Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007)

The Trust must commission/complete a review of clinical records and their storage against the standards cited in the Data Protection Act. All clinical areas must ensure that records have been returned to the central archive when patients are discharged or move through services. An audit needs to be conducted in relation to the most recent 10 near misses or serious incidents to ensure that the clinical records have been correctly archived following an internal investigation. Trust personnel must be reminded of their duties and obligations to maintain clinical records to professional standards during clinical supervision. Random spot audits of clinical case files should be conducted across all clinical teams to ensure correct ordering and storage of clinical records.

It is strongly recommended that there should be a single and well identified place within the case record of every service user where the latest care plan and risk assessment and management plan is kept together with a brief synopsis of the history, this should be updated every six months.

It is strongly recommended that when the RiO Electronic Record System is installed that the Trust identifies a well identified place within the RiO System where the latest care plan and risk assessment and management plan is kept together with a brief synopsis of the history, this should be updated every six months. The location must be Trust- wide and in the same place for all case records.

The Risk Policy needs to be reviewed to more closely align the Risk Screening Tool (Level 1) with the in depth Risk Assessment (Level 2). The policy needs to specify that where a risk is identified at the screening stage then an in-depth assessment focusing on that particular risk needs to be conducted and a management plan developed. Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services (Department of Health, 2007) should be used as guidance to underpin the revised risk assessment and management policy. The policy should be structured to reflect the functions of the various teams e.g. Crisis Team, CMHT etc. The Trust needs to ensure that risk management plans are drawn up following risk assessments where either significant risk is identified or where current trigger factors, which might increase risk, are present. Random spot audits need to be carried out to support the annual audit plan. Risk assessment is a component of the CPA process and is to be included in management and clinical supervision. A service audit needs to be completed six months after the implementation of the revised policy to ensure that it has been acted upon.

The Clinical Team Leaders and Team Managers must as a matter of urgency ensure that all staff are aware that, under the remit of the Mental Health Act 1983 (as amended 2007), if there is concern about a service user relapsing they are legitimately able to undertake / refer for an emergency Mental Health Act Assessment.

When a service user is being discharged from the inpatient service, especially after a lengthy period in hospital, the community psychiatrist who will be taking over the care and treatment should be invited, and should attend, the meeting so that they have direct knowledge of the situation and can plan their future involvement.

The workload of consultant psychiatrists should be regularly monitored to ensure that they are not being spread too thinly across too many areas of responsibility. This should be linked to the Clinical Audit Programme and routinely reviewed.

The Co-Medical Directors should ensure that consultant psychiatrists have a well identified pathway to help and advice should they need assistance in any aspect of their work.

The Devon Partnership NHS Trust must ensure that there are clear care pathways within and between mental health services. This should be based on: clear operational policies for each service; unambiguous acceptance criteria for referrals which make it absolutely clear who the service is for; a named manager within the service who will deal with any questions a referrer may have about the service an overall care pathway analysis to ensure that there are no gaps created by the acceptance criteria which leave some eligible service users without an appropriate service. The Care Pathways should be regularly audited and any complaints or plaudits from service users used as part of the audit.

The carers of service users must be offered an assessment of their own needs and any help that they may require in order to fulfil their caring role. The Devon Partnership NHS Trust and Devon County Council should undertake an audit of case records to determine whether Carers’ Assessments are being offered and whether their identified needs are being met.

Clear concise Operational Policies are developed to enable staff to understand their core function and responsibilities. These should include reference to core policies such as CPA and the key Clinical Practice Standards. Operational service managers need to develop a core operational policy for the area they manage highlighting the area of practice such as age range, geographical area covered, services available. Clinical team leaders need to plot out the systems and processes that operate within their team such as referral criteria, assessment method, liaison with primary care/specialist services, allocation, supervision, discharge criteria, team meetings. Operational policies must be consonant with best practice guidelines such as the national Policy Implementation Guides, CPA policy or NIHCE guidelines A mechanism for the disseminating policies and policy revisions needs to devised and implemented by the Clinical Governance Committee. Adherence to operational policies needs to be regularly monitored as part of an on-going audit programme.

The implementation of the Clinical Practice Standards and the Practice Quality Audit needs to be strengthened across the Trust. Clinical audit participation needs to be developed through: being a standing item on all clinical team meeting agendas being included in individual annual appraisal and personal development plans being monitored through supervision forming part of all employees core job description

A robust annual audit plan, reflecting the Clinical Practice Standards and the standards specified in ‘Services Good Enough for My Family’, needs to be developed and widely disseminated. This will need to detail the roles and responsibilities of team leaders and managers not just in terms of data collection but also their involvement in action planning to rectify short falls. The support services that are available across the Trust, such as coaching and Patient Safety Officers need to be targeted at those teams that struggle to complete the audit cycle. Clear time scales need to be incorporated into the annual audit plan to enable individual practitioners and teams to manage their time.

The Trust need to review the Serious Untoward Incident (SUI) Policy to include: The introduction of reflective feedback sessions following serious incidents and near misses. The involvement of clinical teams in the development of recommendations. How learning and recommendations are to be shared across the Trust. Greater clarity about the involvement of victim and perpetrator family in Internal Investigations and how they will be supported thorough out the process. Providing staff with support through the internal investigation process and an early sight of the resultant report and its recommendations.