Recommendation
Where a risk assessment tool is to be used, there should be clear guidance as to when a more detailed risk assessment is triggered. This should include when and how such information is shared between various agencies.
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1. Risk Assessment
This recommendation is for the Local Authority and Youth Offending
When a risk assessment tool is to
Team
be used, there should be clear
guidance as to when a more
detailed risk assessment is
triggered. This should include when
and how such information is shared
between various agencies.
Recommendation
There are now more rigorous data sharing arrangements in force than were evident at the time of the incident. This is not to imply that previous arrangements had any direct or indirect causal link to the death of patient I. …
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There are now more rigorous data sharing arrangements in force than were evident at the time of the incident. This is not to imply that previous arrangements had any direct or indirect causal link to the death of patient I. It would be of great assistance if all agencies involved with a young person such as patient I had access to all relevant records via an electronic system. This would present a more rounded picture of the particular individual to the professional involved. Further this would allow a more thorough risk assessment which, in turn, would make the identification of any appropriate services more straightforward. Effective interagency working is fundamental to the delivery of good mental health care and mental health promotion and could be supported by more effective data sharing.
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2. Data Sharing Policy and Procedure
NTW invested significant resources in the initial work relating to becoming a
It would be of great assistance if all
pilot site for ‘Contact Point’: a shared multi agency data system prior to its
agencies involved with a young
National implementation. Unfortunately due to a change in government
person such as patient I had access
policy this initiative was cancelled at National level.
to all relevant records via an
electronic system. This would
All Trust services, including Children and Young Peoples’ Services (CYPS), Completed
present a more rounded picture of
use an electronic health record system called RiO to input and store
Patient I Independent Investigation Action Plan – Published - Version 4 – 14 January 2014 1
the particular individual to the information about patients. The Trust and its Local Authority partners
professional involved. Further this recognise the value of sharing records via electronic systems and have
would allow a more thorough risk undertaken work to facilitate this.
assessment which, in turn, would
make the identification of any The current position is that in Northumberland and Newcastle there is an
appropriate services more overnight exchange of key clinical information between the Trust’s
straightforward. Effective electronic health record system and two Local Authority systems. In other
interagency working is fundamental localities there are reciprocal arrangements in place to have ‘read only’
to the delivery of good mental health access to electronic records. These processes support effective verbal and
care and mental health promotion written communication between professionals but are not seen as a
and could be supported by more substitute.
effective data sharing.
Difficulty sharing information led to the government commissioning a
second review of information governance by Dame Fiona Caldicott . The
review reinforced the six original Caldicott principles and made one addition
which should help with sharing information in future.
Information Sharing
The added principle is:
“The duty to share information can be as important as the duty to protect
patient confidentiality”. The Review highlights that for health professionals to
act in a patient’s best interest, they need to have all the available
information about the patient to do so. However, it is acknowledged that
current information governance provisions (or at least the interpretation of
them) have led to information not being shared when it should be.
Accordingly, Recommendation 2 of the Review specifically states that:
“for the purposes of direct care, relevant personal confidential data should
be shared among the registered and regulated health and social care
professionals who have a legitimate relationship with the individual.”
The advent of the Common Assessment Framework has provided a
Patient I Independent Investigation Action Plan – Published - Version 4 – 14 January 2014 2
framework to support multiagency working utilising the Team Around the
Child/family approach. This supports robust multiagency working and the
sharing of information. NTW CYPS staff participate fully in this process.
Recommendation
Where treatment is being offered to a child such as was offered to patient I, such treatment should be evidence based and should comply with the appropriate NICE guidelines. In addition there should be a clear written care plan in …
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Where treatment is being offered to a child such as was offered to patient I, such treatment should be evidence based and should comply with the appropriate NICE guidelines. In addition there should be a clear written care plan in relation to that treatment.
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3. Health Care Treatment of
Patient I as a Child The Trust, as does the Panel, recognise that requirement at both a National
and local level have developed since Patient I was offered treatment as a
Where treatment is being offered to
child.
a child such as was offered to
patient I, such treatment should be
The young person was seen and assessed in Child and Adolescent Mental
evidenced based and should comply
Health Services (CAMHS) and given a diagnosis of ADHD. He was
with the appropriate NICE
prescribed medication in accordance with prescribing procedures and NICE
guidelines. In addition there should
guidance and the ongoing care and treatment was monitored by a
be a clear written care plan in
community paediatrician as was common practice at the time. This young
relation to that treatment.
person was also offered other forms of interventions to address behavioural
issues such as support from a nursery nurse.
As mentioned under recommendation 2 above, The advent of the Common Completed
Assessment Framework has provided a framework to support multiagency
working utilising the Team Around the Child/family approach. This supports
robust multiagency working and the sharing of information and would be
reflected in an associated care plan.
Since its formation in 2006, the Trust has had clear policy statements
regarding all young people having a care plan which should be cognisant of
and build on any Team Around The Child care plan in place. The current
policy NTW(C)48 is compliant with Department of Health guidance.
Refocusing CPA (2008) sets out that for young people who do not have
complex needs such that they meet the criteria for CPA, the care plan can
be recorded as a clinical letter, meeting the following standards:
o Should be written using language / terms that the young person /
parents / carers (if appropriate) are able to understand as much as it is
practicable.
Patient I Independent Investigation Action Plan – Published - Version 4 – 14 January 2014 3
o The care plan should clearly contain:
o The date of contact / clinic / visit;
o The current plan of intervention / care / treatment agreed with the
young person / and their parent/carer (if appropriate) and who is
providing this, the goals of the intervention including those
determined by the young person;
o Indicate the circumstances in which the young person may need
extra help and the associated crisis arrangements;
o The outcome of the assessment of risk.
Recommendation
It is clear that school attempts were made to involve all relevant agencies in discussions on a regular basis about the various presenting problems which patient I exhibited. A system which involves health, YOT, education, police, social care is clearly …
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It is clear that school attempts were made to involve all relevant agencies in discussions on a regular basis about the various presenting problems which patient I exhibited. A system which involves health, YOT, education, police, social care is clearly of benefit. A more rigorous and regularised protocol for carrying this into effect needs to be agreed and appropriately resourced. It is clear that such a system has particular application in larger schools whose catchment area includes pupils with higher than average levels of YOT involvement and social problems.
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5. Core Group/Team Around the Policy and Procedure
Child At the time that this young man was in high school, the school was a leader
in the city in developing a multiagency forum for partners to meet to discuss
It is clear that school attempts were children and young people of concern in order to plan a coordinated
made to involve all relevant approach to their management and support.
agencies in discussions on a regular
basis about the various presenting In recent years this has been replaced by the Team Around the Child Completed
problems which patient I exhibited. Approach as part of the Common Assessment Framework, as outlined
A system which involves health, above in recommendation 2 and 3.
YOT, education, police, social care
is clearly of benefit. A more rigorous
and regularised protocol for carrying
this into effect needs to be agreed
and appropriately resourced. It is
clear that such a system has
particular application in larger
schools whose catchment area
includes pupils with higher than
average levels of YOT involvement
and social problems.