Independent investigation into the care and treatment of Mr B

Since 2012 the Trust has made progress to ensure effective systems are in place for care planning across all services. From 2016 home treatment and acute inpatient services are operationally delivered as one service line. This has ensured that home treatment and the inpatient wards work closely together to plan care and manage risk. The Trust’s operational protocols clearly set out the importance of establishing as early on as possible the reason for referral to home treatment or the purpose of admission to inpatient services. This has been critical in supporting care planning for patients during the respective treatment episode. The Trust has a well-established programme of audit to check the completion and quality of risk assessments against trust guidelines. This has been informed by on-going feedback from the Care Quality Commission (CQC) and the Trust’s commissioners. The governance processes within the Trust have undergone a thorough review to ensure assurance is provided on quality and compliance. The Trust has reviewed the documentation used for care plans and risk assessments. From January 2017 a single risk assessment is used in adult mental health, this tool links to the inpatient and home treatment team care planning tool. The care planning tool allows the creation of care plans based on identified risks and needs which ensure care plans are comprehensive and appropriate. In community services a Recovery and Support Plan has been developed to support clinicians to develop a comprehensive care plan considering a patient’s needs and risks. This includes sharing information with others. The Trust has worked to ensure systems are digitalised and taken directly from the clinical notes. This includes compliance/completion information is available to teams via the My Dashboard function in the clinical notes system. This allows real time monitoring of compliance with care planning. A digital audit process ensures that care planning in both home treatment and inpatient services is not only completed but to a high quality. This digital process provides an audit framework and centralises the results. The digital audit of the quality of care plans commenced in October 2017, these require each CAG to review care plans completed within their services with the findings being reviewed in CAG governance meetings. The findings of the audits are reviewed at Acute Care Clinical Academic Group (CAG) governance executive meetings to monitor progress and implement actions where practice falls short. As psychiatric liaison services are based in Accident and Emergency Departments, a separate formal care plan is not devised because episodes are usually one off. The treatment plans for patients assessed in this setting are communicated in writing to the GP with a copy to the patients. There are specific documentation standards that are monitored by the clinical service lead and the findings are shared in the Psychological Medicine and Integrated Care CAG governance executive meeting. Patients who are receiving care from other part of the service must have a crisis plan that liaison practitioners in A&E can use to inform next steps in crisis management. The next step for the psychiatric liaison service is to expand the digital audit tool to reviewing GP letters. These approaches apply to all patients accessing crisis care, regardless of Mental Health Act Status or whether they are subject to the Care Programme Approach (CPA) or not. Any future developments in care planning processes will be auditable using the Trust’s digital audit tool. Psychological Medicine & Integrated Care CAG Clinical Director & Deputy Director Acute Care CAG Clinical Director, Deputy Director – Crisis Care & Deputy Director – adult inpatient  The Digital Audit Tool for Implementation of Care plans are being completed amended digital tool in line with Trust standards. evaluate treatment plans by There is work being undertaken 31/03/2018 to improve quality of care plans formulated by liaison practitioners that are and ensure that they are linked included in GP letters. to the risk assessment.  Continue to ensure that crisis plans of known services user are kept up to date by the relevant community teams. Further actions relate to the monitoring of the existing SLaM processes.  The findings from digital audits of care plans will continue to be a standing agenda item to discuss and act upon by the CAG governance executive meetings. Review and monitoring of the efficacy of actions due:  31/10/2018

The Trust has addressed the actions in relation to this recommendation through several policies and their implementation.  Domestic Abuse Policy v2.3 (2017)  Managing Safeguarding Allegations Against Employees v1 (2016)  Safeguarding Adults Policy v2.3 (2016)  Safeguarding Children Policy, Principles and Procedures v5 (2015) During 2016 the Trust reviewed the Domestic Abuse Policy and made updates that ensure that this recommendation is addressed. All clinical staff are given a brief introduction to domestic violence and abuse as part of both safeguarding children and safeguarding adults mandatory training. In addition to this, staff can also access e-learning around domestic violence and abuse via the trust’s domestic violence and abuse intranet site and should be encouraged to attend face to face training. All domestic violence and abuse champions must attend specific training to undertake that role. This training will be provided by either the local safeguarding children’s boards or the domestic violence and abus abuse voluntary sector. Locally the Trust have developed effective working relationships with Croydon Family Justice Centre. The Trust attends the Croydon Borough Domestic Abuse system wide network meeting and has provided education about mental health at these events. The Trust has a nominated Borough lead who attends the Croydon MARAC, providing information about known service user as per our information sharing agreement. Safeguarding Team Director of Social Care & Trust named nurse for Safeguarding Children and Domestic abuse lead Actions to be raised in the Trust Safeguarding Committee for oversight.  Continue to monitor and embed the domestic abuse policy  Review of compliance in line with Domestic Abuse Policy, Safeguarding Adults Policy and Safeguarding children Policy by: September 2018 Action to be raised under any other business at next Trust Safeguarding Committee on 18 January 2018 Review and monitoring of the efficacy of actions due: September 2018

The Trust has developed electronic resource pages on the Trust intranet to provide current information on Domestic Abuse, contacts of external agencies and where to access support. Locally in Croydon, Domestic Abuse information is displayed in community teams and bathrooms. Safeguarding Team Director of Social Care & Trust named nurse for Safeguarding Children and Domestic abuse lead  Actions to be raised in the Trust Safeguarding Committee for oversight. January 2018  The Trust will audit the knowledge of how to access Domestic Abuse advice from 2 team leaders in each Borough to ascertain if improvements need to be made in this area. March 2018  A Trust wide event will be held in 2018 focussing on the learning from domestic violence and abuse September 2018

The Trust Safeguarding Adults policy was revised in 2016, in light of both the Care Act 2014 and the new London Multi-Agency Safeguarding Adults Policy & Procedures (2016). The Trust policy reflects the statutory requirements and London procedures. The statutory framework introduced under Section 42 of the Care Act applies specific safeguarding duties to any person aged 18 or above whom: • Has need for care and support (whether or not the Local Authority is meeting any of those needs) and; • Is experiencing, or is at risk of, abuse or neglect, and • As a result of those care and support needs, is unable to protect themselves from either the risk of, or the experience of abuse or neglect. The revised Trust Safeguarding Adults policy (2016) gives advice on what other processes may be applicable to support a person in relation to a concern that falls outside the above Care Act S.42 remit, including signposting to local Domestic Abuse services, involvement of Police or referral to MARAC. The revised Trust policy also includes an Appendix, with supplementary information regarding Domestic Violence, adapted from ‘Pan London’ 2016 Safeguarding Team Director of Social Care & Trust Safeguarding Adults Lead Safeguarding adults is part of the mandatory training provided by the Trust. Compliance is monitored by each of the clinical areas. Action to be raised under any other business at next Trust Safeguarding Committee on 18 January 2018 Policy update completed in 2016 Review and monitoring of the efficacy of actions due by: September 2018

There is a clear interface between community teams and inpatient services. Prior to admission the Trust’s Acute Referral Centre identifies any potential barriers to discharge which is shared with the inpatient and community team. Within the Acute Referral Centre there is a Clinical Lead who focuses on the interface between the inpatient and community team. Each inpatient ward holds ward rounds which invite community staff and key agencies to be part of their care plans. The Acute Clinical Academic Group, who are responsible for adult inpatient beds, in 2017 the CAG developed and implemented the admission and discharge checklist which supports the implementation of the Trust Discharge and Transfer Policy. This also contains a discharge plan which can be hand written or typed and given to the client and relevant professionals. The CAG are undertaking a Quality Improvement in this area to monitor its efficacy and ensure implementation. Acute CAG Head of Nursing Clinical Director Service Director • A Quality Improvement piece of work is underway to improve the communication between inpatient and community teams in Lambeth. The learning from this will be shared across the Trust March 2018 • The Acute CAG will continue to monitor and embed the Admission and Discharge Checklist using quality improvement methodology. Further actions relate to the monitoring of the updated SLaM processes. • The Acute CAG will review the efficacy and provide an update on learning will be shared through the Serious Incident Review Group. Review and monitoring of the efficacy of actions due: October 2018

Since 2012 the Trust has amended the process for sign off for comprehensive serious incident investigations. The commencement and sign off of incident investigations are through strategy meetings to ensure all stakeholders are present to review and agree the specific actions before the sign off of the report. Where the allocated lead is not available they will be consulted with to ensure the action is appropriate and can be implemented. The Trust holds Lessons Learned events on the themes from serious incidents and complaints. Lessons are taken into the Team Leaders events, safeguarding events and shared with the education and training team to ensure that training is designed with an awareness of real life situations and learning from serious incidents. The Board has a quarterly report on the lessons learned from serious incidents. This is reviewed and any actions identified for further learning. The report is published on the Trust’s intranet and shared with staff via CAG governance committees and team leader meetings. Blue Light Bulletins are produced where specific learning and/or actions are identified. These are circulated widely throughout the Trust and reviewed in teams across the Trust. Locally, each Clinical Academic Group holds a serious incident panel which reviews serious incident investigations and monitors learning from action plans. The panels review and identify if there is learning to be shared across the Trust. The Trust has moved away from paper based action plans moving to an electronic system. The system allows actions to be themed, evidence to be uploaded to support the implementation and progress of actions. Actions are allocated to a lead which results in a notification email to be sent to them. Clinical Academic Groups monitor actions as they are nearing their due dates and provide reminders to leads. Real time dashboards can be produced to allow oversight of outstanding and overdue actions. Local Serious Incident Panels were established with each of the SLaM commissioners to ensure there was adequate monitoring and oversight of learning. From December 2017 onwards, the Executive Director of Nursing commenced a single monthly Serious Incident Review Group which has oversight of all serious incidents within the Trust. The Group joins commissioners and clinicians from the Trust to review investigations and agree actions plans. The Executive Director of Nursing chairs monthly Clinical Quality Compliance meetings, these monitor the implementation of actions from serious incidents. Executive Director of Nursing  The Trust’s audit department are currently completing an audit on the Lessons Learned from incidents including compliance with timescales for completion. Actions will be identified from the audit with oversight from the Quality Committee. March 2018  The Trust is commissioning an independent human factors consultant to review the themes and lessons from the serious incidents to identify further recommendations. April 2018

Since 2012 the Trust has amended the process for sign off for comprehensive serious incident investigations. The commencement and sign off of incident investigations are through strategy meetings to ensure all stakeholders are present to review and agree the specific actions before the sign off of the report. Where the allocated lead is not available they will be consulted with to ensure the action is appropriate and can be implemented. The Trust holds Lessons Learned events on the themes from serious incidents and complaints. Lessons are taken into the Team Leaders events, safeguarding events and shared with the education and training team to ensure that training is designed with an awareness of real life situations and learning from serious incidents. The Board has a quarterly report on the lessons learned from serious incidents. This is reviewed and any actions identified for further learning. The report is published on the Trust’s intranet and shared with staff via CAG governance committees and team leader meetings. Blue Light Bulletins are produced where specific learning and/or actions are identified. These are circulated widely throughout the Trust and reviewed in teams across the Trust. Locally, each Clinical Academic Group holds a serious incident panel which reviews serious incident investigations and monitors learning from action plans. The panels review and identify if there is learning to be shared across the Trust. The Trust has moved away from paper based action plans moving to an electronic system. The system allows actions to be themed, evidence to be uploaded to support the implementation and progress of actions. Actions are allocated to a lead which results in a notification email to be sent to them. Clinical Academic Groups monitor actions as they are nearing their due dates and provide reminders to leads. Real time dashboards can be produced to allow oversight of outstanding and overdue actions. Local Serious Incident Panels were established with each of the SLaM commissioners to ensure there was adequate monitoring and oversight of learning. From December 2017 onwards, the Executive Director of Nursing commenced a single monthly Serious Incident Review Group which has oversight of all serious incidents within the Trust. The Group joins commissioners and clinicians from the Trust to review investigations and agree actions plans. The Executive Director of Nursing chairs monthly Clinical Quality Compliance meetings, these monitor the implementation of actions from serious incidents. Executive Director of Nursing  The Trust’s audit department are currently completing an audit on the Lessons Learned from incidents including compliance with timescales for completion. Actions will be identified from the audit with oversight from the Quality Committee. March 2018  The Trust is commissioning an independent human factors consultant to review the themes and lessons from the serious incidents to identify further recommendations. April 2018

The Trust provides weekly monitoring updates to each of the clinical academic groups, Chief Executive and Executive Director of Nursing. These monitor compliance with the timescale for complaints. The Quality Compliance Meetings chaired by the Executive Director of Nursing provides individual CAG monitoring. Any delays to complaints being completed are reviewed in details to ensure that complaints are signed off. Deputy Director of Nursing To strengthen the Trust’s complaint policies several actions have been identified. • The Trust will amend the part 1 strategy meeting standard agenda for any concurrent processes to be referenced to ensure agreement on the investigation process Completed in December 2017 • The Trust investigations policy will be reviewed and amended to outline how complex investigations can be investigated through the complaints and incidents processes April 2018 • The Trust Complaints policy will be updated to provide clarity on the investigation processes June 2018

Since 2012, the Trust has undertaken a number of quality improvements in regards to risk assessment and risk management plans. This has included recovery orientated crisis planning for known patients, development of a new electronic risk assessment tool and ensuring risk assessment is the foundation of care planning in the inpatients and home treatment services. Crisis planning, particularly for people with a personality disorder, is informed by NICE guidance. With development of psychological treatments for people with personality disorder working collaboratively with service user to manage their risk is a central feature of this therapeutic work. This collaborative approach is embedded across all our treatment services and these plans follow service user when they are accessing crisis services (liaison psychiatry, home treatment and inpatient services) As a result of our journey over the last 5 years, which has been informed by feedback from the Care Quality Commission (CQC)the Trust have developed a single electronic comprehensive risk assessment tool that was implemented in January 2017 that is used by all of our services. The tool includes assessment fields for the common clinical risk domains. This information is then used to develop a risk formulation that informs clinical management. The management plan is incorporated into the assessment tool and articulates what the action is and by whom. The assessment tool also includes an evidence based clinician rated outcome assessment for people who are actively suicidal. Once the risk management plan is completed, the risk domains identified for a service user are automatically populated in their care plan. Compliance/completion information is available to teams via the My Dashboard function in the clinical notes system. This allows real time monitoring of compliance with risk assessment standards. As with care planning the Trust’s digital audit includes a review process for risk assessments, which is subject to the same scrutiny as care plans. As part of the risk assessment audit the Trust looks for evidence of regular review. Where there has been no change in risk the assessment should be reviewed six monthly. Where there has been a risk episode or change in risk, this should be updated on the day of the issue coming to the attention of the service. As with care planning these approaches apply to all patients accessing crisis care, regardless of Mental Health Act Status or whether they are subject to the Care Programme Approach (CPA) or not. Psychological Medicine & Integrated Care CAG Clinical Director & Deputy Director Acute Care CAG Clinical Director, Deputy Director – Crisis Care & Deputy Director – adult inpatient  Continue to ensure that a schedule of monthly randomised auditing of risk assessments is carried out by each team Further actions relate to the monitoring of the existing SLaM processes.  Continue to ensure that crisis plans of known patients are kept up to date by the relevant community teams. Review and monitoring of the efficacy of actions due: 31/10/2018  Continue to ensure that findings from digital audits of risk assessments are a standing agenda item to discuss and act upon by the CAG governance executive meetings.

The Trust has criminal justice in mental health teams who provide assessments in police custody. The teams signed an information sharing agreement with the Metropolitan Police in 2015. Within this there is specific reference to a client’s offending history. The Trust’s staffs are encouraged to routinely enquire about Police warning markers and a summary of offending history, particularly in regards to violent offences as this informs our own risk assessment. However it is at the discretion of the Custody Sargent if they share information about offending history as this is on a case by case basis. Behavioural and Developmental Psychiatry CAG Clinical Director Patient Safety Lead for Mental Health, NHS England (London Region) Independent Incident Review Group  No on-going actions identified for SLaM Agreement signed in 2015  NHS England London Region will share the independent investigation with the Metropolitan Police via the Independent Incident Review Group (IIRG) to allow the Metropolitan Police to consider any additional actions February 2018

The Trust has taken a number of steps since 2012 to consider the needs of carers and their role in care. The Trust is committed to implementing the national standards from the Triangle of care. Inclusion and Recovery In 2015 the Trust produced guidance on How to find the right balance – Carers and Confidentiality to provide clear guidance on how Trust staff should engage with carers and inform carers of what to expect from SLaM services. The Trust has a Family and Carer’s handbook with the second edition published in 2017. Both documents are available on the Trust external website which allows carers to access these at a convenient time. These are designed to empower carers to raise concerns and to ensure that staffs are confident in responding appropriately and sensitively. The Trust has reviewed the documentation of carer’s assessments to ensure these provide the best support to carers and family in August 2017 the Trust introduced the updated Carers Support and Engagement Plan which is designed to ensure that staff identify and engage with carers and then offer appropriate information and support. The plan pulls through all relevant carers from the patient's clinical notes. The plan is printed and given to the carer as a summary document. The plan has a dedicated section about a service user’s background, which includes prompts about significant relationships. In addition, the Trust’s child risk screen requires data about a service user’s contact with children and other people who have regular contact with the identified children. When the patient is able, we will gain a more in-depth understanding of significant relationships. We will also work with people close to the service user to gather this information, especially in the inpatient setting. Relationships with family and carers are considered as part of the assessment completed by an Approved Mental Health Practitioner for services users detained under the Mental Health Act, this social information to inform the Trust’s own assessment. Director of Social Care & Prof Head of OT/Lead Social Inclusion and Recovery  Compliance to be added to individual team dashboards March 2018  The Trust will continue to monitor completion through the monthly Quality Compliance Meeting Further actions relate to the monitoring of the existing SLaM processes. Review and monitoring of the efficacy of actions due: June 2018

The Trust has reviewed the Safeguarding Children Policy, Principles and Procedures v5 (2015) since 2012 and currently provides training at differing levels with a plan for refreshers. This forms part of the Trust’s mandatory training and is monitored in clinical teams and centrally through the education and development department. Levels include  Safeguarding Children Level 1  Safeguarding Children Level 1 and 2  Safeguarding Children Level 3 The Trust revised the Safeguarding children documentation on the clinical records system and implemented revised documentation which allows improved monitoring of safeguarding by flagging to users entering a patient’s clinical notes. Safeguarding Team Director of Social Care & Trust named nurse for Safeguarding Children and Domestic abuse lead  The Trust will discuss this recommendation in the Safeguarding Committee to gauge the efficacy of the new processes and identify any further actions. Action to be raised under any other business at next Trust Safeguarding Committee on 18 January 2018  A policy review is scheduled for July 2018. This report and recommendation will be considered as part of the policy review. July 2018

Specialist community teams provide interventions based on diagnosis. Since 2012 The Trust has implemented a personality disorder clinical pathway, which supports correct and timely diagnosis. People with personality disorder are supported by treatment community teams who review care and treatment at a minimum of six months. It is at this review that either confirmation or change of diagnosis is made. Appropriate planning and risk management will be put in place. The diagnosis will be changed on the clinical record and communicated to the GP. The Trust developed a personality disorder c with implementation from July 2015 onwards. With the development of improved access to services for people with personality disorder, there has been an overall improvement in timely diagnosis. However, for people who are not known to service the diagnosis of personality disorders is informed by an on- going assessment. This is because certain personality disorder can be missed diagnosed, especially when a person is misusing substances. The Trust must be certain before we give this diagnosis to a service user because of the impact this can have on their life. This is particularly challenging when there is limited contact with mental health services in the past. Education and support is critical before feeding back this diagnosis and as already mentioned this will take time. Psychological Medicine & Integrated Care CAG Clinical Director& Service Director  Continue to ensure that as part of the CPA review process that diagnosis is reviewed, documented and communicated to the service user and other relevant parties. Further actions relate to the monitoring of the existing SLaM processes.  Continue to ensure that at the point of changes to diagnosis care plans and crisis care plans are reviewed where appropriate. Review and monitoring of the efficacy of actions due: October 2018  CPAs are reviewed monthly by the CAG

Since 2012, the Trust have developed and implemented a Personality Disorder Clinical Pathway in July 2015. The pathway has four tiers based on a patient’s needs: 1. Peer support for people with personality disorders 2. Access to personality disorder specific therapies within the community team that the person accesses. Long term therapy for people whose risk is managed is available in our secondary psychological therapy services. 3. 18 month structured day programme for people with complex needs 4. Access to personality disorder inpatient programmes for people who cannot be discharged from hospital until they receive this treatment (this is external provision to the trust and funded by NHS England) The Trust believes that this pathway has improved the experience and treatment outcomes of people with a personality disorder. Critical to ensuring that the person is accessing the right part of the pathway is engagement and on-going assessment. Psychological Medicine & Integrated Care CAG Clinical Director& Service Director  Continue to monitor the efficacy of the Trust’s Personality Disorder Clinical Pathway. On-going with monitoring through the Psychological Medicine and Integrated Care Pathway Meeting monthly.  Identify resources to implement new evidence based treatments.

The Local Care Record launched in February 2016, the system allows GP and local hospital records to be viewed from within the Trust’s clinical notes for Southwark and Lambeth patients. GP registration can be identified and confirmed by all clinical staff. The Trust is currently working with other boroughs to replicate this system. For all boroughs, clinical teams have access to the NHS Spine which provides current details of GP. This forms part of the admin roles within teams and is monitored through Business Intelligence Dashboards. The Trust’s Acute Referral Centre ,triage all potential admissions to hospital) has access to the NHS Spine which provides details of patient's GP. This will be flagged before admission to inpatient services. There is an admission and discharge checklist in place which contains a prompt to clinical and administration staff to confirm a patient's GP status. Medical Director  The Trust will review the current system of providing access to the NHS Spine to ensure that all clinical services have access April 2018  The Trust will continue to work with other Boroughs as part of the integration of records Review of current stage due April 2018

The Trust have continued to ensure that all Psychiatric Liaison Team staff located in Croydon University Hospital have access to A&E records. Access to CHS A&E records by liaison staff, continues to be available-currently on electronic systems and previously on paper systems - for the outcome of their assessment to be recorded in these records. Clinical practice continues to require dual note entry which has been emphasised and highlighted. From December 2017 the Trust has received confirmation that an electronic solution has been successfully implemented to more easily facilitate dual record entry by the Trust team on both CHS and SLAM records through a single computer terminal - completed action December 2017. Electronic flags have now been placed on electronic patient record systems for both CHS (CERNER) and SLAM (EPJS) for highlighting risks, actions and completion of care plans. Psychological Medicine & Integrated Care CAG Clinical Director & Deputy Director  Audit of documentation by the Psychiatric Liaison Team to take place to provide additional assurance May 2018  Continue to work with Croydon Health Services NHS Trust to ensure good standards of documentation in both systems. Further actions relate to the monitoring of the updated SLaM processes.  On-going monitoring of established actions as per monitoring and evaluation column Review and monitoring of the efficacy of actions due: June 2018

Since 2012, the Trust’s lone working policy requires each community service to have a local lone working protocol. This requires practitioners to communicate home visits to the duty worker for that day. It is the duty workers responsibility to liaise with the local practitioner to ensure they are safe. A discreet password unique to the team would indicate if a practitioner was in trouble. The protocol is also clear that when a service user has a history of violence, visits should be in pairs. This approach was validated by the Care Quality Commission in 2016. Risk and Health and Safety Team Head of Risk and Assurance  The Health and Safety Fire Committee will review the lone working policy in 2018. March 2018  Continue to annually review local lone working protocols compliance against the trust’s Lone Working Policy. Further actions relate to the monitoring of the updated SLaM processes. Review and monitoring of the efficacy of actions due: September 2018