NHS England
NHS / Health Body
Action Taken
NHS Improvement is working with mental health trusts to improve patient safety through a national mental health safety initiative. They are also reviewing concerns and failings with the Trust and have put changes in place and are working on a support package for the Trust. (AI summary)
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Dear Mr Rheinberg RE: Terence Andrew Bennett deceased am writing in response to your letter dated 14 September and the attached copy of the report following the Inquest into the death of Mr Bennett Please accept my apologies for our in responding: On behalf of NHS Improvement (NHSI) may take this opportunity to express our sincere condolences to the family of Mr Bennett following his tragic death. NHSI is grateful to you for sharing the report and, as you suggest, acknowledge the findings have relevance to other Trusts in the country. We will ensure are shared internally. The Coroner also find it helpful to know about a national programme to improve mental health services and how we are working with the Trust to address the failings identified in the Coroners report: have set out details below: This year NHSI in partnership with the Care Quality Commission (CQC) was tasked by the Secretary of State to improve patient safety in mental health trusts by delivering a national mental health safety initiative. The overall aim of the programme is for NHS trust providing core mental health services in England to have understood their safety priorities and have made a measurable improvement in at least one area of mental health safety by 31 March 2020. In order to meet this aim, the programme will work to: Align Arm's Length Bodies (ALBs) understanding and resources relating to safety, assurance and improvement culture Create sustainable mental health improvement resources Map existing networks, resources, and best practices relating to safety across mental health services Work with the Department of Health and Social Care to ensure its approach is aligned to national policy NHS Improvement is the operational name for the organisation that brings together Monitor; NHS Trust Development Authority , Patient Safety, the National Reporting Learning System , the Advancing Change team and the Intensive Support Teams delay they may every key and
The programme's underlying approach to safety is one that addresses leadership, capability and culture_ The areas of focus are: Safety on mental health wards (including restrictive practice, violence and sexual safety) Medications management Use of informatics to support safety at all levels Environmental awareness Safe management of referrals and waiting lists Increase in knowledge and expertise at a regional level Plus, any areas agreed by individual trusts and the Mental Health Safety Improvement Programme In addition, the Eive_Year Fonward_View for _Mental Health set out clear recommendations on suicide prevention and reduction, and made a commitment to reduce suicides by 10% nationally by 2020/21 Alongside this, the Secretary of State announced a zero suicide ambition for mental health inpatients in January of this year and NHSI is working closely with other ALBs to help services achieve this aim: The approach includes supporting trusts to develop clear understanding of the definition and practical implementation of the ambition including processes to support the identification of patients who present as a high risk of self-harm or suicide. In addition to these points relating to improving patient safety in mental health, outline below our regulatory and oversight approach with system partners to provide assurance that appropriate action is taken to address the serious failures identified through this, and other Coroner's reports As you may be aware, the original incident was recorded as a Serious Incident (SI) on the Strategic Executive Information System (known as StEIS) in accordance with Serious Incident Framework: Under the Framework; a trust's CCG (in this case Wiltshire CCG) oversees its response to an Sl, both the immediate action required through to undertaking the investigation and producing a final report and action plan: If there is a Coroner's inquest the SI is not closed until the outcome from the inquest is known and satisfactory responselaction plan is developed. When the Regulation 28 letter was received by Wiltshire CCG in September 2018 it did raise concerns similar to the themes previously identified by the Trust's 'root cause analysis' (that was undertaken as part of the investigation into Sl) particularly around reducing the number of suicides These concerns led to the system partners setting up a quality improvement summit to focus on suicide prevention, with its first meeting being held in September. The follow up is planned for December 2018. NHSI, NHS England, Wiltshire CCG, Swindon CCG and Bristol CCG are participating in this_ NHS Improvement is the operational name for the organisation that brings together Monitor; NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System_ the Advancing Change team and the Intensive Support Teams. key key the the
In addition; the system partners have been working together to review the CO-ordinated regulatoryloversight approach to the concerns and failings identified by the Coroner: NHSI has discussed with the Trust the Coroner's report and the changes that have already been put in place_ It has also commented on the Trust's response to the Coroner and action plan to address the issues raised. We will continue to oversee and hold the Trust to account for its actions at our monthly oversight meetings and through regular calls with the Trust's Director of Nursing and Medical Director. NHSI is also working with the Trust and partners on a support package for the Trust as it reviews and strengthens its governance arrangements for quality. trust you will find this information of assistance and should you require any further detail please do not hesitate to contact me
The programme's underlying approach to safety is one that addresses leadership, capability and culture_ The areas of focus are: Safety on mental health wards (including restrictive practice, violence and sexual safety) Medications management Use of informatics to support safety at all levels Environmental awareness Safe management of referrals and waiting lists Increase in knowledge and expertise at a regional level Plus, any areas agreed by individual trusts and the Mental Health Safety Improvement Programme In addition, the Eive_Year Fonward_View for _Mental Health set out clear recommendations on suicide prevention and reduction, and made a commitment to reduce suicides by 10% nationally by 2020/21 Alongside this, the Secretary of State announced a zero suicide ambition for mental health inpatients in January of this year and NHSI is working closely with other ALBs to help services achieve this aim: The approach includes supporting trusts to develop clear understanding of the definition and practical implementation of the ambition including processes to support the identification of patients who present as a high risk of self-harm or suicide. In addition to these points relating to improving patient safety in mental health, outline below our regulatory and oversight approach with system partners to provide assurance that appropriate action is taken to address the serious failures identified through this, and other Coroner's reports As you may be aware, the original incident was recorded as a Serious Incident (SI) on the Strategic Executive Information System (known as StEIS) in accordance with Serious Incident Framework: Under the Framework; a trust's CCG (in this case Wiltshire CCG) oversees its response to an Sl, both the immediate action required through to undertaking the investigation and producing a final report and action plan: If there is a Coroner's inquest the SI is not closed until the outcome from the inquest is known and satisfactory responselaction plan is developed. When the Regulation 28 letter was received by Wiltshire CCG in September 2018 it did raise concerns similar to the themes previously identified by the Trust's 'root cause analysis' (that was undertaken as part of the investigation into Sl) particularly around reducing the number of suicides These concerns led to the system partners setting up a quality improvement summit to focus on suicide prevention, with its first meeting being held in September. The follow up is planned for December 2018. NHSI, NHS England, Wiltshire CCG, Swindon CCG and Bristol CCG are participating in this_ NHS Improvement is the operational name for the organisation that brings together Monitor; NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System_ the Advancing Change team and the Intensive Support Teams. key key the the
In addition; the system partners have been working together to review the CO-ordinated regulatoryloversight approach to the concerns and failings identified by the Coroner: NHSI has discussed with the Trust the Coroner's report and the changes that have already been put in place_ It has also commented on the Trust's response to the Coroner and action plan to address the issues raised. We will continue to oversee and hold the Trust to account for its actions at our monthly oversight meetings and through regular calls with the Trust's Director of Nursing and Medical Director. NHSI is also working with the Trust and partners on a support package for the Trust as it reviews and strengthens its governance arrangements for quality. trust you will find this information of assistance and should you require any further detail please do not hesitate to contact me