Independent investigation into the care and treatment of Mr X and Mr Y

The Trust will review current liaison arrangements between locality directorates and Forensic Services, looking in particular at referral thresholds. The review will ensure that in future formulation processes will be sensitive enough to take into account complex presentations utilising the skills and services to be found within the organisation. This process will be completed within six months of the publication of this report.

The Tower Hamlets Clinical Commissioning Group must review these guidelines in conjunction with health and housing partners to audit embeddedness and fitness for purpose. This process will be completed within six months of the publication of this report.

For the current arrangements to be audited within six months of the publication of this report.

The Trust will develop an audit system sensitive enough to detect whether risk assessment is based upon historic information pertinent to the ongoing care and treatment of named service users. This to be developed within six months of the publication of this report.

for the work already in train to be reviewed within six moths of the publication of this report.

As a minimum care standard, service users who have a Care Coordinator but who are not subject to CPA will have a Crisis and Contingency Plan made available. This work should be embedded within six months of the publication of this report.

Following the incident involving Mr X and Mr Y and prior to both the internal and independent investigations, the Operational Lead of Bethnal Green CMHT met with senior representatives of Providence Row Housing Association to debrief and to exchange ideas about how tools could be introduced in order to improve communication between agencies. A Joint Working Protocol was developed between Bethnal Green CMHT and Daniel Gilbert House which includes guidance on mutual communication. This was subsequently extended to all hostel providers within Tower Hamlets following discussion with these providers. This process will be reviewed within six months of the publication of this report.

A tool has been developed for hostels to advise how to access support if staff are concerned about a resident, whether known or unknown to secondary mental health services and whether within or outside the CMHT hours of operation. This was designed as a flow chart in poster form for easy reference. Training has now been delivered by the CMHT to hostel staff on both these tools. The Joint Working Protocol has been subject to a review cycle following which it was amended. These tools to be rolled out to other directorates. It may be necessary to amend content to reflect local variations. This process will be reviewed within six months of the publication of this report.

Relationships between the CMHTs and hostel providers can be developed, and continuity of care improved, by identifying a small number of Care Coordinators as Link Workers for each hostel. Link Workers to act as point of contact for the hostels and to act as Care Coordinators for all service users in their link hostel who require Care Coordination under the care of a specific team. A similar arrangement has been successful following implementation in mental health supported accommodation provision. Changes of staffing to be clearly communicated between agencies. It was also agreed to consider, if practicable, the facilitation of CPA clinics at hostels and to develop an information sharing protocol between the CMHTs and hostels. This process will be reviewed within six months of the publication of this report.

For Health (commissioners and providers), Housing and the Local Authority to develop an Escalation Procedure in order to be able to respond to concerning behaviour from one hostel resident to another by use of planning and communication across teams and agencies. The procedure will also take into account the need for the ‘global’ situation within a hostel to be ascertained on a regular basis in order to assess the collective risk presented by having large numbers of people with chaotic lifestyles living together in one place. This process will be completed within six months of the publication of this report.

An Accommodation Pathways Working Group has now been established and meets every two months with membership including senior Trust managers and clinicians, LBTH Supporting People commissioners and a senior representative of the HOST Team. This process will be reviewed within six months of the publication of this report.

The Trust, the London Borough of Tower Hamlets and housing will review the Dual Diagnoses Service strengthening the input for this large cohort of clients who currently do not meet the CMHT threshold. This work should be completed within six months of the publication of this report.

To develop workshops involving themes of the stigma of mental illness and associated features of masking and denial of symptoms, in the context of comparison of various cultural norms as well as an appreciation of the service user as an individual who may or may not share various cultural/ social values. This work should be embedded within six months of the publication of this report.

In future all multi-agency reports will be shared across all of the relevant agencies via a formal briefing process.

Of the various hostels based in Tower Hamlets, the client group has changed over the years and now includes a greater number of service users under the care of secondary mental health services. Placements are accessed via the homeless services HOST Team but at the time of the incident there was no consistent system for placement review to explore potential move-on nor a forum to discuss interface issues and referrals pathways. Action: An Accommodation Pathways Working Group has now been established and meets every two months with membership including senior Trust managers and clinicians, LBTH Supporting People commissioners and a senior representative of the HOST Team. This process will be reviewed within six months of the publication of this report.

The Trust internal investigation and joint Commissioner investigation process did not communicate its findings to all of the stakeholders concerned. This prevented learning from taking place and the timely development of safer practice. This work should be embedded within six months of the publication of this report. Action: In future all multi-agency reports will be shared across all of the relevant agencies via a formal briefing process.

A number of service users of the CMHTs have named Care Coordinators but are not subject to CPA. At present, no core CPA documentation such as Risk Assessment, Care Plan and Crisis and Contingency Plan need be maintained. It is noted that in the case of the incident in question, hostel staff had little information on the key professionals involved in Mr. X’s care or how to respond in the event of a crisis. Communications between the CMHT and hostel have significantly improved due to good practice initiatives. The Trust and the Local Authority etc. need to work through how the learning from the Mr X case, and the subsequent good practice arising from lessons for learning, can be rolled out across the whole Trust and other housing providers. We heard at the workshop that there was: 1. A new joint working protocol with simple guidelines to support housing providers accessing immediate support from secondary care mental health services (with a flow chart of all OoHs contacts). 2. Training to the Daniel Gilbert Hostel. 3. Work ongoing to consider a named CMHT link worker for each hostel/housing provider. 4. Work ongoing to consider how care, crisis and contingency plans can be made available to housing for all mental health service users even those who do not meet Care Coordination/CPA criteria. 17.12. A key point was identified as being the role of the Care Coordinator in pulling all of the agencies and services together in the best interests of the service user, and once designated this role had key responsibilities over and above those other practitioners in other services to ensure the ongoing flow of communication. Care Coordinators need to be more mindful of their role. The communication between CMHTs and GPs is now part of the CQUIN process. Action 1: for the work already in train to be reviewed within six moths of the publication of this report. Action 2: As a minimum care standard, service users who have a Care Coordinator but who are not subject to CPA will have a Crisis and Contingency Plan made available. This work should be embedded within six months of the publication of this report.

Risk assessment processes need to be tightened for those service users with a stable/medium/long-term relationship with the Trust. Reviews should be conducted and an assurance provided that historic risk information is brought together and that ongoing/new risk information is considered as part of a dynamic risk assessment process as routine. Risk assessments should be multidisciplinary/agency and perhaps the CPA meeting should be used to assess risk in a more defined manner. Action: The Trust will develop an audit system sensitive enough to detect whether risk assessment is based upon historic information pertinent to the ongoing care and treatment of named service users. This to be developed within six months of the publication of this report.

Good practice has been highlighted regarding the relationship between the CMHT and Dual Diagnosis Service, the Specialist Addiction Unit, the hostel and Health E1 Medical Centre. However, issues have been raised regarding the operation of the Dual Diagnosis Service in terms of its relationship with partner addiction services and referral pathways. Action: The Trust, the London Borough of Tower Hamlets and housing will review the Dual Diagnoses Service strengthening the input for this large cohort of clients who currently do not meet the CMHT threshold. This work should be completed within six months of the publication of this report.

It was discussed at the lessons for learning workshop that a more “stringent formulation” process was required particularly for service users with a combined psychosis, substance misuse and forensic history. The issue was raised about the thresholds for forensic assessment to support diagnostic and risk formulation. The issue was also raised as to whether the Trust should lower the threshold for forensic assessment referral. Action: The Trust will review current liaison arrangements between locality directorates and Forensic Services, looking in particular at referral thresholds. The review will ensure that in future formulation processes will be sensitive enough to take into account complex presentations utilising the skills and services to be found within the organisation. This process will be completed within six months of the publication of this report.

Given the large number of residents at each hostel, many of whom present with significant and complex risk and varying states of vulnerability and anti-social behaviour, there is a need to develop an overarching strategy to monitor and as necessary respond to escalation of behaviour of concern related to relationships between hostel users. Action: For Health, Housing and the Local Authority to develop an Escalation Procedure in order to be able to respond to concerning behaviour from one hostel resident to another by use of planning and communication across teams and agencies. The procedure will also take into account the need for the ‘global’ situation within a hostel to be ascertained on a regular basis in order to assess the collective risk presented by having large numbers of people with chaotic lifestyles living together in one place. This process will be completed within six months of the publication of this report.

The lessons for learning workshop discussed at length the issues around information sharing between agencies, particularly between health and hostels. The group decided that a core set of information should be agreed between the agencies and that this should form a recommendation. The recommendation should address issues pertaining to patient confidentially, consent, safety thresholds etc. It was also agreed that an information sharing protocol should also be developed in order to promote safety and joined up working. A profile should be developed that outlines what information is expected from each professional (across all services and agencies) involved with a service user. This profile should identify who needs to know what and when. A core dataset should be developed (e.g. risk and crisis plans, relapse information, change of workers, medication etc.). The core data set should apply to ALL service users whether they are subject to CPA/CMHT services or not. The workshop acknowledged that there were often chaotic service users who did not meet CMHT thresholds and that satellite clinics should be provided for advice to hostels and primary care. It was recognised that different types of service users would require specific information sharing criteria to be identified. Action 1: Following the incident involving Mr X and Mr Y and prior to both the internal and independent investigations, the Operational Lead of Bethnal Green CMHT met with senior representatives of Providence Row Housing Association to debrief and to exchange ideas about how tools could be introduced in order to improve communication between agencies. A Joint Working Protocol was developed between Bethnal Green CMHT and Daniel Gilbert House which includes guidance on mutual communication. This was subsequently extended to all hostel providers within Tower Hamlets following discussion with these providers. This process will be reviewed within six months of the publication of this report. Action 2: A tool has been developed for hostels to advise how to access support if staff are concerned about a resident, whether known or unknown to secondary mental health services and whether within or outside the CMHT hours of operation. This was designed as a flow chart in poster form for easy reference. Training has now been delivered by the CMHT to hostel staff on both these tools. The Joint Working Protocol has been subject to a review cycle following which it was amended. These tools to be rolled out to other directorates. It may be necessary to amend content to reflect local variations. This process will be reviewed within six months of the publication of this report. Action 3: Relationships between the CMHTs and hostel providers can be developed, and continuity of care improved, by identifying a small number of Care Coordinators as Link Workers for each hostel. Link Workers to act as point of contact for the hostels and to act as Care Coordinators for all service users in their link hostel who require Care Coordination under the care of a specific team. A similar arrangement has been successful following implementation in mental health supported accommodation provision. Changes of staffing to be clearly communicated between agencies. It was also agreed to consider, if practicable, the facilitation of CPA clinics at hostels and to develop an information sharing protocol between the CMHTs and hostels. This process will be reviewed within six months of the publication of this report.

Mr X was from an East African cultural background and as such there was an opportunity to explore issues surrounding stigma, denial of symptoms and masking of symptoms which can be common features in people of this background, however this was not explored. Action: To develop workshops involving themes of the stigma of mental illness and associated features of masking and denial of symptoms, in the context of comparison of various cultural norms as well as an appreciation of the service user as an individual who may or may not share various cultural/ social values. This work should be embedded within six months of the publication of this report.

The referral system has been improved since the transfer from paper to electronic records. Referrals are now highlighted and audited. The system is fully integrated at the present time Action: For the current arrangements to be audited within six months of the publication of this report.

The role of housing should be clarified with regard to medication management. Some hostels in the area are required to support medication compliance and mental health monitoring – others are not. At the lessons for learning workshop we heard from the Tower Hamlets Clinical Commissioning Group that guidelines are now in place. Action: The Tower Hamlets Clinical Commissioning Group must review these guidelines in conjunction with health and housing partners to audit embeddedness and fitness for purpose. This process will be completed within six months of the publication of this report.