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.