An independent investigation into the care and treatment of MS: Published 14 November 2018

In accordance with the Recommendations made in Mental Health in General Hospitals: Treat as One (Date of publication: 26th January 2017) all hospital staff who have interaction with patients (including clerical and security staff), should receive training in mental health conditions in general hospitals. Training should be developed and offered across the entire career pathway, from undergraduate, to workplace-based continued professional development.

Following the care of MS, the Independent Investigation Team understands that a review has been undertaken by LYPFT and LTHT which has addressed a number of the concerns highlighted in this report. The review has resulted in significant changes to the model of liaison services and has been supported by significant additional income from commissioners. In order to establish the success of the review conducted by LYPFT referred to in paragraph 5.1 above and to confirm that the recommendations in the NCEPOD report ‘Treat as One’ report have become embedded in current practice, it is recommended that an audit is conducted by LYPFT. The audit should seek to establish the nature and extent of multi-disciplinary working involving professionals and clinicians when caring for mental health patients being treated on general wards following the introduction of the new model of working. As a minimum, the audit should cover the following areas; a. The nature of the problem (diagnosis or formulation); b. The legal status of the patient and their mental capacity in the event that a decision might need to be made, if relevant; c. A clear documentation of the mental health risk assessment – immediate and medium term; d. Whether the patient requires any additional risk management e.g. observation level; e. A management plan, including medication or therapeutic intervention; f. Advice regarding contingencies, e.g. ‘if the patient wishes to self-discharge please do the following….’ g. A clear discharge plan in terms of mental health follow-up; h. Mental health involvement in transfer process from acute setting; i. Risk assessment relating to discharge process including any transfer arrangements. j. Such an audit should seek to establish the involvement of organisations or individuals without specialist knowledge such as transport providers in the MDT process. Having completed the audit any deficiencies identified should be rectified and the audit repeated to confirm effectiveness thus completing the audit cycle.

In order to overcome the divide between mental and physical healthcare, liaison psychiatry services should be fully integrated into general hospitals. The structure and staffing of the liaison psychiatry service should be based on the clinical demand, both within working hours, and out-of-hours, so that they can participate as part of the multidisciplinary team.

LYPFT is required to undertake an audit to establish whether the delay in issuing a comprehensive discharge summary is a Trust wide issue and if so, to formulate a strategy in order to address any issues which are identified.

LYPFT is required to adopt a strategic response in relation to its consolidation of patient records, i.e. the migration of the paper and digital notes system into one system. The Independent Investigation Team is of the view that ideally, this should be the unification of records within an electronic system, capable of allowing a care professional at any given stage of treatment to retrieve information relating to the patient and in particular, the status of their risk assessments, at a glance, in order to ensure that they have all requisite and relevant clinical information necessary to make an informed decision on the appropriate next step. For instance, in relation to the facts of MS’s case specifically, a significant issue identified by the Independent Investigation Team related to the fact that key information, of considerable clinical significance to Trainee Psychiatrist 2’s decision to discharge MS from LYPFT, was ‘lost’ in the paper notes and therefore not readily available. A successfully ‘consolidated’ patient record or comprehensive risk assessment, (preferably electronic) could, in this instance, have provided the relevant clinician with information that could have resulted in a significantly different direction in MS’s care, at the time that clinician needed it. A strategic response at LYPFT Board level is therefore required in order to address the practical difficulties faced by their clinicians when presented with the challenge of accessing a service user’s historical records over multiple systems. The loss of information when migrating to electronic service user records is also a risk which must be addressed. New database packages allow a Care Professional to retrieve from their (consolidated) electronic patient record to show the service users under a team member’s care, and the update status of risk assessments for the last 6 months. This does not address the needs of a patient who has had previous admissions over a period of time. Consequently, a protocol should be developed to ensure a review of paper and electronic records held for service users who have experienced a number of episodes of care, such as MS.