Independent investigation into the care and treatment provided to Mr X by Devon Partnership NHS Trust (2013)

Recommendation 1: Diagnosis and Dual Diagnosis Care Pathway We have improved the way that we work in relation to dual diagnosis and how this is organised and monitored. We have done this through working in partnership across mental health services and DPT-led drug and alcohol services in Torbay and with Rise Recovery in Devon, initially, and since 2018 recently with Devon Together Alliance, the new contract holders. A Dual Diagnosis over- arching steering group meets regularly and there are frequent meetings in all areas of Devon between our community teams and the local drug and alcohol services. These meetings include discussion of clients on the teams’ caseloads and reviews of how services are designed and operated. Locality leads have been introduced to focus on and progress joint working and opportunities for joint training. Protocols and pathways that describe how we will support our clients have been agreed and put into practice. Practice now includes offering patients a joint assessment with both DPT assessment and drug and alcohol service staff present in the one assessment appointment. This was initially piloted in the Exeter area and has since been made available across Devon. Clients with a possible dual diagnosis are identified at the time that they are referred into our services. Services also now have reciprocal arrangements to refer directly to each other for support in joint working. There are some limitations, however, on the number of joint assessments that can take place due to capacity with the provider. Not all service users want or accept a joint assessment, but we will continue to work to increase the number of people for whom this helpful initial assessment takes place. Most people with a dual diagnosis are cared for by our adult services, but occasionally care is led by one of our older adult teams. Joint assessments with drug and alcohol services can again be offered. Our older adult teams also work closely with voluntary agencies in the community who support older people with alcohol or substance abuse problems. We have made changes to our electronic records system ‘Care Notes’ to enable managers to easily identify clients who have a dual diagnosis and ensure that their care is reviewed in staff supervision and action taken if the good practice pathways are not being followed. These changes to Care Notes include identifying when a joint assessment with a drug and alcohol service should take place and whether risk assessments and care plans have been developed and agreed jointly with other services. Different services still use different patient record systems but where it is possible, we have trained staff to access each other’s databases. Our Dual Diagnosis Policy and the associated Mental Health and Substance Misuse Interface Protocol describe policy and practice agreed in Devon and Torbay Dual Diagnosis Strategy. This includes joint working principles and expectations agreed between drug and alcohol services, mental health services, commissioners and those with lived experience. Policy incorporates the local and national context of approaching care and treatment for dual diagnosis and for following NICE guidelines and best available evidence. Policy emphasises our commitment to close working relationships across teams, services and agencies; relationships that are beneficial and necessary to deliver excellent care and treatment. We expect all employees to deliver care and treatment that is commensurate with Policy and follows the associated Protocol; an annual audit, now in its 7th phase, covers the active and measurable points of NICE guidance. Our Policy and Protocol are in the process of planned review with finalisation in early 2022. In addition, related Trust policies (for example how we use care co-ordination and the Care Programme Approach) have been reviewed to include explicit guidance on clients with a dual diagnosis. This progress has been supported and further evidenced by a recent CQC report (published 2nd September 2021): Skilled staff to deliver care: The teams included or had access to the full range of specialists required to meet the needs of patients under their care. Managers made sure that staff had the range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff. The service had, or had access to a range of specialists to meet the needs of each patient and managers made sure staff had the right skills, qualifications and experience to meet the needs of the patients in their care, including bank and agency staff. Managers gave each new member of staff a full induction to the service before they started work, supported staff through regular, constructive appraisals of their work and supported staff through regular, constructive clinical supervision of their work. (Ref: p. 28-29). Multidisciplinary and inter-agency team work: Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The team(s) had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation. Staff held regular multidisciplinary meetings to discuss patients and improve their care. Staff made sure they shared clear information about patients and any changes in their care, including during transfer of care. Staff had effective working relationships with other teams in the organisation and with external teams and organisations. (Ref: p. 29-30). Further developments are underway as part of the community framework for mental health programme of work. The Devon community developments seek to improve person-centred care and support through multi-agency teams coming together around each primary care network population. These teams will routinely work together to ensure individuals’ care and treatment is based on their assessed needs regardless of service boundaries. In these multi-agency teams, drug and alcohol services and core mental health teams will continue to support one another through advice guidance and partnership working alongside other services such as primary care, employment services and voluntary sector. Improved information sharing will be enhanced through shared access to records and the development of personalised plan with the individual and their support in a format that is shared across all agencies involved. (Ref: https://www.england.nhs.uk/wp-content/uploads/2019/09/community-mental-health- framework-for-adults-and-older-adults.pdf) An objective of this work is to improve access and outreach into the community. The formation of mental health multi-agency teams enables quick access to mental health advice and guidance for all agencies and an ability to step up support through routes other than formal referral processes. Working closely with a newly formed voluntary sector alliance, mental health teams will develop outreach strategies particularly within communities who may not routinely seek support such as street homeless, traveller and farming communities. As part of the community developments a rehabilitation and recovery team is being established in each locality to meet the needs of individuals who have a functional impairment due to their severe mental illness, this is frequently complex psychosis. All rehabilitation practitioners will undergo training in substance misuse and receive supervision and support from drug and alcohol services. Rehabilitation practitioners will in turn provide mental health training and supervision to substance misuse workers thus improving the dual diagnosis pathway and identification of severe mental illness in those accessing drug and alcohol support. In 2018, the National Inquiry into Suicide and Safety in Mental Health (NCISH) published the evidence based ‘Ten Key Ways to Improve Safety’ with the recommendation that these became the focus for Mental Health Trusts to improve safety. These elements of safer care are presented as quality and safety statements about clinical and organisational aspects of care and NCISH evidence is cited in national policies and clinical guidance and regulation in all UK countries. (Ref: NCISH | Annual report 2018: England, Northern Ireland, Scotland and Wales - NCISH (manchester.ac.uk). Embedding the Ten Ways to Improve Safety into Trust policy, process and practice is therefore a core approach to safety in those who are under the care of our clinical services. The Ten Ways include a focus on reducing alcohol and drug misuse which also has clear links with the standard on personalised risk management. Our half day Level 2 Clinical Risk Assessment training includes reference to the evidence base related to understanding the risks associated with drug and alcohol misuse, a trauma informed approach and emphasises the importance of a personalised risk assessment approach and associated safety planning. Senior clinicians conduct desk top reviews following serious incidents against the Ten Ways and this includes rapid learning regarding dual diagnosis and also informs more comprehensive patient safety investigation. Action Progress and Implementation Action Progress Status 7. Auditing and monitoring progress The standard of care for those with a dual diagnosis is measured once a year since 2017 via a multi-agency audit and patient survey. • The 2018 audit showed some challenges with arranging joint assessments, which were explored and discussed with the drug and alcohol service providers and local authority commissioners to consider how we may further develop our partnership working. • The most recent audit carried out in December 2019 – January 2020 showed an improvement in many areas of joint working, there continue to be areas for improvement; local teams are working together to agree and implement the recommendations of the audit. • Improvement plans have focused on the multi-agency aspect and have been supported by multi-agency workshops which included presentations from service users, outlines of good practice, presentation of audit results and lessons learned from incidents for teams to develop their expertise and practice. Representatives from all assessment teams and drug and alcohol services attended. Further developments: Developments to implement the Devon Community Framework commenced in Summer 2021. All local implementation teams include drug and alcohol services as a key member of the multi-agency team. Established clinical discussion and integrated working will continue to be built upon through these developments. • Audit was paused in 2020/2021 due to challenges and pressures presented by the covid-19 pandemic. Audit has now been re-established and data collection for the 7th phase of the audit for 2021/2022 is currently taking place.

Recommendation 1: Diagnosis and Dual Diagnosis Care Pathway We have improved the way that we work in relation to dual diagnosis and how this is organised and monitored. We have done this through working in partnership across mental health services and DPT-led drug and alcohol services in Torbay and with Rise Recovery in Devon, initially, and since 2018 recently with Devon Together Alliance, the new contract holders. A Dual Diagnosis over- arching steering group meets regularly and there are frequent meetings in all areas of Devon between our community teams and the local drug and alcohol services. These meetings include discussion of clients on the teams’ caseloads and reviews of how services are designed and operated. Locality leads have been introduced to focus on and progress joint working and opportunities for joint training. Protocols and pathways that describe how we will support our clients have been agreed and put into practice. Practice now includes offering patients a joint assessment with both DPT assessment and drug and alcohol service staff present in the one assessment appointment. This was initially piloted in the Exeter area and has since been made available across Devon. Clients with a possible dual diagnosis are identified at the time that they are referred into our services. Services also now have reciprocal arrangements to refer directly to each other for support in joint working. There are some limitations, however, on the number of joint assessments that can take place due to capacity with the provider. Not all service users want or accept a joint assessment, but we will continue to work to increase the number of people for whom this helpful initial assessment takes place. Most people with a dual diagnosis are cared for by our adult services, but occasionally care is led by one of our older adult teams. Joint assessments with drug and alcohol services can again be offered. Our older adult teams also work closely with voluntary agencies in the community who support older people with alcohol or substance abuse problems. We have made changes to our electronic records system ‘Care Notes’ to enable managers to easily identify clients who have a dual diagnosis and ensure that their care is reviewed in staff supervision and action taken if the good practice pathways are not being followed. These changes to Care Notes include identifying when a joint assessment with a drug and alcohol service should take place and whether risk assessments and care plans have been developed and agreed jointly with other services. Different services still use different patient record systems but where it is possible, we have trained staff to access each other’s databases. Our Dual Diagnosis Policy and the associated Mental Health and Substance Misuse Interface Protocol describe policy and practice agreed in Devon and Torbay Dual Diagnosis Strategy. This includes joint working principles and expectations agreed between drug and alcohol services, mental health services, commissioners and those with lived experience. Policy incorporates the local and national context of approaching care and treatment for dual diagnosis and for following NICE guidelines and best available evidence. Policy emphasises our commitment to close working relationships across teams, services and agencies; relationships that are beneficial and necessary to deliver excellent care and treatment. We expect all employees to deliver care and treatment that is commensurate with Policy and follows the associated Protocol; an annual audit, now in its 7th phase, covers the active and measurable points of NICE guidance. Our Policy and Protocol are in the process of planned review with finalisation in early 2022. In addition, related Trust policies (for example how we use care co-ordination and the Care Programme Approach) have been reviewed to include explicit guidance on clients with a dual diagnosis. This progress has been supported and further evidenced by a recent CQC report (published 2nd September 2021): Skilled staff to deliver care: The teams included or had access to the full range of specialists required to meet the needs of patients under their care. Managers made sure that staff had the range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff. The service had, or had access to a range of specialists to meet the needs of each patient and managers made sure staff had the right skills, qualifications and experience to meet the needs of the patients in their care, including bank and agency staff. Managers gave each new member of staff a full induction to the service before they started work, supported staff through regular, constructive appraisals of their work and supported staff through regular, constructive clinical supervision of their work. (Ref: p. 28-29). Multidisciplinary and inter-agency team work: Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The team(s) had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation. Staff held regular multidisciplinary meetings to discuss patients and improve their care. Staff made sure they shared clear information about patients and any changes in their care, including during transfer of care. Staff had effective working relationships with other teams in the organisation and with external teams and organisations. (Ref: p. 29-30). Further developments are underway as part of the community framework for mental health programme of work. The Devon community developments seek to improve person-centred care and support through multi-agency teams coming together around each primary care network population. These teams will routinely work together to ensure individuals’ care and treatment is based on their assessed needs regardless of service boundaries. In these multi-agency teams, drug and alcohol services and core mental health teams will continue to support one another through advice guidance and partnership working alongside other services such as primary care, employment services and voluntary sector. Improved information sharing will be enhanced through shared access to records and the development of personalised plan with the individual and their support in a format that is shared across all agencies involved. (Ref: https://www.england.nhs.uk/wp-content/uploads/2019/09/community-mental-health- framework-for-adults-and-older-adults.pdf) An objective of this work is to improve access and outreach into the community. The formation of mental health multi-agency teams enables quick access to mental health advice and guidance for all agencies and an ability to step up support through routes other than formal referral processes. Working closely with a newly formed voluntary sector alliance, mental health teams will develop outreach strategies particularly within communities who may not routinely seek support such as street homeless, traveller and farming communities. As part of the community developments a rehabilitation and recovery team is being established in each locality to meet the needs of individuals who have a functional impairment due to their severe mental illness, this is frequently complex psychosis. All rehabilitation practitioners will undergo training in substance misuse and receive supervision and support from drug and alcohol services. Rehabilitation practitioners will in turn provide mental health training and supervision to substance misuse workers thus improving the dual diagnosis pathway and identification of severe mental illness in those accessing drug and alcohol support. In 2018, the National Inquiry into Suicide and Safety in Mental Health (NCISH) published the evidence based ‘Ten Key Ways to Improve Safety’ with the recommendation that these became the focus for Mental Health Trusts to improve safety. These elements of safer care are presented as quality and safety statements about clinical and organisational aspects of care and NCISH evidence is cited in national policies and clinical guidance and regulation in all UK countries. (Ref: NCISH | Annual report 2018: England, Northern Ireland, Scotland and Wales - NCISH (manchester.ac.uk). Embedding the Ten Ways to Improve Safety into Trust policy, process and practice is therefore a core approach to safety in those who are under the care of our clinical services. The Ten Ways include a focus on reducing alcohol and drug misuse which also has clear links with the standard on personalised risk management. Our half day Level 2 Clinical Risk Assessment training includes reference to the evidence base related to understanding the risks associated with drug and alcohol misuse, a trauma informed approach and emphasises the importance of a personalised risk assessment approach and associated safety planning. Senior clinicians conduct desk top reviews following serious incidents against the Ten Ways and this includes rapid learning regarding dual diagnosis and also informs more comprehensive patient safety investigation. Action Progress and Implementation Action Progress Status 7. Auditing and monitoring progress The standard of care for those with a dual diagnosis is measured once a year since 2017 via a multi-agency audit and patient survey. • The 2018 audit showed some challenges with arranging joint assessments, which were explored and discussed with the drug and alcohol service providers and local authority commissioners to consider how we may further develop our partnership working. • The most recent audit carried out in December 2019 – January 2020 showed an improvement in many areas of joint working, there continue to be areas for improvement; local teams are working together to agree and implement the recommendations of the audit. • Improvement plans have focused on the multi-agency aspect and have been supported by multi-agency workshops which included presentations from service users, outlines of good practice, presentation of audit results and lessons learned from incidents for teams to develop their expertise and practice. Representatives from all assessment teams and drug and alcohol services attended. Further developments: Developments to implement the Devon Community Framework commenced in Summer 2021. All local implementation teams include drug and alcohol services as a key member of the multi-agency team. Established clinical discussion and integrated working will continue to be built upon through these developments. • Audit was paused in 2020/2021 due to challenges and pressures presented by the covid-19 pandemic. Audit has now been re-established and data collection for the 7th phase of the audit for 2021/2022 is currently taking place.