Independent investigation: Nicole TownshendJane Malkin, Leicester (2007)

LPT needs to ensure that its crisis resolution and home treatment professionals have access to up-to-date and appropriate clinical records when conducting emergency mental health assessments. At the time this MHSU was receiving home treatment the CRHT did not have access to core clinical information electronically, for example the most recent CPA document, the most recent risk assessment and any significant correspondence. The city CRHT’s operational policy in 2006 did not address the issue of what information was required by the CRHT from a service user’s regular care team when it accepted a client for home treatment. Neither did the operational policy for community mental health teams (CMHTs) address what information they will routinely provide if a service user was transferred to the care of another team such as CRHT or the Psychiatric Early Intervention Service. It is therefore the recommendation of the IIT that the Executive Director with responsibility for quality and innovation determines with the Service Manager of the crisis resolution teams what core clinical information must be provided to them when a known patient is referred for a crisis assessment. It is the IIT’s perspective that any minimum data set should include copies of the: most recent CPA document; most recent assessment and risk management plan; and most recent outpatient correspondence sent to the service user’s GP. In addition to the above, because LPT does not yet have an electronic records system, it is recommended that as standard where a service user is accepted for home treatment there is a face-to-face handover involving the service user’s regular care coordinator, or that the crisis team attends at the regular team’s base to extract information that will enable safe and effective home treatment.

The operational policy for LPT’s crisis resolution and home treatment service must set out clear and measurable standards for how service users are discharged. The crisis resolution and home treatment operational policy must set out clearly the standards expected when service users are discharged from the crisis resolution and home treatment service. Historically no such standards have been detailed. The draft policy tabled for presentation at the LPT senior clinical group in July 2010 does now contain discharge standards which meet the principles of the points highlighted below. These standards have been incorporated as a result of this investigation. East Midlands SHA will need to satisfy itself that the standards remain in the final ratified policy document. The IIT expects such standards to include the following principles: When discharge becomes a consideration and the service user is on a CMHT caseload, there will always be a discharge CPA meeting, or at minimum a face-to-face meeting with the service user’s care coordinator. If a face-to-face meeting/discharge CPA meeting is not possible then the reasons for this are clearly stated in the service user’s clinical records. When a service user is to be discharged back to the care of primary care services (i.e. there is no continuing mental health care from specialist mental health services), a formal discharge summary containing the same information as a discharge letter from community or inpatient services is faxed to the service user’s GP within five working days of discharge. If the discharge is a planned discharge, there should be no reason why this is not achievable.

LPT’s crisis resolution and home treatment service must ensure that its discharge summaries provide complete information to GPs and other relevant mental health teams and agencies. The information provided on the discharge summaries from the CRHT to GPs and other professionals was inadequate in 2007. The management team for crisis resolution and home treatment services must ensure that, as standard, the following are addressed in all discharge correspondence: current diagnosis; problem summary (how the service user came into contact with the crisis service and a synopsis of the clinical progression); treatment/interventions provided; recovery impressions; current risks (self, others, safeguarding, fitness to drive, neglect, financial, engagement with services); medication; and recommendations. The proposed discharge summary document, that will be implemented in the LPT crisis resolution and home treatment service following ratification of its revised operational policy, does require the presentation of the information tabled above. Because the discharge summary document has been developed following feedback provided to the crisis resolution and home treatment service during this investigation, it will be East Midlands SHA’s responsibility to ensure that implementation of the policy and the proposed documentation tools occurs in a timely manner. The IIT suggests that the revised operational policy should be ratified and implemented by 1 October 2010.

LPT must ensure that up-to-date and appropriate clinical records are available to staff conducting emergency mental health assessments. Although home treatment is for relatively short periods of time, if it subscribes to the concept of “one patient, one set of clinical records”, LPT does need to ensure that this is achieved manually in the absence of functional electronic records. It is not acceptable that a service user’s main clinical record does not contain a full record of all significant care interventions and the detail of care and treatment delivered. LPT needs to set out clearly its strategy, including the financing, of how it is going to achieve the standard of “one patient, one set of clinical records”. This is not the current position in LPT and each team (CMHT, CRHT, Psychiatric Early Intervention etc) is maintaining its own records relating to the service user. That these records are merged when the service user is fully discharged from the service is not sufficient. Clinical practitioners must be able to access all relevant information about a service user if they are to develop effective and safe care plans. If providing this information electronically is not achievable for LPT then it must set out how it intends to meet the principle with its current (predominantly manual) system of clinical records. Maracis, the current LPT electronic records system, does not achieve this.

The LPT crisis resolution and home treatment service needs to minimise the loss of information along the communication pathway from those making referrals to the assessing mental health practitioners. This investigation highlights the dangers of introducing too many variables in a communication pathway when service users are referred for assessment by the CRHT. In this case, information from the deliberate self harm (DSH) team was passed verbally to a triage nurse who made notes of the discussion, which were then provided to the mental health professionals (MHPs) asked to assess the service user. There was a loss of important information during this process. Consequently it is the recommendation of the IIT that: A faxable referral form is developed for the CRHT which provides clear headings for entering specific information. It should have an accompanying guidance sheet detailing its purpose and how it will be used. All future referrals to the CRHT should be made, or confirmed, in writing on this form. All faxed referrals are supplemented with telephone follow up by the CRHT triage nurse, or preferably the mental health professionals tasked with undertaking any subsequent assessment. For the deliberate self harm (DSH) assessment form to be extended so that greater detail about the assessment can be recorded. This should include full details of any discussions the DSH team has with a service user’s regular care team and the outputs of this. If a DSH MHP believes admission to be the only option at the time of their assessment, this should be made explicit at the time of referral so that this perspective is clear to the next team, who may not be conducting their assessment until sometime later. Consequently consideration needs to be given to ensuring that a prompt for this opinion is included on any revision of the DSH assessment form. The DSH assessment form needs to record the contact numbers for the assessing DSH professionals, so that the assessing CRHT MHP can make proactive communication with this team. Indeed LPT could explore the practicalities of expecting the assessing CRHT MHP to have a direct conversation with the referrer prior to their assessment rather than this solely being undertaken by the CRHT triage nurse. This would reduce the opportunity for miscommunication, misinterpretation of information, and information loss. The current draft (July 2010) of the revised crisis and home treatment team operational policy does not fully address this recommendation, and the wording over whether or not telephone referrals will be routinely accepted is less than clear. It currently implies that telephone referrals will be acceptable. It is the recommendation of the IIT that the normal standard of practice should be for faxed referrals, followed up by telephone communication, in all but exceptional circumstances.

All crisis resolution and home treatment professionals in LPT must recognise the increased accountability they accept when they elect not to seek the advice of the on-call psychiatric team when undertaking out of hours assessments. A culture of not using available medical input out of hours has no place in the delivery of an effective and safe crisis resolution and home treatment service. The IIT has formed the view that it is not customary for crisis resolution and home treatment professionals to seek medical input into their out of hours crisis assessments where these are conducted on hospital premises, most usually A&E. It is essential that all crisis resolution and home treatment MHPs understand that their accountability and responsibility for a service user commences at the point they make the decision to accept this service user for home treatment, and that it is at this point that a care and treatment package, even if this is a short term package, needs to be agreed between the assessing professionals and the service user. In this case the MHPs did agree with the service user that she was to stay at home until assessed by a consultant psychiatrist the following morning. This was however an inadequate plan for this service user. To assist MHPs in accurately recording their rationale for any treatment options instituted or not instituted, the IIT considers that it is important that the crisis team assessment tool prompts the assessing MHPs to record the immediate care and treatment agreement/contract agreed with the service user. Where this is out of hours and there is no liaison with available medical practitioners (registrar grade and above), then the reason for this should also be recorded. Similarly, where it is considered that medication is not necessary the rationale for this should also be recorded. The design of the assessment tool should reliably remind crisis resolution and home treatment professionals of the need for this information. The IIT has formed the view that one of the reasons that CRHT MHPs may not be accessing medical advice out of hours is because of the variability of response they have received. LPT needs to explore this further, and to agree the minimum level of experience and qualification necessary in medical practitioners in order to provide crisis resolution and home treatment professionals with the calibre of assessment and advice required when making decisions regarding home treatment as an alternative to admission. Note: Although the IIT has been advised that crisis resolution and home treatment team staff have been reminded about utilising out of hours medical staff during the assessment process, there is nothing specific in the July 2010 draft of the operational policy. If this remains absent, then LPT must make explicit its rationale for not addressing this to East Midlands SHA.

The managers of LPT’s crisis resolution and home treatment service must map out the core and specialist knowledge, skills and competencies required of mental health professionals working within the service and ensure that all of its staff meet these competencies. What has not been evidenced in LPT is any formal consideration of the enhanced skills and knowledge required by MHPs working in crisis resolution and home treatment, and the development of a competency framework. This gap is a national one and not limited to LPT. There is no clearly defined skill and competency framework for nursing staff working in this field. Because HSG(94)27 investigations are intended to generate local improvements, it is the IIT’s recommendation that LPT develops a clearly defined and measurable competency and skills framework for all MHPs undertaking assessments, where the output of the assessment is a decision for home treatment or hospital admission. Nurses undertaking these assessments do require an enhanced set of competencies, and LPT must satisfy itself that all staff engaged in the crisis resolution and home treatment assessments can practise to the required level of competency.

LPT must continue to ensure that all clinical staff are aware of issues that may affect a service user’s fitness to drive, and ensure that they know what measures they can take to deliver their duty of care to the service user and also to the public. LPT needs to consider developing its own practice policy document about the role and responsibility of all clinical practitioners in relation to the assessment of fitness to drive, their responsibilities in relation to the service user and the advice they should be providing to them where fitness to drive is questionable. Such a policy needs to be cognisant of the DVLA guidance on fitness to drive, and the General Medical Council and other professional bodies’ guidance which gives clear direction regarding clinical professionals’ responsibilities. Fitness to drive as a focal topic should be a component of LPT’s core and update risk assessment training, and this case could be a useful case to study. Specifically all mental health practitioners, including medical staff, must appreciate that any of the following may constitute fitness to drive issues: any significant and prolonged impairment of concentration; sleep deprivation; medication changes; hallucinations; and psychotic episodes. The basic requirements for driving set out in California Medicine (September 1966, vol 105 (3), pages 197 – 200), as follows, may be useful pointers for staff to be mindful of: A basic minimum of strength and mobility. Ability to see and concentrate adequately on the roadway and traffic. Ability to interpret and make judgments about real or impending changes in the traffic situation. Knowledge of traffic laws.

East Midlands Strategic Health Authority is requested to liaise with the Department of Health to determine the best way to explore with the DVLA the issue of communication with medical practitioners following its assessment of an individual’s fitness to drive. The IIT recommends that whenever fitness to drive has been assessed for medical reasons and a driving licence reinstated, that both the driver’s GP and the doctor who completed the medical questionnaire for the DVLA are notified. In this case the MHSU’s consultant psychiatrist between April 2006 and January 2007 was not aware that the DVLA had reinstated her licence on an ordinary basis for one year. The letter advising that this had occurred was sent to the MHSU’s GP, although the consultant had completed the DVLA’s medical questionnaire and had had most contact with the MHSU. Had the MHSU’s consultant psychiatrist been aware of licence reinstatement, she would have been required to notify the DVLA of the MHSU’s fitness to drive issues between October and November 2006. This would have resulted in further assessment by the DVLA. Although one cannot say what the outcome of this would have been, it would have been an opportunity to pay further attention to the MHSU’s fitness to drive.