Independent investigation: Pamela Hardy, Wombwell (2010)

The ‘Did not attend, not available for a planned appointment’ policy currently in place within South West Yorkshire Partnership Foundation NHS Trust
Although the Trust was not the responsible provider of mental health services at the time of the JK incident, the Independent Team recommends that the Trust reviews its above identified policy document to ensure that it contains clear and unequivocal guidance with regards to the following:
 The range of actions required of staff if a service user is not available for a planned appointment, whatever its location. The range of actions might include:
 Whether the case must be discussed at the next team meeting;
 Who needs to be informed;
 The conduct of an up-to-date risk assessment to appropriately inform any decision as to „the way forward‟, or a review of the current risk assessment;
 The appropriateness of leaving a note, sending a text, sending an email, contacting a family member, etc.
 The range of interventions that a care co-ordinator/CMHT would automatically be expected to consider in determining the way forward.
 Standards of documentation required following an unsuccessful home/community visit.
It is the perspective of the Independent Consultant Psychiatrist that “in practice a clear published algorithm is helpful in both creating awareness and uniformity of response”.

Training and ‘skills, rule and knowledge’-based performance regarding Autistic Spectrum Syndrome Disorders
The Independent Team fully acknowledges the strides made with regards to developing a clear care pathway for individuals with Asperger‟s Syndrome who are provided with care, support and treatment via the specialist mental health service.
However, in addition to the implementation of the new care pathway and diagnostic service, the current provider of mental health services in Barnsley must achieve a situation where it has clarity regarding those staff for whom baseline knowledge about Autistic Spectrum Disorders (ASD) is a core competency, and for whom an enhanced level of skill and expertise is required. The Independent Team considers that mental health practitioners working as care co-ordinators within the community mental health team setting ought to have a baseline understanding of ASD, and issues that require specific consideration in relation to the delivery of an effective care plan. Consequently, the Trust must determine what constitutes the baseline skill and knowledge for ASD it requires of its care co-ordinator staff. This can then be used within the management and clinical/professional supervision framework, and in the professional development planning for these staff, so the competencies are attained where they are identified as lacking.
In addition to the above, because the effectiveness of training relies on the extent to which the trainee absorbs, interprets and then practises, it is essential that in the short term there is a robust audit framework surrounding the care and management of the service user with ASD. This will enable the Trust to determine the extent to which its staff have understood the disorder, and also the care planning needs. The Independent Team would expect the Trust to involve the staff working in its ASD diagnosis and treatment service to conduct case-note reviews in the first instance, so that an experience-based and robust audit tool can be developed.

Safeguarding
To date, the main focus of two out of three audits undertaken around Safeguarding Vulnerable Adults have been quantitative in nature and therefore have not assessed the quality of safeguarding practice, or the quality of documentation around safeguarding interventions. A case file audit was undertaken in 2010 but none has been conducted since then.
The Barnsley Safeguarding Adults Board (SAB) sub group for Performance and Quality Assurance has now taken the responsibility to oversee the audit programme using data from areas such as the recent audit NHS Barnsley Safeguarding Adults Clinical Audit Report which went to the Safeguarding Adults Board on Tuesday 5 March 2013, and service user feedback to identify areas for further investigation. (The exert from a recent action plan below demonstrates its commitment to this.)
Objective How to be delivered Time frame Responsible person or group
To ensure audits To compile a directory of audits To compile a register Performance take place to ensure and monitor outcomes making by June 2013, and to Management and staff are following recommendations to Practice monitor this on a Quality Assurance safeguarding policy Learning Sub Group or monthly basis. Sub Group and procedures and Safeguarding and MCA/DOLS that the quality of Training Sub Group as necessary safeguarding practice is maintained and improved.
The Independent Team also understands that each provider organisation is to become responsible for its own safeguarding vulnerable adult audits. Because safeguarding vulnerable adults is such an important issue the Independent Team recommends that Barnsley PCT, (or its successor) as the commissioner of mental health services, along with its partners South West Yorkshire Mental Health Partnership NHS Foundation Trust, and Barnsley Metropolitan Borough Council, commit to a timeframe for the implementation of the qualitative audit of practice and sets out clearly how they are to achieve this.
In addition, the organisations listed above may wish to consider the merits of conducting a multi-agency Failure Modes and Effects Analysis1 of the Safeguarding process to determine if there are any contemporary „hot spots‟ that would benefit from further control measures, to minimise the risk of omissions occurring within the process.
Both of the above recommendations supports the commitment of the the Barnsley Safeguarding Adults Board (SAB) sub group for Performance and Quality Assurance to broadening and deepening the audit of safeguarding adults practice for the residents of Barnsley so that meaningful assurance regarding adherence to expected policy and practice standards can be achieved.

Investigation practice
The Independent Team identified a number of aspects where investigation practice did not meet recognised good practice standards within the conduct of the PCT‟s investigation. It is essential that in future investigations the current mental health provider can be assured that its investigators have the following competencies and can demonstrate these:
Formulation of the investigation team
The lead investigator must work with a team of relevantly qualified specialist advisors. In this case, relevant advisors would have come from the following disciplines:
 Social Care
 Safeguarding
 Substance misuse services
 Medical – consultant psychiatric input
 Specialist Asperger‟s advice
 Advocacy
Although there was „at a distance‟ input from most of the above, and social care was actively involved in the conduct of the JK investigation, the specialist advisor input was not as comprehensive as it could or should have been. Although „virtual‟ involvement can be effective, it is essential that relevant specialists are present at the right staff interviews so that detailed and relevant professional and practice exploration can be achieved.
Preservation of information
The practice of deleting the working versions of the timeline once the investigation team considers it to be complete must stop with immediate effect.
Each iteration of the timeline should be saved, with strict adherence to version control numbering and dating.
The working timeline(s) provide a clear and auditable framework for assessing how an investigation team came to ask questions of interviewees at interview.
An independent team conducting a quality assurance review must be able to assess the whole process undertaken by an internal investigation team.
Investigative interview skills, specifically:
In the JK case, the interviewers did not listen sufficiently to what they were told, did not use the practice of „reflect back‟ and did not adhere to the following well-published good practice in investigative interviewing:
 Cognitive interviewing skills (speak less, listen more, use of reflect back);
 Use of open, non-leading and non-judgemental questions;
 Objective, detached, un-opinionated.
In addition to the above, the Independent Team expects the Trust‟s lead investigators to understand how to formulate an interview validation grid as a core component of the preparation for interview.
Data Analysis Skills for analysing complex information
An unstructured non-repeatable approach was taken to the analysis of the JK interviews. This was less than ideal. It is important that the current provider of mental health services in Barnsley is confident that its investigators understand the principles of:
 Content analysis for each significant concern or serious lapse in standards/care/treatment;
 Affinity mapping;
 Human Factors frameworks, including the NPSA framework and the fishbone‟;
and can apply these principles consistently in investigations conducted on the Trust‟s behalf.

Case Transfer Protocol
The current Case Transfer Protocol is significantly more robust than its predecessor. However, it is essential that the Case Transfer Process is subject to scrutiny via case file audit against the published standards. Some consideration of target percentage compliance with each standard would also be of merit.
The Independent Team also recommends that consideration is given to conducting a failure modes and effects analysis of this process, particularly at the stage where a young person is being transferred out of social care to another partner agency. The Independent Team considers that the JK case could be used as the „back-drop‟ for the failure modes and effects analysis, thus involving Children‟s Disabilities Service, Continuing Care, the specialist day centre attended by JK, and community mental health services ( ideally the team involved with JK).

Risk Assessment Practice
There was a significant lapse in standards with regards to information transfer and risk management practice in the case of JK. The current provider of mental health services must satisfy itself and its commissioners that its CMHT staff have the relevant knowledge and competencies to deliver effective risk assessments and risk management and contingency plans that are cognisant of the whole person and his/her social circumstance for all CPA patients, regardless of his/her diagnosis and why he/she is on the team‟s caseload.

Advocacy
The Independent Team considers that there was little attention given during the internal interviews as to the staff‟s appreciation of the need to support JK‟s self-actualisation, including the omission of staff to find an advocate for him. For staff to have relied on the day centre to have fulfilled this role was not appropriate. There are published standards in relation to advocacy; the Royal College of Psychiatrists report 171 on advocacy has standards set out in the appendix of this report, and the Quality Performance Mark “Assessing the Quality of Advocacy Provision” 2nd edition contains a complete assessment framework.
To assure itself and its commissioners that the lapse in advocacy support in the JK case is not a continuing issue, the current provider of mental health services should benchmark itself against these standards and provide its commissioners with the report of its findings, including proposed plans to address areas where remedial action is shown to be required. Initially this audit should be delivered within Barnsley and then on a planned basis, which takes account of any pre-existing audit timetable, the audit ought to be rolled out corporately.

Working with complex families and substance misuse
The JK case demonstrated a lack of insight by the CMHT and the Third Sector substance misuse agency of the complexity JK‟s mother‟s substance dependency brought to the home environment and the increased risk to JK himself. There was no evidence in the clinical records, or in the internal investigation report, that anyone explored with JK how he was coping with his mother‟s substance misuse or how it made him feel. Furthermore, there is no evidence that alerts raised by other family members were afforded the consideration they should have been in respect of JK, and in respect of his mother‟s capacity to remain a Carer for him.
Consequently, it is the recommendation of the Independent Team that:
 Professionals working in substance misuse services must be required to work proactively with families to find out from family members, particularly those „living with‟ the person with the substance misuse problem, how the situation is affecting them and to provide guidance on coping strategies, support groups and self-help groups that can assist them in addressing the impact that the „substance misuser‟ is having on them.
 There is always a joint professionals meeting where it is known that there are two family members living in the same household and both are receiving mental health and/or substance misuse services.
 All professionals and agencies involved in this case need to reflect on how they approach the care and case management of individuals with substance misuse when there are other family members who have a mental health disorder and/or are vulnerable, because of other reasons, to the negative impact alcohol dependency can bring to day-to-day living, including an increased risk of abuse.
The Independent Team expects that this reflection forms a formalised component of the professionals/management supervision for each member of staff concerned and that the wider messages are incorporated into existing training programmes, such as:
 Dual Diagnosis;
 Risk Assessment and Management;
 Care Planning/Care Programme Approach;
 Substance misuse-specific workshops.