Independent investigation into the care and treatment of Patient L: October 2014

To maximise the impact of the Trust’s focus on record-keeping standards, the Independent Team recommends that a more traditional peer review audit approach is instituted. Such an approach aims to deliver consistently high quality record keeping and regular opportunity for reflective practice. A Peer Review model includes:  Staff in and across CMHTs meeting together and auditing a ‘fixed’ number of each other’s records and providing real-time feedback.  Collecting qualitative data as part of the process so that it contributes to the global information-gathering process.  Training for staff identified as facilitators for the ‘peer review’ in how to conduct a peer review. Band 6 staff and/or Senior Practitioners might be considered for this.  Facilitation of the process at least until it is established and working well. Note: Once a peer review process is embedded, it may not be necessary to maintain skilled facilitation of this as staff will become accustomed to doing it, and a simple guidance/rules of engagement framework may be sufficient. In addition to the above: Given the central importance of access to accurate and complete information in order to deliver safe and effective care, the Independent Team remains unclear as to how the Trust’s adult community and inpatient services utilises the results of its record-keeping audit activity to:  Benchmark documentation standards across its service.  Inform learning, development and supervision requirements. The Independent Team therefore recommends to each management team for these services that it ensures there is transparency with regards to this component of its commitment to enhancing quality, and assuring consistency of practice standards.

The Community Services Directorate must agree core components of the assessment process, including risk assessment that must be conducted for all unscheduled care contacts regardless of an individual practitioner’s perspective about a patient. This will deliver a consistent approach to the assessment of these service users and enhance the defendability of decisions made. The Independent Team understands that the CMHT sub-team (Access/Recovery Home Treatment) has been developing individual operational polices that are currently in draft format and close to being agreed and finalised. It is unclear whether these provide clear guidance regarding baseline expectations of the quality and content of unscheduled care contacts. Therefore to achieve the stated objective of this recommendation the Directorate is recommended to ensure that it sets out clear measurable standards that make explicit the minimum requirements of what constitutes an acceptable depth of assessment for all unscheduled care contacts. In the case of Mr L, clearer clinical direction at the time would have supported a more appropriate depth of probing into his paranoias than that which occurred. In addition to the above: The revised operational policies need to make clear:  Where all unscheduled care contacts are to be documented, e.g. in the progress notes, in the ‘review section of Insight’, etc.  How all unscheduled care contacts are to be documented, e.g. using SBAR (situation, background, assessment and recommendation). http://www.institute.nhs.uk/quality_and_service_improvement_tools/qu ality_and_service_improvement_tools/sbar_-_situation_- _background_-_assessment_-_recommendation.html

The Trust must ensure that all of its lead investigating officers for serious incidents, complaints and professional performance reviews know how to apply the National Patient Safety Agency’s Incident Decision Tree. The purpose of this is to achieve transparency and consistency across the organisation about how recommendations stating that an individual professional performance review is necessary are made. Note: The NPSA’s interactive Incident Decision Tree is currently unavailable. However the Independent Team believes that this will become available again online as an interactive tool in 2015 via: http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/human-factors- patient-safety-culture/?entryid45=59900 A useful online article about using the incident decision tree can be found at: http://www.ncbi.nlm.nih.gov/books/NBK20586/

The Trust must ensure that all of its Senior Practitioners have in place up to date job descriptions which make clear the remit of the position and the essential features against which the success of the post holder will be measured. If this is achieved there should be clarity amongst this group of professionals regarding common goals and values regardless of the team they are working with and those goals that are specific to the team they are working with. The Trust has invested in the development of its senior practitioner role that was clearly apparent to the Independent Team when it visited four CMHT bases in July 2014. However, it did not leave with the confidence that there were up-to-date job descriptions in place for all of these professionals which set out:  The commonly expected role and responsibility of the senior practitioner, regardless of which part of the acute care pathway he/she was working in.  Those aspects of job role and responsibility that were unique to the specific part of the pathway to which the post is attached. Consequently, the management team for adult service community and in- patient is recommended to review the current position with regards to the job descriptions of these post-holders and to ensure:  That the core deliverables, regardless of the team a senior practitioner is assigned to, are clear and transparent.  That the job descriptions and performance framework for all senior practitioners at present in post actually reflect the requirements of the job they are currently delivering.

The Trust needs to be consistently confident that its serious incident reports demonstrate:  Where practice met and/or exceeded expected practice standards  Where practice seriously fell below expected practice standards  A systems analysis of each serious practice lapse identified so that it properly understood  That the findings, conclusions and recommendations set out in an investigation report are evidence based The achievement of the above should deliver:  Reports that stand up to scrutiny  Reports that demonstrate the Trust’s compliance with the principles of ‘Being Open’  Recommendations that lead to systems focused, S.M.A.R.T action plans with outcomes that can be measured. To ensure it is in a position to do this, the Trust is encouraged to explore how it can develop a ‘top team’ of investigators who have the following competencies:  Competent construct of an analytical timeline and/or safety control process map.  Effective investigative interview skills.  Knowledge about a range of other effective information- gathering techniques such as observational studies, surveys, etc.  Know-how to conduct an auditable and repeatable information analysis of all data (evidence) gathered.  A good understanding of human factors/systems analysis and understands how to apply this to the analysis of any serious lapses identified in the care and treatment of the patient.  Understands what constitutes a robust recommendation.  Understands the ‘fail-safe’ attributes of the recommendations made.  Effective report-writing skills (plain English as a minimum). Note: The Trust has already agreed with the Independent Team that it will organise for training to be delivered to staff most likely to be conducting moderate to high impact incidents within six months of the independent report being published.

The Trust needs to achieve a situation where each directorate management team has a common approach and standard when it comes to following-up on professional performance recommendations arising from a serious incident investigation. This recommendation is related to recommendation three and recommendation five. In the case of Mr L, the execution of the in-house recommendations made was left to the local team managers, one of whom was also involved in the case. Consequently, the depth of professional performance review conducted, and the degree of reflective practice achieved by the individuals involved and the wider team, was insufficient. Appropriate questions were neither asked nor answered. To minimise the risk of this occurring again, and to enable the Trust to deliver the intent of this recommendation it is suggested that: Across all directorates:  A Team Manager unconnected with the team involved in the incident, or Associate Director, should be appointed to facilitate the ‘deep dive’ into an individual’s reflection on his/her practice.  Clinical supervision following a lapse in professional practice standards is never provided by a colleague who was also involved in the same incident scenario. Corporately: There is a clear and auditable process for logging and monitoring recommendations made as a consequence of board-level serious-incident reports, so that the Trust can provide an account, when asked:  For all recommendations with regards to implementation and/or non-implementation.  Of the impact of recommendations implemented in terms of improvements in practice, safety and quality, i) within the local team, ii) across an entire directorate, and iii) across a range of directorates where the recommendation is relevant to more than one service. Note: The Independent Team is aware that the Adult Service Directorate – Community has already undertaken measures to ensure that appropriately senior staff unassociated with the team involved in a serious incident are appointed to conduct any ‘deep dive’ required into the practice of individuals or teams.

The process of risk assessment must enable the classification of riskiness of service users across a range of indicators using an approach that supports the maintenance of team focus on clients who do not meet classical high-risk criteria A traffic light system is one approach to achieving the above. However, it is not universally applied in all mental health services. However, because of the benefit it can bring to classifying the riskiness of service users across a range of indicators, and its effectiveness in maintaining team focus on clients who do not meet classical high-risk criteria, it and other similar type processes (where these exist) need to be re-evaluated by the Trust and a decision made about implementation of a tracking/alert system in its community mental health teams. Note 1: Mr L constituted a service user who did not meet classical definitions of risk. The Independent Team considers that Mr L would have at least been an amber, and possibly a code red, client for the early intervention service had such a system been utilised at the time. This it believes would have enhanced the opportunity for a more thorough assessment of him on 28 March 2014. Note 2: The Assistant Team Leader for the Mr L’s CMHT has already volunteered to undertake research into the experience of traffic light systems in use in other mental health trusts, and to research its possible benefits and challenges for Sheffield Health and Social Care Trust. Note 3: The Director and Assistant Director of the Community Services Directorate are asked to take lead responsibility for this recommendation.

Medical Staff There are two distinctly separate components to this recommendation. Firstly: The Independent Team recommends that the Trust provides the Clinical Commissioning Group with the assurance it needs that trainee doctors are supervised in line with current RCOP guidance. Secondly: The Independent Team recommends that the Trust devise an audit method to capture the frequency with which a request is made for duty psychiatrist in-put, the availability of the duty psychiatrist and his/her ability to respond when advice about and/or an assessment of a service user is requested. The Trust must have a clear understanding of the sufficiency of current duty psychiatric provision, and challenges experienced in the provision of this that may introduce a patient safety risk. In addition to the above, the Independent Team considers that there is merit in the Trust exploring how it can capture information highlighting the occasions where medical advice ought to have been sought but it was not sought, and the reasons for this.