Independent investigation into the care and treatment of Mr G

1. Revised Absent without leave (AWOL) and Missing persons policy to ensure all staff are aware of the requirement to complete an incident form and write up details of all incidents in clinical notes. 2. Developed a checklist to ensure all aspects of Absent without leave (AWOL) and Missing persons process in terms of recording and follow up are available and used. 3. Trust developed a discharge process to include that all relevant documents including section 17 leave forms are put in patients notes on discharge. 4. An Absent without leave (AWOL) and Missing persons Working Group has been set up focusing on: - Following through the reduction of Absent without leave (AWOL) and Missing persons risks by spot checks of records from the Matron. - Reduce the likelihood of Service Users leaving clinical environments without the knowledge of staff and/or without having an agreed leave or arranged absence. - Providing clear guidance to staff regarding action which minimise such incidents. -To monitor episodes of Absent without leave (AWOL) and Missing persons incidents and identify strategies to reduce the occurrences of incidents. 5. The Trust will carry out clinical simulation AWOL exercise to test how the policy works in practice. 6. To interlink and implement policies relating to the return of a patient to hospital (AWOL, safeguarding and property policy). Completed July 2015 1-3. The Absent without leave (AWOL) and Missing persons policy was extensively reviewed in 2015 (and is currently being updated): the policy has clear sections and guidance for staff on the process, roles, recording, risk and how to manage the return of patients. It is now the Trust process that Absent without leave (AWOL) and Missing persons Group and every patient has an AWOL management action plan in place including actions to be taken when they return to the ward. Staff from the ward will also carry out immediate welfare checks and try to establish the whereabouts of the patient. AWOL grab packs are being used. Details of the patient are recorded and shared with the police. We are currently consulting with patients on the use of photos. 4. An effective Absent without leave (AWOL) and Missing persons group is in place that meets monthly. The Acute matron leads the work in this area and oversees the process. There is now a close working with police and missing people units who attend monthly meetings. Every Absent without leave (AWOL) and Missing persons incident is subject to review in the Absent without leave (AWOL) and Missing persons group and by spot checks of records from the Matron. A Local Security Management Specialist (LSMS) is also in place to liaise with police. The Trust submit to the MH benchmarking and have been one of the lowest in London for Absent without leave (AWOL) figures. The Trust Quality and Safety and Quality report contains a section on AWOL and is shared monthly with the Trust Quality Governance Committee, Quality Committee and commissioners at the monthly Clinical Quality Review Group. The report also goes to the Board (on a monthly basis) to provide high level oversight of this area. 5. Minutes of the AWOL and Missing persons Group re outcome of this exercise. 6. Copies of updated policies. M a r c h 2 0 1 8 AWOL and Missing persons Group. March 2018 Quality Governance Committee/ CCG Assurance visits.

1. To ensure that the Mental Health Act Training that runs fortnightly uses this homicide as a clinical example to address the prescribing of mental health leave and the importance of good documentation around this. 2. To ensure that all staff have attended Mental Health Act Training at least once every 3 years as per the minimum requirement. 3. The Recommendations from this report are to be taken to the Acute Learning Lessons Workshop and the bulletin produced is circulated to all divisions within Trust and reviewed at team meetings. March 2018 1 -2. Section 17 leave is part of the MHA training and A core skill for the Multi disciplinary Team (MDT). The training specifically addresses questions around nurses' risk assessments before allowing patient to take their section 17 leave, reviewing how section 17 leave is used and feeding back to THE MDT so it can be reviewed and modified; including nurses' powers to stop section 17 leave when there are risk concerns. Nurses can challenge and review leave at any time where the identify any issues and changes in presentation. Training compliance is monitored and there is an action plan in place to increase current training compliance to 85% by March 2018. Section 17 leave is audited as part of the MHA audit programme. MHA compliance and training is overseen by the Mental Health Law Committee which is chaired by a Non Executive Director and is a sub committee of the Board. The Committee also receives reports from the Mental Health Act Inspections carried out on wards. 3. A serious incident report was completed at the time and an action plan created. The new recommendations and actions in this report will be shared as part of lessons learned. The learning from this report will be imparted to staff through lesson learned workshops (and attendance recorded).

1. Absent without leave (AWOL) and Missing persons incidents are recorded on Datix. 2. Ensure clear policies for managing records and record keeping. 3. The Trust has put in place and information governance team to support subject access requests and information governance processes Completed May 2014 1. Absent without leave (AWOL) and Missing persons incidents are recorded on Datix and uploaded to National Reporting and Learning System and this data is shared with CQC. AWOL figures are reported monthly to the AWOL group and recorded on the Quality and Safety report to the Board. The figures on AWOL are also shared with MH benchmarking, the Board and commissioners. NRLS provide 6 monthly benchmarking reports. January 2018 2. The Trust has a clear records management policy that was updated to aligned with care notes. The policy is currently being updated to include the standards used in the Trust clinical audit tool. The Trust wide clinical audit of records cycle began in October 2017 and will be completed in January 2018. Initial results for one division were shared with the Board in November 2017 and regular updates will be provided throughout the audit cycle. To support best practice in record keeping the Trust has stipulated in the Clinical Supervision Policy, 2017, supervision must take place at least 10 times a year. 2 of the key domains include, clinical scenario & risk management, care planning. Clinical record keeping must be included within this and monitored as part of supervision. An audit tool has been developed to monitor this. The policy will be launched in December 2017. Completed August 2015 3. There is now an information governance team in place who co-ordinate requests for records to ensure this is done promptly and all the relevant information is included. There is a legal support services lead in place to ensure this is done correctly. Subject access requests are monitored and reported to the Information Governance Committee. The figures show that the Trust has significantly improved in meeting timely requests for records. There is guidance for staff on IG and training with a good level of compliance. The Trust also participate in the annual information governance toolkit assessment. The current 2017 score is 96% satisfactory The Trust will undertake an audit of AWOL in January 2018 to provide assurance that the current processes are working.

1. The Trust now uses the patient record keeping software 'Care notes'. Validation of notes is not required on this software. When notes are printed from Care notes they automatically include all entries. Completed June 2015 1. There is guidance, training and support for staff on how to use Care notes. There is a Care notes group that oversees the Care notes system. Reports on completion of the records in Care notes can be accessed by staff on the clinical dashboards.