Sheffield Health and Social Care
NHS / Health Body
Action Taken
Sheffield Health and Social Care NHS Foundation Trust and Sheffield Children's NHS Foundation Trust are working jointly, updating team protocols to ensure young people returning home to independent or supported living receive contact within 24 hours of A&E discharge. They have also identified an Operational Director Lead and will participate in a city-wide review, expecting a report between March and May 2018. (AI summary)
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Dear Ms Slater Re: Regulation 28 Report to Prevent Future Deaths Daisy French (Deceased) Following the Regulation 28 Report to Prevent Future Deaths issued on 9 November 2017 to the Secretary of State for Health, please find below the details %f a joint response from Sheffield Health and Social Care NHS Foundation Trust (SHSC) and Sheffield Children's NHS Foundation Trust (SC NHS FT) The Trusts also enclose a copy of a Regulation 28 Action Plan which has also been compiled as a result of the Report The MATTERS OF CONCERN and the Trusts' responses are as follows: The communicationlinformation sharing between CAMHS and Adult Services Current information sharing between Child and Adolescent Mental Health Services (CAMHS) ad the Adult Services can and does take place via telephone calls or written letters As CAMHS and the adult servicesITrusts have different IT patient record systems, it presents challenge for each service to be accessed by the other. Also, each Trust's fire wall and data protection governance systems prevents Sheffield Teaching Hospitals (STH) and SHSC staff accessing CAMHS patient records (as held by SC NHS FT) and CAMHS accessing the adult Emergency Department (as held by STH) records to ascertain which CAMHS patients have recently attended the Emergency Department (ED) at STH: SC NHS FT had recognised, to the Coroner's verdict in the case of Daisy French, the risks around 16 and 17 year olds, known to CAMHS and presenting with Deliberate Self Harm to the ED or Sheffield Adult Liaison Service at STH in relation to access to records CAMHS is trying to establish pathway of data exchange between STHIED and CAMHS but this has been problematic, due to data protection governance; SC NHS FTs Medical Director and Chief Information Officer are working to resolve this block and enable flow of information from STHIED to CAMHS and vice versa_ It should also be noted that there has always been the 24/7 facility for SHSC and STH staff to_ phone the CAMHS 1st on call (via SC NHS FT's switch board) and ask for a verbal history of the young person presenting in the ED at STH as the CAMHS 1st on call has access to CAMHS electronic records prior
2 Transition of care from CAMHS to Adult Services Whilst there was evidence of transition planning between the services it is clear from the point of transition from children's to adult services there was no regularly documented evidence of continued collaboration post transfer; including access to historical information held by CAMHS We recognise critical multi-agency collaboration is in order to safely transition young person; to ensure that all parties are working collaboratively and in the best interests of the young person. We are strengthening the existing Transitions Protocol for 16 and 17 year olds across multiple areas, including but not exclusive to: Early Intervention in Psychosis; Eating Disorders; Community Mental Health Teams; Hospital Liaison; Autism Services. Inclusive of the principles of the national Commissioning for Quality and Innovation (CQUIN) goals relating to transitions and learning from transition case examples; we will ensure that the Transitions Protocol will be improved and jointly signed off by both Trusts and regularly audited: Deviation from the Transitions Protocol will be managed on a case by case basis inclusive of both Trusts_ Transition lead nurses from both SC NHS FT and SHSC are working together to produce a patient journey pathway that incorporates feedback from the pre and post transition questionnaires_ Preparatory events have taken place involving both Trusts in November 2017 , for example a Transition workshop which involved experts by experience as well as clinicians from both Trustslservices_ In addition, an event will take place on 5 January 2018 concentrating on mapping the crisis and emergency care pathways for 16 and 17 year olds, which should give more clarity on the city's provision and highlight gaps. The Transitions Protocol has been revised through joint sessions with representation both Trusts. Wider consultation on the Transitions Protocol is now required and the revised Protocol be formally adopted through both trusts' governance processes by 31 March 2018. Following joint approval; the Trusts will ensure that the process is regularly audited and action taken when process is shown to deviate_
3. Out of hour's provision for 16 to 18 years It has been agreed that SHSC will continue to provide as necessary; assessment and treatment for under 18 year olds, out of hours_ The Section 136 bed for Children & Young People is now in operation within SC NHS FT. The Sheffield Adult Liaison Service now operates 24/7 365 days per year: This will ensure timely response to any 16 or 17 year old presenting to the adult A&E Department; This provision will remain in place until such time as more robust commissioning and provision is in place. SC NHS FT has also recognised the gap in provision of a fully funded CAMHS Mental Health Liaison Consultant; and at cost to the Trust; has appointed into this position, so as to support the current CAMHS service and provide a of reference around the care CO-ordination of the 16 and 17year olds_ SC NHS FT awaits the national publication of a CAMHS mental health Iiaison service specification, which will allow the city to benchmark on its current provision. SC NHS FT will work with local commissioners on the benchmarking exercise. how from will point
Placement of an under 18 year old in a Crisis house for adults SHSC is working with Rethink Mental Illness to develop a protocol for under 18 year olds being admitted into the adult crisis house_ This is to ensure that appropriate safeguards are put in place to provide support when such requirement arises and when it is clinically indicated that this is a better alternative to admitting under 18 year olds to an adult psychiatric ward. SHSC will offer its knowledge and expertise in developing community based alternatives, appropriate to need, to the Children's Services_ The Protocol (as referred to above) will be developed and approved through appropriate governance processes by 31 March 2018.
5. Returning an under 18 year old to supported living setting following a mental health act assessment where no staff are on duty at the premises Following the inquest; SHSC has taken the decision to update its team's working protocols to ensure that any young person (16-17 year old) returning home to independent or supported receives appropriate contact within 24 hours Of discharge from an A&E attendance In addition, the initial plan of care will identify any immediate support needs and details of crisis response services. SHSC has also identified an Operational Director Lead, who will oversee transitions going forward to ensure timely action against the points identified above Child Death Overview Panel Review Evidence was provided at the inquest that all of the matters about which the Coroner had expressed concern during the hearing would also be considered in the city wide review in which both Trusts are participating in_ The Trusts also note that there is a Learning Lessons Review which is meeting 26 February 2018 and the findings from this review will be reported into the Child Death Overview Panel review: The Trusts understand that the review is due to be completed within 4 6 months of the inquest hearing and therefore expect the report between March May 2018_ On receipt; the Trusts will promptly action the recommendations as set out in the review which have not already been addressed following the inquest and will add to the action plan as appropriate. We hope that this response outlines a clear direction and a commitment from the two Trusts to work together to address the issues outlined in your letter. Please do contact us should you require any further information.
2 Transition of care from CAMHS to Adult Services Whilst there was evidence of transition planning between the services it is clear from the point of transition from children's to adult services there was no regularly documented evidence of continued collaboration post transfer; including access to historical information held by CAMHS We recognise critical multi-agency collaboration is in order to safely transition young person; to ensure that all parties are working collaboratively and in the best interests of the young person. We are strengthening the existing Transitions Protocol for 16 and 17 year olds across multiple areas, including but not exclusive to: Early Intervention in Psychosis; Eating Disorders; Community Mental Health Teams; Hospital Liaison; Autism Services. Inclusive of the principles of the national Commissioning for Quality and Innovation (CQUIN) goals relating to transitions and learning from transition case examples; we will ensure that the Transitions Protocol will be improved and jointly signed off by both Trusts and regularly audited: Deviation from the Transitions Protocol will be managed on a case by case basis inclusive of both Trusts_ Transition lead nurses from both SC NHS FT and SHSC are working together to produce a patient journey pathway that incorporates feedback from the pre and post transition questionnaires_ Preparatory events have taken place involving both Trusts in November 2017 , for example a Transition workshop which involved experts by experience as well as clinicians from both Trustslservices_ In addition, an event will take place on 5 January 2018 concentrating on mapping the crisis and emergency care pathways for 16 and 17 year olds, which should give more clarity on the city's provision and highlight gaps. The Transitions Protocol has been revised through joint sessions with representation both Trusts. Wider consultation on the Transitions Protocol is now required and the revised Protocol be formally adopted through both trusts' governance processes by 31 March 2018. Following joint approval; the Trusts will ensure that the process is regularly audited and action taken when process is shown to deviate_
3. Out of hour's provision for 16 to 18 years It has been agreed that SHSC will continue to provide as necessary; assessment and treatment for under 18 year olds, out of hours_ The Section 136 bed for Children & Young People is now in operation within SC NHS FT. The Sheffield Adult Liaison Service now operates 24/7 365 days per year: This will ensure timely response to any 16 or 17 year old presenting to the adult A&E Department; This provision will remain in place until such time as more robust commissioning and provision is in place. SC NHS FT has also recognised the gap in provision of a fully funded CAMHS Mental Health Liaison Consultant; and at cost to the Trust; has appointed into this position, so as to support the current CAMHS service and provide a of reference around the care CO-ordination of the 16 and 17year olds_ SC NHS FT awaits the national publication of a CAMHS mental health Iiaison service specification, which will allow the city to benchmark on its current provision. SC NHS FT will work with local commissioners on the benchmarking exercise. how from will point
Placement of an under 18 year old in a Crisis house for adults SHSC is working with Rethink Mental Illness to develop a protocol for under 18 year olds being admitted into the adult crisis house_ This is to ensure that appropriate safeguards are put in place to provide support when such requirement arises and when it is clinically indicated that this is a better alternative to admitting under 18 year olds to an adult psychiatric ward. SHSC will offer its knowledge and expertise in developing community based alternatives, appropriate to need, to the Children's Services_ The Protocol (as referred to above) will be developed and approved through appropriate governance processes by 31 March 2018.
5. Returning an under 18 year old to supported living setting following a mental health act assessment where no staff are on duty at the premises Following the inquest; SHSC has taken the decision to update its team's working protocols to ensure that any young person (16-17 year old) returning home to independent or supported receives appropriate contact within 24 hours Of discharge from an A&E attendance In addition, the initial plan of care will identify any immediate support needs and details of crisis response services. SHSC has also identified an Operational Director Lead, who will oversee transitions going forward to ensure timely action against the points identified above Child Death Overview Panel Review Evidence was provided at the inquest that all of the matters about which the Coroner had expressed concern during the hearing would also be considered in the city wide review in which both Trusts are participating in_ The Trusts also note that there is a Learning Lessons Review which is meeting 26 February 2018 and the findings from this review will be reported into the Child Death Overview Panel review: The Trusts understand that the review is due to be completed within 4 6 months of the inquest hearing and therefore expect the report between March May 2018_ On receipt; the Trusts will promptly action the recommendations as set out in the review which have not already been addressed following the inquest and will add to the action plan as appropriate. We hope that this response outlines a clear direction and a commitment from the two Trusts to work together to address the issues outlined in your letter. Please do contact us should you require any further information.