Independent investigation into the care and treatment of Mr S

A Clinical Alert stating that all staff Clinical Alert Mental Health Law 30 September Manager 2016 need to be clear of the type of legal framework that was applied to a Recommendation 1 patient’s admission to a secure inpatient unit should be disseminated The Trust must ensure that when to all mental health staff. a team is liaising with a secure inpatient unit regarding care for a patient following discharge, the receiving team must ensure that they are clear what legal framework applied to the period of Inpatient care and treatment.

The Trust will ensure that positions of individuals who sign off key documents are stated, and that this expectation is reflected in policy documents. The CNWL policy on policies now explicitly states: “Responsibilities - This section should list the key responsibilities covered or allocated by the document, and the person, group and committee(s) that is responsible for each. Functional names should always be used in preference to people’s names.” Action completed

An audit of compliance with this Completed audit and Clinical Lead for Women’s 30th November recommendation will be undertaken recommendations arising from and Adolescent Service. 2016 Recommendation 2 within the Wells Unit (secure this. adolescent service). Monitored via WLFS Quality West London Mental Health Trust Matters Meeting. must ensure that prior to Trust wide Quality Matters and discharging a detained patient Quality Committee Meetings. from inpatient services, a section 117 aftercare meeting is held and that appropriate mental health aftercare plans are identified and put into place.

Statement from Central and North West London NHS Foundation Trust (CNWL): We extend our sincere condolences to the family and friends of Ms A for their sad loss and we acknowledge the pain and distress that they have endured. In addition to the actions already taken following our internal panel of inquiry, the Trust has fulfilled all of the recommendations made in the independent investigation, so actions are implemented and embedded to improve practice. This action plan has been monitored externally by the North West London Collaboration of Clinical Commissioning Groups, who have closed the action plan following their appraisal of evidence submitted by the Trust, and context given at an action plan closure meeting with them. Statement from the North West London Collaboration of Clinical Commissioning Groups North West London Clinical Commissioning Group (CCG) offer our sincerest condolences to all those family members and friends affected by this sad incident. NWL CCGs works with CNWL NHS Foundation Trust to seek assurance that the services they provide are safe; effective; caring and responsive. NWL CCGs has met with the Trust and is assured that the action plan has been completed. The Trust will continue to provide a range of evidence to the CCG to ensure they are providing services in line with the requirements stipulated within the contract held between the CCG and the Trust, the NHS Constitution, and Fundamental Standards of Care regulations.

An annual rolling programme of Care Completed audit forms Head of Information 28 February 2017 Records Audits is in place across the Governance Trust co-ordinated by the Care Recommendation 3 Records Group. The Trust must undertake a Audit templates are under review and Revised audit form review of record keeping across are being developed by the Quality Written analysis and 30 November the Trust, Directorate The audit will pay recommendations to each 2016 paying particular attention to the particular attention to record keeping division. child and adolescent mental compliance within the Child and Written communication and health service, Adolescent Mental Health Service. feedback to teams and services and implement an on-going audit from each divisional leads.

The CCG will produce an SOP that describes the systems and processes to enable it to be assured and monitor that SI action plans have been completed within the prescribed dates set by a provider. Evidence of a SOP that has been signed off by Director of Quality NWL CCGs. Completed action NWL CCGs Serious Incident Policy updated at Ratified in September 2020. This has a section on closure of action plans. The CCG is actively liaising with the Providers in terms of completion of their action plans for Homicides and Never Events. The CCG has adapted its database to be able to identify when actions should be completed by the Provider and this data is added once they have received the final report. This improvement will allow the CCG to request updates on completed action plans from the new year from the providers using a revised monthly provider status report. The assurance on the robustness of this system will be provided on the completion of action 4.

Completion of Trust wide audit Written analysis and Head of Information 31 October 2016 (recommendation 3 and 5) recommendations to each Governance division. Recommendation 4 The Trust must undertake an Development of the Data Quality Written communication and audit across the organisation to Policy feedback to teams and services Chief Clinical Information 30 September identify the degree of compliance from each divisional leads Officer 2016 with the record keeping policy. Communications to written and sent QRG’s Where there are concerns about out trust wide via weekly news compliance, the Trust must Ratified Policy implement a training programme Written Communications in Trust to ensure that all staff understand Quick Reference Guides to support weekly news the importance of all staff in relation to data quality (record communications regarding a keeping) available on the Learning and patient being filed within the Development Zone, (e learning). clinical record. The Trust must Example Quick Reference Guide also implement on on-going To support the Data Quality System 30 September programme of audit to provide standards of practice are being 2016 assurance that records are developed for clinicians dependent on completed correctly. level of responsibility to be overseen by Divisional Directors, Service Directors and Team Managers in conjunction with Performance Quality Data Quality System standards of Leads practice for the different levels within the organisation 30 September 2016

The CCG will undertake a Deep Dive of SI’s 12 months post the date of the SOP being approved to be assured that actions have been completed by a provider. Completion of the Deep Dive and a review of the recommendations from the Deep Dive. Deep Dive to be included in the NWL CCG Serious Incidents Report for Q4 of 2021/22 which is presented to the Quality and Performance meeting across NWL CCGs.

The audit template will incorporate specific questions in order to ensure that that the Trust has assurance that Revised audit form the correct procedures are followed in Recommendation 5 relation to compliance with the record Revised audit forms keeping policy and storage and Correspondence to divisions The Trust must ensure that when archiving practice. outlining actions and timescales placing records into storage and for completion archive, correct procedures are The audit templates will be followed to ensure successful disseminated to each division for retrieval at a later date. completion and the results will be An audit programme must also be submitted to the Care Records Group implemented on each occasion to by 17th January 2017 for analysis and Quarterly Information provide assurance that records recommendations. Governance reports have been stored correctly. Minutes of Information Any incidents that are reported via the Governance meetings outlining incident electronic reporting system discussions and action points relating to stored or archived records are included in the Information Governance quarterly report in order to identify issues and take appropriate action as necessary to minimise the risk of

A Clinical Risk Alert will be circulated Clinical Risk Alert and evidence of Clinical Safety 30 September Foundation Trust to all Psychiatric Liaison Teams who cascade to teams Manager 2016 will review the alert within team meetings and supervision sessions. Recommendation 6 The Trust must work with partner This will outline learning from this agencies providing accident and incident and requesting that the local Minutes of Psychiatric Liaison 31 October 2016 emergency services to ensure that Operational Policy should outline Team meetings the joint operational policies are guidance emphasising that all complied with, in particular that Psychiatric Liaison clinicians should Supervision records clinical records are available to review the patient’s A and E psychiatric liaison staff in a timely assessment (CAS card) prior to Copy of Psychiatric Liaison Team fashion, to facilitate fully completing the mental and state and Operational Policy informed assessment of patients. clinical risk assessment. The alert will also include guidance on the actions to be taken in any instance where this process is not followed i.e. incident reporting and documentation within the clinical record

The Trust welcomes this Standardised template Associate Director of 31 October 2016 recommendation as it enables us to Quality and Service build upon our existing systems. The Improvement Clinical Policies group oversees and Recommendation 7 approves clinical polices, trust wide. Each Clinical Policy must follow a The Trust must ensure that standardised template (cover sheet). operational policies are followed. The Trust must implement a Key aspects of each Clinical Policy are process to ensure that staff highlighted on the title page to inform understand the importance of key staff of aims and objectives of the aspects of policies. The Trust must policy. Example standard front page 30 September also implement a systematic 2016 process to provide assurance All new policies or new policy updates regarding compliance. are communicated to staff trust wide in the Trust’s weekly news Example communications for 31st October 2016 trust weekly news Assurance re compliance with clinical policies to be sought via  Clinical Supervision  Appraisal 31st October 2016  Completion of mandatory Trust compliance re appraisals training and essential to role and mandatory training training Supervision records  Completion of competency Training attendance frameworks and assessments Competency frameworks e.g. medicines assessments  Signed statements by staff Trust and local induction that key polices have been attendance records read and understood  Trust induction  Local induction

The Trust’s Clinical Risk Assessment The Revised Clinical Risk and Risk Clinical Safety Manager 31st January 2017 Foundation Trust and Risk Management Policy require Assessment Policy additional guidance as outlined. Recommendation 8 The Policy needs to be ratified by the Clinical Policy Group The Revised Clinical Risk and Risk 31st January 2017 The Trust must review the risk Assessment Policy-ratified by the assessment policy to clarify how Executive Director of Nursing and risk assessments should be Quality managed when the service user Communications informing all mental has a history that indicates a health staff of the additional guidance Communications material 31st January 2017 significant risk, but the clinical need to be circulated to all Trust team is unable to meet with the Mental Health via Internal Clinical Risk service user to fully analyse the Alert and the Trust Weekly News current risk.

In 2013 NHS England London Region Minutes of National Secure NSFMHFYP Network/NHS Core business and CCG) Specialised Commissioning assumed Forensic Mental Health Service E CAMHS Case Managers ongoing responsibility for commissioning all for Young People Network /Individual Trusts monitoring of Recommendation 9 specialised inpatient care for children Meetings (redacted to protect effectiveness and young people including those patient confidentiality) Commissioners of child and requiring secure services. All referrals adolescent mental health services to medium secure inpatient services must have systems in place to are considered by the national CYP assure themselves that child and Forensic Network on a weekly basis adolescent mental health service and assessments scheduled as part of providers respond in a timely this meeting. All referrals for fashion to requests for assessment prior to admission are assessments when the young approved by the Responsible Clinician person is in an institutional for the CYP (Consultant Child and setting. Adolescent Psychiatrist in the local CAMHS service). CCG commissioned CAMHS services are responsible for making timely referrals for children and young people who may require assessment for inpatient admission. The NHS England national Tier 4 CAMHS Service Specification sets out the expectations and timescales Service Specification included in NHS England Supplier Core business and required of providers in delivering the NHS England contracts with Tier 4 Managers ongoing assessment function for all CAMHS CAMHS Providers monitoring of inpatient referrals. The national effectiveness service specification is included as part of the NHS England Specialised Commissioning contract. All referrals for Tier 4 CAMHS admissions are made using the national referral procedure and information template. Service Review Reports and NHS England CAMHS Case Core business and NHS England CAMHS Case Managers outcome of ward visits Managers ongoing support local teams to access services monitoring of where required, and maintain effectiveness oversight of provider quality and patient pathways including discharge planning processes. Minutes of the Clinical Quality Local commissioners and Core business and All these processes will be monitored Group (CQG). contract leads. ongoing as part of the monthly formal contract monitoring of clinical group meeting.

The HTT have incorporated this action into the revised Operational Policy. In situations where patients are for example finding it difficult to engage with the service and risks are perceived to be complex, where support from several team members may be overwhelming or the patient may have stipulated a preference for working with a minimal number of staff. Decisions in relation to this issue take place in the daily review meetings.

Since this incident occurred mental health services in Hillingdon have undergone a service redesign. The new service was launched in March 2016. The changes brought together the Assessment and Brief Treatment (ABT) team and the Community Recovery Teams to form three locality community mental health teams (CMHTs) aligned with Hillingdon GP practices: Hillingdon North, Hillingdon West and Hillingdon East. As a result of the service redesign the ABT as a stand-alone team no longer exists; the duty function provided by the ABT is incorporated into the revised teams. The teams support two patient groups dependent on level of risk and need; those patients who are newly referred by a range of agencies for assessment and short term intervention including referral on to other services within secondary care and sign posting to external agencies including for example housing and alcohol and drug services and those with a higher complexity of needs who require support and monitoring on CPA. The multi-disciplinary team continues to provide duty cover through use of a rota; duty seniors provide senior support for duty workers to discuss patients and make joint decisions in terms of care and treatment. The model supports a greater level of continuity and partnership working in relation to assessing and supporting vulnerable patients where risks and needs are highly complex. In addition, where possible joint visits do still take place with the HTT and the relevant CMHT

Please see response to recommendation no. 2. Consultant Psychiatrists working in CMHTs hold a combination of patients supported on the Care Programme Approach and Lead Professional Care in addition to providing initial assessment of patients newly referred to the CMHT.

The Clinical Director and Borough Director for Hillingdon Mental Health Services attend a twice yearly network meeting with local GPs. There is a GP representative for mental health services so that other GPs have direct access to the service and are able to raise any issues or concerns in relation to the care provided to their patients. Each GP has been given contact details for the Clinical Director, Borough Director and Service Manager. There is also network newsletter that all GP’s receive which the GP MH lead uses to update all GP’s about any possible changes or developments within the service Additionally the Clinical Director attends the GP mental health master class to provide training and development in relation to supporting patients with mental health problems. CNWL now have The Single Point of Access (SPA) team, which offers mental health triage for routine, urgent and emergency referrals, in addition to information and advice 24 hours a day, 7 days a week, 365 days per year. The team takes referrals from GPs, other statutory services such as the Police and London Ambulance Service, and non-statutory services such as housing providers. The team are also able to make appointments with the appropriate locality community mental health team. People can also make enquiries on behalf of a family member or friend.

A system (standardised forms-MH2, 3, 4 and 5) is in place to support mental health services to liaise with GPs in order to keep them informed of decisions made by mental health services at the point a patient is referred by a GP, following a review of care and treatment and when a decision is made to transfer the patient back to the GP. Team members also ensure that where necessary telephone contacts are made to the GP to follow up written feedback

The inpatient/HTT discharge notification form, which is sent to the GP includes a section which indicates where the patient is being discharged/transferred to either within CNWL or back to the GP.

Guidance was issued by the Trust medical director and chief operating officer to all clinical staff in May 2014. Information Governance training completion annually is mandatory for all staff and includes Caldicott principles for guidance regarding information sharing. The IG training is currently being reviewed to further support staff understanding of collaborative working and information sharing to ensure that professionals have comprehensive information of the care and treatment that clients are receiving from non-Trust health providers.

Advice was sought from the GMC, who informed the then Medical Director that whilst they would expect doctors to cooperate with inquiries, it is not a statutory obligation and in this situation the doctor had cited justifiable and mitigating circumstances. Minutes of a meeting from 9 May 2014 are available for assurance and evidence.

The Trust Incident and Serious Incidents Policy advises managers on the importance of staff debrief following incidents and the serious incident investigation process requires investigators to note whether or not staff have been offered support. The trust has an extensive programme to support staff at work, which staff can access directly.