Essex Partnership University NHS Foundation Trust
NHS / Health Body
Action Taken
Essex Partnership University NHS Foundation Trust acknowledges concerns about their Crisis Response Service (CRS) and triage procedures. They have clarified guidance on the UK Mental Health Triage Scale and rectified a typing error in the Standard Operational Policy regarding triage codes and response times. A memo has been sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale. (AI summary)
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Dear Ms Harding,
Phephisa Siphelele Mabuza (RIP)
I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 15th July 2024 in respect of the above, which was issued following the inquest into the sad death of Phephisa Mabuza.
I would like to begin by extending my deepest condolences to Phephisa Mabuza’s family. The Trust sympathises with their very sad loss.
The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to these concerns in the hope that this provides both yourself and Phephisa Mabuza’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised.
I should say at this point, that in considering our replies we have again reviewed / confirmed the assurances previously provided to your Court. Each concern however has been looked at afresh, and has been cascaded to team leads.
Concern a)
“Essex Partnership University NHS Foundation Trust Crisis Response Service follows the UK Mental Health Triage scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. The scale is embedded within the 111 Triage form utilised by clinicians in their clinical decision making following a triage.
The Trust has departed from the national guidance for category D presentations such that the local guidance has been amended to reflect a 7 day response when the national guidance states 72 hours”
Response:
The Crisis Response Services (CRS) across the Trust follow the UK Mental Health Triage Scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. This form of triage scale is only used within the Crisis Response team. Whilst this guidance is not produced by NICE, it is the accepted guideline for use across the country for those organisations who offer this service.
Since CRS was started at the Trust in 2020, the scale is embedded with our 111 Triage form and offers guidance to clinicians in their clinical decision-making following a triage, however Category D has been
amended to reflect 7 days. During our investigations, the Trust was unable identify exactly why the decision was taken, however it appears to have been done to align with our community services in their operational frameworks, as the Trust embedded CRS into its services. In light of this, the senior management in the CRS and the Business Partners, have met to take forward this point. We now have clear clinical rationale frameworks, consistency, and appropriate and safe time frames for our patients coming through CRS.
Additionally work is underway in order to ensure Trust Policies align with national standards as required.
Concern b)
“Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours- same day response and do not reflect the scale on the 111 Triage form or the national guidance”.
Response:
The existing Standard Operational Policy in place is only for use by the Crisis Response Services across the Trust. It is acknowledged that the triage response times on Triage Codes D and E on the appendix were incorrectly stated as “Within 24 hours – Same Day” response, and do not reflect the scale on the form in use on the clinical system. This was owing to a typing error when the policy was completed, and that was unfortunately not picked up before the document went live. The Trust sincerely apologises for missing this, and the confusion it caused to both the Court and to the family.
The Standard Operational Policy has been reviewed and the identified errors rectified. A memo has been sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale in informing their clinical judgment in the decision making process. This has also been shared with the leads covering the other CRS teams.
I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We appreciate that there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care.
Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above.
We trust that your Court will share, as standard, a copy of this reply with Phephisa Mabuza’s family
Yours sincerel Chief Executive
Phephisa Siphelele Mabuza (RIP)
I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 15th July 2024 in respect of the above, which was issued following the inquest into the sad death of Phephisa Mabuza.
I would like to begin by extending my deepest condolences to Phephisa Mabuza’s family. The Trust sympathises with their very sad loss.
The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to these concerns in the hope that this provides both yourself and Phephisa Mabuza’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised.
I should say at this point, that in considering our replies we have again reviewed / confirmed the assurances previously provided to your Court. Each concern however has been looked at afresh, and has been cascaded to team leads.
Concern a)
“Essex Partnership University NHS Foundation Trust Crisis Response Service follows the UK Mental Health Triage scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. The scale is embedded within the 111 Triage form utilised by clinicians in their clinical decision making following a triage.
The Trust has departed from the national guidance for category D presentations such that the local guidance has been amended to reflect a 7 day response when the national guidance states 72 hours”
Response:
The Crisis Response Services (CRS) across the Trust follow the UK Mental Health Triage Scale in classifying the urgency and service response requirements of clinical presentations at the point of contact. This form of triage scale is only used within the Crisis Response team. Whilst this guidance is not produced by NICE, it is the accepted guideline for use across the country for those organisations who offer this service.
Since CRS was started at the Trust in 2020, the scale is embedded with our 111 Triage form and offers guidance to clinicians in their clinical decision-making following a triage, however Category D has been
amended to reflect 7 days. During our investigations, the Trust was unable identify exactly why the decision was taken, however it appears to have been done to align with our community services in their operational frameworks, as the Trust embedded CRS into its services. In light of this, the senior management in the CRS and the Business Partners, have met to take forward this point. We now have clear clinical rationale frameworks, consistency, and appropriate and safe time frames for our patients coming through CRS.
Additionally work is underway in order to ensure Trust Policies align with national standards as required.
Concern b)
“Essex Partnership University NHS Foundation Trust's existing standard operational policy document for the Crisis Response Service incorrectly states triage codes D and E on the appendix as 'within 24 hours- same day response and do not reflect the scale on the 111 Triage form or the national guidance”.
Response:
The existing Standard Operational Policy in place is only for use by the Crisis Response Services across the Trust. It is acknowledged that the triage response times on Triage Codes D and E on the appendix were incorrectly stated as “Within 24 hours – Same Day” response, and do not reflect the scale on the form in use on the clinical system. This was owing to a typing error when the policy was completed, and that was unfortunately not picked up before the document went live. The Trust sincerely apologises for missing this, and the confusion it caused to both the Court and to the family.
The Standard Operational Policy has been reviewed and the identified errors rectified. A memo has been sent to all clinicians within the service reminding them of the use of the UK Mental Health Triage Scale in informing their clinical judgment in the decision making process. This has also been shared with the leads covering the other CRS teams.
I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We appreciate that there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care.
Please do let me know if you require any further information at this stage, including copies of any of the documents referred to above.
We trust that your Court will share, as standard, a copy of this reply with Phephisa Mabuza’s family
Yours sincerel Chief Executive