Lancashire and South Cumbria NHS Foundation Trust
NHS / Health Body
Action Planned
Lancashire and South Cumbria NHS Foundation Trust is auditing documentation compliance weekly, monitoring Mental Health Act documentation daily, and has developed an inpatient safety matrix including Section 17 Leave. They are rolling out a pre and post leave assessment form and plan to undertake a rapid improvement event. (AI summary)
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Dear Neil
Re: Prevention of Future Death Report Following Inquest into the Death of David Clark
Please find a response to the regulation 28 you issued to the Trust dated 06 February 2020 along with the action plan. The action the Trust has taken in relation to the matters of concern you raised are summarised below:
1. That documentation in relation to leave was not completed fully and incorrect forms used.
Unit Level o The Orchard WM and Matron are auditing compliance with Safety & Security (SaS) documentation weekly (attachment 2).
Trust Level o Monitoring and reporting of Mental Health Act documentation - The Mental Health Law Team monitor the status of all detained patients daily and send a daily status report to each ward for review. The report is sent to Responsible Clinicians, Matrons, Ward Mangers, Deputy Ward Managers, Nursing staff, Medical Secretaries, Pharmacy and any additional staff as appropriate (attachment 3).
o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.
o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021.
o A practice note has been issued to Ward Managers, Lead Nurses and Doctors reminding them of their accountability in following MHA documentation and Trust policy (attachment 5).
2. That the AWOL procedure was not followed.
Unit Level: o The Trust policy and procedure for AWOL has been updated and in line with this staff agree with service users the time they will return from leave. If the service user has not returned by the agreed time AWOL procedures are implemented (SaS documentation, attachment 6).
o AWOL procedure has been discussed at the Orchard In-Patient Development days and followed up with email to ensure all staff understand new process (email re AWOL procedures, attachment 7).
o The Head of Nursing has completed a supervision session with the Ward Manager and Matron. Trust Level: o The Trust policy and procedure for AWOL has been reviewed and reflects the learning from the investigation (attachment 8).
3. That a handover was not undertaken between Safety and Security workers.
Unit Level: o The SaS handover has been reviewed and new forms disseminated which include the SaS worker agreeing that the handover has taken place. The SaS paperwork is audited weekly and demonstrates that handovers are consistently being undertaken (SaS handover documentation, attachment 9).
Trust Level: o Learning regarding the handover has been shared with the rest of the Trust. SaS handover is part of the Trust’s Safety and Security Procedure and an audit is planned for Q1 2020/21 to ensure that the wards are using the correct documentation and this is being completed appropriately
o A rapid improvement event to review the role and to revise documentation, if required, was due to be undertaken in March 2020 however this has been paused due to COVID 19; the new target date is July 2020.
4. That there was a lack of training on policy and procedure.
Unit Level: o In-Patient Development days included discussion regarding AWOL procedures (follow up email, attachment 7).
o All new staff are inducted to the SaS procedures (attachment 10)
Trust Level: o Ward Managers Task & Finish Group established which includes looking at Policy and Practice. o Clinical risk assessment training - A practice note was sent out trust-wide on 31/01/2020 clarifying the training expectations of all mental health staff. Clinical risk training has now been made mandatory for all clinical staff delivering mental health services (attachment 11).
5. That there remains outstanding an appropriately sufficient action plan.
The Trust acknowledges that further work needed to be undertaken to the action plan to reflect the additional views of you and Mr Clark’s family. The strengthened action plan is attached. The Trust Quality Committee will oversee this action plan going forward.
Furthermore 2 additional actions that have been undertaken:
• A debrief with the staff involved in the care of Mr Clark following learning from the inquest on 12 February 2020 has been undertaken.
• Learning in relation to this serious incident and the concerns regarding the care of Mr Clark have been shared with the Ward Manager and the Matron in supervision on 19 February 2020 by the Head of Nursing, Mental Health.
I am mindful of the impact of the Trust’s response to COVID-19, in the Trusts ability to complete actions in a timely manner, please let me know if you require any further information.
Re: Prevention of Future Death Report Following Inquest into the Death of David Clark
Please find a response to the regulation 28 you issued to the Trust dated 06 February 2020 along with the action plan. The action the Trust has taken in relation to the matters of concern you raised are summarised below:
1. That documentation in relation to leave was not completed fully and incorrect forms used.
Unit Level o The Orchard WM and Matron are auditing compliance with Safety & Security (SaS) documentation weekly (attachment 2).
Trust Level o Monitoring and reporting of Mental Health Act documentation - The Mental Health Law Team monitor the status of all detained patients daily and send a daily status report to each ward for review. The report is sent to Responsible Clinicians, Matrons, Ward Mangers, Deputy Ward Managers, Nursing staff, Medical Secretaries, Pharmacy and any additional staff as appropriate (attachment 3).
o Section 17 leave - An inpatient safety matrix which will audit this practice at ward level includes a section of Section 17 Leave. The audit tool has been developed and agreed with Ward Managers (attachment 4). However implementation has been paused due to COVID 19 (new target date September 2020) once implemented compliance will be reported on a monthly basis through the Senior Leadership Team.
o Work has been undertaken to the new electronic care record RiO which now includes a pre and post leave assessment form. This is in place in Secure Services and is to be rolled out across the Trust by March 2021.
o A practice note has been issued to Ward Managers, Lead Nurses and Doctors reminding them of their accountability in following MHA documentation and Trust policy (attachment 5).
2. That the AWOL procedure was not followed.
Unit Level: o The Trust policy and procedure for AWOL has been updated and in line with this staff agree with service users the time they will return from leave. If the service user has not returned by the agreed time AWOL procedures are implemented (SaS documentation, attachment 6).
o AWOL procedure has been discussed at the Orchard In-Patient Development days and followed up with email to ensure all staff understand new process (email re AWOL procedures, attachment 7).
o The Head of Nursing has completed a supervision session with the Ward Manager and Matron. Trust Level: o The Trust policy and procedure for AWOL has been reviewed and reflects the learning from the investigation (attachment 8).
3. That a handover was not undertaken between Safety and Security workers.
Unit Level: o The SaS handover has been reviewed and new forms disseminated which include the SaS worker agreeing that the handover has taken place. The SaS paperwork is audited weekly and demonstrates that handovers are consistently being undertaken (SaS handover documentation, attachment 9).
Trust Level: o Learning regarding the handover has been shared with the rest of the Trust. SaS handover is part of the Trust’s Safety and Security Procedure and an audit is planned for Q1 2020/21 to ensure that the wards are using the correct documentation and this is being completed appropriately
o A rapid improvement event to review the role and to revise documentation, if required, was due to be undertaken in March 2020 however this has been paused due to COVID 19; the new target date is July 2020.
4. That there was a lack of training on policy and procedure.
Unit Level: o In-Patient Development days included discussion regarding AWOL procedures (follow up email, attachment 7).
o All new staff are inducted to the SaS procedures (attachment 10)
Trust Level: o Ward Managers Task & Finish Group established which includes looking at Policy and Practice. o Clinical risk assessment training - A practice note was sent out trust-wide on 31/01/2020 clarifying the training expectations of all mental health staff. Clinical risk training has now been made mandatory for all clinical staff delivering mental health services (attachment 11).
5. That there remains outstanding an appropriately sufficient action plan.
The Trust acknowledges that further work needed to be undertaken to the action plan to reflect the additional views of you and Mr Clark’s family. The strengthened action plan is attached. The Trust Quality Committee will oversee this action plan going forward.
Furthermore 2 additional actions that have been undertaken:
• A debrief with the staff involved in the care of Mr Clark following learning from the inquest on 12 February 2020 has been undertaken.
• Learning in relation to this serious incident and the concerns regarding the care of Mr Clark have been shared with the Ward Manager and the Matron in supervision on 19 February 2020 by the Head of Nursing, Mental Health.
I am mindful of the impact of the Trust’s response to COVID-19, in the Trusts ability to complete actions in a timely manner, please let me know if you require any further information.