An independent investigation into the care and treatment of Colin – April 2025

Information about Colin did not travel with him.
A ‘This Is Me’ (or equivalent care passport) document should be commenced in conjunction with the patient (where possible) and their carers when a diagnosis of dementia is given. This should be updated and refreshed throughout the patient’s journey and shared with all health and social care professionals involved in their care.

Care plans were not person-centred.
Patients with dementia (and/or delirium) must have person-centred care plans to ensure that care and treatment that is appropriate, meets their needs and reflects their personal preferences.

Within Broomfield and Basildon Hospitals there were occasions when clinical policies and procedures were not complied with.
The Trust must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that all policy/procedures are subject to regular audit or testing and staff trained in their use to ensure that required outcomes for patients are being achieved:
1. Medicines Management Policy in relation to the prescribing and administration of medications, and to include recording of allergies to medications, medication omissions, controlled drugs, sedation and rapid tranquillisation.
2. Medical Equipment Policy and checking the expiry dates of medical equipment/devices prior to use, particularly in relation to pressure infusion bags.
3. Care of Patients With Dementia Policy in relation to referrals to the Dementia Nurse, use of ‘This is Me’, care planning and unnecessary moves between wards.
4. Recognition and Management of Delirium Policy in relation to screening, medications management and care planning.
5. Observation/Enhanced Supervision Policy in relation to the roles, responsibilities and training requirements of security officers and other staff who undertake these tasks, record keeping and incident reporting (for staffing shortfalls and incidents of violence and aggression).
6. Record Keeping Policy in relation to nursing assessments, person-centred care planning and documentation of the rationale for key changes in care.
7. Admission, Discharge and Transfer Policy in relation to unnecessary moves between wards, internal handovers between wards and departments, and external handovers between Trust services and other organisations.
8. Palliative Care and End of Life Policy in relation to information sharing with the patient/family members and decision making.

Within Broomfield and Basildon Hospitals there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity.
The Trust needs to ensure that key aspects of the Mental Capacity Act are subject to regular audit or testing and staff trained in its use to ensure that people without capacity are supported in key decision making and within appropriate legal frameworks. Key areas of focus include:
1. Capacity assessments and best interests decisions in relation to care and treatment, accommodation and finance.
2. Deprivation of Liberty Safeguards in relation to capacity assessments, documentation, the management of challenging behaviours and the use of restrictive interventions, and involvement of the safeguarding team.
3. Lasting Power of Attorneys and their involvement in key decision making.
4. Advocacy in relation to appropriate use and referrals.
5. Safeguarding adults in relation to referrals and the response to concerns raised

There were several occasions when requests for emergency psychiatric input or consideration for a MHA assessment should have been made sooner when Colin was medically stable.
The Trust must ensure that patients who have behavioural and psychological symptoms receive a psychiatric assessment during or immediately after incidents of violence and aggression, with consideration of a Mental Health Act assessment if medically stable.

Incidents were not always reported or had insufficient information to allow a comprehensive investigation to be undertaken.
The Trust must ensure that the following policy is subject to regular audit or testing and staff trained in its use to ensure that required outcomes for patients and their carers are being achieved:
• Incident Reporting and Management Policy in relation to restrictive interventions and the reporting of incidents of violence and aggression, and the management and investigation of serious incidents.

Concerns raised by ML were not always responded to or acted upon in a decisive manner.
The Trust must ensure that the following policy is subject to regular audit or testing and staff trained in its use to ensure that required outcomes for patients and their carers are being achieved:
• PALS and Complaints Handling Policy in relation to the management of concerns and complaints raised by carers.

The acute hospital environment did not support improvements in Colin’s mental health and wellbeing.
The Trust should expedite the refurbishment of designated cubicles which can appropriately accommodate patients who have behavioural and psychological symptoms.

Within the inpatient and community teams there were occasions when clinical policies and procedures were not complied with.
The Trust must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that all policy/procedures are subject to regular audit or testing and staff trained in their use to ensure that required outcomes for patients are being achieved:
1. Medicines Management Policy in relation to the prescribing and administration of medications, and to include sedation and rapid tranquillisation.
2. Care of patients with dementia in relation to use of ‘This is Me’ and care planning.
3. Record Keeping Policy in relation to person-centred care planning.

Within the community there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity.
The Trust needs to ensure that key aspects of the Mental Capacity Act are subject to regular audit or testing and staff trained in its use to ensure that people without capacity are supported in key decision making and within appropriate legal frameworks. Key areas of focus include:
1. Capacity assessments and best interests decisions in relation to care and treatment, accommodation and finance.
2. Deprivation of Liberty Safeguards in relation to capacity assessments, the management of challenging behaviours and the use of restrictive interventions, and involvement of the safeguarding team.
3. Lasting Power of Attorneys and their involvement in key decision making. Advocacy in relation to appropriate use and referrals.
4. Safeguarding adults in relation to referrals and the response to concerns raised.
5. Advocacy in relation to appropriate use and referrals.

There were several occasions when emergency psychiatric input or a MHA assessment should have been considered when Colin was medically stable.
The Trust must ensure that patients who have behavioural and psychological symptoms receive a psychiatric assessment during or immediately after incidents of violence and aggression, with consideration of a Mental Health Act assessment if medically stable.

Within Goodmayes Hospital there were occasions when clinical policies and procedures were not complied with.
The Trust must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that all policy/procedures are subject to regular audit or testing and staff trained in their use to ensure that required outcomes for patients are being achieved:
1. Care of patients with dementia in relation to use of ‘This is Me’ and care planning.
2. Record Keeping Policy in relation to person-centred care planning.

Within Goodmayes Hospital there was some occasions when there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity.
The Trust needs to ensure that key aspects of the Mental Capacity Act are subject to regular audit or testing and staff trained in its use to ensure that people without capacity are supported in key decision making. Key areas of focus include:
1. Capacity assessments and best interests decisions in relation to finance.
2. Lasting Power of Attorneys and their involvement in key decision making.
3. Advocacy in relation to appropriate use and referrals.
4. Safeguarding adults in relation to referrals and the response to concerns raised.

Within the care home there were occasions when clinical policies and procedures were not complied with.
Woodland View Care Home must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that all policy/procedures are subject to regular audit or testing and staff trained in their use to ensure that required outcomes for patients are being achieved:
1. Medicines Management Policy in relation to the administration of medications, and to include medication omissions, sedation and rapid tranquillisation.
2. Physical health monitoring including the requirement for and response to physiological observations.
3. Care of patients with dementia in relation to use of ‘This is Me’ (or an equivalent) and care planning.
4. Admission in relation to compliance with the criteria for acceptance to the home.

Within the care home there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity.
Woodland View Care Home needs to ensure that key aspects of the Mental Capacity Act are subject to regular audit or testing and staff trained in its use to ensure that people without capacity are supported in key decision making and within appropriate legal frameworks. Key areas of focus include:
1. Capacity assessments and best interests decisions in relation to care and treatment, accommodation and finance.
2. Deprivation of Liberty Safeguards in relation to capacity assessments, documentation, the management of challenging behaviours and the use of restrictive interventions.

Incidents were not always reported in line with regulations and to facilitate a comprehensive investigation to be undertaken.
Woodland View Care Home must ensure that the following policy is subject to regular audit or testing and staff trained in its use to ensure that required outcomes for patients and their carers are being achieved:
1. Incident Reporting and Management Policy in relation to restrictive interventions and the reporting of incidents of violence and aggression.

Within the care home there were occasions when clinical policies and procedures were not complied with.
Anisha Grange Care Home must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that all policy/procedures continue to be subject to regular audit or testing and staff trained in their use to ensure that required outcomes for patients are being achieved:
1. Medicines Management Policy in relation to the administration of medications, and to include sedation.
2. Physical health monitoring including the requirement for and response to physiological observations.
3. Safeguarding adults in relation to documenting the rationale for when safeguarding referrals are not required, as part of incident management processes.