Independent investigation: Ryan Walsh, Cheshunt (2008)

Patient safety was compromised in this case by a failure to adopt a structured approach towards diagnosis. This could have been mitigated by a robust supervision process or equally by discussion in a MDT meeting. The EIP Service has strengthened its supervision and MDT processes since this incident and has produced clinical and practice standards for Early Intervention in Psychosis. However, the Independent Investigation Team is of the view that these systems should be the subject of regular audit to ensure that the improvements which have been made have been implemented and that they are effective.

EIP may wish to consider reviewing their policies and procedures regarding the recording of medication and/or prescriptions in order to ensure that a full record of the medication dispensed is maintained. The EIP Service should scan or otherwise record copies of prescriptions issued to service users in the service user’s records.

The EIP Service should take steps to ensure that, when a clinician wishes to prescribe a drug which is unlicensed for the condition for which it is prescribed, the service user’s express consent is obtained concerning the increased risk of side effects. The EIP Service should review and strengthen its procedures relating to the monitoring of medication side effects. The EIP Service may wish to review its procedures relating to the monitoring of antidepressants in young people both in relation to ensuring that a review is undertaken following a request from a doctor and also in relation to how that review is undertaken, in what circumstances and by whom. The EIP Service may wish to review its procedures relating to the consent process attached to the prescription of medications which are prescribed outside the guidance produced by NICE and recommendations made in the BNF.

The Clinical Standards should be revised to include a process for referral of service users for psychological review and assessment.

The Clinical Standards introduced by the EIP Service constitute a positive step forward in terms of improving its own control structure and processes. The EIP Service should consider the introduction of ‘Practice Guidance Notes’, setting out what is required by each element of the Standards to ensure consistency of implementation of the Standards across the service. There are different models of clinical supervision that reflect the differing professional training and expectations, work contexts and needs of team members. The Standards are silent as to how supervision is to be carried out in practical terms to ensure that a consistent standard is applied across the MDT. The Independent Investigation Team understands from interviewing team members that there has been a great deal of discussion within the team but no consensus reached due to differences in professional attitudes towards supervisory practice. This failure to reach a consensus and adopt a consistent stance is a significant threat to the clinical governance framework operated by the EIP Service. The Standards do not incorporate any ‘failsafe’ procedures. The Standards assume that they will be implemented by team members. The Standards are not designed to mitigate the effect of a team member failing to comply with the Standard in order to protect the object of supervision which is stated to be the ‘quality of recovery outcomes for EIP clients’. Significantly, if a social worker failed to bring a case to supervision for 3 months, for example because of work load pressure, there is nothing to catch that omission and ensure that that client’s case is brought into the supervision process. The Independent Team were concerned about responses which it received concerning how compliance with the Standards is achieved. For example, questions were asked about checking that care co-ordinators were entering supervisory records into Care Notes. No audit has been undertaken of this and so it is not clear whether compliance with the Standards is being achieved. Given the importance of the Standards to the clinical governance structure of the EIP, it is a matter of concern that an audit cycle has not been implemented to assess the level of compliance with its objectives. The Standards were due to be reviewed in June 2011. To date this review has not taken place. This is disappointing, given that an opportunity has been missed to evaluate what has gone well with the introduction of the Standards and what has not gone as well with a view to making improvements in the provision of care. The Standards are silent as to the responsibilities of supervisor and supervisee. For example, it is not clear whose responsibility it is to ensure that supervision takes place on a 3-monthly basis. There is some clarity upon the practicalities of supervision in the HPFT Statement on Supervision, but there may be merit in this aspect of the Standards being reviewed in order to ensure clarity for staff in EIP. The Standards do not address the issue of client confidentiality in the supervision process.

The Independent Investigation Team is of the view that an audit should be undertaken to review the effectiveness of the introduction of the Standards and specifically to ensure that cases are now being referred to MDT Meetings, in accordance with the terms of the Standards.

The EIP Service should consider and produce guidance for staff as to the use of the ‘hot spot’ facility in order to maximise its benefit.

The Independent Investigation Team believes that care planning could be improved by a slot being made available at the weekly MDT Meeting to allow for discussion of more complex care planning and ongoing planning issues. The documentation surrounding care planning should be reviewed to make it easier for care co-ordinators to structure care into its key elements. The quality of care planning should feature in the clinical audit cycle of the EIP Service.

The interests of the service user should be placed at the centre of the decision to transfer care co-ordination, and not the interests of the relevant service. Transfer of care co-ordination should be agreed with the service user, and this should also be documented.

Practitioners should be reminded of the professional requirement to maintain accurate and contemporaneous records. The Independent Investigation Team recommends that the Clinical Governance Lead for HPFT is given a copy of this report in order to assess the training needs of staff in the EIP Service with regard to note keeping standards. Cheshunt CMHT should desist from the practice of highlighting paragraphs of their letters to GPs with marker pen.