Avon and Wiltshire Mental Health NHS Trust
NHS / Health Body
Action Taken
The Trust has already taken action to address the issues including emphasizing the need for staff to record explicit consent on information sharing forms and reviewing the Trust's consent to share information procedures. They have also clarified that the AWP switchboard can call 999 in an emergency and ensured that staff are aware of individualised communication options for service users. (AI summary)
View full response
Dear Ms Voisin,
I am writing in response to the Regulation 28 Prevention of Future Deaths report received in connection with the death of Mr Christopher Michael Seal. I welcome the opportunity to respond to the issues you have raised and improve the safety of our services for patients and families. I will respond to each of the issues in turn.
The information sharing form Immediate action has been taken regarding the current ‘Consent to Share’ form in use across the Trust. This has been discussed at local Quality and Standards meeting and the Learning from Experience Forum, where key learning from the untimely death of Mr Seal has been shared and disseminated. It has been emphasised that all staff need to record explicit consent,
i.e. stating what information can be shared, with whom and what their contact details are. The Trust recognises that the consent to share information form could and should be clearer, as could the staff guidance. In light of the General Data Protection Regulation (GDPR), the Governance Team are now reviewing the Trust’s consent to share information procedures. Once they have ensured that the framework is compliant with GDPR, we then will proceed with making the recording and retrieval of consent to share is in place and the clinical processes, supporting guidance, recording processes and information presentation will be improved, aligned and communicated by the end of June 2019. We are also working with the Senior Practitioner for Family Interventions to provide staff training regarding involving relatives and carers, including working with service users who might initially be reluctant to allow this but may change their views over time. Furthermore, the Trust is engaged with year long improvement programme with ‘Making Families Count’ initiative, set up by NHS England, collaborating to improve families’ involvement in mental health services and ensure that learning from their experience is used to improve services and reduce avoidable harm. This family led group has delivered two sessions to Trust staff already, the most recent in February 2019.
Ms M. E. Voisin, Senior Coroner, Area of Avon Avon Coroner’s Court, Old Weston Road, Flax Bourton, Avon, BS48 1UL
Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.'
Date of amended information entered onto RiO records system
The Trust recognises the confusion this caused staff and indeed the Court and we welcome the fact that this has been highlighted for improvement. The training and guidance for staff has consequently been amended. The RiO clinical support now states that it is acceptable to either edit the most recent RiO form, or to create a new form. It is not acceptable to edit forms other than the most recent. This has been disseminated to clinical staff through team meetings and is being circulated to staff via an internal ‘Red Top Alert’.
Next of Kin details recorded on RiO and link to National Spine
This issue has helped us identify that we need to improve the way we synchronise our mental health records at the Trust in order to connect with the National Spine. When we first register a service user, the electronic patient records system, RiO, synchronises with the National Spine. Each time the record is accessed following this, RiO checks with the National Spine and if differences are noted, the user is asked to accept or reject changes. If a response is not given, this means that anomalies are not resolved or information is incomplete.
The Trust is working to find a technical solution to create a work list of records that require synchronisation in order that administrative staff might be able to complete this task and improve compliance (target completion date 31 August 2019). There is a secondary issue that where there is no Next of Kin recorded, the absence of this is not evident. There is presently a development request to place an indicator on the front screen of the record showing the Next of Kin/In Case of Emergency contact, or the absence of that record in red, in order to make this more obvious to the clinician/user (target completion date 31 July 2019).
The demographics page on RiO
Staff have been reminded what the minimum information requirement is, and that this includes completion of the demographics page. A random selection of patient records are audited monthly and team managers have been made aware that completed demographic information is a requirement for all staff.
Lack of “No Response policy” for those in primary care.
The ‘No Response’ Policy is applicable to secondary and tertiary care. The policy states that for patients in primary care, the GP is informed of the lack of response to a planned visit. A planned visit is taken to mean planned and agreed between the staff member and the service user. Discussions have been held with the GP Mental Health Lead who has reinforced the expectation that the need to inform that GPs will be based on clinical judgement of staff involved. The expectation is that AWP would assess the risk based on all the available evidence, and alert the GP where appropriate, i.e. when risk or likely risk is increased.
No “welfare check policy” for those in primary care
AWP have contacted Avon and Somerset Police to request close liaison and joint working regarding their ‘Welfare Check Policy’ to ensure understanding and expectations are aligned. The local representative for the Avon & Somerset Crisis Concordat will maintain close follow
Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.'
up on this at these meetings or directly with the Police Mental Health Liaison Officer. In addition, the police are holding a conference in March 2019 with the theme “What information we should be sharing relating to a person’s mental health concerns and, how/with whom to best manage risk?" They are looking at exploring:
What is the scale of the demand/risk at the moment – for police and partners? What are the risks to the lack of communication of these concerns from one agency to another? What information should be gathered/shared by the police - how and with who? What are the consent considerations? How are a patient’s care and support needs best identified and addressed? AWP BaNES will engage with this forum and we welcome the opportunity for further joint working.
Timeliness of RiO entries
AWP’s guidance is that for Inpatient, Intensive and Outpatient records should be completed in real time – in practice, this may mean by the end of the shift, hence up to 24 hours. For the community services the recording period may increase to 72 hours in some circumstances. It is expected that a consideration of risk would inform any decision to delay writing entries. Guidance for staff is located on the Trust intranet and is attached as Appendix 1 below.
Trust guidance is in line with what professional bodies expect of their staff. NMC Code of Conduct, states: “10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event.” HCPC Standards of Conduct, Performance and Ethics state “10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.” College of OT Code of Ethics and Professional Conduct states: “2.6.1 You must accurately and legibly record all information related to your involvement with the service user, as soon as practically possible after the activity, in line with the standards of the Health and Care Professions Council, the College of Occupational Therapists and local policy. Any record must be clearly dated, timed and attributable to the person making the entry.” British Association for Social Work and Social Workers states: “11. Maintaining clear and accurate records: Social workers should maintain clear, impartial and accurate records and provision of evidence to support professional judgements. They should record only relevant matters and specify the source of information.” The intensive service switchboard and their ability to react to protecting life
I apologise that the evidence given by Ms Spaull indicated that the AWP switchboard does not have the ability to call 999 in an emergency but advise the service user to make the call; this is
Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.'
incorrect. The switchboard can and do call 999, as appropriate, when an emergency situation requires this.
Methods of contact with service user
AWP has local procedures for text access for people who are deaf or hard of hearing. It is recognised that some service users, regardless of disability, may prefer forms of communication other than phone calls. Where this is indicated an Individualised approach to communication with the service users will be considered and planned. However, e-mail or texting high risk information is not always suitable as information can be missed or there can be technical risks. The Trust has ensured that all staff are aware of the individualised communication options and that they are suitably able to have appropriate conversations with service users about the risks of various communication methods
The Trust policy is that only NHS.net to NHS.net emailing is secure. Social media use such as Facebook messaging and Whatsapp are not used because of risks to information governance, particularly confidentiality.
I hope the information provided indicates how seriously the Trust has taken the death of Mr Seal and how committed we are to embedding the learning, improving patient safety and reducing avoidable harm. If there is any further information you require we would be happy to provide this.
I am writing in response to the Regulation 28 Prevention of Future Deaths report received in connection with the death of Mr Christopher Michael Seal. I welcome the opportunity to respond to the issues you have raised and improve the safety of our services for patients and families. I will respond to each of the issues in turn.
The information sharing form Immediate action has been taken regarding the current ‘Consent to Share’ form in use across the Trust. This has been discussed at local Quality and Standards meeting and the Learning from Experience Forum, where key learning from the untimely death of Mr Seal has been shared and disseminated. It has been emphasised that all staff need to record explicit consent,
i.e. stating what information can be shared, with whom and what their contact details are. The Trust recognises that the consent to share information form could and should be clearer, as could the staff guidance. In light of the General Data Protection Regulation (GDPR), the Governance Team are now reviewing the Trust’s consent to share information procedures. Once they have ensured that the framework is compliant with GDPR, we then will proceed with making the recording and retrieval of consent to share is in place and the clinical processes, supporting guidance, recording processes and information presentation will be improved, aligned and communicated by the end of June 2019. We are also working with the Senior Practitioner for Family Interventions to provide staff training regarding involving relatives and carers, including working with service users who might initially be reluctant to allow this but may change their views over time. Furthermore, the Trust is engaged with year long improvement programme with ‘Making Families Count’ initiative, set up by NHS England, collaborating to improve families’ involvement in mental health services and ensure that learning from their experience is used to improve services and reduce avoidable harm. This family led group has delivered two sessions to Trust staff already, the most recent in February 2019.
Ms M. E. Voisin, Senior Coroner, Area of Avon Avon Coroner’s Court, Old Weston Road, Flax Bourton, Avon, BS48 1UL
Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.'
Date of amended information entered onto RiO records system
The Trust recognises the confusion this caused staff and indeed the Court and we welcome the fact that this has been highlighted for improvement. The training and guidance for staff has consequently been amended. The RiO clinical support now states that it is acceptable to either edit the most recent RiO form, or to create a new form. It is not acceptable to edit forms other than the most recent. This has been disseminated to clinical staff through team meetings and is being circulated to staff via an internal ‘Red Top Alert’.
Next of Kin details recorded on RiO and link to National Spine
This issue has helped us identify that we need to improve the way we synchronise our mental health records at the Trust in order to connect with the National Spine. When we first register a service user, the electronic patient records system, RiO, synchronises with the National Spine. Each time the record is accessed following this, RiO checks with the National Spine and if differences are noted, the user is asked to accept or reject changes. If a response is not given, this means that anomalies are not resolved or information is incomplete.
The Trust is working to find a technical solution to create a work list of records that require synchronisation in order that administrative staff might be able to complete this task and improve compliance (target completion date 31 August 2019). There is a secondary issue that where there is no Next of Kin recorded, the absence of this is not evident. There is presently a development request to place an indicator on the front screen of the record showing the Next of Kin/In Case of Emergency contact, or the absence of that record in red, in order to make this more obvious to the clinician/user (target completion date 31 July 2019).
The demographics page on RiO
Staff have been reminded what the minimum information requirement is, and that this includes completion of the demographics page. A random selection of patient records are audited monthly and team managers have been made aware that completed demographic information is a requirement for all staff.
Lack of “No Response policy” for those in primary care.
The ‘No Response’ Policy is applicable to secondary and tertiary care. The policy states that for patients in primary care, the GP is informed of the lack of response to a planned visit. A planned visit is taken to mean planned and agreed between the staff member and the service user. Discussions have been held with the GP Mental Health Lead who has reinforced the expectation that the need to inform that GPs will be based on clinical judgement of staff involved. The expectation is that AWP would assess the risk based on all the available evidence, and alert the GP where appropriate, i.e. when risk or likely risk is increased.
No “welfare check policy” for those in primary care
AWP have contacted Avon and Somerset Police to request close liaison and joint working regarding their ‘Welfare Check Policy’ to ensure understanding and expectations are aligned. The local representative for the Avon & Somerset Crisis Concordat will maintain close follow
Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.'
up on this at these meetings or directly with the Police Mental Health Liaison Officer. In addition, the police are holding a conference in March 2019 with the theme “What information we should be sharing relating to a person’s mental health concerns and, how/with whom to best manage risk?" They are looking at exploring:
What is the scale of the demand/risk at the moment – for police and partners? What are the risks to the lack of communication of these concerns from one agency to another? What information should be gathered/shared by the police - how and with who? What are the consent considerations? How are a patient’s care and support needs best identified and addressed? AWP BaNES will engage with this forum and we welcome the opportunity for further joint working.
Timeliness of RiO entries
AWP’s guidance is that for Inpatient, Intensive and Outpatient records should be completed in real time – in practice, this may mean by the end of the shift, hence up to 24 hours. For the community services the recording period may increase to 72 hours in some circumstances. It is expected that a consideration of risk would inform any decision to delay writing entries. Guidance for staff is located on the Trust intranet and is attached as Appendix 1 below.
Trust guidance is in line with what professional bodies expect of their staff. NMC Code of Conduct, states: “10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event.” HCPC Standards of Conduct, Performance and Ethics state “10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.” College of OT Code of Ethics and Professional Conduct states: “2.6.1 You must accurately and legibly record all information related to your involvement with the service user, as soon as practically possible after the activity, in line with the standards of the Health and Care Professions Council, the College of Occupational Therapists and local policy. Any record must be clearly dated, timed and attributable to the person making the entry.” British Association for Social Work and Social Workers states: “11. Maintaining clear and accurate records: Social workers should maintain clear, impartial and accurate records and provision of evidence to support professional judgements. They should record only relevant matters and specify the source of information.” The intensive service switchboard and their ability to react to protecting life
I apologise that the evidence given by Ms Spaull indicated that the AWP switchboard does not have the ability to call 999 in an emergency but advise the service user to make the call; this is
Chair Charlotte Hitchings Trust Headquarters Bath NHS House, Newbridge Hill, Bath BA1 3QE Chief Executive Dr Hayley Richards __________________________________________________________________________ _____ 'We are a teaching, learning and research trust; we aim to inform you about relevant opportunities, unless you tell us otherwise.'
incorrect. The switchboard can and do call 999, as appropriate, when an emergency situation requires this.
Methods of contact with service user
AWP has local procedures for text access for people who are deaf or hard of hearing. It is recognised that some service users, regardless of disability, may prefer forms of communication other than phone calls. Where this is indicated an Individualised approach to communication with the service users will be considered and planned. However, e-mail or texting high risk information is not always suitable as information can be missed or there can be technical risks. The Trust has ensured that all staff are aware of the individualised communication options and that they are suitably able to have appropriate conversations with service users about the risks of various communication methods
The Trust policy is that only NHS.net to NHS.net emailing is secure. Social media use such as Facebook messaging and Whatsapp are not used because of risks to information governance, particularly confidentiality.
I hope the information provided indicates how seriously the Trust has taken the death of Mr Seal and how committed we are to embedding the learning, improving patient safety and reducing avoidable harm. If there is any further information you require we would be happy to provide this.