Mental Health related deaths

Action Planned (AI summary) The Trust will introduce a referral requirement for on-call psychiatrists in specific risk scenarios, amend assessment templates to include consideration of family concerns, implement monthly supervisions for bank staff, introduce regular learning sessions from serious incidents, and review advanced clinical risk training with relevant case scenarios.

Action Planned (AI summary) The Trust will ensure referrals for urgent MHA assessments are accompanied by a telephone conversation, risks will be made explicit, and the timing of the MHA assessment will be explored with the referrer to agree/mitigate risk.

Action Planned (AI summary) The Trust and BHCC are developing a joint policy and guidance to improve communication and define responsibility between the organisations to improve the safety of voluntary patients waiting for acute mental health beds. Actions include reviewing existing policies and protocols, implementing new documentation procedures, and providing staff training, to be completed by April 2021.

Action Planned (AI summary) The Trust has introduced a 24-hour response telephone line and is developing an Initial Response Service (single point of access for people presenting with mental distress). All new staff members are required to attend a corporate welcome day induction and complete statutory training depending on their role. A former Police Superintendent has been recruited as Mental Health Liaison Officer. A trigger process to identify escalating risk in adults has been launched, including a more focused letter to GPs, with draft letter to be subject to a process of consultation. The Trust launched the Initial Response Service as a single point of access for people in mental distress. A standardised triage tool has been developed for adult mental health services throughout the Trust, and the Trust is involved in a national project to improve access to patient information.

Action Planned (AI summary) Norfolk and Suffolk NHS Foundation Trust has increased capacity through the opening of four crisis house beds in Norwich, with plans to open two additional crisis houses in the coming months, as well as extra ward capacity for older people. The Trust has reviewed its bed management processes to ensure clinically-led admissions.

Action Planned (AI summary) MPFT is reviewing the fence structure around the garden on Laurel Ward, with options including a full replacement fence or retrofitting an anti-climb dome; the Trust is also discussing ways to complete searches of the garden at set frequencies, such as bi-monthly, and these will be addressed through the Trust’s Health and Safety Committee for action and monitoring.

Action Planned (AI summary) The Limes will contact receiving care homes to share information when a resident is considering a move. They will also invite local Social Services and GP practice to coffee mornings to build a working relationship. Suffolk County Council is undertaking a Safeguarding Adults Review, with themed learning points to be defined. The review is expected to be completed by mid-December 2020, with full sign off by the SAB in February 2021.

Action Planned (AI summary) CRG Medical states a member of the mental health team attends all MHA s117 meetings and they now have a dual system for patient records, audited weekly. They provide advice on registering with a community GP and provide a discharge summary that is now accessible to GPs through NHS Spine. They also employ a social inclusion representative to assist with discharge arrangements. EPUT states that the Clinical Guidelines for Community Mental Health Service Users disengaging or non-concordant with current prescribed treatment plan is currently under review to ensure it is comprehensive and provides clear guidance for staff.

Action Planned (AI summary) Lincolnshire County Council plans to implement a working protocol for mental health and substance misuse services, take into account best practice when re-commissioning drug and alcohol services, review dual diagnosis provision, and consider partnership commissioning with the CCG. We Are With You charity has jointly agreed to review Dual Diagnosis pathways, embedded information sharing expectations, and reviewed staff structures to introduce specialist Dual Diagnosis roles. They have also enhanced reciprocal training to LPFT and regularly attend interface meetings and provide opportunities for staff from various organisations to spend time within their teams. The Trust plans to update training programmes to focus on dual diagnosis, reinforce the role of carers, review the Care Programme Approach, and engage with commissioners to ensure appropriate funding for patients with dual diagnoses. They also aim to remove barriers to information sharing and promote data gathering and benchmarking.

Action Planned (AI summary) Essex Highways has identified three potential options to improve safety at the St Dominic Road Footbridge and prefers installing full-height corrugated steel parapets. A full structural assessment is estimated to be completed by the end of January 2021, with design and refurbishment works to follow, subject to Network Rail approval.