Independent investigation: John Speakman, Wigan (2006)

Where service users with substance misuse problems are engaged for assessment and/or treatment delivery by general adult services, rather than specialist dual diagnosis services, it is important that a thorough exploration of the service user’s substance misuse is undertaken, recognising that this can be challenging and some service users will not want to divulge this honestly. The clinical records of such a service user should clearly show the exploration of substance misuse. The following headings are a suggestion of the key questions that may support the effective recording of a clinician’s exploration of this issue:  How does the service user feel about his/her substance misuse? (Does he/she accept there is a problem, for example?)  How has the service user’s substance misuse affected him/her (continue to affect him/her)? (For example, getting into fights, loss of job, loss of home, loss of relationships, loss of self-esteem, feels angry, sad, etc.)  What, if anything, does the service user want to do about his/her substance misuse?  What help/support does the service user feel that he/she needs to address his/her substance misuse? In cases where a service user expresses a wish to address the substance misuse problem, the clinical record should also set out:  What information has been provided to the service user about statutory addictions services, voluntary addictions services and self-help groups in his/her local community.  Whether or not the service user has been supported in referring him or herself to the local substance misuse service.  Whether or not a referral to the Dual Diagnosis Service is appropriate; and, if yes, whether such a referral has been actioned.  What the ongoing care plan for the service user is in relation to his/her substance misuse, and how it is to be reviewed. In cases where the service user does not wish to discuss his/her substance misuse problem, or accept any help or support in relation to this, a clear record should be made to this effect. The Independent Team recommends that review of the clinical records and care plans of service users with addictions is given specific attention via the team managers’ regular records audit activity and also via periodic specifically targeted retrospective audit activity. For example, this could be managed via a peer review audit process facilitated by staff trained in dual diagnosis, or specialist addictions staff.

This recommendation has been separated into two distinct components. Part 1 To deliver Recommendation 1, 5 Boroughs Partnership NHS Trust must ensure that its staff working in general adult mental health services are informed about and understand:  addictive behaviour;  what compels a service user to remain active in his/her addiction;  what factors can motivate a substance misuser, including alcohol misuse, to change; and  the range of statutory, voluntary and self-help opportunities available to support service users who wish to address their addiction, including those organisations that provide support in achieving complete abstinence from it, where this is the goal of the service user. It is the experience of the Independent Team, as a consequence of undertaking HSG (94)27 investigations, that the knowledge and understanding of mental health staff (not working in specialist addiction services) can be variable in relation to substance misuse and addictive behaviour. In the first instance, the Trust may wish to conduct a knowledge-based assessment using a simple web-based questionnaire tool such as Survey Monkey. The Independent Team suggests that the question content could be formulated with the input of statutory addictions services, voluntary addictions services and service users with addictions who have either achieved a good level of control or have achieved abstinence. As an ‘expert patient group’, addicts should be engaged in the formulation of a meaningful survey tool whose purpose is to test knowledge and understanding of front-line staff. Part 2 If 5 Boroughs Partnership Foundation NHS Trust finds, as a consequence of its assessment of the skills and knowledge of staff around addictions management, is not as robust as it would like and an education programme is considered as a solution to this, 5 Boroughs Partnership Foundation NHS Trust may wish to liaise with neighbouring Mersey Care Trust, whose Dual Diagnosis Service currently delivers three awareness-raising training events a year for Mersey Care Staff. In addition to drawing on its in-house expertise, the training events offered draw on the wide range of expertise available in its local communities, including:  established charities working in substance misuse;  established self-help organisations such as Narcotics Anonymous and Alcoholics Anonymous; and  established carer organisations and self-help groups. If not already established, 5 Boroughs Partnership Foundation NHS Trust may wish to offer a similar education opportunity in its organisation.

Where it is known to mental health and primary care services that a service user has a substance misuse problem and there are closely involved carers/relatives, primary care and mental health services must provide those individuals with information about where they can source support for themselves. Information should at least be available on the following obvious contenders:  Addaction  Action on Addiction  Families Anonymous – for families of drug addicts (including alcohol)  Al-Anon – for families and friends of those with an alcohol problem. An internet search should reveal the range of charities and self-help groups in the North West who offer support for families. An optimal approach would be to develop a self-help information leaflet or booklet for families/carers, or an information pack containing key pieces of literature that may be useful to the family/carer.

The Trust’s own recommendation about the clear documentation of staff in attendance at ward rounds needs to be revisited so that 5 Boroughs Partnership Foundation NHS Trust can show that the identified absence of necessary documentation has been successfully addressed. The Independent Team suggests that the periodic assessment of the clear identification of Trust staff, and multi-agency representatives present at ward rounds and CM/HT team meetings, is incorporated into its standardised documentation audit processes.

The Trust’s own investigation made a recommendation about the clear documentation of the physical examination undertaken of a service user at assessments. The Trust needs to provide assurance on the reliability with which the medical physical examination is now recorded in the service user’s clinical records.

Although 5 Boroughs Partnership Foundation Trust has improved its approach to the conduct of serious untoward incidents, and the structure its investigation report template the Trust needs to continue on its improvement path so that:  The terms of reference used for each investigation is appropriately targeted to the needs of the investigation. A generic term of reference does not achieve this.  Staff tasked with leading serious untoward incidents understand the importance of attending to the detail of:  the investigation tools and techniques appropriate for the investigation in hand;  usage of systems/human factors frameworks and how they can be applied;  undertaking the systems/contributory factors analysis on a problem by problem basis, where significant lapses in care or treatment have been identified;  Stating plainly where care and treatment met the expected local and/or national standards  Trust investigators understand that for some incidents such as suicide and homicide, the purpose of the investigation is not to identify the ‘root causes’ of ‘the incident’, but to identify the ‘root causes’ of any significant/material lapse in the care and treatment afforded the service user. Once this has been determined Trust investigators can then consider the question of causality. (I.e. but for the lapses in care and treatment would the incident still have occurred?)  All recommendations are formulated so that they meet S.M.A.R.T criteria.  Investigation reports that clearly set out:  an executive summary;  why an investigation was commissioned and its purpose;  terms of reference;  investigation limitations;  findings in relation to i) where standards were met, ii) significant lapses in standards and the contributory factors to these lapses, iii) root causes (most significant contributory factors) to any significant lapses in case and treatment;  service user and family/carer involvement;  conclusions;  recommendations; and  relevant appendices.