West London NHS Trust
NHS / Health Body
Action Planned
West London NHS Trust is implementing NICE guidance (NG225), undertaking an audit of CATT processes by December 2023, and providing additional training for staff regarding ASD. They are also in discussion with North West London ICB to develop a local commissioned pathway for ADHD assessment and intervention. (AI summary)
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Dear Professor Wilcox
RE: Regulation 28 Report - Oleg Khala
I write on behalf of West London NHS Trust in relation to the Prevention of Future Deaths Notice sent via email on 6th July 2023. The Trust has now had an opportunity to review the Matters of Concern raised.
I would like to begin by offering my sincere condolences to the family of Mr Khala for their very sad loss. As a Trust we have taken your concerns very seriously and have aimed to address these issues as quickly as possible to ensure lessons are learned to benefit other patients in the future. I will respond to each issue in turn.
Matters of Concern
The generic, tick-box style of history recording by the crisis team (“CATT”) which does not paint a full and proper picture of the mental health of the patient, especially compared to the assessments of psychiatric liaison, are such that risk may be unrecorded and under appreciated by CATT and patients thus be put at risk.
In line with the Practice Guidelines for Crisis Line Response and Crisis Resolution and Home Treatment Teams (Royal College of Psychiatrists Quality Network), our local protocols indicate that CATT assessments should be whenever possible carried out as joint assessment with the referrer.
Trust policy and mandatory training for staff encourages risks to be assessed using a formulation based approach in line with the NICE guidance (NG225) issued in September 2022. This emphasises that risk assessment tools should not be used to predict suicide or determine who or who not should be offered treatment or who should be discharged.
However, it is considered positive practice to consider using validated triage tools such as the UK Mental Health Triage Scale to assess the urgency of response which might be offered to patients presenting in mental health crisis. During 2022 we have adapted our protocols within WLT, informed by the UK Mental Health Triage Scale to guide clinicians triaging assessments regarding which or our services is best placed to meet the needs of the patient in a timely way. The implementation of this is under ongoing review.
It is the responsibility of the CATT staff to ensure that accurate, up-to-date information is collected at the assessment including collateral history from patients’ carer/family member wherever this is possible. The person(s) completing the assessment will communicate and agree the outcome of the assessment with the referrer and discuss the assessment findings in the multi-disciplinary team (MDT) handover. When out of hours’ assessments are completed and the decision is to admit the service user the decision to admit is discussed with the on–call specialist registrar and on-call consultant psychiatrist to agree an appropriate safety and admission plan.
That the role of CATT to look for alternatives to admission may risk CATT discharging patients who would benefit from admission and risk the repeat of making treatment plans that had recently failed such as in this case. Rather than looking for admission alternatives being a core function, should CATT rather better be focussed on the best treatment plan for the individual patient and thus admission being viewed as a clear option where appropriate rather a last resort, as it often appears to be presented in such cases before the coroner.
The Trust expects all assessments, including for CATT, to take into account individual circumstances and clinical need, recognising that CATT may not be suitable for some service users and there are a range of other crisis pathways and interventions available to all patients, including acute inpatient admission under the Mental Health Act 1983, or as a voluntary patient. The service user’s choice of obtaining treatment at hospital or at home should be also taken into account which is a key part of adhering to the least restrictive option for service users.
Home treatment by definition is an appropriate alternative to hospital admission for working age and older adults with severe mental illness (e.g. schizophrenia, manic depressive disorders, severe depressive disorder) with an acute psychiatric crisis of such severity that, without the involvement of a CATT, hospitalisation would be necessary. Such patients should be willing to receive home treatment which can be safely provided in their home environment. Treatment
interventions, procedures and protocols will be evidence-based and compliant with the Quality Network for Crisis Resolution and Home Treatment Teams (QN-CRHTT) standards and NICE (National Institute of Clinical Excellence) guidelines
1 Guidance | Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services | Guidance | NICE
We are confident that these principles are consistent with best practice, for example the core principles identified within The Independent Review of the Mental Health Act 1983 chaired by Professor Sir Simon Wessely “Modernising the Mental Health Act”, published in December 2018
– which emphasised “Choice and Autonomy”, a principle of “Least Restriction… and that less restrictive alternatives must always be considered”, a “Therapeutic Benefit” principle, and a principle of treating “the Person as an Individual”.
That the provision of care co-ordinators be increased and improved so that patients who require them have ready access at the time of need and are not placed on a waiting list.
The Trust received significant investment in 2020-21 to implement a more flexible model of community-based mental healthcare for adults and older adults with a wide range of mental health needs based upon the NHS England Community Mental Health Framework for Adults and Older Adults and the NHS England Long Term Plan. In recent years, concerns about the use of the Care Programme Approach (CPA) in community mental health services have been raised and a new approach is developing. NHS England and NHS Improvement have published a formal statement which states that community mental health services should move away from CPA while meeting core principles of care.
Within the MINT model of care, we aim to support individuals who require long term mental health support with coordinated care by a named clinician, and that this clinician is appropriately skilled to provide the interventions recommended in the coproduced care plan. We also recognise (in line with the national specification for community mental health services, upon which MINT teams have been designed) that some individuals will receive ‘care coordination’ for only a time limited period in line with their needs.
As part of the implementation of this we have developed and are deploying standardized protocols, enhanced documentation practices, and regular training sessions to promote effective coordinated care by any named clinician involved in patient care. These measures aim to mitigate potential risks and ensure that patients receive the highest quality of care in a coordinated manner.
We acknowledge that the implementation of the MINT model in West London NHS Trust has faced a number of challenges, not entirely within the direct control of the Service, and this was recognised in a CQC inspection in 2022. In response to this, the Trust has a robust action plan in train which is addressing the areas of concern highlighted and progress against this is monitored at Board level.
MINT, in line with the community mental health framework, has brought about expanding the roles that support service users in the community with their mental health. This includes occupational therapists, link workers, peer support workers, vocational rehabilitation services, social workers, mental health practitioners and community mental health nurses. This framework provides holistic biopsychosocial model of care and treatment to mental health service users.
We head up ongoing staffing recruitment drives to recruit local and international staff. We have put significant resource into growing our own workforce through apprenticeship posts in allied health professions, nursing and social work apprenticeships. West London have also met staffing needs through international recruitment of appropriate mental health workers. We are working closely with staff and team managers to ensure we are retaining staff through our wellbeing and development opportunities.
That patients to be discharged by CATT, as well as patients to be admitted are discussed with the on-call psychiatrist so that plans may be reviewed, and thus the risk of not admitting patients who would benefit from and/ or require admission such as Mr Khala, are less likely to be discharged inappropriately.
As above, and in line with the Royal College of Psychiatrists Guidance, wherever feasible, every effort should be made to undertake a joint assessment with the referrer.
CATT team members (and other non-medical and trainee medical staff undertaking assessments of patients in crisis) have been reminded that they can request senior discussion with On-call Consultants irrespective of decision to admit, to offer an admission to a home-based care pathway or to discharge. It is the practice within CATT for daily multidisciplinary meetings (MDT) to be held, which play a vital part in overseeing a safe and effective service. The ethos of the MDT is for an inclusive and constructive discussion around the service user where the views of all professionals, regardless of their banding or role are valued and facilitated. Routine MDT meetings always include a consultant psychiatrist.
Service users, including those who are being admitted to a home based treatment pathway, or who are being discharged from CATT, are routinely discussed. Cases of concern (red on the local traffic light system) and new referrals are discussed on a daily basis. All cases must be discussed in MDT at least twice weekly. The focus of MDT discussions is around the formulation of the case, any changes to risk, the progress of the individual, the response to treatment, the indication for and the engagement with allied health professionals, barriers to discharge and likely timing of transfer of care to routine pathways for ongoing support. The MDT will also actively monitor the operational aspects of adequate record keeping (e.g. clinical coding, contemporary risk assessment, up-to-date care plan and physical health checks). Formal documentation of handover is entered into the clinical records contemporaneously and captures the above, as well as all immediate care actions (e.g. frequency of visits, outstanding actions). When using the traffic light system; Red, Amber, Green, (RAG) all new cases and cases of concern are placed on the “Red” caseload until sufficient contact has been made to allow for a reduction to “Amber”. This would not usually be on first contact with the service user. In cases where the risk has increased this should be captured with an escalation in the RAG rating. Changes in RAG should be made through MDT discussion. Planning for the withdrawal of home treatment begins early, the expectation is that the service user will have progressed through the traffic light process (and achieved “green” status) and the identified outcomes will have been met. The decision to discharge the service user from the CATT should be made after consultation between CATT staff, the community team, the care co- ordinator, medical staff, carers and the patient themselves. RAG rating:
RED:
• Patient assessed and accepted by CATT and agreeing to work with us
• Anyone within the first three days of being under the team
• Anyone considered to be requiring review of decision to offer home treatment in favour of arranging admission
• Patients awaiting Mental Health Act assessment
• Patients still in early aspect of their recovery and experiencing predominant symptoms of a mental disorder or crisis which is yet to respond to intervention AMBER: Everyone else GREEN:
• Aims of the CATT have been met
• Referrals have been completed to other agencies
• Understanding reached as to why the crisis occurred and strategies in place to mitigate future episodes
• Patient ready for transfer or care back to primary care or MINT (or other longer term support services)
• Uncomplicated Clozapine titrations or community based ECT
That where psychiatric teams differ in their assessments such as CATT and Psychiatric Liaison, as occurred here, patients are not discharged until opinion is sort from the on-call consultant and re-discussion taken place between those with differing views.
The Clinical Directors, Service Managers, Clinical Leads and Team Managers responsible for CATT and Psychiatric Liaison are in regular discussion about interface matters between their services and cases of concern are reviewed regularly. All are in agreement that it is best practice for assessments to take place and decisions to be made jointly wherever possible, and work is ongoing to embed a culture of ‘trusted assessment’ between the teams in respect of decisions to admit to beds or home-based treatment pathways under CATT.
Where a joint assessment and decision is not possible, the person(s) completing the assessment will communicate and discuss and agree the findings with the referrer, service user and within the multi-disciplinary team (MDT) handover, which involves consultants. The availability of in-hours and on-call psychiatric registrar (approved under section 12 of the Mental Health Act) and consultant) to provide guidance or supplementary assessment in the event of clinical disagreement has been re-communicated to teams, and will be incorporated into work we are doing with partners across North West London to implement clinical escalation protocols.
That expertise covering neurodevelopmental disorders such as ASD and ADHD is available as part of MINT. In July 2022, the Health and Care Act 2022 introduced the requirement that CQC regulated service providers ensure their staff receive training on learning disability and autism which is appropriate to the person’s role. The Part 1/tier 1 Oliver Mc Gowan training on Learning Disability and Autism has been made mandatory for all clinical staff in West London NHS Trust. The content has been developed with reference to tier 1 and tier 2 capabilities contained within the Core Capabilities Framework for Supporting Autistic People and Core Capabilities Framework for Supporting People with a Learning Disability. Both frameworks are nationally recognised and have been developed to provide a focus on the skills, knowledge and behaviours expected for staff offering services to autistic people or people with a learning disability. All staff that require a general awareness of this support for autistic people or people with a learning disability are advised they need to cover all of the tier 1 capabilities in the framework. Part 2 of the training is being developed within West London NHS Trust and will be launched in 2024. In terms of specialised ASD support in West London NHS Trust, Acute Mental Health Services benefits from an Autism Liaison Service which can be contacted for consultative input for any service users with a diagnosis of Autism. Plans are in place to further expand this service for service users within Ealing MINT with a diagnosis of autism or suspected autism, with a view of this being rolled out to other boroughs, if successful. This will also involve consultative input to 16- 25 teams. ADHD assessment and treatment is not commissioned or provided as part of the West London Trust. Service users of the boroughs of Ealing, Hammersmith and Fulham and Hounslow are referred to other services commissioned by North West London Integrated Care Board. They offer diagnosis and treatment for adults with ADHD. Once treatment is stabilised, prescribing and monitoring will be transferred back to the GP. They currently do not offer psychological interventions for the treatment of ADHD in our clinic. The wait time for assessment is currently 18-24 months. GP’s are responsible for making ADHD referrals directly to the other providers if they believe the service user meets the threshold for assessment and on completion of a screening assessment. WLT SPA (single point of access) provides additional support in forwarding all ADHD assessment requests to the other providers directly.
WLT is in discussion with North West London ICB to develop a local commissioned pathway for ADHD assessment and intervention. I hope that we have been able to provide you with assurance that we have reviewed and sought to address the concerns that you have raised. We are committed to continuously improving our services to ensure patient safety, experience and the delivery of high-quality care in line with best practice. Please do not hesitate to contact me should you have any questions or queries.
RE: Regulation 28 Report - Oleg Khala
I write on behalf of West London NHS Trust in relation to the Prevention of Future Deaths Notice sent via email on 6th July 2023. The Trust has now had an opportunity to review the Matters of Concern raised.
I would like to begin by offering my sincere condolences to the family of Mr Khala for their very sad loss. As a Trust we have taken your concerns very seriously and have aimed to address these issues as quickly as possible to ensure lessons are learned to benefit other patients in the future. I will respond to each issue in turn.
Matters of Concern
The generic, tick-box style of history recording by the crisis team (“CATT”) which does not paint a full and proper picture of the mental health of the patient, especially compared to the assessments of psychiatric liaison, are such that risk may be unrecorded and under appreciated by CATT and patients thus be put at risk.
In line with the Practice Guidelines for Crisis Line Response and Crisis Resolution and Home Treatment Teams (Royal College of Psychiatrists Quality Network), our local protocols indicate that CATT assessments should be whenever possible carried out as joint assessment with the referrer.
Trust policy and mandatory training for staff encourages risks to be assessed using a formulation based approach in line with the NICE guidance (NG225) issued in September 2022. This emphasises that risk assessment tools should not be used to predict suicide or determine who or who not should be offered treatment or who should be discharged.
However, it is considered positive practice to consider using validated triage tools such as the UK Mental Health Triage Scale to assess the urgency of response which might be offered to patients presenting in mental health crisis. During 2022 we have adapted our protocols within WLT, informed by the UK Mental Health Triage Scale to guide clinicians triaging assessments regarding which or our services is best placed to meet the needs of the patient in a timely way. The implementation of this is under ongoing review.
It is the responsibility of the CATT staff to ensure that accurate, up-to-date information is collected at the assessment including collateral history from patients’ carer/family member wherever this is possible. The person(s) completing the assessment will communicate and agree the outcome of the assessment with the referrer and discuss the assessment findings in the multi-disciplinary team (MDT) handover. When out of hours’ assessments are completed and the decision is to admit the service user the decision to admit is discussed with the on–call specialist registrar and on-call consultant psychiatrist to agree an appropriate safety and admission plan.
That the role of CATT to look for alternatives to admission may risk CATT discharging patients who would benefit from admission and risk the repeat of making treatment plans that had recently failed such as in this case. Rather than looking for admission alternatives being a core function, should CATT rather better be focussed on the best treatment plan for the individual patient and thus admission being viewed as a clear option where appropriate rather a last resort, as it often appears to be presented in such cases before the coroner.
The Trust expects all assessments, including for CATT, to take into account individual circumstances and clinical need, recognising that CATT may not be suitable for some service users and there are a range of other crisis pathways and interventions available to all patients, including acute inpatient admission under the Mental Health Act 1983, or as a voluntary patient. The service user’s choice of obtaining treatment at hospital or at home should be also taken into account which is a key part of adhering to the least restrictive option for service users.
Home treatment by definition is an appropriate alternative to hospital admission for working age and older adults with severe mental illness (e.g. schizophrenia, manic depressive disorders, severe depressive disorder) with an acute psychiatric crisis of such severity that, without the involvement of a CATT, hospitalisation would be necessary. Such patients should be willing to receive home treatment which can be safely provided in their home environment. Treatment
interventions, procedures and protocols will be evidence-based and compliant with the Quality Network for Crisis Resolution and Home Treatment Teams (QN-CRHTT) standards and NICE (National Institute of Clinical Excellence) guidelines
1 Guidance | Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services | Guidance | NICE
We are confident that these principles are consistent with best practice, for example the core principles identified within The Independent Review of the Mental Health Act 1983 chaired by Professor Sir Simon Wessely “Modernising the Mental Health Act”, published in December 2018
– which emphasised “Choice and Autonomy”, a principle of “Least Restriction… and that less restrictive alternatives must always be considered”, a “Therapeutic Benefit” principle, and a principle of treating “the Person as an Individual”.
That the provision of care co-ordinators be increased and improved so that patients who require them have ready access at the time of need and are not placed on a waiting list.
The Trust received significant investment in 2020-21 to implement a more flexible model of community-based mental healthcare for adults and older adults with a wide range of mental health needs based upon the NHS England Community Mental Health Framework for Adults and Older Adults and the NHS England Long Term Plan. In recent years, concerns about the use of the Care Programme Approach (CPA) in community mental health services have been raised and a new approach is developing. NHS England and NHS Improvement have published a formal statement which states that community mental health services should move away from CPA while meeting core principles of care.
Within the MINT model of care, we aim to support individuals who require long term mental health support with coordinated care by a named clinician, and that this clinician is appropriately skilled to provide the interventions recommended in the coproduced care plan. We also recognise (in line with the national specification for community mental health services, upon which MINT teams have been designed) that some individuals will receive ‘care coordination’ for only a time limited period in line with their needs.
As part of the implementation of this we have developed and are deploying standardized protocols, enhanced documentation practices, and regular training sessions to promote effective coordinated care by any named clinician involved in patient care. These measures aim to mitigate potential risks and ensure that patients receive the highest quality of care in a coordinated manner.
We acknowledge that the implementation of the MINT model in West London NHS Trust has faced a number of challenges, not entirely within the direct control of the Service, and this was recognised in a CQC inspection in 2022. In response to this, the Trust has a robust action plan in train which is addressing the areas of concern highlighted and progress against this is monitored at Board level.
MINT, in line with the community mental health framework, has brought about expanding the roles that support service users in the community with their mental health. This includes occupational therapists, link workers, peer support workers, vocational rehabilitation services, social workers, mental health practitioners and community mental health nurses. This framework provides holistic biopsychosocial model of care and treatment to mental health service users.
We head up ongoing staffing recruitment drives to recruit local and international staff. We have put significant resource into growing our own workforce through apprenticeship posts in allied health professions, nursing and social work apprenticeships. West London have also met staffing needs through international recruitment of appropriate mental health workers. We are working closely with staff and team managers to ensure we are retaining staff through our wellbeing and development opportunities.
That patients to be discharged by CATT, as well as patients to be admitted are discussed with the on-call psychiatrist so that plans may be reviewed, and thus the risk of not admitting patients who would benefit from and/ or require admission such as Mr Khala, are less likely to be discharged inappropriately.
As above, and in line with the Royal College of Psychiatrists Guidance, wherever feasible, every effort should be made to undertake a joint assessment with the referrer.
CATT team members (and other non-medical and trainee medical staff undertaking assessments of patients in crisis) have been reminded that they can request senior discussion with On-call Consultants irrespective of decision to admit, to offer an admission to a home-based care pathway or to discharge. It is the practice within CATT for daily multidisciplinary meetings (MDT) to be held, which play a vital part in overseeing a safe and effective service. The ethos of the MDT is for an inclusive and constructive discussion around the service user where the views of all professionals, regardless of their banding or role are valued and facilitated. Routine MDT meetings always include a consultant psychiatrist.
Service users, including those who are being admitted to a home based treatment pathway, or who are being discharged from CATT, are routinely discussed. Cases of concern (red on the local traffic light system) and new referrals are discussed on a daily basis. All cases must be discussed in MDT at least twice weekly. The focus of MDT discussions is around the formulation of the case, any changes to risk, the progress of the individual, the response to treatment, the indication for and the engagement with allied health professionals, barriers to discharge and likely timing of transfer of care to routine pathways for ongoing support. The MDT will also actively monitor the operational aspects of adequate record keeping (e.g. clinical coding, contemporary risk assessment, up-to-date care plan and physical health checks). Formal documentation of handover is entered into the clinical records contemporaneously and captures the above, as well as all immediate care actions (e.g. frequency of visits, outstanding actions). When using the traffic light system; Red, Amber, Green, (RAG) all new cases and cases of concern are placed on the “Red” caseload until sufficient contact has been made to allow for a reduction to “Amber”. This would not usually be on first contact with the service user. In cases where the risk has increased this should be captured with an escalation in the RAG rating. Changes in RAG should be made through MDT discussion. Planning for the withdrawal of home treatment begins early, the expectation is that the service user will have progressed through the traffic light process (and achieved “green” status) and the identified outcomes will have been met. The decision to discharge the service user from the CATT should be made after consultation between CATT staff, the community team, the care co- ordinator, medical staff, carers and the patient themselves. RAG rating:
RED:
• Patient assessed and accepted by CATT and agreeing to work with us
• Anyone within the first three days of being under the team
• Anyone considered to be requiring review of decision to offer home treatment in favour of arranging admission
• Patients awaiting Mental Health Act assessment
• Patients still in early aspect of their recovery and experiencing predominant symptoms of a mental disorder or crisis which is yet to respond to intervention AMBER: Everyone else GREEN:
• Aims of the CATT have been met
• Referrals have been completed to other agencies
• Understanding reached as to why the crisis occurred and strategies in place to mitigate future episodes
• Patient ready for transfer or care back to primary care or MINT (or other longer term support services)
• Uncomplicated Clozapine titrations or community based ECT
That where psychiatric teams differ in their assessments such as CATT and Psychiatric Liaison, as occurred here, patients are not discharged until opinion is sort from the on-call consultant and re-discussion taken place between those with differing views.
The Clinical Directors, Service Managers, Clinical Leads and Team Managers responsible for CATT and Psychiatric Liaison are in regular discussion about interface matters between their services and cases of concern are reviewed regularly. All are in agreement that it is best practice for assessments to take place and decisions to be made jointly wherever possible, and work is ongoing to embed a culture of ‘trusted assessment’ between the teams in respect of decisions to admit to beds or home-based treatment pathways under CATT.
Where a joint assessment and decision is not possible, the person(s) completing the assessment will communicate and discuss and agree the findings with the referrer, service user and within the multi-disciplinary team (MDT) handover, which involves consultants. The availability of in-hours and on-call psychiatric registrar (approved under section 12 of the Mental Health Act) and consultant) to provide guidance or supplementary assessment in the event of clinical disagreement has been re-communicated to teams, and will be incorporated into work we are doing with partners across North West London to implement clinical escalation protocols.
That expertise covering neurodevelopmental disorders such as ASD and ADHD is available as part of MINT. In July 2022, the Health and Care Act 2022 introduced the requirement that CQC regulated service providers ensure their staff receive training on learning disability and autism which is appropriate to the person’s role. The Part 1/tier 1 Oliver Mc Gowan training on Learning Disability and Autism has been made mandatory for all clinical staff in West London NHS Trust. The content has been developed with reference to tier 1 and tier 2 capabilities contained within the Core Capabilities Framework for Supporting Autistic People and Core Capabilities Framework for Supporting People with a Learning Disability. Both frameworks are nationally recognised and have been developed to provide a focus on the skills, knowledge and behaviours expected for staff offering services to autistic people or people with a learning disability. All staff that require a general awareness of this support for autistic people or people with a learning disability are advised they need to cover all of the tier 1 capabilities in the framework. Part 2 of the training is being developed within West London NHS Trust and will be launched in 2024. In terms of specialised ASD support in West London NHS Trust, Acute Mental Health Services benefits from an Autism Liaison Service which can be contacted for consultative input for any service users with a diagnosis of Autism. Plans are in place to further expand this service for service users within Ealing MINT with a diagnosis of autism or suspected autism, with a view of this being rolled out to other boroughs, if successful. This will also involve consultative input to 16- 25 teams. ADHD assessment and treatment is not commissioned or provided as part of the West London Trust. Service users of the boroughs of Ealing, Hammersmith and Fulham and Hounslow are referred to other services commissioned by North West London Integrated Care Board. They offer diagnosis and treatment for adults with ADHD. Once treatment is stabilised, prescribing and monitoring will be transferred back to the GP. They currently do not offer psychological interventions for the treatment of ADHD in our clinic. The wait time for assessment is currently 18-24 months. GP’s are responsible for making ADHD referrals directly to the other providers if they believe the service user meets the threshold for assessment and on completion of a screening assessment. WLT SPA (single point of access) provides additional support in forwarding all ADHD assessment requests to the other providers directly.
WLT is in discussion with North West London ICB to develop a local commissioned pathway for ADHD assessment and intervention. I hope that we have been able to provide you with assurance that we have reviewed and sought to address the concerns that you have raised. We are committed to continuously improving our services to ensure patient safety, experience and the delivery of high-quality care in line with best practice. Please do not hesitate to contact me should you have any questions or queries.