Recommendations and NHS Action Plans Following
Independent Investigation into the Death of Joanne Bingley SUI 2010/5319
2 years after Joe’s death patients are still being cared for by staff with NO specialist perinatal psychiatric training or experience. This
is in breach of NHS National Service Frameworks, NICE Care Quality Standards and unless patients are told of this as noted by the
Coroner ‘s Inquest arguably fails to obtain informed consent from patients prior to commencing treatment.
At least 8 of the 21 action points to reduce risks to patients, recommended by the Sept 2010 Independent Investigation into the death
of Joanne (Joe) Bingley have either not been implemented or fail to meet Care Quality Commission compliance standards. This is in
complete contrast to the updates and information previously provided to Joe’s family by the NHS (see notes in table below)
The Care Quality Commission review and report into the South West Yorkshire Partnership Foundation Trust published April 2012.
No
1.
Action
1
Agency
KPCT
Recommendation
The PCT will take a lead in developing a Strategy and
Clinical Action Pathway for Perinatal and Infant Mental
Health
Update
Strategy signed off by associated
partnership boards Dec 2010
- April 2012 still not implemented
2.
2
KPCT
As commissioning organisation the PCT will performance
monitor the provider actions of this SUI action plan
Updated actions End Jan 2011
(per this report)
3.
3
KPCT
The PCT will support SCG as lead commissioners in the
regional development of Strategic, contracting and Clinical
Action Pathway for Perinatal Mental Health
Meeting of Specialist Mental Health
Governance Group scheduled 8th Feb
- April 2012 still not implemented
4.
4
KPCT
The PCT need to ensure appropriate ‘Watchful Waiting’ for
patients within Primary Care in line with NICE guidelines
GP representation on group, action plan
development of audit of current practice.
5.
1
SWYPFT
CRHTT initial assessment and care planning: Consideration
of inpatient admission and use of Mental Health Act
Structured template designed and
uploaded to RIO to enable detailed
information available for decision
making. Completed Nov 2010
6.
2
SWYPFT
Recording Medication
All changes to medication now
documented on RIO. Completed Nov
2010
7.
3
SWYPFT
Support Engagement of Service Users in decision
making including provision of written information for
use by /with Service User
8.
4
SWYPFT
Provision of written information for service users/carers
by CRHTT
9.
5
SWYPFT
Liaison with other services
All actions now documented on RIO.
Completed Nov 2010
- Are they told staff not trained?
Service User Evaluation Group and
CRHTT have developed information
leaflets and SU Evaluation Form.
Awaiting feedback and response.
- April 2012 insufficient evidence
- Are they told staff not trained?
Review of CRHT service operational
policy is underway.
10.
6
SWYPFT
Documentation: Contingency plans and clearly show what
indicators the team and Service User have agreed would
demonstrate deterioration and need for review.
Relapse Indicators are now identified in
contingency plans. Completed Nov 2010
11.
7
SWYPFT
Carer Support:
1. Where a full carer’s assessment has not been completed
CRHTT staff will discuss with carers their involvement
in or role in supporting any home based treatment. This
will include an assessment of whether the carer is
willing.
2. This discussion and any carer support needs will be
documented on RIO.
3. CRHTT operational policy changed to include this
requirement.
Completed Nov 2010
- April 2012 insufficient evidence
- Are they told staff not trained?
12.
8
SWYPFT
Communication with families of service users post serious
untoward incident.
Plans and policies revised. Completed
Nov 2010
KPCT = Kirklees and Calderdale Primary Care Trust [LEAD AGENCY]
SWYPFT = South West Yorkshire Partnership Foundation Trust
CHFT = Calderdale and Huddersfield Foundation Trust (Hospitals)
KCHS = Kirklees and Calderdale Health Services
Recommendations and NHS Action Plans Following
Independent Investigation into the Death of Joanne Bingley SUI 2010/5319
No
13.
14.
Action
9
10
Agency
SWYPFT
SWYPFT
Recommendation
Development of Specialist Professional Service
Resource:
1. The Mental Health Trust to develop a Specialist
Perinatal Community Mental Health Resource with
sessional commitment from specialised psychiatrist
2. Working relationship with Leeds Mother and Bay Unit
to have seamless pathway of care into and out of unit.
3. A Strategic Review of Maternal Mental Health Services
is undertaken to support development of clinical
pathway for maternal mental health (Perinatal and infant
Mental Health [PIMH] working group).
Assessment and Risk Tools:
1. Mental Health Trust to review its assessment tools to
ensure they reflect the perinatal context of known risk
factors relating to maternal suicide.
2. Relapse Indicators, SWYPFT to review its use of this
term within the context of acute onset illness.
3. Training should be reviewed to ensure that the
assumptions of risk mitigation factors are critically
challenged particularly in relation to intent and planning
and social support.
Update
Locality involvement in perinatal
strategies implementation group.
Project has been identified with Trust
Change Management Plan. Currently in
scoping phase to identify service
provision in all 3 districts.
- April 2012 not implemented
Risk assessment enhanced within CPA
training. E-learning module currently
being explored.
CPA Updated assessments agreed.
See 11.1
- April 2012 not implemented
15.
11
SWYPFT
Priority Care Pathways: Set-up a strategic group to develop
a clear Clinical Pathway for Maternal Mental Health, to
review current provision and recommend future actions.
See action point 10
16.
12
SWYPFT
Education and training of health professionals working
in crisis and community mental health teams: Training and
awareness-raising to ensure staff are aware of the additional
risks posed by perinatal psychiatric disorder particularly in
relation to tendency to rapidly deteriorate and dominance of
morbid anxiety.
Report and action plan shared,
training/awareness sessions to be
developed, general mangers to
coordinate training/awareness sessions.
Draft strategy circulated, membership of
multi agency group agreed, awaiting
dates for initial meeting.
- April 2012 not implemented and
insufficient according to CQC report
Completed Sept 2010
17.
13
SWYPFT
Clinical Action Pathway for Perinatal and Infant Mental
Health: Trust to work with PCT in finalisation and
implementation.
18.
1
CHFT
Huddersfield Birth Centre audit of the use for women readmitted for support
19.
2
CHFT
Education and training of midwives:
1. Review of Midwifery training and assurance training is
robust.
2. Antenatal Integrated Care Pathway developed with
specific questions recommended by NICE including
personal and family history of mental health issues.
Training sessions for Health Visitors and
Nursery Nurses in Mar 2011.
- April 2012 not implemented and
insufficient according to CQC report
Completed Dec 2010
Completed Dec 2010
20.
3
CHFT
Written communications between Midwives and Health
Visitors to clearly record any suspicions of postnatal
depression.
Not in action plan but implemented
following service users death
Completed Dec 2010
21.
1
KCHS
Education and training of Health Visitors: Ensure Health
Visitors are familiar with the presentation, signs and
symptoms of serious psychiatric disorder following child
birth.
Training plan developed for delivery
through SWYPFT for all Health
Visitors, commences March 2011.
KPCT = Kirklees and Calderdale Primary Care Trust [LEAD AGENCY]
SWYPFT = South West Yorkshire Partnership Foundation Trust
CHFT = Calderdale and Huddersfield Foundation Trust (Hospitals)
KCHS = Kirklees and Calderdale Health Services