Independent investigation: Amina Ali, Sheffield (2004)

The West Continuing Needs Service has commenced work to agree a draft protocol/pathway for managing clinical disputes but the status of this project needs to be elevated so that it is adopted as an Adult Services wide project with defined timescales and deliverables that are monitored by the Trust or Service Governance Committee. Whilst there remains some contention about S2’s Consultant Psychiatrist’s refusal to undertake an assessment of S2 on the 5th December 2002, the questionnaire response provides firm evidence that there is no escalation pathway that can be used by staff within the Service for Adults of Working Age where issues of clinical dispute/concern arise that do not respond to local resolution. The current programme of work being undertaken appears to be very specific to the West Continuing Needs Service and this is no longer appropriate. A working party representative of the teams and professionals working within the Service for Adults of Working Age that reports to the Service Director and Clinical Director needs to be commissioned. In commissioning this work the Management Teams for the Service for Adults of Working Age, specifically the Service Manager and Clinical Director for the Directorate of Rehabilitation Recovery and Specialist Mental Health, need to ensure that there are: Agreed terms of reference/objectives. Agreed timescales for delivery for each phase of the project. Clarity as to who is taking the project lead. Note 1: The Investigation Team believes that it is essential that the profile of this work is raised so that the evolution of the pathway can rise above the specifics of individual practioners. Note 2: The Investigation Team believes that the development of an escalation of concern model must be rolled out organisation-wide once its prototype has been agreed and tested.

SCT needs to undertake a number of developments in relation to the clinically focused risk assessment process and training delivered to its staff. The cases of S1 and S2 highlight the central importance of the clinically focused risk assessment to the delivery of an effective Mental Health Service. The analysis of the care and management of these patients and the questionnaire responses provided to the Investigation Team clearly indicate that SCT’s current approach to training and practice needs to be revised. Specifically the Investigation Team recommends that: With immediate effect the Trust makes its current risk assessment training programme available to its in-patient staff. The Trust implements a unified baseline risk assessment documentation tool for in-patient and community use as soon as possible. The Trust may wish to consider incorporating two specific subsections for in-patient and community use to accommodate the differences in the risk assessment process between these two areas of the service. Regardless of the design of the risk assessment form, to continue with the current situation is untenable. The Trust must make provision in the financial year 2006/2007 and annually thereafter, for the delivery of refresher training in the clinically focused risk assessment every three years to its entire cohort of qualified staff. In the medium term the Trust is encouraged to: Take note of the feedback provided by its staff to this Investigation Team regarding the need for a graduated training programme in the clinically focused risk assesment. Staff currently find the programme geared to the needs of the inexperienced practioner. If the Trust does expand the training opportunities in risk assessment for its staff the Investigation Team encourages the Trust to incorporate; opportunities for staff to explore different ways of documenting their findings. Exploration of the depth of documentation required - the volume of information required - how to construct succinct sentences that convey - the intended message the use and non-use of language - these were all issues that SCT staff highlighted as issues they believed would enhance their documentation of risk, the importance of exploring and documenting circumstance and context of identified risk behaviours with Service User, the process of Peer Supervision as an opportunity for reflection and analysis on the quality of risk assessments undertaken and the quality of the documentation around this. Review and streamline the range of additional assessment tools, such as KVG and Becks44 that are currently in use across Adult Services. In addition to ensure that all staff using these tools have been appropriately trained and receive appropriate supervision.

SCT must establish the baseline information essential to the effective assessment of Service Users detained under the Mental Health Act. In identifying this SCT must ensure that its practice is commensurate with any relevant National Guidance and good practice standards. It is the opinion of this Investigation Team that had S2 received an effective assessment during the period of his initial detention and hospitalisation between 11th November 2002 and the 7th March 2003 then there would have been clarity regarding his diagnosis and clarity regarding the influence of drugs and alcohol on his mental health state. Furthermore staff would have known whether or not his episodes of psychosis were purely generated by his substance misuse or merely exacerbated by this. Clarity about this may have significantly affected the attitude of S2’s Care Coordinator, S2’s Consultant Psychiatrist and other members of the team to S2’s decline from December 2003. At minimum the Investigation Team recommends that the Directorate for Acute, Community and Primary Care Mental Health Services undertakes a case note audit of a percentage of Service Users who have been detained under the Mental Health Act to ascertain: How many of these have a clearly documented diagnosis at the end of their period of compulsory admission? How many had a clearly defined and documented management plan? The frequency with which Service Users present significant challenges to containment for in-patient staff and where no referral is made to the Intensive Support Services. Based on the output of such a specific and detailed practice analysis the Adult Service will have a more precise picture of whether there are development needs for staff in the care and management of these clients whether these issues need to be addressed within the Services Operational Policy for Inpatient Services whether there is merit in periodic audits of this issue. With regard to timescales this is an audit the Investigation Team suggests is planned for the current (2006/2007) financial year. In addition SCT requires staff to document Section 17 Leave on its formalised template rather than the seemingly ad-hoc approach to documenting this that the investigation found. Streamlining of this aspect of practice will enhance the Trust’s ability to audit Section 17 Leave practice. In addition For Action within Six Months As an integral part of the Trust’s patient safety commitment the Investigation Team believes that the Directorate of Acute and Community and Primary Care Mental Health Services must ensure that its staff are aware of the inherent risk in allowing a patient detained under the MHA to leave the ward or the secure garden area, where no Section 17 Leave has been agreed. This could be accommodated within the Trust’s existing Mental Health Act training. The Investigation Team appreciate that there will be occasions where a staff member may consider allowing a detained patient time ‘off the ward’ to be an appropriate risk decision. In such circumstances it is critical that the rationale for this decision is clearly documented in the contemporaneous record. For consideration: The Investigation Team noted that the current Mental Health Act Administrator is well qualified in her field yet she has no active involvement in the education and training of mental health professionals in the understanding and use of the MHA. The Trust may wish to consider how it can maximise the benefit of this resource in the future education of its staff.

The Operational Policy for the CNS Service needs to be updated so that it becomes a valuable and practical document for staff. During the investigation process the Investigation Team identified that the current Operational Policy for the Continuing Needs Service is not fit for purpose. Given the central importance of this document to the overall good functioning of individual practioners and the team the Investigation Team believes that addressing this should be a priority for the service. An effective Operational Policy should; inform the practioner of the purpose of their role inform the practioner of the expectation of them within the service/team direct the philosophy and approach to care guide the practioner to particular policies and other services and agencies with which they are expected to interact. At minimum such a policy would therefore be expected to address the: Clear definition of the clinical and managerial leadership. Clear definition of the roles and responsibilities of individual team members (to include clarity of differentiation between the grades of CPN). Case load allocation and case mix (e.g. 70% on Enhanced CPA 30% on Standard CPA). Collective caseload size for each CNS and the maximum case load for each ‘member’ type The CNS’s relationship with General Practioners (e.g. on a quarterly basis one or more of the CMHT members will meet with the GP practice to look at issues of concern, referral patterns etc). Systems for preceptorship and induction of new staff (to include how different grades of staff are managed and supported). The model of Supervision if SCT decides to allow this to be agreed on a team by team basis. In addition to the above the Investigation Team recommends that a revised operational policy includes clear guidance for staff on engaging with Service Users from Black Minority and Ethnic Communities. It is expected that this guidance will detail: The range of internal and external resources available to support effective engagement with Service Users. Recommended communication pathways. The location of more detailed information about specific internal and external resources including the terms of engagement for external statutory and non-statutory agencies. Note: This recommendation may have relevance across a range of other services within the Mental Health Service in Sheffield. The Investigation Team encourages the Trust to ensure that all Service Directors and Clinical Directors have sight of this so that they can benchmark their own Operational Policies against the principles espoused.

Where multiple agencies are engaged in supporting a Service User then early consent is sought for involving these persons in CPA. Also CPA process must ensure that it supports the involvement of the multi-agency parties in the CPA process. If INSIGHT does not already accommodate the recording of other agencies involved with the Service User incorporation of the facility for this may be useful.

The current system for alerting Team Managers to overdue CPA Reviews is enhanced with the CPA Coordinator having invested authority to ask for the reason for delayed CPA Reviews and to raise any ongoing delay with the Directorate Manager and Clinical Director.

Data on delayed CPA Reviews, including the reasons for any such delay, is incorporated into the existing audit process for CPA. The analysed data should be made available to each CNS for discussion and action planning at their respective Service Governance Meetings. The aggregated data should also be presented at the Service Governance forum for the Directorate of Acute and Community.

Amend Appendix three to the Trust’s current CPA policy (see page 83 of this report).

While SCT were able to evidence that an audit of medical documentation had occurred there appears to have been no audit of the quality of documentation across all professional groups. Given the issues identified regarding the quality of documentation in the case of S1 and the information shared with the Investigation Team at interview it is recommended that; a designated audit tool is developed to support the peer review of clinical records. Issues that might be encompassed within such a tool are i) does the care plan reflect the needs of the patient and set out clearly the intended management plan? ii) is there a clearly documented risk containment and contingency plan? iii) do the progress records contain a clear and accurate description of the Care Coordinators assessment of the Service Users Mental Health State?

where existing audits rely on the collection of data from the clinical record key aspects of the CNST requirements are incorporated. Examples of such requirements are that all entries are legible, and that all entries are dated with printed name/legible signature of author.

The revised approach to Supervision within SCT needs to ensure that it enables; staff to receive a copy of the supervision record staff to be aware of those persons who can provide specialist supervision, and on what basis (this could be through a ‘specialist’ peer review system) the assessment of the effectiveness of an individuals case management and the quality of documentation a balance between the responsibility of the individual to seek out supervision and the responsibility of the organisation to ensure that it is provided on an ‘at least as’ basis, ie that the maximum time period between supervisory sessions is stipulated.

In addition to the above, SCT is encouraged to broaden its current audit tool for Supervision to allow staff to contribute ideas for improving the system of supervision and to describe elements that do not meet their needs as professionals. The clinical audit department might also consider increasing its sample size in Adult Mental Health and differentiating between in-patient and community services.

The Investigation Team is mindful that establishing, and evidencing, medication compliance in the community is fraught with difficulty. However, the Investigation Team does feel that the Directorate for Acute, Community and Primary Care Mental Health Services needs to open a dialogue with its local Primary Care Trust(s) and Local GPs to try and establish a workable system to enable Mental Health Workers to be made aware at an early stage if a Service User is not collecting their medications.

The Investigation Team is aware that considerable effort has been invested by the Trust and in particular the former Service Manager for In-patient Services (Adults of Working Age) to establish a Sheffield Care Trust and South Yorkshire Police Joint Operational Procedures and Guidelines. Once this protocol/ information sharing agreement has ‘bedded in’ the Investigation Team encourages further development of this good work to establish a more effective communication system between the police and the Mental Health Service when a known Service User is taken into custody and released on bail. In the case of S2 had such a system been in place the Care Coordinator would have been made aware of S2’s assault on an apparently random passer-by on the 27th January. This would have increased the chances of a face to face assessment of S2 and the potential for an MHA assessment prior to the incident on the 2nd February 2004.

In addition to this work there may be some merit at the next liaison meeting between the Police Force and the Mental Health Service in establishing precisely what guidance is provided to the Forensic Examiners (Police Surgeons) regarding the appropriate route(s) of contact with the Mental Health Service if information regarding the Mental Health history of an individual is required.