Independent investigation into the care and treatment of Mr E

As a result of the redesign the Trust will review to ensure these reflect the new structure and the communication between the Director of Social Care and Local Probation Services. The Lambeth community team will review their response to any patient who has been released from prison over the past 6 months. The learning from this will be reported through the Lambeth Directorate Governance Executive and Trust Serious Incident Review Group. Any amendments to the protocol will be made following this. The Trust is currently developing improved links with the Local Probation areas through interface meetings with the Director of Social Care. In 2018 the Trust redesigned the structure of services to a Borough based model from a clinical academic group structure.

All prisoners who enter prison are screened by the healthcare team upon arrival. Mental health needs can be identified either through an existing record such as a Prisoner Escort Record, A GP SCR, a referral via a MH Liaison and Diversion team from police custody/court, or an initial screen at reception, a second screen following 72 hours of arrival, or via any other sources of referral during their stay in the establishment. If a prisoner is identified with having a mental health need then HC providers are required to make every effort to obtain details about the individuals care plan and risk assessment from community mental health teams. All providers have been communicated with regard to this requirement. NHS England took over responsibility for commissioning prison healthcare from the following PCTs: 1.HMP Pentonville – Islington 2.HMP Wormwood Scrubs - Hammersmith and Fulham 3.HMP Brixton – Lambeth 4.HMP Wandsworth – Wandsworth 5.HMP Belmarsh – Greenwich 6.HMP Isis – Belmarsh 7.HMP Thameside – Belmarsh 8.HMP Feltham - Hounslow

The Trust has systems in place to ensure changes in team function are reviewed and considered for quality and safety issues and that functions of new teams are clearly communicated. In 2017 the Trust commenced a formal meeting led by the Medical Director and Director of Nursing to ensure any changes to teams have a Quality Impact Assessment completed. The Medical Director and Nursing Director, with the Service Directors, review proposed changes for Quality and Safety issues to mitigate against these as part of any changes. These include the new operating requirements of teams. Human Resources provide local support to Services to ensure changes are captured as part of the consultation process and changes are embedded in line with Trust Policy.

Further review and revision completed in 2018. In 2015 the Trust produced a Carer and Confidentiality booklet to support carers in sharing/receiving information. The guidance supports sharing risk information, receiving collateral information and provides carers with further support details. Carer and Confidentiality training is available for staff. Carer confidentially training for staff being piloted in the inpatient wards along with a video which deals with the difficulties of confidentiality. Each ward and HTT has a carers lead, with protected time for the role. There are bi-monthly carers leads forums. Aim of training: • To provide Carers and Confidentiality Training for all Acute Inpatient Wards. • To deliver the training in partnership with Carers Outcome of training: • For the participants to understand the complexity of ensuring confidentiality whilst supporting carers • For participants to feel more confident when dealing with issues of confidentiality with carers • For participants to understand the experience of carers with regard to confidentiality and the need to be sensitive and empathetic when listening to carers.

The Lambeth Community Team will complete an audit of zoning meetings to review the timeliness of entries into clinical notes following zoning meetings to provide assurance that the current documentation systems are working. A summary of the finding and any additional actions from this audit will be presented at the Lambeth Governance meeting and the Trust Serious Incident Review Group. During these forums a decision will be made about any additional actions required across the Trust. The Trust’s policy supports the documentation of clinical meetings in patient’s notes. Locally policy and protocols support this practice. Information is entered into systems as discussions takes place. Since 2013 the Trust has increased the mobile working devices such as laptops and tablets available to clinical staff. These devices allow staff to document and record clinical notes and meetings clinical notes and meetings without access to a computer. The Trust has updated the clinical notes system to include a zoning tab. As a result, a patient’s zoning status is displayed on the front page of the patient’s clinical notes. The update further aids oversight of zoning status by team leaders and clinicians accessing notes and the associated risk management plans. Electronic dashboards are in place to provide an electronic oversight. Clinical teams have access to clinical notes in their clinical review meetings allowing them to input discussions directly onto the patient record at the time of the meeting.

The Trust monitors use of these discharge emails including their completion within 24 hours of discharge. Since 2013 the Trust has developed and been part of the Local Care Record joining up patient records between GP practices in Lambeth and Southwark with Guy’s & St Thomas’, Kings College Hospital (KCH) and SLaM. The service allows GPs to access Trust records and vice versa. Discharge summaries are now sent electronically from the clinical record to the relevant GP practice. The Trust routinely sends electronic discharge notifications via email to primary care. These include a summary of the discharge plan, any outstanding tasks (e.g. around physical health) and current medication. This is a new initiative that was not in place in the community at the time of the incident

The Trust has reviewed the documentation of carer’s assessments to ensure these provide the best support to carers and family. Monitoring of carer's assessments being offered is now part of the Quality Compliance Monitoring meetings chaired by the Director of Nursing. This will continue to form part of the meetings. The Trust has this as a quality priority with 75% of all carers in Trust services to be offered the engagement and support plan. 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. 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. 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 carers support and engagement plan has also been introduced to provide key information to/for carers re: diagnosis/prognosis, their own support needs, any information they require and so forth as not every carer will be keen for an assessment under the Care Act. It has been informed by the NICE guidance for carers for those with schizophrenia.

A 6 month review of the audit programme commenced in Autumn 2017 will be undertaken by the Lambeth community teams to identify learning and any areas of improvement. The Director of Nursing will receive this report as part of the Quality Compliance Meetings and as part of the Trust Serious Incident Review Group. An action plan will be compiled to address any areas of improvement. A 12 month review will be undertaken to review progress against the action plan and action plan from the 6 month review. The Trust’s internal action plan provided evidence of the completion of risk assessments and escalation of concerns for complex patients using a series of case note audits. The process was commenced with follow up through supervision, zoning and clinical formulation meetings. Formulation and zoning meetings are included in the team local operational protocols. During 2017 the Trust reviewed and further developed electronic audit and monitoring programme of the completion and quality of risk assessments and care plans. These are reviewed in individual Borough governance meetings with themes from these reviewed in monthly Quality Compliance meetings commenced in Autumn 2017 chaired by the Director of Nursing. The electronic quality audit looks at appropriateness of identified risk and plans to manage these. Audits are completed by team leaders and managers which ensures the learning and any patient specific feedback can be given to the team. Until 2018 the Trust held local records of supervision monitored by each of the Clinical Academic Group line management structures. The Trust is moving towards recording the dates of supervision on the LEAP system, which holds data on training and appraisals for staff across the Trust.

A 6 month review of the audit programme commenced in Autumn 2017 will be undertaken by the Lambeth community teams to identify learning and any areas of improvement. The Director of Nursing will receive this report as part of the Quality Compliance Meetings and as part of the Trust Serious Incident Review Group. An action plan will be compiled to address any areas of improvement. A 12 month review will be undertaken to review progress against the action plan and action plan from the 6 month review. The Trust’s internal action plan provided evidence of the completion of risk assessments and escalation of concerns for complex patients using a series of case note audits. The process was commenced with follow up through supervision, zoning and clinical formulation meetings. Formulation and zoning meetings are included in the team local operational protocols. During 2017 the Trust reviewed and further developed electronic audit and monitoring programme of the completion and quality of risk assessments and care plans. These are reviewed in individual Borough governance meetings with themes from these reviewed in monthly Quality Compliance meetings commenced in Autumn 2017 chaired by the Director of Nursing. The electronic quality audit looks at appropriateness of identified risk and plans to manage these. Audits are completed by team leaders and managers which ensures the learning and any patient specific feedback can be given to the team. Until 2018 the Trust held local records of supervision monitored by each of the Clinical Academic Group line management structures. The Trust is moving towards recording the dates of supervision on the LEAP system, which holds data on training and appraisals for staff across the Trust.

The Lambeth community team will review a sample of patients from the full team caseload to ensure appropriate disengagement/DNA processes are in place/are being followed. An action plan will be developed to address learning from this as required. In 2015 Trust has developed a Did Not Attend (DNA) / Disengagement Policy which has been updated since the incident occurred. The most recent policy (2017) included the learning from this incident. The policy contains a 1 page flow chart outlining actions required should a patient disengage. Locally the timeframes for requesting a welfare check may differ. The Trust’s systems currently in place have provide evidence to support the Patient’s disengagement from services systems. is looked at on an individual basis with the risk assessment tool, updated in January 2017 linking to the risk management plan and care plans. Each clinical contact should consider the risks presented by a patient, including if a patient is not engaging with a service. The Trust has increased the use of zoning across the Trust, to provide an at a glance status on risk. Consideration of a patient’s zoning status incorporates the patient’s risk of disengagement. Following changes within the local police, in 2018 the Trust circulated a briefing note on how to access welfare checks. This includes key standards for requesting welfare checks.

A comprehensive training was undertaken during the launch period for the new risk assessment tool. Systems for qualitative and quantitative monitoring have been embedded with team and Trust wide access. The Trust has completed work to ensure that services are configured to allow for best practice in risk assessment. Since 2013 the Trust has revised an updated the policies and procedures for the assessment of clinical risk and management of harm. In January 2017 the trust published an updated risk assessment incorporated a number of tools including risk events and risk management plans into a single format. The Trust developed an electronic audit tool to monitor completion of this document with an audit of quality to support. Risk assessments pull information from previous risk events and provide a framework for the formulation of risk. The Trust has invested in mobile devices which allow clinicians to access and make entries electronic clinical records whilst out of the team base – these include tablet computers and mobile phones.

The review of a service user’s history is part of role transitions for any clinical staff. Clinical staff entering new teams are supported through inductions, handover, and clinical and managerial supervision. Strengthened supervision structures provide oversight and assurance for a robust handover of patients between clinicians. To simplify the information held in patient note’s, in 2017 updates were been made to the risk assessment and care plan documents. The revised documents pull through historic risks and lead to risk management plans. The single care plan in the community allows a formulation of the patient’s presentation, history risks and needs. The Trust has invested in mobile working devices to allow clinicians to access clinical information as required this includes tablet computers and laptops with access to clinical notes.

The Trust monitors delays in Mental Health Act Assessments using the incident reporting system. This allows monitoring and targeted actions for clinicians. During January 2018, the Trust developed a clear escalation process to ensure any delays in mental health act assessments are addressed. The protocol was published in February 2018. Any delay is reported as an incident, with oversight by the Director of Nursing, Chief Operating Officer and Director of Social Care. Information is shared between the Trust and the Local Authority to ensure delays are addressed where possible. Each delay is documented as an incident on the Trust incident reporting system. In May 2018 a multi-agency stakeholder event took place attended by Trust Senior Managers, London Ambulance Service, Police and Approved Mental Health Professionals from the Local Authority. Discussions on blocks were held and actions agreed to address delays. Each Trust Borough will arrange a weekly multi-agency teleconference to ensure any issues in delays with Mental Health Act Assessments are addressed by all stakeholders. The new processes are being embedded and will strengthen existing information sharing and partnership working between the Trust and other agencies involved in Mental Health Act assessments.

The revised section 117 policy will be ratified and circulated as part of the Trust policy bulletin. The policy flow chart and policy will be disseminated to all inpatient wards. The discharge proforma will be included as part of the Trust’s clinical notes system. The Trust will confirm the timescale for completion of this. The Trust has a section 117 aftercare policy in place. Guidance has recently been received from Association of Directors of Adult Social Care in relation to section 117 aftercare. The Trust’s Director of Social Care has reviewed the Trust policy in conjunction with the local social services authorities to ensure the policy and procedure is understandable for staff. The revised policy is currently out for consultation with plans for an update to the clinical notes system using a discharge proforma and a flow chart for staff.

Training on information governance is mandatory, information requests are responded to within. The Trust has clear policies and procedures on information sharing to ensure staff are aware including training, documentation and support from information governance. Information Governance training is mandatory training for all staff with yearly refreshers. This training provides guidance on information sharing and where to seek advice if required. Information sharing is underpinned by the Trust’s Information Sharing Policy which refers to information sharing with police and probation. The information governance team provide guidance on information sharing with other agencies. The Trust’s electronic clinical records, risk assessment and care plans, have specific section about communicating risk and plans as required. The Trust risk assessment tool links to the patient’s risk management plan which can be used for local management of risk such as bail conditions. The Trust has a Police Liaison Committee chaired by a Service Director, attended by local Borough Police Officers. The committee can be used to escalate any immediate communication issues as required.