Independent investigation into the care and treatment of Ms A

This action plan addresses all additional findings Chief Executive Officer Completed Trust Governance Board minutes April 2014 Page 125 of Independent Investigation Report evidences Trust Board Paper March 2017 completion of Internal Action Plan actions 9.1.1 – 10.2.2)

a. Application will be made to a Tribunal for all restricted patients. In exceptional circumstances, where a clinical team believes discharge via the MoJ to be more appropriate, this will be peer reviewed before the ratification. b. Embed learning via good practice meeting March 2015. Service Director Completed 2014 and now on- going Spot check November 2016 – there have been no discharges via MoJ since Ms A incident. All have been completed through the mental health tribunal process

a. April to June 2014 conduct an audit of the 20 (50%) of the conditionally discharged forensic outreach caseload Service Director Completed 2014 and now on- going Spot check November 2016 – Audit completed of restricted patients and the reports that go to MoJ to check that all information is in line with MoJ guidance in terms of content and completeness (audit) Check June 2017 - correspondance reflects behaviours and presentations in records reviewed

a. In line with recommendation 10, the Care Programme Approach and Trust Carer Strategy will be used to enhance carer involvement, to ensure family and other stakeholder engagement, as appropriate. b. The new forensic family, carer and important other directorate and Trust Patient Experience Involvement. Group (papers and minutes) strategy is now live and must ensure robust (Superseded by Trust Support and Networks Strategy 2016 – 19) Medical Director Completed 2014 and now on- going Patient Experience Group minutes (April 2014) Carers groups (minutes) Patient and carer feedback including family and friends feedback questions at Carer Support and Networks Strategy 2016 – 19 including network mapping tool appendix 2 page11. (Cross reference in Report Table 12 13.3.1& Table 13 10.3.1 page 66, 10.5.3 page 95) Check June 2017 - evidence of communication with families during CPA processes and feedback regarding experience of leave in records reviewed

a. Develop a protocol for foreign travel for conditionally discharged patients which will include formal pre and post reviews, as well as standards for communication with the MoJ, key family or friends involved in the visit. b. All foreign travel for conditionally discharged patients will need to be ratified by the peer review group. Service Director Completed April 2014 and now on-going Foreign Travel protocol form Terms of reference Senior Peer review Group Letters regarding agreement or not to travel abroad for restrictive patients. Spot check – November 2016 foreign travel protocol is being followed. Requests are rare. Only one was approved (documented in Conditional Discharge Report)

a) In addition to work within trusts, a pan-London programme is underway. A handover form developed by the MET Police will be piloted in specific London A&Es. The form will be used by the Police and A&E staff when faced with a patient voluntarily presenting to the department with mental health issues (i.e. those not detained). The handover process between the Police and LAS will be scoped to see if a similar handover process is necessary. b) An extensive communications and engagement exercise will take place throughout 2017 which focusses on operationalising London’s s136 pathway. This exercise will aim to clarify roles and responsibilities across the front-line staff (both NHS staff and the police) and to make sure they understand their powers and responsibilities & recruiting local champions. OXLEAS: Superseded by: Mental Health Crisis Care for Londoners: London’s Section 136 and Health Based Place of Safety Specification (December 2016) a & b) Programme Lead of Healthy London Partnership’s Urgent and Emergency Care Programme (this work falls under the mental health crisis care work stream within the programme). a) A pilot will take place in London A&Es to test the handover form’s pilot exercise. The pilot will commence in May for a three month period. Following an evaluation of the pilot a London wide rollout is expected to take place in summer. b) The communications and engagement exercise will commenced in March 2017, and many different activities will take place in 2017 including workshops for front-line staff. OXLEAS: Medical Director Director of Nursing On-going OXLEAS: Oxleas Borough Commander meeting (minutes) OXLEAS: a) Completed handover forms across London as well as a progress report following the handover form’s pilot exercise. b) Progress of implementation will be monitored by London’s Urgent and Emergency Care Board and Clinical Leadership Group and progress reports to the Board will be made available. OXLEAS: Mental Health Crisis Care for Londoners: London’s Section 136 and Health Based Place of Safety specification (December 2016)

a. Prior to being authorised to work independently, all staff within the MHLT to undertake a 9 week induction training programme which includes: 3 weeks shadowing, 3 weeks supervised practice, 3 weeks reflective practice, attending team based risk training. Only when this is completed are staff authorised to work independently. b. All staff will have attended annual risk training. c. All MHLS staff to have completed specific training in relation to risk management. Staff to complete one or more of following courses: risk management including clinical risk, assessment and management of risk in clinical practice and observation and engagement of patients at risk. d. On-going reflection on risk to be undertaken within MHLS clinical meetings and within clinical supervision. (Cross reference in Report Table 14 10.3.1, Table 16 10.3.1 page 66) Director of Nursing Medical Director Completed April 2014 and now on-going Supervision records (Trust electronic learning system) Training records (Trust electronic learning system) Observation training records for all ward staff in mental health (December 2016) Spot check November 2016 – the gold standard induction training remains in place in Greenwich. There is a further modified version in place for temporary staff. STORM training is being introduced to all crisis teams to be completed by May 2017 (STORM training records)

a. Greenwich MHLT to attend Whole System Meetings b. Greenwich MHLT to be based adjacent to Emergency Department c. Greenwich MHLT manager to have daily contact with Emergency Department manager Service Director Completed April 2014 and now on-going Whole Systems Resilience groups (minutes) Since 2016 daily bed flow report (excel)

a. Review MHLT operational policy – include clear procedures for transferring patients admitted via MHLT from the ED department directly to the ward. b. Policy requires staff and security to accompany admitted patients for ED to Oxleas House to ensure safe transfer. c. Policy cascaded to all staff who are required to sign a matrix confirming that they have red and understood the policy. (Cross reference in Report Table 18 10.4.1 page 88) Service Director Completed April 2014 and now on-going Sign off matrix Team meeting (minutes) Feedback and minutes whole system group Process reviewed following CQC feedback in inspection (2016) (minutes CQC actions)

a. Review existing community policy which includes standards and procedures for hand over to working age adults services. (Cross reference in Report Table 22 10.6 page105) Medical Director Completed April 2014 and now on-going Discharge protocol review November 2016 Spot check audit (audit report) Adult community mental health operational policy (Locality AMHS incorporating PCP, ADAPT and ICMP) version 28 (policy) Appendix 14 Standards and procedures for transfer to adult mental health services (policy)

a. Duty forensic on-call rota to commence on 20 September 2015 and formally reviewed in September 2014 and now on-going b. On-call forensic duty doctor will be contacted in the event of a patient open to Bracton / or known to have a forensic history consultation presents in a crisis c. the on-call service to be formally communicated to services Service Director Completed February 2014 On call rota (rotas)

Policies and audits of practice established in respect of: Service Director Completed See recommendation evidence of completion 8 – 20 identified in 2014 action plan, specific evidence: a. Practice of discharging conditionally discharged patients to low supported accommodation which does not have 24 hour staffing a. November 2016 - Practice of discharging conditionally discharged patients to low supported accommodation which does not have 24 hour staffing – no discharges b. Approach taken when patients are conditionally discharged gain employment in terms of communicating with employer and appropriateness of job b. June 2017 - Communicating with employer and appropriateness of job – communications evidenced c. Approach to use mental health tribunal (rather than MoJ by Responsible Clinician) for discharge c. November 2016 - Approach to use mental health tribunal (rather than MofJ by Responsible Clinician) for discharge – no discharges via MoJ d. Practice of recording in correspondence to MoJ to reflect behaviour and presentation d. June 2017 - Practice of recording in correspondence to MoJ to reflect behaviour and presentation descriptions included e. Practice of communicating with families and other stakeholders involved in care during CPA process and day to day management e. June 2017 - Practice of communicating with families and other stakeholders involved in care during CPA process and day to day management – communication evidenced f. Processes to support clinical decisions to allow patients on a conditional discharge to visit other countries f. November 2016 - Processes to support clinical decisions to allow patients on a conditional discharge to visit other countries – processes followed April 2014

a. Set up database to record information (‘notifications’) received from NHS trusts and non-NHS providers about all MAPPA eligible patients. b. Issue practice guidance to all London MAPPA Administrators. c. Hold meeting/s and briefings to inform NHS trusts and non-NHS providers covering London of the new (recently revised) MAPPA – Mental Health guidance, requiring MHTs to notify the MAPPA Co-ordinator/ Administrator of all their MAPPA eligible patients d. MHTs to confirm MAPPA policy (now replaced by London MAPPA Guidance 2014) implementation date d. Action c. above will require mental health services to have procedures in place to: • Identify all their MAPPA eligible cases; • Notify the appropriate MAPPA Co-ordinator/ Administrator (using form ‘MAPPA I’); • Update information and any changes in respect of MAPPA Level 1 cases. a. Business Director, London MAPPA Executive Office a. NHS trusts and non-NHS providers to be informed by 30 September 2017. b. Business Director, London MAPPA Executive Office b. Practice guidance issued by 30 September 2017 c. MAPPA Strategic Management Board Chair and NHS representative c. NHS trusts and non-NHS providers to be informed by 1st June 2017. d. MAPPA representatives in each MHT meetings between SWs and CPNs d. Action c. above will require mental health services to have procedures in place to: • Identify all their MAPPA eligible cases; • Notify the appropriate MAPPA Co-ordinator/ Administrator (using form ‘MAPPA I’); • Update information and any changes in respect of MAPPA Level 1 cases. a. Evidence of the database. b. Practice guidance c. Guidance/briefing materials. Schedule of meeting/s d. Evidence from trusts OXLEAS: MAPPA referrals discussed (Community MHT meetings between SWs and CPNs minutes) Bracton Unit Coordinator Role protocol (protocol)

A directive will be added to the NHS England Operating Policy for MH Homicide Independent Investigations. This will state that all investigation Specific Terms of Reference must include a line about inviting additional panel members with specialist knowledge as necessary. Chair of NHS England MH Regional Leads Forum Completed February 2017 NHS England Operating Policy for MH Homicide Independent Investigations. February 2017

a. Action plan to be presented to Trust Patient Safety Group on 11 March 2014, Forensic Patient Safety Group on 20 March 2014 and Trust Embedding the Learning Patient Safety Group on 8 April 2014 evidences repeating to remind and maintain embedding of learning Chief Executive Officer Completed Minutes of Patient Safety Group meetings 14 April 2014 Forensic Incidents Newsletter March 2016

a. Patient Safety Group to review internal investigations and ensure recommendations are SMART and auditable, leading to effective learning. Director of Nursing Completed 2014 and now on- going Learning Embedded Minutes of Patient Safety Group

a. The Mental Health Liaison Team (MHLT) operational polices to include clear procedures for transferring patients admitted following MHLT assessments from the Emergency Departments direct to wards. Following CQC inspection since 2016, bed management arrangements no longer allow patients to stay in Emergency Departments until a bed is available. Service Director Completed September 2014 MHLT operational policy.

a. The management of serious incidents policy to be revised. b. Audit of staff experiences of level 5 investigations to be completed by April 2014. Head of Patient Safety Director of Human Resources and Organisational Development Completed March 2014 And now on-going Trust Patient Safety Group (minutes 11 March 2014) Governance Board (minutes April 2014) Evidence of 2014 audit of staff experience not available. Staff Partnership confidential focus groups with all staff involved in serious incidents 2015 and 2016 (meeting records and Executive and Board papers and minutes)

Ensure that systems to support are in place: a. Senior management development programmes b. Work plans for medical, therapies, nursing executive committees c. New senior staff performance ratings d. Medical revalidations Chief Executive Officer Completed April 2014 Senior management development programme (feedback reports) And now on- going Medical, therapies and nursing executive work plans (minutes) Staff survey (action plans) Deloittes Well Led review (2014) CQC Inspection (2016)

a. In the first instance consideration is always given to 24 hour supported care. Where it is considered not clinically indicated, high support accommodation will be sought, however in exceptional circumstance, where a greater level of independent accommodation may be appropriate, these cases will be peer reviewed. b. In line with recommendation 10, the conditions upon discharge will be agreed by the MHRT, including discharge destination. c. Annual reviews of discharge pathway (Cross reference in Report Table 21 10.5.4 page 97) Service Director Completed April 2014 and now on-going Directorate referral meetings (minutes) Senior peer review group (minutes) Referral data base 2014 – 2016 (annual review) Protocol for the required discharge pathway (protocol) Spot check: December The annual reviews show that 2014 – 2016 had no discharges for anyone to live alone in independent accommodation. There have been discharges of people to live with their families. There is an up to date protocol which covers the required discharge pathways (protocol)

a. Directorate will produce best practice newsletter regarding third party information exchange and disclosure, This will be formulated based on the Trust policies and professional body guidelines noting in particular that best practice should be in line with latest MAPPA guidelines (2012) b. Separate consideration of disclosure regarding mental health vulnerabilities, and regarding risk to others, will be evidenced, both of which require different actions which need to be recorded. c. Multidisciplinary decisions regarding disclosure must be evidences in progress notes and the updated risk assessment in RiO. d. The Trust will always disclose to an agency the relevant background in relation to criminal offences. (Cross reference in Report Table 10 10.3.1 page 66) Service Director Completed April 2014 and now on-going Disclosure to the workplace policy and flowchart Best practice Newsletter (2015) Check June 2017 - communication evidenced in records reviewed