Sarah Adams

Coroner's concerns

AI summary

Clinicians and other practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions.

View full coroner's concerns

That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions

Responses

3 respondents

Cygnet Health Care Private Sector

15 May 2024 PDF

Action Planned

Cygnet will hold a conference to share actions on improving discharge processes, start a quality improvement project to explore a working arrangement with the Samaritans, and already has a Cygnet Social Worker on Byron Ward to coordinate discharges. (AI summary)

View full response

Dear Madam Inquest touching the death of Sarah Adams I write to provide the response from Cygnet Health Care ("Cygnet") in relation to the Regulation 28 report sent to Cygnet Hospital Harrow, alongside Berkshire Healthcare NHS Foundation Trust and Reading Borough Council, following the above inquest. In the Regulation 28 Report you identified a concern relating to ensuring that staff are trained in the discharge process, and specifically the issues which may arise in respect of out of area placements. For all patients at Cygnet planning for discharge begins from admission. A key part of this is the discharge care plan which is started when a patient is admitted and updated throughout their admission following every ward round. The objective is for this care plan to provide a comprehensive picture of the arrangements for discharge from the time of admission; including risks, discharge location, transfer arrangements and support needs. Care planning and risk assessment training is provided to staff to support them in completing care plans, including discharge care plans. This is via a 4.5 hour face to face session. The session is provided by the Regional Nursing Director to all the Clinical Managers to then be cascaded at each site. At Cygnet Harrow this session has been provided to all members of the multi-disciplinary team (MDT) and is due to be refreshed on an annual basis, or more frequently if a need is identified. This training is aligned with Cygnet's broader training offering, particularly our e-learning risk training. This training is provided to all members of the MDT and refreshed on a two-yearly basis. The session provides guidance to staff in assessing risk, utilising the relevant tools and ensuring that risk assessments are of high quality and triangulated with the care plans, continuous notes and information from families and carers. We are acutely aware that risks can increase at discharge and that risk assessments need to be undertaken carefully to ensure that we implement steps to minimise this. The risk training has been reviewed and from 1 July 2024 will include updated and more specific guidance in relation to risk assessing around discharge. Discharge arrangements are specific to each individual who is being discharged and Cygnet needs to be flexible as it discharges to multiple different community organisations. To ensure that our processes are consistent and nothing is missed Cygnet has detailed policies covering the discharge process. The new discharge policy was reviewed and published March 2024.

This policy was benchmarked with a large mental health Trust to ensure we had the best evidence and our policies were in line with those of the sector. The documentation to support discharge includes the discharge notification form which was also updated in March 2024 to specifically highlight the need to document the plan for post-discharge community support, including when this support will commence. This form is shared with the patient and all relevant stakeholders on discharge to ensure that all relevant agencies are aware of the agreed plan. Cygnet also utilises a discharge checklist which must be completed by the Responsible Clinician for every discharge. Completion of discharge forms and summaries is monitored both locally, via the Medical Director, and centrally at Board level to ensure that all sites are providing the necessary documentation in a timely manner to support onward care. This data is highly visible so that if documents are not being sent in accordance with set timeframes this can be immediately identified and addressed. Further, a supplemental set of training slides for staff induction are in development to provide support to staff in understanding the content of the discharge policy, including the discharge checklist, the key risks to consider, accurate documentation and communication with community teams. These slides will be deployed by 1st June 2024 for all Cygnet Hospital sites to assist new staff with prompt familiarisation with our processes. . In addition, our Group Medical Director is arranging a Safer Discharge Conference planned to go ahead in Summer 2024. The learning conference will look at specific risks associated with discharge and the practical arrangements surrounding discharge. Our stakeholders, including community mental health teams and Local Authority Adult Social Care Teams, will be invited to this conference to share actions taken to improve discharge processes, checklists, policies and improved communication with a focus on patient centredness and to ensure that our commissioners and collaborators are aware of our processes and what role they will undertake in the discharge process. The conference will include panel discussions that involve carers and Expert by Experience leads. It is also planned to invite the Parliamentary and Health Ombudsman to discuss their recent findings and report "Discharge from mental health care: making it safe and patient-centred". On 1 June 2024 we will commence a quality improvement project in relation to the learning from this inquest, this will look at exploring a working arrangement with the Samaritans. This would provide for any high risk patients ready for discharge to be, with their consent, referred to the Samaritans. The Samaritans would then contact the discharged patients within 24 hours and if they have any concerns they can take appropriate action. This model has been successfully utilised in other mental health organisations and can bridge the gap between discharge and being reviewed by their community teams providing an additional risk mitigation and safeguard on discharge. Since this inquest Byron Ward now also has a Cygnet Social Worker. This role provides coordination of the discharge arrangements including liaison with family and community services which further assists with ensure that discharges processes run smoothly. Cygnet Health Care 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 Cygnet Harrow were present in court throughout 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 Ms Adams’ family.

Reading Borough Council Local Authority / Fire Service

PDF

Noted

Reading Borough Council outlines its Standard Operating Procedure for psychiatric hospital discharges, noting that social care practitioners are required to know and act in accordance with it. In the case of Sarah Adams, Adult Social Care were not informed of the discharge. (AI summary)

View full response

Dear sir/madam,

1. This is Reading Borough Council’s (“RBC”) response to Preventing Future Death (“PFD”) report issued following the inquest touching upon the death of Sarah Elizabeth Adams heard between 5 and 8 March 2024, pursuant to coronial powers under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

2. At the conclusion of the inquest, the Coroner found “Ms Adams died by suicide; however, her death was more than minimally contributed to by care and service delivery issues around her discharge from a voluntary in-patient hospital admission for a relapse of her longstanding paranoid schizophrenia and an intentional medication overdose.” The subsequent PFD report was issued in relation to the following matter giving rise to concern: “That clinicians and other hospital, mental health Trust and Social Care practitioners involved in the discharge of patients from in-patient mental health admissions are not trained in the discharge process generally and specifically the issues which may arise in respect of out of area admissions”. This is RBC’s response.

3. The policy governing RBC’s social care involvement in hospital discharges is our Standard Operating Procedure (SOP) of Psychiatric Hospital Discharge (a copy of which is attached).

4. This “outlines the standard operating procedure for the timely discharge of individuals from psychiatric hospitals in Reading” in circumstances when an individual is classified as medically fit for discharge by a multi-disciplinary team. RBC is guided by an approach whereby “from the time at which someone is admitted to hospital, planning should begin for their discharge”.

5. The SOP sets out that: “Most psychiatric hospital discharges where an individual is moving to a community setting (either still under section or with the section lifted) are arranged through the Care Programme Approach (CPA). CPA is a multidisciplinary approach to supporting individuals after discharge with a care plan, care coordinator and ensuring a crisis plan is in place.” Further, the SOP states that “the CPA will combine eligibility under each of these Acts to form a single, cohesive support plan”.

6. The SOP sets out in pathways the processes, conditions, services provided by Adult Social Care dependent on assessments, review and follow ups.

Coroner’s Court Officer Reading Town Hall Blagrave Street Reading RG1 1QH

Executive Director for Communities and Adult Social Care

Civic Offices, Bridge Street, Reading, RG1 2LU

Date: 13th May 2024
– Assistant Director for Operations

reading.gov.uk | facebook.com/ReadingCouncil | twitter.com/ReadingCouncil

7. The SOP notes that “the pathway is dependent on the service user’s circumstances and whether a short-term or long-term change needs to be made to the care package. The allocated worker will continue to hold the case until the service user has either settled into their placement or they have returned to being primarily under the care of health services.”

8. With regards to circumstances in which Mental health beds are occupied by patients who are medically ready for discharge, this is set out in Appendix A of the SOP:

Individuals are considered medically fit and ready for discharge (MFRD) when all three of the following conditions are met:
1. No further interventions are needed that can only be carried out in an inpatient setting The person could be assessed, cared for and treated in their home or a less restrictive setting

2. The multidisciplinary team (MDT) conclude that the person is medically fit and ready for discharge The MDT will include parties external to the trust (for example, social care staff). This involves considering issues such as housing, family/carer needs and the support available in the community, to decide whether discharge would be appropriate. When deciding whether someone is ready for discharge, members of the MDT should explicitly consider the person and their family/carers’ views about whether the person feels ready for discharge and engage with them about the proposed discharge plan.

3. An adequate person-centred discharge has been agreed with the person to carry out any necessary assessments, care and treatment in the community. This will provide clear information about the proposed discharge process and enable the person and their family/carers to shape decisions about discharge.

Once all three criteria are met, the person is medically fit and ready for discharge. Medically fit does not indicate complete recovery, instead it is the point at which the person could be safely assessed, cared for and treated in their home or a less restrictive setting. It is important that all three criteria are met rather than only one or two. Being medically ready for discharge does not mean that the person should be rushed to discharge if the conditions are not in place to continue their recovery outside of hospital with the adequate support/services in place.

9. We confirm that all Adult Social Care practitioners involved in discharge planning are required to know and act in accordance with the SOP. Precise processes regarding discharge planning may differ from Trust to Trust.

10. With regards to local arrangements, the SOP notes that: Berkshire Healthcare NHS Foundation Trust are currently funding a Social Worker and Occupational Therapist based in Prospect Park Hospital to facilitate discharges as part of the Reading ward liaison team alongside health staff. These staff have access to health databases, so can see details of all Reading patients and their journey towards discharge. From the time at which someone is admitted to hospital, planning should begin for their discharge.

11. RBC is aware of the fact that out of area admissions have become more frequent over the last year as the bed base within Berkshire Healthcare NHS Foundation Trust is reduced and are frequently at capacity. As indicated, in all hospital discharges, the SOP is followed, regardless of area. In addition, Adult Social Care would request that no discharge is made until RBC have had 24- hour notification of this and have confirmed or agreed that care is formally in place, or alternative arrangements have been made. In the case of Sarah Adams, Adult Social Care were not informed of the discharge.

Kind regards,

Reading Borough Council Executive Director for Communities and Adult Social Care

Berkshire Healthcare NHS Foundation Trust NHS / Health Body

PDF

Action Taken

The Trust has revised clinical risk training to increase focus on high-risk situations such as transitions of care, out-of-area placements, clear communication in discharge plans, and the 72-hour follow-up process. They have also strengthened guidance to teams on the 72-hour follow up process. (AI summary)

View full response

Dear Madam

I write in relation to the above inquest which concluded on 18 March 2024.

On 20 March 2024 you made a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was sent to Berkshire Healthcare NHS Foundation Trust ("Berkshire Healthcare"), Cygnet Hospital Harrow, and Reading Borough Council, Adult Social Care. I am writing to provide you with the Berkshire Healthcare response to your concerns which relate to ensuring practitioners are trained in the discharge process.

The discharge process for patients admitted to our inpatient services or to out of area placement, starts at the point of admission. This process involves community mental health teams and partner agencies such as Adult Social Care and, in the case of out of area placements, agencies such as the Cygnet Hospital, making plans for the support required by the patient at the point of discharge.

All clinical staff in the Mental Health Divisions undertake Clinical Risk training which includes a focus on admission and discharge from inpatient services. We have now reviewed and revised this training offer across the organisation to ensure that moving forward there will be an increased focus on high-risk situations such as:
• Periods of transition of care between services or organisations (as this is known to be a high-risk period).
• Those placed in out of area placements.
• The importance of clear communications and responsibilities in the discharge plan and steps that will be taken to ensure the plan is carried out; and
• 72 hour follow up process.

These modifications to the Clinical Risk training and guidance further strengthens the training already in place which complies with national guidance. It aims to enhance staff knowledge and skills by providing additional guidance and clarity on the importance of defining, agreeing, and clearly communicating roles, responsibilities, and timelines. The new Clinical Risk training started on 1 May 2024. An enhanced group PRIVATE AND CONFIDENTIAL

Alison McCormick Assistant Coroner for Berkshire Coroner’s Office Reading Town Hall Blagrave Street Reading RG1 1QH

08 May 2024

London House London Road Bracknell Berkshire RG12 2UT Tel: 01189 046500

supervision process has also been developed to run alongside the training to ensure practice is reflecting the expected standards.

In addition, each service has a local induction training programme for new starters to undertake. For services that manage discharges from inpatient settings, including out of area placements, each new starter to the team undergoes on the job training by way of shadowing colleagues completing discharge processes. New starters within inpatient settings have a period of being supernumerary to facilitate the experiential learning of these routine processes. Community team practitioners with caseload management responsibilities receive support from senior colleagues in supervision to ensure discharge processes are followed and managed safely. Discharging people from mental health hospital settings is a routine and everyday occurrence. This allows staff plenty of opportunity to embed the processes from the point they are inducted into their role with the trust.

Our Crisis Response Home Treatment Team (CRHTT) have a Caseload Coordinator role who has a focus on CRHTT discharge planning. They are responsible for the liaison between the host ward (whether out of area or local) and transition into CRHTT where appropriate. They ensure that agreed discharge plans and actions for CRHTT are clear at the point of discharge and are documented, implemented, and followed up.

Further guidance on discharge protocol is available for staff in our Trust policies namely, Risk Assessment / Management in Secondary Care Mental Health, Learning Disabilities Services and CAMHS Policy [CCR003], Clinical Risk and Safety Planning Documentation Guidance, and the Admission, Discharge and Transfer Policy [CRR045]. We have also strengthened our guidance to teams on the 72 hour follow up to give staff additional information around this process including guidance on patients that refuse to be seen during this period.

Finally, more broadly, the Care Programme Approach (CPA) process is presently in the process of changing, in line with guidance from NHS England and the national Community Mental Health Framework. The aim is to ensure that everyone receives the same level of care, including a named key worker for all service users but with a multidisciplinary approach that must be integrated with social care and the voluntary, community and social enterprise. Every member of the MDT will play a prominent role in sharing responsibility for an individual’s care, and it will be the MDT playing the coordinating role across the various organisations and sectors. This will include the responsibility for discharges from inpatient settings. Significant work has been undertaken to review caseloads, improve risk documentation and safety planning as well as updating pathways and links with Voluntary, Community and Social Enterprise organisations.

As a Trust, the safety and wellbeing of those we provide service to is paramount and despite the unfortunate circumstances in which this query has arisen, we welcome the opportunity HM Assistant Coroner has provided for us to review our training provision concerning the discharge process and we have taken this opportunity, as we do with all inquests, to learn from this experience and implement steps to ensure that we continue to provide the best quality care.

Report sections

Investigation and inquest

On 27 May 2022 I commenced an investigation into the death of Sarah Elizabeth ADAMS aged 64. The investigation concluded at the end of the inquest on 18 March 2024. The conclusion of the inquest was that: Ms Adams died by suicide; however, her death was more than minimally contributed to by care and service delivery issues around her discharge from a voluntary in-patient hospital admission for a relapse of her longstanding paranoid schizophrenia and an intentional medication overdose.

Circumstances of the death

Sarah Adams was found deceased at her home address on 19th May 2022. She died from a self administered overdose of prescribed medication taken with the intention of ending her life. On the balance of probability Ms Adams’ death was more than minimally contributed to by care and service delivery issues around her discharge on 18th May 2022 from a voluntary in-patient hospital admission for a relapse of her longstanding paranoid schizophrenia and an intentional medication overdose taken on 4th April 2022. Specifically, a misunderstanding about the Crisis Team visiting Ms Adams on the day of her discharge together with the provision of 5 days of prescribed medication to her likely made a more than minimal contribution to her death. The following care and service delivery issues possibly made a more than minimal contribution to Ms Adams’ death: (a) Delay by the mental health Trust in actioning the care plan on Ms Adams’ discharge from the Crisis Team in October 2021, both in respect of allocating a Care Co-ordinator to her and in arranging an Out Patient Appointment and medication review; (b) The mental health Trust’s response to Ms Adams’ deterioration in February and March 2022.

Similar PFD reports

Shared signals

Coroner's concerns

Responses

Report sections

Similar PFD reports

Related inquiry recommendations

Report details

Responses identified

Sent to

Source links