Independent investigation into the care and treatment of Mr Q: April 2015

The trust should ensure that staff understand the importance of thorough record keeping, in line with trust and national policy. This includes the need to record discussions about patients when their symptoms, diagnosis and treatment has been considered and any subsequent action agreed. The trust should carry out six-monthly audits to ensure compliance. Comprehensive audit plan of record keeping in respect of assessment (including diagnosis), care planning, risk assessment, communication of the care plans. Record keeping a key element of mandatory training in Care Planning and Risk assessment. The importance of record keeping is a key element of the mandatory training programme and its application in respect of CPA and risk assessment.  These actions have been completed, evidenced as follows:  The Trust ensures that staff are aware of the importance of record keeping through a continuous process of audit and feedback of the results to teams.  The Trust’s Quality Assurance (QA) Audit Programme consists of over two hundred individually developed record keeping and patient care standards based on national standards and internal trust targets. These have been developed in collaboration with clinicians in each service, as well as patients and carer representatives.  Each clinical service within the boroughs has developed an individually tailored audit tool which is used within monthly clinical supervision to evaluate the quality of the patient record. Reports are produced at team level on a monthly basis by selection of a sample of records for audit, and are reviewed quarterly by service managers and senior managers at ‘deep dive’ review meetings.  Detailed results and a thematic review are reported 6 monthly to the Quality and Safety Committee of the Board and shared with Commissioners via CQRG. As of July 2015 the Thematic Review showed sustained compliance of 95% across key standards assessed. Of the 200 standards assessed, specific standards of relevance to this case, based on audits of Haringey services in the period October 2014- May 2015, include record keeping of assessment (96%), care planning (94%), communication with GP and partner agencies (95%), and risk assessment (95%).

Diagnosis needs to be assessed as part of CPA process, and this is assured through a regular audit programme. In Complex Care services of the type involved in this case, diagnostic uncertainty is common; whereas in this case, the issue is whether to treat psychotic symptoms robustly with antipsychotic medication concurrently with psychotherapeutic treatment, this forms part of routine clinical discussion. The relevant teams will be asked to reflect this recommendation and include it in their team based learning. In addition, all teams will have access to an expert forum at which diagnostic uncertainty and associated risks can be discussed with a range of multi-disciplinary expertise. These actions have been completed, evidenced as follows: Consultants ensure discussion regarding diagnosis is clearly documented within the Care Record. CPA reviews are in place and national standard being met. Recommendation of this report forwarded to team leaders of CCTs with advice, completed August 2015. Unmanaged Risk Fora meet regularly in each borough on a monthly basis and conduct clinical expert reviews at which diagnostic uncertainty is a regular topic.

Routine monitoring of conduct of CPA reviews. Audit of records to assess compliance with CPA processes and outcomes. Mandatory training in application of CPA. This action has been completed, evidenced as follows:  The Trust assures itself about the robustness of CPA process in a number of ways.  The Integrated Quality and Performance Report is reported monthly at the Performance Improvement Committee and quarterly to the Quality and Safety Committee of the Board. The key indicator ‘Percentage of CPA reviews taking place in the last 12 months’ is targeted at 95% and this target was reached or exceeded in the all first three months of 2015/16, being 96% in June 2016 (the latest data available). Regular audits of compliance with CPA are carried out as described in detail under action 1 above. The Trust’s mandatory training programme includes ‘Care Programme Approach and Clinical Risk Assessment’ (CPA and CRA) training.

Discharge planning is a key element of CPA and CRA training. All Complex Care Teams (the key targets of this recommendation and the principal teams delivering ‘long and intensive interventions’) will ensure the decision to discharge is discussed in detail at MDT meeting and discussions regarding timing and status of discharge will be fully documented within patients’ records. Robust Clear arrangements exist in each borough for information sharing with other agencies where there are concerns about risk, through MARAC and MASH. There is a designated lead in each borough with whom clinical teams can discuss discharge arrangements are a factor (see also recommendation 5). Recommendation of this report forwarded to team leaders of CCTs with advice, completed August 2015

Multi Agency Mental Health Monitoring and Liaison Group in place and meets bi-monthly. Information Sharing Agreement (ISA) in place. Police Leads attend meeting. Clinical teams to be made aware of police liaison arrangements so that information sharing can take place when patients of the Trust are making frequent and inappropriate contact with the police. In place as of August 2015 Achieved as of August 2015 Achieved as of August 2015 There is an inter-agency mental health law monitoring and Liaison Group committee that meets 3 monthly where there is senior representation from the police in all three boroughs ( often Inspector rank). Collaborative working between the trust / police/ ambulance at a corporate level is discussed. Clinical teams in BEH are all aware of, and make regular use of, Bryn Shaw the Head of Non-Clinical Risk, who is the named police liaison contact within BEH who links to named liaison officers in each Borough Specialist Police service to ensure communication about patients of shared concern. There are regular meetings in all three boroughs between the trust and borough based policing teams to discuss borough–specific issues including those involving particular patients of mutual concern. Appropriate resolutions or action plans are devised at these meetings which are regularly attended by the Head of Non-Clinical Risk and also by relevant clinicians. The Head of Non-Clinical Risk is available to local police liaison officers who have, and use, his contact details.