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

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 case. Key points to be drawn out are:
• management of complex service users with personality disorder(s), including psychosis, outside of the CPA framework
• domestic abuse
• multi-agency communication, information exchange and engagement
• carer engagement and support.
To achieve: Whole service learning following this independent process.
To reduce the risk of: The modifiable factors in the care and management of Mr G recurring.

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 disorder(s), including
psychosis, outside of the CPA framework
• domestic abuse
• multi-agency communication, information exchange and engagement
• carer engagement and support.
To achieve: Whole service learning following this independent process.
To reduce the risk of: The modifiable factors in the care and management of Mr G
recurring.

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.

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.

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 abuse and safeguarding where the service user may pose a risk to others.
Directed to: The FIRM (risk assessment and management) development team
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 only risks to the service user. Reasonable expectations are that assessed risk will include known episodes of police and/or probation involvement in relation to such behaviours. A reasonable expectation is that the risk assessment process will triangulate what a service user reveals with these agencies where it is clear that the service user has had contact/involvement with them.
What is required 2: Information captured via FIRM that highlights safeguarding concerns for vulnerable adults, such as domestic abuse, should trigger a force-field alert for the assessing professional to consider whether a referral to adult safeguarding, or a domestic abuse agency, is necessary. If it is determined that no action is required, the system must require the professional to record their rationale for this.
To achieve: The standard of situational awareness and professional response expected for harm minimisation in situations of domestic abuse both in terms of risk to a service user and risk posed by a service user, be that physical harm or psychological harm.
To reduce the risk of: The missed opportunities for harm minimisation and/or harm avoidance that occurred in the care and management of Mr G.

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 only risks to the service user. Reasonable
expectations are that assessed risk will include known episodes of police and/or
probation involvement in relation to such behaviours. A reasonable expectation is
that the risk assessment process will triangulate what a service user reveals with
these agencies where it is clear that the service user has had contact/involvement
with them.
What is required 2: Information captured via FIRM that highlights safeguarding
concerns for vulnerable adults, such as domestic abuse, should trigger a force-field
alert for the assessing professional to consider whether a referral to adult
safeguarding, or a domestic abuse agency, is necessary. If it is determined that no
action is required, the system must require the professional to record their rationale
for this.
To achieve: The standard of situational awareness and professional response
expected for harm minimisation in situations of domestic abuse both in terms of risk
to a service user and risk posed by a service user, be that physical harm or
psychological harm.
To reduce the risk of: The missed opportunities for harm minimisation and/or harm
avoidance that occurred in the care and management of Mr G.

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 provided with a carer’s passport, in line with the trust’s Family, Friends and Carers Commitment.
To achieve: An avoidance of the situation Beth and others providing support to Mr G found themselves in – that is, not perceived as providing care support, not having their needs established, having no clear line of communication with the responsible care team, and having a lack of understanding about what it was reasonable to contact the care team about.
To reduce the risk of: The service user’s care team being unaware of the depth and breadth of support being provided, as well as to reduce the risk of a care team not being aware of risk behaviours, escalation of these in the community and concerns held about the service user by non-professionals in the community.

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 Carers Commitment.
To achieve: An avoidance of the situation Beth and others providing support to Mr G
found themselves in – that is, not perceived as providing care support, not having
their needs established, having no clear line of communication with the responsible
care team, and having a lack of understanding about what it was reasonable to
contact the care team about.
To reduce the risk of: The service user’s care team being unaware of the depth
and breadth of support being provided, as well as to reduce the risk of a care team
not being aware of risk behaviours, escalation of these in the community and
concerns held about the service user by non-professionals in the community.