2019

Noted (AI summary) North East London NHS Foundation Trust will provide record keeping training to staff, develop and implement a discharge checklist, conduct audits, update the HTT Service Operational procedure, and update the Trust’s Clinical Handover of Care and Discharge Policy. The Department of Health and Social Care expresses sympathy and states that they expect the North East London NHS Foundation Trust to look carefully at the care provided and take actions to improve care. They outline national actions being taken to support people with severe mental illnesses and prevent suicide.

Noted (AI summary) Milton Keynes CCG describes community-based services that superseded a previous falls service, including a Home 1st Rapids service and the Staying Steady service, and asserts that these meet the original service's objectives.

Noted (AI summary) By 2023/24, anyone experiencing a mental health crisis will be able to call NHS 111 and access 24/7 age-appropriate mental health community support. By 2020/21 no acute hospital will be without a mental health liaison service for all ages in A&E departments and inpatient wards. The CCG acknowledges the coroner's concerns, noting that there appear to have been failings in care delivery which impacted on the ability for a bed to be located for Mr Watson, which BSMHFT have identified and taken actions to rectify.

Noted (AI summary) The Department of Health and Social Care highlights national initiatives to improve mental health services, including expanding CRHTTs, integrating primary and secondary care, and establishing a national single point of contact for mental health crises. They also reaffirm commitment to suicide prevention and will continue measures through the existing suicide reduction programme. The Trust is developing training and guidance for staff on Personality Disorder and patients with Personality Disorder, to be mandated for all staff working within our Home Treatment Teams during 2019/20. A Personality Disorders Strategy which includes clinical standards to be met for patients with a diagnosis of Personality Disorder is being led by the Trust's Chief Psychologist. The CCG acknowledges the coroner's concerns and is unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function and to also improve processes for learning from deaths at the earliest opportunity.

Noted (AI summary) The trust is developing a drug strategy to address illicit substance use in the medium secure unit including risk assessments, educational sessions, opiate replacement consideration and potentially making Naloxone available on discharge; it is anticipated to be in place from January 2020. The CQC clarifies its role in inspections, stating they did not ask the trust to relax rules on takeaways, but did ask for review of blanket restrictions and active risk assessment for patients returning from leave. They review actions taken by organisations if informed of drug problems.