Stage 1 Report into Southern Health NHS Foundation Trust by Nigel Pascoe QC

I firmly recommend a Public Investigation to consider specific outstanding matters of policy. As will be seen, they include recommendations made by Mr West himself.

There was shared learning to come out of this: the executive summary should be shared with the Coroner, families and other stakeholders.

The Recommendations were,
• Within one-month of their Report, the Trust should write to Mr West to acknowledge the failings highlighted in the report and apologise.
• The Trust should pay Mr West £2500 as an ex gratia payment.
• Within three-months the Trust should produce an Action Plan, explaining what it has done and will do to prevent a recurrence of the failings identified and give an update on the actions in that Action Plan.
• Further, the Trust should explain how improvements in its Mental Health Services and Complaint Handling have and will be monitored.

In light of the ongoing injustices that I have found Mr West to have suffered and specifically since the first ex gratia payment in October 2016, three years ago, I would recommend a further payment of £1500.

I recommend an ex gratia payment is made in the order of £1750 to the family of Marion Munns. That is made on the strict basis of a careful consideration of the Ombudsman’s Guidelines on Ex Gratia payments.

I recommend the Trust provide Mrs Small with an update on the implementation of the different recommendations made in the reports.

The Report made specific findings and corresponding recommendations,
• It must be clarified how families and carers are involved in the ‘Triangle of Care’ when service users withhold consent.
• There is a need to simplify and reduce radically, handovers between teams, professionals and services. This will avoid the lack of continuity experienced by David West.
• The Adult Mental Health Care Pathway must be understood and mapped better.
• The establishment of mechanisms to understand better the psycho-social impact of people in distress and their treatment over time.
• There is a need to review Risk Assessments across Adult Mental Health Services and Screening, with results in a centralised, easily accessible system.
• The introduction of ‘non-clinical’ specialist roles to provide support would be beneficial at times of crisis.
• There needs to be a formal approval process for the selection of Independent Investigators and Independent Medical Examiners.
• The organisational structure should focus on multi-disciplinary integrated teams to ensure clear accountability.
• The focus should be on prevention rather than crisis. Thus money should be focused on supporting people early on, and Community Mental Health services could assist with this.

What is needed is a careful, sensitive, detached, forensic examination of the facts to consider exactly how Edward died. This should be done at a Public Investigative Hearing.

I would recommend an ex gratia payment in the order of £2000. That is following the Ombudsman Guidance on Ex Gratia payments at level 4.

There are twenty-one recommendations made in this Report. I will summarise some of them for the purpose of this Report,
• The Trust should respond to complaints in one document. The time frame should be agreed with the family.
• The Trust should implement a rigid system of moving from complaint/Serious Incident learning to implementation.
• There needs to be improved communications and involvement of the people making complaints.
• There should be reform of the processes for meetings and the way they are conducted.
• Where there is a death or serious harm, consideration should be given to the need for an external Independent Investigator.
• An explanation of the structure of the Trust should be provided to the family immediately, if it has not taken place already.
• There should be one person at the Trust who deals with the person who made the complaint.
• Trusts should work together to ensure independent counselling support is available to family members.
• The Trust should look at a range of training.
• The time it takes to respond to complaints needs to be shortened.

I recommend the Trust provide Mrs Small with an update on the implementation of the different recommendations made in the reports, if this has not already been done.

It was recommended that the CCG review and add to current Care Pathways to ensure multi-agency coordination and placement of the service user at the centre of the care and treatment provided.

I warmly endorse the excellent specific suggestion made to me by Mrs Small that a complete new and transparent Independent Investigation process must be put in place by the Trust. Mrs Small has expressed to me her desire for this to ensure that ‘investigations are done correctly from the beginning’, to remove the need for multiple complaints.

The recommendations were,
• TQtwentyone policies for floating support should be reviewed.
• TQtwentyone should not allow staff to work alone if they have not undertaken Basic Life Support training.

The CCG should review and ensure all transition processes are fit for purpose and in keeping with National Guidelines.

There were a number of recommendations made,
• A dedicated, independent team, or specialist family liaison contact, skilled in dealing with bereaved families; advice to be sought from this contact before any meetings with the family; an agenda and key messages for the family should be prepared for these meetings; and a ‘neutral colleague’ should accompany a Trust officer to ‘particularly sensitive meetings’ with the family.
• Investigators should have sufficient seniority, knowledge, training and personal qualities; the investigation process should be more transparent with the early dissemination of more, clearer, information to families.
• More transparency regarding the types of professionals and allied health professionals who care for patients across the Trust.
• Training in investigatory report writing and quality controls.
• An investigation as to whether the Consultant responsible for Marion Munns’ care had seen the draft Investigation Report before the family had had an opportunity to check their accounts, which would have been in breach of the Trust’s data governance policies.
• The investigatory process should be explained to families in some detail at an early stage.
• There should be a review of communication between GPs and the Community Mental Health Team.

The CCG should review the Continuing Healthcare process to identify management of coordination and oversight in relation to vulnerable adults; to make it clear how parents should be signposted and to bring early assessment to the attention of all concerned.

There should be a revision of Care Pathways and multi-agency protocols to ensure effective Communication takes place, with particular attention on vulnerable adults.

It was recommended that all TQtwentyone staff must be brought up-to-date with basic life support techniques with immediate effect. The Trust must conduct an audit to ensure compliance and ensure action is taken and monitored on an ongoing rolling basis.

The Report recommended,
• The use of Mrs Small‘s ‘Cars on the Motorway’ analogy to be transformed into posters in Community areas.
• The Trust leadership course to be refreshed to include service users and families to share their experiences directly to help staff learn.
• A series of service user and family video stories, additionally to be used for wider staff engagement.
• Articles by Carers and patients in the Trust journals.
• Stories to be used to prompt clinical reflection in formal practice supervision sessions.

It was recommended that Health and Social Care providers must ensure that assessment of carers is conducted in accordance with the Care Act 2014.

It was recommended that the Children’s Services Department should consider undertaking an audit of the current volume of Child Protection Investigations undertaken by Children with Disabilities Teams across Hampshire to ascertain if there is a broader pattern of underuse of procedures. Further, they should consider providing additional refresher opportunities for operational teams on the role of the Local Authority Designation Officer and their links with the broader section 47 Child Protection process.

It was recommended that Best Interests and Capacity Assessment must be embedded into the transition Care Pathway and the appointment of independent advocates always considered.

It suggested the findings are shared with the Team Manager for Hampshire County Council as a learning exercise.

It was suggested that where there is an unexpected death, the Trust must work closely with families of the deceased throughout the investigation process.

It was recommended that the Local Authority Designation Officer should record, retrospectively, the concerns related to the relevant members of staff on duty when the incident occurred, so that should any future concerns arise, it is acknowledged.

Because of the past serious failures of investigation, I consider that the arrangement of an independent, robust, Investigative Structure and Process should be set out by the Trust and then examined in public. They need to explain very clearly what exists today and that demands very careful examination. The issue of a transparent investigation process will help, above all other matters, to build confidence in the working life of this Trust. It is one fervently supported by the families, as demonstrated, for example, by the powerful plea to me of Mrs Small.

They recommended that the Head of Service write to Mr and Mrs Hartley to apologise on behalf of the Department for the way in which they responded to Edward Hartley’s injury.

The Recommendations included,
• Development of an acute Care Pathway for older patients in collaboration with the Acute Mental Health Team for Adult Mental Health, so that crisis care required can be extended out of hours, if required.
• Development of the team acuity board, so that it is reviewed by the staff member on duty daily to monitor those presenting with higher risk, with an agreement regarding appropriate actions.
• Ensure staff in the Community Mental Health Team and the inpatient units are aware of the fast track re-referral process to the Community Mental Health Team for patients who are discharged to Primary Care. Ensure patients know on discharge of the re-engagement plan.
• Facilitate a reflective learning session with the Community Mental Health Team to discuss the learning from this Investigation to ensure the Team change practice.
• Increase awareness and understanding within Older People’s Mental Health Service of the Care Programme Approach (‘CPA’) framework and develop comprehensive care planning; that included a review of all caseloads to ensure patients are on the appropriate level of CPA. Ensure all patients who meet the criteria are on CPA.
• All staff to receive training around reviewing and documenting Risk Assessment in line with Trust Policy requirements and check documentation of Risk Assessment in supervision.
• Regular audit of documentation to ensure compliance must take place.
• Review the frequency of monitoring of Care Plans and risk management plans for those subject to CPA and presenting with risk indicators of relapse at the weekly multidisciplinary team meeting.
• Staff to monitor and document in the clinical records evidence of compliance with medicines prescribed and evidence of effectiveness when there have been changes to the dose.
• Review local partnership arrangements and jointly agreed local policy between Mental Health Services, Police, Ambulance Services, Commissioners and the Local Authority to deal with people experiencing mental health crisis.
• Review arrangements for telephone with the Community Mental Health Team so that messages are communicated, phones answered and service users and their families are provided with information of how to make contact.
• Review the individual practice of all staff involved in the care of P1 – Marion Munns.
• Complete an emergency peer review of the Team.
• Review the culture and behaviour of the Team.
• Review the care records of all current patients on the Team c

I recommend a limited Public Investigation that is specific and focused in nature. In particular, that Investigation should address issues that I am not in a position on a paper review to resolve and where such a Public Investigation is still in the public interest. Only then can those concerned have the chance to consider that, at long last, justice has been done. The issues are,
1) The circumstances of the death of Edward Hartley.
2) The operation and role of Care Coordinators.
3) The procedures and practices for conducting Assessments; particularly Risk Assessments, when a patient is discharged, and when Care Pathways are being planned.
4) The implementation of a robust, efficient and effective Complaint Handling procedure.
5) The structures and procedures now in place for Communication and Liaison with patient’s families, both during a patient’s life and afterwards.
6) The establishment or confirmation of a totally independent, robust, Investigative Structure and Process to conduct transparent and fair investigations into serious accidents, deaths and complaints, particularly but not exclusively where there is a mental health element. That recommendation demands a rigorous look at what is in place now in this Trust and the extent to which it meets the necessary criteria. Detailed explanations and submissions need to be made and then properly tested. That recommendation goes to the heart of this Report.
7) Evidence of the development, monitoring and implementation of Action Plans to be provided, with illustrations of effective working Action Plans in the recent past.
8) Evidence should be provided by the Clinical Commissioning Group of the supervisory structure that has been in place since 2011 and how it has been exercised towards the Trust and of any planned changes in the light of public concerns.

In order to have an effective Public Investigation, there must be evidence from members of the Trust and others who can speak precisely and with in-depth knowledge on the narrow topics I have set out above. The Trust should identify such people and statements should be taken before the Hearing and made available to the families and all interested parties.

The failings in regard to the Investigations clearly fall within Level 4, reserved for ‘only the very worst complaint handling cases’ where there is ‘exceptionally poor complaint handling extending over several years’. However, my recommendation for a Level 5 payment is informed by the Guidance on cases of ‘multiple injustices’, which are present here. That would justify the payment of the sum of £5000.

I recommend a process not unlike a well-ordered regulatory hearing, adapted to the particular focus of this Investigation. One example would be the need to enable some sensitive evidence to be heard in private, deciding such a question on well-established principles of public and private interest. It must be a process designed to reach practical working conclusions to improve, where needed, the policy issues which it is considering. For it is time for further constructive change. The families who are concerned deserve nothing less.