Independent investigation: David Kemp, Great Yarmouth (2008)

We recommend that within 3 months of the publication of this report, NHS Lambeth, London Specialised Commissioning Group, and the national DSPD Programme clarify roles and responsibilities for the funding, performance management, oversight and commissioning of this service.

We recommend that the South London and Maudsley NHS Foundation Trust and Croydon Health Services NHS Trust meet, immediately, to establish sound and collaborative working relationships at a senior operational level, to develop clear, shared, agreed and understood policies for the management of medical emergencies for medium secure patients. These procedures to be tested and reviewed on an ongoing basis to establish safe working.

Future planning to manage risk needs to consider the need for ongoing physical restraint whilst patients receive treatment in acute hospital, not just during transit. The investigation team note this has now in fact been incorporated in the Trust Policy for Patient Leave of Absence, Conveyance & Escorting in Medium & Low Secure Services.

Any future discussions and requirements regarding restrictions placed on prisoners subject to detention under Part III of the Mental Health Act between the Ministry of Justice and Forensic Services should be followed up in writing by the Ministry of Justice. The Ministry of Justice should correspond in writing with RMOs (RCs) in relation to any aspect of a patient’s care, or to follow phone calls with written documentation confirming a conversation, to avoid misunderstandings and discrepancies in care.

We recommend that efforts are always made to obtain all past medical records on patients receiving in-patient treatment. The importance of obtaining past records to reduce the risk of serious incidents repeating should be reinforced.

We recommend that there is multi-disciplinary and management input into the timing of admissions to a service about to undergo a period of significant change. It is better to delay admission than risk a serious incident occurring due to staff pressures to manage the change and increased anxiety caused to patients who are still settling into a new environment and are likely to be unsettled in their mental health.

We recommend that the grab pack highlights the nature and level of risk presented by a patient in simplified terms as a guide to appreciating the risk.

We recommend that Social Workers play an active role in liaising with external agencies, including family members and criminal justice agencies, to collect and corroborate information which could be extremely important in risk assessment and management. This should be directed by the RMO (RC) and agreed by the multi-disciplinary team.

We recommend that all admissions, whether they are new or re-admissions, be subject to a multi-disciplinary assessment prior to admission. A medical assessment is key to ascertaining diagnosis and suitability for treatment, but a nursing assessment is necessary to advise and prepare staff for manageability within a ward environment. In the case of a population of patients with a personality disorder, a psychology assessment is also recommended. All assessments should involve the preparation of a written report, and the outcomes of the assessment discussed to agree a final common pathway.

Where such multi-disciplinary meetings take place in future, minutes should be produced and should include agreed actions and a formally agreed plan that should be distributed to all members of the clinical team. We recommend that notes of such meetings recording clinical decisions are entered contemporaneously into ePJS.

We recommend that all new admissions which are undergoing assessment for a time-limited period, which we understood to be 3 months, are subject to weekly multi-disciplinary review.

Nursing leadership and historically high churn rates within the nursing team is a known risk to the Trust for this service. A contingency plan should be in place for managing the risks incurred when senior positions in the team are vacant to ensure stability on the unit. The practice of long periods of acting up does not provide real continuity for the team nor the post holder. The Trust should recruit and appoint a substantive Ward Manager for Waddon Ward immediately. Supervision, mentorship opportunities and appropriate training for managers must be resourced that are specific to this client group to prevent staff burnout. The full involvement of the nursing staff in the assessment, treatment planning and provision of therapeutic interventions must be monitored and audited on an ongoing basis to ensure that it is embedded and continues. Admissions should be carefully monitored and risk assessments completed to ensure the service has capacity and is functioning at safe levels for current patients as well as new individuals without permanent nursing leadership. If necessary, alternative arrangements for admissions should be made to ensure service continuity and patient care.

A robust strategy for monitoring the Recruitment and Retention of all staff in the FIPT Service, especially Waddon Ward, should be produced and monitored monthly and include the involvement of the MDT. This strategy should include meaningful feedback from staff that leave the service and must be fed back into the service via Clinical Governance and other performance management meetings. A threshold should be agreed and set on the maximum vacancy levels of staff to be held by the team on Waddon Ward. If breached, these should ensure extra resources be provided and admissions stopped until the team is stabilised. Links with other similar services must be forged to develop strategies for staff support. Staff should be polled annually on their experience of working within the FIPT Service and concerns noted and acted upon by senior staff. Leaver’s questionnaires should be fully utilised by management to examine why high management turnover has occurred and possible solutions to end the cycle.

That RMOs (now Responsible Clinicians, RCs) complete Section 17 leave forms when any detained patient is granted leave for any purpose. That a copy of the care plan, outlining appropriate measures to protect the public, be placed, for the guidance of the escorting nurses, in the ‘grab pack37’ which is now in place on the unit for the transfer of emergencies. That escorting nurses are made aware of this care plan and conditions. We recommend that for Restricted Patients, the limitations of Section 17 leave for any hospital treatment are clearly defined in the Care Plan in relation to the freedom of movement, contacts, and visitors a patient may have. That the use of Section 17 for restricted patients be routinely and regularly audited.

Training in relational security and boundary management be included within the induction package and all staff become familiar with the terminology and behaviours required to maintain a therapeutic and dynamic service environment38. This could be evidenced by better retention/reduction in sickness levels and a reduction in ward incidents. This needs to be clearly reinforced by reference to the Mental Health Act to ensure there is a clear understanding of the implications and requirements under Part III of the Act and the meaning of restriction within this.

Regular monitoring of the usefulness of the current 2 week induction process should be undertaken and feedback sought on any improvements required to ensure it is an evolving process and meets the needs of all staff that experience it. Supernumerary status must be preserved during induction for all staff. Agency staff Induction must be reviewed and ensured that it meets relational and procedural needs of the service.

The Fallon Inquiry highlights concerns over communications usage and sets guidelines which should be adapted by River House to include mobile phone usage. We recommend that it is essential to control and monitor the use of ward-based telephones carefully in order to prevent abuse, control fraud and prevent the introduction of prohibited substances and articles into the Hospital. We recommend a revised policy on the use and restriction of access to mobile phones whilst in the unit, based on best practice and guidelines arising from the Fallon Inquiry, is developed, implemented, and regularly audited for implementation.