North East London NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust has hired agency staff on a semi-permanent basis, approved budget for reduced caseloads, provided training and supervision for staff, and amended the electronic admission checklist to include prompts for obtaining collateral information from other Trusts. (AI summary)
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Dear Miss Persaud
Re: Inquest Touching upon the death of David Ayotunde Walker
I refer to your letter dated 21st October 2021 and the enclosed Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.
Concerns At the conclusion of the hearing into the death of David Ayotunde Walker, you expressed concern on the matters below as follows:
1. Between end of May 2020 to November 2020, Mr Walker was allocated four different care coordinators. There was evidence that only one of these care coordinators established a therapeutic relationship with Mr Walker. Many of the care coordinators were locum staff.
2. On admission to hospital on the 10th November 2020, no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker. Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information, that should have been available to the North East London Foundation Trust team. There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought.
We have taken the following actions in relation to your concerns:
High turnover of care coordinators and only one formed a therapeutic relationship To act on the concerns immediately, agency staff have been sourced to support the Waltham Forest Community Recovery Teams. These staff have been recruited on a semi-permanent basis, whilst staff recruitment is taking place.
PRIVATE AND CONFIDENTIAL
Miss N Persaud Her Majesty’s Coroner East London Walthamstow Coroners Court
Chair: Chief Executive:
Approval has been given for the service to recruit over the establishment budget to allow for reduced caseloads, so care coordinators can build relationships with patients.
All staff, including temporary staff will be supported with training during induction and will be provided clinical supervision, to ensure that they are appropriately managing patients’ identified risks and are building relationship with patients they work with.
All clinical supervisors will be provided with a template / prompt that highlights the key elements of care coordination such as relationship building, risk management and caseload management, so staff are supported in their work with patients.
The service has explored new ways of delivering care to ensure all patients on the caseload are appropriately managed. The new proposal will introduce a high intensity and lower intensity caseload management model, which will include risk management at every level with senior staff supervision.
No evidence collateral healthcare information sought Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.
I would like to take this opportunity to thank you for raising your concerns as part of the inquest. We find the learning from inquests extremely valuable and are very grateful for your comprehensive investigations, which benefit not only the families of the deceased, but also the Trust and its current & future service users.
Re: Inquest Touching upon the death of David Ayotunde Walker
I refer to your letter dated 21st October 2021 and the enclosed Regulation 28 report, issued in respect of your concerns regarding the risk of future deaths.
Concerns At the conclusion of the hearing into the death of David Ayotunde Walker, you expressed concern on the matters below as follows:
1. Between end of May 2020 to November 2020, Mr Walker was allocated four different care coordinators. There was evidence that only one of these care coordinators established a therapeutic relationship with Mr Walker. Many of the care coordinators were locum staff.
2. On admission to hospital on the 10th November 2020, no steps were taken to seek collateral information from other Trusts involved in the care of Mr Walker. Mr Walker had been under the care of East London Foundation Trust in July and August 2020 and this Trust held a great deal of vital risk information, that should have been available to the North East London Foundation Trust team. There was no evidence that the admission check list included the requirement for collateral healthcare information to be sought.
We have taken the following actions in relation to your concerns:
High turnover of care coordinators and only one formed a therapeutic relationship To act on the concerns immediately, agency staff have been sourced to support the Waltham Forest Community Recovery Teams. These staff have been recruited on a semi-permanent basis, whilst staff recruitment is taking place.
PRIVATE AND CONFIDENTIAL
Miss N Persaud Her Majesty’s Coroner East London Walthamstow Coroners Court
Chair: Chief Executive:
Approval has been given for the service to recruit over the establishment budget to allow for reduced caseloads, so care coordinators can build relationships with patients.
All staff, including temporary staff will be supported with training during induction and will be provided clinical supervision, to ensure that they are appropriately managing patients’ identified risks and are building relationship with patients they work with.
All clinical supervisors will be provided with a template / prompt that highlights the key elements of care coordination such as relationship building, risk management and caseload management, so staff are supported in their work with patients.
The service has explored new ways of delivering care to ensure all patients on the caseload are appropriately managed. The new proposal will introduce a high intensity and lower intensity caseload management model, which will include risk management at every level with senior staff supervision.
No evidence collateral healthcare information sought Our inpatient services have sent communication to all inpatient staff, which clearly outlines how staff can access ELFT records through an external shared link on the patient electronic record. As part of the Admission process, the electronic Admission checklist / audit section on RIO, will be amended to include a section which asks whether a patient is known to another Trust and prompts staff to obtain collateral information, as part of the standard admission process. A further reminder will be sent to all medical and nursing staff to ensure that this is obtained at the earliest opportunity.
I would like to take this opportunity to thank you for raising your concerns as part of the inquest. We find the learning from inquests extremely valuable and are very grateful for your comprehensive investigations, which benefit not only the families of the deceased, but also the Trust and its current & future service users.