5 Borough Partnership NHS
NHS / Health Body
Action Taken
The Trust has looked into the concerns raised and has put an action plan in place after a period of no psychological input on the Grasmere Unit due to maternity leave, despite a patient's need. Actions include: All referrals to be written on specific form and recorded on electronic system, the manager to ensure annual leave handover forms are discussed within team meetings, and operation of an electronic patient record. (AI summary)
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Dear Miss Kearsley Re: Mrs Roseanne Cooke (Deceased) Thank you for letter dated 10 November 2014 with regards to your findings into the death of Mrs Rosanne Cooke and the directions given under Regulations 28 and 29 of the Coroner's (Investigations) Regulations 2013. The Trust takes the matters described within the letter extremely seriously and hopes this response addresses the concerns you have raised. In addition have demonstrated to your satisfaction the learning within the Trust as a result of your correspondence Taking points inturn can confirm the following actions have been undertaken by the Trust: Psychological Input - Grasmere Unit Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trultt Headquarters, Hollins Park House; Hollins Lane Winwick, Warrington; WAZ 8WA Mini Com Number 01925 664094 Trust hope your
The Trust has looked into the concerns you have raised regarding psychological input whilst Mrs Cooke was patient on Grasmere Unit and the following has been established_ The Grasmere Unit Psychologist was on maternity leave, from 1 October 2013 _ 1 September 2014. Mrs Cooke was admitted on 7 March 2014. Psychology cover was Provided during the period of maternity leave by the Psychological Therapy staff Knowsley Recovery Team who attended ward rounds and provided psychological assessmentlinterventions a8 requested by Grasmere Unit: Unfortunately there is no record of Grasmere Unit staff referring Mrs Cooke, despite the identified need for psychological input: An action plan has been produced and is attached for your information. However ! have taken the opportunity to summarise actions below. The Trust operates a process for services to plan for extended such as maternity leave, however recognise, in this instance, this did not work as well as it should would like to assure you that additional steps will be added to the process to ensure actions and those responsible are more formally identified. These steps are detailed within the attached action plan, along with action owners and dates for completion, and include: Support from the Professional Lead for Psychology, who will review Psychology provision across the Trust and advise as to the options available for Cross cover Psychology arrangements_ Production of an extended leave plan that will have clear deadlines and ensure alternatives are identified at least four weeks prior to commencement of the planned leave. The Business Manager will ensure Grasmere Unit staff are instructed to provide more detailed entries into the electronic record system relating to psychological input discussions This will include their immediate action(s) in relation to the patient_ The Leadership Team for Grasmere Unit will commission an audit of the psychology referral documentation to ensure it identifies the type, level and urgency of referral: II. Referral Process for Psychological Services Ris evidentthat a delay occurred in processing Mrs Cooke's referral to Warrington Recovery Team's Psychology Service. would like to offer my unreserved apologies to the family of Mrs Cooke for this delay which was a result of the Care Co-ordinator Failing to submit a referral to Warrington Psychological Therapies (Warrington Recovery Team) in a timely manner. Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane; Winwick, Warrington; WAZ 8WA Mini Com Number 01925 664094 from the leave KBou, i5A
In response to this the Borough's Leadership Team has implemented a plan to identify reasons for this failure via an audit of internal referrals to Psychological Therapies by Warrington Recovery Team: Findings from the audit will be developed into recommendations for improving the referral process The failure to refer in a timely manner will be addressed with the Care Co-ordinator via Trust Management process and Clinical Supervision. III: Discharge Planning Meetings The Trust operates a standard in relation to Discharge Planning which reflects the Programme Approach (CPA) principles. This includes a requirement for practitioners to ensure safe , effective transition for patients would like to take this opportunity to advise you of Trust activity to implement use of the Safer_Mental Health Checklist; developed by the National Patient Safety Agency (NPSA) This checklist ensures that the activity in relation to a patients transfer from one team to another is planned and monitored. The checklist also includes a review of the Risk Management Plan prior to any change in service and a review of CPA status between transfer and receiving teams_ It is evident that Warrington Recovery Team (as the receiving team) failed to send any representation to the Multi-Disciplinary Team MDT meeting and this is an oversight on our part: In order to address the Warrington Recovery Team Manager will ensure annual leave handover forms are completed These will detail actions pertaining to individual service users, and also which staff member within the Team will ensure these are completed in the absence of the Care Co-ordinator. These forms will be referenced at existing weekly Recovery Team meetings. The manager will ensure annual leave handover forms are discussed within the Team Meeting prior to any planned leave_ This action will address the potential of such an oversight recurring and will also ensure that actions are known by all team members and recorded IV. Communication between Teams The Trust operates an electronic patient record which ensures that activity in one team can be accessed by other Trust teams supporting the same patient Information relating to contact from Mrs Cooke's family was recorded and detailed concerns and request for a home visit to his wife for the next Having reviewed Mrs Cooke's electronic record the following the Care Co-ordinator contacted Mrs Cooke to discuss During this contact; Mrs Cooke Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane Winwick; Warrington; WAZ 8WA Mini Com Number 01925 664094 8 Meetings Care delivery this, day. day, 480uf Disabl
described feeling much better, and was out at the time of the call, dealing with banking affairs and it was agreed to to the scheduled appointment for the next day: The Care Co-ordinator was assured by her conversation with Mrs Cooke and advised that should Mrs Cooke's feelings change in any way, then she was to make contact with her Care Co-ordinator. In conclusion would again like to offer my apologies to the family of Mrs Cooke for the failings identified. trust this letter and attached action plan addresses the concerns raised. If ! can be of any further assistance or You require further information about the steps we have taken please do not hesitate to contact me_
The Trust has looked into the concerns you have raised regarding psychological input whilst Mrs Cooke was patient on Grasmere Unit and the following has been established_ The Grasmere Unit Psychologist was on maternity leave, from 1 October 2013 _ 1 September 2014. Mrs Cooke was admitted on 7 March 2014. Psychology cover was Provided during the period of maternity leave by the Psychological Therapy staff Knowsley Recovery Team who attended ward rounds and provided psychological assessmentlinterventions a8 requested by Grasmere Unit: Unfortunately there is no record of Grasmere Unit staff referring Mrs Cooke, despite the identified need for psychological input: An action plan has been produced and is attached for your information. However ! have taken the opportunity to summarise actions below. The Trust operates a process for services to plan for extended such as maternity leave, however recognise, in this instance, this did not work as well as it should would like to assure you that additional steps will be added to the process to ensure actions and those responsible are more formally identified. These steps are detailed within the attached action plan, along with action owners and dates for completion, and include: Support from the Professional Lead for Psychology, who will review Psychology provision across the Trust and advise as to the options available for Cross cover Psychology arrangements_ Production of an extended leave plan that will have clear deadlines and ensure alternatives are identified at least four weeks prior to commencement of the planned leave. The Business Manager will ensure Grasmere Unit staff are instructed to provide more detailed entries into the electronic record system relating to psychological input discussions This will include their immediate action(s) in relation to the patient_ The Leadership Team for Grasmere Unit will commission an audit of the psychology referral documentation to ensure it identifies the type, level and urgency of referral: II. Referral Process for Psychological Services Ris evidentthat a delay occurred in processing Mrs Cooke's referral to Warrington Recovery Team's Psychology Service. would like to offer my unreserved apologies to the family of Mrs Cooke for this delay which was a result of the Care Co-ordinator Failing to submit a referral to Warrington Psychological Therapies (Warrington Recovery Team) in a timely manner. Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane; Winwick, Warrington; WAZ 8WA Mini Com Number 01925 664094 from the leave KBou, i5A
In response to this the Borough's Leadership Team has implemented a plan to identify reasons for this failure via an audit of internal referrals to Psychological Therapies by Warrington Recovery Team: Findings from the audit will be developed into recommendations for improving the referral process The failure to refer in a timely manner will be addressed with the Care Co-ordinator via Trust Management process and Clinical Supervision. III: Discharge Planning Meetings The Trust operates a standard in relation to Discharge Planning which reflects the Programme Approach (CPA) principles. This includes a requirement for practitioners to ensure safe , effective transition for patients would like to take this opportunity to advise you of Trust activity to implement use of the Safer_Mental Health Checklist; developed by the National Patient Safety Agency (NPSA) This checklist ensures that the activity in relation to a patients transfer from one team to another is planned and monitored. The checklist also includes a review of the Risk Management Plan prior to any change in service and a review of CPA status between transfer and receiving teams_ It is evident that Warrington Recovery Team (as the receiving team) failed to send any representation to the Multi-Disciplinary Team MDT meeting and this is an oversight on our part: In order to address the Warrington Recovery Team Manager will ensure annual leave handover forms are completed These will detail actions pertaining to individual service users, and also which staff member within the Team will ensure these are completed in the absence of the Care Co-ordinator. These forms will be referenced at existing weekly Recovery Team meetings. The manager will ensure annual leave handover forms are discussed within the Team Meeting prior to any planned leave_ This action will address the potential of such an oversight recurring and will also ensure that actions are known by all team members and recorded IV. Communication between Teams The Trust operates an electronic patient record which ensures that activity in one team can be accessed by other Trust teams supporting the same patient Information relating to contact from Mrs Cooke's family was recorded and detailed concerns and request for a home visit to his wife for the next Having reviewed Mrs Cooke's electronic record the following the Care Co-ordinator contacted Mrs Cooke to discuss During this contact; Mrs Cooke Chief Executive: Mr. Simon J. Barber Chairman: Mr. Bernard Pilkington Trust Headquarters, Hollins Park House, Hollins Lane Winwick; Warrington; WAZ 8WA Mini Com Number 01925 664094 8 Meetings Care delivery this, day. day, 480uf Disabl
described feeling much better, and was out at the time of the call, dealing with banking affairs and it was agreed to to the scheduled appointment for the next day: The Care Co-ordinator was assured by her conversation with Mrs Cooke and advised that should Mrs Cooke's feelings change in any way, then she was to make contact with her Care Co-ordinator. In conclusion would again like to offer my apologies to the family of Mrs Cooke for the failings identified. trust this letter and attached action plan addresses the concerns raised. If ! can be of any further assistance or You require further information about the steps we have taken please do not hesitate to contact me_