Independent review of the care and treatment of Mr X

London

Published 01 Jan 2022

Subject Mr X

This is the independent investigation report into the care and treatment of Mr X published on the 26thJanuary 2022. Mr X was in receipt of services from East London Foundation Trust.

Report PDF Action Plan NHS England Source

Acceptance Status

Accepted 2

Total Recommendations 2

About this data

Acceptance Status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

Recommendations (2)

1 ELFT

Accepted

Recommendation

The Trust should ensure that for those service users with a primary diagnosis of personality disorder (and offending histories), there is clarity and agreement between teams and services within ELFT, including both formal and informal processes for resolving uncertainty and … Read more

Actions to achieve recommendation: The report and associated recommendation will be raised and discussed at a Trust Wide Personality Disorder task and finish group where appropriate actions will be agreed to For the small numbers of transfers from Changing Lanes to community. Implementation Lead: Medical Director for London Mental Health services and the Trust Director of Therapies. By when: Sep-20. Evidence of Completion: Paper from the Trust Wide Personality Disorder task and finish group re. Service users with a primary diagnosis of personality disorder (and offending histories). Monitoring & evaluation arrangements: Plans as agreed by the Trust Wide Personality Disorder task and finish group re. Service users with a primary diagnosis of personality disorder (and offending histories). Monitoring and evaluation of these plans will be via the Personality Disorder Strategy Group.

2 NHS England

Accepted

Recommendation

NHS England should ensure that a pan-London ‘task and finish’ group is set up with key provider and commissioner stakeholders. The aim of this work is to focus on health service provision for individuals with a primary diagnosis of personality … Read more NHS England should ensure that a pan-London ‘task and finish’ group is set up with key provider and commissioner stakeholders. The aim of this work is to focus on health service provision for individuals with a primary diagnosis of personality disorder and a history of offending behaviour that does not meet the threshold for OPD pathway specialist services; and to address the issues of inconsistency that are raised in this report. The goal is to ensure that concerns regarding risk, leadership and the efficiency of service delivery – together with greater clarity regarding the model of care - are resolved. It is likely that there is learning from the implementation of the OPD pathway that could be incorporated into any recommendations for the wider personality disorder service delivery. We suggest that a ‘task and finish’ group could comprise a mix of senior professionals, commissioners and service users from across London, in order to develop a protocol that sets out expectations for the accessibility and suitability of mental health services for this group of individuals. Such a protocol should: • Be based on the current evidence base for effective management of individuals with personality disorder and offending histories • Draw on senior mental health experience of service elements that have maximum beneficial impact • Ensure a range of accessible and personality disorder-relevant offers are available for service users • Emphasise those aspects of service user experience that are most closely linked to ‘services that can be helpful’ • Develop a protocol that is resource neutral • Provide commissioners with clear guidance as to ‘what good looks like’ in this area of work. • Incorporate areas of good practice or innovation that can be replicated across trusts. • Recommend a mechanism by which pan-London boundary disputes (geographical and inter-service) can be resolved in a timely manner in order to facilitate access to services. • Ensure that the work considers the need for an interface with new developments in the OPD pathway, Provider Collaboratives, and the new Integrated Care Partnerships. Show less

Actions to achieve recommendation: For this work to be incorporated into the Mental Health Transformation work stream with a responsbility for developing the London Community Personality disorder pathway Support systems for staff working with complex needs. Further actions to achieve recommendation; Hold x 6 Task and Finish Group. September 2021 Review and complete Summary Report. November 2021 Hold monthly T&G meetings to review progress. Develop 2022 Business Plan for CEN/PD HLP programme that includes actions from T&G CMSVRP pilots announced. January 2022 Carry out 2022 business plans. Implementation Lead: Executive Director of Performance, NHSE/I London. By when: Ongoing. Task group has been meeting monthly since May 2021. Evidence of Completion: Task and Finish Group established. The group has divided the work into following themes: Prevention, Leadership and Partnership, Access to service provision; Interventions, Carer and Significant other support; Commissioning, Training and Support systems for staff working with complex needs. The task group have recognised that this work is being implemented at a time new systems and structures are being embedded across health care and longer term successful engagement of work streams identified requires ongoing partnership working and leadership via the London Integrated Care systems in collaboration with London Mental Health Provider Collaborative teams, Mental Health Care Trusts, Healthy London Partnership and NHS England and NHS Improvement London region. Minutes of Task & Finish Group meetings. Copy of Summary Report Copy of the Business Plan CMSVRP pilots announced. Copy of Summary of Outcomes and Community Board minutes. Monitoring & evaluation arrangements: Serious Untoward Incident Task and finish group has been meeting monthly since May 21. There is ongoing oversight to ensure this work is embedded into new system structures via the Mental Health Transformation Programme. Monitoring and Evaluation will be via the Mental Health Transformation Programme. Minutes of MH Tranformtion Board Q2 Apr/22-Jun/23