Herefordshire Worcestershire NHS
Integrated Care Board
Action Taken
Herefordshire Worcestershire NHS states that the Community Service Manager has worked with Herefordshire MIND to co-produce a Standard Operating Procedure (SOP) for the Community Mental Health Link Worker Service in Herefordshire, which has been implemented in draft form. MIND Link workers now have established links with the Neighbourhood Mental Health teams and daily access to the ‘duty worker’. (AI summary)
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Dear Sirs,
Re: Regulation 28: Report to Prevent Future Deaths in respect of Ms. Caroline Staite
I am writing in response to your report to prevent future deaths dated 14th October 2024 addressed to me, I am grateful for the opportunity of responding to your concerns.
The Trust is always keen to learn from any tragic incident and I hope that this response satisfies you that we have reviewed the issues raised appropriately.
Following the very sad death of Ms Caroline Staite we identified some areas of learning following our internal patient safety review process which we believe cover the points you have outlined in your Regulation 28 Notice. Whilst we were not called to the Inquest, which may have provided an opportunity for us to expand on the issues identified in our patient safety review, I hope that the information below provides you with confidence that the concern you have identified is being fully addressed.
Your concern: Point 1
The Neighbourhood Mental Health teams should ensure that their procedures are sufficiently robust regarding the safely of patients for consideration by MIND.
Action: Since this time our Community Service Manager, Diane Topham, who oversees our Neighbourhood Mental Health Team has worked closely with the Herefordshire MIND service to co-produce a Standard Operating Procedure (SOP) for the Community Mental Health Link Worker Service in Herefordshire.
I can inform you that the SOP has been implemented in draft form; it is currently going through our organisational ratification process for final sign off.
We thought that it was important that the SOP clearly outlines the scope of the link worker role as follows:
“People receiving a service from the Neighbourhood Mental Health Services can receive support from the Community Mental Health Link worker according to identified need. These include:
• People where risk is currently being well managed.
• People who have been assessed, do not need the care of the Neighbourhood Mental Health Team but need support to access community services.
• People who have been under the care of a support worker and are ready for step-down but still have some social needs.
• People ready for step down from the Neighbourhood Mental Health Team but who require community support to enable them to do this.”
Your Concern: Points 2 and 3
The process for the return of the patients from MIND to the care of the Neighbourhood Mental Health team should be transparent and encouraged if the MIND worker feels it is appropriate.
If so, requested by the MIND worker the patient should be returned to the care of the Neighborhood Mental Health team and the involvement of the MIND worker discontinued.
Action: The MIND Link workers now have established links with the Neighbourhood Mental Health teams and daily access to the ‘duty worker’ (registered professional) or Team Manager/ Clinical Lead, where they can identify any areas of concern with care and treatment plans.
If the care and treatment plans indicated are beyond the knowledge and skill set of the Link worker (the acuity of the persons symptomology increases or risk increases) the person will be returned to the care of the Neighbourhood Mental Health team. It should be noted that the Link Workers do not need to wait for a planned meeting they can access the support of the Neighbourhood Mental Health team at any point within core working hours should this be clinically indicated.
In addition, the Link Workers also have open access to the weekly multi professionals’ meetings in the Neighbourhood Teams should they wish to discuss a case.
Conclusion
I would like to thank you for drawing this matter to my attention, I confirm that the point you raised has been carefully considered and the response set out above. I confirm that I have no submissions to make about publishing this response.
If you have any further queries do not hesitate to contact me.
Re: Regulation 28: Report to Prevent Future Deaths in respect of Ms. Caroline Staite
I am writing in response to your report to prevent future deaths dated 14th October 2024 addressed to me, I am grateful for the opportunity of responding to your concerns.
The Trust is always keen to learn from any tragic incident and I hope that this response satisfies you that we have reviewed the issues raised appropriately.
Following the very sad death of Ms Caroline Staite we identified some areas of learning following our internal patient safety review process which we believe cover the points you have outlined in your Regulation 28 Notice. Whilst we were not called to the Inquest, which may have provided an opportunity for us to expand on the issues identified in our patient safety review, I hope that the information below provides you with confidence that the concern you have identified is being fully addressed.
Your concern: Point 1
The Neighbourhood Mental Health teams should ensure that their procedures are sufficiently robust regarding the safely of patients for consideration by MIND.
Action: Since this time our Community Service Manager, Diane Topham, who oversees our Neighbourhood Mental Health Team has worked closely with the Herefordshire MIND service to co-produce a Standard Operating Procedure (SOP) for the Community Mental Health Link Worker Service in Herefordshire.
I can inform you that the SOP has been implemented in draft form; it is currently going through our organisational ratification process for final sign off.
We thought that it was important that the SOP clearly outlines the scope of the link worker role as follows:
“People receiving a service from the Neighbourhood Mental Health Services can receive support from the Community Mental Health Link worker according to identified need. These include:
• People where risk is currently being well managed.
• People who have been assessed, do not need the care of the Neighbourhood Mental Health Team but need support to access community services.
• People who have been under the care of a support worker and are ready for step-down but still have some social needs.
• People ready for step down from the Neighbourhood Mental Health Team but who require community support to enable them to do this.”
Your Concern: Points 2 and 3
The process for the return of the patients from MIND to the care of the Neighbourhood Mental Health team should be transparent and encouraged if the MIND worker feels it is appropriate.
If so, requested by the MIND worker the patient should be returned to the care of the Neighborhood Mental Health team and the involvement of the MIND worker discontinued.
Action: The MIND Link workers now have established links with the Neighbourhood Mental Health teams and daily access to the ‘duty worker’ (registered professional) or Team Manager/ Clinical Lead, where they can identify any areas of concern with care and treatment plans.
If the care and treatment plans indicated are beyond the knowledge and skill set of the Link worker (the acuity of the persons symptomology increases or risk increases) the person will be returned to the care of the Neighbourhood Mental Health team. It should be noted that the Link Workers do not need to wait for a planned meeting they can access the support of the Neighbourhood Mental Health team at any point within core working hours should this be clinically indicated.
In addition, the Link Workers also have open access to the weekly multi professionals’ meetings in the Neighbourhood Teams should they wish to discuss a case.
Conclusion
I would like to thank you for drawing this matter to my attention, I confirm that the point you raised has been carefully considered and the response set out above. I confirm that I have no submissions to make about publishing this response.
If you have any further queries do not hesitate to contact me.