Leicestershire Partnership NHS Trust
NHS / Health Body
Action Planned
The Trust acknowledges concerns about the Crisis team's service and states that it has received additional investment of £962k to enhance the service. An audit reviewing patients open to Crisis Services between September 2018 and September 2019 will be completed by end of November 2019 to establish the band of staff and the number of visits they have completed. Additionally, the Trust will review local guidance for staff on pre-visit preparation. (AI summary)
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Dear Mrs Brown
Re: Kim Beverley Morris
Further to your report dated 28 August 2019, in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, I offer the following response.
We have investigated the matters of concern that have arisen during the course of the inquest of Mrs Kim Beverley Morris. Leicestershire Partnership NHS Trust takes these matters very seriously and I hope that you and Mrs Morris’s family will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again.
The matters of concern you have raised are as follows:
The Crisis team is not offering a service that is suitable to support such high risk individuals as Mrs Morris and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care.
Service Response We acknowledge your concerns that we are not able to offer a service to support such high risk individuals, and would like to reassure you that, as a Trust we take these concerns seriously. We have received additional investment to further enhance the Crisis Service, to enable us to improve the service we deliver.
Our additional investment of £962k will further enhance the staffing in the Crisis Service by recruiting 8.5 whole time equivalent registered staff and 12.6 whole time Direct dial:
Email: fra
Our Ref: KM/REG28/
15 October 2019
By email to Leicester.coroner@leicester.gov.uk Lydia Brown Assistant Coroner Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester LE1 9BG
Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ Chair: Cathy Ellis Chief Executive: Angela Hillery We are a smoke-free Trust. NHS organisations now use 100 per cent recycled paper as part of our sustainability commitment View our privacy notice at www.leicspart.nhs.uk/_Aboutus-Whatwedowithyourinformationprivacynotice.aspx
equivalent unregistered staff. These additional staff will increase the capacity of the team, and alleviate some of the known high demand and pressures. A full time Psychologist is also being recruited to support psychological interventions and will provide supervision and support to staff in the team. We are expecting that this additional support will be fully in place by the end February 2020.
The concerns specifically related too:
1. There were numerous visits and telephone encounters with many different individuals and the role of the key worker did not reduce these.
Service response
We are reviewing the Standard Operating Procedure (SOP) for the Keyworker role, and their responsibilities within the Crisis team. This review will ensure that we clearly define the expectations for the Keyworker role for Registered Nurses, Mental Health Practitioners and Health Care Support Workers employed in the team. The SOP will confirm the responsibilities for assessment, ongoing care planning, monitoring of service users and discharge planning. Clear information about the role of the Keyworker will be available to patients, families and carers by the end of November 2019.
2. It was accepted that Mrs Morris be referred to a Community Psychiatric Nurse to continue her engagement and continuity of care prior to discharge, but no contact was made prior to her discharge, potentially leaving her fearful of a delay.
Service response The discharge process for patients under the care of the Crisis team to Community Mental Health Team (CMHT) is being reviewed to ensure that there is an agreed and documented referral process with a prioritisation rationale for the patient to be immediately allocated to a CMHT team member. The Crisis team will retain responsibility for the patient until an appointment with the CMHT team member has been offered. The Crisis team will work with the CMHT to ensure that the crisis and contingency plan is updated. Our Matron for Crisis Services will have responsibility for ensuring that ongoing monitoring is in place to ensure compliance is adhered to. This new process will be fully in place by the end of December 2019.
3. The Court was told that due to the team set up, continuity of visits was not possible and that the demands on the team significantly outweigh the resources available.
Service response We accept our continuity of care is challenged and want to assure you we are committed to improve this area of care with the new investment outlined above. We have already implemented new ways of allocating registered clinicians for assessments to increase the time available to deliver treatment. Registered staff members are now rostered four weeks of carrying out assessments only. Outside of these blocks they will then focus on treatment. This process was implemented in
Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ Chair: Cathy Ellis Chief Executive: Angela Hillery We are a smoke-free Trust. NHS organisations now use 100 per cent recycled paper as part of our sustainability commitment View our privacy notice at www.leicspart.nhs.uk/_Aboutus-Whatwedowithyourinformationprivacynotice.aspx
June 2019 and the team are currently monitoring the impact this has on continuity of care. In addition our new resources and new posts associated with this will result in an increase in daily packages of care we are able to offer. We will be completing an audit reviewing patients open to Crisis Services between September 2018 and September 2019 to establish the band of staff, and the number of visits they have completed for patients open during this timeframe. This will be completed by end of November 2019 and will allow us to have a clear understanding of the current continuity of care delivered by the Crisis team, and enable us to develop an improvement plan in this area.
We are also reviewing the NHS National Benchmarking data and are committed to working with other Trusts to ensure best practice within our Crisis Service.
4. Mrs Morris suffered distress at having to tell her story repeatedly to new workers.
Service response The additional investment will support our commitment to improving the continuity of care of all patients in Crisis we support. This includes the review of our local guidance for staff on pre-visit preparation, which expects all staff to read the previous visit entry, review any recent risk assessments, confirm outstanding actions from the previous visit have been completed, and check any communication needs prior to the scheduled visit. We will develop a spot check tool to establish that the changes as the result of the review of the local guidance have been embedded into practice. We will ensure that we are able to offer assurances of our compliance on this through co-producing a spot check tool directly with our service users.
As a Service we are all committed to ensuring that all the identified service actions are robust and completed within the agreed timescales. We hope this reassures you that we are taking appropriate action in response to your findings.
If I can be of any further assistance to you please do not hesitate to contact me.
Re: Kim Beverley Morris
Further to your report dated 28 August 2019, in accordance with paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, I offer the following response.
We have investigated the matters of concern that have arisen during the course of the inquest of Mrs Kim Beverley Morris. Leicestershire Partnership NHS Trust takes these matters very seriously and I hope that you and Mrs Morris’s family will be satisfied that we have taken the appropriate measures to prevent such an occurrence happening again.
The matters of concern you have raised are as follows:
The Crisis team is not offering a service that is suitable to support such high risk individuals as Mrs Morris and that the expectations of service users are low due to the high and unrelenting pressures and demands on the individuals trying to provide care.
Service Response We acknowledge your concerns that we are not able to offer a service to support such high risk individuals, and would like to reassure you that, as a Trust we take these concerns seriously. We have received additional investment to further enhance the Crisis Service, to enable us to improve the service we deliver.
Our additional investment of £962k will further enhance the staffing in the Crisis Service by recruiting 8.5 whole time equivalent registered staff and 12.6 whole time Direct dial:
Email: fra
Our Ref: KM/REG28/
15 October 2019
By email to Leicester.coroner@leicester.gov.uk Lydia Brown Assistant Coroner Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester LE1 9BG
Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ Chair: Cathy Ellis Chief Executive: Angela Hillery We are a smoke-free Trust. NHS organisations now use 100 per cent recycled paper as part of our sustainability commitment View our privacy notice at www.leicspart.nhs.uk/_Aboutus-Whatwedowithyourinformationprivacynotice.aspx
equivalent unregistered staff. These additional staff will increase the capacity of the team, and alleviate some of the known high demand and pressures. A full time Psychologist is also being recruited to support psychological interventions and will provide supervision and support to staff in the team. We are expecting that this additional support will be fully in place by the end February 2020.
The concerns specifically related too:
1. There were numerous visits and telephone encounters with many different individuals and the role of the key worker did not reduce these.
Service response
We are reviewing the Standard Operating Procedure (SOP) for the Keyworker role, and their responsibilities within the Crisis team. This review will ensure that we clearly define the expectations for the Keyworker role for Registered Nurses, Mental Health Practitioners and Health Care Support Workers employed in the team. The SOP will confirm the responsibilities for assessment, ongoing care planning, monitoring of service users and discharge planning. Clear information about the role of the Keyworker will be available to patients, families and carers by the end of November 2019.
2. It was accepted that Mrs Morris be referred to a Community Psychiatric Nurse to continue her engagement and continuity of care prior to discharge, but no contact was made prior to her discharge, potentially leaving her fearful of a delay.
Service response The discharge process for patients under the care of the Crisis team to Community Mental Health Team (CMHT) is being reviewed to ensure that there is an agreed and documented referral process with a prioritisation rationale for the patient to be immediately allocated to a CMHT team member. The Crisis team will retain responsibility for the patient until an appointment with the CMHT team member has been offered. The Crisis team will work with the CMHT to ensure that the crisis and contingency plan is updated. Our Matron for Crisis Services will have responsibility for ensuring that ongoing monitoring is in place to ensure compliance is adhered to. This new process will be fully in place by the end of December 2019.
3. The Court was told that due to the team set up, continuity of visits was not possible and that the demands on the team significantly outweigh the resources available.
Service response We accept our continuity of care is challenged and want to assure you we are committed to improve this area of care with the new investment outlined above. We have already implemented new ways of allocating registered clinicians for assessments to increase the time available to deliver treatment. Registered staff members are now rostered four weeks of carrying out assessments only. Outside of these blocks they will then focus on treatment. This process was implemented in
Trust Headquarters: Bridge Park Plaza, Bridge Park Road, Thurmaston, Leicester. LE4 8PQ Chair: Cathy Ellis Chief Executive: Angela Hillery We are a smoke-free Trust. NHS organisations now use 100 per cent recycled paper as part of our sustainability commitment View our privacy notice at www.leicspart.nhs.uk/_Aboutus-Whatwedowithyourinformationprivacynotice.aspx
June 2019 and the team are currently monitoring the impact this has on continuity of care. In addition our new resources and new posts associated with this will result in an increase in daily packages of care we are able to offer. We will be completing an audit reviewing patients open to Crisis Services between September 2018 and September 2019 to establish the band of staff, and the number of visits they have completed for patients open during this timeframe. This will be completed by end of November 2019 and will allow us to have a clear understanding of the current continuity of care delivered by the Crisis team, and enable us to develop an improvement plan in this area.
We are also reviewing the NHS National Benchmarking data and are committed to working with other Trusts to ensure best practice within our Crisis Service.
4. Mrs Morris suffered distress at having to tell her story repeatedly to new workers.
Service response The additional investment will support our commitment to improving the continuity of care of all patients in Crisis we support. This includes the review of our local guidance for staff on pre-visit preparation, which expects all staff to read the previous visit entry, review any recent risk assessments, confirm outstanding actions from the previous visit have been completed, and check any communication needs prior to the scheduled visit. We will develop a spot check tool to establish that the changes as the result of the review of the local guidance have been embedded into practice. We will ensure that we are able to offer assurances of our compliance on this through co-producing a spot check tool directly with our service users.
As a Service we are all committed to ensuring that all the identified service actions are robust and completed within the agreed timescales. We hope this reassures you that we are taking appropriate action in response to your findings.
If I can be of any further assistance to you please do not hesitate to contact me.