Independent investigation: Janet Hossein, East London (2007)

Audit of CPA documents
Effective care co-ordination depends on effective communication with all agencies engaged with a mental health service user. This did not happen in this case. The limitations of the independent investigation mean that the Independent Investigation Team does not know if the lapse that occurred in this case was an isolated occurrence or if there is a culture of non-communication with other teams, services and agencies. It is incumbent on East London Foundation Trust to determine whether or not its staff reliably communicates with involved third parties in the delivery of effective care and treatment to its service users.
Consequently, the Independent Investigation Team recommends that, within the context of existing activities, namely:
 management supervision;
 CPA audit; and
 Record-keeping audit,
East London Foundation Trust determines:
 Whether it is possible from the existing design of its documentation tools to identify those service users engaged with other services and agencies; and
 Whether the records evidence:
 Consent reliably being sought from service users to engage with third party services/agencies;
 Direct communication from the community mental health team to identified third party services/agencies;
 Invitation of third parties/agencies to CPA reviews.
 Appropriate exception reporting, i.e. if no communication where third party service/agencies are involved, why this decision has been made.
If it is possible with the current design of documentation to assess the above, then East London Foundation Trust must ensure that evidence of appropriate communication with relevant third parties involved in a service user‟s care and treatment is included in contemporary activities such as:
 CPA audit;
 Record-keeping audit;
 Peer review; and
 Management supervision.
Evidence of such audit will need to be provided to the relevant commissioners of its services.
If it is not possible to assess the above activities on the basis of the current design of documentation tool(s), the Independent Investigation Team recommends that the Trust considers amending the documentation tools at the time of next review to enable the assessment of the above, or alternatively devising another method of conducting the audit.
Target audience: The Medical and Nursing Directors, the Director of Governance and Locality Managers.
Timescale: The Independent Investigation Team suggests that East London Foundation Trust make provision for addressing the above in line with its existing audit timetable.
All community mental health team leaders should be directed to raise the issue on a periodic basis during clinical team meetings and to address the same issue during management supervision as a form of local self-assessment. The provision (by the Trust) of a common, but simple, audit tool for managers may assist this process.

The minutes of the community mental health team weekly clinical team meetings were uninformative, consisting only of a list of service users discussed/for discussion. Consequently, the Independent Investigation Team recommends that it would be prudent to develop a minutes template that enables accurate and appropriately detailed minutes to be taken of the weekly clinical team meeting. The advantages of doing so are that:
 All services providing the „same service‟ are working to a common set of standards;
 It is easier for these important documents to be audited when required;
 When staff move from team to team, the core systems and processes that are not „service dependent‟ are uniform.
Suggested headings for a „minutes template‟ are:
 Persons present and designation;
 Business matters;
 Case discussions:
 Patient ID and traffic light rating;
 Assigned care co-ordinator;
 Key features presented;
 Key decisions made and/or advice given;
 Date for review.
Target audience: The Director of Governance and the Director of Operations at East London Foundation Trust.
Timescale: This is a simple, practical recommendation that should be readily addressed and implemented not later than three months after the publication of this report. If East London Foundation Trust decides not to implement this recommendation, it must provide a reasoned rationale for this to its commissioners.

In this case the quality of medical record-keeping by community mental health team medical staff was not of an acceptable standard. There was an over-reliance on the care co-ordinator to make accurate records of assessments conducted by medical staff.
In this case the staff-grade doctor did not consider that the service user‟s presentation in April 2007 was such that an assessment under the Mental Health Act (1983) was required. However, there was no evidence in the clinical records of the medical assessment on the basis of which this decision was made. This was not acceptable.
The Independent Investigation Team recognises that the approach to, and philosophy of, care and treatment within the community mental health teams within East London Foundation Trust has altered significantly since 2007. However, it recommends that the Trust provides assurance to its commissioners about the current record-keeping standards required of medical staff and provides evidence of how those standards are currently audited in relation to:
 The making of records by doctors following contacts with and assessments of service users;
 The quality of the records; for example, consistent methodology for recording a mental state examination and to a sufficient level of detail.
Note: The Independent Investigation Team is aware that East London Foundation Trust has a detailed records audit tool of a quantitative nature. However, this tool does not necessarily assess the quality of record-keeping, or differentiate between the standards required of medical staff and non-medical staff.
Target audience: The Medical Director and Clinical Leads.
Timescale: It should be possible to incorporate this recommendation into the standardised approach the Trust takes to records audit and peer review, including for medical staff. On this basis, East London Foundation Trust should be able to incorporate this recommendation into its next timetabled notes audit.
The Trust‟s supervision framework for medical staff should also provide opportunity for the ongoing assessment of the quality of medical record-keeping.
The time period for the audit of medical record-keeping quality should be notified to the Trust‟s commissioners at the action planning meeting prior to publication of this report.

It was clear to the Independent Investigation Team that the care co-ordinator to Mr SU, whose care and treatment was the subject of this investigation, does appreciate the importance of offering carers a Carer‟s Assessment. The commitment to the provision of a Carer‟s Assessment was endorsed by the then, and current, community mental health team leader. However, in this case the mother of Mr SU was not offered such an assessment because of a perceived conflict of interest for the care co-ordinator.
The Independent Investigation Team considers that East London Foundation Trust must assure the commissioner of their services that:
 Carers‟ Assessments are offered to all carers and family members who are providing support to a Service User, regardless of whether the service user wants their care co-ordinator to be in communication with the care/family member or not.
 That the Trust has a system in place to enable a Carer‟s Assessment to be offered in circumstances where there is a conflict of interests that would prevent a Service User‟s care co-ordinator from doing so; for example, a threat to the therapeutic relationship between care co-ordinator and service user.
 That where a Carer‟s Assessment is identified as being required and is subsequently not provided then the reason(s) for the non-provision are clearly documented, aiming for a 100% documentation rate.
Target audience: The Director of Nursing and Service/Operational Managers.
Timescale: The audit component of this recommendation can be absorbed into the Trust‟s existing audit framework and timetable.
The issue of how the conduct of a „local‟ Carer‟s Assessment is progressed, where it is not appropriate for the care co-ordinator to do so, needs to be determined within the Trust. The process agreed will need to be reflected in relevant Trust policy and also in Community Mental health Teams operational policies. Because the Independent Investigation Team recognises that this is a complex issue it recommends that the Trust agrees the timeframe and process within which this issue is to be addressed at the action planning meeting with its commissioners prior to the publication of this report.
Note: The Independent Investigation Team is referring to the assessment of a carer‟s needs as it can be delivered within mental health services, and not the more far-reaching assessment which is the responsibility of the local authority.

Although it was clear to the Independent Investigation Team that East London Foundation Trust has taken action on the recommendations it made following its own internal investigation into the care and treatment of Mr SU, whose care and treatment is subject to this independent investigation, the Trust was not able to provide any information showing that it had subsequently tested out the impact (or benefit) of the actions taken with regard to practice, quality or safety improvement.
It is therefore a recommendation of the Independent Investigation Team that East London Foundation NHS Trust devises a process by which it can reliably test the impact of all recommendations made following its internal investigation of its categorised serious untoward incidents, and the impact of implementing the recommendations made following independent investigations such as this one.
The Independent Investigation Team suggests that for all such action plans devised the Trust‟s serious incident committee does not sign these off unless the action plan identifies:
 How the impact of implementation is to be measured;
 The timetable for „post-implementation‟ audit in the short, medium and, where appropriate, the long term.
It is essential that the Trust is aware of actions taken that do not result in the desired level of improvements in practice, quality and safety and that it does not assume that this has been achieved.

The analysis of the Trust‟s own investigation did not reveal information consistent with an effective investigation process, or one that evidenced knowledge and competency in information analysis or root cause analysis.
Consequently, it is important that East London Foundation Trust:
 Identify lead investigators for its serious untoward incident investigations who:
 Understand what constitutes an effective investigation.
 Have the skills to take comprehensive interview records, or are supported by administration staff competent to do so.
 Know how to formulate „care management concerns‟ and/or critical questions.
 Know how to conduct a repeatable information analysis using the evidence gathered during the investigation process.
Content analysis with affinity mapping would be one such approach.
 Understand how to differentiate between the contributory factors to a specified problem and the most significant factors, otherwise referred to as root causes.
 Understand that, for complex investigations following incidents such as homicide and suicides where the service user remained under the direct care of the Trust, applying a contributory factors framework „to the incident‟ rather than to the specifically identified problems in the case management is not the correct application of process.
 Have an understanding of the fail-safe attributes of improvement measures and know how to write S.M.A.R.T. (specific, measurable, achievable, realistic and timely) recommendations.
In addition to the above, it is recommended that the committee quality assuring the Trust‟s serious untoward incident investigations also have a good understanding of the above.
Target Audience: The Director of Nursing and Quality Assurance and the Associate Director of Governance.
Timescales: All Trust‟s should have a register of individuals who are competent in the above. However, it is recognised that achieving this has proved challenging for Trusts. The Independent Investigation Team considers that, within 18 months of the publication of this report, East London Foundation Trust must be able to evidence to its commissioners that it can consistently deliver serious untoward investigation reports that evidence the above.