Level 5 Serious Incidents Annual Report
2012-13
Richard Vergez, Associate Director, Corporate Governance
September 2013
Executive Summary
This Annual Report provides an overview of both the Level 5 Serious Incidents (SIs) reported during 2012/13
and the RCA reports completed during this period. In principle it covers all parts of the Trust (i.e. Mental Health
and Community Services) but in fact focuses only on Mental Health as the Community Services did not have
any L5 Serious Incidents in 2012/13.
Level 5 SIs have reduced in number in each of the past 6 years (61 in 2006/07, down to 39 in 2011/12).
However in 2012/13 the number was 50, an increase of 28% on the previous year. During the year, there were
4 alleged homicides and 4 apparent inpatient on-ward suicides, all of which required investigation by a NED
chaired panel of inquiry. Previously the number was around 2 a year. These two factors represent an increase
both in the overall number of L5 SIs and of those requiring the highest level of investigation.
According to the National Confidential Inquiry Annual Report, the rise in patient suicides (in 2011) probably
reflects the rise in suicide in the general population, which has been attributed to current economic difficulties.
Analysis against previous years shows Level 5 SI reports continue to contain a large number of
recommendations regarding communication, risk assessment and management and record keeping. However,
dual diagnosis / substance misuse were not prominent in the recommendations from reports completed in the
past year.
A mid-year analysis of demographic data on patients involved in L5 incidents showed a marked increase in
suicides involving men (although it is now nearer to the national average), with improvements in the number
who had had a risk assessment on time or within the past 12 months, being compliant with medication and
fewer having physical healthcare issues. These were indicators that were moving in the right direction.
An initiative launched by CNWL to benchmark the past 3 years suicide data with other London providers of
mental health services is taking place. The results will provide a London-wide analysis of suicide. Although not
ready in time for this report, the results will be reported to the Board.
The number of apparent inpatient on-ward suicides is considerably higher than in previous years. However, the
reports of the 2 completed investigations are generally not critical of care and treatment. The number and
significance of recommendations from these reports is smaller and less critical than those relating to previous
reports on inpatient suicides. Neither of the 2 inpatient suicides were considered to be predictable.
In respect of alleged homicides, of which there were two by patients during the year, the areas where
recommendations remain a key theme are communication and risk assessment & management. These echo
the recommendation themes contained in other serious incident reports.
The distribution of the 50 SIs occurring in this period shows the highest number being in Acute, Community
Recovery and ABT Service lines. However comparison with previous years is not possible as the restructuring of
mental health services was fully implemented in April 2012.
The timescale for completion of RCA reports is 45 working days (from the incident being reported) and 60 for
cases such as inpatient suicide and homicide. These targets have been challenging for often complex
investigations. During 2013/14 the Trust is introducing a team of 3 full-time investigators who will be available
to work on serious incident and complaints investigations. This will facilitate investigations being completed
within timescale, and to a higher and more consistent quality standard.
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Level 5 Serious Incidents Annual Report 2012-13
1.0
Introduction
1.1
This report details two aspects of Level 5 Serious Incidents (SIs). First a description of the data
relating to Level 5 SUIs that occurred in 2012-13; second a description of the main groups of
recommendations from RCA reports completed during this period.
1.2
All Level 5 SIs during 2012/13 occurred in the Mental Health and Allied Specialities, there were
none in the Trust’s community services.
2.0
The national picture
2.1
The following is an extract from Consultation on Preventing Suicide in England1, which helps to
set the context for this report. “Over the last 10 years, progress has been made in reducing the
already relatively low suicide rate to record low levels (2007 was the lowest rate on record).
The past couple of years have seen a slight increase in suicide rates, but the 2007–09 rate is
still no higher than the level in 2005–07. Until the past couple of years, there had also been a
sustained reduction in the rate of suicide in young men under the age of 35, reversing the
upward trend since the problem of suicides in this group first escalated over 25 years ago”.
2.2
The latest annual report from the National Confidential Inquiry2 states that suicide by mental
health patients in 2011 in England rose by 13% over the previous year. Whilst it says that
comparison with previous years is difficult, it is likely that this is a true rise in patient suicide,
following a previous fall. The rise probably reflects the rise in suicide in the general population,
which has been attributed to current economic difficulties.
3.0
Level 5 Serious Incidents occurring in 2012-13
3.1
There were a total of 50 Level 5 SIs that were reported between 1st April 2012 and 31st March
2013.
3.2
Table 1 shows Level 5 SIs occurring in 2012-13 by service line.
Table 1
12/13 12/13 12/13
Q1
Q2
Q3
Acute Inpatient
5
5
2
Assessment & Brief Treatment
2
1
4
Child & Adolescence Mental Health
Services (CAMHS)
0
0
0
Community Recovery
3
3
5
Offender Care
0
1
0
Older People and Healthy Ageing
2
1
1
Psychological Medicines
1
1
1
Rehabilitation
1
0
1
Totals:
14
12
14
12/13
Q4
4
3
1
1
0
0
0
1
10
Total
16
10
1
12
1
4
3
3
50
1Source:
2
Consultation on Preventing Suicide in England - A cross-government outcomes strategy to save lives (July 2011)
Source: The National Confidential Inquiry into suicide and homicide by People with Mental Illness Annual Report July 2013
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Level 5 Serious Incidents Annual Report 2012-13
3.3
Table 2 gives a comparison between the number of Level 5 SIs occurring in 2012-13 with those
occurring within the previous 6 years.
Table 2
Year
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
3.4
Quarter 1
17
8
15
11
8
11
14
Quarter 2
11
17
13
11
10
13
11
Quarter 3
17
11
11
11
16
5
14
Quarter 4
16
23
15
17
7
10
11
TOTAL
61
59
54
50
41
39
50
The data reveals a gradual (36%) decline in Level 5 SUIs between 2006/07 and 2011/12.
However in 2012/13 the number increased from 39 to 50, a 28% increase on the previous
year.
65
60
55
50
45
40
35
30
2006/07
3.5
2007/08
2008/09
2009/10
2010/11
A breakdown of level 5 SIs by boroughs is shown below.
Table 3
BOROUGH
Q1
Q2
LB Brent
4
0
LB Harrow
3
2
LB Hillingdon
0
6
RB Kensington &Chelsea
3
2
City of Westminster
4
0
Other
0
1
Q3
4
1
1
4
2
2
2011/12
Q4
4
1
3
1
2
0
2012/13
Total
12
7
10
10
8
3
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Level 5 Serious Incidents Annual Report 2012-13
3.6
The gender of patients involved in L5 SIs over the period changed slightly over the previous
year, with a larger percentage of males involved. The graph below shows the figures for CNWL
in 2011/12 and 2012/13 alongside the figure for 2011 from the National Confidential Inquiry
report.
NCI 2011
F
2012/13
M
2011/12
0
20
40
60
80
3.7
Although the figures vary, generally the proportions have remained the same.
3.8
The percentage of patients recorded as having a dual diagnosis is set out below, against the
figures from the NCI report. It is apparent that the number of patients involved in L5 Sis
identified as having a dual diagnosis in CNWL is markedly lower than the national figure. It
should be noted, however that the NCI figure relates only to patients who committed suicide
whilst the CNWL figures include some patients who were involved in SIs that did not involve
suicide.
Y
N
N/A
Unknown
NCI 2011
(%)
54
46
0
0
2012/13
(%)
36
48
2
14
5
Level 5 Serious Incidents Annual Report 2012-13
2012/13
Unknown
N/A
N
Y
NCI 2011
0
10
20
30
40
50
60
3.9
Although 36% of the SIs involved patients with a dual diagnosis, it should be noted that only t
recommendations (out of a total of 150) related to this area. That indicates that the
management of dual diagnosis was not a major contributory factor in relation to the majority
of the SIs.
4
Mid-year analysis of SI data
4.1
During 2012/13 the Trust became aware of the increase in the number of L5 SIs and carried
out an analysis of the data at that time. This that L5 reports continued to contain a large
number of recommendations regarding communication, risk assessment and management
and record keeping. However, dual diagnosis / substance misuse no longer features at all,
whilst service line management (interface issues) and discharge planning / discharge
arrangements have been identified as new factors requiring further attention.
4.2
Demographic data on patients involved in L5 incidents showed a marked increase in suicides
involving men (although nearer to the national average), with improvements in the number
who had had a risk assessment on time or within the past 12 months, being compliant with
medication and fewer having physical healthcare issues. These are indicators that are moving
in the right direction. The other significant difference is an increase in people who are white
British committing suicide (37% in 2010 to 53% in 2012).
4.3
It was concluded that the increase in L5 SIs may have been linked to the reported increase in
suicide rates at a national level in 2011 (then estimated at 8%).
5
Benchmarking
5.1
In order to review the increase in SIs in as broad a perspective as possible, an initiative was
launched by CNWL to benchmark the past 3 years suicide data with other London providers of
mental health services. The results will provide a London-wide analysis of suicide.
5.2
Although regrettably not ready in time for this report, the results will be reported to the
Board.
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Level 5 Serious Incidents Annual Report 2012-13
6
Alleged Homicides
6.1
There were 2 alleged homicides by patients during the year 2012/13 (and a total of 4 since
December 2011). In 2 of the 4 cases the investigations were completed and their
recommendations analysed.
6.2
Since 2007 there have been 5 other homicides by CNWL patients. The recommendation
themes of these reports are shown below, against those of the two reports completed in the
past year.
Recommendations
Risk Assessment and management
Communication
Record keeping
Training and development
Policy compliance
Supervision / role of staff
Dual diagnosis
CPA / care planning
Carer support
DoH Policy Implementation Group compliance
Organisational arrangements
Community Treatment Orders
Homelessness services
Handover arrangements
Community housing
Transfer process
Multiple team / inter-agency working
Incidents 2007-10
Incidents
2011-13
2
3
5
4
5
4
3
2
1
1
1
1
1
1
1
3
5
2
1
1
2
1
2
6.3
The above table shows that in relation to alleged homicides, communication and risk
assessment & management are the areas where recommendations are key themes. These
reflect the key issues from other L5 reports during 2012/13.
7
RCA reports completed in 2012-13
7.1
All level 5 SIs are subject to investigation using a methodology called Root Cause Analysis
(RCA). This seeks not only to establish what happened but to clarify how and why events
occurred in the way they did and to identify, in particular, any system issues that require
attention. 40 RCA investigations were completed during 2012-13, some of which related to
incidents that occurred in 2011-12.
7.2
The timescale for completion of RCA reports is 45 working days (from the incident being
reported) and 60 for cases such as inpatient suicide and homicide. These targets are
challenging for often complex investigations.
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Level 5 Serious Incidents Annual Report 2012-13
7.3
During 2013/14 the Trust is introducing a team of 3 full-time investigators who will be
available to work on serious incident and complaints investigations. This will facilitate
investigations being completed within timescale, and to a higher and more consistent quality
standard.
8
Recommendations made in RCA Reports
8.1
In total 150 recommendations were made in RCAs completed during the year. These have
been grouped into broad categories and the full list of the recommendations is found in
Appendix 1. Some recommendations cover more than one category but have been listed
under the category that appears to represent their main purpose. A summary of the key issues
that arise from the recommendations is set out below. To provide some flavour for the types
of recommendations that have been made, some examples are also included below.
8.2
Communication and information sharing (17)
There are 17 recommendations in this area, 9 relate patients and carers and the others to
more general aspects of communication. In relation to patients and carers, these outline the
need for improvements in communication during the care pathway and following a serious
incident, providing crisis support information to family members when clinical risk is assessed
as high and opportunity to discuss their supportive and caring role pre-discharge to explore
the level of support that they are able to provide.
The general aspects includes sharing information with third parties, including private and
voluntary sector providers, sharing information with external experts and liaison with GPs
where there may be delays in seeing referred patients.
Examples:
“After the initial assessment, a formal letter should be sent to GP/referrer and copied to GP
within an agreed time frame”
“If the service’s attempts to contact a service user prove unsuccessful, the service user’s GP
should be informed of this difficulty. This should be done promptly in cases considered
urgent”
“There is a need to identify action aimed at improving the communication experience
between inpatient staff and carers”
“Where clinical risk is considered to be high, contact must be made where feasible with
family/carers and appropriate information including the crisis number given to them”
8.3
Risk Assessment and Management (15)
15 recommendations are made in this area. They cover recommending the point of care at
which the assessment should be carried out, the need for a full assessment for new patients
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Level 5 Serious Incidents Annual Report 2012-13
with complex needs, reinforcing the need to follow the requirements of the policy and
reviewing the compliance monitoring arrangements, the need to consider previous history
when assessing risk and highlighting points that should be included in risk assessment training.
Examples:
“Risk assessments are completed within an agreed acceptable timeframe and reviewed at
significant points of clinical decision making for all patients, and shared with all
professionals involved in their care to inform current risk management”
“The Trust should ensure that there is a full and comprehensive assessment process for all
service users who have complex needs”
“Staff caring for patients should consider previous history and treatment in assessing risk
and establishing care plans”
“There is a need for all staff to ensure that all relevant risk event history is captured for all
patients to inform current risk assessment and risk management plans”
8.4
Staff support and training (24)
This is a broad category which encompasses recommendations covering areas relating to the
competency of staff, the need for effective supervision arrangements, the need for support for
staff, training for staff in risk assessment, physical health, emergency procedures, domestic
violence, dual diagnosis, search procedures and safeguarding. One report highlights the need
for a robust system of induction for temporary and permanent staff and another clarification
of how resuscitation decisions are communicated to members of the team.
Examples:
“All team staff should know who their supervisor is and undergo regular supervision as per
Trust Policy”
“All clinicians should receive clinical supervision, which may be peer supervision, if the
member of staff is a consultant psychiatrist”
“All staff on inpatient units have ongoing regular physical health training updates (working
with the general side to establish practice and seek support)”
“A robust system is needed to ensure that when all staff, either temporary or permanent
are inducted they are made aware of how to escalate issues both in hours and out of
hours”
8.5
Documentation / Record Keeping (20)
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Level 5 Serious Incidents Annual Report 2012-13
Recommendations relate to the timely preparation of summary reports on patients, recording
of patient contacts, recording significant events in patients’ health records, keeping notes up
to date and properly maintaining leave record forms.
14 of the recommendation referred to JADE. These covered aspects including technical issues
such as highlighting entries, reports and other important information, extending access to
JADE, and ensuring important information is recorded on the system.
Examples:
“Nursing staff should be reminded of the need to record significant acts in patients’ health
records”
“Staff making retrospective entries after an incident or death should indicate this clearly in
the notes e.g. with an explanatory annotation”
“A full description of considerations and decisions made in MDT handover meetings should
be documented on JADE immediately”
“Urine Drug Screens, Person Searches and Room Searches should be available for entry as a
Casual Assessment on JADE. This would ensure consistency of documentation of these
interventions and ease the audit of compliance”
8.6
Interface working / responsibilities (28)
Service line restructuring took full effect in April 2012 and this section includes those
recommendations that relate to the provision of services, both within and across service lines.
This includes a review of operational policies and procedures post transition into Service Lines
to ensure that new or amended services work collaboratively and that there are no gaps in
service provision (this was an issue evident in several SIs during the year); for guidance to be
issued on how and when to escalate difficulties and barriers to accessing specialist services;
for robust care pathways and protocols to be developed between service lines; or services to
cooperate to develop a single care plan when a patient is under the care of more than one
service line; for communication to improve between teams when a patient is in crisis.
In relation to external partnership working, recommendations included reviewing joint
protocols especially in relation to assessing risk; the need for senior interface meetings with
partner organisations; clarifying responsibilities for patients and handover arrangements when
they move to another area and in relation to acute hospitals, managing and assessing
intoxicated patients in A&E and agreeing a transfer checklist particularly for issues around
physical health history.
Examples:
“Interface meetings should be in place that promote collaborative working with patientcentred, safe, quality care at the heart of the problem-solving agenda”
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Level 5 Serious Incidents Annual Report 2012-13
“Service Line Management to issue guidance on how and when to escalate difficulties and
barriers to accessing specialist services”
“When a patient is under the care of more than one service, these service should coordinate their work to ensure that the patient has a single care plan, and staff liaise with
each other as appropriate”
“The issue of managing and assessing intoxicated patients in A&E should be raised at
interface forums and additional joint working guidance/policy should be agreed/reviewed
between CNWL and Acute Trusts”
8.7
CPA / care planning and discharge arrangements (13)
7 recommendations covered areas such as CPA Care and Support Plans being produced within
the Jade CPA review system; for new patients to have a report including a formulation and
treatment or intervention plan, even if that may include further assessments; for inpatient
nursing staff need to be made aware that they are responsible for ensuring that each inpatient
has an inpatient care plan, linked to the risk assessment; and for Patients on CPA who reside
out of borough to be regarded as higher risk and be prioritised for supervision. 5
recommendations covered areas such as the development of more robust guidelines around
what discharge means from within different parts of the services; reminding staff that when
discharging patients back to primary care, information should be provided on CNWL contact
details and any lead professionals involved; and developing a procedure for transferring
patients who have moved out of the CNWL catchment area.
Examples:
“CPA Care and Support Plans should be produced within the Jade CPA review system so that
care coordinators are reminded of the requirement of producing a CPA care and support
plan”
“Where there is existing physical health co-morbidity and associated risk factors there
should be a care plan and risk form completed, which is specific to these needs”
“Patients on CPA who reside out of borough should be regarded as higher risk and be
prioritised for supervision, with involvement more senior staff if needed and considered for
transfer”
“More robust guidelines around what discharge means from within different parts of the
services and of how this information is shared with the client and other support services”
8.9
Environmental (4)
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Level 5 Serious Incidents Annual Report 2012-13
4 recommendations included the need for environmental risk assessments or improvements
to named sites and a review to using plastic bags in inpatient sites.
Examples:
“The Trust should review whether an alternative to using plastic bags in inpatient units is
possible”
“To consider fitting a lock and intercom on the Horton Main Gate pedestrian entrance with
the link to the houses”
8.10
Multi-Disciplinary Teams (MDT) (5)
Although there are 5 recommendations in this section, matters relating to the work of MDTs
arose in a range of other areas. Here the issues related to discussions at MDT meetings to;
accessing all sources of information; the need for a robust escalation protocol following a
patient DNA
Examples:
“Case discussion should be evident at Multi-Disciplinary Team meetings to ensure a holistic
approach to care”
“Review of the Clinical Team meeting with the aim to improve attendance and contribution
and ensure the structure includes awareness of CTO patients”
8.11
Observation and engagement of inpatients (3)
This is a critically important aspect of inpatient care and 3 recommendations were made which
covered the need for staff to ensure observations were completed; close observation charts to
be fully completed and discussed at team meetings; and for observations to be tailored to the
service user’s rehabilitation needs.
Example:
“All inpatient nursing staff should be reminded of the need to ensure that if they are unable
to carry out a general or intermittent observation of a patient, they must arrange for a
colleague to do so”
8.12
Referral Process (5)
The 5 recommendations include screening of referrals by a clinician within an acceptable
timescale and calculating response times to referrals.
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Level 5 Serious Incidents Annual Report 2012-13
Examples:
“For a single point of entry (triage) into primary care mental health services”
“In the case of a Duty Practitioner arranging an urgent assessment appointment for another
team member; the Duty Practitioner should make attempts to discuss the referral with the
assessing practitioner before the appointment date / time”
8.13
Service development issues (6)
This is a broad category which includes review the need for secretarial and admin support;
developing guidelines on indicative case loads; examining staff ratios; and considering the
resources needed for people with personality disorders
Examples:
“Sufficient administration and secretarial support should be available to clinicians”
“Improve access to specialist services for Personality Disorders”
8.14
Other (10)
The 10 recommendations in this section cover areas such as reviewing delays in offering
appointments; guidance on medical cover during long periods of leave from hospital; for the
Mental Capacity Act to be used for patients who are unable to consent to voluntary admission
where the MHA is not appropriate; conducting inpatient search exercises; and ensuring that
patients are clerked and examined including physical health upon admission to hospital.
Examples:
“The Mental Health Act office to issue guidance on Responsible Clinician cover for long
periods of leave”
“Acute ward staff carry out periodic search exercises to help them better identify items that
could be used in a suicide attempt”
“All service users should be clerked and examined including physical health by either the
ward doctor, or duty doctor if the ward doctor is not available”
Richard Vergez
Associate Director, Corporate Governance
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Level 5 Serious Incidents Annual Report 2012-13
Appendix 1 – Full list of recommendations from completed RCA reports
1.
Communication and information sharing
General issues
 Practitioners should explicitly record to whom clinical correspondence, including
invitation to care planning meetings, should be copied.
 Where any potential risk is identified to either an individual or member of staff that
this is communicated immediately and the information recorded in that individual’s
notes. The recorded information should also identify who have been informed, when
they were informed, and the action that was taken.
 Requests for opinions from external experts should provide clarity regarding the
purpose and function of the request with demonstrable consideration of that opinion
prior to further relevant decisions being taken regarding clinical care.
 After the initial assessment, a formal letter should be sent to GP/referrer and copied
to GP within an agreed time frame.
 If the service’s attempts to contact a service user prove unsuccessful, the service
user’s GP should be informed of this difficulty. This should be done promptly in cases
considered urgent.
 Clearer guidelines to be available for CNWL staff on communication standards when
sharing information with the private sector for those patients not on CPA.

Clinicians to be reminded of the need to communicate and discuss key
changes to a patient’s care through the appropriate channels. This should
include informing the team’s Consultant of any significant medication changes
carried out by junior members of staff.
 ABT Team needs to engage in pre-assessment discussions with referrers regarding
advice on medication where indicated if there is likely to be a delay in assessment
being carried out.
Patients and carers
 Each inpatient ward and clinical team should ensure that there is a system in
place to meet carers and families in order to obtain further information
regarding the patient and provide support for the carers and families.
 Where appropriate, all partners/spouses/carers/significant others should have
an opportunity to discuss their supportive and caring role pre-discharge to
explore the level of support that they are able to provide. This would help to
ensure more effective discharge planning
 There is a need to develop a protocol or incorporate guidelines within the
Serious Incident Policy to support carers and families following a level 5
incident. This is to include guidelines regarding the appropriate packing of
belongings following the death of an inpatient.
 There is a need to identify action aimed at improving the communication
experience between inpatient staff and carers
 To remind mental health professionals to give information to carers about
local carers' support groups (which can still be accessed by carers once the
patient has been discharged from secondary care).
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Level 5 Serious Incidents Annual Report 2012-13





The service where an SI occurs must ensure appropriate support is given to the
nearest relative and family
Where clinical risk is considered to be high, contact must be made where
feasible with family/carers and appropriate information including the crisis
number given to them.
To ensure that all new Service Users receive adequate orientation of the local
site and surrounding area according to their needs
Multidisciplinary teams working on D Ward and the other two Triage wards to
decide when carers should be informed about a patient’s change in leave
status and document this decision and discussion held with the carer
electronically on JADE.
ABT Team staff should aim to provide face to face contact with service users.
Where engagement is an issue, staff should aim to work collaboratively with
family members to facilitate face to face contacts with service users

2.
Referral Process






3.
For a single point of entry (triage) into primary care mental health services
The service manager should ensure that referrals are screened by a clinician within a
clinically-acceptable timescale following receipt, that the screening is documented,
and that a mechanism is in place for ensuring that this has occurred.
Initial assessment should include a history of illicit drug use and the Bromley Screening
Tool should be used to quantify and record this.
Calculate response rate to referrals to Brent ABT and agree an action plan to improve
response rate.
In the case of a Duty Practitioner arranging an urgent assessment appointment for
another team member; the Duty Practitioner should make attempts to discuss the
referral with the assessing practitioner before the appointment date / time
Risk Assessment and Management



Where forensic consultation is provided that the FoCuS team ensure that efforts
are made to enhance the inpatient team’s understanding of, and involvement in,
risk assessment and management. That this is a shared task in which the roles and
responsibilities of each team are clearly defined and structures are in place to
ensure they are adhered to. In addition the FoCuS team will follow clear processes
to ensure an appropriate sharing of information takes place which is agreed and a
written record completed
Risk assessments are completed within an agreed acceptable timeframe and
reviewed at significant points of clinical decision making for all patients, and
shared with all professionals involved in their care to inform current risk
management.
Risk assessment should be carried out at initial assessment appointments
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Level 5 Serious Incidents Annual Report 2012-13












4.
Patients should receive quarterly risk assessments and care plan reviews
documented as a minimum, or when any significant changes are identified
regarding risk or a change in treatment
Level 1 inpatient falls risk assessment tool should be completed for all patients on
admission and those with a falls history should have a multifactorial falls risk
assessment with a falls prevention care plan
Review of compliance monitoring arrangements for risk assessment/risk
management and CPA policy and procedures for all staff (Acute and Recovery
Service)
The Trust should ensure that there is a full and comprehensive assessment process
for all service users who have complex needs.
A risk assessment should be undertaken for all new users of mental health
services, and at intervals thereafter as appropriate as per Trust clinical Risk
Assessment Policy.
Ensure systems are in place on Danube ward for completion of risk assessment
documentation consistent with trust policy (ward manager reported systems
issues during and following transition to ‘triage’ ward status). Risk assessment
audit on Danube therefore recommended.
All Hillingdon ABT and HTT staff will receive communication to remind them of the
importance of completing risk assessment tools in line with the CNWL Assessment
and Management of Clinical Risk and Safety Policy.
Patients with a history of overdose and who have previously not defaulted on
visits should be considered at serious risk and we recommend that an escalation
process is developed by HTT, which supports staff and next of kin
Staff caring for patients should consider previous history and treatment in
assessing risk and establishing care plans
Risk Assessment must be carried out after the first contact with a newly referred
patient, as per Trust Policy. Retrospective audit of the content of risk assessment
to be carried out. Risk assessments to be reviewed and discussed in all feedback
meetings.
Teaching session to be arranged for staff on risk factors for suicide (with particular
emphasis on the relevance of suicidal threats and action to be taken in the event
of such threats).
There is a need for all staff to ensure that all relevant risk event history is captured
for all patients to inform current risk assessment and risk management plans
Staff Support & Training
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Ensure systems in place on Danube ward (and other acute settings), for staff debriefing and support following SUI’s.
That all staff are reminded of the importance to ensure they read previous entries
written by colleagues on SystemOne (prison system).
Competency of Senior Staff - there clearly is an issue relating to the performance of
the Senior Staff not only on duty that day but in communicating outcomes of Audits
they carry out - formal performance management is recommended and/or disciplinary
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investigation.
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All team staff should know who their supervisor is and undergo regular supervision as
per Trust Policy.
There is a local Rehab Service line out of hours on call rota which is currently being
reviewed, this includes the Roxbourne Unit (otherwise a recommendation would have
been made)
Provision of regular support for staff working within Home Treatment Teams and on
Triage wards where involvement in ‘positive risk’ taking is routinely carried out. For
example the implementation of regular MDT reflective practice groups, robust 1:1
supervision structures.
Debriefing following serious incidents should be routine practice. If the circumstances
don’t allow for debrief shortly after the incident, this should be deferred until a later
date when all key staff can attend. We would recommend that CNWL staff involved in
this case meet with staff representatives from Kean Street to de-brief and review their
joint work of the case in the context of Kean Street’s registration change. This would
be with a view to identifying any possible local and service wide learning opportunities
regarding care provision in services undergoing registration change
A Reflective Practice group be set up to support staff who work with very difficult and
complex cases.
Staff require training around risk assessments, assessing falls risks and care planning,
documentation, the Mental Capacity Act and DOLs.
Team Manager to review training needs in relation to use of Clustering tool. (NB the
team has had local training on 18 July and 8 August 2012.)
All staff on inpatient units have ongoing regular physical health training updates
(working with the general side to establish practice and seek support).
Training sessions to be implemented with crash teams, when dealing with emergency
situations
The Trust should ensure that there is guidance and training available to staff detailing
a consistent approach to manage service users who are not engaging with their care
plan and monitor the efficacy of its use by a process of clinical audit.
The Trust should ensure that all clinical staff have adequate training and are all aware
of their responsibilities under the Trust’s Domestic Violence Policy and the criteria for
the escalation of concerns through the risk assessment and management process.
Further training on Clustering needs to be delivered to all staff.
The Local Home Treatment Team need to ensure that all staff are aware of and
understand the HTT Operational Policy where guidelines for the following key areas
are documented: The need to pre-arrange a date and time of the initial assessment
jointly with the patient and/or their carer. / The need to involve the patient and/or
carer in plans for discharge. / The need to provide a timely medical review. This
should include history of presentation, mental state, past history and medication
review. A management plan should be formulated in conjunction with the patient. /
The need to where possible plan for patients to be seen by the same members of
staff.
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Level 5 Serious Incidents Annual Report 2012-13
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5.
Training - despite all staff being trained in Emergency Life Support it is clear that the
teams understanding needs to be re-visited. This can be done via ELS training drills to
be carried out by Trust Resuscitation Officer, or by again re-training staff. Competency
levels need to be reviewed in Appraisals and Supervision.
Review of training needs in dual diagnosis of all members of Brent ABT. All staff to be
trained by end of 2013/14.
Training in search procedures must be actioned by 30th July 2013.
The trust should carry out at least two ‘dummy’ crash calls on the ward by 31st July
2013.
All clinicians should receive clinical supervision, which may be peer supervision, if the
member of staff is a consultant psychiatrist.
A robust system is needed to ensure that when all staff, either temporary or
permanent are inducted they are made aware of how to escalate issues both in
hours and out of hours.
Full review needs to be carried out on how resuscitation decisions are communicated
to the team and how they are reached - the policy needs to be looked at by all staff to
ensure it is adhered to.
The role of the keyworker necessitates an in-depth knowledge of a patient’s critical
information, forensic history and the associated risks arising out of this. Local
induction and training should be reviewed to ensure a full understanding of the
critical information of which they should be aware is emphasised.
Documentation / Record Keeping
General
 Staff making retrospective entries after an incident or death should indicate this
clearly in the notes eg with an explanatory annotation
 Summary reports should always be completed either at the time of discharge of a
patient or when requested by other agencies involved in that individual’s care and
that processes are put in place in order that the MAPPA lead ensures that these are
actioned.
 All patient contacts are recorded on the appropriate electronic system that provide
detailed information, in particular of one to one sessions and that this is audited on a
regular basis.
 Nursing staff should be reminded of the need to record significant acts in patients’
health records
 Notes need to be kept up to date. This should be completed by staff and monitored
by seniors
 A tracking system needs to be put in place for paper files to ensure that they do not go
missing. (Admin)
 The Ground Leave and Community Leave Record form needs to be completed fully, as
recommended by the Trust Informal Patient Leave Policy for all patients. D Ward
needs to maintain a system to monitor return times and act when informal patients
do not return as expected. D Ward nursing staff should take the Ground Leave and
Community Leave Record form into the ward handover meeting to ensure that
accurate information of leave is provided.
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Documentation - clearly the standards of documentation needs to be reviewed to
ensure that vital discussions with family and other professionals are recorded.
JADE
 A means of highlighting important individual entries, correspondence, reports and/or
other important information on Jade which may be of particular interest to clinicians
will be required so that they can rapidly find important patient information without
having to read the full patient record.The practice of scanning multiple documents
into a single file on JADE should be actively discouraged.
 The Local Drug and Alcohol Service to have access to Jade in order for information to
be easily shared across the different services within the Trust.
 All actual or attempted contacts with service users, or with the service user’s GP or
other professional, should be documented promptly in the JADE progress notes.
 All multi-disciplinary team meetings to be recorded in detail on JADE.
 Documentation on Jade-HTT & ABT staff to obtain guidance on improvement to the
quality of entries.
 Decisions as to why short term allocation are made, along with reasons for closure
should be clearly recorded on Jade.
 When an assessment is completed and uploaded onto documents an entry should be
made on Jade progress notes to summarise the assessment and indicate that it took
place.
 A full description of considerations and decisions made in MDT handover meetings
should be documented on JADE immediately.
 All actions taken must be documented on Jade as soon after the event as possible.
 For ABT Team to routinely record Multi-Disciplinary Team discussions in Assessment
Feedback Meetings on JADE.
The Trust to identify a solution by which to flag up or inform staff if a client
has an identified forensic history.
 Urine Drug Screens, Person Searches and Room Searches should be available for entry
as a Casual Assessment on JADE. This would ensure consistency of documentation of
these interventions and ease the audit of compliance.
 Service to ensure that systems are in place that gives assurance that the data input to
JADE is accurate and up-to-date. A system of audit should be developed to give
assurance to the service that the clinical data contained within JADE is robust
6.
Interface Working / Responsibilities
Internal
 The FoCuS team’s operational policy is reviewed specifically to include how the FoCuS
team can provide a service for informal patients who may be resident on general
acute or rehabilitation psychiatric wards.
 There needs to be a review of operational policies and procedures post transition into
Service Lines to ensure that new or amended services work collaboratively and that
there are no gaps in service provision.
 Interface meetings should be in place that promote collaborative working with
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Level 5 Serious Incidents Annual Report 2012-13
patient-centred, safe, quality care at the heart of the problem-solving agenda.
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Service Line Management to issue guidance on how and when to escalate difficulties
and barriers to accessing specialist services.
On-going Development of a robust care pathway and protocol between ABT, HTT and
Psychiatric Liaison Services in Hillingdon Adult Mental Health Services
The medical director and head of nursing should remind staff that if a patient is being
referred to another unit for specialist support (such as the PICU), they should provide
a full summary of their needs and risks.
When a patient is under the care of more than one service, these service should coordinate their work to ensure that the patient has a single care plan, and staff liaise
with each other as appropriate
HTT to ensure that all staff are aware of the action to be taken when an urgent
referral is made to them by another team. Audit to be carried out to ensure safe
practice.
Improve communication between teams involved in a patient’s care during crises When a patient contacts a non-treating team in crisis (e.g. CRT or A&E liaison),
information about the contact should be shared immediately with the treating team
(including the care co-ordinator if appropriate).
Caseload of CCOs in Recovery SL need to be reviewed to ensure that staff are not
carrying an unmanageable case load
The FoCuS team’s operational policy is reviewed specifically to include how the FoCuS
team can provide a service for informal patients who may be resident on general
acute or rehabilitation psychiatric wards
In cases where an individual is in receipt of services from more than one team then
the roles and responsibilities of the individual teams are set out clearly in the person’s
treatment plan and all professionals involved in that plan understand their
responsibility towards that particular patient. This should be audited in line with
regular evaluation of the service against the operational policy
External
 Review of joint protocol – more robust guidelines around joint working and sharing of
information with specific detail around the carrying out of joint risk assessments and
home visits (and what events might precipitate the need to review)
 Senior management interface meetings and local opportunities for less formal
interface meetings should be established between CNLW and Hillingdon Hospital. This
should involve all levels of staff and provide additional support for staff with the aim
of fostering good joint working relationships
 To include within the protocol, guidelines around who/how and the timescale, for
feeding back supplementary information to Children and Family Services once an
initial referral has been made
 CNWL and WLMHT consider developing a Risk Management Review Panel comprised
of senior clinicians and that complex cases in regard to risk assessment and
management are presented to the panel for advice and additional expertise.
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Level 5 Serious Incidents Annual Report 2012-13
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7.
Where service users are facing potential relocation out of borough and require
continuity of care, local services should remain responsible for these service users'
care unless and until care is handed over to services in the new locality following
relocation
Ensure that there are clear processes in place for handover of patients from one unit
to another. That the appropriate level of staff carries out the handover.
Working relationships and the sharing of clinical responsibility between CNWL and
Mind should be formalised if this has not already been done.
Clearer guidelines to be available for CNWL staff on communication standards across
multi -agency working, particularly in the case of first presentation to mental health
services.
The Trust should agree a robust process for ensuring that actions that arise from Multi
Agency Risk Assessment Conference (MARAC) meetings are swiftly assessed and
monitor the effectiveness of this by a process of annual audit.
Write a Hillingdon Police Liaison Policy that includes information on: When and how
to obtain Bail Conditions from Police / When and how to identify the Officer in Charge
at the Metropolitan Police / When and how information may be shared by CNWL with
the police / When and how information may be shared by the Metropolitan Police
with CNWL.
Consideration should be given to the interface between the private sector and tertiary
mental health services.
It is recommended that the Trusts consider how services might be developed to meet
the needs of such individual both within general and forensic services
To liaise with CLCH and the Prison to ensure that all relevant services are made aware
when patients are being transferred out to other prisons, to ensure continuity of care
The issue of managing and assessing intoxicated patients in A&E should be raised at
interface forums and additional joint working guidance/policy should be
agreed/reviewed between CNWL and Acute Trusts.
A transfer checklist agreed between General Medical setting and Mental Health
particularly relating to physical health history.
Gathering of collateral information from GP, police or any involved services should
form part of the assessment process
CPA / Care Planning
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CPA Care and Support Plans should be produced within the Jade CPA review system so
that care coordinators are reminded of the requirement of producing a CPA care and
support plan.
All patients should, following an initial assessment of a time limited nature, have a
report including a formulation and treatment or intervention plan, even if that may
include further assessments. This should form part of regular audits of caseload
reviews.
All inpatient nursing staff need to be made aware that they are responsible for
ensuring that each inpatient has an inpatient care plan, linked to the risk assessment.
This ensures that care and treatment is clear and that all staff involved and the patient
are aware of the how the patient's needs will be met.
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Discharge arrangements
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9.
Where there is existing physical health co-morbidity and associated risk factors there
should be a care plan and risk form completed, which is specific to these needs.
The team to be reminded of the operating protocol relating to responsibility of care
during a referral and transfer process, and the need to ensure robust follow up so that
the transfer occurs within the set timeframe. The panel are aware this has been
reinforced trustwide through the development of a new transfer policy
To systematically determine the psychological needs of prisoners under the In-reach
Team who have received or are likely to receive long sentences and have difficulty
adjusting to prison
Patients on CPA who reside out of borough should be regarded as higher risk and be
prioritised for supervision, with involvement more senior staff if needed and
considered for transfer.
More robust guidelines around what discharge means from within different parts
of the services and of how this information is shared with the client and other
support services.
That staff should be aware that friends who do not live with a patient should not
be expected to take on the role of being a ‘protective factor’ when discharging
that patient back to the community and that training sessions for the
Psychological medicines staff to offer knowledge and support around this issue
should be arranged.
To remind mental health teams that when discharging patients back to primary
care, contact details of the Assessment and Brief Treatment Team, and of any lead
professionals involved, should be given in correspondence to GPs.
Consideration should be given to drafting a guidance document re: seven day
follow-up. This would list practical advice from learnt experience, (e.g. check
whether the mobile number a patient gives you is serviceable before they are
discharged), and emphasise that the immediate period following discharge is a
vital opportunity to engage with recently discharged in-patients
Procedure for transferring Patients who have moved out of area. - The CPA policy
states that “if a service user moves from one area to another the team for the new
catchment area should be notified immediately. Sufficient details must be
provided in case they need to respond to an emergency situation…” (p. 31,
paragraph 11.4). Where issues of identifying relevant local services for transfer are
identified by staff, these should be escalated through CNWL management
processes.
To review current arrangements to support, monitor and manage clients whilst
still inpatients as leave/discharge approaches
Environmental matters
 A risk assessment of the environment of The Roxbourne Unit was undertaken to
identify any safety issues.
 The trust should review whether an alternative to using plastic bags in inpatient
units is possible.
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Level 5 Serious Incidents Annual Report 2012-13
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10.
Multi-Disciplinary Teams
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Case discussion should be evident at Multi-Disciplinary Team meetings to ensure a
holistic approach to care.
To review the way in which HTT engage and interact clients during the early
leave/discharge period. Review of the current model
Review of the Clinical Team meeting with the aim to improve attendance and
contribution and ensure the structure includes awareness of CTO patients. (NB this was
implemented by the team by 25 July 2012.)
The HTT service needs to develop a robust escalation protocol following service user
DNA.
In the case of the Duty Practitioner not having access to all sources of information (in
this case the IT drive) needed to carry out all duties and responsibilities whilst on Duty,
they should inform a senior team member immediately.
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11.
Observation and Engagement of Patients
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12.
To take forward the visibility improvements to Rushett and Westfield identified
under ‘Visibility on Houses’.
To consider fitting a lock and intercom on the Horton Main Gate pedestrian
entrance with the link to the houses.
All inpatient nursing staff should be reminded of the need to ensure that if they are
unable to carry out a general or intermittent observation of a patient, they must
arrange for a colleague to do so.
Close observation charts to be fully completed and discuss policy at team meetings.
To produce a local protocol clarifying that Observations are tailored to the service
user’s rehabilitation needs, and so hourly observations are not always appropriate.
The Trust’s Observation Chart is completed accordingly; to record as a minimum a
head count of service users at Shift Handovers and Meal Times using an adapted
Observation Chart.
Service development issues
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Sufficient administration and secretarial support should be available to clinicians.
The Recovery Service Line should develop guidelines on indicative case loads
To consider whether the Staff/Service User ratio for Rushett, Westfield and the
Cottages at weekends is sufficient for Service User safety.
Improve access to specialist services for Personality Disorders - Brent services
should develop guidelines (including contact details) for accessing specialist PD
services, and for securing funding from the local PCT
Current services in Harrow to consider facilitating care and support for people
with personality disorders
The Acute service line to undertake regular monitoring and a review of trends
related to serious incidents occurring on discharge from Triage / Home Treatment
Teams
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13.
Other
 The local service manager should ensure that delays in offering appointments are
at clinically acceptable levels
 The Mental Health Act office to issue guidance on Responsible Clinician cover for
long periods of leave.
 Staff to be reminded of the need to review and have a thorough knowledge of
recent events and contacts in the patient file
 The Mental Capacity Act should be used for all patients who are unable to consent
to voluntary admission if the Mental Health Act is no longer appropriated
 The role of care co-ordinator should be separate to that of the staff nurse.
 Acute ward staff carry out periodic search exercises to help them better identify
items that could be used in a suicide attempt
 The medical director should issue guidance that if medical staff consider a section
5(2) MHA assessment should be carried out if a patient wants to take their
discharge they should indicate if that assessment should also be made prior to
granting unescorted leave.
 A Mental Health Act assessment should be always considered in cases where there
have been difficulties in engaging clients in necessary treatment for severe
depression where less restrictive measures have proved ineffective.
 All service users should be clerked and examined including physical health by
either the ward doctor, or duty doctor if the ward doctor is not available. If this is
not able to be done on admission, further attempts should be made to complete
the clerking and physical examination by the ward doctor.
 It should be made explicit for service users who receive prescriptions from the
trust, how to get that description both filled initially and repeated once through
the medication prescribed is finished, and that it should be obtained from the GP
even though it was initially written by their psychiatrist often at a different clinic
or location. Service users and their carers may not necessarily know about this
procedure, particularly if I have not been born in the UK.
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Level 5 Serious Incidents Annual Report 2012-13