Source · Investigations in the NHS

An independent investigation into the care and treatment of patient E: Published January 2025

North East and Yorkshire Published 01 Jan 2025

This is the executive summary of the independent investigation into the care and treatment of patient E.

Acceptance status

Per recommendation

No Response Published

Total recommendations

About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

14 total

Recommendation

There were weaknesses in the application of the Failure to Attend Policy. The Trust must strengthen their response to patient non-engagement by: • identifying patients at risk of non-engagement who are on CPA, and entitled to Section 117 aftercare; • … Read more

Recommendation

There was an inadequate discharge plan and no Section 117 meeting in advance of discharging Patient E from the CMHT in May 2021. • The Trust must ensure discharge planning processes are revisited to ensure that Section 117 reviews are … Read more

Recommendation

There was infrequent CLM supervision in this case that was not in line with Trust policy. The challenges of managing a patient who did not engage were not adequately explored and resolved. The Trust must assure itself that anyone providing … Read more

Recommendation

The monitoring of Patient E’s medication, efficacy, side effects and his compliance was not adequate. • The Trust must ensure that services users on anti-psychotic medication are monitored at appropriate intervals for side effects using the appropriate methods (e.g. LUNSERS … Read more

Recommendation

There were missed opportunities in the clinical management of Patient E’s care, including critical tasks not being completed by frontline staff and compliance controls used by management to prioritise a deteriorating patient and assess risk. Mental Health Trust 1, Council … Read more

Recommendation

Patient E received Section 117 aftercare. It is the duty of the local authority and the ICB to ensure this is provided and reviewed. Patient E was discharged from the CMHT with no involvement of the local authority in May … Read more

Recommendation

There were weaknesses in the way the IHTT and the CMHT communicate to each other about persistently non-engaging patients. The Trust must provide guidelines to IHTT so that they know when and why to feedback to CMHTs about referred patients … Read more

Recommendation

As Patient E’s condition deteriorated, there was an increasing lack of engagement with him and his family members, and no evidence of any attempts to provide education about the nature and course of his illness and its treatment. Patient E … Read more

Recommendation

There was variation in work systems which meant that doctors and other staff had different ways of completing risk assessments documentation. Safeguarding forms do not require the assessor to consider either risks to vulnerable adults by patients or the risk … Read more

Recommendation

There were inadequate systems in place to monitor the frequency and quality of risk assessments. Trust-level data was not sensitive enough to provide adequate intelligence about whether individual patients were being risk assessed at the appropriate frequency. The Trust must … Read more

Recommendation

At the time of the incident the CMHT did not have a risk stratification system to indicate which patients were at higher risk of deterioration or were at risk of harm to themselves or others. A system which could have … Read more

Recommendation

There were delays in referring Patient E to IHTT because of barriers to effective communication between the GP and FRS. The first urgent referral from the GP was not responded to appropriately. • The Trust should develop a standard operating … Read more

Recommendation

a: CMHT care planning for erratic and sporadic patient engagement When Patient E was not engaging in the autumn of 2021 there was no contingency/care plan to guide the service response as required by Trust policy. The Trust must provide … Read more a: CMHT care planning for erratic and sporadic patient engagement When Patient E was not engaging in the autumn of 2021 there was no contingency/care plan to guide the service response as required by Trust policy. The Trust must provide assurance to the appropriate sub-committee of the Board that CMHTs are responding appropriately to service users who do not engage in line with Trust policy. b: CMHT member team roles at complex case meetings There was a misunderstanding between team members of their respective roles regarding who should and could discuss cases at the complex case meeting. The Trust must provide assurance to the appropriate sub-committee of the Board that all CMHT staff are aware of who can take cases to the complex case meeting, and that staff fully understand the reasons for doing this. c: Part-time working – impact on providing equitable access to care Appointments were delayed due to key CMHT staff being part-time, with no suitable alternative arrangements in the event of non-urgent matters requiring attention within normal working hours. • The CMHT SOP must articulate what needs to be done by when and whom, so that patients can be seen quickly by being offered an appointment with another member of the team when their own clinical team are not working, thereby providing equitable access to care. • The Trust must provide assurance to the appropriate sub-committee of the Board that the SOP has been implemented and evaluated in respect of the continuity of cover and part time working. d. IOT threshold for acceptance. Patient E was referred to but not accepted by IOT as he had limited engagement with CP2. However, he was not engaging with his care coordinator or the IHTT and would have benefited from a more assertive approach. IOT referral and acceptance criteria should be revisited and tested in the light of this case. e. CMHT operating hours Patient E would have benefited from contact from the CMHT in the evening, but this could not happen because the service is commissioned to deliver a Monday to Friday ‘9 to 5’ service. The Trust should work with commissioners to understand the demand for, and benefits of, CMHT extended hours working beyond Monday to Friday 9 to 5, so as to scope the nature of such a service and build this into strategic development plans. Show less

Recommendation

CP2 received ad hoc supervision and did not attend routine team and governance meetings due to being part time. The Trust must revisit the arrangements in place for locum/part-time consultants and examine what support is needed to ensure they receive … Read more