An independent inquiry into the care and treatment of JK: December 2016

All service users who meet the criteria for the Care Programme Approach are now allocated a care co-ordinator who works in partnership with the service user and aims to build a therapeutic relationship. The care co-ordinator remains constant and provides continuity during the involvement of other professionals. Compliance with this standard is monitored by the ‘Tableau’ business intelligence tool. Service users who do not meet the criteria for CPA will have a lead practitioner either through their consultant psychiatrist or through a practitioner led clinic. The Trust has developed guidance for these and other clinics. No service users who are being followed up only in outpatients would now be seen by a series of junior doctors. Instead at the end of a rotation their care will be passed back to the consultant and they will continue with that consultant. In the case of JK he would not now have a series of junior doctors providing his care. The Trust currently reports on all CPA compliance activity to its commissioners through the regular joint Clinical Quality Review Meetings (CQRM). The Trust’s CPA 12 month review up to November 2017 demonstrated compliance across all services of above 96%. This means that all patients on CPA have had their care reviewed by a care co-ordinator at the appropriate time interval. The CPA audit looks for evidence in the medical records of care planning collaboration and care planning details, as well as sharing of the completed care plan (CPA and non-CPA) with service users and other health professionals, and the involvement of carers. There are plans for a new section to be added which will seek the views of patients directly. A further CPA audit was undertaken in January 2018. Results, not yet fully analysed, indicate (amongst other indicators) significant improvements in the proportion of service users who were appropriately on CPA, documented evidence of the involvement of families and carers, service user involvement in risk assessment, and service user involvement in a CPA review (up from 78% to 94%). This comprehensive document is broken down by team, thus providing useful information for targeting further training and service development. There was clear accountability for the achievement of these action points in the Trust’s action plan. The actions were appropriate to address this recommendation and were robust and auditable. It appears that the actions have been completed. However such actions will need continuing monitoring particularly at times of pressure on the service.

The Trust has developed the ‘Triumph’ Psychosis pathway with the Academic Health Science Network. This provides guidance for staff, carers and service users on what NICE interventions should be offered. The first year evaluation indicated some relatively small but positive improvements in care provided for individuals and their families. The availability of cognitive behavioural therapy for psychosis has been increased and a set of ‘Triumph’ leaflets have been produced which explain the therapeutic options, including cognitive behaviour therapy, family work and family and friends support groups. Outcome measures for the early intervention in psychosis service (EIP) include a focus on social circumstances, e.g. accommodation and employment, and will provide measures of improvement in these areas. A recent review demonstrated that the pathway was meeting its targets in 80% of cases. NHS Southampton CCG has funded access to the Healios family work website which aims to empower patients and families affected by mental and physical illnesses. Carers’ workers are employed within teams and some staff across EIP and community mental health teams (CMHTs) are trained family workers. In Southampton, employment workers have been attached to each CMHT by the Local Authority using NICE approved employment interventions. The employment workers help service users to find work and then support them and employers to maintain that employment. Reports in March and August 2017 from this Integrated Mental Health Employment Service indicate that this is a valuable and effective service. We heard from Trust staff that the service is highly valued. Assessment of relapse indicators is included in Wellness Recovery Action Planning and MyCrisisPlan which are being used with service users. The report to the Clinical Quality Review Meeting (CQRM) in December 2017 indicated that the pathway has had a significant impact on practice. The report audited in detail the care provided to three service users with early psychosis and identified where practice had followed the pathway and where there were gaps. This recommendation has been incorporated into the development of the Triumph psychosis pathway. The pathway appears to be comprehensive, clinically appropriate and quite ambitious in its scope. Many elements of the pathway are auditable, particularly if qualitative evaluation techniques are used, to complement quantitative data. These actions were therefore appropriate to achieve this recommendation and are embedded in service-wide changes in service delivery and practice. Like other action points they will need continuing audit and evaluation. However, there was a recommendation in the internal investigation that all risk information held in earlier paper records should be uploaded onto the electronic RiO system so that it would be available currently. We were told that this has not happened in all cases. There was lack of clarity about whether the paper records would be available in community teams and outpatients or whether they would require requests to take them out of archives. This needs further clarification.

There have been several developments to address this issue. In Southampton, the charity Carers in Southampton has delivered training for staff, and there is also training for carers through the Recovery College. The Adult Mental Health Division are also hosting ‘Learning Networks’ on working with families and carers, with families attending to talk to staff about their experiences. The Trust commissioned a review of families’ experiences of the investigation process following the death of a loved one. A consistent theme to emerge from the families who participated was that engagement with them was poor even before their loved one died, making engagement after their death a much more difficult process. The review recommended that the Trust should work with service users, patients, families and staff to identify, develop and implement best practice on engaging with families. This resulted in the development of a separate Family Involvement Action Plan. The action plan is comprehensive and contains 31 action areas many of which focus on family involvement from the beginning of care, training of staff, and confidentiality. The majority of the action points were recently assessed as complete or on track. We have been told of a significant culture change in relation to family engagement within the Trust. Some of this has come about through family involvement following an incident when they are keen to make sure that something similar does not happen to other families in future. The Trust has a new small tri-fold leaflet, entitled ‘Families, carers and friends - what to expect from us during a person’s care and treatment’. This leaflet is clear, well-written and jargon free. It sets out how the Trust will enable family members to be involved in the development of services and in the care of their family member by listening, responding to concerns, and valuing their expertise and knowledge. This recommendation has been addressed through a comprehensive plan to focus on what has been recognised as a Trust-wide issue which needed some fundamental rethinking. The actions are appropriate and relevant and the original recommendation has been fully addressed.

This has been addressed in a number of ways: New Being Open and Duty of Candour policy and procedure guidance; A leaflet for patients and their families entitled ‘Information on investigation into serious incidents’ which describes what happens when things go wrong. In the event of a death a personalised letter is written to the family offering condolences and informing them of the investigation including how they can participate. Guidance on family involvement in the Procedure for Reporting and Investigating Deaths. There are three levels of Duty of Candour / Being Open training. The basic level is now electronic, leading to a significant increase in staff undertaking the training. Between April 2017 and February 2018, 4799 clinical staff successfully completed this training. The electronic training programme is incorporated into induction and will be repeated by existing staff every three years. Training on the Duty of Candour and the involvement of families within the two day Investigation Officers training. Compliance with Duty of Candour is recorded within the risk management system and is monitored in two ways: a) Through the serious incident process with the 48 hour panel asking the question as to whether the initial contact has been made and b) ensuring someone is nominated to lead on determining what contact/support the patient or the family require. We have seen evidence of this in an extract from a regional Initial Management Assessment (IMA) panel where the duty of candour and a nominated person to link with the family of a deceased service user were discussed. The review of the serious incident investigation reports through both divisional and corporate panels. Recognition through the involvement of families in the investigation process that different people want a varying level of support that is completely individualised to their wishes. Recruitment of a Family Liaison Officer (FLO) whose role it is to offer that higher level of individual support and act as a contact point for advice and signposting to other services. There is evidence of the FLO reporting regularly to the Caring Group and other meetings. Trust-wide master class training provided by the FLO and chaplain on how to share difficult information with family members. In addition the Trust’s Family Involvement Action Plan includes details of a significant number of action points relating to serious incidents and family involvement, most of which are reported as being on track. The Trust has developed a range of relevant and appropriate changes in policy and practice which address this recommendation. There is evidence that these are having a significant impact on the way in which families are kept informed and supported following a serious incident. Once again this is ongoing work.

Whilst the numbers are very low, for the most serious incidents (homicides and inpatient suicides) initial contact with families is now from an Executive Director. For other serious incidents, the Executive Director for each division is notified through the Ulysses system via a serious incident alert. This is followed up by an internal notification form which alerts them to the external reporting of a serious incident on the STEIS system. The 48 hour panel, which is chaired in each division by either the Clinical Services Director, Head of Nursing or Head of allied health professionals (AHPs), oversees the process of determining who the most appropriate person would be to take forward contact with family members or the patient themselves. They will keep the executive director appraised of the situation and will facilitate their involvement in family liaison if this is requested. This recommendation appears to have been fully addressed through these action points. We were told about two recent serious incidents following which Executive Directors have taken the lead in making contact with the families.

There is now a clear process for incident reporting and investigating all of which is recorded on the electronic system, Ulysses. Each area within the Trust has a 48 hour panel which meets at 1 pm daily to review any incidents in the previous 48 hours. The panel membership may vary but generally includes the head of nursing, the clinical services director and the manager who has written the serious incident report. Action plans and recommendations are then scrutinised at the divisional panel and the corporate panel. All information on serious incidents is also uploaded onto STEIS and reported to the commissioners. Reports on all incidents are taken to the Quality and Safety Committee (a committee of the board which has three non-executive director members). This committee may ask for more information. Reports on impact graded category 5 serious incidents go to the Board in full. There are joint meetings with the CCG and the Trust which focus on the review of actions plans. The Clinical Quality Review Meeting (CQRM) receives the numbers of serious incidents, some information about new incidents and those which have been closed and their learning points. However the details of incidents are not taken to this meeting. Instead there is a joint meeting twice a month between the CCGs and the Trust referred to as the Serious Incident Closure Panel or the Serious Incidents (SI) Commissioners Review Panel which scrutinises reports and action plans and considers closure of the investigation. The ongoing work of implementation of action plans is followed up within the Assurance Panel which meets monthly and is convened by the Trust and attended by at least two of the CCGs. This meeting is also known as the Evidence of Improvement Panel, and receives details of recommendations and action plans when they are nearing completion. These are often attended by clinical staff who are able to tell the meeting about the actual implementation of recommendations in practice. The action plans are not automatically signed off at the meeting, rather the panel may ask for further evidence or more detail. Processes have been put in place to ensure that in addition to the current information they receive, Trust Board members will receive the full details of investigation reports for particularly serious incidents. This will include reports into: homicides; inpatient suicides; where the incident has been reported to the National Reporting and Learning System (NRLS) as the most serious Grade 5 category and deaths where the inquest resulted in a Prevention of Future Deaths Report from the Coroner. Each month, a Corporate Governance paper is presented at Public Board meetings. This includes an appendix which details items that have been reported to Board members in the previous month. This section will now include details of reporting to Board members on the above four groups of particularly serious incidents. Evidence will also be obtained through the QSC minutes. This recommendation appears to have been fully addressed and the actions have been embedded into Board practice.