Independent investigation: John TaylorBeverley Taylor, Skipton (2021)

There were weaknesses in the application of the Failure to Attend Policy. The Trust must strengthen their response to patient non-engagement by: • identifying patients at risk of non-engagement who are on CPA, and entitled to Section 117 aftercare; • monitoring and prioritising those patients; • ensuring that these patients are discussed in CLM and in MDTs and that contingency plans are formulated; and • ensuring that the current Trust policies on Failure to attend’ and ‘Non-compliance with Treatment’ are robustly followed for service users in receipt of CPA and Section 117 aftercare.

There were weaknesses in the way the IHTT and the CMHT communicate to each other about persistently non-engaging patients. The Trust must provide guidelines to IHTT so that they know when and why to feedback to CMHTs about referred patients who are persistently not engaging.

As Patient E’s condition deteriorated, there was an increasing lack of engagement with him and his family members, and no evidence of any attempts to provide education about the nature and course of his illness and its treatment. Patient E and his family were not provided with an opportunity to improve their knowledge and understanding of medication options and their side effects. Improving the education and compliance of service users and carers of people with psychosis is best practice guidance14 The Trust must ensure that CMHTs have effective processes in place, so service users and families are offered timely information and educational opportunities about the course and nature of psychosis including medications and their side effects in line with best practice guidance.

There was variation in work systems which meant that doctors and other staff had different ways of completing risk assessments documentation. Safeguarding forms do not require the assessor to consider either risks to vulnerable adults by patients or the risk of exploitation of patients. • The Trust must ensure that all staff (including locum staff) are trained on and are using standardised methods to document risk assessments on SystmOne. This should be audited within six months. • The Trust should revise safeguarding forms to include guidance on safeguarding risks to vulnerable adults/others.

There were inadequate systems in place to monitor the frequency and quality of risk assessments. Trust-level data was not sensitive enough to provide adequate intelligence about whether individual patients were being risk assessed at the appropriate frequency. The Trust must introduce more sensitive and effective controls that monitor and maintain appropriate frequency and quality of risk assessments for complex patients. This should be led by the individual patient’s needs (as distinct from a standard annual target). We understand the Trust is considering implementation of the Management and Supervision Tool15 to support this.

At the time of the incident the CMHT did not have a risk stratification system to indicate which patients were at higher risk of deterioration or were at risk of harm to themselves or others. A system which could have supported the team to convey essential information about dynamic risk would have enhanced awareness in the wider team, and would have helped prioritise the service response. We understand the Trust is considering developing this. The Trust must ensure it has an approach for a risk stratification or an early warning system for patients in CMHTs to enhance team awareness of situations where patients may be deteriorating and to help identify and prioritise those patients at higher risk of deterioration.

There were delays in referring Patient E to IHTT because of barriers to effective communication between the GP and FRS. The first urgent referral from the GP was not responded to appropriately. • The Trust should develop a standard operating procedure (SOP) for urgent referrals from primary care. This should include clear response times, what to do if the situation escalates further and clear points of contact, and feedback to the referrer. • This should be discussed with primary care services through the integrated care board (ICB) and communicated to all practices. • The Trust should monitor all urgent referrals made to IHTT and report to the Quality Board on any delays experienced.

a: CMHT care planning for erratic and sporadic patient engagement When Patient E was not engaging in the autumn of 2021 there was no contingency/care plan to guide the service response as required by Trust policy. The Trust must provide assurance to the appropriate sub-committee of the Board that CMHTs are responding appropriately to service users who do not engage in line with Trust policy. b: CMHT member team roles at complex case meetings There was a misunderstanding between team members of their respective roles regarding who should and could discuss cases at the complex case meeting. The Trust must provide assurance to the appropriate sub-committee of the Board that all CMHT staff are aware of who can take cases to the complex case meeting, and that staff fully understand the reasons for doing this. c: Part-time working – impact on providing equitable access to care Appointments were delayed due to key CMHT staff being part-time, with no suitable alternative arrangements in the event of non-urgent matters requiring attention within normal working hours. • The CMHT SOP must articulate what needs to be done by when and whom, so that patients can be seen quickly by being offered an appointment with another member of the team when their own clinical team are not working, thereby providing equitable access to care. • The Trust must provide assurance to the appropriate sub-committee of the Board that the SOP has been implemented and evaluated in respect of the continuity of cover and part time working. d. IOT threshold for acceptance. Patient E was referred to but not accepted by IOT as he had limited engagement with CP2. However, he was not engaging with his care coordinator or the IHTT and would have benefited from a more assertive approach. IOT referral and acceptance criteria should be revisited and tested in the light of this case. e. CMHT operating hours Patient E would have benefited from contact from the CMHT in the evening, but this could not happen because the service is commissioned to deliver a Monday to Friday ‘9 to 5’ service. The Trust should work with commissioners to understand the demand for, and benefits of, CMHT extended hours working beyond Monday to Friday 9 to 5, so as to scope the nature of such a service and build this into strategic development plans.

CP2 received ad hoc supervision and did not attend routine team and governance meetings due to being part time. The Trust must revisit the arrangements in place for locum/part-time consultants and examine what support is needed to ensure they receive regular supervision are able to attend relevant departmental meetings.

There was an inadequate discharge plan and no Section 117 meeting in advance of discharging Patient E from the CMHT in May 2021. • The Trust must ensure discharge planning processes are revisited to ensure that Section 117 reviews are being held in line with Trust Policy. • The relevant Trust policy16 should be reviewed to include any learning from this case and to ensure the expectations for what staff will do are clear. The policy should be reissued within six months.

There was infrequent CLM supervision in this case that was not in line with Trust policy. The challenges of managing a patient who did not engage were not adequately explored and resolved. The Trust must assure itself that anyone providing supervision routinely do so in line with the Trust’s good practice standards.

The monitoring of Patient E’s medication, efficacy, side effects and his compliance was not adequate. • The Trust must ensure that services users on anti-psychotic medication are monitored at appropriate intervals for side effects using the appropriate methods (e.g. LUNSERS or monitoring blood results) and the services user’s condition is monitored for clinical worsening and efficacy in line with NICE guidance.17 • Existing medication audit processes within Mental Health Trust 1 should be revised in light of this recommendation.

There were missed opportunities in the clinical management of Patient E’s care, including critical tasks not being completed by frontline staff and compliance controls used by management to prioritise a deteriorating patient and assess risk. Mental Health Trust 1, Council 2b and ICB 2 must provide assurance that learning from this case in relation to complex (non-engaging and subject to Section 117) patients, such as Patient E, is shared and joint systems put in place to address the above recommendations (1–13). This will also support the assurance review to be undertaken by Niche 6 to 12 months after the publication of this report.

Patient E received Section 117 aftercare. It is the duty of the local authority and the ICB to ensure this is provided and reviewed. Patient E was discharged from the CMHT with no involvement of the local authority in May 2021, and they were not informed, and a planned review did not happen in October 2021. The Trust must develop effective processes for the monitoring of compliance with Section 117 aftercare policies. Council 2b, ICB 2 and Mental Health Trust 1 do not have a jointly agreed Section 117 policy in place (although there is an agreed policy between the Trust and Council 1). Council 2b, ICB 2 and Mental Health Trust 1 must develop, agree and implement a robust Section 117 after care policy which includes effective monitoring and oversight arrangements.