Addiction Dependency Solutions
Action Planned
ADS has re-negotiated with Pennine Care NHS Trust for clinical advice and supervision, and has commissioned Applied Suicide Intervention Skills Training (ASIST) for shared care staff. (AI summary)
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Dear Ms Mutch; Regulation 28 Report to Prevent Future Deaths following the inquest of Stuart Michael Campbell who died, at 41 Agecroft Road, Bredbury, Stockport; on 5th March 2017. 1 am writing to you to respond to the matters of concern raised by your investigation into the circumstances surrounding the death of Stuart Campbell: On gth March 2017 you commenced your investigation into Stuart's death and this concluded on 28th September 2017. 2 As you are aware Addiction Dependency Solutions (ADS) is currently the lead provider for partnership of organisations delivering One Recovery Oldham Substance Misuse Services. The contract for the delivery of services was awarded by Oidham MBC in April 2015. The One Recovery Partnership led by ADS includes Pennine Care NHS Foundation Trust; Sodexo Justice Services and ACORN Recovery Projects, which is part of the Calico Housing Group. 3 ADS takes very seriously its responsibility to act swiftly and across the whole organisation on what it learns from deaths in our care. Our response focuses on the operational delivery areas for which We responsible: Additionally our response will attempt to explain how we will make the changes you seek and use our role as lead provider to cascade learning throughout ADS and lever changes with our sub-contractors.
4. During your inquiry you highlighted two principle matters of concern for Addiction Dependency Solutions (ADS) The inquest was told that the shared care standard operating protocol between ADS and Pennine Care NHS Foundation Trust had an escalation policy to be followed where an ADS worker felt the needs of an individual could not be met in shared care_ Patrons: Mr ) Kennedy, CBE, DL Mr N Stoller, BCE, € St J,DL Lord Lieutenant Warren Smith JP Chairman: Janusz Karczewski SIrwwikowski Chief Executive: Lady Rhana Bradley, DL Head Office: 155-141 Oldham Street, Manchester M4 ILN 0161 831 Z400 15 0161 832 7971 headoffice @adsolutions, OrE uk Conncci wvith us
CnDADSolutionsuk Rcp Enad nt JmniL 702559 Tomp Iny Rcrsicrfir [ncland' 1419036 , IMSTINMOPTE are
Addiction ADS Dependency Solutions Aprogressive 2lst century addiction charity_
5. It is acknowledged that this escalation had not taken place in Stuarts care and case management The GP (Responsible Medical Officer) had not seen Stuart in the 3 months before his death and it was unclear to you how shared care discussions were facilitated and documented, 6, Furthermore; it was also unclear to you what guidance was available to ADS workers and you ask for clarification regarding the provision for clinical support for ADS workers. 7, As you know; Stuart Campbell was seen in One Recovery by an ADS worker from 2nd November 2016 to his death in on 5th March 2017 . His care was delivered as part of the shared care arrangement with General Practices and Pennine Care NHS Foundation Trust Stuart had been previously treated by Pennine Care NHS Foundation Trust since 1993. His care was transferred to ADS from Pennine Care as part of making changes to the shared care offer to ensure more integrated partnership delivery across Oldham. 8_ It should perhaps be explained that GPs play a pivotal role for patients who are considered suitable to receive their treatment in primary care. In these cases, the GP may be the keyworker or that role can be provided as in Stuart's care, by a drug worker supporting the GP in a shared care arrangement: The keyworker should still work within the recommended treatment and recovery care planning framework: The treatment and recovery care plan is based on a comprehensive assessment and describes how the specific roles, responsibilities and actions of the GP , the shared care worker and any others involved, will be shared in delivering coordinated care in this setting: 9_ Shared responsibilities will often include monitoring of compliance and ensuring communication and continuity of care_ The RMOIGP generally leads on prescribing interventions, changes and additions to medication, and addressing other healthcare needs_ A shared care worker generally leads on monitoring_progress against treatment goals, developing holistic treatment plan and ensuring multidisciplinary discussion when appropriate: For GPs working at a more specialist level (for example; a GP with a special interest) the role may be somewhat different but in all cases this should be clear in the treatment and recovery care plan:
10.A standard operating protocol was developed by clinical staff (Clinical Nurse Manager) from Pennine Care NHS Trust prior to transfer which detailed the mechanisms used for managing this change in working practice. This standard operating protocol mirrored relevant clinical guidelines, including relevant National Institute for Health and Care Excellence guidance and the 2017 update to misuse and dependence: UK guidelines on clinical management
11.A number of shared care clinics were identified as suitable for transfer to ADS. Three senior ADS workers were identified to manage these clinics alongside the primary care Responsible Medical Officer (RMO) : Joint working, shadowing and a phased hand over of clinical care commenced in the first week of October 2016 (18 months after contract award) with 2 full day clinics in Failsworth and Royton: The Responsible Medical Officer for the clinical care of shared care clients is the General Practitioner regardless of which partner operates the clinic. 2 Patrons: Mr Kennedy, CBE, DL Mr N Stoller, BCE, € St ], DL Lord Licutenant Warren Smith JP Chairman: Janusz Karczowski Slowikowski Chief Executive: Lady Rhona Bradley, DL Head Office: 135-141 Oldham Strect Marchester M4 IN 0161 831 2400 4 0161 832 7971 headoffice@adsolutions Org uk Connctt with uS wwwadsolutiors E uk DMUApSolutiorsUK nenron chaetty Tnniac; 7025-] Compiny F tt |in; enf jd 1190413 Ktsi 'E(FLE drug Drug
Addiction ADS Dependency Solutions Aprogressive Zlst century addiction charity 12Appropriately sharing information is recognised as a key factor in supporting the safety and wellbeing of patients. As part of this transfer a cOpy case summary file for each case was given to the relevant ADS worker taking over the clinic. This comprised; a clinical case summary, 6 months copies of current case notes, a risk assessment and care plan and any recent relevant correspondence sent or received about the service user: Contacts and case management records and drug screening results are recorded on the GP Primary Healthcare IT system (EMIS) which the ADS workers have access to as well as on the core service case management system.
13. The three ADS shared care workers are co-located in Oldham with Pennine Care medical and nursing staff and all ADS staff have ad hoc access to_advice and guidance as required. Ali ADS shared care had undertaken the Pennine Care NHS Foundation Trust Competency Assessment Framework (CAF) training for giving out prescriptions and completed the relevant self-assessment paperwork before the clinics were transferred_
14. TheiADS workers had also been trained in taking urine samples and doing instant drug testing: Clinical notes for all clients transferred to the ADS worker shared care clinics were all recorded on the ADS case management system (Nebula):
15.The standard operating protocol clarified how to manage patients who became unstable in their _ use and who might require transfer back to core services. In these specific cases, a clinical discussion should take place with the RMO (GP) about the need to transfer back to core services before a referral is made_ A further clinical discussion should then be had with a Pennine Care NHS Trust medical officer regarding suitability for transfer back to core services. The client would then be booked into a new starter session at the secondary care core service for a joint review with both the ADS shared care worker and Pennine Care staff.
16.When clinical care is transferred back to the secondary care core service, the keyworker and case management responsibility changes to Pennine Care NHS Trust workers along with a transfer letter to the prescribing GP. The RMO for this phase of treatment reverts to Pennine Care NHS Trust under its governance systems until the client is transferred back to shared care where the GP would resume medical responsibility for the substance misuse treatment
17. There is no requirement for ADS staff to complete any additional paperwork to transfer a service user back t0 Pennine Care_ Case notes continue to be kept on the case management system by Pennine Care staff. A risk assessment and care plan is placed n the case management system: ADS staff should give the prescription records to Pennine staff for future management: If the patient has previously been open to Pennine Care, their notes are retrieved from archive to ensure that any historical risk and clinical information informs the future treatment episode. 18 The standard operating protocol also covers management of controlled drugs and prescriptions and it specifies how to manage patients who are being removed from their GP practice due to challenging 3 Patrons: Mr ] Kernecy, CBE DL Mr N Stoller, BCE, € St ],DL Lord Lieuterent Warren Smith JP Chairman: Janusz Karczewski-Slowikowski Chicf Executive: Lady Rhona Bradley, DL Head Office: 135-141 Oldham Street, Marichestcr M4 ILN 0161 831 2400 0161 832 7971 headoffice@adsalutions org uk Conncctwithus adsolutions OTg uk DMDADSolutunsuk
-acar 70255} Compaly [tet lin €nlind 1 3036 , Kntsul? IYTT(I"E drug
Addiction ADS Dependency Solutions A progressive Zlst century addiction charity behaviour It details procedures to follow when patients miss their appointment in the GP clinic or contact to say they can't attend and it covers the transfer of clients core service to GP shared care clinics_
19.As part of our detailed response to your concerns ADS will ensure that all our shared care staff receive additional training and re-training with regard to the standard operating protocol: We will re- train all staff in managing shared care and in the escalation procedure. This will also include specific guidance on multi-disciplinary shared care discussions. ADS will ensure that this re-training is completed by 20th December 2017 .
20.ADS will also undertake t0 carry out full care plan reviews with all shared care patients across the 2 full clinics in Failsworth and Royton (59 patients in total) in conjunction with the local GPIRMOs and this will be completed by 31st March 2018.
21.ADS has re-negotiated with the Pennine Care NHS Trust senior manager in Oldham One Recovery to provide ongoing clinical supervision via medical and nursing staff for all 3 ADS shared care staff on monthly basis This will ensure regular ongoing opportunities for case reviews and discussions for clinical advice and planning with medical specialists from 30th November 2017. 22 Furthermore: ADS has commissioned Applied Suicide Intervention Skills Training (ASIST) across the organisation. ASIST is two-day interactive workshop in suicide first aid. It teaches participants to recognise when someone may have thoughts of suicide and work with them to create a plan that will support their immediate safety. Studies show that the ASIST methods help reduce suicidal feelings in those at risk and is a cost-effective way to help address the problem of suicide. It trains staff to be suicide alert identify people who have thoughts of suicide Understand the reasons behind thoughts of suicide and the reasons for Assess risk and safety develop a plan to increase the safety of the person at risk of suicide. Recognise invitations for help and potential barriers of seeking help. ADS staff in Oldham who work in shared care will attend by December 31st 2017.
23. have summarised the 4 actions in table form as appendix below. The delivery of these reforms and actions by ADS in Oldham will be fully completed by 31st March 2018. The implementation process and timetable has taken into account the fact that the substance misuse contract for Oldham and Rochdale has now been awarded to Turning Point by Oldham MBC and Rochdale MBC from Ist April 2018.
24. wish to re-assure you that we are committed to the delivery of appropriate , safe and effective services, particularly in relation to the competence of staff to meet and safely manage complex needs.
25.| hope that the actions and information we have provided offer you some assurances in relation to the findings ofyour investigations The areas you have highlighted for the prevention of future deaths Patrons: Mr Kernedy, CBE, DL Mr N Stoller, ECE, C St /, DL Lortd Lieutenant Warren Sinith JP Chairman: Janusz Karczewski-Slowikovski Chief Executive: Lady Rhana Bradley, DL Head Office: 135-141 Oldham Street_ Marichester M4 ILN 0161 831 2400 03 0161 832 7971 headoffice@adsolutiars OrE uk Conncct withu; www adsalutions OrE uk onoaDSolutionsUk 702559 Cuciet iqy Ertiki i590ju5 IMISTRAtOr{ from day " living: Key E
Addiction ADS Dependency Solutions A progressive 2lst century addiction charity_ will be cascaded throughout ADS via our Board of Trustees and via our Safeguarding and Effectiveness Committee and shared with all One Recovery sub-contractors. We will also undertake to share the recommendations and actions with Oldham's Suicide Prevention Working Group: 26, report has prompted action and it is the focus of our continuing commitment to improving services for the support of vulnerable people:
4. During your inquiry you highlighted two principle matters of concern for Addiction Dependency Solutions (ADS) The inquest was told that the shared care standard operating protocol between ADS and Pennine Care NHS Foundation Trust had an escalation policy to be followed where an ADS worker felt the needs of an individual could not be met in shared care_ Patrons: Mr ) Kennedy, CBE, DL Mr N Stoller, BCE, € St J,DL Lord Lieutenant Warren Smith JP Chairman: Janusz Karczewski SIrwwikowski Chief Executive: Lady Rhana Bradley, DL Head Office: 155-141 Oldham Street, Manchester M4 ILN 0161 831 Z400 15 0161 832 7971 headoffice @adsolutions, OrE uk Conncci wvith us
CnDADSolutionsuk Rcp Enad nt JmniL 702559 Tomp Iny Rcrsicrfir [ncland' 1419036 , IMSTINMOPTE are
Addiction ADS Dependency Solutions Aprogressive 2lst century addiction charity_
5. It is acknowledged that this escalation had not taken place in Stuarts care and case management The GP (Responsible Medical Officer) had not seen Stuart in the 3 months before his death and it was unclear to you how shared care discussions were facilitated and documented, 6, Furthermore; it was also unclear to you what guidance was available to ADS workers and you ask for clarification regarding the provision for clinical support for ADS workers. 7, As you know; Stuart Campbell was seen in One Recovery by an ADS worker from 2nd November 2016 to his death in on 5th March 2017 . His care was delivered as part of the shared care arrangement with General Practices and Pennine Care NHS Foundation Trust Stuart had been previously treated by Pennine Care NHS Foundation Trust since 1993. His care was transferred to ADS from Pennine Care as part of making changes to the shared care offer to ensure more integrated partnership delivery across Oldham. 8_ It should perhaps be explained that GPs play a pivotal role for patients who are considered suitable to receive their treatment in primary care. In these cases, the GP may be the keyworker or that role can be provided as in Stuart's care, by a drug worker supporting the GP in a shared care arrangement: The keyworker should still work within the recommended treatment and recovery care planning framework: The treatment and recovery care plan is based on a comprehensive assessment and describes how the specific roles, responsibilities and actions of the GP , the shared care worker and any others involved, will be shared in delivering coordinated care in this setting: 9_ Shared responsibilities will often include monitoring of compliance and ensuring communication and continuity of care_ The RMOIGP generally leads on prescribing interventions, changes and additions to medication, and addressing other healthcare needs_ A shared care worker generally leads on monitoring_progress against treatment goals, developing holistic treatment plan and ensuring multidisciplinary discussion when appropriate: For GPs working at a more specialist level (for example; a GP with a special interest) the role may be somewhat different but in all cases this should be clear in the treatment and recovery care plan:
10.A standard operating protocol was developed by clinical staff (Clinical Nurse Manager) from Pennine Care NHS Trust prior to transfer which detailed the mechanisms used for managing this change in working practice. This standard operating protocol mirrored relevant clinical guidelines, including relevant National Institute for Health and Care Excellence guidance and the 2017 update to misuse and dependence: UK guidelines on clinical management
11.A number of shared care clinics were identified as suitable for transfer to ADS. Three senior ADS workers were identified to manage these clinics alongside the primary care Responsible Medical Officer (RMO) : Joint working, shadowing and a phased hand over of clinical care commenced in the first week of October 2016 (18 months after contract award) with 2 full day clinics in Failsworth and Royton: The Responsible Medical Officer for the clinical care of shared care clients is the General Practitioner regardless of which partner operates the clinic. 2 Patrons: Mr Kennedy, CBE, DL Mr N Stoller, BCE, € St ], DL Lord Licutenant Warren Smith JP Chairman: Janusz Karczowski Slowikowski Chief Executive: Lady Rhona Bradley, DL Head Office: 135-141 Oldham Strect Marchester M4 IN 0161 831 2400 4 0161 832 7971 headoffice@adsolutions Org uk Connctt with uS wwwadsolutiors E uk DMUApSolutiorsUK nenron chaetty Tnniac; 7025-] Compiny F tt |in; enf jd 1190413 Ktsi 'E(FLE drug Drug
Addiction ADS Dependency Solutions Aprogressive Zlst century addiction charity 12Appropriately sharing information is recognised as a key factor in supporting the safety and wellbeing of patients. As part of this transfer a cOpy case summary file for each case was given to the relevant ADS worker taking over the clinic. This comprised; a clinical case summary, 6 months copies of current case notes, a risk assessment and care plan and any recent relevant correspondence sent or received about the service user: Contacts and case management records and drug screening results are recorded on the GP Primary Healthcare IT system (EMIS) which the ADS workers have access to as well as on the core service case management system.
13. The three ADS shared care workers are co-located in Oldham with Pennine Care medical and nursing staff and all ADS staff have ad hoc access to_advice and guidance as required. Ali ADS shared care had undertaken the Pennine Care NHS Foundation Trust Competency Assessment Framework (CAF) training for giving out prescriptions and completed the relevant self-assessment paperwork before the clinics were transferred_
14. TheiADS workers had also been trained in taking urine samples and doing instant drug testing: Clinical notes for all clients transferred to the ADS worker shared care clinics were all recorded on the ADS case management system (Nebula):
15.The standard operating protocol clarified how to manage patients who became unstable in their _ use and who might require transfer back to core services. In these specific cases, a clinical discussion should take place with the RMO (GP) about the need to transfer back to core services before a referral is made_ A further clinical discussion should then be had with a Pennine Care NHS Trust medical officer regarding suitability for transfer back to core services. The client would then be booked into a new starter session at the secondary care core service for a joint review with both the ADS shared care worker and Pennine Care staff.
16.When clinical care is transferred back to the secondary care core service, the keyworker and case management responsibility changes to Pennine Care NHS Trust workers along with a transfer letter to the prescribing GP. The RMO for this phase of treatment reverts to Pennine Care NHS Trust under its governance systems until the client is transferred back to shared care where the GP would resume medical responsibility for the substance misuse treatment
17. There is no requirement for ADS staff to complete any additional paperwork to transfer a service user back t0 Pennine Care_ Case notes continue to be kept on the case management system by Pennine Care staff. A risk assessment and care plan is placed n the case management system: ADS staff should give the prescription records to Pennine staff for future management: If the patient has previously been open to Pennine Care, their notes are retrieved from archive to ensure that any historical risk and clinical information informs the future treatment episode. 18 The standard operating protocol also covers management of controlled drugs and prescriptions and it specifies how to manage patients who are being removed from their GP practice due to challenging 3 Patrons: Mr ] Kernecy, CBE DL Mr N Stoller, BCE, € St ],DL Lord Lieuterent Warren Smith JP Chairman: Janusz Karczewski-Slowikowski Chicf Executive: Lady Rhona Bradley, DL Head Office: 135-141 Oldham Street, Marichestcr M4 ILN 0161 831 2400 0161 832 7971 headoffice@adsalutions org uk Conncctwithus adsolutions OTg uk DMDADSolutunsuk
-acar 70255} Compaly [tet lin €nlind 1 3036 , Kntsul? IYTT(I"E drug
Addiction ADS Dependency Solutions A progressive Zlst century addiction charity behaviour It details procedures to follow when patients miss their appointment in the GP clinic or contact to say they can't attend and it covers the transfer of clients core service to GP shared care clinics_
19.As part of our detailed response to your concerns ADS will ensure that all our shared care staff receive additional training and re-training with regard to the standard operating protocol: We will re- train all staff in managing shared care and in the escalation procedure. This will also include specific guidance on multi-disciplinary shared care discussions. ADS will ensure that this re-training is completed by 20th December 2017 .
20.ADS will also undertake t0 carry out full care plan reviews with all shared care patients across the 2 full clinics in Failsworth and Royton (59 patients in total) in conjunction with the local GPIRMOs and this will be completed by 31st March 2018.
21.ADS has re-negotiated with the Pennine Care NHS Trust senior manager in Oldham One Recovery to provide ongoing clinical supervision via medical and nursing staff for all 3 ADS shared care staff on monthly basis This will ensure regular ongoing opportunities for case reviews and discussions for clinical advice and planning with medical specialists from 30th November 2017. 22 Furthermore: ADS has commissioned Applied Suicide Intervention Skills Training (ASIST) across the organisation. ASIST is two-day interactive workshop in suicide first aid. It teaches participants to recognise when someone may have thoughts of suicide and work with them to create a plan that will support their immediate safety. Studies show that the ASIST methods help reduce suicidal feelings in those at risk and is a cost-effective way to help address the problem of suicide. It trains staff to be suicide alert identify people who have thoughts of suicide Understand the reasons behind thoughts of suicide and the reasons for Assess risk and safety develop a plan to increase the safety of the person at risk of suicide. Recognise invitations for help and potential barriers of seeking help. ADS staff in Oldham who work in shared care will attend by December 31st 2017.
23. have summarised the 4 actions in table form as appendix below. The delivery of these reforms and actions by ADS in Oldham will be fully completed by 31st March 2018. The implementation process and timetable has taken into account the fact that the substance misuse contract for Oldham and Rochdale has now been awarded to Turning Point by Oldham MBC and Rochdale MBC from Ist April 2018.
24. wish to re-assure you that we are committed to the delivery of appropriate , safe and effective services, particularly in relation to the competence of staff to meet and safely manage complex needs.
25.| hope that the actions and information we have provided offer you some assurances in relation to the findings ofyour investigations The areas you have highlighted for the prevention of future deaths Patrons: Mr Kernedy, CBE, DL Mr N Stoller, ECE, C St /, DL Lortd Lieutenant Warren Sinith JP Chairman: Janusz Karczewski-Slowikovski Chief Executive: Lady Rhana Bradley, DL Head Office: 135-141 Oldham Street_ Marichester M4 ILN 0161 831 2400 03 0161 832 7971 headoffice@adsolutiars OrE uk Conncct withu; www adsalutions OrE uk onoaDSolutionsUk 702559 Cuciet iqy Ertiki i590ju5 IMISTRAtOr{ from day " living: Key E
Addiction ADS Dependency Solutions A progressive 2lst century addiction charity_ will be cascaded throughout ADS via our Board of Trustees and via our Safeguarding and Effectiveness Committee and shared with all One Recovery sub-contractors. We will also undertake to share the recommendations and actions with Oldham's Suicide Prevention Working Group: 26, report has prompted action and it is the focus of our continuing commitment to improving services for the support of vulnerable people: