An independent investigation into the care and treatment of Thomas: Published 23 July 2018

This case underlines the lack of expectation of residential care home staff to be able to deliver a range of physical health observations that individuals in a normal domestic situation either independently, or with the support of family/carers undertake at home. Objectively Thomas may have benefited from having his temperature, respiration rate and pulse checked when he was unwell with chest infections. This could have formed part of his individual support plan and may have enabled a more accurate assessment of Thomas’s wellbeing to have been achieved during periods when he was unwell. Furthermore, these basic observations in the last week of Thomas’s life may have alerted care staff to the fact that Thomas was deteriorating, when this was not obvious from his outward behaviour.
The author of this report appreciates that staff employed by care home providers are not professionally qualified. However, if a basic range of physical health monitoring is within the competency of a normal domestic household, then it seems reasonable that at least this standard is expected as the normal for a residential care facility, where the provider provides a surrogate for the care and support a family might otherwise provide. The local and regional nursing teams of NHS England North and the commissioners of residential care home placements in the three district councils Thomas resided in are asked to raise this issue with the Care Quality Commission to achieve wider exploration of this issue so that uniformity of expectation can be achieved nationally.

The ambulance service must achieve reliability and consistency across all its response teams regarding the practice of safety-netting when a decision is made not to transfer an individual to hospital. Safety-netting is where the responding crew make sure that appropriate steps are put in place to assure the ongoing safety of the individual, and to ensure that appropriate and timely clinical follow up happens. In this case that should have occurred the next morning.
As part of the roll-out and use of the ‘non-conveyance leaflet’, the ambulance service is recommended to audit the success of this intervention within the first six months of roll-out.

The ambulance service must satisfy itself that the error of not referring Thomas for primary care follow-up is a one-off incident and does not represent a wider problem across its attending crews, especially regarding residential care facilities. It is recommended that the audit of this issue be presented to the clinical commissioning group along with any remedial action plan, should this be shown to be required.

The adult safeguarding boards in the three districts Thomas resided in need a process that provides evidence-based assurance that concerns about abuse are being appropriately responded to within and across local authority boundaries, including:
• capturing the voice of the service user
• an independent investigation process where clusters of concerns materialise in a single care facility
• more in-depth assessment of the overall approach to care where the volume of concerns being raised indicates this is required.
Furthermore, if there is a history of safeguarding concerns for an adult at risk, and he/she is placed with a new provider in a new authority, a system of reliable handover of information about the history needs to be achieved so that the newly responsible safeguarding team are situationally aware.

Thomas’s experiences, and those of others highlighted in recent public reports including the Learning Disabilities Mortality Review Annual Report 2017 highlights a need for commissioners to review and reconsider in the current assurance mechanisms used to instil confidence that residential care providers are providing services that are legally compliant; safe, effective and of good quality. Furthermore, that Service Users are free from abuse of any kind.
Thomas’s family did not consider that they were provided with any objective assurance of the above during his short adult life.
Devising a workable and sustainable system of assurance may well be challenging, as methods that enable the lived experience of residents to be captured is time consuming. Nevertheless, this cannot be used as a reason for not utilising approaches such as participant and non-participant observer studies2. The author suggests this intervention could be used a few times a year, with additional interventions conducted if concerns about quality, safety, compliance or abuse are raised.

A full and validated account of the information provided to and shared by participants at a Mental Health Act review panel must be consistently achieved to avoid critical loss of important information about what was discussed and agreed at the time. This case has highlighted the dangers of not capturing this standard of record.
This and all mental health trusts are asked to consider the following, consider the extent to which they already do this, and if not consider implementing the below as a component of their plan to achieved the stated objective:
• ensure that notes and minutes taken by the hearing managers are scanned and saved alongside the final hearing report and decision made. The lack of retention of comprehensive minutes in this case required the firm of solicitors representing Thomas’s father to retrieve those that the involved solicitor had made immediately prior to and during the meeting. These minutes created a different picture of events than the memory recall of the meeting chair.

When a mental health tribunal or managers hearing in convened, those responsible for convening the meeting must achieve a situation where all clinical and non-clinical staff who have a significant involvement in the situation giving rise to the hearing or meeting are asked to provide a written submission, or oral evidence at the hearing.
In Thomas’s case this did not happen. This resulted in an incomplete picture of the situation and removed the ability of the panel to properly consider its options regarding adjournment. The impact of this lack of situation awareness was stressful for Thomas, his family and all staff involved.

A service user’s My Support Plan should be just that. This independent process identified that Thomas’s My Support Plan was a document created by whichever agency was dominant in Thomas’s care at the time. This did not lead to a plan of care that enabled Thomas, or his family, to provide input to the short-, medium- and long-term goals in a way that enabled them to be equal partners in his care planning. Furthermore, issues such as achieving a long-term residential placement for Thomas in his home town, where he wanted to be, lacked cohesion and clarity. Whilst all agencies were committed to facilitating Thomas’s return to his home town, how this was to be achieved and the timeframe for achieving this was not as clear for the family as it should have been. The District Council, in Thomas’s home town, its health partners and residential care providers need to determine how the principle of the My Support Plan being truly representative of the needs and aspirations of the service user, can be achieved for individuals in receipt of multi-agency services.
In taking this forward, the District Council in, Thomas’ home town, and its partners are also asked to consider how the agreed short-, medium- and long-term goals for an individual can be more concretely formulated within the My Support Plan, so progress with the plan can be accurately assessed and relevant adjustments made where necessary. This would assist in providing the transparency on process and progress that was missing for Thomas.