Independent investigation: Douglas Scott, Manor Park (2007)

East London Foundation NHS Trust must ensure that all mental health teams using a Traffic Light System for clinical management purposes, rather than resource management, audit the system on an agreed periodic basis to provide assurance that it is working as intended and to the expected standard of reliability. With regards to priorities, it is essential that the Tower Hamlets early intervention service conducts such an audit as soon as possible, as to date there has been no audit of system reliability since its implementation in 2006. This is not good governance. In formulating an appropriate audit process, the Independent Team recommends that at least the following factors are incorporated:  The appropriateness of the traffic light level/zone.  The quality of documentation when a decision is made to manage a service user outside of the protocol guidelines.  The quality of documentation when a decision is made to move a service user to a lower-risk tier of the traffic light system.  Whether the documented frequency of medical review evidences protocol compliance, and where the frequency does not meet this, do the notes provide a reasonable explanation as to why? (For example, a decision has been made for less frequent reviews and is a documented component of the management plan, or the service user has DNA‟d for appointments.)  Appropriateness and frequency of medication review.  Appropriateness of actions planned, following consecutive periods of non-attendance for planned contacts, that the traffic light system says requires action.

When a considerable change is made to a service, and the role expectations of the staff working in that service, East London Foundation NHS Trust must ensure that it has appropriate processes in place to ensure the following issues are considered and addressed, where appropriate. In this case, the early intervention service responsible for Mr SUA‟s care and treatment had, almost immediately prior to him becoming a patient, been the Early Psychosis Service operating on a psycho-social model and not a care co-ordination model. There was no effective transition period for staff and neither were the role changes and staff development needs given sufficient attention in the way the transition was managed. For at least one member of staff, there was little to no resemblance between the job he had been doing and his newly expected role. In designing a system to ensure that appropriate consideration is given to staff development and supervision when there are notable changes made to the functionality, and purpose, of a clinical team, the following components are recommended for inclusion:  Clarity about the critical success factors for the „new‟ or „revised‟ service.  A map of existing systems and processes within „the existing‟ team and the degree to which they meet the new expectation.  A knowledge and skills map of what is required to reliably deliver achievement of the new/revised service‟s critical success factors.  For safety-critical activities, a Failure Modes and Effects map (control map) and/or Task Analysis should be conducted in the planning phases for significant service change.  Where significant alteration to an individual practitioner‟s job description is required, the individual should be advised of this and its implication.  A training needs analysis and/or self-assessment against an appropriate knowledge and skills map.

The Clinical Lead and Team Manager for Tower Hamlets early intervention service must assure themselves that there is a detailed clinical review prior to a planned CPA meeting and that the content of this is comprehensively documented in the relevant service user‟s records. In this case, although both involved medical staff reported such a review occurring, both also reported no knowledge of the extent to which Mr SUA had not been present for planned assessments in November 2006 and January 2007.

Following the death of Mr D, an executive director of East London and the City Mental Health Trust met with the relatives of Mr D to share with them the findings and recommendations of the internal investigation. The family of Mr D found the Trust‟s representative to be insufficiently informed about Mr D, the circumstances of the care and treatment of Mr SUA, and over protective of the Trust‟s investigation report. Consequently it is essential that East London Foundation NHS Trust ensures that when serious untoward incidents occur and there is a decision to meet with the family of a service user and/or the family of „the victim‟ the person tasked with meeting with the family:  Knows the name of the service user.  Knows the name of the victim.  Is fully conversant with the care the service user received and in particular the antecedent period to the incident.  Has given careful consideration as to his/her response if the family ask to read the report, and/or to be provided with a copy of it at the time of the meeting.  Considers seeking a legal opinion on the content of the Trust‟s internal investigation report before a meeting with the family is arranged so that any issues in how the information is presented can be appropriately addressed.  Is accompanied by a senior member of the clinical team responsible for the patient where it is possible and reasonable to achieve this. The Independent Team is mindful that East London Foundation NHS Trust currently appoints named investigators and/or Panel Chairs for all of its serious untoward incident investigations and that a component of their role is to be fully conversant with the incident, its antecedents and the identity of affected family members/victims. Because it now has this system in place the Independent Team recommends that the Trust assure its commissioners that :  the lead investigator/panel chair leads the feedback process to families in all cases; and  the lead investigator/panel chair is accompanied by a senior member of the clinical team when meeting with families. In addition the Trust must:  Finalise its policy and practice guidance on the process on sharing of reports and activities that must be completed in advance of this. This policy guidance must meet the standards of „Being Open‟ as espoused by the National Patient Safety Agency and the principles listed above.