Berkshire Healthcare NHS Trust
NHS / Health Body
Action Taken
Berkshire Healthcare has commenced a programme of work to move away from the Care Programme Approach (CPA) in line with national guidance, including new five-day clinical skills training, focus on robust discharge planning and 72 hour follow up. The Trust has updated its Transfer and Discharge policy in June 2024, setting out expectations for staff in relation to corresponding with the patient's GP on discharge. (AI summary)
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Dear Madam
Re: Inquest touching the death of Mohammed Ellaboudy
I write on behalf of Berkshire Healthcare NHS Foundation Trust ("Berkshire Healthcare") further to the inquest of Mr Ellaboudy which took place on 24 April 2024 to provide a response to the concerns raised in the Regulation 28 report dated 30 April 2024.
Care Coordination for recently discharged patients
Berkshire Healthcare are progressing changes to the way care is coordinated, planned, and delivered for our mental health patients, treated in the community. We have commenced a programme of work to move away from the Care Programme Approach (CPA). This is in line with guidance from NHS England and the national Community Mental Health Framework (which has been coproduced with service users, carers and professionals) and calls for providers to move away from care co-ordination as an intervention in itself and focus on delivering compassionate, meaningful, intervention-based care which has been planned between the service user and their care team. The roll out of this new model has commenced.
To support staff to deliver within the new model new five-day clinical skills training is now in place, that we are progressing staff through. This includes the responsibilities of the Named Worker such as spending time face to face with the person and those important to them, to collaboratively work out what might be helpful in their situation and to determine the outcomes they want to achieve, what strengths and resources they have to achieve these outcomes, and what interventions and support are available. Furthermore, the need to provide targeted interventions, including relapse prevention as well as a focus on robust discharge planning, 72 hour follow up after discharge from an inpatient mental health setting and the provision of evidence-based interventions is also included in this work that commenced on the 12th June 2024. Supervision of individual members of staff following training is embedded into the model, with audit and peer review processes to ensure new standards are being met. This aspect will commence in October 2024. The Trust’s Transfer and Discharge from Mental Health and Learning Disability In- Patient Care Policy CCR045b has been updated from June 2024 to reflect the changes.
Face to face rather than telephone appointments
As explained, in evidence at the inquest, face to face appointments are the default mode of treatment for out-patient appointments and this is set out in standard work for the Named Worker. However, there will be occasions where a remote appointment is considered to be more appropriate, for example, where this is more convenient for patients, or the team are using alternative strategies to promote engagement. Where a decision is made for an appointment to be undertaken remotely, the rationale must be provided and documented. A quarterly audit process is being designed and implemented to ensure compliance with Heidi Connor Senior Coroner for Berkshire Coroner’s Office Reading Town Hall Blagrave Street Reading RG1 1QH
18/06/2024 London House London Road Bracknell Berkshire RG12 2UT
this process. The results of this audit will be shared within the monthly Divisional Patient Performance, Safety and Quality meeting (PPSQ).
Regularity and thresholds for MDT discussions
MDT (Multi-Disciplinary Team) meetings occur weekly within the Community Mental Health Teams and are open to all staff to discuss concerns, complex cases, risk, safeguarding concerns, and discharges. These meetings are structured to ensure comprehensive review and coordination of patient care. The threshold for discussing cases in MDTs includes any significant change in a patient's condition, risk factors, or treatment plan. Additionally, any concerns raised by family members or primary care providers can be brought to these meetings for discussion. This priority system is in place as it is not feasible to discuss every patient every week due the high number of patients being held on caseloads. There is documented standard work for our MDT meetings which sets out the criteria for which cases should be brought to this meeting.
In addition to regular MDT meetings, staff are encouraged to utilise other forums such as the Risk Panel and the Complex Case Forum. These forums provide additional opportunities to address high-risk situations and complex cases in a multidisciplinary setting, ensuring a thorough review and collaborative approach to patient care.
Staff are also encouraged to utilise the Multiagency Risk Frameworks and other safeguarding frameworks to ensure comprehensive risk management involving all relevant agencies and stakeholder especially when concerns around medication concordance, safeguarding or engagement with services are identified. This facilitates a multi-agency care plan to address issues. The provision of these various forums ensures that staff have multiple avenues to address concerns, collaborate on care plans, and manage risks effectively. For this particular case, a reflective workshop took place with the service involved to reflect on the concerns and to ensure the learning is shared with the wider team.
Clear route for family to report concerns in absence of consent for information sharing with family.
Our existing policies, carers strategy, and training highlight the importance of hearing the family concerns, even in the absence of consent to information sharing having been provided by the patient. Teams have clear guidance on listening and collaborating with family within the Trust Risk Policy. If a family have concerns that cannot be addressed by the team member these can be escalated to the MDT, Team Manager or Clinical Director. The Trust complaints and PALS systems are also available if issues cannot be resolved.
In addition, a new panel is being developed (for implementation in October 2024) in response to direct feedback from carers that they would value an opportunity to have a voice and seek a second opinion on care plans for their family when they are worried or have concerns. The panel will act in an advisory, supportive capacity to carers/family. The panel's remit will be to: ▪ Provide a platform for carers to seek a second opinion or consultation regarding the care and treatment of their family member under BHFT Mental Health Services ▪ Offer expert guidance, recommendations, and support to carers so they can better understand and address the complex needs and challenges. ▪ To provide support and signposting to family members if they are worried about the patient’s condition. Any carer may refer to the panel by completing a brief online form and assistance can be provided with this by calling the number provided or sending an SMS message. If the criteria are met for participation a date and time will be offered within 24 hours of a referral being received.
The criteria for referral will include: ▪ Where there is a concern about the patient and the carer does not feel heard by the treating team. ▪ Where, in the view of the carer, a proposed discharge from services presents a concern about risk and unmet need.
▪ Where there is a lengthy or protracted admission that the carer is concerned may be causing harm. ▪ When a patient does not consent to information sharing but the family are worried and have not felt supported by the treating team
Consent should be sought from the patient for their care to be discussed, however, in situations where the patient does not consent, this will not be a barrier to the panel going ahead (whilst maintaining patient confidentiality). Brief bullet points of action notes will be documented in the patient's record rather than lengthy meeting minutes to ensure relevant points are easily captured.
For learning in this particular case, a reflective workshop took place with the service involved to reflect on the concerns and to ensure the learning is shared with the wider team. Staff were reminded of the importance of ensuring that families are informed about their right to share concerns and that these concerns are discussed in the team to agree the most appropriate action.
Policy or expectation for correspondence with primary care after patient discharge
As mentioned above, the Trust’s Transfer and Discharge from Mental Health and Learning Disability In- Patient Care Policy CCR045b has been updated in June 2024. This sets out expectations for staff in relation to corresponding with the patient's GP on discharge, including ensuring the care plan is updated to include the 72 hour follow up. In addition to this our Interim Mental Health Care Planning and Treatment policy highlights the need to liaise with the GP where there is a significant change in presentation, risk or care plan or where there are issues relating to disengagement that may lead to discharge. The workshop for this case, that took place on 4th June 2024, was facilitated by the clinical governance lead, for reflection with the wider team and also highlighted the importance of clear communication, medication monitoring and relapse prevention strategies. Berkshire Healthcare takes the care and safety of its patients extremely seriously and is continuously working to improve its practice to provide the highest possible standard of care. Representatives from Berkshire Healthcare were present in court during the inquest to ensure that the learning from this matter was captured and disseminated. I hope that this response provides some measure of reassurance to HM Assistant Coroner and Mr Ellaboudy's family.
Re: Inquest touching the death of Mohammed Ellaboudy
I write on behalf of Berkshire Healthcare NHS Foundation Trust ("Berkshire Healthcare") further to the inquest of Mr Ellaboudy which took place on 24 April 2024 to provide a response to the concerns raised in the Regulation 28 report dated 30 April 2024.
Care Coordination for recently discharged patients
Berkshire Healthcare are progressing changes to the way care is coordinated, planned, and delivered for our mental health patients, treated in the community. We have commenced a programme of work to move away from the Care Programme Approach (CPA). This is in line with guidance from NHS England and the national Community Mental Health Framework (which has been coproduced with service users, carers and professionals) and calls for providers to move away from care co-ordination as an intervention in itself and focus on delivering compassionate, meaningful, intervention-based care which has been planned between the service user and their care team. The roll out of this new model has commenced.
To support staff to deliver within the new model new five-day clinical skills training is now in place, that we are progressing staff through. This includes the responsibilities of the Named Worker such as spending time face to face with the person and those important to them, to collaboratively work out what might be helpful in their situation and to determine the outcomes they want to achieve, what strengths and resources they have to achieve these outcomes, and what interventions and support are available. Furthermore, the need to provide targeted interventions, including relapse prevention as well as a focus on robust discharge planning, 72 hour follow up after discharge from an inpatient mental health setting and the provision of evidence-based interventions is also included in this work that commenced on the 12th June 2024. Supervision of individual members of staff following training is embedded into the model, with audit and peer review processes to ensure new standards are being met. This aspect will commence in October 2024. The Trust’s Transfer and Discharge from Mental Health and Learning Disability In- Patient Care Policy CCR045b has been updated from June 2024 to reflect the changes.
Face to face rather than telephone appointments
As explained, in evidence at the inquest, face to face appointments are the default mode of treatment for out-patient appointments and this is set out in standard work for the Named Worker. However, there will be occasions where a remote appointment is considered to be more appropriate, for example, where this is more convenient for patients, or the team are using alternative strategies to promote engagement. Where a decision is made for an appointment to be undertaken remotely, the rationale must be provided and documented. A quarterly audit process is being designed and implemented to ensure compliance with Heidi Connor Senior Coroner for Berkshire Coroner’s Office Reading Town Hall Blagrave Street Reading RG1 1QH
18/06/2024 London House London Road Bracknell Berkshire RG12 2UT
this process. The results of this audit will be shared within the monthly Divisional Patient Performance, Safety and Quality meeting (PPSQ).
Regularity and thresholds for MDT discussions
MDT (Multi-Disciplinary Team) meetings occur weekly within the Community Mental Health Teams and are open to all staff to discuss concerns, complex cases, risk, safeguarding concerns, and discharges. These meetings are structured to ensure comprehensive review and coordination of patient care. The threshold for discussing cases in MDTs includes any significant change in a patient's condition, risk factors, or treatment plan. Additionally, any concerns raised by family members or primary care providers can be brought to these meetings for discussion. This priority system is in place as it is not feasible to discuss every patient every week due the high number of patients being held on caseloads. There is documented standard work for our MDT meetings which sets out the criteria for which cases should be brought to this meeting.
In addition to regular MDT meetings, staff are encouraged to utilise other forums such as the Risk Panel and the Complex Case Forum. These forums provide additional opportunities to address high-risk situations and complex cases in a multidisciplinary setting, ensuring a thorough review and collaborative approach to patient care.
Staff are also encouraged to utilise the Multiagency Risk Frameworks and other safeguarding frameworks to ensure comprehensive risk management involving all relevant agencies and stakeholder especially when concerns around medication concordance, safeguarding or engagement with services are identified. This facilitates a multi-agency care plan to address issues. The provision of these various forums ensures that staff have multiple avenues to address concerns, collaborate on care plans, and manage risks effectively. For this particular case, a reflective workshop took place with the service involved to reflect on the concerns and to ensure the learning is shared with the wider team.
Clear route for family to report concerns in absence of consent for information sharing with family.
Our existing policies, carers strategy, and training highlight the importance of hearing the family concerns, even in the absence of consent to information sharing having been provided by the patient. Teams have clear guidance on listening and collaborating with family within the Trust Risk Policy. If a family have concerns that cannot be addressed by the team member these can be escalated to the MDT, Team Manager or Clinical Director. The Trust complaints and PALS systems are also available if issues cannot be resolved.
In addition, a new panel is being developed (for implementation in October 2024) in response to direct feedback from carers that they would value an opportunity to have a voice and seek a second opinion on care plans for their family when they are worried or have concerns. The panel will act in an advisory, supportive capacity to carers/family. The panel's remit will be to: ▪ Provide a platform for carers to seek a second opinion or consultation regarding the care and treatment of their family member under BHFT Mental Health Services ▪ Offer expert guidance, recommendations, and support to carers so they can better understand and address the complex needs and challenges. ▪ To provide support and signposting to family members if they are worried about the patient’s condition. Any carer may refer to the panel by completing a brief online form and assistance can be provided with this by calling the number provided or sending an SMS message. If the criteria are met for participation a date and time will be offered within 24 hours of a referral being received.
The criteria for referral will include: ▪ Where there is a concern about the patient and the carer does not feel heard by the treating team. ▪ Where, in the view of the carer, a proposed discharge from services presents a concern about risk and unmet need.
▪ Where there is a lengthy or protracted admission that the carer is concerned may be causing harm. ▪ When a patient does not consent to information sharing but the family are worried and have not felt supported by the treating team
Consent should be sought from the patient for their care to be discussed, however, in situations where the patient does not consent, this will not be a barrier to the panel going ahead (whilst maintaining patient confidentiality). Brief bullet points of action notes will be documented in the patient's record rather than lengthy meeting minutes to ensure relevant points are easily captured.
For learning in this particular case, a reflective workshop took place with the service involved to reflect on the concerns and to ensure the learning is shared with the wider team. Staff were reminded of the importance of ensuring that families are informed about their right to share concerns and that these concerns are discussed in the team to agree the most appropriate action.
Policy or expectation for correspondence with primary care after patient discharge
As mentioned above, the Trust’s Transfer and Discharge from Mental Health and Learning Disability In- Patient Care Policy CCR045b has been updated in June 2024. This sets out expectations for staff in relation to corresponding with the patient's GP on discharge, including ensuring the care plan is updated to include the 72 hour follow up. In addition to this our Interim Mental Health Care Planning and Treatment policy highlights the need to liaise with the GP where there is a significant change in presentation, risk or care plan or where there are issues relating to disengagement that may lead to discharge. The workshop for this case, that took place on 4th June 2024, was facilitated by the clinical governance lead, for reflection with the wider team and also highlighted the importance of clear communication, medication monitoring and relapse prevention strategies. Berkshire Healthcare takes the care and safety of its patients extremely seriously and is continuously working to improve its practice to provide the highest possible standard of care. Representatives from Berkshire Healthcare were present in court during the inquest to ensure that the learning from this matter was captured and disseminated. I hope that this response provides some measure of reassurance to HM Assistant Coroner and Mr Ellaboudy's family.