South Staffordshire and Shropshire Healthcare NHS Trust
NHS / Health Body
Action Taken
The Trust has reviewed and amended its Serious Incident Review process and now employs a full-time Serious Incident Review Co-ordinator and Administrator. Reports now go through an additional governance process, with commissioners carrying out a challenge review. (AI summary)
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South Staffordshire and Shropshire Healthcare NHS] NHS Foundation Trust A Keele University Teaching Trust The Trust now has a clear policy and process for receiving and storing third party information in RiO which is in line with national policy: Lengthy written communications are uploaded to RiO as sent; s0 are available to the care team and a note made in the progress notes to identify they have been stored and the location. Verbal communication is recorded in progress notes in line with policy. c) How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for the information they have provided? Third party information is treated as confidential and is only made available to members of the care team: It is not shared with service user. As stated in Ia) above, the Trust follows Caldicott Principles in the management of all service user information; Where these principles would be breached the recipient of the information would not acknowledge, to the third party , that the service user was known to the service other than with the explicit agreement of the service user: 2 During the period that Angela was receiving assistance from the Trust there is minimal evidence of a multi-disciplinary team being involved. Predominantly one community mental health nurse took responsibility. While it may not have affected the outcome in this case a team approach involving a number of professionals. Is this something that the Trust needs to look at? The Trust mental health teams are all multi-professional and the model of working within all teams is multi-disciplinary, the care and treatment provided to all service users is overseen by the teams s0 even in circumstances where a person may be receiving interventions associated with a care plan from a single professional the individual practitioner will be discussing the care with other members of the team in caseload and team supervision: Upon referral all new patients are discussed at the FACT (Functional Assertive Community Treatment Model) meeting which is held 4 times a week. All professions are represented at each meeting: Key information is recorded in the individual patients health record were it can be accessed by team members in the absence of key workers In Angela's case the community mental health nurse did see Angela with the team medic and worked together to medically manage Angela's symptoms_ The community mental health nurse was working closely with Angela to develop a therapeutic relationship. The direct intervention of multiple different professionals at this time would have had a detrimental effect on the therapeutic relationship being developed. Page 2 ol 3 the they
South Staffordshire and Shropshire Healthcare NHS] NHS Foundation Trust A Keele University Teaching Trust 3 Generally the serious incident review process is a very helpful one. In this case however a number of concerns about Angela's treatment were not picked up by the review. Is the pressure on those carrying out this process reducing the effectiveness of the reports? Thank you for your comments regarding the overall helpfulness of the Serious Incident Review Process can confirm that since the time of this specific Serious Incident Review, the process has been reviewed and amended The Serious Incident Review Process follows a structured and robust process with internal and external governance arrangements in place The Trust now employs full-time Serious Incident Review Co-ordinator and Administrator to support Investigating Officers in the review process The Serious Incident Review Co- ordinator works within the Trust's Quality and Risk Department to help improve processes that are used to ensure the quality production of reports relevant to serious incidents. They support Investigating Officers in the completion of Serious Incident Reports and Significant Event Reviews and are responsible for the completion of Chronological and concise reports_ The Serious Incident Review Co-ordinator supports and encourages an open and fair approach to incident identification and investigation, supported by a learning culture: In addition the reports now go through an additional governance process in that our commissioners carry out a challenge review to signing the report off for release this response helps to address your concerns. However if you require any further information please do not hesitate to contact me
South Staffordshire and Shropshire Healthcare NHS] NHS Foundation Trust A Keele University Teaching Trust The Trust now has a clear policy and process for receiving and storing third party information in RiO which is in line with national policy: Lengthy written communications are uploaded to RiO as sent; s0 are available to the care team and a note made in the progress notes to identify they have been stored and the location. Verbal communication is recorded in progress notes in line with policy. c) How is patient confidentiality protected in these circumstances and what about circumstances where third parties request confidentiality for the information they have provided? Third party information is treated as confidential and is only made available to members of the care team: It is not shared with service user. As stated in Ia) above, the Trust follows Caldicott Principles in the management of all service user information; Where these principles would be breached the recipient of the information would not acknowledge, to the third party , that the service user was known to the service other than with the explicit agreement of the service user: 2 During the period that Angela was receiving assistance from the Trust there is minimal evidence of a multi-disciplinary team being involved. Predominantly one community mental health nurse took responsibility. While it may not have affected the outcome in this case a team approach involving a number of professionals. Is this something that the Trust needs to look at? The Trust mental health teams are all multi-professional and the model of working within all teams is multi-disciplinary, the care and treatment provided to all service users is overseen by the teams s0 even in circumstances where a person may be receiving interventions associated with a care plan from a single professional the individual practitioner will be discussing the care with other members of the team in caseload and team supervision: Upon referral all new patients are discussed at the FACT (Functional Assertive Community Treatment Model) meeting which is held 4 times a week. All professions are represented at each meeting: Key information is recorded in the individual patients health record were it can be accessed by team members in the absence of key workers In Angela's case the community mental health nurse did see Angela with the team medic and worked together to medically manage Angela's symptoms_ The community mental health nurse was working closely with Angela to develop a therapeutic relationship. The direct intervention of multiple different professionals at this time would have had a detrimental effect on the therapeutic relationship being developed. Page 2 ol 3 the they
South Staffordshire and Shropshire Healthcare NHS] NHS Foundation Trust A Keele University Teaching Trust 3 Generally the serious incident review process is a very helpful one. In this case however a number of concerns about Angela's treatment were not picked up by the review. Is the pressure on those carrying out this process reducing the effectiveness of the reports? Thank you for your comments regarding the overall helpfulness of the Serious Incident Review Process can confirm that since the time of this specific Serious Incident Review, the process has been reviewed and amended The Serious Incident Review Process follows a structured and robust process with internal and external governance arrangements in place The Trust now employs full-time Serious Incident Review Co-ordinator and Administrator to support Investigating Officers in the review process The Serious Incident Review Co- ordinator works within the Trust's Quality and Risk Department to help improve processes that are used to ensure the quality production of reports relevant to serious incidents. They support Investigating Officers in the completion of Serious Incident Reports and Significant Event Reviews and are responsible for the completion of Chronological and concise reports_ The Serious Incident Review Co-ordinator supports and encourages an open and fair approach to incident identification and investigation, supported by a learning culture: In addition the reports now go through an additional governance process in that our commissioners carry out a challenge review to signing the report off for release this response helps to address your concerns. However if you require any further information please do not hesitate to contact me