executive summary - hundredfamilies€¦ · executive summary commissioned by nhs north of england...

Independent Investigation

into the

Care and Treatment Provided to Mr. X

by the

Northumberland Tyne and Wear NHS Foundation Trust

Executive Summary

Commissioned by

NHS North of England

February 2014

Report Prepared by: HASCAS

Report Authored by: Dr. E Gethins Consultant Forensic Psychiatrist

Dr. A Johnstone CEO HASCAS

Independent Investigation Report Mr. X

2

Contents

1. Preface

Page 3

2. Condolences

Page 3

3. Incident Description and Consequences

Page 3

4. Background and Context to the Investigation

Page 4

5. Terms of Reference for the Independent Investigation

Page 4

6. The Independent Investigation Team

Page 5

7. Summary of Findings and Conclusions

Page 6

8. Notable Practice

Page 10

9. Recommendations and Progress made by the Trust since the

Homicide

Page 11


3

1. Investigation Team Preface

The Independent Investigation into the care and treatment of Mr. X was commissioned by

NHS North of England pursuant to HSG (94)27.1 The Investigation was asked to examine the

circumstances associated with the death of Mrs. X who was found dead at her home address.

Her son, Mr. X, who lived with her, was subsequently arrested. He was subsequently

convicted of manslaughter on the grounds of diminished responsibility.

Mr. X received care and treatment for his mental health condition from the Northumberland

Tyne and Wear NHS Foundation Trust. It is the care and treatment that Mr. X received from

this organisation that is the main subject of this Investigation.

Investigations of this sort should aim to increase public confidence in statutory mental health

service providers and promote professional competence by ensuring that lessons are learned

and applied. The purpose of this Investigation is to learn any lessons that might help to

prevent any further incidents of this nature and to help to improve the reporting and

investigation of similar serious events in the future.

2. Condolences to the Family and Friends of Mr. Y

The Investigation Team would like to extend its sympathies and condolences to the family

and friends of Mrs. X. The Investigation Team are mindful that not all the issues related to

the homicide can be addressed by this report but we hope that it will help to clarify at least

some of the outstanding questions that and will allow family and friends to understand the

circumstances associated with the death of Mrs. X more clearly.

3. Incident Description and Consequences

Mr. X received care and treatment from the Northumberland Tyne and Wear NHS

Foundation Trust, and its predecessor bodies, for a period of some 20 years. During this time

it was acknowledged that he had a severe and enduring mental illness.

As time moved on Mr. X’s mother, with whom he lived, became physically unwell and

increasingly dependent upon him. On the day he killed his mother Mr. X dialled 999 and told

the police what he had done. When police attended they found Mrs. X in the living room

dead. Mr. X was arrested and taken into custody. His mental health deteriorated whilst he was

in custody and he was subsequently transferred to a secure hospital. At trial he was convicted

of manslaughter by virtue of diminished responsibility.

1. Health Service Guidance (94) 27


4

4. Background and Context to the Investigation (Purpose of Report)

HASCAS Health and Social Care Advisory Service was commissioned by NHS North of

England (the Strategic Health Authority abolished on 32 March 2013) to conduct this

Investigation under the auspices of Department of Health Guidance EL (94)27, LASSL (94) 4,

issued in 1994 to all commissioners and providers of mental health services.

This guidance, and its subsequent 2005 amendments, includes the following criteria for an

independent investigation of this kind:

i) When a homicide has been committed by a person who is or has been under the

care, i.e. subject to a regular or enhanced care programme approach, of specialist

mental health services in the six months prior to the event.

ii) When it is necessary to comply with the State’s obligations under Article 2 of the

European Convention on Human Rights. Whenever a State agent is, or may be,

responsible for a death, there is an obligation on the State to carry out an effective

investigation. This means that the investigation should be independent, reasonably

prompt, provide a sufficient element of public scrutiny and involve the next of kin

to an appropriate level.

iii) Where the SHA determines that an adverse event warrants independent

investigation. For example if there is concern that an event may represent

significant systematic failure, such as a cluster of suicides.

The purpose of an Independent Investigation is to thoroughly review the care and treatment

received by the patient in order to establish the lessons to be learnt, to minimise the

possibility of a reoccurrence of similar events, and to make recommendations for the delivery

of Health Services in the future, incorporating what can be learnt from a robust analysis of

the individual case.

5. Terms of Reference

To examine the circumstances of the health care and treatment of Mr. X, in particular:

“the quality and scope of his health care and treatment, in particular the

assessment/mitigated and management of risk;

the appropriateness of his treatment, care and supervision in relation to the

implementation of the multi-disciplinary Care Programme Approach and the

assessment of risk in terms of harm to himself and others. This should take into

consideration other family members in receipt of services, as well as those who may

be in a carer role;

the standard of record keeping and communicated between all interested parties;


5

the extent to which his care corresponded with statutory obligations and relevant

guidance from the Department of Health and other professional bodies;

carer support issues;

explore trigger events including those that could have changed the outcome

safeguarding issues;

prepare an independent report of the findings of that examination and make

recommendations to NHS England”.

6. The Independent Investigation Team

Selection of the Investigation Team

The Investigation Team was comprised of individuals who worked independently of The

NHS Foundation Trust subject to this Investigation.

Investigation Team

Dr. Androulla Johnstone Chief Executive - HASCAS Health and Social

Care Advisory Service and Investigation Nurse

Member

Dr. Elizabeth Gethins

Associate - HASCAS Health and Social Care

Advisory Service and Consultant Forensic

Psychiatrist Member

Support to the Investigation Team

Mr. Greg Britton

Investigation Manager - HASCAS Health and

Social Care Advisory Service

Work Conducted

liaison with the commissioner and provider organisations;

review of the health and social care records for both Mr. X and his mother;

review of Police statements;

review of the Trust-based Serious Incident Management Review;

review of the evidence and transcripts from the interviews conducted by previous

Investigations;

review of the initial written findings of previous Investigations;

completion of a chronology of the events and identification of any care and service

delivery problems;

group interview with Trust Board Executive Officers;

workshop with staff from Northumberland Tyne and Wear NHS Foundation Trust,

Adult Social Care, Newcastle City Council, and Newcastle upon Tyne Hospitals NHS

Foundation Trust;

provision of a written report and executive summary.


6

7. Findings and Conclusions Regarding the Care and Treatment Mr. X Received

7.1. Findings

The HASCAS Investigation Team identified nine thematic issues that arose directly from

analysing the care and treatment that Mr. X received from the Northumberland Tyne and

Wear Foundation NHS Trust.

1. Diagnosis. Prior to the homicide all clinicians recognised Mr. X had an enduring

mental illness. Over the years there was a difference of opinion regarding whether Mr.

X had a Bi-polar Disorder or Schizophrenia. This does not appear to have adversely

affected the care and treatment he ultimately received. However neither the social and

family situation was taken into full account nor issues relating to Mr. X’s personality.

A robust formulation may have raised flags in the months preceding Mrs. X’s

homicide in relation to both her illness and his dependency.

2. Medication and Treatment. Mr. X was on antipsychotic medication since his early

20s and this was monitored by the GP, the depot clinic and the outpatient clinic.

Issues were identified about the monitoring of medication and medication levels

(Lithium), communication between the GP, the Depot Clinic, and successive

Consultant Psychiatrists, and who took the ultimate responsibility for medicines

management.

Mr. X was on the caseload for twenty years and listed as not being eligible for

psychological treatment. The Investigation found this to be unsatisfactory as there was

little evidence to demonstrate how alternative approaches to working with Mr. X and

family were explored in accordance with national best practice guidance.

3. Use of the Mental Health Act (1983 and 2007). Section 117 aftercare arrangements

were not managed well by the Trust. However whether Mr. X was managed formally

via Section 117 or not he had a good package of aftercare and any omission made no

contribution to the death of Mrs. X. There is no evidence to show that the lack of use

of the Mental Health Act (1983 & 2007) was an issue in this case. Mr. X was a

capacitous adult over a period of twenty years who did not meet the criteria for

detention under the Act.

4. Care Programme Approach (CPA). Mr. X received a good level of CPA up until

the time of his inpatient discharge in May 2001, prior to this time Mr. X’s care and

treatment were provided in a holistic manner. In 2001 Mr. X was discharged from

CPA. After this time the Trust had problems operationalising the CPA policy.

Consultant Psychiatrists acted as Care Coordinators and these individuals had large

caseloads which made fulfilling the role of Care Coordinator unrealistic. In the years

preceding Mrs. X’s death there were problems when referring service users for care


7

coordination due to pressures on the service. Consequently this led to few referrals

being made.

The Investigation heard that Mr. X was thought to be on ‘Standard CPA’ at the time

he killed his mother. The Investigation found that in general Mr. X received a high

level of follow up and that it was difficult to understand how this could have been

improved upon even had he been on full CPA. However full CPA could have led to

more structured review processes and a greater degree of coordination and

communication regarding his particular needs in relation to his mother’s deteriorating

physical heath and his growing needs as her carer.

5. Risk Assessment. The Investigation found no evidence of formal risk assessment

processes. Risks were initially recognised in the early years of Mr. X’s contact with

services in relation to his lack of insight, non-compliance with medication and alcohol

consumption. These risks were much less obvious in later years. His risk was

recognised as likely to increase as his mother’s health deteriorated. However although

identified, this risk was not proactively planned for.

6. Service User Involvement in Care Planning and Treatment. Mr. X was a

capacitous adult who was able to engage with his care and treatment and make his

needs known. In the early years his parents were very involved in his care but in later

years Mr. X was seen as more able and independent.

When his mother’s physical health began to decline Mr. X was offered a carer’s

assessment which he declined. Mr. X appears to have been supported at the time by

his family and additional offers of support were made by services to help him with his

mother at home which both he and his mother refused.

7. Carer Assessment and Family Involvement in Care Planning and Treatment. In

the past Mrs. X had acted as a carer for her son. When her physical health began to

decline the roles reversed and Mr. X became the main carer for his mother. Both Mr.

and Mrs. X had capacity and were able to make their needs known. Mr. X was offered

a carer assessment, which he declined, following his mother’s last admission to

hospital. However based upon what was known, and what should have been known,

about the family dynamic the Investigation found that a more proactive approach

should have been taken as it was recognised Mr. X’s mental health was prone to

relapse when faced with family-based change and that his mother’s condition would

continue to deteriorate.

8. Documentation, Professional Communication and Team Working. The

Investigation found clinical record keeping was of a poor overall standard. The

change over to the electronic RIO system was considered to be unreliable and this led

to clinical staff maintaining their own professional records which hindered good

professional communication.


8

9. Clinical Governance. In recent years the Trust has developed its clinical governance

systems. These are now robust and can both detect and manage failing clinical teams.

The Investigation found this to be an area of current notable practice within the Trust.

7.2. Summary and Conclusions

Care and Treatment of Mr. X

What Went Well

Mr. X received care and treatment from mental health services over a twenty-year period.

During this time he did not disengage and his mental health remained stable for the majority

of the time. Despite changes to key clinical staff, continuity was maintained with Mr. X and

services were provided which monitored him on a regular basis and ensured that both he and

his family were involved in all of the key decisions that were made. It was recognised that

Mr. X could on occasions become non-compliant with his medication but this was managed

well in that Mr. X was prescribed depot medication which was administered at a clinic where

he could be assessed and any medication non-compliance both managed and monitored.

Where Services Were Weak

The Investigation found that several care and treatment processes were suboptimal during the

twenty-year period in which Mr. X was a user of mental health services. There was a basic

lack of holistic assessment which took into account Mr. X’s family and social context. There

was also a restricted set of care and treatment options available to Mr. X, for example, no

family-focused or psychological therapy was offered and this stance was not reviewed over

the years. There was also an absence of formal risk assessment.

Mr. X was on ‘Standard’ CPA at the time he killed his mother. The Investigation concluded

that this was appropriate given his long period of stability. However there were occasions,

when Mr. X’s mental health had broken down, when an ‘Enhanced’ CPA could have been of

benefit to him but was not available due to restrictions placed upon the service. The CPA

provided to Mr. X was largely uni-professional in nature and whilst maintaining monitoring

and review opportunities did not extend to providing a Wellness and Recovery Plan (WRAP)

or any kind of personalised care and recovery approach. Had a more holistic approach been

taken then it is likely that Mr. X may have experienced an improvement in his quality of life

as it is known he had enjoyed working at an allotment project during an earlier point of time

in his care and treatment with the Trust.

Initially Mr. X’s parents acted as his carers when he experienced a breakdown in his mental

health and maintained a supportive environment for him when he was well. It would appear

that they were not offered a carer assessment; however it is evident that they were involved in

Mr. X’s care and treatment and that they were consulted when key decisions were made, for

example, medication management.

In later years Mr. X became a carer to his mother when her physical health deteriorated.

During this period his role as a carer was recognised and he was offered a carer assessment


9

which he declined. Mental Health Services recognised that Mr. X would probably experience

a relapse once his mother died but no proactive support was put in place to mitigate against

this. However the Investigation recognised that Mr. X was a capacitous adult who was

entitled to reject the offers of help that were given to him.

Summary

Mr. X was an individual who suffered from a severe and enduring mental illness who

remained stable for long periods of time and who received a consistent level of support from

services. The level of service he received was effective in that it maintained his health and

wellbeing for a period of some twenty years and was able to intervene in a timely manner on

the few occasions when Mr. X’s mental health declined.

Predictability and Preventability

Whilst it can be understood that some of the care and treatment processes were suboptimal,

materially this had little effect on the effectiveness of the package that Mr. X received. It is

important not to use a hindsight bias when establishing whether or not the homicide of Mrs.

X could have been either predicted or prevented. The Investigation concluded that it could

not have been predicted that Mr. X could have killed his mother. Even had risk assessments

been conducted on a formal and regular basis it is unlikely that any risk of harm to others

would have been detected. Neither Mr. X nor any family had ever expressed any concerns

about his risk of harm to others.

The Investigation concluded that the homicide of Mrs. X was not preventable when

examining the actions of statutory services. Mr. X and his mother were offered a package of

care in keeping with their wishes. In the last few months of Mrs. X’s life both Mr. and Mrs. X

were monitored and reviewed and support put into place. It is a fact that Mr. X stopped

attending for his depot medication in the weeks preceding his mother’s death. However he

had missed depot medication in the past without any deterioration to his mental health. The

treating team adhered to the Trust’s policy and alerted Mr. X’s consultant and continued to

monitor and manage the situation. Mr. X did not fall off the radar and was not ignored by the

service.

In order for a causal relationship to be found between any act or omission on the part of

mental health services and the homicide of an individual the following has to be present:

the knowledge (in this case that Mr. X’s mental health was in decline; he appeared

stable up until he was interviewed by the Police following the homicide);

the opportunity (to be able to intervene once any deterioration was known);

the legal means (for Mr. X to be compelled under the Mental Health Act, for example,

to take his medication).

In the case of Mr. X none of these factors were present.

It should also be remembered that clinicians work without the benefit of hindsight. Clinicians

often have to take positive risks. There are often several different options open to a treating


10

team. A decision may be causal; however there may be no culpability. Treating teams do not

operate with the benefit of hindsight. If any decision is made with the best information

available to the team at the time, then it will be the best decision that could have been taken;

even if an incident occurs as a result. What an investigation team needs to understand is the

rationale behind the decision made. The Investigation concluded that Mr. X was being

supported and monitored appropriately and that the homicide of Mrs. X could not have been

prevented.

Trust Present-day Care and Treatment Delivery

The Trust demonstrated to the Investigation that substantial work has been undertaken to

improve and modernise services, incident management and clinical governance systems. The

Investigation concluded that whilst homicides perpetrated by mental service users cannot

always be either predicted or prevented, the services provided by the Trust are delivered in

accordance with national best practice guidance and that and that this should mitigate against

any future serious untoward incidents of a similar nature from occurring again.

8. Notable Practice

The Investigation found several areas of notable practice which have developed since the

death of Mrs. X and are of direct relevance to the findings and conclusions of this

Investigation.

Personalised Care

The Trust has put in place a significant amount of work to ensure that each service user is at

the centre of their care and treatment. This has been achieved by the development of a series

of activities under the ‘About Me’ scheme. This provides the service user with a

comprehensive set of personalised activities and booklets that are about their own unique

plan of care and treatment. The booklets comprise:

a ‘Review of Me’ booklet for carers;

a ‘Treatment for Me’ booklet which details each service user’s crisis plan and the key

processes by which to trigger it;

an ‘Ongoing Treatment for Me’ booklet which contains the crisis plan, how to

recognise relapse, care plans and advice on how to maintain wellbeing and recovery

based upon the service user’s own preferences and experience;

an ‘Introduction to Me’ booklet which contains information the service user would

like to share with services and which forms a base upon which to build a personalised

care and treatment approach;

a ‘Review of Me’ booklet which invites the service user to state what has worked

well and what needs to be changed regarding service approach.

This method, in conjunction with the Trust-wide Wellness and recovery Planning (WRAP)

process, provides a service user-centred approach. All clinical staff are trained in the WRAP


11

and service users and their carers are informed about how this works in a series of

presentations and booklets in an accessible and easy to understand manner.

Carer Support and Advice

A carers’ pack called Shining a Light on Carers is available. The pack contains:

a useful contacts for new carers leaflet;

a Common-sense Guide to Patient Confidentiality leaflet;

a Carers’ Charter;

a Checklist for Carers’ of People with Mental Health Problems;

a Carers’ Pocket Handbook.

The pack is well presented, written in plain English and contains relevant advice for carers. In

addition clinical staff have been issued with guidance so that they understand better the kind

of information and support that carers require. A comprehensive Getting to Know You

questionnaire is also used in order to determine the level of involvement and support each

carer requires with a plan of how this will be achieved. The evidence provided to the

Investigation demonstrates that the Trust has a well developed and integrated approach to

working with carers.

Trust Governance Culture and Staff Involvement

The Trust has a particular approach to clinical governance and regards this as being the most

important function of the Trust Board. Each Executive Director is notified of every SUI and

complaint that comes into the Trust in ‘real time’. This means that each Executive Director is

notified instantly and can build up a picture of trends as they occur. This direct approach to

the management of clinical governance ensures that each Director is aware of emerging

trends and of the efficacy of service development and improvement schemes.

The Trust has a commitment to staff involvement and has ensured that a large representative

sample of clinical staff have been in included in the current service Transformation process.

The Executive Board members are visible and accessible and manage the challenges of

working across a large geographical site by ensuring that visits made on a regular basis to all

service areas which ensure a tangible connectivity between clinical areas and the Board.

9. Recommendations and Progress made by the Trust since the Homicide

The purpose of developing recommendations is to ensure that lessons are not only learned,

but influence directly the development and management of services to ensure future patient

and public safety. The Investigation Team worked with the Northumberland Tyne and Wear

NHS Foundation Trust to formulate the recommendations arising from this inquiry process.

This has served the purpose of ensuring that current progress, development and good practice

has been identified. The recommendations set out below have not been made simply because

recommendations are required, but in order to ensure that they can improve further services

and consolidate the learning from this inquiry process. This Section is set out in two halves.


12

The first addresses provider recommendations, the second addresses commissioner

recommendations.

9.1. Recommendations for Northumberland Tyne and Wear NHS Foundation Trust

Each recommendation is set out below in accordance with the relevant progress that the Trust

has already made since the time of the incident.

9.1.2. Diagnosis

Service Issue One. The Trust did not provide a robust diagnostic formulation for

Mr. X; whilst this did not contribute to the death of Mrs. X the lack of

formulation meant that Mr. X was not always understood in his full diagnostic

and social context.

Trust Actions since the Homicide

Formulation

All new service users have a formulation in place which allows the team to understand each

individual in the context of their diagnosis and difficulties, such as, relationships, social

circumstances, life events, and the sense that they have made of them. Families and carers are

also involved when appropriate. Improving formulation has been a key part of the Trust’s

Safety Programme.

The development of the core assessment document associated with Trust Care Coordination

and CPA Policy, ratified in November 2010, is now used by all services and clinicians in the

Trust. This is part of the electronic care record supports and enables holistic assessment as it

encompasses health and social care needs and consequently biopsychosocial formulation.

The core assessment has a formulation section which once validated on the electronic care

record cannot be changed. However when the ‘create new’ facility of the electronic record is

used the previous formulation pulls through, so is readily available to view by clinical staff. It

is required to be amended or added to at significant points of transition e.g. admission to an

inpatient ward, referral to another service either for transfer or to facilitate joint working.

The electronic record also clearly identifies how many assessments have been entered. This

enables clinical staff to easily view assessments and associated formulations over the time

period of the record. All clinicians involved in a patient’s care and treatment must keep

accurate and contemporaneous records and it is the responsibility of the Care Co-

ordination/Lead Professional to make sure that all clinical information is up-to-date on the

electronic patient record (RiO) at any point of transition of care. This would be in addition to

a face-to-face or verbal handover, or discussion as part of the review process. The recently

developed transition protocol reinforces the need to do this.


13

In addition to this, clinicians have caseload management with their clinical supervisors on a

regular basis, which includes a records check of a number of open cases to look at the quality,

not just completion, of the record. A safety message from the Executive Medical Director

was circulated to all staff in the Chief Executive’s Bulletin in September 2012 to reinforce

the importance of the formulation and evaluation of risk.

The work currently underway as part of the safety programme will be further embedded

through transformation of community services. At this stage of intervention it is also

envisaged that the plan for discharge and potential transfers of new service users will include

a formulation however for existing service users who may have been with services for a long

time; this is part of a going forward strategy with a plan of work linked to planned CPA and

care coordination reviews. Formulation will capture the needs of the patient across their

physical social and psychological presentations consider previous history, recognise strengths

and stressors and lead to a plan of care to support identified needs. Formulation will aid

effective diagnosis.

Transformation update

Progress on formulation and diagnosis will be further strengthened by the design of new

community pathways which is part of a two-year transformation programme. The new

pathways will minimise transitions for service users and enhance communication and joint

working where planned transitions are necessary. The clinical record has been redesigned to

include a standardised framework for formulation which will be prominently displayed along

with the risk assessment. Standard work has been developed for reviews which greatly

enhances multidisciplinary input and reformulation

The design of the new model has included the development of a standardised formulation

which will be completed for all patients using the ‘5P’ model which includes social and

family contexts as well as personality issues. Formulation review is also an integral part of

the pathway for all patients. The formulation will inform the care pathway and care plan.

Within the transformation plans it is also intended that all existing patients care and treatment

will migrate to the new ways of working to ensure equity and quality of service for all. The

service user and where appropriate, their carer, will have a copy of the formulation and initial

plan of care to take away with them after the meeting which follows completion of

assessment/review. Training of all staff will ensure that all staff are aware of the standards

expected.

Recommendation One.

The Trust will, in conjunction with its commissioners, audit the new

arrangements within 12 months of the publication of this report. The audit will

ensure that all of the key points identified above have been implemented

successfully and will make further recommendations for any additional

developments that are required.


14

Recommendation Two. The Trust will report on the progress of its new

community pathway to commissioners on the publication of this report in order

to ensure that all care and treatment delivered to service users is seamless and

that communications across all stakeholders is being managed in accordance

with expectation.

9.1.3. Medication and Treatment

Service Issue Two. The status of the physical treatment centre in terms of role,

responsibility and communication issues between the GP, CMHT and

Consultant are raised as areas that need urgent consideration and improvement.

Service Issue Three. There was a lack of best practice treatment options

provided to Mr. X and his family.


Prescribing

The Trust is clear that prescribing and review of medication is the ultimate responsibility of

an appropriately qualified member of staff. This can be a doctor or a non medical prescriber.

At the time of the incident some Consultant Psychiatrists had large community caseloads and

this resulted in some decisions relating to care being made and not fully communicated. This

has been addressed and it is now very clear what the accountabilities and responsibilities are

of Consultant Psychiatrists with a lead professional role. Emphasis has been placed on the

need to ensure that if prescribing responsibility changes that this is agreed, clearly

communicated, planned and documented.

The Trust now has in place a number of ‘step-down services’ for service users with less

complex needs who would have previously been seen in out–patient clinics. The lead

professional role in these services can be taken on by non-medical prescribers, this ensures

that robust plans are in place for the ongoing review of medication whilst freeing up the

capacity of Consultant Psychiatrists to manage those with more complex needs.

The Trust is part of the National Pathfinder for Non Medical Approved/Responsible

Clinicians. The extension of such roles is a key enabler for the transformation of services

ensuring services users receive safe and effective care.

Shared Care Protocols

The Trust now has in place a number of shared care protocols with primary care. The Trust is

continuing this work with Clinical Commissioning Group colleagues ensuring that there are

clear pathways and expected standards in place for the transfer of responsibility of

medication prescribing. A GP advice line has been introduced in some localities to support

and advise GP’s who may be prescribing and reviewing psychiatric medication. This will be

rolled out further in line with transformation.


15

Physical Health Monitoring

Work is progressing to develop an agreed, standardised model for the delivery of physical

healthcare monitoring to community patients across the Trust. In Sunderland locality, where

the transformation work has been most advanced, a ‘one stop shop’ incorporating physical

health monitoring, advice and medication administration is already well established. This

team supports monitoring and titration of Lithium and Clozapine as well as administering,

monitoring effectiveness and reviewing side effects for some patients who receive depot

medications. This has replaced the need to have separate clinics for monitoring of each

different medication for example Lithium and Clozapine and the administration of depot

injections which previously occurred in the three main bases within the locality. This has

improved the level of clinical expertise in relation to these areas.

In Newcastle a small team of nursing staff form the physical treatment centre that supports

the delivery of Electro Convulsive Therapy (ECT) and provides Clozapine and Lithium

monitoring. This team also provides depot clinics across Newcastle. There are now clear

protocols and individualised care plans in place for escalating to all appropriate clinicians

when service users have not attended for their depot. This ensures continuity of treatment of

the depot medication and early intervention when people do not attend.

Treatment and Interventions

In some teams Consultant Psychiatrists are still assigned to the role of lead professional for

large numbers of patients and carry large caseloads. This is being actively addressed through

the transformation of community services as part of the principal community pathways work.

As highlighted above, in order to free up consultants to work with service users with greater

complexity of needs, a number of initiatives have been developed such as nurse led ‘step

down clinics’.

If Mr. X was receiving a service today it is likely that his needs would best be met within the

step-down clinic. Extensive work linked to robust formulation and care planning has taken

place since the time of the incident. Now, a plan of care would be agreed collaboratively

wherever possible by clinicians with service users. The Trust’s Care Coordination Policy

describes how complexity of need informs the decision as to whether a service user has

enhanced needs (on CPA). The clustering process is also concerned with describing the type,

severity and complexity of patient need. A plan of care would be based on the standardised

nationally agreed care pathway for a service user presenting with that need, if for some

reason the plan of care was going to deviate from the national expectation then the rationale

for that should also be readily available within the clinical record.

CPA and clustering processes provide expectations about the minimum frequency at which

patients should be reviewed. Reviews are always clinically led and professional judgement

applied however to aid clinicians maximum timescales for reviews are available within Trust

policy guidance.


16

To support the involvement of service users in their own care and to promote recovery

focussed interventions, the Trust has also introduced use of Wellness, Recovery and Action

Plans (WRAP). Over 300 staff of all disciplines have now been trained with WRAP, this

training has been delivered in collaboration with service users and is ongoing. WRAP

supports the safer discharge of patients, outlining a collaboratively agreed plan to support

wellness and can include medication management issues as well as addressing a wide range

of needs as identified by the individual.

Had there been a clear formulation, regular review processes and care plan for Mr. X then

discharge could perhaps have been considered a little sooner. However without a clear plan

this probably prevented the decision being made to discharge him or to have a care plan in

place to work along a discharge pathway. In hindsight, it is recognised that Mr. X may have

benefitted from a wider range of social and therapeutic interventions to encourage a greater

level of social contact.

There is thriving voluntary sector in the area where Mr. X lived. The Local Authority has

kept a community resource for adult mental health and there is a significant amount of

support and recovery based accommodation. People who live in Newcastle have access to a

range of services within the voluntary sector. It is recognised that although a great deal of

work is done with partners that services need to continue to work together to ensure that

service users can gain maximum benefit from the available resources. This is one of the key

principles of the transformation programme. To support this transformation, new staff roles

such as peer support workers have also been developed to work with service users in the

community across pathways bridging traditional service boundaries with the Local Authority,

voluntary sector and into primary care.

Pathway Developments

Within the newly designed community model, evidence-based treatments will be delivered in

line with nationally agreed care packages. There is a clear discharge pathway for service

users. Discharge is considered and planned for from the beginning of the pathway for all

patients and is part of the documentation that they and partners receive. The new model has

regular review meetings built in as well as additional meetings which can be added at the

request of user or carer or any other professional involved. A robust system of review should

avoid any gaps in care in relation to medication as well as other interventions. Smooth

transitions through the pathway are part of the service redesign and the plan will be

negotiated with the user and all partner agencies concerned. The GP is a key partner in this

regard.

The redesigned pathways will ensure a level loading of work across a multidisciplinary team

and realistic work loads have been calculated to inform the design and establishments of the

new teams. Care coordination is a specific role which is recognised in the Care pathway and

sufficient time is built in to the job plans of all disciplines to ensure that whichever

professional undertakes this task is able to do it effectively.


17

A key objective within the new model is to enhance partnership working. The Trust is

working with Local Authorities to develop more integrated ways of working and it is

anticipated that co-location of Council services and other professionals with the Trust’s teams

will greatly enhance joint working. Within the new service model, a ‘step up function’ has

been designed which will enable all members of the team involved in the care of patients to

request additional interventions for patients who are potentially relapsing. Entry into this step

up function would also indicate that a review of formulation and plan of care was required. A

stepped approach to leaving the service as part of a planned discharge pathway has already

been introduced in some localities and is being rolled out as part of the new community

model. Previously, there were few options to support service users in a graduated way out of

services, this was an issue and a challenge for service users but it is anticipated that the

stepped approach to discharge will support people back to primary care more effectively.

A single point of access for all urgent and non-urgent referrals and enquiries will be in place

to support service users who may need to come back into the Trust once discharged to

primary care. The single point of access already in place South of Tyne now also has a sign

posting role, recognising that the Trust can’t provide services to everyone and that some

services are best provided by other services.

Recommendation Three. The Trust will, in conjunction with its commissioners,

audit the new arrangements within 12 months of the publication of this report.

The audit will ensure that all of the key points identified above have been

implemented successfully and will make further recommendations for any

additional developments that are required.

9.1.4. Mental Health Act (1984 & 2007)

Service Issue Four. There was a lack of clarity around the registering and

reviewing of Section 117 of the Mental Health Act.


Section 117 Aftercare

Section 117 is a duty imposed on Local Authorities and Clinical Commissioning Groups to

provide aftercare to patients detained in hospital under the relevant sections. The Mental

Health Act Code of Practice sets out clearly that such aftercare should be planned within the

framework of Care Programme approach. The Trust Care Coordination Policy (updated in

February 2009) incorporated the requirements of Refocusing CPA (2008) in conjunction with

its six Local Authority partners.

For service users on CPA the care plan will also include:

financial issues (if appropriate);


18

medication changes, including who is the prescriber, where medication is obtained

from, instructions for administration, how monitoring will be undertaken and where

appropriate Depot clinic/ Clozaril clinic, follow-up. The service user will be offered

information about the medication including benefits and side effects;

any physical health needs;

outpatient appointments;

social requirements;

a risk management plan that recognises and builds on protective factors;

a crisis plan;

seven-day follow up and action to be taken if the service user does not attend;

explicit information relating to services provided under Section 117 (where

applicable);

statement on best interest if any aspect of the care plan concerns client without

capacity in relation to that area of intervention.

The electronic care record (Rio) provides a specific place on the care plan for identification

that the service user in subject to Section 117 and what services are being provided.

In the intervening period following the incident, the Trust participated in Primary Care Trust

(PCT) led work north of Tyne to try and agree a joint policy and process with the three Local

Authorities North of Tyne. There were significant differences of opinion as to the

responsibility for the Section 117 register. Unfortunately this work did not progress, after the

Trust provided its response, to the initial draft due to the demise of the PCT.

Transformation Update

Partnership Working

Within the transformation of community services the concept of integrated working across

health, social care and voluntary sector is a key component of service delivery.

Partnership/integration work streams are a key enabler to the transformation programme and

are now in place with representation across agencies. It is hoped that in the future some

community teams will be able to be co-located and where necessary interagency assessments,

reviews, care-planning and discharge arrangements take place. Whilst this may not address

the strategic monitoring of Section 117 it should ensure that at the point of service delivery

regular meaningful reviews of plans of care and of legal status take place.

The Care Coordination policy is due for review (May 2014).

Recommendation Four. Newcastle Local Authority and the Clinical

Commissioning Group lead on, and work with the Trust, to produce joint

guidance in relation to the application of Section 117 in the context of care co-

ordination.

Recommendation Five. The Trust will, in conjunction with its commissioners,



19




9.1.5. Care Programme Approach

Service Issue Five. The understanding, operationalising and recording of the CPA

process in relation to Mr. X was poor. Care Coordinators were not aware of their

responsibilities under CPA and the service was pressured and unable to respond to the

demand for service users who required an ‘Enhanced’ approach.


The Care Coordination and CPA Policy (October 2008) set out that service users on a

standard level of care coordination/CPA would usually require the support or intervention of

one agency or discipline. Their care would usually be coordinated by the professional they

were receiving services from. This would include service users who attended psychiatric

outpatient appointments. In such cases their Consultant Psychiatrist would act as their Care

Coordinator. Service users placed on Standard level of care co-ordination/CPA would have

been assessed as:

being likely to self manage problems;

having an active informal support network;

being of little or no danger to themselves or others;

being likely to maintain appropriate contact with services e.g. doctor, community

team (mental health or learning disabilities).

An Enhanced level of care coordination / CPA was for service users who have severe and

enduring mental health problems and/or a learning disability and/or complex needs; and who

were likely to need more help and support from a number of different services and

professionals. This level of care would have included people who:

have multiple care needs that require coordination between different agencies such as

health, Social Services, housing, employment and the voluntary sector etc.;

are only willing to cooperate with one professional or agency but they have multiple

care needs;

are in contact with a number of agencies (including the criminal justice system);

are likely to require more frequent and intensive interventions than provided under

standard care coordination/CPA, perhaps with medication management;

are more likely to have mental health problems and/or a learning disability co-existing

with other problems such as substance misuse;

are more likely to be at risk of harming themselves or others;

are hard to engage, difficult to maintain contact with, and more likely to disengage

from services;

pose a risk if they lose contact with services, for example, because of a history of

repeated relapse due to a breakdown in their medical and/or social care.


20

The policy at that time outlined that the requirement for any change of care coordination/CPA

should be based on identified changes in the service user’s presenting needs and/or risks. The

review of Mr. X’s care and treatment indicates that at that time he was capacitous, he

generally attended his appointments or rang to re-arrange and was engaged in services. In

terms of support at the time he was visited by his brother daily, sister every weekend, aunt

one-two per week. There were also other support networks going into the family home: carer

for mother every morning (were offered an increase to twice per day but both Mr. X and his

mother refused this), district nurse every two-three weeks. Mr. X was generally being seen at

the depot clinic and at out patient appointments and had the option of contacting services in

the interim if he needed to. When he had decompensated previously him or one of his

siblings’ contacted services, and actively sought help from the GP or mental health services.

It was therefore probably reasonable to assume that if Mr. X decompensated again he and/or

his family would seek help. Using these criteria at the time of the incident, it would therefore

appear that Mr. X met the criteria for standard CPA at the time of the incident.

Since the time of the incident there has been an extensive review of the ways of working of

Consultant Psychiatrists. All clinicians working with patients are now expected to have in

place clear collaborative plans of care which include a discharge plan. There is also a greater

emphasis on the multidisciplinary team supporting their medical colleagues when patients are

deteriorating; this is more robustly addressed through transformation of community services

as previously discussed and further outlined below.

The current Trust Care Coordination and CPA Policy is a joint one with Local Authority

partners and reflects the changes set out in Department of Health (DH) guidance Refocusing

CPA 2008. The implementation of this policy was underpinned by awareness training of the

new DH guidance and a training programme for staff in adult services.

Social Work staff can and do act as care co-ordinators/lead professionals. In line with DH

guidance refocusing CPA, service users who are not on CPA re required to have a review at

least annually and where there are other agencies involved with service users they should be

part of the review process. However consent would be needed to involve professionals

involved with another family member unless issues of risk were such to override the

confidentiality owed to the service user.

At the time of the incident, one of the difficulties perceived by the Consultant Psychiatrists as

lead professionals was the multidisciplinary teams’ ability to respond flexibly to increase

interventions with service users at a time of increased need. It was felt that the only way to

access a CPN within the team was to make a referral for a care coordinator and this was felt

not to be readily available. There is now a good understanding that if there is the need for a

period of intervention from another professional to meet additional need that this doesn’t

automatically equal enhanced needs and that the decision criteria is the complexity of need

not the number of professionals. There is currently a duty system in place within community

teams to respond to urgent needs and critical situations can be referred into the crisis service,


21

however building intensive planned activity into teams is an issue that is being addressed

within transformation and is outlined below.

Transformation Update

The newly designed model for community services includes a ‘Step Up’ function which will

enable staff to respond more quickly to meet the needs of service users. This function will

help to build flexibility into the community team. It is envisaged that this will be a staff

resource that can be ‘pulled’ to service users with the greatest need at short notice. The team

will have two core functions: planned intensive interventions to support discharge from

hospital and a short to medium term response to acuity and need. The team will be available

seven days a week working between 8.00 and 20.00 hours each day. It is also proposed that if

a patient has accessed the crisis team for a brief period then they can equally ‘step down’

through the step up function from the crisis team back to the care of a lead professional who

could be a Consultant Psychiatrist.

As part of the ongoing work, simplification of the administrative processes within and across

teams linked to care coordination are being built in, this will enable clinicians to accurately

reflect the level of need through CPA without the administrative burden. Through

transformation, care coordination and lead professional responsibilities at a local level have

been reviewed and principles agreed in relation to how this should work in practice.

Recommendation Six. The Trust will, in conjunction with its commissioners,





Recommendation Seven. The Trust will review its Care Programme Approach

Policy as planned in May 2014 incorporating the lessons learned from

examination of this case.

9.1.6. Risk

Service Issue Five. Risk assessment processes were weak and informal and did

not adhere to the spirit of the Trust risk assessment and management policy.


Review of Risk

For service users who do not have enhanced needs formal reviews should be at least once a

year and will involve the service user, any identified carer and any professionals involved in

an individual’s treatment or care including any involved from a multi agency perspective. If

Mr. X was receiving a service now, the review would be an opportunity to consider how care

is going to be transferred to others including the prescribing and administration of depot


22

medication. This consideration would also have included potential risks and relapse

indicators if medication was not administered. Additionally as previously outlined, the work

undertaken to ensure that all patients are regular reviewed and that as a result of that review

the formulation and plan of care are updated to reflect current need should ensure effective

care and treatment are in place and care is not allowed to drift in an unplanned way.

Assessment and Management of Risk

The FACE risk assessment was the specified clinical tool for the assessment of risk however

implementation at the time of the incident was patchy especially by medical staff in busy

outpatient clinics. Risk assessment and risk management has received and continues to

receive a great deal of focus. FACE is now deeply implemented and is integrated into the

electronic care record.

Recognising the limitations of FACE, the Trust has reviewed the use of this across services

and subsequently introduced a phased approach to risk assessment by the use of a narrative

risk assessment template for initial assessments and to reassess the risk for patients who are

not on CPA. The clinical record is electronically configured so that each time a new risk

profile or narrative is created all of the information previously recorded automatically pre

populates the new record. The trust additionally sets the standard that all patients should have

a crisis and contingency plan in place where there has been a significant level of risk

assessed. At the point of discharge it is expected that risk and care plans are updated. As

previously outlined, service users are also actively encouraged to complete WRAP (Wellness

and Recovery Plans) plans in order where possible to self manage their condition with clear

plans for staying well.

The Trust has reviewed its approach to risk assessment and management training, training

programmes are regularly reviewed to reflect evaluations and best practice. Training is now

significantly different; the focus used to be on the completion of the risk assessment, now it is

more focussed about how professionals work collaboratively with service users, carers and

other professionals to understand risk and manage it. The emphasis of the training is now

about recognising individual risks and developing effective plans to mitigate against those

identified risks with an appreciation that risk is dynamic.

The Trust recognises that this area is an area requiring continuing attention and development

and this is why it is one of its key safety themes of the safety programme.

Recommendation Eight. The Trust will, in conjunction with its commissioners,






23

9. 1.7. Carer Assessment and Carer Experience


No service issues were found. However the Trust has developed the services provided in this

area. The Trust has undertaken a lot of work in this area in collaboration with service users

and has developed a range of documentation now available for service users to record their

perspective and wishes. The pack includes:

Introduction to Me;

Treatment for Me;

Ongoing Plan for Me;

Review of Me – carer version.

The Wellness Recovery Action Plan (WRAP) is now in place for services and training

packages are underway with over 300 staff currently trained. The Trust is working with

service users to develop peer support networks to enhance the service user’s recovery

journey.

There is a thriving voluntary sector in the area and the Local Authority has retained a

community resource for mental health. The Trust has a range of services with the voluntary

sector and they work well together. There is now a greater appreciation and focus within

services of the requirement to address service user’s needs in a more holistic manner and that

the potential impact of life stressors and events can affect the symptoms that service users

present with.

As previously outlined, service developments such as ‘step-down’ clinics and the

introduction of peer support workers will enhance the service that is provided to people with

ongoing needs such as Mr. X. The Trust is committed to ensuring its services provide a

recovery focussed culture where decisions around care are made collaboratively with service

users and their carers.

Recommendation Nine. The Trust will, in conjunction with its commissioners,





9.1.8. Service User Involvement

Recommendation 10. The Clinical Commissioning Group/s is/are asked in

conjunction with Northumberland Tyne and Wear services and the Acute Trust

to ensure that the identification of, involvement and communication with, carers


24

across pathways including primary care is established and incorporated into all

clinical assessment and referral processes.

9.1.9. Documentation and Professional Communication

Service Issue Six. Team working, leadership and caseload management were

dysfunctional immediately prior to and at the time of Mrs. X’s death. Record

keeping and communication processes were not effective and fell short of both

national and local practice best practice guidance.


Record Keeping

The Trust has a clear records management policy which describes expected practices in

relation to creating and maintaining a clinical record. All services in the Trust now use the

electronic clinical record RIO. This means that all teams are able to see previous episodes of

care and current plans of care; this has increased staff confidence in the electronic system. All

staff are trained prior to being able to access RIO on its functionality, as well, when

electronic updates are put in place training is made available centrally and locally. There is

also an information technology team to support the practical use of RIO and senior clinicians

available to offer advice about the content of the record when required. The Trust has also

developed a guide to clinical record keeping which all people who input into the clinical

record are expected to adhere to, this compliments Royal College Guidance.

Team Working and Communication

All mainstream community services are now managed within the ‘Planned Care’ group of the

Trust. This follows the realignment of services under a business model review in 2011.

The Trust covers six localities with a triumvirate of a clinical director, a senior clinical nurse

and a directorate manager overseeing the localities. Each locality has a service manager

working to the triumvirate and a clinical community manager interfacing directly with the

teams.

Lead consultants and community matrons are also in place to support clinical practice and

operational management in localities and teams. Directors and senior managers regularly visit

and meet with teams

Team leaders are trained to deliver regular clinical supervision within teams and also lead

regular multidisciplinary team meetings that will discuss clinical matters as well as day to day

operational issues. Team leaders are supported by line management but also the workforce

department to manage all aspects of staff matters including training, sickness and matters

relating to conduct. Team leaders have regular meetings where they come together with

senior managers to discuss a wide range of topics and receive communication relating to

current issues. Team leaders also have access to the Trust dashboard which provides them


25

with information about a range of metrics relating specifically to their team and how it is

functioning.

The Trust is undertaking a transformation programme with community clinicians being at the

centre of the design of the future model. Through the period of developing the new model all

community services have been engaged with locally via team meetings and also via local

forums with senior managers and the lead clinicians involved in development. These

meetings allow the staff to offer ideas relating to the changes and also explore the

implications of the new model within their locality.

A high level of work has been undertaken within community teams to ensure they have the

correct level of resources and skills to deliver the services required, this includes an

assessment of the skills of all staff in each team to deliver evidence based treatments and

interventions in line with the nationally mandated care packages. This resulted in a local

skills matrix to baseline current skills and has informed future training which is currently

underway across teams.

Community Mental Health Teams have been reorganised to ensure a good critical mass is in

place to deliver the services within a discrete locality. Within Newcastle the North and East

teams have come together and are now based within one building. The entire

multidisciplinary team is based together ensuring good team coherence and support. The

team has a good consistency of members with a team leader who has been in place now for

over three years ensuring consistency of approach to quality of care and sustainability of

service improvements.

Recommendation Eleven. The Trust will, in conjunction with its commissioners,





executive summary - hundredfamilies€¦ · executive summary commissioned by nhs north of england...

Documents