Independent investigation into the care and treatment of Mr C and Mr D: December 2013

Recommendation eight CANDI’s Medical Director informs all doctors in the This recommendation will be Trust’s Psychiatric services raised at the Consultants that they have a duty to meeting and from this 20 August 2014 Dr Vincent Kirchner ensure participation in the escalated through the lines of Deputy Medical Director multidisciplinary decisions medical management to all made for patients for which doctors in the organisation. they are responsible. The Trust’s Medical Director to inform all doctors in the This recommendation will be Trust Psychiatric services raised at the Consultants that they have a duty to meeting and from this ensure that a patient’s escalated through the lines of Dr Vincent Kirchner medication is appropriate, medical management to all 20 August 2014 Deputy Medical Director and being suitably managed doctors in the organisation. within the CPA process. The implementation of this This recommendation will be Recommendation is raised at the Consultants monitored by including this meeting and from this issue in individual and group escalated through the lines of supervision at all levels, and medical management to all by periodic audit. doctors in the organisation. Dr Vincent Kirchner This will be monitored through 20 August 2014 Deputy Medical Director regular supervision and quarterly audits.

Recommendation five Within both Trusts risk Review Clinical Risk Policies September 2014 Acosia Nyanin assessments and and procedures to ensure Head of Regulation & management plans are standards are set in relation to Quality Assurance completed within an agreed risk assessments and acceptable timeframe and management that these are reviewed at significant points of clinical decision making for all Review risk audit standards September 2014 Clinical Directors patients, and shared with all within the CPA audits to professionals involved in ensure this recommendation is their care to inform current addressed risk management. Supervision facilitates the routine review of actual cases to ensure this is embedded as part of See recommendation one standard clinical practice, and to enable corrective action to be taken if required, as in Recommendation One. The implementation of this Recommendation is monitored by periodic audit. See recommendation two

Recommendation four Meetings in which clinical Develop/review the clinical September 2014 Clinical Directors decisions are made about an team meetings process as set individual’s care be organised out within service operational so as to ensure that the policies necessary clinical records have been reviewed prior to Develop standards to follow September 2014 Clinical Directors the team making decisions when carrying out a clinical about the care of the patient. team meeting and ensure these are inserted into the The effective implementation appropriate operational of this recommendation be policies monitored within the Team Supervision Process as Set up an audit to ensure October 2014 Clinical Directors outlined above in compliance with this action Recommendation One. The standard practice of clinical teams in relation to this recommendation is monitored by periodic audit.

Recommendation nine Both Trusts review their Ensure appraisals systems in guidance to consultants, place and that appraisals are managers and senior current. This to be monitored clinicians making explicit the via the Trust performance Trust’s expectations with process regard to their role in leading the teams in which they work. The effectiveness of implementing this guidance is monitored through normal appraisal processes.

Recommendation one Claire Johnston (Director of Nursing & People)/ Dr Both Trusts further Review Supervision policy September 2014 Mark Cole (Head of develop their supervision and procedures Learning & Development) policies and procedure to facilitate supervision Re-launch policy September 2014 Claire Johnston (Director being used to provide of Nursing & People)/ assurance to the Trust Review/redesign supervision October 2014 /Paul Calaminus (Chief Board that patient care is training programme. Operating Officer)/Heads of the required standard. of Professions (HOPs) Set out priority groups to October 2014 The supervision process receive training Dr Mark Cole includes scrutiny of Head of Learning & current samples of actual Design a supervision audit September 2014 Development care delivery at every level tool to ensure clinical practice Dr Mark Cole (Head of reflects the requirements Set out a supervision audit September 2014 Learning & of the clinician’s monitoring programme Development)/HOPs professional duties. which will report to Clinical Governance. For BEHMHT Ian Clift The supervision process this will be via the service Deputy Director of Nursing includes scrutiny of line governance groups. current samples of actual care delivery at every level to ensure adherence to prescribed changes in 1 Recommendation Actions Interim date Final Completion Date Lead person practice such as those required by the recommendations in this report. Regular audits take place Quarterly audits of September 2014 Acosia Nyanin to demonstrate that the supervision records will Head of Regulation & supervision chain is highlight quality and identify Quality Assurance identifying and any deficiencies in practice. addressing any deficiencies in the quality Audits will be monitored by the balance scorecard patients process.

Recommendation seven Within both Trusts all This can be carried out in September 2014 transfers and discharges of liaison with the action patients follow a identified in recommendation comprehensive protocol that three sets out a checklist. The Investigation Panel are aware that the North London Forensic Service have developed and are now using such a list. CANDI should consider developing a similar process for all external and internal transfers and discharges. Supervision facilitates the routine review of actual cases See recommendation one to ensure this is embedded as part of standard clinical practice, and to enable corrective action to be taken if required. The implementation of this is monitored by periodic audit.

Recommendation six Within both Trusts the Set up a Case Management October 2014 Dr Vincent Kirchner Quality Assurance Policy, which includes Deputy Medical Director Programme is revised to reviewing documentation as ensure that Teams assessing part of the case management and caring for psychiatric process Dr Vincent Kirchner patients are producing Care Deputy Medical Director Plans that reflect a Review/redesign a care October 2014 comprehensive planning audit tool, which understanding of the current covers this recommendation. Clinical Directors psychiatric, social, family circumstances and risk Carry out a care plan audit, characteristics of the and report the outcome to November 2014 individual they are treating. clinical governance These audits form part of BEHMHT to continue their QA regular Clinical Governance assessments which will Team Meetings. capture all aspects of care planning. Ongoing rolling programme in place reported via Deep Dive and service line governance meetings.

Recommendation ten BEH review the regular Report and recommendation June 2014 Mary Sexton, training for the Trust’s to be discussed with the Chair Executive Director of Managers under the Mental of the Mental Health Act Nursing, Quality and Health Act and ensure that Committee. Full report to be Governance regular meetings occur tabled at the Mental Health between the Managers and Act Committee October 2014. clinicians involved in Managers’ Hearings to The Mental Health Act facilitate effective working. Committee to oversee the implementation of this December 2014 Michael Chalmers, The implementation of this recommendation in respect of Mental Health Act Recommendation is training and support to Manager monitored by including this hospital managers involved in 10 issue in individual and group hearings. supervision for those clinicians involved in such Mental Health Act office to hearings, and by periodic coordinate discussions audit of decisions recorded between hospital managers September 2014 Michael Chalmers, by Managers. and clinicians to facilitate Mental Health Act effective working. Manager Mental Health Act Committee to receive formal updates on section arrangements for all Already in place Michael Chalmers, service users held under the Mental Health Act Mental Health Act. Manager 11

Recommendation three Both Trusts clarify explicit Acosia Nyanin (Head of minimum standards for care Review admission and September 2014 Regulation & Quality coordinators and support discharge policies and Assurance) with Clinical these with documents to procedures Directors assist care coordinators in their role (for example the Ensure a discharge check list is September 2014 Acosia Nyanin discharge check list produced implemented Head of Regulation & by BEH in response to the Quality Assurance findings of the internal investigation). Design a local audit tool to September 2014 Acosia Nyanin (Head of ensure compliance in utilising Regulation & Quality These standards form a the check list. Assurance) with Clinical benchmark within the Directors supervision process which Set out a reporting structure September 2014 includes scrutiny of actual for audit results Acosia Nyanin care delivery and records so Head of Regulation & as to enable corrective action See also recommendation one Quality Assurance to be taken if required, as in Recommendation One. The implementation of this Recommendation is monitored by periodic audit.

Recommendation two Acosia Nyanin Head of Regulation & Both Trusts reinforce the Review CPA Policies September 2014 Quality Assurance position of clinical care management as the Review CPA training in terms September 2014 Dr Mark Cole cornerstone of patient of accessibility and uptake Head of Learning & care in their psychiatric Development services. The essentials of Review CPA audits to ensure September 2014 this are contained within this recommendation is Clinical Directors the Trusts’ CPA policies captured in the audit and include the appropriate use and Set out a programme to September 2014 Acosia Nyanin sharing of clinical ensure cyclical reporting of Head of Regulation & information to inform CPA audits to Clinical Quality Assurance clinical decision-making, Governance and the management of risk. 2 Recommendation Action Interim Date Final Date Lead Recommendation two cont’d The position of CPA be Review of CPA training to reflected and strengthened ensure the recording of CPA in in the training programmes patient notes and the September 2014 Acosia Nyanin (Head of staff are required to attend, formulation and integration of Regulation & Quality and the priorities identified risk assessments are Assurance) with Clinical in individual and group incorporated into training. Directors supervision. Quarterly audits will review supervision records and will take account of the quality of documentation of CPA. Supervision facilitates the routine review of actual Supervisors to review CPA Acosia Nyanin (Head of cases to ensure the documentation with specific September 2014 Regulation & Quality appropriate application of attention to the quality of Assurance) with Clinical the principles of CPA and to documentation. This will be Directors enable corrective action to monitored through the be taken if required, (set out Balance Score Card audits. in Recommendation One). The implementation of this Balance Scorecard will monitor Acosia Nyanin (Head of Recommendation is the implementation of audits Regulation & Quality monitored by periodic audit. The outcome of these audits September 2014 Assurance) with Clinical will be reported to the Clinical Directors Quality Review Group (CQRG) quarterly.