An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust: Published November 2022

Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) must provide significant assurance to the Trust Board and its commissioners that it has a robust environmental and ligature risk assessment process and the ability to respond effectively and urgently to mitigate risks identified through this process.

TEWV must ensure that risk assessments for young people in child and adolescent mental health services (CAMHS) are based on a psychological formulation and a full understanding of the longitudinal patterns and instances of harm, and where possible are developed by a multidisciplinary team (MDT) in conjunction with the young person and their family.

TEWV and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) must ensure that any young person with a recent history of self-ligature has a written care plan that identifies how staff (or families in the case of a community setting) are to care for the young person, and mitigate the risks of fatal self-ligature.

TEWV and CNTW must ensure that plans of care for young people in CAMHS incorporate evidence-based practice.

CNTW must ensure that where there is a risk of re-traumatising young people in restraint, the triggers for trauma are recognised and there are written plans of care to manage this risk.

TEWV must ensure that decisions about observation levels are clearly recorded and that all interventions are clearly documented.

TEWV must ensure that plans of care are written so that they are clear, patient-centred, easy to understand and follow, and guide staff to care for the young person based on the assessment of all needs and risks.

TEWV must ensure that trauma-informed therapy is a routine aspect of a young person’s care provision where there are any considerations of previous trauma, not just diagnosed post-traumatic stress disorder (PTSD), and that there are sufficient staff with the requisite skills to provide this.

Health and social care agencies must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high.

Local Authorities and Health providers must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision where they are in the care of the Local Authority to ensure that support is holistic and meets the educational; social; physical health and emotional needs of children and young people as well as their mental health needs.

CNTW must ensure there is a written protocol that details the pathway for discharge from Ferndene Psychiatric Intensive Care Unit (PICU), including timescales for informing and involving families and the young person in arrangements so that, wherever possible, a young person is not suddenly transferred without adequate preparation.

TEWV and CNTW must ensure the organisational approach to safeguarding young people proactively involves and informs the relevant local Safeguarding Children’s Partnership of all instances where a young person is placed at risk, including the use of unregulated and unsupported accommodation in the community.

TEWV must ensure that services consider and document robust risk management processes to safeguard children where threats have been to made to harm them by older family members who are also service users.

NHS North East and North Cumbria (NENC) Integrated Care Board, as system leaders, should work with the Directors of Children’s Services North East region to commission services that will meet the needs of the small but growing number of young people with complex needs and challenging behaviours that have both health and social care needs. This should include a review of demand to ensure services have the appropriate capacity locally to minimise placing children out of area.

NHS North East and North Cumbria Integrated Care Board, the NENC provider collaborative and relevant local authorities must ensure there is appropriate commissioner safeguarding oversight of all Tier 4 CAMHS inpatient services in the region.

NHS England Specialised Commissioning and the Care Quality Commission (CQC) must ensure that when there is enhanced surveillance of services following quality concerns, the themes and patterns of all incidents are rigorously scrutinised and analysed.

TEWV should ensure there is much greater detail and understanding of the patterns and instances of harm within services through the regular reporting and interrogation of data, when required, to inform both individual patient clinical care planning, and Trust and service understanding of safety and quality issues.

TEWV must redesign its response to incidents and patient safety to provide robust clinical governance, so that it conforms with the NHS England Serious Incident framework (SIF),26 its successor policies and other relevant guidance and best practice, so that it is assured that all relevant incidents are investigated thoroughly, and organisational learning can be quickly put in place.

NHS England Regional Team, NHS North East and North Cumbria Integrated Care Board and the CQC must consider the impact and risks on Tier 4 CAMHS if a local Safeguarding Board is found to be weak or inadequate, or a local provider is found to have a major staffing issue.

TEWV should ensure that it improves its response to complaints, so that complaints are managed in line with NHS England best practice guidance – tracking and reporting this through the relevant Board subcommittee processes.

TEWV should review the Duty of Candour Policy and ensure that it is monitored through the relevant Board subcommittee processes. As part of this it must ensure that where there has been a death in a service, whether through self-harm/suicide or homicide, that families are given appropriate meaningful and regular family liaison and support through personal contact with a nominated officer of the Trust.

Commissioners should assure themselves that providers are following the NHS Child and Adolescent Mental Health Services Tier 4 (CAMHS T4): General Adolescent Services including specialist eating disorder service specification and the QNIC standards for use of mobile phones and social media.