Dear Ms Persaud

Re: Inquest touching upon the death of Trindi Kaur Birdi

I refer to your letter dated 25 November 2020 and the enclosed Regulation 28 report issued in respect of your concerns regarding the risk assessment and management at Psychiatric Liaison Service (PLS).

The Trust has taken into consideration concerns highlighted in the Regulation 28 report and would like to briefly outline the current systems of safeguarding the service users’ risks as well as inform you on what action will be taken to make these systems even more robust to address your concerns.

Current Risk Assessment and Management arrangements

At present the systems to safeguard the patients risk within the trust include the following:  Clinical Risk Assessment and Management policy;  Clinical Risk Assessment and Management mandatory training – standard (one off) and advanced modules (3-yearly)  Learning from Serious Incidents through quarterly directorate-led Lessons Learned events and monthly team business meetings  Monthly risk assessment compliance audits  Monthly clinical supervision with all staff whereby 2-3 clinical cases are reviewed for quality of assessment and care planning, including risk assessment

Policy

NELFT’s Clinical Risk Assessment and Management Policy outlines that NELFT staff should recognise that other agencies may be carrying out risk assessments and have risk management plans in relation to the same patients and that these should be considered.

The policy goes on to address actions that are to be taken where there is a significant difference of opinion between professionals in the risk level or risk management of a patient.

Chair: Interim Chief Executive:

It supports clinicians faced by complex presentations of significant levels of risk to seek advice and support from senior colleagues on duty. Specifically, it outlines that, in the case of different opinions/ conclusions between clinicians it is important for all involved in the risk assessment to review their findings and to discuss the basis for their respective views. Clinicians are instructed that it is not acceptable for an assessment of risk by one professional, or team, to simply be ‘over-ruled’ or ignored by another. It is vital that any such differences are identified, explored, understood and resolved.

The policy goes on to instruct staff to resolve this difference in opinion of risk by obtaining the opinion of a suitably skilled senior clinician, or turning to a senior manager. All such involvement should be documented. This should be done immediately if there is possibility of a serious acute risk.

Further escalation in such matters includes encouraging involvement of the on-call consultant and on-call manager, where required.

Training

The Trust has mandated Clinical Risk Training for clinical staff (non-medical and medical). The standard module is mandated to be completed once and the advanced module is to be completed every three years.

The training content includes outlining Best Practice guidance in risk assessment, learning from the Francis Report and highlights key factors to consider in risk assessment, as documented in the NELFT Clinical Risk Assessment and Management Policy. Two of these factors pertain to this report: one is that positive risk management as part of a carefully constructed plan is a required competence of all mental health practitioners, the other is that the risk management plan should include a summary of all risks identified, formulations of the situations in which these risks may occur and actions to be taken by the practitioner and service user in response to crisis.

Whilst the Clinical Risk Standard training does not go into detail regarding difference of opinion in the risk level rating of a service user, the Clinical Risk Advanced training covers a variety of case scenarios of which this may be one.

Risk assessment quality monitoring

The Trust has a system in place to proactively monitor the quality of the risk assessments. This is to ensure that any deviation from the required standard will be proactively identified in a timely fashion, instead of relying on a serious incident investigation, after a serious incident has taken place, to review the quality of the risk assessments.

In the main, this is conducted through monthly ‘live’ RIO supervision where recent assessments, risk assessments and care plans are scrutinized by the clinician and their immediate supervisor in order to ensure practice standards are maintained. Performance issues that are identified within these meetings are managed in line with the Trust’s Capability Policy.

I can confirm that the monthly supervision compliance for the Psychiatric Liaison Service substantive staff is 100%. Bank staff who are employed temporarily in this service, who have substantive roles in other teams, complete their monthly supervision as part of their substantive roles.

Chair:

Interim Chief Executive:

Action to improve the service

In order to improve the current systems briefly outlined above the trust has agreed to take further actions as follows:
1. A requirement will be introduced for a referral to the on-call psychiatrist to be completed where the presenting risk is significantly different to that of another clinician (including GP) who has reviewed the patient on the same day.
2. The assessment template used within the Psychiatric Liaison Service will be amended to prompt the documentation of the consideration given to concerns raised by friends/family/healthcare staff, protective factors and risk management plan.
3. A requirement will be introduced to conduct regular monthly clinical supervisions with all bank staff who work on a temporary basis with the Psychiatric Liaison Service, where they are not already receiving this within their substantive team.
4. The Psychiatric Liaison Service have committed to introducing a regular monthly session for all staff within this service to learn from historic serious incidents and unexpected deaths.
5. A review of the Clinical Risk Advanced level training to include case scenarios that indicate a difference in clinical opinion, and to reiterate guidance how to address these scenarios.

I hope that the above and the enclosed action plan provides reassurance to you that the Trust has taken this sad incident very seriously and that it reflects our commitment to improve care quality and patient safety. If you have any further queries, please contact my office on .