Independent investigation: Sandra Bainbridge, Belper (2013)

The Trust is required to adopt a strategic response in relation to patient records, i.e. the unification of the paper and digital notes system into one system. The Independent Investigation Team is of the view that this should ideally be an electronic system capable of allowing a care professional to pull up information relating to patients and the status of their risk assessments at a glance. A strategic response at Board level is required in order to address the practical difficulties which clinicians face when presented with the challenge of accessing a service user’s historical records. The loss of information when migrating to electronic service user records is also a risk which must be addressed. New database packages allow a Care Professional to pull information from their electronic patient record to show the people under a team member’s care, and the update status of risk assessments for the last 6 months. This does not address the needs of a patient who has had previous admissions over a period of time. Consequently, a protocol should be developed to ensure a review of paper and electronic records held for service users who have experienced a number of episodes of care. Accordingly, it is recommended that: a) The Trust take steps to unify paper and digital patient records. Until such time as the paper and electronic records have been unified, the Trust must implement a protocol to ensure a review of patient’s paper and electronic records is undertaken at key stages (admission, CPA Review, discharge and transfer). b) Following unification of paper and digital record keeping systems, patients’ historical records must be reviewed and summarised at key stages in their care (admission, CPA Review, discharge and transfer). c) The performance of the requirements at 1 and 2 and the adherence to protocol connected to these recommendations needs to be monitored and audited. d) The findings of these audits are to form part of discussions at regular Quality Assurance Meetings.

“Service-user centred clinical care” is the foundation of CPA care management in delivering services. The essentials of this are contained within the Trust’s CPA policy. They include the systemic review and sharing of clinical information to inform clinical decision-making, and involvement of families (or carers where appropriate) in the management of risk. The Trust’s Quality Assurance Programme should ensure that care plans reflect a comprehensive understanding of the ethos of CPA in order that individual service users’ current psychiatric, social, family circumstances and risk characteristics are addressed and that service user centred care is delivered. Accordingly it is recommended that: a) The ethos of the CPA should be reflected and strengthened in the training programmes which Trust staff are required to attend. b) Every 6 months, each individual service user’s CPA records are audited by the Managers in each service involved in the individual’s care with a view to establishing: 1. Whether CPA is being correctly applied and adhered to; 2. Whether all service users’ risk assessments are up to date; 3. Whether staff are having regular supervision which includes reference to providing care which recognises the ethos of CPA. c) Adherence to this recommendation is audited by the Trust on a 6-monthly basis.

1. The Trust must conduct regular audits to ensure that its managerial supervision policies and procedures to facilitate supervision are being used to promote the delivery of service user centred long term care. 2. The audit process should include scrutiny of current samples of actual care delivery at every level to ensure clinical practice reflects the delivery of service user care viewed from a long-term perspective.

1. “Consent to share” information should be updated regularly to promote effective communication between services, the service user and family members/carers. Protocols and policies should be introduced to secure this. 2. Close family members should always be given a contact point to access the mental health system in a crisis. Communication should be established as early as possible. 3. The Trust reviews its “family involvement strategy” to ensure that family members receive appropriate psychological as well as practical support. 4. In order to obtain a comprehensive understanding of the service user’s current psychiatric, social and family circumstances and risk characteristics, the Trust’s Quality Assurance Programme be revised to ensure that Teams are required to actively seek family members’ involvement and views. 5. Collateral histories should be taken from family members and/or carers to secure a greater insight into a service user’s situation and those of the family members/carers themselves. The standard practice of clinical teams in relation to these Recommendations is monitored by periodic audit.

1. In order to maximise the learning taken from Ms Z’s fatal attack upon the victim, approaches to serious incidents should take account of the “bigger picture” of a serious incident. For example, investigating how a crisis has developed should be as a means to identifying learning which can generate improvements in service delivery. The Independent Investigation Team recommends that the Trust’s framework for investigating serious incidents be reviewed to implement this Recommendation. 2. The Trust takes active steps to ensure that staff and clinicians are supported in relation to serious incidents. In addition to this, the Trust must also take active steps to ensure that information is shared with staff and clinicians in a timely way, and that a longer term view of “support” is taken. 3. The Trust must implement processes to ensure that the learning from adverse incidents and the action points which are generated are drawn to the attention of staff and clinicians involved in the events in order that learning can be embedded in the day to day practices of those responsible for delivering care. 4. The Trust must take steps to demonstrate greater awareness of the knowledge levels of family members of victims, their specific backgrounds and insights, and their interactions.