Source · Investigations in the NHS

An independent review into the care and treatment of Mr G between 2014-2019: Published May 2022

North East and Yorkshire Published 01 May 2022 Trust South West Yorkshire Partnership NHS Foundation Trust Subject Mr G

This is the extended executive summary of the independent investigation into the care and treatment of Mr G. South West Yorkshire Partnership NHS Foundation Trust has also published an assurance statement into this case.

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

8 total

Recommendation

Learning event Directed to: The Director of Nursing and Quality at the trust What is required: To organise and facilitate an Oxford Model learning event15 to ensure that the widest reflection and learning is achieved across adult services from this … Read more

Recommendation

To organise and facilitate an Oxford Model learning event15 to ensure that the widest reflection and learning is achieved across adult services from this case. Key points to be drawn out are: • management of complex service users with personality … Read more

Recommendation

The Care Programme Approach and care pathways Directed to: The Director of Operations at the trust This review has highlighted the fact that there are service users allocated to the Core team who meet the criteria for CPA and thus … Read more The Care Programme Approach and care pathways Directed to: The Director of Operations at the trust This review has highlighted the fact that there are service users allocated to the Core team who meet the criteria for CPA and thus enhanced care. This was a contributory factor in Mr G not receiving longitudinal assessments and there thus being missed opportunities for reconsideration of his diagnosis. What is required: 1: The trust must determine the extent to which there is a gap in service provision for those service users meeting Care Programme Approach criteria, to ensure that it is aware of its risk management position in relation to this gap, and to have a clear plan for mitigating its impact. 2: For all service users identified as meeting Care Programme Approach criteria, the trust must ensure that there is an auditable and defendable approach to determining which of them are accepted onto the Care Programme Approach as a matter of priority once capacity is released. 3: The trust has implemented a complex case forum, and other initiatives, for service users who may meet the threshold for enhanced care but cannot be accommodated on the enhanced care pathway, as well as service users who are presenting as more complex than the Core team can accommodate. The trust must audit the usage and effectiveness of the safety nets provided and provide assurance that the avenues to achieve a more enhanced and intensive package of support are being used as intended and to identify those service users for whom an enhanced care package must be achieved. 4: Where it is identified clinically that enhanced care must be delivered to a service user and the range of safety nets is not sufficient to deliver an effective or safe package of care, there must be tangible and measurable steps in the care pathway design to enable this to be escalated via the trust’s risk/patient safety committees and brought to the attention of the commissioners. 5: The trust board should receive quarterly reports detailing the number of adult service users who meet the threshold for the Care Programme Approach but are not receiving this intensity of care package and explaining why not. Assurance regarding the delivery of safe and effective care will also be required. To achieve: A safe system of care. To reduce the risk of: Not achieving: • the full depth and breadth of diagnostic consideration • effective multidisciplinary care management consideration and planning • an appropriate level of case management supervision for a complex case such as Mr G’s. Show less

Recommendation

1: The trust must determine the extent to which there is a gap in service provision for those service users meeting Care Programme Approach criteria, to ensure that it is aware of its risk management position in relation to this … Read more 1: The trust must determine the extent to which there is a gap in service provision for those service users meeting Care Programme Approach criteria, to ensure that it is aware of its risk management position in relation to this gap, and to have a clear plan for mitigating its impact. 2: For all service users identified as meeting Care Programme Approach criteria, the trust must ensure that there is an auditable and defendable approach to determining which of them are accepted onto the Care Programme Approach as a matter of priority once capacity is released. 3: The trust has implemented a complex case forum, and other initiatives, for service users who may meet the threshold for enhanced care but cannot be accommodated on the enhanced care pathway, as well as service users who are presenting as more complex than the Core team can accommodate. The trust must audit the usage and effectiveness of the safety nets provided and provide assurance that the avenues to achieve a more enhanced and intensive package of support are being used as intended and to identify those service users for whom an enhanced care package must be achieved. 4: Where it is identified clinically that enhanced care must be delivered to a service user and the range of safety nets is not sufficient to deliver an effective or safe package of care, there must be tangible and measurable steps in the care pathway design to enable this to be escalated via the trust’s risk/patient safety committees and brought to the attention of the commissioners. 5: The trust board should receive quarterly reports detailing the number of adult service users who meet the threshold for the Care Programme Approach but are not receiving this intensity of care package and explaining why not. Assurance regarding the delivery of safe and effective care will also be required. To achieve: A safe system of care. To reduce the risk of: Not achieving: • the full depth and breadth of diagnostic consideration • effective multidisciplinary care management consideration and planning • an appropriate level of case management supervision for a complex case such as Mr G’s. Show less

Recommendation

Risk assessment Although the independent team was impressed by what it has seen of the trust’s revised approach to risk assessment, it identified several possible omissions in the design of the form and the training content. These related to domestic … Read more

Recommendation

What is required 1: The revised FIRM model must facilitate the consistent capture and consideration of information relating to the spectrum of domestic abuse (emotional, psychological, financial, physical). This must encompass risk posed by the service user to others, not … Read more

Recommendation

Carer’s assessments Directed to: Manager (Public Engagements Lead) Partnerships Team What is required: A situation must be achieved where working/informal carers providing emotional, physical, or day-to-day living support to a service user are routinely offered a carer’s assessment and are … Read more

Recommendation

A situation must be achieved where working/informal carers providing emotional, physical, or day-to-day living support to a service user are routinely offered a carer’s assessment and are provided with a carer’s passport, in line with the trust’s Family, Friends and … Read more