Independent external quality assurance review following the independent investigation into the care and treatment of P in the West Midlands

The Child and Family Service (CAFS) Operational Policy was last updated August 2016 and provides clear guidance to clinicians and staff who work within the services for children and young people on how they should work in partnership with the young person, their families and partner agencies. Regular audits are carried out to check implementation of the policy and monitored through the quality and safety structure within the Trust. Examples of this in practice include:  Current assessment paperwork takes into account the family’s needs, and the operational policy recognises that the Trust is utilising Choice And Partnership Approach (CAPA) as a process.  Letters are sent out to schools and partner agencies as active engagement. The service works together in the Electronic Common Assessment Framework (ECAF), Team Around the Family, Care Programme Approach ,Child in Need and Child Protection and SEN processes. The results of these audits are now reported at the CYP Divisional and Quality and Safety Group each month. Results of Q1 18/19 showed 97% compliance, which is evidence that this is implemented in practice Where results identify sub-optimal practice for any month, follow up action is taken through staff meetings, supervision and training offered as necessary for staff. In this way the Trust is able to demonstrate and evidence not only completeness, but embeddedness and impact.

Several DNA policies across the Trust Divisions have been introduced for both adults and children’s services.:  Local systems have been introduced so services can monitor compliance with operational policies, this includes the use of performance packs/dashboards. For example Consultant DNA performance data sets across Sandwell CAMHS on a monthly basis.  There are regular reviews and communications from service managers /Matrons to staff via various means to ensure the policy is complied with and staff understand their role and how to apply the policy in practice. Regular reminders are circulated via local team meetings.  Compliance with policy forms part of workforce supervision as relevant to individual cases; including documentation of agreed actions. Audits to be completed to provide evidence that the DNA Standard operating procedure is embedded and operational. The results of these audits will be reported at the CYP Divisional Quality and Safety Group. Where results identify sub-optimal practice for any month, follow up action is taken through staff meetings, supervision and training offered as necessary for staff. In this way the Trust will be able to demonstrate and evidence not only completeness, but embeddedness and impact

West Midlands Police established with Birmingham and Solihull Mental Health NHS Foundation Trust and West Midlands Ambulance Service a Street Triage programme in January 2013. This programme initially funded by the Department of Health, has been rolled out as a business as usual across the West Midlands Police footprint with three schemes now being delivered. The benefits of having these three organisations together and sharing information for the benefit of the patient and wider safety of our communities has been realised and supported an improved quality of care and support. BSOL CCG – Street Triage performs a key role with the BSOL Mental Health Urgent Care Pathway. The CCG is working with partners to redesign the pathway to become age inclusive, to improve the experience of people in crisis and to make available a range options for people finding themselves in this position.

The new Healthcare Provider at HMP Hewell has reviewed the original report and produced an updated action plan which will be reviewed every 2 months with NHS England. Evidence of report being shared and discussed Schedule of remaining action plan updates Latest action plan update 30 November 2018

The Trust has issued PICU guidelines to all prison healthcare services that have referred to BSMHFT PICU units in the past 3 years. Actions complete. No further actions required.

Prison Service Instruction (PSI) 2011/72 outlines the requirements of all prisoners who are to be released. Paragraph 2.47 states ‘All prisoners must be examined by a healthcare practitioner during the 24 hours prior to discharge.’ NHS England Health and Justice and HMPPS are working together to consider ways of assuring compliance with this PSI. We will explore in partnership the scenarios under which issues of continuity of care can arise from unexpected events or decisions and consider what more can be done to provide assurance that risks are well managed as people transition from custodial care to care in the community. NHS England Health and Justice central team have undertaken a piece of work to develop a national set of clinical template for SystmOne which includes pre- release planning and release/ transfer templates. These templates have been fully endorsed by the NHS England Health and Justice Clinical Reference Group and are reflective of NICE Guidelines and PSI 2011/72. A pilot of these templates will be taking place in August 2017 with full training and roll-out is anticipated in 2017. Agenda, attendance and slides from Nov 2018 housing workshop Primary care workshop arranged 30 March 2019 Prison discharge pilot commenced at HMP Birmingham Commence prison discharge pilot at HMP Hewell 31 June 2019 Review pilot progress every 3 months 31 March 2020 New national prison mental health service specification rolled out across HMPs Birmingham and Hewell – includes new requirements for discharge and follow up 31 April 2019

 For prison to prison transfers the full SystmOne record is available if access rights and patient administration is appropriately completed.  North East London CSU has produced a brief user guide regarding access rights and administration which was shared with providers on 28 April 2017.  The annual prison quality assurance visit process run by NHS England considers this as part of the assurance process. SystmOne user guide supplied 30 November 2018 19/20 annual assurance visit report includes review 31 March 2020 HMP Birmingham dip audit completed 31 December 2019

This issue relates to staff training and awareness rather than legislation and protocols. HMP Hewell: Training in IG confidentiality and information sharing was completed on the 2/3 November 20 16 and 1/2 December 2016 for all mental health staff. This is in addition to mandatory IG training HMP Birmingham: Staff participate in information governance training as part of their mandatory training. In addition data is discussed at local induction and in team meetings. 2018/19 IG compliance report provide by HMP Hewell and HMP Birmingham healthcare providers 30 April 2019 IG mandatory training checked during annual clinical quality visit 31 March 2020 Information sharing guides produced and shared with healthcare teams 31 March 2019

There are robust information sharing protocols in place across the West Midlands in respect to both Adult Safeguarding and Children’s Safeguarding. In Birmingham and Sandwell these information protocols are signed up to by all relevant agencies including NHS provider trusts, NHS commissioners, Local Authorities, West Midlands Police Staffordshire and West Midlands Probation, the Care Quality Commission, West Midlands Fire Service, West Midlands Ambulance Service. With respect to information sharing there has been significant work undertaken across the West Midlands, for example the Mental Health Alliance for Excellence, Resilience, Innovation and Training (MERIT) is an initiative supported by NHS England has a focus on three priority areas: crisis care and reduction of risk, recovery and rehabilitation, and every day services. The vanguard aims to rapidly improve service quality, and increase efficiency, by adopting an IT system where clinical information can be accessed and shared across organisational boundaries around the region. Currently there are 4 partners within the vanguard: Birmingham and Solihull Mental Health NHS Foundation Trust, Black Country Partnership NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust and Coventry and Warwickshire Partnership NHS Trust, who together cover a population of 3.4 million. In relation to the involvement of the Crown Prosecution service and prison services, it is recognised that this is an issue greater than the local services and requires further national debate. Information sharing protocols in place Once the electronic health record in BCPFT has been implemented each of the 4 mental health providers in the West Midlands will use the same information system which will further facilitate information sharing. The first server is scheduled to ‘go live’ in May 2019 with all servers live by December 2019

The Clinical Record Keeping Standards Policy was updated in October 2016 and is aligned to statutory, organisational and professional legislation and standards. The policy gives clear direction as to what information should be recorded and in what format, and clarifies responsibilities for confidentiality, setting out the principles governing the sharing of information. The policy also clarifies for staff the importance of documenting the details and the involvement of other involved agencies. Record Keeping audits are undertaken to check the implementation of the policy and reported through the Quality and Safety Structure within the Trust. The results of these audits are now reported at the CYP Divisional and Quality and Safety Group each month. Results of Q1 18/19 showed 97% compliance which is evidence that this is implemented in practice Where results identify sub-optimal practice for any month, follow up action is taken through staff meetings, supervision and training offered as necessary for staff. In this way the Trust is able to demonstrate and evidence not only completeness, but embeddedness and impact.

 The work of West Midlands Police borders a large number of agencies and information sharing is essential to prevent crime, protect people and help those in need. The policy decisions about how much information to share, with whom and when, can have a profound impact on individuals.  West Midlands Police works with carers, family and friends of individuals to help them get the care and support they need. Sharing information with these people is generally done with the consent of the individual. There may be occasions when a decision to share information is made with individuals in response to an imminent threat or risk of significant harm. This may be done without consent in specific circumstances using a number of available legislative options.  In relation to people within mental health crisis, if the person lacks the mental capacity to make a decision about sharing information with key people, then the Mental Capacity Act is followed to ensure each decision to share information is in the person’s best interests. Decisions and reasoning are recorded. There is an approved Professional Practice policy (which is a national policy). This has been adopted into local practice. This practice will be audited to evidence implementation into practice.

In the West Midlands CCGs commission appropriate services for ex-offenders with mental health problems to access. A piece of work is being undertaken by the NHS current provider Forward Thinking Birmingham and NHS England Health and Justice Team to ensure that health services in prisons are fully aware of the available services and pathways and they have clear referral routes for 0-25 year olds. Assurance relating to this will be sought by NHS England through CCG assurance meetings. NHS England Health and Justice will also work with HMPPS, the prison operators, mental health providers, prison health providers and the CCGs to review processes into these services for unplanned releases. This is currently a national challenge however locally there is significant focus on this. It was agreed as part of the Local Criminal Justice Board (January 2018) and wider regional Mental Health Alliance (March 2018) with support from the Minister that a group of experts would be established to look at the pathway for individuals who are experiencing poor mental health who enter/exit the justice system. A multiagency group with leadership from the West Midlands Combined Authority has been formed to review the justice pathway for individuals with mental health conditions The group undertook an appreciative enquiry exercise at their first meeting on 4th July 2018 and identified from this four task and finish groups: stakeholder/journey mapping and service directory design; co-location; experts by experience network; learning lessons approached. This work continues.

 In respect to Birmingham patients, Forward Thinking Birmingham have developed, and are following, a referral pathway way for 0-25 year old prison leavers, which sees the allocation of an Intensive Case Manager from the onset.  In order to raise awareness of this referral pathway Forward Thinking Birmingham are writing to all prison providers to alert them to the pathway and its content. Meeting to be arranged with FTB and HMP Hewell to review pathway and service offer. 31 December 2018 Joint audit with FTB to be completed to review of a number of cases to ensure compliance with pathway to be undertaken – to be undertaken by YOS team 30 September 2019

 Opened access to services through self-referral and 24-hour crisis support. Parents and carers can also receive support or make a referral to FTB through the Access Centre  Commissioned services from voluntary and community organisations which provide culturally relevant support to children, young people and young adults. This includes psychotherapy and counselling services with expertise in engaging BME young men, as well as mental health support for BME prison leavers  Pause Computer Club launched – 1 ½ hr workshop each week for migrants aged 12-18 to reduce isolation, build confidence and develop valuable skills BSoL CCG – the CCG is working with partners to secure ongoing improvement to the mental health system at all tiers of care. This work is overseen by the Mental Health Programme Delivery Board BSoL CCG will ensure the learning is embedded into the monthly contract and quality review monitoring process, learning from SI and action plan tracking will be a standing agenda item Forward Thinking Birmingham – The service constantly evolves to fulfil the needs of its users. This is evidenced by the regular attendance of a senior member of the FTB team at the monthly commissioning meetings, where services and specifications are regularly issued, in order to ensure the service evolves and develops as needed.

The planning for this lessons learnt event is underway and the date is likely to be post September 2017 dependent on the chairs availability. It will be chaired by Norman Lamb MP. The learning lessons day was held on 6 September 2017 with the Rt. Honourable Norman Lamb MP as a keynote speaker. A Mental health Homicide Oversight group has been established. The inaugural meeting was held 8 November 2018. The terms of reference have been approved which include ensuring oversight of the delivery of recommendations and actions. This group will meet bi- monthly chaired by NHS ENGLAND

There is a current Fairplay Strategy which incorporates the Equality, Diversity and Inclusion agenda. All staff attend Equality and Diversity training as part of Trust induction. Additionally:  The Trust identify if there is a language/interpreting need if indicated at pre- assessments and extended sessions are offered to support this need. Interpreters are booked as necessary  The Trust has an Equality and Inclusion Board where representatives from all groups within the Trust report back on areas of good practice and developments, and areas where there may be potential challenges in providing services. This includes feedback from the Children Young People and Families (CYPF) representative to all service leads including CAMHs.  Members of the Equality and Inclusion Team attend the groups Quality and safety meetings to ensure diversity is embedded within the group and this will form part of the Quality and Safety agenda moving forward.  The Trusts Equality and Inclusion Board have set up a migrant Health Project Resource on the intranet to support staff in understanding the asylum and refugee process as it relates to health and care services that are provided within the Trust. This is available on the Intranet and staff have been alerted to this.  Regular ethnicity audits are carried out to ensure access to the service is representative of the population and this is built into the Divisional audit cycle. The Trust’s Equality and Inclusion Board will oversee the completion of audits to provide evidence that all Trust services are culturally sensitive to the needs of a patient and their families that they recognise and understand the potential impact of immigration on the family and this is fully embedded and operational. The results of these audits will be reported to the Trust’s Equality and Inclusion Board. Where results identify sub-optimal practice, follow up action is taken through staff meetings, supervision and training offered as necessary for staff. In this way the Trust will be able to demonstrate and evidence not only completeness, but embeddedness and impact

Learning from this case and the initial investigation in 2014 was shared widely across the health economy within Birmingham and Sandwell West Birmingham, including GP practices. Additionally the full initial investigation report, executive summary document and family statements were made available electronically on the NHS Birmingham CrossCity CCG website.  To promote awareness within GP Practices a Safeguarding Bulletin which made specific reference to this case was circulated in January 2015 and November 2015.  GPs have had ready access to attend regular scenario based Safeguarding Training events, and general learning lessons sessions from Serious Case Reviews (SCRs) which are informed by the key messages from this case.  To support enhanced safeguarding within primary care there are GP Safeguarding Champions in post who work directly with GP Practices to support the delivery of best practice. Birmingham and Solihull CCG (formerly Birmingham Cross City CCG) will strengthen external evaluation of safeguarding processes within GP practices. This will involve the completion of the BSOL CCG Safeguarding (adults and children) Assurance Tool, engagement with lessons learnt arising from safeguarding case reviews and educational activity required to ensure the practice is fully compliant with the new legislation and guidance for safeguarding which will be required by all practices to comply with in the forthcoming year. Sandwell and West Birmingham CCG commission safeguarding expertise through BSol CCG to ensure a systematic and joint approach to safeguarding across Birmingham and Sandwell, and will be subject to the completion of assurance tool, engagement with lessons learnt and educational activity as described above. GP safeguarding champions in post who work directly with GP practices and continue to share learning and support best practice.

 Nationally there has been significant work to promote carer support, and this has included the development of Carers Registers within GP Practices, additionally the Royal College of General Practitioners has produced a range of Carer Support resources for GP practices.  GP Safeguarding Champions continue to promote the issue of support for carers, and encourage Carer’s Assessment referrals within local practices.  In Sandwell and West In Birmingham it is a requirement of the Primary Care Commissioning Framework for every GP practice to have a Carers Lead, and this is monitored through regular meetings and visits.  In respect to raising awareness regarding adolescent to parent violence and abuse, the Joint Safeguarding Team, which links with all the local CCGs, has included the key messages from the Home Office Information guide: adolescent to parent violence and abuse (APVA) within local scenario based training which has been delivered to GPs.  This guidance is also covered in the nationally approved Identification and Referral to Improve Safety programme (IRIS) training delivered to GP practices. IRIS is a general practice based domestic violence training and support programme that it endorsed by a number of organisations including the Royal College of Psychiatrists. All Birmingham and Sandwell CCGs are actively involved with IRIS.  The 2013 government definition of Domestic Violence has been shared with GPs via training, bulletins, newsletters, GP forums and Practice Nurse Forums.  However despite all this positive work that has taken place to raise this locally, there is currently no comprehensive national electronic system in place to identify when either an individual is a parent, or indeed that they are a parent of a child with mental health problems.  Having reflected on the final version of this report NHS Sandwell and West Birmingham CCG and NHS Birmingham CrossCity CCG have agreed to form a short term working group that will working with relevant parties to: o Develop a short flowchart for Primary Care focusing onto what to do when concerns are raised by a relative or significant other that an individual may be experiencing mental health issues. o Develop 10 top questions to enable frontline staff to have a better sight of risks and safeguarding concerns. o Develop additional guidance for Primary Care concerning how best to raise concerns and risks related to patients with mental health needs. These resources will then be cascaded across GP practices over Birmingham and Sandwell, and shared with NHS England for sharing more widely. Sandwell and West Birmingham CCG Primary Care Commissioning Framework requires every GP practice to have a carers lead. This requirement is monitored via regular meetings and commissioning assurance visits.

Since April 2016 a new domestic abuse alarm system has been introduced by West Midlands Police. The personal alarms are mobile, allowing them to be carried by anyone at risk, and therefore not necessarily limited to one per household. The alarms are trackable and linked directly to the Force’s Control Centre, allowing a fast response to the correct location. Numerous officers and staff have been trained to give out the alarms to avoid delay or risk to victims and training is regularly refreshed. Deployment of the alarms is frequently reviewed and a full risk assessment in liaison with MARAC partners is carried out when an alarm is removed, in consultation with the victim. This is well embedded practice within West Midlands Police. An audit will be undertaken to evidence the practice and to assure that all relevant agencies and the victim is involved in the assessment and decision.

HMP Hewell: The Home Office guidance has been circulated. Practitioners have also attended violence risk assessment and Clinical Risk Management Training. HMP Birmingham: The Home Office guidance has been circulated. In addition a study event by the Domestic Violence (DV) lead, covering all areas of DV, will be held before 30 September 17 HMP Hewell Evidence of policy being re-shared to update existing staff and new employees 30 November 2018 Evidence of clinical risk management, safeguarding children training and safeguarding adult training content supplied Complete Copy of mandatory training policy Complete Quality return mandatory training statistics reviewed monthly. September data provided as evidence Ongoing HMP Birmingham Evidence of policy being re-shared with staff to update existing staff and new employees 30 November 2018 Evidence of clinical risk management, safeguarding children training and safeguarding adult training supplied. 30 November 2018 Evidence of mandatory training policy supplied 30 November 2018 Quality return mandatory training statistics reviewed monthly. September data provided as evidence Ongoing

HMPs Hewell and Birmingham: Staff liaise with known external agencies when undertaking CPA plans. Performance will be assessed as part of the NHS England annual prison clinical quality visit process. NHS England Midlands and East – North Midlands: The new prison clinical IT functionality will connect prisons to the national spine when rolled out (12 months from go live) which will facilitate improved clinical information sharing on reception and on discharge. This is a national programme with roll out expected to commence in 2017. HMP Hewell CPA policy/guidance supplied 30 November 2018 2018/19 Clinical quality visit report available with CPA considered Complete 2019/20 visit report will include CPA review 31 March 2020 HMP Birmingham CPA policy/guidance supplied 30 November 2018 2018/19 Clinical quality visit report available with CPA considered Complete 2019/20 visit report will include CPA review 31 March 2020 NHS England commission review of practice across Midlands prisons 30 June 2019 HMP Birmingham scheduled to go live 31 March 2019 HMP Hewell scheduled to go live 14 May 2019

 The Trust has a system in place to ensure we record the involvement of other agencies in all clinical records. This process is audited through our quality and safety processes. We are currently piloting the electronic health record (EHR) and the move to an EHR will enhance these systems.  The Criminal Justice Team is piloting the EHR, they are recording entries within all clinical notes, letters and assessments now onto the electric health records system which includes details of any additional agencies involved. All correspondence is scanned onto the system with electronic records and notes available to anyone using the system.  The EHR Pilot scheme is being overseen by Estates and Information Management and Technology Steering Group. As part of Transforming Care Together (TCT) there will be a review of the electronic systems to be used as a priority it must have the capacity to record the involvement of other agencies and contact details. Programme of EHR whole system development is planned to commence in Q3 17/18 and extend for 2 years subject to the aforementioned TCT arrangements. The first server is scheduled to go live in May 2019 with all servers live by December 2019. Thereafter the Trust will be able to fully demonstrate the new electronic health record (EHR) is able to facilitate the recording of other agencies involvement and contact details.