Independent investigation: Liaquat Ali, Bury (1999)

In the development of the Action Plan that will follow the report, the Trust should draw together the recommendations of the other three incidents that occurred in 1999, to make absolutely certain that all lessons are learned.

A progress system should be put into place to monitor the completion of action points and any remaining obstacles to progress.

This process should be transparent to prevent a repeat of the lack of progress we noted following the internal inquiry and the Internal Inquiry report. However, it is important that this report should be widely shared in its entirety.

We recommend that the Trust review the implementation of CPA, particularly in Bury, through a quality audit.

Patients in Bury must have access to an Intensive Care Unit facility.

The Trust should be satisfied that the Borough Director in Bury has the necessary management support to enable her to progress the modernisation of Bury Mental Health services.

We appreciate that the Trust has responsibility for Bury, Rochdale, Oldham, Tameside & Glossop and Stockport. The Trust clearly has a demanding and wide agenda, and all of these services will have their strengths and weaknesses. Nevertheless, from our perspective, the situation in Bury is in some respects unique. We, therefore, recommend that the Chief Executive considers how he could provide the leadership and presence required to move the services forward. We are not convinced that a base in Tameside will allow this to happen.

We understand that there is an independent Mental Health Advocacy service in Tameside, where the Trust’s Headquarters is based, but we are aware that independent advocacy input into Bury and Rochdale, for example, has been substantially reduced. We recommend that Bury (this is the focus for our enquiry) should receive a better advocacy service, so that patients and their carers can be empowered to make comments about the services that they receive. Also, this would allow their rights to be considered as part of the decision making process.

In the handling of any serious incidents, when a person in contact with Mental Health services harms another, the Trust should consider their response to the victim and the victim’s family. We cannot suggest what that response should be, as much will depend on the nature of any injuries caused, and if the Criminal Justice System is involved, where, in the process, the individual with mental health problems is. The Trust should make certain that these considerations are part of any serious incident review.

We recommend that the Medical Director of Pennine Care NHS Trust review with Consultant 3 the relevant sections in the report in order to support Consultant 3, and to agree an Individual Personal Development and Continuing Professional Development Plan. We make similar suggestions for Consultant 1.

The Medical Director will need to focus carefully on the appraisal of all the medical staff in Bury. In our view this means that the Medical Director will need to do all of the annual appraisals, for all of the medical staff, until he is satisfied that the Associate Medical Director in Bury is able to take on this task.

The Medical Director should monitor the use of annual leave and study leave for the Doctors in Bury to make sure that they are not working through their annual leave entitlement, and are making good use of their study leave entitlement.

Trust grade doctors and every non-training grade doctors should receive one hour protected and timetabled supervision each week. This should be over and above any other clinical advice.

Whilst we understand the pressures on the time of the Medical Director, we believe that until it is possible to appoint new Consultants to Bury, there will need to be time set aside to become more involved in the services in Bury. We cannot find evidence that the situation with regard to medical staff has changed dramatically. We leave it to the Medical Director and in discussion with the Chief Executive to decide how this recommendation can be translated into action.

The Medical Director should take the lead in ensuring that the necessary changes take place in Bury for an application to be made through the Local Training Scheme to the Royal College of Psychiatrists for approval to train psychiatrists.

A nursing clinical supervision system should be in place to support modern-day nursing practice. A reflective nursing model might be considered.

Nursing staff should receive regular training in managing difficult and aggressive behaviour, and therapeutic engagement with problem patients. Whilst control and restraint is a last resort there should be regular training in this also.

There should be a clear policy for close observation of patients, which reflects standards proposed by the Royal College of Nursing.

Consideration should be given to the appointment of a Nurse Consultant with a particular focus on inpatient services in Bury.

The recording of information should follow agreed guidelines. For example, those provided by the British Association of Social Workers on confidential and ethical recording.

Patients who move out of one area to another should remain the active responsibility of the original authority until a formal handover can be arranged. A formal handover implies real team to team discussion, nor merely a paper passing exercise, and which should be timely and include:
• Team to team discussions
• The provision of background information
• A contingency plan with, for example, a system of rapid transfer back to the original system if the patient moves.

The provision of an approved local authority list of bed and breakfast accommodation to vulnerable adults with mental health problems implies that the addresses on the list are suitable for this group of people.
We appreciate the difficulties of managing individual cases when there is a degree of non-cooperation. However, even when there is a lack of appropriate accommodation this practice (of providing the approved list) should be reviewed as a matter of some urgency.

Training in dual diagnosis and in personality disorder is urgently required for all clinical staff. We recommend multidisciplinary training is set up on a regular basis to prevent mental health issues being obscured by either illicit drug use or personality difficulties.

We recommend that the Trust consider facilitating team-working development in Bury, with medical staff, in order to encourage efficient multidisciplinary processes and decision-making. The medical staff in particular, need to be included in these proposed team-working developments.

We recommend the review of the skill mix and training needs for all staff not just nursing staff.

We do not support the continuation of separate nursing notes and would strongly suggest that multi-disciplinary integrated notes is the model that Bury services (proposed all services) should move towards.

The Trust should develop standards for record keeping consistent with national agreed standards for mental health.

Similarly, the Trust should develop a procedure for the retrieval of appropriate clinical and other information in circumstances where the original records have been lost, stolen or damaged.

All staff, particular including medical staff, should receive regular training in CPA. Which should emphasise the real benefits of the care planning process to individual patients, and stress that it is not just a form filling exercise.

All staff should receive training in clinical risk assessment and management. For example, a clinical base tool such as HCR20 is of use. This is not to suggest that all patients require such a risk tool, but the structure and questions asked in the HCR20 are to help in assessing risk in all patients.

The use of CPA in Bury should be regularly audited.

All staff should have regular training on the use of the Act and Code of Practice, including any changes in case law, which may affect their professional practice. Wherever possible, training should be multi-disciplinary and multi-agency.

All leave for detained patients must be authorised in accordance with Section 17 of the Act and Chapter 20 of the 1983 Mental Health Act Code of Practice. All leave should be documented on the Trust’s Section 17 Leave Form, which should contain all the information requested on each occasion when leave is authorised.

Audit systems should be put in place to monitor compliance.

Senior Managers and staff working on the wards should be made aware of the provisions of Chapter 19 of the Code, which relates to the management of patients presenting particular problems, as a result of their disturbed behaviour. This chapter gives guidance on the response of the clinical team to a serious incident.

The patient’s nearest relative should be actively involved in aftercare planning, if the patient consents, and their views must be documented and properly taken into consideration by the care team.

Aftercare planning, including the granting of leave and discharge arrangements, should comply with paragraph 27.6 of the Code of Practice.

The patient’s Responsible Medical Officer should discharge their responsibilities as set out in paragraph 27.6 of the Code, in particular the assessment of any risk to the patient or third parties and the consideration of the criteria for supervised discharge or guardianship.

The Trust and the local social services authority must strengthen their Section 117 procedures. Individuals who are entitled to aftercare should not be discharged from hospital before appropriate aftercare facilities have been identified. Once discharged, the patient’s progress must be actively monitored. Regular Section 117 meetings should be held, with a contribution to those meetings from the patient’s Responsible Medical Officer.

The Trust’s Supervised Discharge Policy needs to be re-written to better reflect the Department of Health’s Guidance. Staff should receive training on the use of supervised discharge and guardianship.

Although a patient, subject to Section 117 cannot be compelled to accept those services, a failure to engage with services should not be seen as an early opportunity to rescind Section 117. Rather, such failure should trigger an action plan, which seeks to address the patient’s non-compliance with aftercare and, if necessary, allows for a reassessment of the patient’s mental state in order to ascertain whether admission to hospital is indicated.

The Trust and social services authority should give active consideration to the provision of an independent mental health advocacy scheme to assist patients and their carers make comments about the service they receive, and to articulate their own needs and preferences.

Urgent agreement on the allocation of resources from Bury Acute Trust to Pennine Care Trust needs to be reached. It is clear that not all of the funds were fairly distributed between the two Trusts.

A review of funding for the Mental Health Service in Bury is, in our view, necessary so that there can be proper consideration of the years of under-funding that the service has had to endure. We accept that the service in Bury will not be able to catch up in one leap, and that progress is being made, but from our understanding of the financial situation, the chronic under-funding problems have still not been resolved. We recommend that an agreement be reached between the Pennine Care Trust, the Primary Care Trust, and the Strategic Health Authority.

We recommend that the three North West Medium Secure Units and the Secure Commissioning Team consider how to manage, from a service perspective, a North West patient admitted to a North West Medium Secure Unit who is out of their catchment area.
In our view, the Forensic Service needs to consider:
• Involving the local catchment area MSU in the discharge discussions and arrangements
• Using the local catchment area MSU for its knowledge of services and community facilities
• Copying discharge details to the local catchment area MSU
• Whether the local catchment area MSU should have any active involvement with the patient, for example, by sending the member of staff to attend clinical team meetings.

We suggest that the lead clinicians in each of the three MSUs should come to some agreement about how to manage such cases and this agreement should be supported by the Secure Commissioning Team.

We appreciate that there will be changes in how enquiries, following the homicide committed by an individual in contact with Mental Health Services, will be set up and arranged in the near future. However, any review of clinical decision-making, and the organisation, will be hampered if the senior staff use retirement as a means of absenting themselves from the process. In our view this is particularly serious if a Chief Executive takes this stance. We therefore recommend that the Department of Health should consider issuing advice to all Mental Health Trusts on how individuals in contact with one Mental Health and Social Care services are handed over to new services. Good practice in this area should be highlighted.

We suggest that consideration be given to more general advice in relation to l (viii) in the above recommendations.