Independent investigation: Bertha Martin, Cleadon (2008)

1. Northumberland, Tyne and Wear NHS Foundation Trust No Response Published

Recommendation

The investigation panel considers that the Care Programme Approach (CPA) policy of Northumberland, Tyne and Wear NHS Foundation Trust should contain a specific provision that during inpatient admissions, patients with no previous community input should be placed on enhanced care … Read more The investigation panel considers that the Care Programme Approach (CPA) policy of Northumberland, Tyne and Wear NHS Foundation Trust should contain a specific provision that during inpatient admissions, patients with no previous community input should be placed on enhanced care coordination. (Under the latest Department of Health CPA guidance this would mean placing all these individuals on CPA, without having to make the decision at which level they would be placed on, as the process has been simplified since 2008). Show less

10. Organisations responsible for mental health nursing care planning No Response Published

Recommendation

The panel considers it would be appropriate for a review/audit to take place in relation to the quality of the mental health nursing care planning process. This should include:  the dating and signing of the care plan by both … Read more The panel considers it would be appropriate for a review/audit to take place in relation to the quality of the mental health nursing care planning process. This should include:  the dating and signing of the care plan by both the nurses and patient;  a change in the care planning documentation, to include a section for making day to day progress recordings in relation to nursing interventions and a separate section to record the evaluations of the effectiveness of the care plan interventions;  consideration of whether or not the MDT care plan adds value to the nursing care planning communication process. Show less

11. Organisations responsible for nursing care planning documentation No Response Published

Recommendation

There was a considerable amount of information held in the nursing communication sheets relating to identified care plans rather than in the care plans themselves. The panel considers that this detracted from the effectiveness of the nursing care planning process. … Read more There was a considerable amount of information held in the nursing communication sheets relating to identified care plans rather than in the care plans themselves. The panel considers that this detracted from the effectiveness of the nursing care planning process. It is therefore recommended that consideration be given to a review of the use of this documentation to ensure that information is recorded in the most appropriate place. Show less

12. Organisations maintaining clinical records No Response Published

Recommendation

The clarity and legibility of all clinical records are essential qualities to enable appropriate and effective treatment to be delivered. The investigation panel recommends that standards of record keeping are subject to regular review.

13. Organisations involved in patient management and risk assessment No Response Published

Recommendation

The panel recommends that where a vulnerable adult is identified within the risk assessment process as being cared for by a patient (upon discharge in May 2008, patient E resided with victim E), a carer’s assessment must be offered as … Read more The panel recommends that where a vulnerable adult is identified within the risk assessment process as being cared for by a patient (upon discharge in May 2008, patient E resided with victim E), a carer’s assessment must be offered as part of the patient’s management plan. If the assessment cannot be carried out the reasons for this must be clearly stated within the risk assessment and MDT notes and consideration should be given to registering an alert under the safeguarding procedures. Show less

14. social or health care services; GP’s No Response Published

Recommendation

The panel recommends that whenever a social or health care service has any concerns in relation to a service user, insofar as the potential risks that that individual may pose to a vulnerable adult or child, this information should be … Read more The panel recommends that whenever a social or health care service has any concerns in relation to a service user, insofar as the potential risks that that individual may pose to a vulnerable adult or child, this information should be passed onto all the services involved, including the GP’s involved with the patient and the vulnerable person. Show less

15. Hospitals; agencies involved in discharge arrangements No Response Published

Recommendation

When meetings are held at hospital to consider the discharge arrangements for a patient, it is important that all the agencies who are likely to be involved in the discharge arrangements are invited to attend and do attend insofar as … Read more When meetings are held at hospital to consider the discharge arrangements for a patient, it is important that all the agencies who are likely to be involved in the discharge arrangements are invited to attend and do attend insofar as this is practicable. Show less

16. discharging medical team; hospitals No Response Published

Recommendation

When a patient is discharged from hospital following an inpatient admission, on the day of discharge there should be a preliminary discharge letter sent to the patient’s GP outlining the discharge medication and follow up arrangements. A full account should … Read more When a patient is discharged from hospital following an inpatient admission, on the day of discharge there should be a preliminary discharge letter sent to the patient’s GP outlining the discharge medication and follow up arrangements. A full account should be sent to the patient’s GP by the discharging medical team within seven days of discharge describing the patient’s progress during the admission, the medication the patient has been prescribed, the follow up treatment which has been arranged and any risks that have been identified. Show less

17. health professionals No Response Published

Recommendation

Where there are concerns in relation to a vulnerable adult living at the patient’s home, it would invariably be appropriate for there to have been some professional oversight of home leave in order to inform the decision making process prior … Read more Where there are concerns in relation to a vulnerable adult living at the patient’s home, it would invariably be appropriate for there to have been some professional oversight of home leave in order to inform the decision making process prior to discharging a patient. This should not be confined to self- reporting from the patient but should include full inquiries being made of family members whose views should be given such weight as is considered to be appropriate. When undertaking any such assessment the duty of care owed by health professionals extends beyond the patient so as to include consideration of the risk to others. Show less

18. all agencies; GPs No Response Published

Recommendation

The investigation panel recommends that mandatory training in relation to safeguarding vulnerable adults should be offered to practitioners across all agencies, including GPs, to foster a collaborative approach (involving collective responsibility) when issues arise which relate to safeguarding vulnerable adults. … Read more The investigation panel recommends that mandatory training in relation to safeguarding vulnerable adults should be offered to practitioners across all agencies, including GPs, to foster a collaborative approach (involving collective responsibility) when issues arise which relate to safeguarding vulnerable adults. There should be a robust audit of the efficacy of the delivery of this training. Show less

19. All agencies No Response Published

Recommendation

All agencies should be mindful of their individual responsibility to initiate safeguarding procedures in relation to vulnerable adults where appropriate. There should be no assumptions made that other agencies will necessarily have done so.

2. inpatient services; inpatient team No Response Published

Recommendation

In light of the above recommendation, the investigation panel further recommends that inpatient services should identify a CPA coordinator within three working days of a patient’s admission. This should be written into the acute inpatient services operational policies. It should … Read more In light of the above recommendation, the investigation panel further recommends that inpatient services should identify a CPA coordinator within three working days of a patient’s admission. This should be written into the acute inpatient services operational policies. It should firmly place the responsibility on the inpatient team to identify a CPA coordinator. Furthermore, it is recommended that the CPA coordinator should be present at the discharge meeting to agree and arrange an aftercare package of care. Show less

20. MDT meetings No Response Published

Recommendation

When a MDT identifies that a patient is implicated in concerns relating to a vulnerable adult this issue should become a standard item for review within the MDT meetings.

21. Professionals involved in safeguarding procedures No Response Published

Recommendation

When a patient is considered to present a risk to a vulnerable adult, unless it is considered inappropriate to do so, consideration should always be given to involving that patient directly in any safeguarding procedures which relate to the vulnerable … Read more When a patient is considered to present a risk to a vulnerable adult, unless it is considered inappropriate to do so, consideration should always be given to involving that patient directly in any safeguarding procedures which relate to the vulnerable adult. Show less

22. Professionals discharging patients No Response Published

Recommendation

Before discharging a patient to a home environment in which a vulnerable adult is believed to reside, consideration should be given to exploring issues of the mental capacity of the individuals involved and whether they are capable of self-determination in … Read more Before discharging a patient to a home environment in which a vulnerable adult is believed to reside, consideration should be given to exploring issues of the mental capacity of the individuals involved and whether they are capable of self-determination in relation to the decision to live together. Show less

23. individual practitioners; professionals involved in the multiagency process No Response Published

Recommendation

The effective functioning of the safeguarding vulnerable adults procedure relies upon accurate recording of information shared at safeguarding meetings and effective distribution of minutes to all of the professionals involved in the multiagency process. To enable the protection procedures to … Read more The effective functioning of the safeguarding vulnerable adults procedure relies upon accurate recording of information shared at safeguarding meetings and effective distribution of minutes to all of the professionals involved in the multiagency process. To enable the protection procedures to function appropriately, safeguarding duties should be a priority for the individual practitioners concerned, including attendance at meetings. Show less

24. social services; other agencies No Response Published

Recommendation

Where risks have been identified and safeguarding procedures have been initiated, cases should not be closed by social services or other agencies until there has been a satisfactory resolution of the concerns. In any event all decisions should be clearly … Read more Where risks have been identified and safeguarding procedures have been initiated, cases should not be closed by social services or other agencies until there has been a satisfactory resolution of the concerns. In any event all decisions should be clearly recorded and shared with all agencies involved. Show less

25. Safeguarding adults boards No Response Published

Recommendation

Safeguarding adults boards are encouraged to utilise the Association of Directors of Adult Social Services (ADASS) guidance note, ‘Carers and Safeguarding Adults – Working Together to Improve Outcomes’ (2011) to review local practice and learn from the findings of this … Read more Safeguarding adults boards are encouraged to utilise the Association of Directors of Adult Social Services (ADASS) guidance note, ‘Carers and Safeguarding Adults – Working Together to Improve Outcomes’ (2011) to review local practice and learn from the findings of this investigation. Show less

26. Professionals maintaining patient’s clinical notes No Response Published

Recommendation

When a patient, who has been subject to detention under Mental Health Act 1983, becomes an informal patient (either by being discharged from the detention or as a result of the expiry of the section) there should be a clear … Read more When a patient, who has been subject to detention under Mental Health Act 1983, becomes an informal patient (either by being discharged from the detention or as a result of the expiry of the section) there should be a clear record made in the patient’s clinical notes as to the reasons for the change in status. Show less

27. Organisations maintaining patient’s records No Response Published

Recommendation

All clinical notes, including psychology, should be integrated within the patient’s records and be readily accessible to all professionals involved in the individual’s care.

28. GPs surgeries No Response Published

Recommendation

GPs surgeries should consider the viability of instituting a ‘usual doctor’ system whereby a patient is assigned to a particular GP within the practice to assist in the continuity of care and communication with external agencies.

29. GPs practices No Response Published

Recommendation

The investigation panel was informed as to an eight day delay in the processing of important information sent by fax to GP 6 by patient E’s Counsellor 1 in January 2008. GPs practices should review internal communication systems to ensure … Read more The investigation panel was informed as to an eight day delay in the processing of important information sent by fax to GP 6 by patient E’s Counsellor 1 in January 2008. GPs practices should review internal communication systems to ensure that information is received by the patient’s GP promptly. Show less

3. community mental health teams (CMHT) No Response Published

Recommendation

The investigation panel recommends that community mental health teams respond urgently to requests from inpatient services for the allocation of a CPA coordinator and that within five working days from the time of referral the allocated CPA coordinator makes contact … Read more The investigation panel recommends that community mental health teams respond urgently to requests from inpatient services for the allocation of a CPA coordinator and that within five working days from the time of referral the allocated CPA coordinator makes contact with the patient. This minimum standard will require adding to the Community Mental Health Team’s (CMHT) current operational policies. Show less

4. community mental health teams No Response Published

Recommendation

The criteria for acceptance into the Community Mental Health Teams and the allocation of a CPA coordinator, should operate on the basis of a patient’s needs and not be simply led by the diagnosis. An inclusion criteria runs the risk … Read more The criteria for acceptance into the Community Mental Health Teams and the allocation of a CPA coordinator, should operate on the basis of a patient’s needs and not be simply led by the diagnosis. An inclusion criteria runs the risk of excluding patients who may well benefit from a service. In this case, the rigidity of working solely with diagnostic led criteria (as opposed to addressing patient E’s complex needs) resulted in the exclusion of patient E from follow up mental health care in the community. The investigation panel recommends that the operational polices of community mental health teams are adapted to remove such restrictions and to institute a more holistic approach to the criteria for admission to these services. Show less

5. community services No Response Published

Recommendation

Specifically, a diagnosis that a patient is suffering from a personality disorder and/or alcohol related difficulties should not result in any exclusion of the patient from community services following their discharge from hospital.

6. Organisations using risk assessment tools No Response Published

Recommendation

The Sainsbury risk assessment tool used at the material time was considered by the investigation panel to be weak in relation to the protection of vulnerable adults. There should be provision within the risk assessment process to prompt and record … Read more The Sainsbury risk assessment tool used at the material time was considered by the investigation panel to be weak in relation to the protection of vulnerable adults. There should be provision within the risk assessment process to prompt and record issues relating to the safeguarding of vulnerable adults and children. Show less

7. Organisations adopting risk assessment tools No Response Published

Recommendation

The investigation panel recommends that the risk assessment tool which is adopted is a dynamic tool with the capacity to record ongoing incidents of risk and warnings so as to enable a more cohesive and comprehensive risk management plan to … Read more The investigation panel recommends that the risk assessment tool which is adopted is a dynamic tool with the capacity to record ongoing incidents of risk and warnings so as to enable a more cohesive and comprehensive risk management plan to be developed, monitored and reviewed throughout a patient’s admission. Reliance upon mechanistic tick box risk assessments should be avoided. Show less

8. health professionals; Multi Disciplinary Team (MDT) meetings No Response Published

Recommendation

The investigation panel has established that the expressions of concern, alerts and relevant risk incidents were not recorded consistently within the risk profile documentation. Instead, the panel found that although records were made of these warnings, they were distributed throughout … Read more The investigation panel has established that the expressions of concern, alerts and relevant risk incidents were not recorded consistently within the risk profile documentation. Instead, the panel found that although records were made of these warnings, they were distributed throughout the nursing records and as such it would be very difficult for staff to assess the developing overall picture in relation to risk and this therefore hindered the effective review of ongoing risks. The investigation panel recommends that third party information relating to risk should be kept as a composite record which is updated and is immediately available to all health professionals who have access to the records. This record should routinely be considered at Multi Disciplinary Team (MDT) meetings. Show less

9. medical staff; MDT; Northumberland, Tyne and Wear NHS Foundation Trust No Response Published

Recommendation

Written notes from the weekly consultant ward review did not show recorded evidence of discussion on risk assessment and risk management. The panel recommends that a minimum standard is set for medical staff that at every MDT meeting (or at … Read more Written notes from the weekly consultant ward review did not show recorded evidence of discussion on risk assessment and risk management. The panel recommends that a minimum standard is set for medical staff that at every MDT meeting (or at least weekly) a joint risk review is conducted by members of the MDT and recorded within the medical notes. The panel further recommends that Northumberland, Tyne and Wear NHS Foundation Trust undertakes clinical audits of MDT records to assess the quality of risk assessment and management plans that are being considered and recorded therein. Show less