Multi-agency systems review to identify the learning following five homicides in Devon (2018-2019); with a focus on mental health care and management in custody

Recommendation

There should be appropraite available L&D cover in each custody suite in agreed daytime hours. The L&D service should be designed and delivered in a way that meets contractual expectations.

View response

Conduct a multi agency review of the commissioning contract to ensure appropriate cover is available to custody suites for contracted hours. The full Terms of Reference (TOR) of the review to be jointly agreed by Devon & Cornwall Police, Devon Partnership Trust (DPT) and NHS England (NHSE) and to consider whether such a review should be pan Devon & Cornwall. The Peninsula Partnership Group will continue to share best practice and explore opportunities for learning lessons across Devon & Cornwall. Update 01/03/2023 – A Health Needs Assessment of Liaison and Diversion Services across the peninsula is currently underway, and is due for completion by the end of May 2023. The Health Needs Assessment will review the current services against the current service specification and identify gaps in the service specifications. A full report will be follow with recommendations to address any gaps and findings. Please note that the review of the service provided by Devon Partnership Trust (DPT) was completed in March 2021 A review was completed by Devon Partnership Trust together with Devon Integrated Care Board (ICB) in March 2021, led by the Service Manager, Liaison & Diversion Services. The Contract from NHSE to DPT to deliver Liaison and Diversion Services states that there should be L&D cover in each of the 4 custody suites between the hours of 8.00 – 18.00, 7 days a week. Whilst on occasion due to sickness or annual leave, cover arrangements may need to be implemented, no concerns about an inability to access Liaison and Diversion Services have been raised in the last 12 months.

Recommendation

All agencies involved are aware of the individual PACE conditions and any changes of a detained person in custody. Police should ensure that when there is a need for multi-agency healthcare input, all agencies involved are aware of the individual … Read more

View response

To be adopted formally through policy and training by all organisations concerned. Devon & Cornwall Police – Devon and Cornwall Police (DCP) have instigated this learning informally through internal messaging in order to address immediate learning. A change has been proposed to the Custody police documents to incorporate this learning and the importance of this is now stressed in the custody training package for Custody Sergeants and Custody Detention Officers. current custody staff have bene informed of the proposed change to force policies. The following wording has been agreed for the four force policies. ‘The custody office will ensure that when there is a need for multiagency healthcare input of a detainee, all agencies involved will be made of the individual PACE conditions and any changes, such as estimated time of release’. The policies in question are D082 – Healthcare Professionals Policy D148 – Detention, Treatment and Arrest Policy DCP-P-019 – Force Mental Health Policy DCP-Opr-017 – Mental Health Operational Procedure

Recommendation

The overall sharing of information with the Police Healthcare Provider will be sufficient to ensure they can provide the best service possible with the maximum amount of information available. Develop a Protocol between Devon and Cornwall Police in relation to … Read more

View response

The protocol will be assessed and the appropriateness of including the Police Healthcare Provider will be considered. Devon & Cornwall Police – Devon and Cornwall Police have a Data Sharing Agreement (DSA) in place with the Police Healthcare Provider which was finalised on 07/12/2022 and signed by all of the five regional forces that the new Healthcare Provider operates within. This governs a wide ranging information sharing agreement and does assist in capturing exactly how the flow of information between the two agencies is undertaken. This is compliant with all relevant Data Protection legislation and ensures that information passed to the Healthcare Provider is necessary, appropriate, proportionate and lawful. The Healthcare Providers have full access to the electronic custody record that relates to each detainee. This custody record holds all of the key information relating to individuals and their detention and allows the Healthcare Providers the correct amount of information to ensure the care of detainees for the duration of their time in custody.

Recommendation

Revised Peninsula Wide Section 136 policy in place and operational. Set a timescale for the agreement and implementation of the Peninsula Wide Section 136 policy. This should include clarity on the process for using Section 136 if the person is … Read more

View response

Devon & Cornwall Police to lead on the agreement and implementation of a Peninsula-Wide Section 136 policy that takes into account local variation and provides clarity to all relevant partners. DPT – Devon has an up-to-date Section 136 Policy (approved March 2022) which has been agreed with Devon & Cornwall Police and is in use. It is monitored through the Devon Mental Health/Police Liaison Committee. A single Peninsula-Wide Section136 Policy has been drafted and the Assistant Chief Constable Devon & Cornwall Police and Chief Executive Devon Partnership Trust are committed to progressing this. Devon & Cornwall Police: Police have worked closely with DPT in Devon, Livewell in Plymouth and Cornwall Partnership NHS Foundation Trust (CFT) to ensure all NHS health based Place of Safety providers have up to date and appropriate Section 136 policies. The Chief Executive of DPT and the Devon and Cornwall Police Assistant Chief Constable are committed to working collaboratively with the necessary partners across the peninsula (Cornwall Integrated Care Board, South West Ambulance Service Trust, Social Care Approved Mental Health Professional services and Acute Trusts) to progress the draft single Peninsula-Wide Section 136 protocol. Timeframe: an aspirational timeframe of completion by December 2023, that being dependent upon agreement and decisions by other partner agencies upon whom these decisions cannot be enforced.

Recommendation

Mental Health/Police Liaison Committee should include clear reporting structures to the respective Executive Boards in Health and to the office of the Chief Constable. Revision of the terms of reference of the Mental Health/Police Liaison Committee.

View response

The Mental Health/Police Liaison Committee to review its Terms of Reference (TOR) and share with Torbay and Devon Safeguarding Adults Partnership (TDSAP) to provide clarity and assurance regarding the governance arrangements. DPT – The Terms of Reference for the Devon Mental Health/Police Liaison Group have been reviewed and approved. The revised terms of reference confirm the governance of the Devon Mental Health/Police Liaison Group which will formally report to the Devon Mental Health Urgent Care Transformation Board – part of the Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative. This reporting mechanism was agreed with the Chair of the Devon Mental Health Urgent Care Transformation Board on 06/02/2023.

Recommendation

There should be structures in place to include the Police Healthcare Provider in local Memoranda of Understanding and information sharing agreements. The Police Healthcare Provider should be included as a partner in custody/health Memoranda of Understanding and information sharing agreements … Read more

View response

Torbay and Devon Safeguarding Adults Partnership (TDSAP) will seek effective assurance that the Police Healthcare Provider is a signatory to relevant MOUs and ISAs to ensure effective delivery of healthcare. Police – Devon and Cornwall Police have a Data Sharing Agreement (DSA) in place with the Police Healthcare Provider which was finalised on 07/12/2022 and signed by all of the five regional forces that the new Police Healthcare Provider operates within. This governs a wide ranging information sharing agreement and does assist in capturing exactly how the flow of information between the two agencies is undertaken.

Recommendation

Local multi-agency risk evaluation processes should be in place for high risk individuals. Development of multi-agency risk evaluation processes for high risk individuals.

View response

Torbay and Devon Safeguarding Adults Partnership (TDSAP) to seek assurance that there are multi agency risk management processes across Devon for high risk individuals. TDSAP are exploring what currently exists across the Devon County Council footprint. It is widely accepted that a degree of localism is required, therefore TDSAP will look to agree a set of principles to support partners to arrange multi agency risk management meetings as and when these are required. TDSAP will seek appropriate assurance as to how partners are using these principles and arranging multi-agency risk management meetings as needed.

Recommendation

There should be cohesive out of hours mental health service support for multi-agency partners. Evaluation of the Street Triage and Joint Response Unit structures.

View response

DPT and Devon & Cornwall Police to continue the planned evaluation programme for Street Triage and Joint Response Unit. To report regarding the outcomes of the evaluation and recommendations to the Systems Urgent Care Board and the Mental Health/Police Liaison Committee. DPT – Individual service level evaluations of Street Triage and the Joint Response Unit were completed in September 2021. A further review occurred with a paper being presented to the DPT Urgent Care board in November 2022. The police funding for Street Triage is being ended on 30th September 2023, with this in mind the review has recommended that the ongoing funding from DPT is used to deliver a police only professionals line by the First Response Service (FRS). The project is underway with recruitment about to start and an expectation this will be mobilized by the summer 2023. The Joint Response Unit (JRU)– is currently funded by DPT until March 23. A review is in progress to form recommendations, which will go to boards in Feb/March for final decision. At present it is understood that there isn’t any recurrent funding identified from either DPT or the police for this initiative. In wider work, our police colleagues are well engaged at system level transformation to deliver against the LTP’s to have a shared urgent care pathway. The MH desk model via SWAST in Bristol is being scoped for potential replication in Devon, aiming for a triumvirate approach between DPT, Police and SWAST. This work is sitting under the MHLDN umbrella at present, reporting into the system Mental Health and Urgent Care Transformation Board

Recommendation

The ICS Crisis and Mental Health Commissioning Group and TDSAP receive an updated system and oversight assurance report from the Urgent & Crisis Mental Health workstream. The report will seek to provide assurance that there is a coordinated responsive mental … Read more

View response

For TDSAP to request effective assurance from NHS Devon ICS that Crisis Care Concordat actions have been incorporated into urgent and crisis mental health workstreams. NHS Devon – The Mental Health Urgent & Crisis workstream monthly highlight report details progress against agreed system priorities aligned to the Long term Plan that are reflective of the Crisis Care Concordat actions. Overview of delivery is held through NHS Devon’s Quality and Performance Committee. The Mental Health Urgent and Crisis Transformation work stream will present to NHS Devon Performance and Quality Committee an overview of work delivered to date, planned next steps and issues for escalation. It will provide clarity as to how the Crisis Care Concordat actions are reflected within the current work of the Urgent & Crisis Mental Health workstream NHS Devon – NHS Devon will present to TDSAP an overview of work delivered to date, planned next steps and issues for escalation. It will provide clarity as to how the Crisis Care Concordat actions are reflected within the current work of the Urgent & Crisis Mental Health workstream

Recommendation

Mental health assessments carried out by L&D should include a narrative description of the mental state examination. L&D assessment forms should be restructured to provide more guidance in the mental health section of the form, ensuring it encompasses mental state … Read more

View response

Complete an effective audit of L&D assessment forms share the findings/actions with the Torbay and Devon Safeguarding Adults Partnership (TDSAP) to include evidence that the mental health forms include mental state examination. DPT – The Liaison & Diversion assessment forms have been restructured and are included within the Multi-Agency Protocol for Mental Health Act (MHA) Assessments in Custody in Police & Criminal Evidence Act (PACE) which was approved in January 2022 – this includes the Liaison & Diversion Assessment form which includes a narrative section

Recommendation

There should be an agreed and implemented multi-agency protocol for Mental Health Act assessments in custody/under PACE. There should be clear processes in place for making requests for MHA assessments in custody, aligning with NHS processes. This should incorporate: • … Read more

View response

A multi-agency protocol for Mental Health Act assessments in custody/under PACE has been developed. The Strategic Peninsula Mental Health Group need to ensure multi agency sign off and effective implementation across the peninsula. DPT – the Multi-Agency Protocol for MHA Assessments in Custody under PACE was approved by the DPT MHA Operations Committee in November 2021 and the MHA Scrutiny Committee in January 2022 and has been implemented. DCC – The Multi-Agency Protocol was approved and implemented for the Emergency Duty Service (EDS), who provide the out of hours Approved Mental Health Professional (AMHP) Service, in November 2022. Devon & Cornwall Police – There is a Multi-Agency Protocol in place, that is widely known. the outgoing healthcare providers are satisfied that their systems and processes are utilised effectively. they also have an effective handover process for information sharing with L&D.

Recommendation

Healthcare professionals providing police custody healthcare should have the skills and knowledge to make effective mental state examinations. The Police Healthcare Provider should ensure mental health knowledge and training is enhanced to include: • how to gather background information, mental … Read more

View response

The Police Healthcare Provider must continue to provide their staff with the professional currency in terms of skills and knowledge to be able to provide effective mental health care. Devon & Cornwall Police – The outgoing healthcare provider has developed a post-induction Mental Health training programme which is part of a bigger suite of post-induction training that has been developed and written by subject matter experts and accredited by the Faculty of Forensic Legal Medicine (FFLM). This roll-out is complete for all Healthcare Professionals (HCP) and Doctors. This covers: Safe Assessment Low Mood Anxiety Disorders Mania Psychosis, Suicide & Self harm Disorders, Diagnosis & the MSE assessment A suicide and self-harm risk assessment tool has been developed and is now in use across all custody centres that the outgoing healthcare provider has responsibility for. The incoming healthcare provider’s current staff are all trained in specialist mental health training to the required standard by an external provider as well as internal training. All staff are trained to carry out a competent mental health assessment and identify those that need referral to mental health professionals for full assessment and representing as a risk.

Recommendation

HCP assessments should include clarity on the threshold for fitness to detain regarding mental health, and what mental health presentation changes would indicate that a new medical assessment was required and could be requested. Police Healthcare Provider should provide clarity … Read more

View response

The Police Healthcare Provider to ensure their staff continue to have professional currency to undertake robust fitness to detain assessments and are communicating these effectively to police custody staff. Devon & Cornwall Police – Fitness to detain does cover the need for a detained person to be assessed as to their mental health state. The changes brought about by the outgoing care provider in relation to recommendation 4 regarding a roll out of a bespoke training programme and the self-harm and suicide risk assessment tool have adequately covered this recommendation. There is an expectation of continuous communication between a Custody Sergeant and an HCP to address the need to understand changes in presentation. The incoming healthcare provider is fully compliant with the need to assess both physical and mental fitness to detain. The service they offer will be an embedded service with constant HCP presence throughout the 24-hour period with an expectation of constant communication between them and the custody sergeants.

Recommendation

There should be an IT solution which allows access to health and other agency records. The Police Healthcare Provider Healthcare Professional (HCP) should have multiagency agreement for access to NHS records, risk history and clinical information.

View response

To liaise with the Devon and Cornwall care record programme management office to enable access by the Police Healthcare Provider to inform their clinical decision making regarding detained persons registered within Devon and Cornwall. To raise the issue of record access on a national platform. NHS Devon Devon and Cornwall Care Record Programme Board agreed on 7th December 2022 for the Police Healthcare Provider to access the Devon and Cornwall care record and become a data controller. Work is underway to achieve access – however the complexity of the information governance arrangements has required more time to be allocated to this phase. Note Access to DPT Mental Health records by Police Healthcare Provider. DPT – The Police Healthcare Provider can access relevant information from DPT Clinical Records by contacting Street Triage clinicians during their working hours, or DPT Access & First Response Service or by contacting colleagues in the Social Services Emergency Duty Team who have full access to DPT electronic patient records for individuals open to secondary mental health services. The Torbay and Devon Safeguarding Adults Board Information Sharing Agreement is agreed and provides a framework enabling access to clinical records through Devon Partnership Trust Safer Information Team (where relevant).

Recommendation

There will be sufficient capacity within the out of hours Mental Health Service to undertake Mental Health Act Assessments. Devon County Council (DCC) and DPT need to recognise the lack of equivalence and the system pressures that impact on decision-making … Read more

View response

Undertake a review of Emergency Duty Service to ensure there is sufficient capacity within the system to respond to requests for out of hours mental health act assessments. This review will include exploration of system pressures and impact of the lack of Approved Mental Health Practitioners. To progress and embed this Joint Review, by DPT and DCC, to analyse capacity and demand of out of hours’ Mental Health Assessments. DCC – A review of the EDS rota took place August 2019 and this provided additional temporary capacity through increased efficiency. The new rota was implemented April 2020 and an additional Service Manager was recruited to lead on mental health within the Emergency Duty Service. The EDS Governance Board was established in February 2020. A joint review was undertaken and an EDS Options Report presented to the EDS Governance Board in August 2020. A decision was made to replace the generic service for children, adults and mental health into separate specialisms. Additional funding was agreed to enable the separation of services, this will increase AMHP provision in the out of hours service by 300%. A campaign is currently underway to recruit to all posts. The new rota commenced on the 31st October 2022. There is an in principal agreement for DPT to host the out of hours mental health service and become a 24 hour service.

Recommendation

Clinical records should be available to custody healthcare professionals, which includes information about previous contacts, and tracks information requests and responses/outcomes. The Police Healthcare Provider should develop: • electronic clinical records • an auditable process for information requests and responses … Read more

View response

All Police Healthcare Providers going forward, from 1st Oct 2022, should ensure there is an electronic clinical record in place. Ensure there is an ongoing audit for information requests and responses/outcomes and act on any actions accordingly. Devon & Cornwall Police – The outgoing provider whilst bidding for the future contract committed to the use of an electronic record going forward. The incoming provider is already using the SYSTM ONE electronic system.

Recommendation

EDS staff should have access to and be trained in the use of relevant clinical information, when making decisions about out of hours MHAA. Emergency Duty Service staff who have access to relevant clinical information about mental health should be … Read more

View response

To continue to ensure all staff in EDS, including new starters have access to Care Notes with a training offer in place. DCC – Training Courses for Care Notes are in place for all new starters within the service and access is not granted until this has been completed. There is a clear process whereby DCC can request access to Care Notes for a member of staff; that request must be authorised by a Directorate Manager or Deputy Director within DPT and access is not granted without the staff member completing their training on Care Notes (the relevant electronic patient record).

Acceptance status

About this investigation

Recommendations