Tees Esk and Wear Valleys NHS Trust
NHS / Health Body
Action Taken
Following the inquest, the individual nurse received capability management and observed best practices. The Trust is reviewing policy and practice, planning further suicide prevention training, and monitoring implementation via the Directorate's Quality Assurance Group. Trust-wide actions will be allocated to an owner and monitored by the Patient Safety Team. (AI summary)
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Dear Mr Tweddle Regulatlon 28 Report In respect of the death of Mr Jeffrey Gash Thank you for your Regulation 28 report dated 18 August 2014 in respect of the above individual and your findings from the inquest into his death. have tried to address each of your concems in tum below, and have summarised key actions (with timescales) in the appended action plan.
1. The Crisls Team nurse accepted In evldence (that she) should have been more forceful and detalled In explorlng wlth the deceased hls new symptoms, audltory halluclnatlons and hearing volces whlch evldences a Iack of tralning and understandlng of the nature of and Importance of an appropriate level of telephone assessment As you have described, the individual nurse involved in the care of Mr Gash recognised in the inquest that she should have been more detailed in her questioning of him in relation to specific symptoms. This individual has, since the inquest, spent some time reflecting on this with her clinical supervisor: In addition, from September 2013 to January 2014 the individual nurse went through a period of informal capability management During this time she did not undertake the shift co-ordinator role responsibilities and worked all shifts alongside a more senior and experienced member of the team: She observed best practice assessments and then her assessment practice was observed and Way
evaluated: Once the observing expert clinician , Advanced Practitioner and Team Manager were all satsified that she had acheived the appropriate levels of competence she was able t0 resume the shift co-ordinator role Since that time, periodic checks of her assessments (and assessments done by the rest of the team) have been undertaken by the Consultant Psychiatrist to provide assurance that they are of appropriate quality. This has also enabled us to provide specific feedback to staff as needed to help them develop and improve: are now assured that the individual nurse has increased her competence and knowledge in telephone assessment skills together with an overall improvement in team performance.
2. No evldence was provlded at the Inquest to Indicate a formal Trust pollcy on when to decllne home vlslts on the grounds of personal safety and securlty and the nurse relled upon belng told of concerns about vlsiting thls property from colleagues but did not record the same or any explanatlon for her declslon: The absence of a clear pollcy and a pollcy for recording declslons made or understanding and tralnlng thereon is an area of concern: In relation to your specific comments about Trust policy, the Trust Clinical Risk Assesment and Management (CRAM) policy outlines the responsibilities for staff to determine potential risks and the need to document these within the clinical record. The risks identified in relation to Mr Gash at home should have been assessed within gudiance provided by that policy and recorded in the clinical record. Decisions about making Ione or accompanied visits to the home should have been recorded in the clinical record and processes in the Trust Health and Safety workbook also provide guidance on assessing whether a home visit is appropriate or not The Trust also has a Lone Working Procedure which should be completed for all staff who may in the course of their duties have periods where they are working alone including in the context of a high risk visit This is to some extent addressed within SUI report where it is documented that a more assertive approach may have helped within the engagement findings: The policy lead for these areas will be asked to review the relevant policy against your indings and ensure that these are fully taken into account and an implementation plan produced accordingly- In relation to recording the information from colleagues, and the individual nurse's decision making on the shift in question, there is already an 'alerts' section in our electronic care record which staff are asked t0 use t0 document risks in a way that this information is available to all staff working with a specific patient The Team Manager has previously highlighted the importance of recording this with the team, but since Mr Gash's inquest has further reinforced this via team meetings: In addition, the Head of Service for Durham and Darlington AMH Services has asked the Crisis Team Manager to share your recomendations with the Specialty's Acute Care Group in order that the Trust standard operational policy for Crisis Teams can be strengthened accordingly: We visting the the the
also acknowledge the conclusions from the inquest that further options may have been available in the absence of Mr Gash agreeing t0 see the crisis team at the hospital base, and indeed am aware of instances where staff have used alternative venues for appointments. Staff have been reminded of the need t0 explore and utilise alterative appointment venues. 3 Notwlthstanding the fact that the deceased declined to attend the hospltal for a face to face Intervlew, Insufficlent welght was glven to the reason therefore and whether domestlc and other pressures were mllltating agalnst hlm attending were not properly considered, If at all: GIven that there was an Insufflclency of enqulry Into the deceased'$ state of mind and In partlcular a fallure to further explore the Issue of hlm clalmlng to hear volces, an Inadequate assessment of rlsk was undertaken It was accepted by the Trust In evldence that there ought to have been face to face consultatlon wlth the deceased and that had he not agreed to It voluntarlly, then there ought to have been compulsory assessment Since Mr Gash's sad death, the individual nurse has critically reflected upon this at length with the team manager her period of informal capability management described under point 1 above_ agree that more in-depth exploration of his reasons for not wishing to attend should have been undertaken The Trust Did Not Attend policy does highlight that the nurse should have contacted the GP immediately to agree a management plan;, in situations where high risks have potentially been identified. As noted above, the individual nurse has undergone a period of observed practice such that the Advanced Practitioner and Team Manager are now satisfied that she would now manage this situation differently, in that issues would be explored in more depth: We are also confident that she would now, and has been shown t0, use colleagues within the team for additional opinions, and make better use of medical staff for consideration when a formal assessment under the Mental Health Act may be requried. Your recommendations in relation to this have been shared with the team as a whole t0 ensure that their practice reflects the specific actions we have completed with individual nurse. 5, The cllnical rlsk assessment and management pollcy document (verslon 5) whlch was presented In evldence falls to clarlfy the nature and detall of what form of risk assessment needs to be completed when a non In-person face to face Is undertaken: Thus, the notes entered on the PARIS system were unclear as to thelr author's vlew of the risk of hamm where It was accepted In evldence that full detalls of the assessment of risk and Its concluslon are central to the crlsls team process. The Trust has carrled out an SUI. Certaln recommendatlons have been made and are Implemented: The Inquest; however, a8 evldenced above, revealed other Issues not dealt wlth by the SUI and therefore a complete re-evaluatlon of the deceased's contact wlth the Trust should be undertaken taking Into account the evldence glven at the Inquest s0 that a complete overvlew of Trust pollcy dealing with the above matters and any other such revlew might uncover can be considered by management and If agreed, Implemented: and during the belng self
A further review of the Trust's contact with Mr Gash be undertaken, incorporating other matters arising the inquest The review will include the efficacy and relevance of the current Trust policy guidance and an analysis of compliance with that guidance included in the review A Trustwide review of the clinical risk (CRAM) policy and practice is currently underway; with initial reports due in the spring; the information from this Serious Untoward Incident investigation and the inquest will be fed into that review. Further training and development in suicide prevention Is planned for early next year. Implementation plans for the new policy and the training will be evaluted to ensure compliance_ In conclusion; the Adult Mental Health Directorate had begun several pieces of improvement work prior to the inquest t0 address some of the concems, and can only apologise if these were not clear through the evidence given by staff: However there are also a number of Trust-wide issues highlighted through the inquest process which will take a little longer to fully address. The implementation of the actions relating specifcally to issues within the gifit of the Aduit Mental Health Directorate within the action plan attached will be monitored via the Directorate's Quality Assurance Group on monthly basis to ensure completion. In addition review of the effectiveness of the actions, and policy compliance will be reported to the Locality Management and Govemance Board: Trust-wide actions identified will be allocated to an appropriate action plan owner and monitored by the Patient Safety Team by their goverance processes to ensure they are completed to an appropriate standard The Diretorate Quality Assurance Group processes will also ensure that the lessons from this case and associated leaming are shared across other in-patient areas and crisis teams in order that - can assure us that similar issues should not occur elsewhere. The Trust has corporate processes to both monitor completion of serious incident action plans and to audit the efiectiveness of those actions in creating change and improvement hope that the information contained here, and in the amended action plan attached, provides you with the necessary assurance YoU require.
1. The Crisls Team nurse accepted In evldence (that she) should have been more forceful and detalled In explorlng wlth the deceased hls new symptoms, audltory halluclnatlons and hearing volces whlch evldences a Iack of tralning and understandlng of the nature of and Importance of an appropriate level of telephone assessment As you have described, the individual nurse involved in the care of Mr Gash recognised in the inquest that she should have been more detailed in her questioning of him in relation to specific symptoms. This individual has, since the inquest, spent some time reflecting on this with her clinical supervisor: In addition, from September 2013 to January 2014 the individual nurse went through a period of informal capability management During this time she did not undertake the shift co-ordinator role responsibilities and worked all shifts alongside a more senior and experienced member of the team: She observed best practice assessments and then her assessment practice was observed and Way
evaluated: Once the observing expert clinician , Advanced Practitioner and Team Manager were all satsified that she had acheived the appropriate levels of competence she was able t0 resume the shift co-ordinator role Since that time, periodic checks of her assessments (and assessments done by the rest of the team) have been undertaken by the Consultant Psychiatrist to provide assurance that they are of appropriate quality. This has also enabled us to provide specific feedback to staff as needed to help them develop and improve: are now assured that the individual nurse has increased her competence and knowledge in telephone assessment skills together with an overall improvement in team performance.
2. No evldence was provlded at the Inquest to Indicate a formal Trust pollcy on when to decllne home vlslts on the grounds of personal safety and securlty and the nurse relled upon belng told of concerns about vlsiting thls property from colleagues but did not record the same or any explanatlon for her declslon: The absence of a clear pollcy and a pollcy for recording declslons made or understanding and tralnlng thereon is an area of concern: In relation to your specific comments about Trust policy, the Trust Clinical Risk Assesment and Management (CRAM) policy outlines the responsibilities for staff to determine potential risks and the need to document these within the clinical record. The risks identified in relation to Mr Gash at home should have been assessed within gudiance provided by that policy and recorded in the clinical record. Decisions about making Ione or accompanied visits to the home should have been recorded in the clinical record and processes in the Trust Health and Safety workbook also provide guidance on assessing whether a home visit is appropriate or not The Trust also has a Lone Working Procedure which should be completed for all staff who may in the course of their duties have periods where they are working alone including in the context of a high risk visit This is to some extent addressed within SUI report where it is documented that a more assertive approach may have helped within the engagement findings: The policy lead for these areas will be asked to review the relevant policy against your indings and ensure that these are fully taken into account and an implementation plan produced accordingly- In relation to recording the information from colleagues, and the individual nurse's decision making on the shift in question, there is already an 'alerts' section in our electronic care record which staff are asked t0 use t0 document risks in a way that this information is available to all staff working with a specific patient The Team Manager has previously highlighted the importance of recording this with the team, but since Mr Gash's inquest has further reinforced this via team meetings: In addition, the Head of Service for Durham and Darlington AMH Services has asked the Crisis Team Manager to share your recomendations with the Specialty's Acute Care Group in order that the Trust standard operational policy for Crisis Teams can be strengthened accordingly: We visting the the the
also acknowledge the conclusions from the inquest that further options may have been available in the absence of Mr Gash agreeing t0 see the crisis team at the hospital base, and indeed am aware of instances where staff have used alternative venues for appointments. Staff have been reminded of the need t0 explore and utilise alterative appointment venues. 3 Notwlthstanding the fact that the deceased declined to attend the hospltal for a face to face Intervlew, Insufficlent welght was glven to the reason therefore and whether domestlc and other pressures were mllltating agalnst hlm attending were not properly considered, If at all: GIven that there was an Insufflclency of enqulry Into the deceased'$ state of mind and In partlcular a fallure to further explore the Issue of hlm clalmlng to hear volces, an Inadequate assessment of rlsk was undertaken It was accepted by the Trust In evldence that there ought to have been face to face consultatlon wlth the deceased and that had he not agreed to It voluntarlly, then there ought to have been compulsory assessment Since Mr Gash's sad death, the individual nurse has critically reflected upon this at length with the team manager her period of informal capability management described under point 1 above_ agree that more in-depth exploration of his reasons for not wishing to attend should have been undertaken The Trust Did Not Attend policy does highlight that the nurse should have contacted the GP immediately to agree a management plan;, in situations where high risks have potentially been identified. As noted above, the individual nurse has undergone a period of observed practice such that the Advanced Practitioner and Team Manager are now satisfied that she would now manage this situation differently, in that issues would be explored in more depth: We are also confident that she would now, and has been shown t0, use colleagues within the team for additional opinions, and make better use of medical staff for consideration when a formal assessment under the Mental Health Act may be requried. Your recommendations in relation to this have been shared with the team as a whole t0 ensure that their practice reflects the specific actions we have completed with individual nurse. 5, The cllnical rlsk assessment and management pollcy document (verslon 5) whlch was presented In evldence falls to clarlfy the nature and detall of what form of risk assessment needs to be completed when a non In-person face to face Is undertaken: Thus, the notes entered on the PARIS system were unclear as to thelr author's vlew of the risk of hamm where It was accepted In evldence that full detalls of the assessment of risk and Its concluslon are central to the crlsls team process. The Trust has carrled out an SUI. Certaln recommendatlons have been made and are Implemented: The Inquest; however, a8 evldenced above, revealed other Issues not dealt wlth by the SUI and therefore a complete re-evaluatlon of the deceased's contact wlth the Trust should be undertaken taking Into account the evldence glven at the Inquest s0 that a complete overvlew of Trust pollcy dealing with the above matters and any other such revlew might uncover can be considered by management and If agreed, Implemented: and during the belng self
A further review of the Trust's contact with Mr Gash be undertaken, incorporating other matters arising the inquest The review will include the efficacy and relevance of the current Trust policy guidance and an analysis of compliance with that guidance included in the review A Trustwide review of the clinical risk (CRAM) policy and practice is currently underway; with initial reports due in the spring; the information from this Serious Untoward Incident investigation and the inquest will be fed into that review. Further training and development in suicide prevention Is planned for early next year. Implementation plans for the new policy and the training will be evaluted to ensure compliance_ In conclusion; the Adult Mental Health Directorate had begun several pieces of improvement work prior to the inquest t0 address some of the concems, and can only apologise if these were not clear through the evidence given by staff: However there are also a number of Trust-wide issues highlighted through the inquest process which will take a little longer to fully address. The implementation of the actions relating specifcally to issues within the gifit of the Aduit Mental Health Directorate within the action plan attached will be monitored via the Directorate's Quality Assurance Group on monthly basis to ensure completion. In addition review of the effectiveness of the actions, and policy compliance will be reported to the Locality Management and Govemance Board: Trust-wide actions identified will be allocated to an appropriate action plan owner and monitored by the Patient Safety Team by their goverance processes to ensure they are completed to an appropriate standard The Diretorate Quality Assurance Group processes will also ensure that the lessons from this case and associated leaming are shared across other in-patient areas and crisis teams in order that - can assure us that similar issues should not occur elsewhere. The Trust has corporate processes to both monitor completion of serious incident action plans and to audit the efiectiveness of those actions in creating change and improvement hope that the information contained here, and in the amended action plan attached, provides you with the necessary assurance YoU require.