Surrey and Borders Partnership NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust will update its CPA policy and Acute Care Services Operational Protocol to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge. The CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust. (AI summary)
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Dear Ms Topping
Inquest touching the death of Mary Gwanyama Regulation 28 Report to Prevent Future Deaths (PFD) Surrey and Borders Partnership NHS Foundation Trust’s Response
I am writing in response to your Regulation 28 Report to Prevent Future Deaths, hereafter referred to as the ‘PFD’, issued on the 21st April 2021 following the inquest touching upon the death of Mary Gwanyama. I would like to thank you for investigating this matter so thoroughly and for bringing the matters of concern you have to my attention. In the PFD, you identified five key areas of concern that had arisen from the inquest. I will address each one in turn below, with details of action we have taken or plan to take to address the issues.
1. Discharge planning and homeless patients In the PFD, you said that Ms Gwanyama was discharged from the Abraham Cowley Unit without a discharge planning meeting taking place in circumstances where there was no confirmation that she was eligible for housing provision and with no plan as to what would happen after the Travel Lodge placement ended. You identified that there is no policy in place which prevents a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit.
The Trust accepts that a discharge CPA meeting was not held prior to Ms Gwanyama being discharged from the Abraham Cowley Unit and, given she was homeless at the time and her housing situation was uncertain, such a meeting should have taken place. Accordingly, the Trust’s CPA policy and Acute Care Services Operational Protocol will be updated to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge.
Whilst we fully appreciate your concerns about no policy being in place, it is unfortunately not possible for the Trust to have a policy in place that prevents patients from being discharged into homelessness from our inpatient units. The onus is our duty to engage appropriately with and make the statutory referral to District and Borough Councils’ Housing Departments to find a homeless person settled accommodation. The pre-discharge planning would also involve our homelessness 16 June 2021
2
‘Duty to Refer’ to the District and Borough Housing Departments to include them in the discharge CPA meeting. The discharge CPA meeting must be attended by all the relevant professionals in a multi-agency approach.
2. Medical reviews In the PFD, you said that Ms Gwanyama was not subject to a medical review from the 28th March 2018 to the 26th May 2018 and that there is no policy in place which mandates when or if a patient should be subject to face to face review by a Consultant Psychiatrist after discharge from the acute unit.
Senior clinicians within the Trust have considered this issue, and our need to be agile to respond to people with differing needs. For that reason, the decision as to whether a person under HTT requires a medical review is risk and needs led within the context of a multi-disciplinary approach which includes a Consultant Psychiatrist. (It should however be noted that it is already mandated that a patient must have follow up with community services within 72 hours of discharge from hospital, within an overall multi- disciplinary approach.)
As explained in letter dated 24th March 2021, consideration is given at the daily HTT handover meetings, where there is a doctor present, as to how to best meet people’s needs within their overall care plan. It should also be noted that in addition to the handover meetings, each HTT holds weekly clinical reviews attended by the full multi-disciplinary team. During this review, each person on the HTT caseload is systematically reviewed to determine the appropriateness of the existing care plan, risk management plans including medical review and discharge plans.
To strengthen our approach to risk assessments and risk management, our HTT is now also going to use the SBAR (Situation, Background, Assessment and Recommendations) which will support evidence-based multi-disciplinary review. The HTT Operational Policy will be updated to reflect this and strengthen the documentation and decision making regarding medical reviews.
3. Risk assessments In the PFD, you said that no formal risk assessment was undertaken of Ms Gwanyama and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit. Further, that the informal risk assessments undertaken in the Abraham Cowley Unit prior to her discharge failed to place any weight on the impact on Ms Gwanyama of a discharge with an inchoate plan for her housing and arrived at an incorrect assessment of her risk. The risk assessments were not sufficiently rigorous, and evidence based.
In letter dated 24th March 2021, he outlined the significant improvements that have been made regarding risk assessments since Ms Gwanyama’s death. In particular, he highlighted that a new risk assessment node has been developed on SystmOne, which was rolled out in October 2019 together with a training package focussed on:
a. Understanding risk assessment,
3
b. Understanding risk factors (dynamic and static),
c. How to make the best risk assessment,
d. The link between risk assessment and care plans, and
e. How to understand SystmOne’s new risk assessment tool.
In addition to this, in April 2021 we recruited a Lead Nurse for Quality and Practice, specifically for inpatient services. Part of her role is around ensuring the quality of our inpatient care plans and risk assessments and identifying areas for improvement. We have also delivered a significant amount of Suicide Prevention Training across our clinical services.
Weekly audits of risk assessments and care plans are conducted by Senior Matrons in ACU and Farnham Road Hospital. We also have in place a discharge checklist, to include whether a risk assessment has been completed prior to discharge. These checklists have been in place for some time; however, they are not routinely audited. We are therefore going to add to the weekly audits a review of the discharge checklist, to ensure they are being completed appropriately and the learning loop closed.
We are also reviewing our Risk Assessment and Management Policy to support and guide our staff in how to be confident in risk assessments risk and management.
4. Premature discharge In the PFD, you said that Ms Gwanyama was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient the time had been taken to observe the effectiveness of her prescribed medication. You said this appeared in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. Further, that her care coordinator was not involved in the discharge planning.
The Trust considers that this issue will also be addressed by the change in policy and practice that will require a discharge CPA meeting to take place prior to a homeless person being discharged from the ward, with all the relevant professionals involved.
5. Community based treatment In the PFD, you said the fact that Ms Gwanyama was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. You said that there is no policy which governs how often a patient should be seen once in the community to review the risk assessment and monitor compliance with medication.
Since Ms Gwanyama’s death, our community teams have implemented the SBAR process during their MDT reviews to RAG rate patients and determine how often they should be seen in the community based on their assessed risk. People’s risk changes and people will move through the different levels of risk-based contact. If a patient is rated Red, this requires weekly contact. If a patient is rated Amber, this requires fortnightly contacted. If a patient is rated Green, then the contact ranges from monthly
4
appointments to annual outpatient appointments – the level of contact to be determined by the MDT.
Our CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust. Our policy is going to ensure that, where a patient is in transition to a neighbouring Trust, we will still provide face to face or telephone/virtual contact as we would base this on the SBAR/RAG rating and identified frequency of need, until the transfer process is complete. If the patient is residing in an area which is relatively local to the team and easily accessible by travel, then we would expect the team to travel to visit the patient if necessary.
Further, where a patient’s needs are considered urgent, then the CMHRS will be guided to make a referral to the patient’s local HTT/Crisis service (as this does not require a CPA transfer), to ensure their immediate care needs are met and risks assessed and appropriately supported.
I attach the Trust’s action plan that has been devised, to monitor and track our improvement work. The delivery of the plan will be monitored through our established Inpatient Improvement Board, chaired by the Chief Operating Officer and Chief Nursing Officer. Regular briefings will be made to myself, as Chief Executive and the Executive Directors.
On behalf of the Trust, I would like to offer our sincere condolences to Ms Gwanyama’s family for their loss and hope that our actions outlined above assures you and them that we have learnt and continue to learn from her death.
Inquest touching the death of Mary Gwanyama Regulation 28 Report to Prevent Future Deaths (PFD) Surrey and Borders Partnership NHS Foundation Trust’s Response
I am writing in response to your Regulation 28 Report to Prevent Future Deaths, hereafter referred to as the ‘PFD’, issued on the 21st April 2021 following the inquest touching upon the death of Mary Gwanyama. I would like to thank you for investigating this matter so thoroughly and for bringing the matters of concern you have to my attention. In the PFD, you identified five key areas of concern that had arisen from the inquest. I will address each one in turn below, with details of action we have taken or plan to take to address the issues.
1. Discharge planning and homeless patients In the PFD, you said that Ms Gwanyama was discharged from the Abraham Cowley Unit without a discharge planning meeting taking place in circumstances where there was no confirmation that she was eligible for housing provision and with no plan as to what would happen after the Travel Lodge placement ended. You identified that there is no policy in place which prevents a vulnerable patient being discharged into homelessness from the Abraham Cowley Unit.
The Trust accepts that a discharge CPA meeting was not held prior to Ms Gwanyama being discharged from the Abraham Cowley Unit and, given she was homeless at the time and her housing situation was uncertain, such a meeting should have taken place. Accordingly, the Trust’s CPA policy and Acute Care Services Operational Protocol will be updated to reflect that anyone who is homeless must have a CPA discharge meeting on the inpatient ward prior to discharge.
Whilst we fully appreciate your concerns about no policy being in place, it is unfortunately not possible for the Trust to have a policy in place that prevents patients from being discharged into homelessness from our inpatient units. The onus is our duty to engage appropriately with and make the statutory referral to District and Borough Councils’ Housing Departments to find a homeless person settled accommodation. The pre-discharge planning would also involve our homelessness 16 June 2021
2
‘Duty to Refer’ to the District and Borough Housing Departments to include them in the discharge CPA meeting. The discharge CPA meeting must be attended by all the relevant professionals in a multi-agency approach.
2. Medical reviews In the PFD, you said that Ms Gwanyama was not subject to a medical review from the 28th March 2018 to the 26th May 2018 and that there is no policy in place which mandates when or if a patient should be subject to face to face review by a Consultant Psychiatrist after discharge from the acute unit.
Senior clinicians within the Trust have considered this issue, and our need to be agile to respond to people with differing needs. For that reason, the decision as to whether a person under HTT requires a medical review is risk and needs led within the context of a multi-disciplinary approach which includes a Consultant Psychiatrist. (It should however be noted that it is already mandated that a patient must have follow up with community services within 72 hours of discharge from hospital, within an overall multi- disciplinary approach.)
As explained in letter dated 24th March 2021, consideration is given at the daily HTT handover meetings, where there is a doctor present, as to how to best meet people’s needs within their overall care plan. It should also be noted that in addition to the handover meetings, each HTT holds weekly clinical reviews attended by the full multi-disciplinary team. During this review, each person on the HTT caseload is systematically reviewed to determine the appropriateness of the existing care plan, risk management plans including medical review and discharge plans.
To strengthen our approach to risk assessments and risk management, our HTT is now also going to use the SBAR (Situation, Background, Assessment and Recommendations) which will support evidence-based multi-disciplinary review. The HTT Operational Policy will be updated to reflect this and strengthen the documentation and decision making regarding medical reviews.
3. Risk assessments In the PFD, you said that no formal risk assessment was undertaken of Ms Gwanyama and no risk assessment was recorded in her records prior to her discharge from the Abraham Cowley Unit. Further, that the informal risk assessments undertaken in the Abraham Cowley Unit prior to her discharge failed to place any weight on the impact on Ms Gwanyama of a discharge with an inchoate plan for her housing and arrived at an incorrect assessment of her risk. The risk assessments were not sufficiently rigorous, and evidence based.
In letter dated 24th March 2021, he outlined the significant improvements that have been made regarding risk assessments since Ms Gwanyama’s death. In particular, he highlighted that a new risk assessment node has been developed on SystmOne, which was rolled out in October 2019 together with a training package focussed on:
a. Understanding risk assessment,
3
b. Understanding risk factors (dynamic and static),
c. How to make the best risk assessment,
d. The link between risk assessment and care plans, and
e. How to understand SystmOne’s new risk assessment tool.
In addition to this, in April 2021 we recruited a Lead Nurse for Quality and Practice, specifically for inpatient services. Part of her role is around ensuring the quality of our inpatient care plans and risk assessments and identifying areas for improvement. We have also delivered a significant amount of Suicide Prevention Training across our clinical services.
Weekly audits of risk assessments and care plans are conducted by Senior Matrons in ACU and Farnham Road Hospital. We also have in place a discharge checklist, to include whether a risk assessment has been completed prior to discharge. These checklists have been in place for some time; however, they are not routinely audited. We are therefore going to add to the weekly audits a review of the discharge checklist, to ensure they are being completed appropriately and the learning loop closed.
We are also reviewing our Risk Assessment and Management Policy to support and guide our staff in how to be confident in risk assessments risk and management.
4. Premature discharge In the PFD, you said that Ms Gwanyama was prematurely discharged from the Abraham Cowley Unit suffering from severe depression and before sufficient the time had been taken to observe the effectiveness of her prescribed medication. You said this appeared in part to have been because the imperative to discharge patients took precedence over adequate discharge planning and assessment. Further, that her care coordinator was not involved in the discharge planning.
The Trust considers that this issue will also be addressed by the change in policy and practice that will require a discharge CPA meeting to take place prior to a homeless person being discharged from the ward, with all the relevant professionals involved.
5. Community based treatment In the PFD, you said the fact that Ms Gwanyama was placed out of area made it difficult for her to participate in community based treatment and significantly impacted on the ability of her care coordinator and community psychiatrist to support her. You said that there is no policy which governs how often a patient should be seen once in the community to review the risk assessment and monitor compliance with medication.
Since Ms Gwanyama’s death, our community teams have implemented the SBAR process during their MDT reviews to RAG rate patients and determine how often they should be seen in the community based on their assessed risk. People’s risk changes and people will move through the different levels of risk-based contact. If a patient is rated Red, this requires weekly contact. If a patient is rated Amber, this requires fortnightly contacted. If a patient is rated Green, then the contact ranges from monthly
4
appointments to annual outpatient appointments – the level of contact to be determined by the MDT.
Our CMHRS Operational Policy is going to be updated, with specific attention to the ‘transition’ process to another Trust. Our policy is going to ensure that, where a patient is in transition to a neighbouring Trust, we will still provide face to face or telephone/virtual contact as we would base this on the SBAR/RAG rating and identified frequency of need, until the transfer process is complete. If the patient is residing in an area which is relatively local to the team and easily accessible by travel, then we would expect the team to travel to visit the patient if necessary.
Further, where a patient’s needs are considered urgent, then the CMHRS will be guided to make a referral to the patient’s local HTT/Crisis service (as this does not require a CPA transfer), to ensure their immediate care needs are met and risks assessed and appropriately supported.
I attach the Trust’s action plan that has been devised, to monitor and track our improvement work. The delivery of the plan will be monitored through our established Inpatient Improvement Board, chaired by the Chief Operating Officer and Chief Nursing Officer. Regular briefings will be made to myself, as Chief Executive and the Executive Directors.
On behalf of the Trust, I would like to offer our sincere condolences to Ms Gwanyama’s family for their loss and hope that our actions outlined above assures you and them that we have learnt and continue to learn from her death.