Independent investigation into the care and treatment of Mr Z

The Trust must ensure that • West London Forensic Services (WLFS) Responsible Clinician • Sept 2020 • WLFS have drafted a new discharge policy in consultation with inpatient and community forensic services. In final stages of Consultation currently. • D i r e c t o r a t e P a t h w a y s M e e t i n g c h a i r e d b y t h e
discharge planning includes the discharge policy has been updated to reflect Clinical Lead • May 2019 (Completed) • WLFS have established community forensic attendance in weekly ward rounds with an information pathway to and from WL community forensic team and ward team. Clinical Lead for Low Secure and Community
following elements and develop a all the learning from this Serious Incident. Clinical Director • August 2015 (Completed) • Community forensic staff attend CPAs and pre-discharge 117 meetings for all rehab ward patients. Monthly.
system to ensure standards are • Legal matters related to discharge are • August 2018 (Completed) • WLFS have developed an aide memoir for community forensic staff to use to check that discharge planning is following process and good practise. •FOS/SCFT allocation and performance
maintained. discussed within multiagency Section 117 • September 2018 • Everyone discharged from secure care to WLT community forensic service is placed on the amber alert in the RAG system for one month – this means that contact is at a database reviewed weekly by RCs, Community
• How legal conditions of discharge meeting. Invitees will always include the minimum of every week and that contact is discussed with the whole team every week; that the family/carers are contacted and liaised with during the post discharge 4 weeks. Team Manager, Social Workers and MH
are interpreted. hostel or identified placement, the • January 2018 (Completed) • 48 hour follow up is in place following all discharges from Forensic Services to WLT Forensic Community teams. Practictioners.
community team, Service Users' legal • January 2018 (Completed) • WLFS do not discharge on Fridays or prior to bank holiday weekends. •Audit of CPA minutes presented to Clinical
• Provide a complete discharge representative and carers (with the Service • January 2016 (Completed) • WLFS discharge all Conditionally Discharged Restricted Patients (CDRP) to WLT Forensic Community team to a triangle model which includes RC, SS, and MH Practictioner. Improvement Groups Directorate and Service
summary and care plan which Users permission). • January 2018 (Completed) • WLFS won’t accept a transfer of care from inpatient services unless the HCR20 is up to date and of good quality. It is then reviewed within the first 3 months of discharge by Wide.
includes contingency management • March 2020 (Completed) WL community forensic services. •Quality and Performance indicators
prior to discharge. • September 2020 • Specialist Forensic Community Team now have identified hostel link workers to communicate about the general updates of hostel providers and any queries they may have monitored through monthly Trust Clinical
for the service. Governance meeting, bi-annual Trust
1 TLW • d e D li e v f e in ry e a w s h w o e i l s l a re s s w po ha n t s ible for • January 2016 (Completed) • WLFS have created a discharge checklist as part of the Discharge Policy (to be completed prior to discharge): - MAPPP (Multi Agency Public Protection Panel) referral and Management Team performance reviews and
interventions are to occur and • September 2020 c • o A n s f i s r o m o a n t i a o s n a ; J d IG is S c A ha W rg a e n l d o c V a io ti l o e n n c is e i d Li e a n is t o if n ie O d f t f h ic e e r c o li m ais m o u n n ( i w ty it f h o i r n e p n r s o ic b t a e t a io m n ) w ; H ill C a R ll 2 o 0 ; a C te a r t e h r e C p o r n o t p a o c s t; e I d D c ; l S in o i c c i a a l l t S e u a m p p to rt p ; a B r u t d ic g ip e a t s t ; e a i s n p d a is r c t h o a f d r g i e s c p h la a n rg n e in p g o . l icy through Trust Wide Quality Committee.
when. • In progress • The pre discharge 117 meeting clarifies who is responsible for fulfilling the conditions of discharge (Service User (SU), Carer, Professionals) in the pre-discharge 117 meeting
and ensuring these actions are listed in the care plan, specifically addressing the conditions of discharge and how they are to be met. Clearly set out in discharge policy
• September 2020 • Planned event for accommodation providers regarding community forensic services and risk management, designed in collaboration with service users, victims and families of
• Must include carers, provider • January 2016 (Completed) victims. This is delayed due to the Covid lockdown but design work continues.
service staff and all relevant clinical • The new discharge policy sets out the terms of providing Discharge Summaries to community forensic services in a timely manner.
personnel. • Community forensic services currently do not have any statutory responsibility for identifying placements. However, we collaborate where possible with RLAs to advise and
consult on appropriate placements in our view.

The Trust must ensure that • WLFS provides Version 3 HCR20 training to Director of Nursing & • January 2018 (Completed) •Audit of HCR20 presented to Clinical
agreed standardised risk all registered clinical staff. Patient Experience • January 2018 (Completed) Improvement Groups Directorate and Service
assessment (including HCR-20) • West London Trust has developed a Clinical Director WLFS • January 2018 (Completed) Wide.
protocols, practice and Business Intelligence system (WLBI) which Head of Knowledge • January 2018 (Completed) • Audits completed and presented to WLFS Clinical Governance Meeting. •Quality and Performance indicators
documentation are monitored to shows clinical staff the compliance with Management • January 2018 (Completed) • Audit occurs on a 3 yearly audit cycle. monitored through monthly Trust Clinical
reflect the outcomes from the HCR20 in real time. Head of Psychological • January 2018 (Completed) • Performance of WLBI monitored monthly through Clinical Governance Meetings.• Community forensic psychologist undertakes regular audits of the HCR20. Governance meeting, bi-annual Trust
Trust’s internal action plan. • Regular qualitative audits are undertaken. Therapies & Audit WLFS• January 2020 • They then prioritise which HCR20s require review and will undertake work with the clinical team to review and complete the HCR20, including one to one sessions with Management Team performance reviews and
2 TLW The focus of monitoring should be • We share the HCR20 with hostel providers. clinicians. through Trust Wide Quality Committee.
on communicating risk related • July 2020 • We complete the CPA risk assessment reviews in collaboration with the hostel provider, service users and carers/others. January 2018
information, reviewing of risk • Reviewed all of our lone working procedures.
assessments and management • Planned event for accommodation providers regarding community forensic services and risk management, designed in collaboration with service users, victims and families of
plans considering additional victims. This is delayed due to the Covid lockdown but design work continues.
information and the development • We are participating in a specialist community forensic team pilot which includes more wrap around care and other forms of support and intervention, including the
of a risk formulation. introduction of: - occupational therapists; recovery workers, peer support workers and a Carers Lead as well as a WTE psychologist to provide community based therapies.

The Trust must ensure that joint • West London Forensic Services (WLFS) Responsible Clinician • January 2016 (Completed) • Prior to discharge all conditionally discharged restricted patients under FOS/SCFT have an allocated Social Worker and a Forensic Community Mental Health Nurse as well as •Audit of CPA minutes presented to Clinical
working practices with other discharge policy has been updated to reflect Clinical Lead Responsible Clinician responsible for their care. This is documented on the FOS/SCFT allocation and performance database. Improvement Groups Directorate and Service
organisations reflect developments all the learning from this Serious Incident. Clinical Director • January 2018 (Completed) • Invitations to attend CPA/pre discharge 117 meetings are sent to organisations that will be providing day to day care on discharge of patients. Wide.
in practice and protocol arising • Risk Assessments, Risk Management Plans Director of Nursing & • January 2018 (Completed) • Risk assessments and care plans are shared with the accommodation provider. •Quality and Performance indicators
from this incident and the internal and Contingency Plans are discussed within Patient Experience • April 2019 (Completed) • There has been significant investment within FOS/SCFT: monitored through monthly Trust Clinical
investigation action plan outcomes.multiagency Section 117 meetings. Invitees . 1 WTE (Whole Time Equivalent) New RC post Governance meeting, bi-annual Trust
Specifically, that joint risk will always include the hostel or identified . Extra psychology input Management Team performance reviews and
3 TLW a p s la s n e s s , s m co e n n t t in a g n e d n m cy a p n l a a a g n n e e s m an e d n t p U l s a e c r e s m ' le e g n a t, l t r h e e p r c e o s m m en m ta u t n iv it e y a t n e d am ca , r S e e r r s v ( ic w e i t h . . 1 1 W ne T w E r O e T co p v o e s r t y F s O u S p / p S o C r F t T worker to help smooth transition from inpatient to community services through Trust Wide Quality Committee.
agreed protocols for discharge and the Service Users permission). . 4 MH Practictionerposts
recall are agreed in each individual • The Learning from this incident will shared • July 2020 • There has also been investment to the FoCuS community team as well as new funding for a Specialist Community Forensic Team (SCFT) covering Ealing, Hounslow and Brent.
case. internally within the Trust and externally. SCFT is a new team that provide robust 24/7 follow up to former forensic inpatients. It is a multidisciplinary team that works closely alongside other organisations working with
• September 2020 an individual in the community.
• Trust Wide Learning Lesson Agenda & via London-wide forums

The Trust must ensure that staff • All Forensic Outreach Service/ Specialist Director of Organisation On-going Training Records Trust Wide Workforce Planning Group.
are appropriately skilled and Community Forensic Team (FOS/SCFT) Development & Supervision Records WLFS Governance Meeting.
competent to undertake the role of Community Psychiatric Nurse and Social Workforce PDR Records• As well as Supervision Training: - FOS/SCFT Clinical Improvement Group
Social supervisor. Workers now undertake a training manual FOS/SCFT Team • Clinical and Social Supervision refresher training for the whole team so everybody understands the roles. Meeting.
on the role of the Social Supervisor as part of Manager • Provision of: - KUF - Knowledge and Understanding Framework Training” this supports staff to understand personality disorder and to work with service users with personality
the Social Supervisor training course. There Service Director Low disorder more effectively, HCR20; MAPPP; Appropriate Adult; Tree of Life - focuses on facilitating collaborative recovery in a multicultural and multi-ethnic group ; Trauma
4 TLW is no accredited national training but WLT Secure & Community Informed Care; Peer Based Approaches; Formulation - understanding the presenting problem, predisposing factors, precipitating factors, perpetuating and protective factors –
Social Work department run training twice a • Change the MH Practictioners and MH Practictioners to Mental Health Practitioners in the table.
year.
• Competence reviewed through supervision
and Personal Development Reviews.

The Trust must ensure that it has a • All agency staff that are booked through Director of Organisation • July 2016 (Completed) • Pre-employment checks for temporary staff are undertaken before commencing clinical contact. Trust Wide Workforce Planning Group.
robust process for checking that all the Temporary Staffing Team are booked Development & • The Trust has implemented an automated alert system for Line Managers of professional registered staff to inform them when their professional registration is due to lapse. WLFS Senior Management Team Meetings.
staff are appropriately registered through framework agencies, which are Workforce NHSI agency review - Agencies are only
with their professional body, and required to undertake appropriate checks engaged if they are on the approved
this should include ensuring that including registration. Framework. All suppliers on the framework
any agency staff employed are have been audited to ensure ability to comply
5 TLW appropriately registered. with NHS pre-employment check standards.
The agency will ensure that the candidate is
compliant with all the pre-employment checks
– References, Professional Registrations, ID
check, Right to work, training, OH clearance
and DBS clearance.
Internal audit

In partnership with LCH, the a) Develop an escalation process for Chief Executive- London Completed. An eligibility criteria, 1. Escalation process for registering relapse/ risk/ areas of concern. Quarterly performance monitoring of the
commissioners of Collette House registering relapse/ risk/ areas of concern Cyrenians escalation process, flowchart and 2. Concern escalation flowchart. service is undertaken by the Adult Support
should clarify the role and nature protocol were developed in 2017. 3. Escalation e-mail protocol Team. Quality assurance of the service is also
of the Collette House service The escalation process, flowchart undertaken by the Adult Support Team.
provision, including the limits of and protocol were agreed by the
the service, and clear thresholds London Borough of Ealing and The London Borough of Ealing and Ealing
for raising and escalation of any Ealing CCG in 2017. Clinical Commissioning group are currently
concerns. reviewing the service specifications for mental
health services. This review is on-going and the
anticipated completion date is September
2020. As part of this review, the documents
agreed in 2017 will be reviewed to ensure they
align with the processes of the Recovery
Teams. In addition, the strategic relevance and
purpose of services would be reviewed when
6
EBL/HCL t a h n e d r e st a ra re te c g h ic a n p g ri e o s r i i t n ie n s a . tional and local policies
b) Clarify the eligibility criteria of Collette Mental Health The eligibility criteria was Copy of the eligibility criteria. As mentioned above, a review of the service
House Commissioner- developed in 2017 and reviewed specifications of mental health services is on-
LBE/ECCG as part of an overall review of going. As part of this the eligibility criteria has
service specifications of mental been agreed. In addition, the eligibility criteria
health. of services such as Collette House would be
Completed September 2020. reviewed when there are changes to national
and local policicies.