Independent investigation into the care and treatment received by Mr B

EPUT must assure ourselves that we have an effective shared risk management information system in place which supports: 1. Effective sharing of risk information, so that teams can work collaboratively and produce up-to-date risk assessments and support plans which clearly identify routes of escalation. 2. Recording and sharing of actions taken and their impact, so that all system partners are assured that effective action has been taken in response to risk 3. The involvement of the individual and their family/carer so that their concerns and opinions are heard and can contribute to risk management. 4. Having processes in place which look at the quality of risk assessments and care plans, so that they are used to effectively support people using services. Target date (Measurement Tool & action frequency of monitoring owner Progress, Comments & Evidence (SMART) implementat (eg daily, monthly) (role, team ion directorate) EPUT must assure ourselves that we 1. Training on risk Team December Record keeping have an effective shared risk assessment. manager 2025 Training has been delivered on clinical record keeping. management information system in 2. Organisation of place which supports: professionals meetings DDQS A separate training package is also being developed to 1. Effective sharing of risk for when multiple support newly appointed care co-ordinators. information, so that teams can providers are involved. work collaboratively and produce 3. Audit results of risk As part of a Trust-wide programme to put in place eSOPs, up-to-date risk assessments and assessments including the Clinical Record Keeping Standard Operating support plans which clearly involvement of families Procedures is in development. It has a section on risk identify routes of escalation. assessments. 2. Recording and sharing of actions taken and their impact, so that all New Trust care plan is due to be implemented in next system partners are assured that quarter. effective action has been taken in response to risk There is auditing of person-centred care plans and risk 3. The involvement of the individual assessments.

EPUT, Southend-on-Sea City Council, Brook Meadows House and Commisceo Primary Care Solutions must have a system in place which provides a notification when actions have not been taken and assurance that: • When safeguarding concerns or alerts are raised, actions are taken. • Outcomes of actions and their impact are assessed and recorded and shared with all relevant parties. Target date: Dec 2025 Progress, Comments & Evidence: 1. Regular monitoring of Team manager, Trust-wide Safeguarding Adults Procedural Guidance safeguarding incidents and DDQS and in place. issues through CIRG, Safeguarding At the time of this incident, the team was integrated management of Datix and with social care and therefore Recovery and QoC. Wellbeing would have taken the lead in the inquiry. This has now changed as the team is no longer integrated and the local authority now leads safeguarding investigations. This does not however negate the care co-ordinator from having a responsibility to keep their patients safe. Safeguarding referrals are managed through our incident reporting system.

EPUT must: 1. Evaluate caseloads for acuity and volume and develop a plan so that staff are working with equitable workloads. 2. Evaluate local capabilities and training needs for complex case management and develop a plan to address any gaps so that staff have the right support and knowledge, skills, supervision and mentoring to perform their roles. 3. Assure itself there is effective monitoring of which cases are held by the duty team, that risks are being managed effectively, and that people are allocated a care coordinator as soon as possible. Target date: Dec 2025 Progress, Comments & Evidence: Evidence from review of Team manager Increase in substantive staff over agency. caseload review. Trust one-to-one support template for supervision. Supervision rates and Improvement to allocation of care coordinator structure. process, including communication to the patient and GP. The team has been reconfigured to work in geographical clusters which aims to provide better support and accountability for unallocated patients.

EPUT must review its processes for referral into Psychological Services to ensure that: 1. People using the service are aware that they can access individual therapy without first having to attend the Psychological Awareness Programme. 2. The referral process is fit for purpose and monitored by the leadership team, and that level of risk is considered. 3. People’s preference for how they engage with services (virtually or face to face) is considered. 4. Staff understand what psychological therapies are available, and how to refer people to them. 5. Referrals clearly indicate which pathway is being requested. 6. Access to psychology is equitable across the Trust; EPUT and the integrated care systems (ICS) must identify any shortfalls in capacity in the commissioning of psychology across their footprint and work together to ensure that it meets national guidelines. 7. Suitably qualified and experienced staff deliver psychological therapy for depression as a first line of treatment in line with NICE guidance. 8. They work with psychology staff to develop a system to upskill others in the community mental health team to mitigate the long waiting times for psychological intervention. Target date: Dec 2025 Progress, Comments & Evidence: Team manager and Dec 2025 People can access the Psychological Awareness Performance and quality data Head of South East Programme (PAP) prior to an individual assessment for Psychological Services Essex Adult or therapy and personalised plan made with patients Training information Community who opt not to access this. Psychological There are weekly locality meetings across the area. Services Clinical decision making is always employed to ensure that intervention delivery will meet individual needs to best ensure safe and high quality practice. Discussions are held in supervision and through a weekly Psychological Services clinical discussion meeting. The Southend Recovery and Wellbeing staff have undertaken a series of training sessions in psychological therapies to upskill them to better support patient waiting for psychological interventions. All therapy plans are personalised and needs led. Where this matches NICE guidelines, the services delivers referenced models. Clinical decision making is always employed to ensure that intervention delivery will meet individual needs to best ensure safe and high quality practice. These discussions are held in supervision and through a weekly Psychological Services clinical discussion meeting, to further assure competent and optimal clinical decision making.

EPUT, MSE, Southend-on-Sea City Council and Brook Meadows House must assure themselves that: 1. All health and social care professionals understand the scope and limits of the services each team offers. 2. The model of care and delivery meets the needs of people placed there and staff have the knowledge, skills and capabilities to meet the needs of people placed there. 3. There is a link to the specialist services to meet the needs of people placed in the assessment unit. 4. There is an effective escalation system to flag where there are challenges in collaborative working and solutions can be found to ensure that service users’ needs are met. 5. All organisations involved in delivering care should assure themselves that: multidisciplinary meetings are arranged to plan care which considers all the care needs of the individual. 6. The roles and responsibilities of all health and social care professionals involved in delivering care are agreed. 7. Multidisciplinary reviews of delivery of care are carried out at agreed intervals and in response to risk. 8. Care and risk plans are developed and reviewed regularly by the multidisciplinary teams and the service user to monitor their efficacy. Target date: Dec 2025 Progress, Comments & Evidence: Team manager Dec 2025 Local management: Review of cluster working.  Weekly MDTs Training information.  Cluster meetings with consultants  Supervision sessions to include review of patients mental health, social and physical health needs. Shared care planning and risk management: When other professionals are involved with a patient, separate professionals meetings are arranged by the care co-ordinator or key responsible professional. Additional physical health training is being incorporated into the community mental health teams’ training: Physical health staff link contacts will be provided through the training plan to support collaborative working.

EPUT needs to: • Ensure that reasons for posthumous access to records are defined in the record keeping policy • Assure itself that all records, including contacts with partner agencies, are being recorded in line with expected practice Target date: Dec 2025 Progress, Comments & Evidence: New clinical record keeping DDQS Dec 2025 Clinical record keeping guidance in development. guidance, which includes There is auditing of person-centred care plans and specific information in relation risk assessments. to posthumous entries Clinical record keeping audit.