*Independent investigation into the care and treatment of Mr H: June 2013

The Independent Team has been provided with a copy of the proposed new policy document, “Policy on the Transfer of Clients From Low Secure Services”. Detailed constructive commentary has been provided to the authors of the document via The Trust’s Head of Serious Incidents. Because of the increased risks associated with any transition period (i.e. transferring or discharging a patient from Team A to Team B), The Trust is asked to consider carefully the feedback provided, and to outline a clear rationale to the commissioners of its forensic and general adult mental health services if it decides not to embrace the principles of the commentary and advice provided.

Building on Recommendation 1, The Trust is recommended to conduct a multi-disciplinary Failure Modes and Effects Analysis2 (FMEA), or Control / Barrier Analysis across the forensic and general adult psychiatric service of its “Policy on the Transfer of Clients From Low Secure Services”. Ideally this should occur prior to implementation of the policy document. In conducting the FMEA, Control/Barrier Analysis, The Trust is encouraged to set out the specific requirements of the new policy document in the order in which the activities are intended to happen, and also to consider setting out a flow diagram of who (or what professional) is expected to do and when. (The use of the principles of Swim Lanes may assist with this.) Once the FMEA chart reflects The Trust’s policy (practice standard) requirements, then an appropriate group of professionals can be invited to conduct the identification of known and potential ‘risk’ points in the process. For validation purposes, a second group of similarly qualified professionals working in the same areas could also be asked to contribute. Once ‘risk’ or hazard points are identified: • The consequence of the ‘risk/hazard’ occurring in the system as currently designed needs to be realistically and pragmatically worked through, including the ability of existing safety control to contain or mitigate the risk/hazard. • The robustness of current and proposed safety controls needs to be considered at each risk/hazard point. • Each of the multi-professional groups needs to consider whether there are any additional steps in the transfer process that, if introduced, would reduce the likelihood of occurrence of the identified risks/hazards, or the consequences of them if they were to occur. • The work of both groups needs to be ‘brought together’ for comparative analysis and an agreed and cohesive remedial plan implemented. Note 1: There is a wealth of technical information available about FMEA on ‘the net’ and the NPSA’s RCA e-learning tool kit contains information about Control/Barrier Analysis as do some of the referenced texts on this site. The Health Foundation has also been sponsoring a Safer Clinical Systems project at Warwick Medical School since 2008, and this may be a useful resource for The Trust. Note 2: The above recommendation is of particular relevance to the Mr H case, as it is recognised that transition periods between teams, services and organisations pose a heightened opportunity for risk. Taking a proactive approach to the identification of these prior to policy launch is one way of reducing this risk.

Although the Trust’s investigation utilised nationally available guidance templates during the conduct of its investigation, and in principle met with the then and currently required investigation standards, there were a number of features of the Mr H investigation that could have been improved on if the Trust is to optimise opportunities for effective learning, and the consistent delivery of an effective investigation. The Independent Team recognises that this recommendation represents a ‘gold standard’ in the conduct of adverse event reviews, but it considers that SEPT has the necessary commitment at Executive and local levels of the organisation to deliver investigations of a higher quality. To achieve this, the areas of investigation practice that the Independent Team considers the Trust may wish to consider are: • The clear formulation of core competencies for all investigators tasked with the conduct of high impact/ high consequence incidents such as the case of Mr H. These core competencies might include: (cid:1) Knowledge of a range of investigation techniques such as analytical Timelining, Control Analysis, Person / Placement grids (cid:1) Knowledge of how to conduct a repeatable information analysis using tried and tested qualitative research techniques such as Content Analysis and Affinity Mapping (cid:1) Knowing what issues to conduct a contributory factors analysis on (cid:1) Investigative Interviewing, including question formulation such as the “tell all” instruction, reflect back, and effective note taking (cid:1) The quality of interview records made. Attention needs to be given to interview records that are data rich, and reflect the full depth and breadth of the interview content, including evidence of ‘reflect back’. (cid:1) The Trust, as a component of the quality assurance standards must include consideration of the fairness with which lapses in practice have been addressed across all professional groups. Although not at all intended the Mr H report did not come across as balanced in its criticisms across the range of professional groups involved. In addition to the above points, specific and detailed guidance has been provided by the Independent Team to The Trust with regards to: • The conduct of the investigative interview; • The formulation and analysis of identified care concerns (significant lapses in practice standards).

As a consequence of the Mr H case, The Trust undertook a root and branch review of the operational management and clinical leadership of community mental health teams. The intention was to achieve a wholesale improvement in clinical and operational functioning. One specific issue of direct relevance to the Mr H case is how service users are reallocated within a community mental health team if their care co-ordinator goes on medium- to long-term sick leave, or leaves the team. The Trust needs to satisfy itself that the improvements implemented for community mental health teams has resulted in a situation where there is no opportunity for the circumstances Mr H endured to be repeated. That is, when his care co-ordinator was absent from work, he was allocated to a community support worker (this should not have happened), and when the community support worker left the team in January 2012, Mr H was left as an ‘outpatient’ follow-up-only patient. The recommendation of the Independent Team is that the Executive Directors of Integrated Services Bedford and Luton; and Essex, must satisfy themselves that, in comparable circumstances, regardless of whether or not the service user has a forensic history, all of the community mental health teams are consistently attending to the appropriate reallocation of care co-ordination responsibility. The results of the assessment of this aspect of practice and community team operations must be reported to the Director of Adult Services and the Chair of the Clinical Governance and Quality Committee.

Building on Recommendation 1, The Trust is recommended to conduct a multi-disciplinary Failure Modes and Effects Analysis2 (FMEA), or Control / Barrier Analysis across the forensic and general adult psychiatric service of its “Policy on the Transfer of Clients From Low Secure Services”. Ideally this should occur prior to implementation of the policy document. In conducting the FMEA, Control/Barrier Analysis, The Trust is encouraged to set out the specific requirements of the new policy document in the order in which the activities are intended to happen, and also to consider setting out a flow diagram of who (or what professional) is expected to do and when. (The use of the principles of Swim Lanes may assist with this.) Once the FMEA chart reflects The Trust’s policy (practice standard) requirements, then an appropriate group of professionals can be invited to conduct the identification of known and potential ‘risk’ points in the process. For validation purposes, a second group of similarly qualified professionals working in the same areas could also be asked to contribute. Once ‘risk’ or hazard points are identified: • The consequence of the ‘risk/hazard’ occurring in the system as currently designed needs to be realistically and pragmatically worked through, including the ability of existing safety control to contain or mitigate the risk/hazard. • The robustness of current and proposed safety controls needs to be considered at each risk/hazard point. • Each of the multi-professional groups needs to consider whether there are any additional steps in the transfer process that, if introduced, would reduce the likelihood of occurrence of the identified risks/hazards, or the consequences of them if they were to occur. • The work of both groups needs to be ‘brought together’ for comparative analysis and an agreed and cohesive remedial plan implemented.