Independent review into the care and treatment of Mr X

The Draft Report was reviewed by the Safeguarding Adult Review (SAR) Group who felt given the on-going activity that the recommendation was being addressed without a time limited group. However, this would be kept under review and future SAR authors / panels would be sited on this Review. Current Position Full Review of Safeguarding Model in the Local Authority a) In 2017 The LA undertook an extensive independent practice audit – whereby a team of expert independent safeguarding practitioners audited a large number of case files/ interviewed practitioners in the LA and across the partnership. As part of this work there was a focus on multi-agency communication. It is to be noted that Croydon has an integrated model of social care in Mental Health with South London and Maudsley NHS Foundation Trust (SLAM). As part of this work cases from Mental Health were included. Outcomes of enquiries audited – with a focus on Making Safeguarding Personal. b) New ‘hybrid system in place’ – The Local Authority has in place a team of experienced social workers which lead on S42 Enquires. c) There is in place a live tracking system of safeguarding concerns. This acts to prevent drift in cases and reports from the Police (Merlins). This supported • by a weekly report • daily meeting between S42 and intake / front door team • safeguarding consultation – supports practitioners across partnership • weekly reports escalated to heads of service • There is a clear process for sharing Merlins with Mental Health contacts. Since 2017 As part of the changes to safeguarding – there have been significant changes to the way in which the Intake / Front door team operate (Croydon Adults Support). There is closer links with the Police: tracking processes for Merlins (see above). A key initiative which impacts on this review is that within the service there is a specialist Mental Health worker – who also supports the screening of Merlins Provider Concerns reported to CSAB Croydon Council. d) Quality Assurance across LA & CSAB • On-going audits of safeguarding work • Dashboard of indicators around safeguarding performance • Commissioning monitoring - framework – Commissioning and safeguarding partnership – focuses on a preventative approach to provider challenges – • Intelligence Sharing sub group (CSAB) This is key to preventative work. It involves all key Agencies including LA/NHS/CQC/Met Police / SLAM) and identifies through shared intelligence which Providers (including hospitals to focus on). An outline plan is agreed which is implemented outside the sub group and is reviewed by the sub group going forward. It maps our providers where there are issues across Croydon • Multi Agency Audits led by the CSAB e) Monthly Safeguarding Governance meeting between Adult Social Care & SLAM/Mental Health – this looks at issues of communication / S117 / safeguarding activity / outcomes of SARs action plan f) Safeguarding Adults Review (SARS) Completed • Two recent SARs have focused on the interrelationship between the SLAM / MH services and the safeguarding system / issues of communication being developed. • The Madelaine case focussed on a young woman with a range of life challenges who was placed in Croydon by the LB of Wandsworth. • Learning event CH focussed on many of the issues identified by Mr X Review – and evidenced improvements – particularly in the communication between SLAM/ ASC / Police CSAB SAR Sub Group met to discuss Mr X report, this Sub Group is chaired by Heath and vice chair from SLaM which includes the CSAB lay member. Group was of the view that the nature of the recommendations had been addressed by previous initiatives many of them noted in this document. The Group felt another SAR involving Wandsworth was to be started and that this SAR should ensure that the issues identified in MR X – in respect to CSAB were addressed in this SAR Issues to be addressed in SARs going forward g) Learning and Development CSAB - Programme of Multi- Agency SAR ‘bite size training’ focusing on a range of issues which includes communication between Agencies Programme of Multi- Agency training in place, Safeguarding has helped to improve links between professionals Range of other courses – Domestic Violence / Self Neglect / Safeguarding Law / Professional Curiosity Mental Capacity Training across CSAB member agencies Next Steps Croydon Council / SLAM / CSAB - In discussion with the Corporate Director (DASS - Director of Adult Social Care) and Head of MH/ Director of Operations the following next steps have been agreed a) On publication the Report to be reviewed by ASC SMT and the Directorate Management Team. b) Discussions with SLAM and Commissioners at senior level as to whether the recommendations need further action on. c) Discussions with CCG at Senior Level to ensure actions are in place across the partnership. d) Discussions at SAR Group – see above e) S75 Agreement being reviewed – ensure the learning from Mr X case is embedded in the discussions going forward

1. An agreed protocol for interagency working within the legal framework for conditionally discharged forensic patients. To aid protocol development SWLSTG will lead in production of a Process Flow document which will seek to ensure that protocol provides clarity on: a. expectations for responsible clinician, social supervisor, and care coordination for such patients. b. arrangements for risk management and information sharing. c. arrangements to mitigate any barriers to joint working d. arrangements for effective liaison and joint working with primary care and registered GP. Protocol – June 2022 1. A protocol document produced. 2. An agreed plan for implementation and review of the protocol, including appropriate governance arrangements for ongoing oversight. Implementation Plan – July 2022 2. Agreed - Implementation Plan agreed across stakeholders. - Action plan considered as part of ongoing functional review of the CCG/ICS - Agreed leads (by job role) confirmed from each organisation (CCG/ICS and SWLSTG) Monitoring and evaluation to be led by the ICS Quality function. (Due diligence is being undertaken to ascertain ICS arrangements for monitoring of action plans for serious incidents and final arrangements will be confirmed on the conclusion of this CCG/ICS transition work). 3. Engage with South London Partnership (SLP) to ensure that protocol is appropriately embedded in complex care placement commissioning arrangements. Director of Mental Health Transformation 3. Agreement in place on future use of the SW London Strategic Operational Interface Meeting for information sharing and risk management. Actions undertaken and delivered prior to agreement of this Action Plan • Wandsworth CCG, and from the end of 2018 Kingston and Richmond CCG, have monitored actions undertaken by SWLSTG and Southleigh Hospital since the incident occurred, and those from the internal and external investigation recommendations, via the Serious Incident Review Group. • The SWL CCG Serious Incident Review Group is held monthly with the purpose of reviewing incidents, monitoring actions, recognising and drawing out themes and supporting learning to enable safer patient care. The group and its records are a repository of learning and shared knowledge. The group is made up of specialist clinical and safety staff from the trust, the CCG and where appropriate outside organisations or patient representatives. There are records held of regular review of the progress against actions for this case and evidence is held supporting completion. • Through the SLP Forensic Provider Collaborative, the SLP assumed responsibility from NHSE for commissioning Medium and Low Secure inpatient units, and some community forensic teams, in October 2020. The SLP took responsibility for the oversight of StEIS in October 2021. • The SLP Complex Care Programme took on responsibility for 100% Health Funded placements from November 2020 which includes some people stepping down from forensic services. However South West London CCG retains it commissioning responsibility for investigating Serious Incidents in these placements. The role of SLP is to work with Providers to ensure the service user is safe and the correct contractual process for reporting the SI is followed, learning is shared, and mitigation plans are in place to prevent similar incidences. • The SLP ensures that all patients placed in private inpatient units such as Southleigh are reviewed a minimum of twice per year (every six months) by an allocated Clinical Assessor from the SLP Clinical Assessment Team (Complex Care) and this can be increased wherever there is an identified need to warrant this. Additional reviews would be undertaken should concerns be raised by the provider to us as commissioners of the placement. • Reviews include input from the patient, Provider, family/carers and Care Coordinator (this would be from CMHT’s or Forensic Outreach Service) and social care colleagues when relevant. Any issues with engagement from community teams would be escalated to the Trust lead to take up with senior management to ensure the community team are engaged. • The Strategic Operational Interface Meeting (SOIM) has been developed with key strategic representative from SWL LAs, SWLSTG and SWL CCGs. A key output from the group is the sign off of a SWL Memorandum of Understanding between all the LA’s and SWLSTG which includes the interfaces for care coordinator and social work.