Independent investigation: Sharon Moore, Lisburn (2003)

It is the panel’s clear view, and our first recommendation, that the Board should publish this report, and that it should provide copies, in advance, to the two families involved. In support of this recommendation we have not used the names of staff involved. The panel acknowledges that the Board, in considering this recommendation, must look to its obligations to the families involved, and explore issues such as human rights and data protection.

Evidence heard by the panel could be interpreted as suggesting that the Form 5 is used in Lagan Valley Hospital as a ‘stop-gap’ pending the arrival of the Consultant, and that it is subject to veto by other hospital staff. This would clearly not be the purpose intended for the Form 5 and we recommend that all Trusts should review their use of Form 5s to ensure that they comply with the Code of Practice to the Mental Health Order.

We believe the Consultant did not act illegally in stopping the process begun by the completion of a Form 5. However, we would recommend that once the process has begun it should normally be allowed to continue, with appropriate contact made among hospital staff, the GP, Approved Social Worker and nearest relative.

The panel agreed that the term “Detain if wishes to leave” is not a satisfactory one. It is clearly open to interpretation. It is not in keeping with the processes required under the Mental Health (Northern Ireland) Order 1986 and could appear to mean detention by default. It could also contravene the patient’s human rights. The panel recommends that this phrase should no longer be used.

We recommend that the Department put in place a robust audit of each service provider’s implementation of the May 2004 Guidance on ‘Discharge from Hospital and the Continuing Care in the Community of People with a Mental Disorder who could Represent a Risk of Serious Physical Harm to Themselves or Others’.

While we believe that much of the 2004 Guidance could be implemented without significant additional resources, we recommend that the Department should consider providing whatever resources prove necessary for the re-training of staff in new responsibilities outlined in the Guidance, such as those of the Care Co-ordinator.

We recommend that the Trust should ensure that there are formal guidelines in place for its community staff to follow in ‘loss of contact’ cases and that these are brought to the attention of all community staff.

We further recommend that all care plans (for those who meet the criteria under the 2004 Guidance) should include relapse indicators and crisis and contingency planning, particularly in relation to loss of contact with services.

The panel recommends that all policies and procedures should: • be developed with multi-disciplinary input and include user/carer consultation where appropriate; • be signed off at Trust Board level; • clearly state the purpose of the policy; • include reference to relevant statutory provisions and/or Guidance that have dictated or influenced the policy; • provide definitions; • be disseminated to those who have been identified as being affected by the policy (including new staff such as junior doctors and locums), with this process supported by targeted training or awareness-raising; • clearly state actions that are required of staff, and clearly identify the staff responsible for carrying these out; • provide for a robust system of monitoring and evaluation and demonstrate how this will relate to clinical governance arrangements; • provide for a review within one or two years (as appropriate); and • provide a clear linkage to other policies and procedures relevant to the subject matter and list any policies that are superseded by them.

We recommend that the Trust (and others delivering similar services) should seek the assistance of the National Patient Safety Agency (NPSA) to train staff in the techniques of Root Cause Analysis (RCA), and that they should then develop policies and guidance on how untoward incidents are to be managed. We understand that the Department of Health, Social Services and Public Safety is in discussion with the NPSA about the development of a service level agreement. We would hope, therefore, that health and social care professionals will learn from those who are already using the RCA techniques, and implement them in Northern Ireland as soon as possible.

Other policies that we have considered differentiate between, and provide definitions of, untoward incidents and serious untoward incidents. They provide categories of incidents, with each category requiring a different response for which clear instructions are given. There is also a clear indication of staff responsibilities, including the reporting of each incident. The panel found this to be a very thorough approach, and one which we endorse and recommend for use by this and other Trusts.

We recommend that the Trust’s response to homicides should be included in revised policies and procedures on Serious Untoward Incidents, rather than forming a stand-alone policy.

We recommend that nursing staff who receive a patient into their care from the police or ambulance staff should exchange contact information with those staff. Nurses should record this information, together with the time of transfer, on the patient’s file. We believe this to be important in terms of the safety of both patients and staff.

In the panel’s view, admission to and discharge from adult mental health in-patient facilities should be considered a single process that provides staff with a framework for providing structured and continuous care. Our recommendation is that the Trust’s Procedures for admission and discharge should not be separate.

The panel recommends that risk assessment should be included, or cross-referenced, in an Admission and Discharge policy. The panel has noted the section of the 2004 Guidance on ‘Identification of those at-risk prior to discharge’ and would endorse its contents as suitable for inclusion in the Trust’s Admission and Discharge policy.

We recommend that relevant policies, particularly those pertaining to the delivery of care from the point of admission to the point of discharge, explicitly detail the Primary Nurse role. The duties and responsibilities of the role should be defined, as should the process as to how staff are allocated to that role. Similarly, clarity is required for the role of Associate Nurse, and how this role backs up and complements the work of the Primary Nurse. Equally important is the need to inform patients and their family and carers of the name and responsibilities of the Primary Nurse, as soon as possible after admission.

We recommend that the Trust must ensure that there is an adequate Assessment and Management of Risk Policy. The policy must be clear on responsibilities, how and when risk is to be assessed, managed and reviewed, and how records should be kept. The policy should be consistent with, and draw from, the 2004 Guidance on Discharge (etc.). It must also be supported by an appropriate risk assessment tool, which should facilitate collation of information on historical, current and future risk.

We recommend that the initial risk assessment should be completed through joint assessment by the doctor and nursing staff. If a joint interview with the patient is not immediately possible or desirable, then medical and nursing staff should come together, as soon as possible after their initial assessments, to produce a joint risk assessment and to jointly agree the patient’s care. The risk assessment form would then be signed by both medical and nursing staff.

We recommend that when police are involved in an admission because of a patient’s aggression or violence, all relevant details should be obtained from the police, by the hospital, including previous instances of aggression or violence. Such action should also form part of the risk assessment process when a patient self-reports to mental health staff about incidents of his or her violent or aggressive behaviour that have involved the police.

Assessment and Management of Risk is applicable to all service users. However, we recommend that a full risk history (including neglect, exploitation and other vulnerabilities as well as violent and aggressive behaviour) should be undertaken on those patients considered to fall under the 2004 Guidance. It is important that someone is given responsibility for creating and updating each individual patient’s history and ensuring it is available to all those involved in a patient’s continuous care. We believe that this is a role that might be undertaken by a Key Worker, as referred to in the 2004 Guidance, but we recommend that adequate training must be provided to whoever is allocated this role.

We recommend that the Observations policy should explicitly refer to the ‘Assessment and Management of Risk’ policy as one that is linked to it. There is also an obvious link to the Admissions and Discharge policy and this should be recorded too. In all cases, we believe that the initial decision on observations (after the time for ‘Admission Level’ observations has ‘expired’) should be based on a joint medical and nursing assessment. The policy should clarify responsibilities, showing clearly who can apply and who can amend levels of observations, and under what circumstances they can do so.

We recommend that the Trust should consider the introduction of a “Level of Observations Record” which would provide a co-signed record of decisions taken on the levels of observations to be applied. This would be retained prominently in the file and would help communication between nursing shifts.

We recommend that all patients’ observations levels should be formally reviewed at least once a week (at the multi-disciplinary Team Assessment Meeting (TAM)), discussed with the patient and carers and decisions (including “no change”) documented in the file.

We recommend that decisions on patients being allowed to leave the Unit (e.g. ground pass, hourly pass, day pass etc.) should be covered by the Leave Policy. In this context, clear responsibilities should be established regarding decision-making for these ‘passes’ and the policy should stipulate that decisions are recorded on the patient’s file. In addition, we recommend that the policy should be clear on the responsibilities of families/carers regarding accompanying patients off the ward.

We would endorse the existing Leave policy’s requirement that the decision to agree to a patient going on planned leave should normally be taken by the multi-disciplinary team at the TAM. We further recommend that this decision should be documented on the patient’s file, and discussed with the patient, relevant community resources (e.g. CPN, Day Centre) and with carers (where appropriate). This will help ensure that the period of leave, and the team’s expectations of the patient and others, are clearly understood.

We recommend that the Leave Policy should contain provisions requiring staff to inform the patient and carer/family about crisis and contingency planning in the event that something goes wrong during the period of leave. Staff should also provide a point of contact where the carer/family members can avail of advice.

We recommend that the policies (and procedures) on Observations and Leave should be explicitly cross-referenced.

We acknowledge that it may be difficult for one file to cover both care in the community and periods of in-patient admission. However, we believe it is entirely practical for all multi-disciplinary records to be kept in one section of the in-patient file in continuous, chronological order and we recommend this to the Trust. We also believe that the inpatient care team should receive a report from the community team as part of the admissions process.

We recommend that nursing staff should be encouraged to follow the recommended practice found in Guidelines produced by the Nursing & Midwifery Council (NMC): ‘Guidelines for records and record keeping’.

We recommend that all information available at the time of a multi-disciplinary team meeting (e.g. reports of aggressive behaviour) should be evaluated by the team, particularly in terms of re-assessment of risk, observations level and leave status, and that decisions flowing from this evaluation should be documented on the patient’s file. The details recorded should be agreed by those present at the TAM.

We recommend that all notes documented in patients’ files should record the actual, or approximate, time of events.

We recommend that the Trust’s Report Writing and Record Keeping Policy should have a clear section on record-keeping. The Trust may even wish to consider separating the two into two different policies. Either way, the revised policy should incorporate our recommendations and information taken from the NMC Guidelines. The policy should highlight the importance of record-keeping and set appropriate standards for it.

We recommend that the Trust’s AWOL policy should provide greater clarity about staff’s responsibilities when voluntary patients are AWOL, including the need to alert the Consultant and senior management at an earlier stage than was done in this case. This is particularly important where risk factors have been identified regarding a patient.

We recommend that the AWOL policy should be put into effect immediately when a patient is noticed to be missing. The policy, however, needs to cater for the circumstances where a patient, either voluntary or detained under the Mental Health Order, has been located and is known to be safe. The policy should also give clear instructions that decisions related to such circumstances must be recorded on the patient’s file and that an alternative plan of action for the patient’s return to hospital should also be recorded.

We recommend that the AWOL policy should be clear that the Nurse-in-charge at the time of an AWOL ‘event’ is responsible for arranging the immediate actions under the policy (organising a search, informing the senior nurse, (whether on-site or on-call) SHO, next of kin/carers, assessing risk and informing the PSNI. It should also be clear that the SHO must inform the Consultant.

We recommend that the AWOL policy should establish clear categories of risk under which the patient should be assessed when his absence is noted. The Nurse-in-charge should be identified as having responsibility for considering the most recent risk assessment, (including a full risk history if available) the care plan and the most recent clinical entries in order to establish the appropriate category. The decision as to whether or not to contact the police should be a joint one, following detailed discussion with the SHO (or duty SHO) and the on-call senior nurse (outside routine hours). The discussions and decision should be recorded on the patient’s file. When a decision is made to inform the police, they must be given information from the assessment of risk that has just been made.

We recommend that the AWOL policy should require that next of kin/carers be given advice about what to do if they locate the patient, and given a specific contact point or communication channel for use in such circumstances, and for more general contact regarding the AWOL situation.

We recommend that the Trust consider the development of a standard ‘AWOL form’ which could be used to prompt specific actions and to capture information likely to be of use if the police are involved. This may include information on the patient’s appearance, clothing, possible whereabouts, level of risk presented and current mental state.

We recommend that the AWOL policy should include both immediate and longer-term actions, which should be proportionate to the assessed level of risk. Action might, for example, include a multi-disciplinary review, from which a clear plan of action should emerge. Where the police have been informed they should be invited to participate in the multi-disciplinary review, and clear roles and responsibilities should be identified between Trust and police personnel.

We recommend that an action plan emerging from a multi-disciplinary review should include identification of a person responsible for informing all others involved in a patient’s care in the community (e.g. GP, CPN, Social Worker, Day Centre, Hostel management, carers, voluntary sector providers, as appropriate). This is likely to be one the roles of the ‘Key Worker’ (as defined by the 2004 Guidance) and this role must be incorporated into the new AWOL policy. When they are being alerted, these people should also be advised regarding their response should they locate the patient.

We recommend that the action plan should include provision to make hospital staff aware of what they should do if the patient should appear at the hospital, and how they are expected to co-operate with family, carers and the police. There must be clear responsibility given to individuals to ensure that this information is transmitted to the various nursing shifts.

We recommend that the Trust should consider retraining for all staff who may be faced with responding to an AWOL situation. In addition, the AWOL policy should be quite clear that the nurse in charge should take the lead when such circumstances arise.

The panel endorses the following recommendations from the ‘Safety First Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental illness - 2001’: • “services should make provision for patients with severe mental illness and alcohol or drug misuse as part of mainstream mental health services”; • “Local services should have a strategy for the comprehensive care of patients with dual diagnosis, to include liaison between mental health and substance misuse services, statutory and voluntary agencies, staff training and the appointment of key staff who will lead clinical developments”; and • “training for staff in general psychiatry services should include the management of alcohol and drug misuse.”

While it is our hope that the Trust will ensure that its current service provision lives up to these recommendations, we would also recommend that the Department should ensure that the services recommended above are among those that are commissioned by the various Boards.

We recommend that the Trust should develop a procedure by which community mental health staff remain actively involved after their patients’ admission to hospital, and that they are also involved in discharge planning for individual patients back into the community. This is consistent with the 2004 Guidance and, together with our recommendations of community staff involvement in Leave and AWOL policies, should ensure maximum integration between hospital and community services and continuity of care.

We recommend that the development of supervision arrangements, proposed in the Trust’s Learning and Development Strategy and Action Plan 2005-2008 (Draft 2), must address Clinical Supervision. This should include clear identification of responsibility for putting in place a written policy to introduce and maintain Clinical Supervision for Nursing staff. The policy’s contents should be in accordance with the Nursing and Midwifery Council’s principles on Clinical Supervision as contained in: ‘Supporting nurses and midwives through lifelong learning’ (revised edition April 2002).

We recommend that the Trust undertakes appropriate assessment of training needs to ensure that training provision is focused on individuals’ continued professional development and organisational needs, and that a multi-disciplinary approach to training should be facilitated where appropriate.

In order to maximise confidence in, and to protect the integrity of, any investigation (whether internal or external) the panel recommends that the Trust should make it standard practice for all papers relevant to a patient’s care (from whatever source and from first contact with services) to be secured immediately after such a serious incident and stored at one site. We recognise that papers may be required for a number of purposes, including internal reports, but this can be managed from the central site, and copies, rather than original documents, can be used. We further recommend that the responsible Board should satisfy itself that papers have indeed been secured in a timely fashion.