Independent investigation: John McGrath, Stapleford, Nottingham (2009)

As a corporately delivered service, all AO Teams in Nottinghamshire Healthcare NHS Trust should have a consistency in approach across all of its core systems and processes, including the zoning system. Nottinghamshire Healthcare NHS Trust must ensure that all of its AO teams work to a common operational policy, with the individual requirements of these reflected accordingly. The County North Operational Policy provides a useful framework for achieving consistency for the whole service. In addition to the operational policy, issues such as the method for minutes taking at ‘same type’ meetings could be standardised so that across-team audits are easier to accomplish. Finally, a key issue that was identified as significant in the care and treatment of the MHSU subject to this investigation observation was the lack of formalised criteria for moving service users up and down the traffic light ratings, and a lack of clearly defined clinical expectation/intervention associated with each level of the traffic light or zone. Although there is variability in how AO, and other specialist teams, approach the usage of traffic light and other zoning systems, these systems are central to service user management. Consequently, having a robust framework, including features that dictate the focused discussion of a service user and the documentation of clinical decisions subsequently made, is sensible. It is therefore recommended that the AO service managers, team leaders and clinical leads explore: (cid:1) the range of approaches currently in use across the AO teams; (cid:1) approaches in other mental health trusts and other teams such as early intervention services; (cid:1) the range of criteria that might constitute a robust framework for dictating the necessity for clinical discussion of a service user at the weekly clinical team meeting, and/or the service user’s escalation up the zoning system; (cid:1) the process by which the service user, once escalated up the zoning system, can be ‘de-escalated’. In conjunction with the above, it is recommended that: (cid:1) clear guidelines are developed for the zoning system agreed; (cid:1) documentation standards around clinical decision making are agreed; (cid:1) the way the zoning system is to be audited, including audit criteria and the frequency of audit, is agreed and planned for.

If the current model of AO is to continue in Nottinghamshire, it is essential that there is an increase in the provision for dedicated medical sessions to the County South AO Team. This investigation, and the Trust’s own investigation, identified insufficient medical sessions provided to this AO Team. This means that the provision of necessary and meaningful medical input is challenging. It is the contention of CUK that, had there been more appropriate levels of medical input provided by the Trust, then it may have made an impact on the assessment and management of the MHSU involved in this incident. If an increase in medical sessions were to be achieved, CUK considers that this should result in: (cid:1) a more robust approach to the gathering of historical information about a service user; (cid:1) greater medical involvement in the initial assessment of service users referred to the AO service.

That the County South AO Team undertakes a randomised audit of a 20% sample of its current caseload to determine to what extent all relevant historical risk factors are detailed within the contemporary risk assessment and effective care co-ordination documents. Note: If such an audit reveals findings that show: (cid:1) significant gaps in the contemporary risk assessment and/or effective care co-ordination documents, (cid:1) a lack of rigour in the information provided to AO by feeder teams such as community mental health teams, then a more far-reaching audit of risk assessment will be required across all adult service teams (general and specialist), exploring: (cid:1) the methods by which staff access historical information for a new client with a pre-existing history; (cid:1) how historical information is recorded and whether the current process facilitates ease of retrieval; (cid:1) the transfer of information between documents, e.g. sequential risk assessments; and (cid:1) the transfer of information between services, e.g. CMHT to AO. Note 2: This recommendation should be implemented across all AO teams in Nottinghamshire.

There needs to be an AO Managers’ Forum across Nottinghamshire Healthcare NHS Trust.

Nottinghamshire Healthcare NHS Trust needs to consider developing more practice-based training for its qualified community staff around the requesting of and organisation of a Mental Health Act Assessment. This and the Trust’s own investigation highlighted a lack of clarity amongst staff about the mechanics of organising a Mental Health Act Assessment. Discussion with a number of approved mental health practitioners about this suggested that a more practically focused training opportunity would be of benefit. However, this case may not be representative of the general level of understanding across mental health professionals. In the first instance the Trust may wish to conduct a fit-for-purpose survey of staff to determine the overall level of understanding about the requesting of, organisation of and conduct of a MHA assessment. This would enable it to determine i) whether there is a clear need to modify and/or expand the current MHA training provided within the Trust’s non-AMHP staff; ii) what needs to be provided. The persons best placed to design such a survey instrument would be the Mental Health Act Manager and a selection of Approved Mental Health Practitioners.