Recommendation
The investigation panel considers that the Care Programme Approach (CPA) policy of Northumberland, Tyne and Wear NHS Foundation Trust should contain a specific provision that during inpatient admissions, patients with no previous community input should be placed on enhanced care …
Read more
The investigation panel considers that the Care Programme Approach (CPA) policy of Northumberland, Tyne and Wear NHS Foundation Trust should contain a specific provision that during inpatient admissions, patients with no previous community input should be placed on enhanced care coordination. (Under the latest Department of Health CPA guidance this would mean placing all these individuals on CPA, without having to make the decision at which level they would be placed on, as the process has been simplified since 2008).
Show less
Recommendation
The panel considers it would be appropriate for a review/audit to take place in relation to the quality of the mental health nursing care planning process. This should include: the dating and signing of the care plan by both …
Read more
The panel considers it would be appropriate for a review/audit to take place in relation to the quality of the mental health nursing care planning process. This should include:
the dating and signing of the care plan by both the nurses and patient;
a change in the care planning documentation, to include a section for
making day to day progress recordings in relation to nursing interventions
and a separate section to record the evaluations of the effectiveness of
the care plan interventions;
consideration of whether or not the MDT care plan adds value to the
nursing care planning communication process.
Show less
Recommendation
There was a considerable amount of information held in the nursing communication sheets relating to identified care plans rather than in the care plans themselves. The panel considers that this detracted from the effectiveness of the nursing care planning process. …
Read more
There was a considerable amount of information held in the nursing
communication sheets relating to identified care plans rather than in the care
plans themselves. The panel considers that this detracted from the
effectiveness of the nursing care planning process. It is therefore
recommended that consideration be given to a review of the use of this
documentation to ensure that information is recorded in the most appropriate
place.
Show less
Recommendation
The clarity and legibility of all clinical records are essential qualities to enable
appropriate and effective treatment to be delivered. The investigation panel
recommends that standards of record keeping are subject to regular review.
Recommendation
The panel recommends that where a vulnerable adult is identified within the risk assessment process as being cared for by a patient (upon discharge in May 2008, patient E resided with victim E), a carer’s assessment must be offered as …
Read more
The panel recommends that where a vulnerable adult is identified within the
risk assessment process as being cared for by a patient (upon discharge in
May 2008, patient E resided with victim E), a carer’s assessment must be
offered as part of the patient’s management plan. If the assessment cannot be
carried out the reasons for this must be clearly stated within the risk
assessment and MDT notes and consideration should be given to registering
an alert under the safeguarding procedures.
Show less
Recommendation
The panel recommends that whenever a social or health care service has any concerns in relation to a service user, insofar as the potential risks that that individual may pose to a vulnerable adult or child, this information should be …
Read more
The panel recommends that whenever a social or health care service has any
concerns in relation to a service user, insofar as the potential risks that that
individual may pose to a vulnerable adult or child, this information should be
passed onto all the services involved, including the GP’s involved with the
patient and the vulnerable person.
Show less
Recommendation
When meetings are held at hospital to consider the discharge arrangements for a patient, it is important that all the agencies who are likely to be involved in the discharge arrangements are invited to attend and do attend insofar as …
Read more
When meetings are held at hospital to consider the discharge arrangements
for a patient, it is important that all the agencies who are likely to be involved in
the discharge arrangements are invited to attend and do attend insofar as this
is practicable.
Show less
Recommendation
When a patient is discharged from hospital following an inpatient admission, on the day of discharge there should be a preliminary discharge letter sent to the patient’s GP outlining the discharge medication and follow up arrangements. A full account should …
Read more
When a patient is discharged from hospital following an inpatient admission,
on the day of discharge there should be a preliminary discharge letter sent to
the patient’s GP outlining the discharge medication and follow up
arrangements. A full account should be sent to the patient’s GP by the
discharging medical team within seven days of discharge describing the
patient’s progress during the admission, the medication the patient has been
prescribed, the follow up treatment which has been arranged and any risks
that have been identified.
Show less
Recommendation
Where there are concerns in relation to a vulnerable adult living at the patient’s home, it would invariably be appropriate for there to have been some professional oversight of home leave in order to inform the decision making process prior …
Read more
Where there are concerns in relation to a vulnerable adult living at the patient’s
home, it would invariably be appropriate for there to have been some
professional oversight of home leave in order to inform the decision making
process prior to discharging a patient. This should not be confined to self-
reporting from the patient but should include full inquiries being made of family
members whose views should be given such weight as is considered to be
appropriate. When undertaking any such assessment the duty of care owed
by health professionals extends beyond the patient so as to include
consideration of the risk to others.
Show less
Recommendation
The investigation panel recommends that mandatory training in relation to safeguarding vulnerable adults should be offered to practitioners across all agencies, including GPs, to foster a collaborative approach (involving collective responsibility) when issues arise which relate to safeguarding vulnerable adults. …
Read more
The investigation panel recommends that mandatory training in relation to
safeguarding vulnerable adults should be offered to practitioners across all
agencies, including GPs, to foster a collaborative approach (involving
collective responsibility) when issues arise which relate to safeguarding
vulnerable adults. There should be a robust audit of the efficacy of the delivery
of this training.
Show less
Recommendation
All agencies should be mindful of their individual responsibility to initiate
safeguarding procedures in relation to vulnerable adults where appropriate.
There should be no assumptions made that other agencies will necessarily
have done so.
Recommendation
In light of the above recommendation, the investigation panel further recommends that inpatient services should identify a CPA coordinator within three working days of a patient’s admission. This should be written into the acute inpatient services operational policies. It should …
Read more
In light of the above recommendation, the investigation panel further recommends that inpatient services should identify a CPA coordinator within three working days of a patient’s admission. This should be written into the acute inpatient services operational policies. It should firmly place the responsibility on the inpatient team to identify a CPA coordinator. Furthermore, it is recommended that the CPA coordinator should be present at the discharge meeting to agree and arrange an aftercare package of care.
Show less
Recommendation
When a MDT identifies that a patient is implicated in concerns relating to a
vulnerable adult this issue should become a standard item for review within the
MDT meetings.
Recommendation
When a patient is considered to present a risk to a vulnerable adult, unless it is considered inappropriate to do so, consideration should always be given to involving that patient directly in any safeguarding procedures which relate to the vulnerable …
Read more
When a patient is considered to present a risk to a vulnerable adult, unless it is
considered inappropriate to do so, consideration should always be given to
involving that patient directly in any safeguarding procedures which relate to
the vulnerable adult.
Show less
Recommendation
Before discharging a patient to a home environment in which a vulnerable adult is believed to reside, consideration should be given to exploring issues of the mental capacity of the individuals involved and whether they are capable of self-determination in …
Read more
Before discharging a patient to a home environment in which a vulnerable
adult is believed to reside, consideration should be given to exploring issues of
the mental capacity of the individuals involved and whether they are capable of
self-determination in relation to the decision to live together.
Show less
Recommendation
The effective functioning of the safeguarding vulnerable adults procedure relies upon accurate recording of information shared at safeguarding meetings and effective distribution of minutes to all of the professionals involved in the multiagency process. To enable the protection procedures to …
Read more
The effective functioning of the safeguarding vulnerable adults procedure
relies upon accurate recording of information shared at safeguarding meetings
and effective distribution of minutes to all of the professionals involved in the
multiagency process. To enable the protection procedures to function
appropriately, safeguarding duties should be a priority for the individual
practitioners concerned, including attendance at meetings.
Show less
Recommendation
Where risks have been identified and safeguarding procedures have been initiated, cases should not be closed by social services or other agencies until there has been a satisfactory resolution of the concerns. In any event all decisions should be clearly …
Read more
Where risks have been identified and safeguarding procedures have been
initiated, cases should not be closed by social services or other agencies until
there has been a satisfactory resolution of the concerns. In any event all
decisions should be clearly recorded and shared with all agencies involved.
Show less
Recommendation
Safeguarding adults boards are encouraged to utilise the Association of Directors of Adult Social Services (ADASS) guidance note, ‘Carers and Safeguarding Adults – Working Together to Improve Outcomes’ (2011) to review local practice and learn from the findings of this …
Read more
Safeguarding adults boards are encouraged to utilise the Association of
Directors of Adult Social Services (ADASS) guidance note, ‘Carers and
Safeguarding Adults – Working Together to Improve Outcomes’ (2011) to
review local practice and learn from the findings of this investigation.
Show less
Recommendation
When a patient, who has been subject to detention under Mental Health Act 1983, becomes an informal patient (either by being discharged from the detention or as a result of the expiry of the section) there should be a clear …
Read more
When a patient, who has been subject to detention under Mental Health Act
1983, becomes an informal patient (either by being discharged from the
detention or as a result of the expiry of the section) there should be a clear
record made in the patient’s clinical notes as to the reasons for the change in
status.
Show less
Recommendation
All clinical notes, including psychology, should be integrated within the
patient’s records and be readily accessible to all professionals involved in the
individual’s care.
Recommendation
GPs surgeries should consider the viability of instituting a ‘usual doctor’ system
whereby a patient is assigned to a particular GP within the practice to assist in
the continuity of care and communication with external agencies.
Recommendation
The investigation panel was informed as to an eight day delay in the processing of important information sent by fax to GP 6 by patient E’s Counsellor 1 in January 2008. GPs practices should review internal communication systems to ensure …
Read more
The investigation panel was informed as to an eight day delay in the
processing of important information sent by fax to GP 6 by patient E’s
Counsellor 1 in January 2008. GPs practices should review internal
communication systems to ensure that information is received by the patient’s
GP promptly.
Show less
Recommendation
The investigation panel recommends that community mental health teams respond urgently to requests from inpatient services for the allocation of a CPA coordinator and that within five working days from the time of referral the allocated CPA coordinator makes contact …
Read more
The investigation panel recommends that community mental health teams respond urgently to requests from inpatient services for the allocation of a CPA coordinator and that within five working days from the time of referral the allocated CPA coordinator makes contact with the patient. This minimum standard will require adding to the Community Mental Health Team’s (CMHT) current operational policies.
Show less
Recommendation
The criteria for acceptance into the Community Mental Health Teams and the allocation of a CPA coordinator, should operate on the basis of a patient’s needs and not be simply led by the diagnosis. An inclusion criteria runs the risk …
Read more
The criteria for acceptance into the Community Mental Health Teams and the allocation of a CPA coordinator, should operate on the basis of a patient’s needs and not be simply led by the diagnosis. An inclusion criteria runs the risk of excluding patients who may well benefit from a service. In this case, the rigidity of working solely with diagnostic led criteria (as opposed to addressing patient E’s complex needs) resulted in the exclusion of patient E from follow up mental health care in the community. The investigation panel recommends that the operational polices of community mental health teams are adapted to remove such restrictions and to institute a more holistic approach to the criteria for admission to these services.
Show less
Recommendation
Specifically, a diagnosis that a patient is suffering from a personality disorder and/or alcohol related difficulties should not result in any exclusion of the patient from community services following their discharge from hospital.
Recommendation
The Sainsbury risk assessment tool used at the material time was considered by the investigation panel to be weak in relation to the protection of vulnerable adults. There should be provision within the risk assessment process to prompt and record …
Read more
The Sainsbury risk assessment tool used at the material time was considered by the investigation panel to be weak in relation to the protection of vulnerable adults. There should be provision within the risk assessment process to prompt and record issues relating to the safeguarding of vulnerable adults and children.
Show less
Recommendation
The investigation panel recommends that the risk assessment tool which is adopted is a dynamic tool with the capacity to record ongoing incidents of risk and warnings so as to enable a more cohesive and comprehensive risk management plan to …
Read more
The investigation panel recommends that the risk assessment tool which is adopted is a dynamic tool with the capacity to record ongoing incidents of risk and warnings so as to enable a more cohesive and comprehensive risk management plan to be developed, monitored and reviewed throughout a patient’s admission. Reliance upon mechanistic tick box risk assessments should be avoided.
Show less
Recommendation
The investigation panel has established that the expressions of concern, alerts and relevant risk incidents were not recorded consistently within the risk profile documentation. Instead, the panel found that although records were made of these warnings, they were distributed throughout …
Read more
The investigation panel has established that the expressions of concern, alerts and relevant risk incidents were not recorded consistently within the risk profile documentation. Instead, the panel found that although records were made of these warnings, they were distributed throughout the nursing records and as such it would be very difficult for staff to assess the developing overall picture in relation to risk and this therefore hindered the effective review of ongoing risks. The investigation panel recommends that third party information relating to risk should be kept as a composite record which is updated and is immediately available to all health professionals who have access to the records. This record should routinely be considered at Multi Disciplinary Team (MDT) meetings.
Show less
Recommendation
Written notes from the weekly consultant ward review did not show recorded evidence of discussion on risk assessment and risk management. The panel recommends that a minimum standard is set for medical staff that at every MDT meeting (or at …
Read more
Written notes from the weekly consultant ward review did not show recorded evidence of discussion on risk assessment and risk management. The panel recommends that a minimum standard is set for medical staff that at every MDT meeting (or at least weekly) a joint risk review is conducted by members of the MDT and recorded within the medical notes. The panel further recommends that Northumberland, Tyne and Wear NHS Foundation Trust undertakes clinical audits of MDT records to assess the quality of risk assessment and management plans that are being considered and recorded therein.
Show less