Andrew Nixon
PFD Report
All Responded
Ref: 2022-0165
Sent To
Response Status
Responses
1 of 1
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
1. During the inquest evidence was heard that:
i. Mr Nixon was not known to mental health services prior to February 2021.
ii. Mr Nixon's accompanied him to every appointment he had with the Home Treatment Team. She had never had dealings with the Mental Health Services previously.
iii. Mr Nixon had given permission to the Mental Health Services to share information with . On one occasion it was deemed that a doctor could not impart patient information to Mr Nixon's because he wrongly thought he did not have permission from the patient to do so.
iv. Mr Nixon's was unaware that he had disclosed "occasional suicidal thoughts" and was therefore unable to assess the risk of Mr Nixon to himself and accordingly did not take any steps to protect him.
v. The Care Plan, Escalation Plan, Emergency Plan were not drawn up in writing until after Mr Nixon's death. No paperwork was sent to Mr Nixon (and in turn not seen by his partner) by the Home Treatment Team prior to his death. Mr Nixon's partner was not therefore party to or privy to any risk assessment.
vi. A Carer's Assessment was considered but thought not appropriate as it was believed that Mr Nixon's (who was present at all consultations with the Home Treatment Team) was part of what was seen as ''an intelligent and resourceful couple".
vii. The Trust has a patient information leaflet describing what support and advice can be given to a carer. There is a Carer Assessment tool available.
2. I have concerns with regard to the following:
i. The failure to ensure that family members/carers are fully involved from the outset in the risk assessment process and that they have a full comprehension of steps being taken and/or decisions being made. I believe the Trust should take a more proactive approach.
ii. There should be criteria to be applied as to who should be considered for a Carer's Assessment at the earliest appointment with the Home Treatment Team. Such criteria should include whether the patient has given permission to share information; whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the carer in relation to steps taken and decisions made and whether they need further help.
iii. Such criteria may lead to a full carer's assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient.
i. Mr Nixon was not known to mental health services prior to February 2021.
ii. Mr Nixon's accompanied him to every appointment he had with the Home Treatment Team. She had never had dealings with the Mental Health Services previously.
iii. Mr Nixon had given permission to the Mental Health Services to share information with . On one occasion it was deemed that a doctor could not impart patient information to Mr Nixon's because he wrongly thought he did not have permission from the patient to do so.
iv. Mr Nixon's was unaware that he had disclosed "occasional suicidal thoughts" and was therefore unable to assess the risk of Mr Nixon to himself and accordingly did not take any steps to protect him.
v. The Care Plan, Escalation Plan, Emergency Plan were not drawn up in writing until after Mr Nixon's death. No paperwork was sent to Mr Nixon (and in turn not seen by his partner) by the Home Treatment Team prior to his death. Mr Nixon's partner was not therefore party to or privy to any risk assessment.
vi. A Carer's Assessment was considered but thought not appropriate as it was believed that Mr Nixon's (who was present at all consultations with the Home Treatment Team) was part of what was seen as ''an intelligent and resourceful couple".
vii. The Trust has a patient information leaflet describing what support and advice can be given to a carer. There is a Carer Assessment tool available.
2. I have concerns with regard to the following:
i. The failure to ensure that family members/carers are fully involved from the outset in the risk assessment process and that they have a full comprehension of steps being taken and/or decisions being made. I believe the Trust should take a more proactive approach.
ii. There should be criteria to be applied as to who should be considered for a Carer's Assessment at the earliest appointment with the Home Treatment Team. Such criteria should include whether the patient has given permission to share information; whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the carer in relation to steps taken and decisions made and whether they need further help.
iii. Such criteria may lead to a full carer's assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient.
Responses
Response received
View full response
Dear Mr Middleton, Thank you for your report under Regulation 28 for the prevention of future deaths, following the inquest on the unfortunate death of Mr Andrew Nixon. We have now had time to review your comments and we are able to respond to your concerns. We will begin with a broader outline of our current service commitment to family and carer involvement before responding to your concerns in detail.
Commitment to Family & Carer Involvement
Triangle of Care
Somerset NHS Foundation Trust (SFT) Mental Health and Learning Disabilities Directorate has been part of the Triangle of Care accreditation scheme since it began. On 12 May 2016, the Trust was awarded a second quality star by of the Carers’ Trust.
We have 42 Triangle of Care Leads working across Mental Health Inpatient wards, Community Mental Health Services (adults), Home Treatment Teams, Older Persons Community Mental Health Services, our Perinatal Mental Health Team, and our Intensive Dementia Support Service. Their role is to achieve better collaboration and partnership with carers in the service user and carer journey through a typical acute episode.
The objectives of the triangle of care are the implementation of the six key elements
1. Carers and the essential role they play are identified at first contact or as soon as possible thereafter.
2. Staff are ‘carer aware’ and trained in carer engagement strategies.
3. Policy and practice protocols re. Confidentiality and sharing information are in place.
4. Defined post(s) responsible for carers are in place.
5. A carer introduction to the service and staff is available, with a relevant range of information across the acute care pathway.
6. A range of carer support services is available
Musgrove Park Hospital Parkfield Drive Taunton TA1 5DA
The Triangle of Care Team are a small team who support the Triangle of Care Leads, providing regular supervision and updates. The most recent event was focussed on the topic of family and carer involvement in suicide prevention.
The Triangle of Care Steering Group has been paused during Covid which coincided with something of a hiatus at the Carer’s Trust which oversees the national Triangle of Care programme. The Carer’s Trust have since re-invigorated the national programme, and the Trust have booked dates to recommence the local steering group with a refreshed membership in September 2022. The Regional Triangle of Care group is chaired by the Trust’s Director of Mental Health and Learning Disability Care who is also a representative at the national group led by the Carer’s Trust.
The Triangle of care eLearning remains available to all staff but is due a review and refresh to take account of learning from feedback and incidents. The table below illustrates the uptake of Triangle of Care Training, as of February 2022, in our Mental Health and Learning Disabilities Directorate and the Trust’s Primary Care & Neighbourhoods Directorate where the Older People’s Community Mental Health services are managed. Directorate Number to be Trained Number Trained Number Expiring Training Require d Percentag e Trained Mental Health and LD 460 367 7 86
81.3% Primary Care & Neighbourhoods 100 88 3 9
91.0% Triangle of Care Substantive Staff Totals 560 455 10 95
83.0%
A Quality Improvement Project is currently being launched to refresh the Triangle of Care strategy beginning in Community Mental Health Services. This project has support from corporate and directorate colleagues who attend the mental health Serious Incident Review Group and includes the Trust’s Medical Director for Mental Health and Community Services as well as the Trust’s Associate Medical Director for Mental Health and Learning Disability Care. Preliminary meetings are scheduled during August to support the QI project and the Triangle of Care Steering Group. Within the Triangle of Care, there are a range of family/carer/social network-based approaches available in Somerset FT which include Family therapy, brief systemic intervention, Family intervention for psychosis, Triangle of Care meetings in Community Mental Health Services and Home Treatment Teams, and family liaison on inpatient wards,
Carers charter
The Somerset NHS Foundation Trust carers charter is available on our website. Our carers' charter - Carers - Somerset NHS Foundation Trust (somersetft.nhs.uk)
Carers service
The Carers Assessment Service covers patients in older persons, adults and children’s services with an establishment of 10.9 full time assessment workers and 1.6 full time managers (12.47 full time staff excluding admin). Patients within our primary care mental health services can access support and signposting via Somerset Carers. Free support & information for Carers just like you. - Somerset Carers
The SFT carers service has a webpage on the SFT website and has developed a booklet on caring for people with mental health conditions. NEWInformation-for-Carers-of-People-with- mental-health-conditions-2022.pdf (somersetft.nhs.uk).
The service, established in 2002, supports families and carers of people with mental health issues in Somerset and is committed to the principles of the Triangle of Care. The Triangle of Care is the cornerstone on which the trust is building and developing its carers policy and carers charter for the future.
The report showed that between February 2021 and January 2022 the Carers assessment service received 1,353 referrals, the table below breaks the referrals down by area.
Team Referrals Mendip 342 Sedgemoor 267 South Somerset 374 Taunton 243 Somerset Coast 127 Total 1353
Suicide prevention training
The Mental Health and Learning Disability Directorate is currently launching Connecting with People suicide awareness, and suicide response training for Mental Health clinical staff.
This training makes explicit reference to the Triangle of Care and a significant aspect of the training is focussed on collaborative care/safety planning and the need for family and carer involvement. The SAFETool which is a suicide assessment framework which staff are introduced to in this training includes prompts for inclusion of family and carer views about risk.
Clinical risk assessment and management training
The mandatory clinical risk training which is delivered to all mental health staff includes content (taught and case studies) about involving families and carers, confidentiality and consent, sharing information and collaborative risk assessment.
Response to your specific points: In your report, you raised the following concerns:
1. There should be criteria to be applied as to who should be considered for a Carer’s assessment at the earliest appointment with the Home Treatment Team.
2. Such criteria should include whether the patient has given permission to share information, whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the of the carer in relation to steps taken and decisions made and whether they need further help.
3. Such criteria may lead to a full carer’s assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient
CONCERN 1. Criteria to be applied as to who should be considered for a Carer’s assessment at the earliest appointment. We appreciate the impact that a person’s mental illness may have on their families and carers, as well as wanting to support families and carers to be as involved as much as it is possible in the care of their loved ones. As such, Carer’s assessments are a routine part of the services we offer.
1.1 Current referral criteria for Carers assessments The Carer’s Assessment service operating procedure was last reviewed in July 2020 and is due to be reviewed in 2023. The service operates under broad referral criteria, defining a carer as someone who:
• Looks after a relative, partner, friend or neighbour who needs support because of mental ill health.
• Who may be under 18 years of age and caring for a parent or relative with mental health problems.
• Who may not live in the same house or area as the person they care for.
• May provide full-time or part-time support to the person they care for.
• May not be the only person looking after the person they care for, they may be one of several people, both professional and non-professional.
The service has deliberately chosen to offer flexibility in its response to people who define themselves as having a caring role. It is the view of the service that all carers should have the opportunity to access support in their caring role if the carer and the patient consider that they might benefit from it.
Carers may be referred by mental health staff or may self-refer to the service. The consent of the patient to whom the carer is linked is not required for referral to be made. Carers can also be signposted to carer support and resources without a formal carers assessment.
Current position
We acknowledge that that in this case, was unfortunately not offered a carers assessment during her contact with our service.
It is important that staff make available to all carers the opportunity to have a carer’s assessment or signpost to other stakeholders for support. Whilst carers assessment may not be indicated in all cases, and our service capacity means we would only be able to include providing carers assessments to main carers only, it is possible that staff may not be fully aware of the availability of the resource or of who might benefit from it.
What we are already doing
• In 2021/2 we conducted a Quality Improvement project on involving families and carers in suicide prevention (2020-21) where it was noted that misunderstandings about the use of the word ‘carer’, both on the part of the patient/ their family and friends and the staff member may limit the number of referrals to the carers assessment workers.
• The above project also identified via staff focus groups that that there are difficulties with the processes required in our electronic record system for carer registration and referral.
• A follow-on Quality improvement Project which arose from these findings is currently in progress to address the issue of simplifying the process of registration and referral for clinicians. (see action plan)
• The carer information webpage on the Trust website has recently been updated with information and signposting resources. Carers - Carers - Somerset NHS Foundation Trust (somersetft.nhs.uk)
• A QR code to link to the webpage is currently in development for distribution to patients and their carers.
• The carers assessment service has developed leaflets for people caring for a young person, adult or older adults ‘Are you caring for someone’ and a carer’s information pack. TEMPLATE_PIB_Booklet_APRIL_2020.indd (somersetft.nhs.uk)
What we plan to do: (please also refer to action plan)
• The ‘Are you caring for someone?’ leaflet will be sent out routinely with all first appointment letters so that patients can pass the information to their carers as soon as possible.
• The Home Treatment Team plan to include carers assessment in their checklist for clinical review meetings so that carers assessment is reviewed on a weekly basis, as well as to their caseload boards where carers assessment will be marked as complete once families and carers have been asked about their carer needs and been signposted to relevant information. The team currently review
whether family liaison has been offered, and this standard will be added to this process.
• Home Treatment Teams are in the process of recruiting peer support workers who will undertake to perform an outreach function to families and carers on the caseload, checking attendance and understanding of the plan of care.
• We will provide an update to all clinical staff about ensuring patients and their carers are aware of carers support resources and to explore with patients and their carers whether assessment is indicated, for example where a carer is expressing difficulty and stress because of their caring role.
• We will add more specific reminders to explore carers assessments with patients and their families/carers in our clinical risk training.
• We will include the standard that carers assessment has been considered and discussed with family and carers in the caseload management tool.
• We will design a Quality Improvement project which is co-produced with experts by caring, experts by experience and experts by training to explore further mechanisms by which we can ensure greater and earlier family and carer involvement in care planning, and decision making, and sharing risk information.
• We will use our learning from the above QI project to inform revisions to the Carer’s Assessment service operating procedure when it is reviewed in 2023.
CONCERN 2.“Such criteria should include whether the patient has given permission to share information, whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the of the carer in relation to steps taken and decisions made and whether they need further help”
2.1 Consent by the patient to share information
Regrettably, a clinician was not aware that the patient had given consent to the trust to discuss Mr Nixon’s care with . It is understood that this was a new member of staff who was not familiar with this process.
Current position:
Consent to share information in line with the Trust confidentiality policy is recorded in the electronic patient record (RiO) on the patient front page which is accessible to all staff. Completion of the confidentiality statement is reviewed in the caseload management tool which staff are asked to complete as a routine monitoring process.
It is recognised that current recording of consent to share information on the electronic system focusses on exclusions (who the person does not want to share information with) rather than allowing recording of detailed wishes about confidentiality (what is acceptable to share, and with whom).
What we have already done
The recent quality improvement project (2020-21) which focussed on initiatives to increase family and carer involvement led to the development of a poster campaign about consent and confidentiality (enclosed), based on the SHARE document Documents :: Zero Suicide Alliance. Make Consent Count v2.4.pptx
Recommended wording from the above ‘SHARE’ document has been incorporated into our Dialog+ care planning tool to establish with patients who they would like to be involved in their care and who their emergency contact should be (this may not be their Next of Kin). We have also included the standard that ‘Confidentiality statement has been completed on Rio during this care episode’ into our caseload management tool. What we plan to do (please see action plan)
• Develop 7-minute briefing and redistribute to all staff with poster about consent and confidentiality, reminding all staff to update the consent to share information screen, and reminding them where to access information about consent in Rio.
• Explore improved/broader recording for consent to share information in Rio to include who can be involved, how much can be shared and what, plans and agreements about who in the patient’s social network we should contact in the event of nonattendance.
• Include reminder about confidentiality statement location in electronic record system in Clinical Risk Assessment and Management training.
2.2 Information gathering about whether the patient and/or the carer have been involved with mental health services previously
We will be able to gather information about previous patient involvement from our electronic records and we will add carer involvement as a recommendation to frontline staff undertaking assessments.
2.3 Recording whether the carer has been/will be present during consultations
Recording who is present during a consultation should be a routine part of record keeping and we will ensure that staff are reminded of this. Dialog+ also includes a tick box and free text box with the prompt to establish at an early stage who the patient would wish to involve in their care.
2.4 The level of understanding of the of the carer in relation to steps taken and decisions made and whether they need further help. Where a carer has been referred for a carers assessment, carers assessment workers already check with clinicians where they have become aware of the carer not being clear about decisions made and where they require further help.
Our service relies on our clinicians to build relationships with patients and their carers in order to check whether the carer feels fully included in care planning and decision making and can understand the rationale for any decisions taken. We recognise that we need to explore this further, and this will be an explicit focus for the co-produced away day, to involve experts by caring, by experience and by learning which we will be convening in September to launch our next Quality Improvement Project to improve Family and Carer involvement in patient care.
CONCERN 3: “Such criteria may lead to a full carer’s assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient.” As a Trust we are committed to ensuring that family members and carers are involved in the risk assessment and care planning process. We appreciate that on this occasion and although Ms Greenwood was present in many appointments that Mr Nixon had with Mental Health Services, an escalation and safety plan did not involve her sufficiently in understanding that Mr Nixon had had suicidal thoughts, or in helping her support her partner though a safety/escalation plan.
3.1 Involving families and carers at the earliest opportunity What we have already done:
To ensure the participation and engagement of families and carers the following processes have also been introduced:
• All appointment letters currently include a standard invitation to bring family members/friends or carers and we have ensured that this is also included in invitations for online appointments using ‘Attend anywhere’, our online platform.
• As well as peer workers in home treatment teams, we are currently recruiting Engagement workers to Community Mental Health Services who will also provide an outreach function to families and carers to encourage attendance at assessment meetings.
• As part of our Directorate governance processes, The Mental Health Directorate expects all staff to complete a routine caseload management tool. This includes monitoring of family and carer involvement in care planning (in Dialog+), family and carers involvement in safety/escalation planning, collecting Next of Kin and carer contact details, and to check that confidentiality is discussed and reviewed regularly with the patient.
3.2 Involving families and carers in care planning and developing safety/escalation plans Best practice would indicate that wherever possible and where consent permits, families and carers should be routinely involved in the sharing of risk information, in the co-production of safety and escalation plans, and should understand the rationale for decisions in the patient’s care.
What we have already done
• Since Mr Nixon’s death we have introduced a new care planning tool, Dialog +, which replaces the previous Care Planning Approach. Dialog + encourages the involvement of families and carers by explicitly requesting their views and encouraging the co- development and sharing of the care plan with identified families and carers.
• A recent quality improvement project (2020-21) focussed on initiatives to increase family and carer involvement and has led to the roll out of a plan to share care plans with families at discharge from hospital, and check understanding of care/safety plans, and a shared safety planning initiative in Children’s services.
• The involvement of families and carers in safety/escalation plans is already monitored within the Trust case notes audit.
What we plan to do: (refer to action plan)
• All patients discharged from the service should have a co-produced safety plan which is shared with consent wherever possible with identified family/friend of carer. Our routine record keeping audit includes this as part of its assurance. Thank you in advance for your consideration of this preventing future deaths response. We hope that you are assured by our response and our ongoing commitment to strengthening our involvement with families and carers.
Commitment to Family & Carer Involvement
Triangle of Care
Somerset NHS Foundation Trust (SFT) Mental Health and Learning Disabilities Directorate has been part of the Triangle of Care accreditation scheme since it began. On 12 May 2016, the Trust was awarded a second quality star by of the Carers’ Trust.
We have 42 Triangle of Care Leads working across Mental Health Inpatient wards, Community Mental Health Services (adults), Home Treatment Teams, Older Persons Community Mental Health Services, our Perinatal Mental Health Team, and our Intensive Dementia Support Service. Their role is to achieve better collaboration and partnership with carers in the service user and carer journey through a typical acute episode.
The objectives of the triangle of care are the implementation of the six key elements
1. Carers and the essential role they play are identified at first contact or as soon as possible thereafter.
2. Staff are ‘carer aware’ and trained in carer engagement strategies.
3. Policy and practice protocols re. Confidentiality and sharing information are in place.
4. Defined post(s) responsible for carers are in place.
5. A carer introduction to the service and staff is available, with a relevant range of information across the acute care pathway.
6. A range of carer support services is available
Musgrove Park Hospital Parkfield Drive Taunton TA1 5DA
The Triangle of Care Team are a small team who support the Triangle of Care Leads, providing regular supervision and updates. The most recent event was focussed on the topic of family and carer involvement in suicide prevention.
The Triangle of Care Steering Group has been paused during Covid which coincided with something of a hiatus at the Carer’s Trust which oversees the national Triangle of Care programme. The Carer’s Trust have since re-invigorated the national programme, and the Trust have booked dates to recommence the local steering group with a refreshed membership in September 2022. The Regional Triangle of Care group is chaired by the Trust’s Director of Mental Health and Learning Disability Care who is also a representative at the national group led by the Carer’s Trust.
The Triangle of care eLearning remains available to all staff but is due a review and refresh to take account of learning from feedback and incidents. The table below illustrates the uptake of Triangle of Care Training, as of February 2022, in our Mental Health and Learning Disabilities Directorate and the Trust’s Primary Care & Neighbourhoods Directorate where the Older People’s Community Mental Health services are managed. Directorate Number to be Trained Number Trained Number Expiring Training Require d Percentag e Trained Mental Health and LD 460 367 7 86
81.3% Primary Care & Neighbourhoods 100 88 3 9
91.0% Triangle of Care Substantive Staff Totals 560 455 10 95
83.0%
A Quality Improvement Project is currently being launched to refresh the Triangle of Care strategy beginning in Community Mental Health Services. This project has support from corporate and directorate colleagues who attend the mental health Serious Incident Review Group and includes the Trust’s Medical Director for Mental Health and Community Services as well as the Trust’s Associate Medical Director for Mental Health and Learning Disability Care. Preliminary meetings are scheduled during August to support the QI project and the Triangle of Care Steering Group. Within the Triangle of Care, there are a range of family/carer/social network-based approaches available in Somerset FT which include Family therapy, brief systemic intervention, Family intervention for psychosis, Triangle of Care meetings in Community Mental Health Services and Home Treatment Teams, and family liaison on inpatient wards,
Carers charter
The Somerset NHS Foundation Trust carers charter is available on our website. Our carers' charter - Carers - Somerset NHS Foundation Trust (somersetft.nhs.uk)
Carers service
The Carers Assessment Service covers patients in older persons, adults and children’s services with an establishment of 10.9 full time assessment workers and 1.6 full time managers (12.47 full time staff excluding admin). Patients within our primary care mental health services can access support and signposting via Somerset Carers. Free support & information for Carers just like you. - Somerset Carers
The SFT carers service has a webpage on the SFT website and has developed a booklet on caring for people with mental health conditions. NEWInformation-for-Carers-of-People-with- mental-health-conditions-2022.pdf (somersetft.nhs.uk).
The service, established in 2002, supports families and carers of people with mental health issues in Somerset and is committed to the principles of the Triangle of Care. The Triangle of Care is the cornerstone on which the trust is building and developing its carers policy and carers charter for the future.
The report showed that between February 2021 and January 2022 the Carers assessment service received 1,353 referrals, the table below breaks the referrals down by area.
Team Referrals Mendip 342 Sedgemoor 267 South Somerset 374 Taunton 243 Somerset Coast 127 Total 1353
Suicide prevention training
The Mental Health and Learning Disability Directorate is currently launching Connecting with People suicide awareness, and suicide response training for Mental Health clinical staff.
This training makes explicit reference to the Triangle of Care and a significant aspect of the training is focussed on collaborative care/safety planning and the need for family and carer involvement. The SAFETool which is a suicide assessment framework which staff are introduced to in this training includes prompts for inclusion of family and carer views about risk.
Clinical risk assessment and management training
The mandatory clinical risk training which is delivered to all mental health staff includes content (taught and case studies) about involving families and carers, confidentiality and consent, sharing information and collaborative risk assessment.
Response to your specific points: In your report, you raised the following concerns:
1. There should be criteria to be applied as to who should be considered for a Carer’s assessment at the earliest appointment with the Home Treatment Team.
2. Such criteria should include whether the patient has given permission to share information, whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the of the carer in relation to steps taken and decisions made and whether they need further help.
3. Such criteria may lead to a full carer’s assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient
CONCERN 1. Criteria to be applied as to who should be considered for a Carer’s assessment at the earliest appointment. We appreciate the impact that a person’s mental illness may have on their families and carers, as well as wanting to support families and carers to be as involved as much as it is possible in the care of their loved ones. As such, Carer’s assessments are a routine part of the services we offer.
1.1 Current referral criteria for Carers assessments The Carer’s Assessment service operating procedure was last reviewed in July 2020 and is due to be reviewed in 2023. The service operates under broad referral criteria, defining a carer as someone who:
• Looks after a relative, partner, friend or neighbour who needs support because of mental ill health.
• Who may be under 18 years of age and caring for a parent or relative with mental health problems.
• Who may not live in the same house or area as the person they care for.
• May provide full-time or part-time support to the person they care for.
• May not be the only person looking after the person they care for, they may be one of several people, both professional and non-professional.
The service has deliberately chosen to offer flexibility in its response to people who define themselves as having a caring role. It is the view of the service that all carers should have the opportunity to access support in their caring role if the carer and the patient consider that they might benefit from it.
Carers may be referred by mental health staff or may self-refer to the service. The consent of the patient to whom the carer is linked is not required for referral to be made. Carers can also be signposted to carer support and resources without a formal carers assessment.
Current position
We acknowledge that that in this case, was unfortunately not offered a carers assessment during her contact with our service.
It is important that staff make available to all carers the opportunity to have a carer’s assessment or signpost to other stakeholders for support. Whilst carers assessment may not be indicated in all cases, and our service capacity means we would only be able to include providing carers assessments to main carers only, it is possible that staff may not be fully aware of the availability of the resource or of who might benefit from it.
What we are already doing
• In 2021/2 we conducted a Quality Improvement project on involving families and carers in suicide prevention (2020-21) where it was noted that misunderstandings about the use of the word ‘carer’, both on the part of the patient/ their family and friends and the staff member may limit the number of referrals to the carers assessment workers.
• The above project also identified via staff focus groups that that there are difficulties with the processes required in our electronic record system for carer registration and referral.
• A follow-on Quality improvement Project which arose from these findings is currently in progress to address the issue of simplifying the process of registration and referral for clinicians. (see action plan)
• The carer information webpage on the Trust website has recently been updated with information and signposting resources. Carers - Carers - Somerset NHS Foundation Trust (somersetft.nhs.uk)
• A QR code to link to the webpage is currently in development for distribution to patients and their carers.
• The carers assessment service has developed leaflets for people caring for a young person, adult or older adults ‘Are you caring for someone’ and a carer’s information pack. TEMPLATE_PIB_Booklet_APRIL_2020.indd (somersetft.nhs.uk)
What we plan to do: (please also refer to action plan)
• The ‘Are you caring for someone?’ leaflet will be sent out routinely with all first appointment letters so that patients can pass the information to their carers as soon as possible.
• The Home Treatment Team plan to include carers assessment in their checklist for clinical review meetings so that carers assessment is reviewed on a weekly basis, as well as to their caseload boards where carers assessment will be marked as complete once families and carers have been asked about their carer needs and been signposted to relevant information. The team currently review
whether family liaison has been offered, and this standard will be added to this process.
• Home Treatment Teams are in the process of recruiting peer support workers who will undertake to perform an outreach function to families and carers on the caseload, checking attendance and understanding of the plan of care.
• We will provide an update to all clinical staff about ensuring patients and their carers are aware of carers support resources and to explore with patients and their carers whether assessment is indicated, for example where a carer is expressing difficulty and stress because of their caring role.
• We will add more specific reminders to explore carers assessments with patients and their families/carers in our clinical risk training.
• We will include the standard that carers assessment has been considered and discussed with family and carers in the caseload management tool.
• We will design a Quality Improvement project which is co-produced with experts by caring, experts by experience and experts by training to explore further mechanisms by which we can ensure greater and earlier family and carer involvement in care planning, and decision making, and sharing risk information.
• We will use our learning from the above QI project to inform revisions to the Carer’s Assessment service operating procedure when it is reviewed in 2023.
CONCERN 2.“Such criteria should include whether the patient has given permission to share information, whether the patient and/or the carer have been involved with mental health services previously; whether the carer has been/will be present during consultations; the level of understanding of the of the carer in relation to steps taken and decisions made and whether they need further help”
2.1 Consent by the patient to share information
Regrettably, a clinician was not aware that the patient had given consent to the trust to discuss Mr Nixon’s care with . It is understood that this was a new member of staff who was not familiar with this process.
Current position:
Consent to share information in line with the Trust confidentiality policy is recorded in the electronic patient record (RiO) on the patient front page which is accessible to all staff. Completion of the confidentiality statement is reviewed in the caseload management tool which staff are asked to complete as a routine monitoring process.
It is recognised that current recording of consent to share information on the electronic system focusses on exclusions (who the person does not want to share information with) rather than allowing recording of detailed wishes about confidentiality (what is acceptable to share, and with whom).
What we have already done
The recent quality improvement project (2020-21) which focussed on initiatives to increase family and carer involvement led to the development of a poster campaign about consent and confidentiality (enclosed), based on the SHARE document Documents :: Zero Suicide Alliance. Make Consent Count v2.4.pptx
Recommended wording from the above ‘SHARE’ document has been incorporated into our Dialog+ care planning tool to establish with patients who they would like to be involved in their care and who their emergency contact should be (this may not be their Next of Kin). We have also included the standard that ‘Confidentiality statement has been completed on Rio during this care episode’ into our caseload management tool. What we plan to do (please see action plan)
• Develop 7-minute briefing and redistribute to all staff with poster about consent and confidentiality, reminding all staff to update the consent to share information screen, and reminding them where to access information about consent in Rio.
• Explore improved/broader recording for consent to share information in Rio to include who can be involved, how much can be shared and what, plans and agreements about who in the patient’s social network we should contact in the event of nonattendance.
• Include reminder about confidentiality statement location in electronic record system in Clinical Risk Assessment and Management training.
2.2 Information gathering about whether the patient and/or the carer have been involved with mental health services previously
We will be able to gather information about previous patient involvement from our electronic records and we will add carer involvement as a recommendation to frontline staff undertaking assessments.
2.3 Recording whether the carer has been/will be present during consultations
Recording who is present during a consultation should be a routine part of record keeping and we will ensure that staff are reminded of this. Dialog+ also includes a tick box and free text box with the prompt to establish at an early stage who the patient would wish to involve in their care.
2.4 The level of understanding of the of the carer in relation to steps taken and decisions made and whether they need further help. Where a carer has been referred for a carers assessment, carers assessment workers already check with clinicians where they have become aware of the carer not being clear about decisions made and where they require further help.
Our service relies on our clinicians to build relationships with patients and their carers in order to check whether the carer feels fully included in care planning and decision making and can understand the rationale for any decisions taken. We recognise that we need to explore this further, and this will be an explicit focus for the co-produced away day, to involve experts by caring, by experience and by learning which we will be convening in September to launch our next Quality Improvement Project to improve Family and Carer involvement in patient care.
CONCERN 3: “Such criteria may lead to a full carer’s assessment. It is noted that there will always be a delay between assessments and the drawing up of care plans etc which will then be sent out to the patient. By establishing an early process of engaging with carers the medical professionals may build in further protective factors for the patient.” As a Trust we are committed to ensuring that family members and carers are involved in the risk assessment and care planning process. We appreciate that on this occasion and although Ms Greenwood was present in many appointments that Mr Nixon had with Mental Health Services, an escalation and safety plan did not involve her sufficiently in understanding that Mr Nixon had had suicidal thoughts, or in helping her support her partner though a safety/escalation plan.
3.1 Involving families and carers at the earliest opportunity What we have already done:
To ensure the participation and engagement of families and carers the following processes have also been introduced:
• All appointment letters currently include a standard invitation to bring family members/friends or carers and we have ensured that this is also included in invitations for online appointments using ‘Attend anywhere’, our online platform.
• As well as peer workers in home treatment teams, we are currently recruiting Engagement workers to Community Mental Health Services who will also provide an outreach function to families and carers to encourage attendance at assessment meetings.
• As part of our Directorate governance processes, The Mental Health Directorate expects all staff to complete a routine caseload management tool. This includes monitoring of family and carer involvement in care planning (in Dialog+), family and carers involvement in safety/escalation planning, collecting Next of Kin and carer contact details, and to check that confidentiality is discussed and reviewed regularly with the patient.
3.2 Involving families and carers in care planning and developing safety/escalation plans Best practice would indicate that wherever possible and where consent permits, families and carers should be routinely involved in the sharing of risk information, in the co-production of safety and escalation plans, and should understand the rationale for decisions in the patient’s care.
What we have already done
• Since Mr Nixon’s death we have introduced a new care planning tool, Dialog +, which replaces the previous Care Planning Approach. Dialog + encourages the involvement of families and carers by explicitly requesting their views and encouraging the co- development and sharing of the care plan with identified families and carers.
• A recent quality improvement project (2020-21) focussed on initiatives to increase family and carer involvement and has led to the roll out of a plan to share care plans with families at discharge from hospital, and check understanding of care/safety plans, and a shared safety planning initiative in Children’s services.
• The involvement of families and carers in safety/escalation plans is already monitored within the Trust case notes audit.
What we plan to do: (refer to action plan)
• All patients discharged from the service should have a co-produced safety plan which is shared with consent wherever possible with identified family/friend of carer. Our routine record keeping audit includes this as part of its assurance. Thank you in advance for your consideration of this preventing future deaths response. We hope that you are assured by our response and our ongoing commitment to strengthening our involvement with families and carers.
Report Sections
Investigation and Inquest
On the 11th March 2021, an investigation was commenced into the death of Andrew Arden Nixon, born on the 20th April 1963 The investigation concluded at the end of the Inquest on the 31st May 2022. The Medical Cause of Death was: la Hanging The conclusion of the Inquest recorded Suicide
-4 CIRCUMSTANCES OF THE DEATH Mr Nixon's mental health deteriorated around October 2020. He was treated by his GP and prescribed anti depressants. Following disclosures relating to self harm his GP made an emergency referral to the Mental Health Team on 11/2/21. Mr Nixon was contacted and assessed by the Home Treatment Team during February 2021 and discharged from that service on 2/3/21. On 3/3/21 Mr Nixon was found suspended by a ligature in wooded grounds in North Dorset.
-4 CIRCUMSTANCES OF THE DEATH Mr Nixon's mental health deteriorated around October 2020. He was treated by his GP and prescribed anti depressants. Following disclosures relating to self harm his GP made an emergency referral to the Mental Health Team on 11/2/21. Mr Nixon was contacted and assessed by the Home Treatment Team during February 2021 and discharged from that service on 2/3/21. On 3/3/21 Mr Nixon was found suspended by a ligature in wooded grounds in North Dorset.
Copies Sent To
, Leigh Day Solicitors
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