Independent investigation: Suryakant Patel, Harlington, London (2006)

It has been requested that the National Patient Safety Agency work with the Department of Health to ensure that it’s recent information sharing guidance4 is translated into clear workable operational policies in individual mental health trusts. The message that needs to be underlined is that in all circumstances where there is benefit to the service user in sharing information with other agencies, such as the police, third sector agencies and probation, then all reasonable efforts should be made to obtain the consent of the service user to do so. In circumstances where the service user withholds consent, or obtaining consent is not possible, the healthcare team must then consider the risk to the service user and the wider public of not sharing the information. The issues considered and the output of this consideration must be documented in the service user’s clinical record and risk management plan. Furthermore the professionals should seek advice from: the Trust’s Caldicott Guardian, the vulnerable persons officer, the police liaison officer, where appropriate, particularly if there is any uncertainty whatsoever as to the most reasonable course of action to take, i.e. ‘to share’ or ‘not to share’. In this case the AOT did not tell other agencies that the MHSU had changed his name by deed poll because of concerns around client confidentiality. Furthermore it did not proactively engage with the police in the risk and contingency planning for the service user because of similar concerns. These concerns are commonplace amongst mental health professionals. However, to have shared information with the police in this case would have undeniably been in the MHSU’s best interests. In this case, lack of clarity about when it is acceptable and not acceptable to share information without consent contributed to a lack of opportunity for incident prevention.

It was the working assumption of the Assertive Outreach Team caring for the MHSU that if he was ‘picked up’ at an airport without any money, identification, or tickets to board a plane, then he would be taken to a place of safety and mental health services would therefore become immediately involved with him. This is what had occurred on two of the previous three occasions he had attended at an international airport. The AOT believed that because the MHSU had been arrested by the police before that there would automatically be a record on the Police National Computer (PNC) about him and the circumstances of his arrests. Unfortunately this was not the case. Trespass is not a criminal offence and therefore does not generate a PNC record. The PNC does however have the facility to record core information about service users about whom the mental health services have significant concerns if they go ‘absent without leave’ (AWOL), or fall out of contact with the services. Furthermore the PNC can accommodate instructions on what actions to take, and who to contact, should the service user be stopped by the police in ‘identified circumstances’ and a check made against their identity. A service user does not have to have to have any previous criminal record for this facility to be utilised. An ad hoc survey of a small number of mental health professionals revealed that about 50% were unaware that the PNC could be used positively as part of the risk management planning for a service user. It also revealed that 100% of those professionals approached believed that if a person arrested for any reason a PNC record would be generated and that the circumstances of the arrest would also be recorded. The responses received also suggested that the bar is set quite high when it comes to sharing information with other agencies because professionals are anxious of being in breach of the Data Protection Act. (See recommendation 1.) In this case had important information about the MHSU been entered onto the PNC in advance of the incident, as part of a proactive risk management and contingency plan, then this incident in all probability would have been prevented. Because of the numbers of victims as a result of this incident, and its potential preventability, it is essential that all mental health professionals are aware: Of the importance of proactive information sharing with other agencies where to do so enhances the safety of the service user and/or the safety of the public, even if the service user withholds consent. Of the optimal times to address the issue of information sharing and the obtaining of consent with a service user. For example after a relapse and in the early period of wellness. Of the practical measures professionals can take to determine whether the information sharing is lawful if a service user refuses consent, or is unable to give consent (i.e. liaison with the Caldicott Guardian, the Trust’s vulnerable person’s officer and the police liaison officer – essentially reasoning it out with others). Of the scope of the PNC for logging the details of service users who are known to go AWOL when unwell and place themselves in high risk situations (e.g. vulnerable or dangerous situations), and/or pose a potential serious risk of harm to others. And the absolute acceptability of this where the mental health professional(s) believe that to add a service user to the PNC will enhance the risk management plan and therefore the safety and well being of the service user. To achieve the above it is essential that training workshops on data protection, clinical risk assessment (as it pertains to service users) and local and national guidance documents and policy on information sharing ensure that the above messages are incorporated and that staff do not have an ungrounded fear of information sharing that is detrimental to the delivery of safe and effective care. To ensure that this very important issue, in particular the scope of the PNC to support effective risk management planning, receives the attention it needs, the Director of Patient Care and Partnerships/Chief Nurse for NHS Yorkshire and the Humber is asked to bring this recommendation to the attention of the Chief Nursing Officer for the NHS and the NHS Medical Director so that an effective risk reduction solution can be generated, working with relevant partners such as the police and the Information Commissioner’s Office.

One of the relapse triggers for the MHSU was medication non-compliance and on numerous occasions staff underlined for the MHSU the absolute importance of taking his medication. However, at some times the MHSU took only very low doses of his medication and his care coordinator, an occupational therapist (OT), and other non-medical staff were not sufficiently aware that this posed an inherent risk of relapse. Discussions between the IIT and the OT identified a potential professional conflict between the guidance provided by the College of Occupational Therapists (COT) to its members about medicines management and the role and responsibility of a care coordinator. It was the OT’s understanding, in 2005, that the College advised that OT’s did not need to have any knowledge about medicines. However, with the evolution of New Ways of Working5 in mental health, in the opinion of the IIT, that a care coordinator, regardless of his/her professional background, does need to have at least a basic understanding of the medicines their clients are on and the usual dose range of these. Clearly it would be unreasonable for an OT to take responsibility for complex medicines management. However it should be within their capability to be informed about the medications prescribed for clients for whom they are care coordinator. Guidance issued by the COT to its members in September 2008 makes clear the responsibility for an OT to ensure that he/she has the competencies to fulfil their job role. For a care coordinator this must include a basic knowledge of common mental health medications, the normal dosage and common side effects. It is recommended that the allied health professionals (AHP) lead in the Directorate of Patient Care and Partnerships at NHS Yorkshire and the Humber and the SWYMHT OT liaise with the COT on the matter of what skills and competencies are required by OTs who are care coordinators for service users. The COT should take an active role in working with relevant partners in defining these core competencies, especially as they relate to medicines management, for the sake of consistency nationally.

This investigation highlighted two issues which need to be addressed in client-focused risk assessment training delivered in all mental health trusts and in documented risk assessments. The first is the concept of ‘risk vulnerability’, a concept that was not well understood by all members of the MHSU’s care team. Furthermore it does not appear to be routinely included in risk assessment training. In the case of the MHSU, situational stress increased his risk vulnerability but was not a ‘relapse indicator’ per se. The lack of appreciation of this concept did adversely affect the risk management plan agreed within his care team. The second is staff’s awareness of the risks posed by service users engaged in sports such as karate, kick boxing, boxing, kung fu etc. When individuals become competent in any of these sports their hands and feet are considered to be dangerous weapons. For some of these sports such as kick boxing, it does not take long for some degree of competency to be achieved as this case highlights. It is essential that mental health professionals’ awareness of this is enhanced as it has real implications within the process of risk assessment, and the documentation of identified risk, especially where service users are prone to relapse and to hit out with their hands and feet. It is therefore recommended that the Adult Services Lead for NHS Yorkshire and the Humber liaise with the chairs of the national Mental Health and Learning Disability Nurse Directors’ and Leads’ Forum and national Mental Health Medical Directors’ Forum respectively, so that this case can be used for learning lessons nationally. The appropriateness of incorporating the issue of (i) risk vulnerability and (ii) awareness of risks associated with martial arts and other contact sports, such as boxing, into risk training programmes shall be considered by these fora. Consideration should also be given to liaising with the Royal College of Psychiatrists.