Independent investigation: Karen Godden, Leicester (2007)

The management team for adult services in LPT needs to establish on a CMHT by CMHT basis, in the city and the county, the number of service users who are on “open contact” and the professionals’ rationale for this. If the dominant reason for “open contact” is to enable rapid re-access to specialist mental health services, as was the case for this MHSU, then LPT must review its systems to enable service users to achieve a fast-track route back into the system without having to be treated as a “new” referral. If an effective system can be achieved it will enable CMHTs to discharge service users while they are well whilst also having, and giving, confidence that those service users who are likely to relapse will be able to re-access specialist mental health services in a timely manner with a care team they know.

In many respects it appears that the Care Programme Approach (CPA) and risk assessment (RA) are embedded in community and inpatient practice. However the IIT does have some concern about the quality of the information entered on to the CPA and RA documentation tools. This concern is particularly focused on the risk prevention and contingency plans generated within the community. Therefore, LPT needs to consider how it assesses the quality of content, and the frequency with which CPA and RA plans are critically appraised within the context of management and clinical supervision. In partnership with frontline staff, LPT needs to continue its work of fine-tuning the design of its documentation tools so that they best promote the standard and quality of documentation to which it aspires. The following information should be stated clearly in risk assessments and risk prevention and crisis management plans so that they can be as useful as possible. Where a professional indicates the presence of current and/or previous risk behaviours these must be described, including the context in which they are displayed and their known consequences. LPT can assist its staff in this when it updates the current RA documentation tool. Consideration could be given to including a free text space after each main section of the actuarial element of the RA tool. The action plan must state precisely what is required and not just be a bulleted list. This is not acceptable practice. For example if enhanced visiting is required it would be useful to indicate the minimum frequency for this. Contingency plans must be sufficiently detailed so that if no-one is available who knows the service user, then any other professional dealing with the crisis has immediate access to all essential information to enable them to implement the crisis plan. This should include all essential contact numbers, any known haunts and hangouts of the service user, and details of significant others. The crisis plan should also state what core activities and actions must be delivered in the management of crisis, including those professionals who must be notified. It is expected that LPT will conduct an audit of risk assessment documentation across all of its services to check whether this is being done. The IIT encourages LPT to utilise a peer review process in addition to more formalised documentary audit tools.

In 2004 a recommendation was made to LPT regarding the provision of clinically focused risk assessment for its staff. The IIT is encouraged that all community staff had accessed risk assessment and CPA training within the Trust and that both CPA and risk assessment were part of the same training workshop. However, the IIT is concerned that not one of the inpatient staff it spoke with had been provided with the same training opportunities or input. LPT must ensure that clinical risk assessment training, as it relates to the assessment of risk in service users, is provided to inpatient as well as community staff. The IIT recognises that there may be significant cost implications associated with this, depending on how LPT chooses to address the training deficit. The IIT suggests therefore that LPT must present a proposal of how it will address this essential area of training for all of its staff working within Adult Services in the next financial year (2010/11).

The IIT is disappointed at the lack of formalised joint working arrangements between the MHSU’s CMHT and his wife’s AOT. However, it is commendable that LPT has addressed this issue in its current CPA policy document implemented in 2007 (page 14, section 3.4). Although the principles espoused at section 3.4 appear plainly stated to the IIT, its impression is that LPT’s professionals are still not always certain about when one should consider joint working. The IIT therefore recommends the use of this case, and previous relevant serious untoward incidents where joint working would have enhanced the quality of care to the service users, as case studies within LPT’s CPA training workshops. The IIT also recommends that this case be used to highlight the issue of joint working in the next quarterly issue of its learning from experience bulletin TRAIL3. It is incumbent on LPT to ensure that TRAIL is circulated to all CMHTs and inpatient services regardless of whether they are city or county based.

Although the internal investigation team did meet with the family of this MHSU during the course of its investigation, there was no immediate post incident support provided to the family by the MHSU’s care team. Neither was any support offered to the family of Miss K. Today LPT has a “Being open” policy that is in line with the guidance provided by the National Patient Safety Agency. Section 5.1, page 5, of LPT’s policy is explicit about the requirement to communicate with families and carers following serious incidents. However there is a gap in the policy document relating to communication with: the family and/or carer(s) of the service user(s) involved in the serious incident, and the family of any victim(s), if this is different to the family of the service user, where harm has been caused by a service user, after the incident has been investigated. Section 7, pages 6 and 7, of LPT’s policy does not make explicit the requirement for staff to meet with and feed back to the respective families and/or carers the findings and recommendations of the internal investigation process. Sending a family a copy of the Trust’s internal investigation report in the post is neither sufficient nor acceptable. It is therefore recommended that an addendum to the policy is issued as the IIT does not believe that remedy of this can wait until the policy is reviewed in October 2010.

LPT’s internal investigation report did not evidence that a reflective or analytical approach had been taken to the investigation of the MHSU’s care and management. Furthermore the report was written in a rather congratulatory style and this caused offence to Miss K’s family and to the family of the service user. The incident management policies in LPT are now far more robust than they were in 2007. Furthermore a director of LPT is given the responsibility of overseeing the investigation process and for the quality of the end report. What continues to be absent from LPT’s policy documents is any practical guidance for staff who are identified as having the correct skills and aptitude for investigating. The LPT’s incident reporting toolkit, which incorporates the guidance on incident investigation, talks of a structured investigation process but does not set this out anywhere in the policy document. Furthermore it does not set out clearly the core competencies that are required of staff who take the operational lead for SUI investigations. The IIT suggests that the following should be considered as core competencies for anyone asked to lead SUI investigations. An understanding of the basic, key components of a robust investigation process. Knowledge of how to construct an analytical timeline (e.g. a tabular timeline) and to which types of incidents it should always be applied. Knowledge of how to construct a validation and triangulation map once all questions to be asked have been identified. Recognising the importance of the lead investigator having ‘hands on’ involvement at all key stages of the investigation process. (Delegation to uninvolved third parties is not good practice). An understanding of investigative interviewing using a cognitive style. Knowledge about what constitutes acceptable and unacceptable interviewing practice. For example there should never be just one interviewer who is also the note keeper. The need for as full a record as possible of everything discussed within the interview scenario. Knowledge of data analysis techniques such as content analysis and affinity mapping. How to use the ‘fishbone diagram’. Knowledge of how to write a high level report that is likely to be made available to non-professionals such as the family of a service user and the family of a victim. It is recommended that these competencies are included in LPT’s incident reporting and investigation tool kit as an appendix, and that where a staff member does not possess these competencies they are mentored by someone who does until they are considered competent. LPT is also encouraged to set out in an appendix of this policy document its investigation framework, i.e. the key stages of the investigation process that it expects all SUI investigators to utilise.