South Warwickshire review

GEH and SWFT should jointly review the issues about discharge planning, referral systems and failures of inter-agency communication, which have been highlighted by this DHR. The Review should aim to:
 Establish the facts of what actually occurred, including whether or not the referrals to SWFT (as stated in GEH’s IMR and chronology) were in fact sent by GEH and / or received by SWFT.
 Having established the facts, to identify the root causes of no ICT service (now known as Community Emergency Response Team) being provided and the District Nursing service only commencing as a result of a direct request by the perpetrator, following the victim’s last discharge.
 Establish a multi-agency action plan (for implementation by GEH, SWFT and any other relevant parties) to address the root causes. This is likely to include work to ensure that that future hospital discharge plans are clearly recorded and agreed between GEH and partner health and social care providers, for services to be delivered within time frames specified in the discharge plan.
This recommendation should be overseen by the relevant Warwickshire Clinical Commissioning Group, who should report to Warwickshire Safeguarding Adults Board (SAB) on the findings of the GEH/SWFT Review and on implementation of the resulting action plan. Lead involvement by the SAB is indicated, as the issue of discharge planning is recognised as a wider Safeguarding Adults concern, rather than being specific to issues of domestic abuse or homicide, which would have indicated a lead role for the Community Safety Partnership (CSP).

GEH should further review the questions raised by this DHR (see section 3.6) about the victim’s mental capacity to consent to treatment, during her admissions in May and June 2014 and the A&E attendance on 14 June. This Review should consider whether or not clinicians worked appropriately and in line with the MCA Code of Conduct and Deprivation of Liberty Safeguards. GEH should advise the CCG of the findings from this Review and any action plan which may follow.

Key learning from this case should be shared and utilised within the Warwickshire area and more widely, with a specific reference to the key learning points relating to:
 Hospital discharge planning
 Raising awareness about the needs of older and ‘hard to reach’ carers who may refuse help and / or go to considerable lengths to conceal the need for carer support services.

The CSP Chair should write to the Care Quality Commission (copied to the relevant Warwickshire CCG) drawing their attention to the findings of this DHR, with specific reference Recommendations 1 and 2.

To re-iterate within care planning training and via a learning alert across the Trust the importance of effective communication between professionals, services and agencies and the need for the patient and their experience to be at the centre of this where agencies hold differing views as to the source of the ill health .

MCA training and regular updates for all decision makers.

As a response to this Review awareness will be highlighted in the Safeguarding Adults training when it is reviewed in April 2015.