Independent investigation: Leo Norris (10 days old), Brixham (2010)

DPT will audit the implementation of the perinatal pathway as described in 19.3 above.

DPT will establish perinatal services to cover all areas of Devon and Torbay in accordance with commissioner requirements.

DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are pregnant. Specifically a written care plan covering pregnancy, delivery and the postnatal period should be developed for pregnant women with a current or past history of a severe mental illness, usually in the first trimester.

This written care plan should: o be developed in collaboration with the woman and her partner, family and carers, and relevant healthcare professionals o include increased contact with specialist mental health services (including, if appropriate, specialist perinatal mental health services) o be recorded in all versions of the woman’s notes (her own records and maternity, primary care and mental health notes), and o be communicated to the woman and all relevant health care professionals.

DPT will, in conjunction with its commissioners, seek to establish a presence within MASH on an ongoing basis and will continue to advocate for the multiagency hub arrangements extending to encompass Torbay.

DPT will review its training needs analysis and training provision to consider whether face-to-face and inter-agency training below level 3 might be more effective in helping staff to identify relevant cases and improve their awareness of how cases should be managed.

DPT will continue to monitor the uptake of training identified as being required in relation to safeguarding children and strengthen its performance management in respect of uptake.

DPT will incorporate a review of the number of hours allocated to the Named Nurse post within its current review of the safeguarding governance arrangements, engaging with commissioners as required, to ensure that safeguarding maintains a high profile.

South Devon Healthcare Trust will monitor the uptake of training identified as being required in safeguarding children.

DPT will establish perinatal services to cover all areas of Devon and Torbay in accordance with commissioner requirements.

DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are pregnant. Specifically a written care plan covering pregnancy, delivery and the postnatal period should be developed for pregnant women with a current or past history of a severe mental illness, usually in the first trimester.

This written care plan should: o be developed in collaboration with the woman and her partner, family and carers, and relevant healthcare professionals; o include increased contact with specialist mental health services (including, if appropriate, specialist perinatal mental health services); o be recorded in all versions of the woman’s notes (her own records and maternity, primary care and mental health notes); and o be communicated to the woman and all relevant health care professionals.

DPT will incorporate the key questions identified from the audit of clinical risk assessment into the Clinical Record Self Monitoring Process. This will improve the monitoring and performance management of this key area of practice by providing information which is then routinely considered at service and team level. This should identify and support services and teams where further improvement is needed.

DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are pregnant. Specifically a written care plan covering pregnancy, delivery and the postnatal period should be developed for pregnant women with a current or past history of a severe mental illness, usually in the first trimester.

This written care plan should: o be developed in collaboration with the woman and her partner, family and carers, and relevant healthcare professionals; o include increased contact with specialist mental health services (including, if appropriate, specialist perinatal mental health services); o be recorded in all versions of the woman’s notes (her own records and maternity, primary care and mental health notes); and o be communicated to the woman and all relevant health care professionals.

DPT will review its practice standards to ensure that they are more explicit in describing how the views of a person’s family or supporters should inform assessment, formulation and recovery plans.

DPT will develop and incorporate into the Clinical Record Self Monitoring Process question/s to check the completeness of the clinical record; that it records all contact, or attempted contact, with an individual client, and reflects all clinical discussions, informal or formal, concerning the individual client, to improve the completeness and coherence of the clinical record.

DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are pregnant. Specifically a written care plan covering pregnancy, delivery and the postnatal period should be developed for pregnant women with a current or past history of a severe mental illness, usually in the first trimester. This written care plan should: o be developed in collaboration with the woman and her partner, family and carers, and relevant healthcare professionals; o include increased contact with specialist mental health services (including, if appropriate, specialist perinatal mental health services); o be recorded in all versions of the woman’s notes (her own records and maternity, primary care and mental health notes); and o be communicated to the woman and all relevant health care professionals.

South Devon Healthcare Trust will monitor the implementation of the policy concerning the handover of the care of a mother from one midwifery team to another.

DPT will establish perinatal services to cover all areas of Devon and Torbay in accordance with commissioner requirements.

DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are pregnant. Specifically a written care plan covering pregnancy, delivery and the postnatal period should be developed for pregnant women with a current or past history of a severe mental illness, usually in the first trimester.

This written care plan should: o be developed in collaboration with the woman and her partner, family and carers, and relevant healthcare professionals; o include increased contact with specialist mental health services (including, if appropriate, specialist perinatal mental health services); o be recorded in all versions of the woman’s notes (her own records and maternity, primary care and mental health notes); and o be communicated to the woman and all relevant health care professionals.

DPT will complete the service redesign work in preparation for the implementation of PbR cluster pathways in 2013. This will fundamentally change the structure of services and both simplify and clarify care pathways. Implementation will include a communication plan with DPT clinicians and referring clinicians in respect of the new structures and pathways.

DPT will publish its ratified operational policies on the Trust internet and Clinical Team Leaders will be tasked with ensuring all team members are conversant with the operational policy for their team through induction and supervision.

DPT will audit understanding of and adherence to operational policies and care pathways.