*Independent investigation into the care and treatment of Patient 2009/3245: January 2014

The panel were encouraged to hear at interview that steps had been taken by the Trust to ensure transparency of multiple concurrent projects following the introduction of an overview project framework. However, the inquiry believes that the effectiveness of practitioners’ workloads being monitored is also essential in both supporting and challenging staff to develop best practice and to promote high standards of care. All agencies should be able to demonstrate robust systems of monitoring work load pressures inclusive of individual practitioner caseloads.

Patient 2009/3245 was transferred on numerous occasions to different treating Consultants. The Panel considered that continuity of mental health care would have been greatly improved had there been in use a comprehensive standardised transfer summary by the clinical staff treating Patient 2009/3245. The inquiry, therefore recommends the introduction of a transfer summary template which as a minimum common standard should cover key historical issues which is likely to include diagnosis, treatment plan, medication, Section 117 details, MAPPA, forensic history and to clearly signpost relevant past assessments. The transfer summary should be available on the PARIS system and ideally, be readily accessible from the patient’s home page.

The importance of ensuring clarity and accuracy of recording and dissemination of information is an essential part of inter-agency working. The panel were concerned at the effectiveness of the system of exchange of information between Mental Health Services and the accommodation provider - New Horizons (Teesside). The inquiry therefore recommends a review of the current information sharing protocol with partner organisations in order to achieve collaborative care coordination and to implement a regular systematic audit of compliance annually in this area.

(a) The effectiveness of the action taken by the Trust following their internal review relating to MAPPA was not demonstrated to the panel at interview. The inquiry therefore recommends the development of a strategy to increase the understanding and knowledge of practitioners as to the role and processes associated with MAPPA locally, and; (b) The criteria and MAPPA referral procedures should be clearly understood by all relevant staff. This should form part of any induction training, and; (c) In addition the inquiry recommends that it should be possible to readily identify patients who have been subject to MAPPA; this should be clearly recorded on PARIS, and;. (d) Where there has been Health and / or Social Services involvement with patients; these organisations must be represented at MAPPA meetings when decisions are made to alter a patient’s level of registration or discharge them from MAPPA.

Current strategies should be reviewed within inter-agency working (inclusive of non-statutory agencies), to ensure practitioners and those delivering care understand the significance of risk assessment, risk management and the established relationship between historical risk and current risk. The sharing of formal risk assessment information should be considered.

(a) The inquiry recommends that the Tees, Esk and Wear Valley NHS Foundation Trust and the Local Authorities that it works in partnership with should review the current policy in relation to Section 117 aftercare and endorse their joint working approach. They should ensure full compliance of their joint responsibilities for those patients subject to Section 117 by demonstrating the effectiveness of their revised governance arrangements, and; (b) In addition, the panel were concerned during the clinical staff interviews about the lack of staff awareness of Section 117 entitlement and therefore the inquiry recommends comprehensive clinical guidance (which should confirm who should attend any Section 117 aftercare meetings, especially when the patient is unlikely to be given any costed services). Training should also be given to front line clinical staff about what the practical implications are for patients who have been detained under Section 3 and who are subject to Section 117 aftercare, and; (c) The Trust should also ensure that it is possible to readily identify all those patients subject to Section 117 aftercare through enforcement of central registration and also Section 117 to be clearly recorded on the PARIS system.

It was apparent to the inquiry from the evidence of the witnesses that despite the Trusts adherence to Departments of Health’s framework for CPA, in the case of Patient 2009/3245, he met the criteria for CPA but these CPA standards were not fully met. The panel therefore, recognise the need for the Trust to systematically audit and robustly monitor compliance with the CPA policy to ensure progress in line with national priorities and any noncompliance to be clearly identified and rectified.

Tees, Esk and Wear Valley NHS Foundation Trust should review their governance systems to ensure they can demonstrate continuous and systematic monitoring of compliance and where necessary corrective action, to the Clinical Risk Policy by practitioners.

To review Trust procedures to ensure the dissemination of information to senior clinical staff of the conclusions and recommendations of internal and external reports investigating serious untoward events.

The recommendations of this independent review should be endorsed and in addition the panel recommends:- (a) An action plan is developed and shared with key stakeholders both internal and external to implement the recommendations of this report and; (b) The Board of Tees, Esk and Wear Valley NHS Foundation Trust has a regular agenda item to monitor progress on the implementation of the action plan.