Report - Norbury incidents, night of 1st October 2012
A review of management costs and arrangements, including medical and other
professional engagement in the management process, and investment in supporting and
developing clinical practice.
A forensic service review which examines patient flow through RH, including: case-
mix, triage, assessment and the management of patients who require forensic intensive
Development of an agreed protocol which specifies the core competencies and
behaviours necessary for effective clinical leadership and multidisciplinary working at ward
level, for which the RC and Team Leader have accountability to deliver.
It is evident that the BDP CAG commits itself to thoughtful initiatives, as can be evidenced in the
examples provided by the BDP CAG in section 17 of this Independent report. Furthermore,
comprehensive action plans are generated as and when required.
Successful implementation of action plans aimed at securing maxim impact with regard to relational
security, pathways, risk reduction, improving patients and staff safety, the physical environment and
service delivery in its broadest sense, is crucially dependent on transformational leadership which
engages all staff in the process of leadership and management, and in particular a collective medical
responsibility from within the forensic service for the service as a whole system.
Arguably, if clinical leadership and managerial oversight at every level had been stronger in the
preceding months, this would have reduced the likelihood of occurrence of the incidents which have
been subjected to examination by the Independent Team.
The appointment of a new BDP CAG Service Director creates a fresh opportunity for
transformational leadership in forensic services. The Independent team suggests there are three
A review of management costs, culture, and arrangements and of the medical and
other professional input into the management and leadership processes. Consideration
should be given to the potential for an increased amount of clinical input. To be completed
by September 2013. 3.1.2
A forensic service review which examines patient flow through RH, including: case-mix,
triage, assessment, recovery, and the management of patients who require forensic
intensive care. This should be underpinned by clear and consistent clinical leadership in the
decision-making process. To be completed by October 2013. 3.1.3
Development of an agreed protocol which specifies the core competencies and
behaviours necessary for effective clinical leadership and multidisciplinary working at ward
level for which RCs and Team Leaders have clear leadership accountabilities. To be
completed by October 2013 (The NHS Leadership Academy provides a Clinical Leadership
10 Independent Report - Norbury incidents, night of 1st October 2012
Comprehensive relational security competency testing for all current and new employees
(including NHSP staff). All employees to be tested by March 2014. 3.3
Redesign Norbury Ward to create safe egress from the nursing station, removal of the moon-
shaped structure, provision of a managed and restricted environment between the main airlock and
the ward, provision of improved staff rest room facilities which incorporate a staff toilet, and the
installation of acoustic noise-reducing panels. Plans to be agreed by October 2013. 3.4
If Norbury Ward is to continue to function as a PICU then the ICA should be reprovided. 3.5
Designation of a critical incident room. Immediate action. 3.6
Restrict access to pornographic TV channels. Immediate action. 3.7
Careful consideration should be given to the installation of patients’ ward telephones which have
been manufactured or modified in such a way as to prevent emergency (999) calls being made. 3.8
The alarm buttons on the walls were compromised by the insertion of a matchstick leading to a
continuous alarm sounding. If the alarm can be overridden (stopped) by staff, then a clear
instruction package needs to be disseminated amongst staff to ensure that ward-based staff can
cancel these alarms. If this is not possible then consideration should be given to the installation of
new and tamper-proof alarm buttons. 3.9
Operation Metallah should be audited at quarterly intervals (from the date of implementation)
with particular reference to communication flows and sharing of key clinical information so that risk
assessment can be carried out promptly by the police. 3.10
The RC and Team Leader should be informed of riot or hostage taking situations which require
police assistance, the on-site presence of an on-call manger and when the Bronze, Silver and Gold
command structure is invoked, regardless of whether they are on-call or not. To be done with
immediate effect. 3.11
The Ascom Protocol/Guidance dated 31/03/13, due for consideration by the BDP CAG Policy
Committee, has the full support of the Independent team. Once approved, compliance should be
reviewed within three months and subjected to further review at six monthly intervals. 3.12
Current access to substance misuse services at RH, regardless of which ward patients may be
on, should be reviewed to ensure ease of access, when this is considered to be clinically appropriate
by the RC. To be completed by October 2013. 3.13
Clinical teams at RH should have ease of access to a dual diagnosis practitioner, to ensure that
they receive timely specialist advice, when patients with mental illness have present with substance
misuse. To be completed by December 2013.
The Mental Health Act Office to develop a robust mechanism to ensure that RCs always and
without fail maintain adequate Consent to Treatment practice. For immediate action and
completion by October 2013.
There is a need to improve contemporaneous clinical record keeping by senior medical staff in
particular. Consideration could be given to the design and implementation of an electronic system to
monitor the frequency of multidisciplinary patient contact.
11 Independent Report - Norbury incidents, night of 1st October 2012
The practice of supervised confinement reviews by senior doctors requires attention. An audit
designed to monitor compliance with the Supervised Confinement Policy should be commenced
without delay and the results (and an appropriate action plan) shared with the Care Quality
The process for inpatient transfers to forensic services should be reviewed. A clearly agreed
protocol for this purpose needs to be agreed and regularly monitored to assure:
20.17.1 Assessment of internally-referred patients by the intended receiving team takes
place as a standard operating procedure
20.17.2 HCR20 risk assessments are conducted by the referring team as a standard operating
20.17.3 A transfer form is completed as a standard operating procedure.
The current Forensic Inpatient Emergency Transfer protocol recommends the inclusion of a current
and complete HCR20 at the time of patients transferring between wards. The Independent team
found that transfers went ahead more often than not without transfer forms (i.e. clinical summaries)
in place. It found also that HCR20s are not updated for this purpose and did not accompany
transferring patients. For immediate action and completion by July 2013.
Although the Independent Team has been advised of the ‘priority status’ enjoyed by Norbury
Ward in terms of SpR allocation, the RC for the ward gave a different account. If gaps in the
allocation of an SpR (or SpRs) occur, when all reasonable steps have been taken to provide an SpR,
an immediate impact assessment should be undertaken and documented by the Co-Clinical Director
(Forensic Service), in conjunction with the Norbury Ward RC on each occasion. In addition suitable
alternative medical cover arrangements should be put in place, and or reasonable adjustments to
the clinical workload, to ameliorate the risks. For immediate action.
12 Independent Report - Norbury incidents, night of 1st October 2012