Independent investigation report into the care and treatment of Mr N in Derbyshire

To review systems and processes in relation to risk management and care planning. DHCFT replaced its previous FACE risk assessment tool with a new safety assessment tool in 2015. This process has been incorporating additional updates during the last 12 months. A number of pilots have also been rolled out in relation to more area specific tools.

For the service to review admission process in relation to Section 2 MHA patients into the Kedleston Unit. The operational policy for the Kedleston Unit has been updated and no longer excludes the admission of patients under Section 2 of the Mental Health Act.

To ensure appropriate systems are in place to monitor and review safeguarding referrals and action plans. The Trust has processes in place to appropriately record and action safeguarding referrals, which are audited on an annual basis. This process will continue to take place alongside ongoing audits to ensure our practice remains at the expected standard.

A standard operating procedure is in place, with clear timelines and accountability. The PICU proposal has been revised. A revised escalation protocol has been designed to aid the smooth transition if patients need/require additional levels of service into a high level of clinical care provision. This is a single point of access. Urgent referrals are in place.

To revise and adjust protocols regarding PICU and out of area. Revisions have been made to the DHCFT PICU and out of area protocols and a new flowchart has been developed between partners, to include the NHS England secure service specification protocol. This agreed new practice is in place. A revised local management team operating procedure has been updated and has been included in on call and business continuity procedures.

This has been agreed and NHC NHS FT Trust have agreed to the protocol

The Derby & Derbyshire CCG commissions PICU beds from a selection of NHS (non-Derbyshire) and private providers. PICU beds are accessible and work has been undertaken to support this work through a PICU Manager. There are some residual risks that a PICU provider could refuse admission due to clinical grounds. Therefore, in cases of this nature an escalation protocol has been drafted. The protocol/escalation meeting was co-designed on 8 November 2019, and has been agreed. Urgent access to PICU and a PICU contract is secured through a contract and is in place. The Trust has written an expression of interest to the CCG to provide a PICU service within Derbyshire. This includes a clinical case for change based upon current PICU needs together with the longer term needs of a future growing population.

To revisit the Trust’s Emergency Incident Response plan and whether it is fully activated including record keeping. DHCFT has emergency incident response and business continuity plans and procedures in place, available to all staff. The Trust’s on call rotas ensure the availability of two levels of on call managers at all times outside of usual working hours. In the event of serious disruption (such as closing the 136 suite for more than five days for example) emergency planning principles and practice would be adopted. DHCFT note the feedback to improve record keeping of all escalations and evidence of those actions, with dates and times.

To seek additional advice from the CQC as health regulator, national regarding seclusion practice and definitions of an ‘independent review’ and review the Trust’s policy in light of this information. The policy has been reviewed and advice from the CQC national team on definition of an independent review (see below)*. DHCFT will ensure record keeping defines any future independent team, and include details how are they are independent from the team that recommended seclusion. This action is therefore is complete We have sought and will seek further advice from the CQC and other trusts and benchmark practice as part of further quality improvement. * Response from the CQC: The Code isn’t completely specific about what ‘independent’ means in the independent MDT review of seclusion discussed at paragraph 26.141 onwards. I think it is clear from para 26.142 that it means independent of the treating team. As such it would seem clear that the purpose of the Code here is to ensure that people, who have not been involved in the decision to seclude, or reviews of that decision to date in this episode, are asked to review what is going on.