Independent investigation: Kenneth Godward (77)Roger Lamb, St James’ Hospital, Leeds (2015)

We recommend that LTHT and LYPT work together to ensure that the mental health needs of patients are properly addressed when they are admitted to an acute general ward. We would suggest that mental health, diagnoses and medications are included … Read more We recommend that LTHT and LYPT work together to ensure that the mental health needs of patients are properly addressed when they are admitted to an acute general ward. We would suggest that mental health, diagnoses and medications are included in the admission information and for people living with schizophrenia that there is a requirement to ensure that the patient’s care is discussed at the earliest opportunity within a multi-disciplinary (mental health and general acute) team. Show less

We recommend that LTHT take steps to improve the practical skills and understanding of general acute ward staff with regards to the use of Deprivation of Liberty Safeguards and the Mental Capacity Act.

We recommend that LTHT take steps to ensure that appropriate referral criteria are developed to advise pharmacy staff when they should seek advice from a pharmacist working in specialist mental health services, and a psychiatrist, in the cases of patients … Read more We recommend that LTHT take steps to ensure that appropriate referral criteria are developed to advise pharmacy staff when they should seek advice from a pharmacist working in specialist mental health services, and a psychiatrist, in the cases of patients with severe and enduring mental illness such as schizophrenia. Show less

We recommend that LTHT conduct a risk assessment when vulnerable patients may be in a bay with patients who are aggressive or agitated. We further recommend that LTHT take steps to ensure that where patients are inappropriately placed together that … Read more We recommend that LTHT conduct a risk assessment when vulnerable patients may be in a bay with patients who are aggressive or agitated. We further recommend that LTHT take steps to ensure that where patients are inappropriately placed together that additional staffing is secured to maintain their safety. Show less

We recommend that LTHT take steps to review their care planning documentation to ensure that there is an opportunity to describe an overview of the patient’s care needs. We further recommend that LTHT include this in their clinical audit programme.

We recommend that LTHT ensure that the pharmacy service routinely carry out checks on prescription sheets to identify if patients have had repeated missed doses of the same drug. Where there are repeated missed doses, we recommend that LTHT ensure … Read more We recommend that LTHT ensure that the pharmacy service routinely carry out checks on prescription sheets to identify if patients have had repeated missed doses of the same drug. Where there are repeated missed doses, we recommend that LTHT ensure that pharmacy staff escalate these cases to the consultant and Ward Manager in charge of the patient’s care. Show less

We recommend that LTHT take steps to ensure that when patients are given intramuscular medication to calm them and to reduce an episode of aggression or disturbed behaviour, a plan is made to effectively look after them and maintain their … Read more We recommend that LTHT take steps to ensure that when patients are given intramuscular medication to calm them and to reduce an episode of aggression or disturbed behaviour, a plan is made to effectively look after them and maintain their safety when the medication effect wears off. Show less

We recommend that LTHT and LYPT work together to ensure that there is clarity about where decisions regarding patients who are being treated by both Trusts are recorded. Furthermore, we recommend that both Trusts adjust their healthcare records policies accordingly. Read more We recommend that LTHT and LYPT work together to ensure that there is clarity about where decisions regarding patients who are being treated by both Trusts are recorded. Furthermore, we recommend that both Trusts adjust their healthcare records policies accordingly. Show less

We recommend to both Trusts and Commissioners that: a) Terms of reference documents include a version control and date by which they are finally agreed. b) We recommend that in future investigation reports the exact wording from the finally agreed … Read more We recommend to both Trusts and Commissioners that: a) Terms of reference documents include a version control and date by which they are finally agreed. b) We recommend that in future investigation reports the exact wording from the finally agreed terms of reference are included in the final report to ensure there is no doubt as to what they should cover. This should be included in internal investigation protocols for both Trusts and in the closure checklist process for Commissioners. c) Internal investigations are focused on the incident itself, not just the care and treatment of one patient. d) If families identify issues during the investigation that they wish to be addressed, that are not covered within the terms of reference, that the investigator requests a review of the terms of reference by the commissioner of the investigation. This should then consider if the families concerns and questions are adequately explained within the terms of reference, and if not expand them to cover the issues and identify any extra resources that are required and made available to the investigation team e) Complex Level 2 investigations are conducted with an investigation team (of more than one person) that comprises professionals with expertise in investigation techniques and specialist knowledge in the clinical areas to be investigated f) Future terms of reference for provider led investigations specify the level of investigation to be carried out and describe the incident to be investigated. To assist in clarity, terms of reference should include the date, location and a brief description of the incident and outcome. g) Future terms of reference must include the investigation methodology that the investigation team are expected to follow, and that this should be consistent with national guidance in place at the time. Show less

We recommend that LTHT and LYPT consider how best to ensure that all learning from the incident that occurred on 28 February 2015 is captured. It would be appropriate to enlist the advice and support of the NHS England (North) … Read more We recommend that LTHT and LYPT consider how best to ensure that all learning from the incident that occurred on 28 February 2015 is captured. It would be appropriate to enlist the advice and support of the NHS England (North) Serious Incident team to do this. Show less

We recommend that LTHT and LYPT report their progress on the above recommendation to the Local Safeguarding Adults Board, to ensure openness and to share learning. This is because this incident has wider safeguarding implications than within the local CCG. Read more We recommend that LTHT and LYPT report their progress on the above recommendation to the Local Safeguarding Adults Board, to ensure openness and to share learning. This is because this incident has wider safeguarding implications than within the local CCG. Show less

We recommend that LTHT and LYPT work together to improve the application of risk assessments and risk management in the acute hospital environment. The work should include training for staff leadership and role modelling from clinical leaders, and regular audit … Read more We recommend that LTHT and LYPT work together to improve the application of risk assessments and risk management in the acute hospital environment. The work should include training for staff leadership and role modelling from clinical leaders, and regular audit of practice to demonstrate an improvement. Risk assessment and management of mental health patients in the acute hospital environment should be included in the clinical audit programme. Show less

We recommend that LTHT provide Ken's and Roger's families with a summary of the information contained in the statements that have been submitted to the Coroner which details their loved ones care and treatment.

We recommend that LTHT offer to meet with the families to address their unanswered questions and discuss changes that have been made following this incident, including:  how staffing levels are calculated and delivered on medical wards; and,  how … Read more We recommend that LTHT offer to meet with the families to address their unanswered questions and discuss changes that have been made following this incident, including:  how staffing levels are calculated and delivered on medical wards; and,  how safeguarding is practised and how the safety and security of staff and patients is supported on medical wards. Show less

We recommend that LTHT issue guidance to staff on general acute wards regarding the criteria to request one-to-one support for patients who are a risk to themselves or others.

We recommend that LTHT conduct a review of the case mix and safety of patients on J19 given the severity of violent incidents. This review should be conducted by security management specialists in conjunction with acute nursing staff on the … Read more We recommend that LTHT conduct a review of the case mix and safety of patients on J19 given the severity of violent incidents. This review should be conducted by security management specialists in conjunction with acute nursing staff on the ward and mental health specialists. Show less

We recommend that the GP practice review all patients on their list that have a severe and enduring mental health diagnosis to ensure that there are no outstanding referrals to mental health services.

We recommend LTHT ensure that the learning regarding listening to families/carers is incorporated into staff training. The essence of this is to ensure that staff understand that carers and family of people with long-standing mental health problems have extremely valuable … Read more We recommend LTHT ensure that the learning regarding listening to families/carers is incorporated into staff training. The essence of this is to ensure that staff understand that carers and family of people with long-standing mental health problems have extremely valuable insight into the risks associated with missed medication. Show less

We recommend that LTHT take steps to ensure that the record-keeping in relation to medication prescription and administration is of the required standard. We suggest that this is included in their clinical audit programme.

We recommend to LTHT that they take steps to ensure that when patients transfer wards that their records are transferred with them avoiding a delay in receiving staff accessing patient information.

We recommend that LTHT take steps to improve the knowledge and understanding of general acute staff in how and when to access specialist mental health input.