Independent investigation: Michael Young, Nottingham (2010)

Nottinghamshire Healthcare NHS Trust needs to ensure in its redesign of its electronic record that the facility to register a different correspondence address to the service user’s own address is included.

Nottinghamshire Healthcare NHS Trust needs to include in its routine demographic information collected on each service user details related to literacy. In this case, the first time the professionals appreciated that Mr S had literacy problems was during the independent investigation process. This situation is completely avoidable.

Nottinghamshire Healthcare NHS Trust needs to engage with the lead for the Public Protection Unit at Nottinghamshire Police to explore how the Police National Computer facility can be appropriately utilised by mental health professionals where it is considered that it is in a service user’s interest, or in the interests of public safety, for a mental health alert to be notated on the PNC for a named individual. Such an alert means that, if the named individual is stopped by the police under circumstances reflecting the mental health alert, then there is a greater likelihood that mental health services would be informed and would be in a position to determine the need for a mental health assessment.

The assessment of the Trust’s internal investigation has identified the need for Nottinghamshire Healthcare NHS Trust to further develop the standard of its serious untoward incident investigations and in particular the presentation of the investigation reports written, so that the investigation report: Clearly sets out the terms of reference to which the investigation was delivered. Makes transparent the investigation methodology and the investigative tools and techniques used. Makes clear the aspects of the service user’s care and treatment that meet or exceed local/national policy expectations. Makes clear the areas where significant lapses in care and treatment standards have occurred. Sets out the contributory factors to each identified significant care and/or treatment lapse and makes clear those contributory factors that are considered by the investigation team to have had the greatest impact. (These could be termed ‘root causes’.) Delivers recommendations that address identified ‘root causes’ and are formulated so that they meet S.M.A.R.T. criteria. Makes clear the overall conclusions of the investigation team in relation to the terms of reference set and also in relation to the realistic potential for incident predictability and preventability. Where specific questions are agreed as requiring an answer in the investigation report, and these are set out alongside the terms of reference, the committee quality assuring the internal report must satisfy itself that these questions have been responded to and that the information presented is backed up by the information gathered during the investigation process.

There were omissions in the Mr S report that should have been identified and addressed via an effective quality assurance process. The Trust must therefore devise a common set of criteria against which each Level 2 serious untoward incident investigation report is benchmarked. This set of criteria must be implemented across the relevant divisional committees who oversee and have responsibility for the acceptance of and quality assurance of serious untoward incident reports on behalf of Nottinghamshire Healthcare NHS Trust.

Nottinghamshire Healthcare NHS T following its own internal investigation recommended that: “Where possible, partner agencies should be engaged and agree to be involved in similar processes to ensure that the lessons learned can be shared to ensure ongoing improvements in the care of individuals whom they deliver services to.” This recommendation has not been delivered. Although the principle of the recommend was and remains appropriate, the way it has been formulated will make it challenging to deliver. Consequently the Independent Team recommends that: A senior Manager in each directorate is given the express responsibility for liaising with third party agencies to seek their cooperation with the internal review of serious adverse incidents where the third party has been involved with the service user, and their involvement is considered necessary. An executive director of the Trust is also identified as the lead executive for engaging with his/her counterpart in the involved partner agency. It is essential that the initiation to participate is initially made at this level in the organisation, especially following incidents of the magnitude of the Mr S case. The Trust develop a template letter that can be used by the Trust’s internal investigation teams for the purpose of communicating with partner agencies following serious adverse incidents.

The Housing Provider needs to reiterate to all relevant staff the importance of documenting significant communications about individual tenants with partner agencies such as mental health services. With the increase emphasis on the independent review process following mental health homicide, domestic homicide, and the serious case review process for children and vulnerable adults it is important that housing officers understand that attention to detail in their written records is increasingly important. When communicating with mental health services important information to record is: i) the reason for the communication; ii) what the context of the communication was; and iii) what the outcome of the communication was.