Source · Investigations in the NHS

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

London Published 01 Jan 2017 Subject Mr X

This is the independent investigation report into the care and treatment provided to Mr X and Mr Y.

Acceptance status

Per recommendation

Action Plan Published

Total recommendations

About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

11 total

Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more 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. Show less

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more 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. Show less

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more