This publication is not in keeping with the general import of mandtory Inquiries that information about what happened and the care and treatment given should be made available to the public so that general lessons can be drawn.
This seems to be a device to exculpate the SHA from any suggestion that the Trust giving the care and treatment was cursory in it's own Internal Inquiry and reflected on its systems and amended them where necessary
It may be that a process of moving to the mandatory external Inquiry which the circumstnces warranted was overtaken by the changes in the overseeing Strategic Health Authorities
This attempt to overcome that delay and confusion is totally inadequate.
The whole point of the mandatory External Inquiries is that they are not by-passed by internal reviews which the public do not see, but that the public are fully informed so that they can see for themselves and can hold to account, what level of mental health public service is acceptable or not acceptable.
This way of asking for an external scrutiny which then comments but gives little or no information about the detail of the care and treatment delivered does nothing toward promoting confidence.
It is open to the conclusion that the managers and SHA Board, elected to act as a public body on our behalf, hold that such matters are best kept to themselves..
This secretive way of 'learning the lessons' is to be condemned.
1 Introduction
1.1 Why an independent review was needed
1.2 Terms of reference
The terms of reference state that the review's purpose;
gcis to provide independent scrutiny of the internal inquiry conducted by Bolton, Salford and Trafford Mental Health NHS Trust. This will include identifying any gaps in the Internal Inquiry and establishing what progress is being made implementing the recommendations.” Full terms of reference are attached at Appendix C.
1.3 Who conducted the review
1.4 How the review was conducted
2 Summary and conclusions
This section is intended to provide an overview of the main conclusions. The evidence is included and discussed in the main body of this report. Recommendations appear throughout this report and are summarised in Section 7.
The methodology adopted by the Internal Inquiry panel was consistent with that required for a comprehensive, robust internal investigation. The presentation and content of the Internal Inquiry report suggest that the methodology was successfully implemented.
The Internal Inquiry report was well written and concise but undated. The context and history were well set out in the report and key themes were adequately covered. However some conclusions were not clearly summarised and three opportunities to make recommendations were missed. (These are dealt with later in this report).
I agree with a key conclusion of the Internal Inquiry that MS's care and treatment was planned within the spirit of the Care Programme Approach (CPA) but that there were ways in which it did not comply fully with the (then) existing CPA policy. I also agree with the conclusion that MS's care was effectively coordinated. The absence of conclusions or recommendations by the Internal Inquiry concerning the (then) existence of a local CPA policy within the Adult Forensic Service may have been an opportunity missed. I am however satisfied that this anomaly has subsequently been addressed and a single CPA Policy is now in use.
It was surprising that the Internal Inquiry did not conclude that work was required across the Trust as a whole on the consistency of risk assessment and the framework for risk management.
This tragic incident and the lessons learned from it have contributed to shared learning across the Trust and where appropriate this has been led by the Adult Forensic Mental Health Service Directorate. The Trust's clinical and social care governance framework has facilitated and enabled that learning.
The post-incident support offered to staff was of a high standard with the exception of the omission of an offer of support for MS's former Responsible Medical Officer (RMO). A recommendation from the Internal Inquiry concerning the offer of support to staff who may have left the Trust's employment, or who were seconded to another employer, would have been helpful. The Trust's policy still does not specifically cover this eventuality.
Coverage of "other issues arising" during the Internal Inquiry was helpful. It demonstrated a willingness to allow the process of the Internal Inquiry to be participative, interactive and not too constrained by terms of reference. This approach is to be commended.
One of the "other issues arising" was not adequately followed through by the Internal Inquiry to form a recommendation. This related to the ethnic diversity of the workforce. In other respects the Internal Inquiry did ensure that adequate attention was given to the issues covered by its terms of reference.
The timeliness of the Serious Incident Review within a week of the incident was commendable. However a delay of at least 10 months after the incident in having an action plan agreed to implement the recommendations of an Internal Inquiry does not represent best practice. This is though, to some extent, mitigated by the fact that some work on service improvement was underway very soon after the incident. For example, discussion of community psychiatric nurse care plans at all out-patient reviews and clarifying the appropriate adult role including who should and should not fulfill it.
The Trust's work on implementing the ICIS computerised records system is impressive and should be commended.
The current policy in the Trust for Reporting and Managing Untoward Incidents appears to be in line with current best practice.
Good progress has been made on the implementation of actions arising from the recommendations of the Internal Inquiry. The relatively few areas where progress has not been so clearly demonstrated, or where there were gaps in the conclusions or recommendations of the Internal Inquiry, are covered by recommendations in this report.
3 A brief overview of MS's care and treatment by the mental health services
The following background information has been extracted from the Internal Inquiry report produced by the Trust and has been validated by a review of the case notes. A case summary prepared for the Internal Inquiry panel by a Consultant Forensic Psychiatrist, was particularly helpful in this respect.
4 The Internal Inquiry
Introduction
This section of the report deals with the membership, terms of reference and methodology of the Internal Inquiry and with the presentation of its report. The analysis, findings, conclusions and recommendations of the Internal Inquiry are considered in Section 5 below.
4.1 Panel Membership
The panel was constituted in accordance with the Trust's Untoward Incidents Policy. The panel was chaired by a non-executive director of the Trust. Its membership appropriately included a Consultant Forensic Psychiatrist who had not been involved in the care or treatment of MS, the Clinical Leader, Adult Forensic Services and the Acting Director of Mental Health Services for one of the localities (Boroughs) served by the Trust. Acknowledgement was given for the support received from the secretary to the panel and the Trust's Clinical Governance Manager.
4.2 Terms of reference
4.3 Methodology
The panel's methodology included an overview of the (then) computerised information system, interviews with relevant members of staff and with the (then) Manager of Wilson Carlile House, scrutiny of clinical and social work case notes, scrutiny of policies and procedures (both Trust wide and service specific), scrutiny of Adult Forensic Service Serious Incident Review minutes and scrutiny of the Wilson Carlile House Internal inquiry report.
Comment
The methodology adopted was consistent with that required for a comprehensive and robust Internal Inquiry. The interviewees included all of the key staff involved in MS's care and treatment and also the appropriate managers within the service. An offer was made to MS's mother to participate in the Inquiry but she chose not to take up the invitation. The presentation and content of the report suggest that the methodology was successfully implemented.
4.4 Presentation of the report
Comment
This was a well written, concise but undated Internal Inquiry report which set out the context and history well before covering the key themes and issues emerging from the Inquiry in a rational and "easy to follow" presentation. However, the "Conclusions" section of the report, whilst concise, did not include a summary of all conclusions. For example conclusions reached on the key issues concerning the use of the Care Programme Approach (CPA) were not included. Three opportunities to make recommendations in the light of findings appear not to have been taken.
Recommendation 1
The Trust should ensure that in future all copies of Internal Inquiry or Review reports are clearly dated.
This section reviews whether the Internal Inquiry considered all the appropriate evidence and examines the consistency of conclusions and recommendations with that evidence. This part of the review is drawn from a close examination of a considerable (7 volumes) volume of health and social care records related to MS, a review of all relevant policies and procedures in place at the time of the incident and of versions of some policies and procedures updated since the incident. It has also been supported by meetings with a small number of practitioners, clinicians and managers from the Trust and the forensic service in which key issues and themes were explored and discussed. Those meetings were of considerable help to the reviewer in this part of the review. The following sub-headings reflect the key themes identified in the Internal Inquiry Report:
5.1 Trust wide and service specific policies and procedures
Overview - all of the policies, procedures and guidelines relevant to the Internal Inquiry appear to have been examined by the Internal Inquiry panel.
Context and Scope - the review of policies and procedures was however undertaken (as required by the terms of reference) in the context of whether service delivery had met statutory and policy requirements and of the application of protocols following a serious incident. The Internal Inquiry did not therefore examine all policies to establish their more general fitness for purpose. Nonetheless, with regard to the (then) Protocol for the Management of Incidents and Staff Debrief the Internal Inquiry report did identify the need for its review. Similarly, having examined the guidelines for escorting patients outside the unit, a need to combine the two (then) existing policies for the Trust and the Edenfield Centre respectively into a single policy document was identified.
Conclusions - the report identified no conclusions in respect of policies and procedures other than that protocols had been followed after the incident and that the issue of the Appropriate Adult role in the Police Liaison Protocol required review. There were however by implication, in conclusions concerning MS's use of cannabis, documentation /record keeping and risk assessment/ risk management, a number of issues identified from which it might have been more clearly concluded that policy reviews were needed. In addition there was no clear conclusion presented regarding the use of the Care Planning Approach as the way of undertaking, monitoring and reviewing care plans for all patients in the Trust including those receiving care and treatment from the forensic service. However, in spite of the lack of firm and clear conclusions on these key issues in the "Conclusions" section of the report most of those issues were addressed, either in the main body of the report and/ or in the recommendations section.
Recommendations - the Internal Inquiry's recommendations concerning policies and procedures appear to be proportionate, appropriate and achievable. (See Paragraph 5.2 below)
Overview - this aspect of the Internal Inquiry's work appears to have been adequately covered.
Context and Scope - the context at the time of the homicide i.e. that there was then a local CPA policy in operation within the Adult Forensic Service is appropriately addressed. The experience of the multi-disciplinary team members most closely involved in MS's care and treatment is also appropriately highlighted.
Conclusions - the findings and conclusions of the Internal Inquiry appear to have been appropriate. They were set out in the sub-section of the Internal Inquiry Report dealing with CPA and were not included or summarised in the "Conclusions" section of the report where they might have stood out more clearly.
Recommendations - the Internal Inquiry's recommendations concerning CPA adequately covered the key issues regarding risk management and risk assessment, adherence to policy, audit of policy compliance and documentation requirements for CPA meetings. There was no recommendation concerning the existence of a local CPA policy in the Adult Forensic Mental Health Service as distinct from the CPA policy for the Trust as a whole.
Comment
The care planning documentation in the clinical records is very well recorded using the Paragon computerised patient record system then in use. I agree with the key conclusion of the Internal Inquiry that MS's care and treatment was planned within the spirit of the Care Programme Approach, but that there were ways in which it did not comply fully with the (then) existing CPA policy. I also agree that MS's care was effectively co-ordinated. The evidence to support those conclusions can be clearly seen in the records and was reinforced in my meetings with practitioners, managers and clinicians.
The absence of conclusions or recommendations concerning the existence of a local CPA policy within the forensic service and how it operated with the Trust's CPA policy may have been an opportunity missed by the Internal Inquiry. However, from my fieldwork discussions it is clear that such anomalies have nonetheless subsequently been addressed so that a single CPA policy is now in place. (Please see Section 6 below)
Overview - this part of the Internal Inquiry's work appears to have been thorough and rigorous.
Context and Scope - the context in which MS's continuous monitoring and support from his social supervisor and input from the multidisciplinary team was provided is well established in the report.
Conclusions - the conclusions within this section of the report seem reasonable and are consistent with the evidence in the records. In the "Conclusions" section of the report the conclusion that social work supervision was frequent and adequate enough appears to be consistent with the evidence in the records.
Recommendations - there were no specific recommendations arising from this aspect of the Internal Inquiry report.
5.4 MS's medical care and treatment
Overview - this section of the Internal Inquiry report appears to be drawn in part from the comprehensive case summary available to the panel (See also Section 3 above). It appears to provide a thorough and rigorous assessment of the medical treatment received by MS, including a full medication review for the period from 10 July 1997 to 28 February 2002.
Context and Scope - the context of MS's earlier psychiatric history and of his long term use of cannabis is well covered. Appropriate references are made to clinical risks, relapse signatures and to issues relating to risk assessment and risk management.
Conclusions - are clearly set out in a sub section entitled "Conclusions on the Care and Treatment of MS". They appear to be appropriate and consistent with the evidence but are not included or summarised in the report's "Conclusions" section.
Recommendations - the report includes a relevant recommendation concerning regular clinical peer review of case files to ensure the quality of clinical care, the quality of documentation and the adherence to relevant policies.
5.5 Risk assessment and management: The Edenfield Centre guidelines
Overview - this key area of the Internal Inquiry's work is covered in a very brief sub-section of the report. Whilst it covered matters relating specifically to guidance for staff at the Edenfield Centre, it did not examine the strengths and weaknesses of arrangements within the Adult Forensic Services or the Trust as a whole for risk assessment or risk management policies, procedures or practice. However, the earlier sub section "Conclusions on the Care and Treatment of MS (See Paragraph 5.4 above) had dealt more comprehensively with a number of risk assessment/ risk management issues and had noted that it had been very difficult for the panel to investigate issues of risk assessment because of the (poor) quality of the documentation available.
Context and Scope - the Internal Inquiry report provided some context for the Edenfield Centre's practice in risk assessment and risk management by reference to the Royal College of Psychiatrists 1996 publication "The Assessment and Management of Clinical Risk". This sub-section confined itself to reporting briefly on the incorporation in 2001 of a set of standards on risk assessment and risk management into the Edenfield Centre's "medical standards" and to the agreement of CPA guidelines (which included additional information on the management of patients and the documentation of issues relative to risk assessment and risk management) prepared in 2000 as unit based standards in October 2000.
Recommendations - eight of the report's 24 recommendations are grouped under a "Risk Assessment and Risk Management" heading. Two of those recommendations relate specifically to CPA and one to the consideration of risk assessment and risk management issues at CPA meetings. The recommendations appear to be appropriate and consistent with conclusions which appear in various parts of the report.
Comment
It is surprising that the Internal Inquiry did not conclude that work was needed across the Trust as a whole on the consistency of risk assessment and the framework for risk management, although I accept that the panel may have felt constrained by its terms of reference.
In practice, from my fieldwork meetings, it appears that this tragic case and the lessons learned have contributed to shared learning across the Trust (and where appropriate led by the Adult Forensic Service) using the Trust's clinical governance processes as an enabling framework. (See also Section 6 below)
5.6 Serious incident review procedure
Overview - in this section of their report the Internal Inquiry panel reviewed the use, by the multi disciplinary team, of the Trust's Serious Incident Review procedure after the incident on 12 February 2002. This included the appropriateness of MS's recall to the Edenfield Centre after the incident, liaison with the Police in the immediate post incident period, the Police Liaison Protocol in relation to Appropriate Adults and a lack of communication and offer of support from the Edenfield Centre to MS's former Responsible Medical Officer (RMO).
Context and Scope - the context for this section of the report was clear and the scope proportionate.
Conclusions - the conclusions from this section of the Internal Inquiry Report appear to be consistent with the evidence and relevant. Key conclusions were included in the "Conclusions" section of the report. For example conclusions regarding the timeliness of the Serious Incident Review and the need to review the Police Liaison Protocol regarding the Appropriate Adult role were both highlighted.
Recommendations - the recommendations under this heading appear to be comprehensive and appropriate.
5.7 Support to staff and others involved in the incident
Overview - the outcome of the Internal Inquiry's review of the support offered is reported concisely, dealing adequately with the feedback the panel had sought and received during interviews with all the key staff involved.
Context and Scope - the context had been adequately set earlier in the Internal Inquiry report. This section appropriately covered support offered to Edenfield Centre staff, support offered by Edenfield Centre staff to staff at Wilson Carlile House and the support offered and provided to MS's mother. The panel had offered to meet with MS's mother but she chose not to take up the offer. This section did not cover the absence of an offer of support to MS's former RMO; an issue which had been covered in an earlier section of the Report (See Paragraph 5.6 above) and which was adequately covered later in the Report's "Conclusions" section. Cross references would have been useful.
Conclusions - the panel concluded that "the support given to all members of staff and to those who were involved in the care and treatment of MS was beyond what could have been expected on an informal and formal level".
Recommendations - there were no recommendations covering this area of the Internal Inquiry's work.
Comment
The meetings during my field work confirmed that the support offered and received was of a high standard except for the omission of MS's former RMO. From the evidence available I would conclude that the support offered was timely, well received and within the agreed policies. It was (apart from the above mentioned omission) therefore within the high standards expected rather than beyond them.
A recommendation would have been appropriate concerning the need to ensure that support was offered to members of staff involved in serious untoward incidents who were no longer employed in the Trust or who were seconded away from their usual place of work. I note that the Trust's current policy does not cover this eventuality.
Recommendation 2
The Trust should ensure that its policy for the reporting and management of untoward incidents makes explicit the need to ensure that any staff involved in such incidents who have left the Trust's employment, or have been seconded to another employer, are offered all the necessary and appropriate support.
5.8 Other issues arising during the Internal Inquiry
Overview - this section of the Internal Inquiry report deals with issues which arose during the work of the Internal Inquiry which may not have related directly to its terms of reference. It seems entirely appropriate that these issues should be considered by the panel and reported upon as part of the process of identifying and creating opportunities to learn lessons form this tragic incident.
Context and Scope - the context for this section was simply around issues raised by people who were interviewed by the panel. The scope was wide ranging. The issues were identified and included in the report as 13 sub-headings. Each issue was briefly described and some commentary from the panel was included
Conclusions - where appropriate conclusions were drawn and included in the "Conclusions" section of the Internal Inquiry Report e.g. concerning the use of cannabis and social worker input.
Recommendations - a number of the Internal Inquiry's recommendations arose from this section. In particular the seven recommendations sub-headed "Issues for Training" can all be tracked back to this section of the report. A number of important matters arising from subtle changes in MS's presentation and the need to recognise the importance of significant life events are covered in the report's recommendations. However one opportunity to make a recommendation to reinforce or confirm the need for more work appears to have been missed. (See comment below)
Comment
This was a particularly useful section of the report, enabling issues not strictly related to the Internal Inquiry's terms of reference to be identified and considered. It demonstrates a willingness to allow the process of the Internal Inquiry to be participative and interactive. This approach is to be commended.
One issue raised in this section of the report appears not to have been adequately carried through to form recommendations: the Internal Inquiry report states that "A member of staff from the Wilson Carlile House raised the lack of staff from ethnic backgrounds within the Edenfield Centre. The lack of racial diversity amongst the Trust staff is a recognised issue, which is currently being dealt with by the Human Resources Department". The matter was not further pursued by the Internal Inquiry and should have formed the basis of an additional recommendation to reinforce the need for the Edenfield Centre and the Trust to pursue, in the light of the Inquiry, a review of ethnic diversity in its workforce and to report progress on the review and its subsequent recommendations and action plan to the Trust Board.
Nevertheless action to address this important issue has since been taken by the Trust. The Equality and Strategy Action Plan which incorporated the Race Equality Scheme April 2005-April 2008 was published by the Trust in 2005. It includes a section on workforce and service user data, providing information on the communities and populations served and the Trust's workforce and patients. Information is presented for gender, ethnicity, disability, age, faith, religion and spirituality and sexual orientation. In relation to the Adult Forensic Directorate,u data on ethnicity of the workforce is included. However, data was not available across the Directorates for the ethnicity of existing patients and it is at present still not possible to compare the ethnicity of patients in the Forensic Service (or other services in the Trust) with the ethnicity of the workforce. This has been identified within the Strategy and Action Plan as a clear area for improvement and from January 2005 action has been taken to effect the necessary consistent collection and recording of ethnicity data across the Directorates in the Trust. There is therefore evidence that the issue is being taken very seriously by the Trust .The Action Plan should ensure that any necessary further action in the light of data on patient and workforce ethnicity data can be identified and put in place.
Comment
From the above review I can conclude that, with the exception of the matters identified in this section of the report, the Internal Inquiry did ensure that adequate and appropriate attention was given to the issues highlighted in their terms of reference for their work. (See Paragraph 1.2 above)
6 Learning the lessons
This section outlines and comments upon the progress the Trust is making towards implementing the recommendations of the Internal Inquiry.
6.1 The action plan
Comment
Whilst the timeliness of the Serious Untoward Incident Review, within a week of the incident, is commendable, a delay of at least 10 months i.e. from March to December 2002 in having an action plan in place does not represent best practice. This is to some extent mitigated by the fact that some work on immediate actions was underway soon after the incident.
Recommendation 3
The Trust should ensure that in future all action plans arising from Internal Inquiries and Reviews are clearly dated.
Recommendation 4
The Trust should review the expected timetables for the completion of Internal Inquiries and Reviews and consider asking that reports of such Inquiries and Reviews are accompanied by draft action plans at the time of their consideration by the Board in order to save time. (For an Internal Inquiry of this scope and complexity a period before reporting of six months would appear to be sufficient)
Recommendation 5
The Trust should review the format for action plans arising from SUIs, internal inquiries and reviews to ensure consistency and to include space for recording evidence of implementation.
Recommendation 6
The Trust should consider developing a monitoring tool to enable the recording and continuous review of the status of actions within action plans until all are signed off with evidence of completion recorded. (Some work on such a model appears to have been done within the Adult Forensic Mental Health Service Directorate)
6.2 Completed actions and gaps in action
From my review of documentation and fieldwork meetings I was able to quickly establish that 15 of the 24 recommendations had been implemented. Of the remaining nine recommendations, seven have been implemented and I have commented on them individually below.
Comment
The Trust's work on implementing the ICIS computerised records system is impressive and should be commended.
I have commented individually on implementation of the remaining seven recommendations.
Following discussion of this recommendation during my fieldwork meetings I have now seen the single policy now in existence. It was most recently reviewed in April 2004 and signed off as such by the Risk and Security Manager. I note that the policy was due for review again in May 2005 but have not seen the confirmation that the review was completed. This recommendation appears therefore to have been implemented.
2 The timing and procedure for SUI Reviews and Internal Inquiries
The current policy for the reporting and management of untoward incidents - dated September 2003 and updated and re-approved by the Trust's Clinical and Social Care Governance Committee on 1 September 2005 - is explicit about timetables for completion of SUI Reviews and Internal Reviews and procedures are very adequately set out. This recommendation has therefore been implemented.
3 Opportunity for those appearing before a panel to review relevant notes
There is no reference to this in the policy for the reporting and management of untoward incidents. I have therefore seen no clear evidence that this recommendation, which concerned both existing Trust staff and those "who are no longer employed in the service", has been implemented.
Comment
The current policy for the reporting and management of untoward incidents is largely in line with current best practice.
Recommendation 7
The Trust should consider the insertion of a paragraph in its policy for the reporting and management of untoward incidents to cover the offer of an opportunity for existing or former staff who are invited to appear before an internal inquiry or review panel, to have prior access to the appropriate notes
This recommendation was made in the context of the police not informing the Edenfield Centre of the incident. My fieldwork meetings confirmed that a Police Liaison Officer had been appointed since the incident and that day to day relationships with the police were consequently improved, with a greater mutual understanding of demands on the respective services.
It was also encouraging to hear of joint work towards producing a memorandum of understanding for the local Multi Agency Public Protection Arrangements (MAPPA) (though it is unlikely that MS would have met the criteria for inclusion). I was pleased to hear about a pilot for dealing with people at MAPPA Level 3. There was however some concern expressed that the predicted number of people at MAPPA Level 3 is likely to exceed the resources available to meet their needs. This together with questions concerning the sharing of information and thresholds for MAPPA, particularly for people considered to be dangerous or potentially dangerous but who do not meet MAPPA criteria, are national issues.
Recommendation 8
The Trust should consider commissioning with its partners in MAPPA a multi agency case-study based workshop. The workshop could explore the interface between MAPPA, adult mental health services, housing and child protection services.
Whilst I was reassured in discussions during fieldwork meetings that this recommendation has been addressed through the buddy system for all Consultant Psychiatrists and via regular weekly supervision for all junior staff, it does not appear to be explicitly covered in the (otherwise excellent) draft multi-disciplinary standards under development within the Adult Forensic Mental Health Service Directorate. I have not seen clear evidence to confirm that this recommendation has been fully implemented across all disciplines.
The Trust should review its training programmes to ensure that appropriate training is available to all relevant staff across disciplines regarding relapse signatures and subtle changes in a patient's presentation. Such training could be extended where necessary to staff working in partner organisations.
Recommendation 10
The Trust should consider whether specific references to relapse signatures and subtle changes in a patient's presentation should be included in the Multi-Disciplinary Standards being developed by the Adult Forensic Mental Health Service Directorate.
This recommendation of the Internal Inquiry arose from an issue identified during panel interviews about the attitude of inpatient staff to community staff when community patients were re-admitted. Whilst I have not seen any documentary evidence to confirm that the implementation of this recommendation has been completed, I am satisfied that the spirit of this recommendation has been satisfied from the consistent answers I received during my fieldwork meetings, and from the fact that an audit of community re-admissions was undertaken by the Directorate's Clinical Leader and that the findings formed the basis of a presentation within the service.
In the action plan the defined action was: "core care plans to be developed for all patients (of the Adult Forensic Mental Health service) in the community and inpatient service where this is an identified issue". I have been unable to find clear evidence that such "core care plans" have been developed, although I accept that the format, recording and documentation of care plans within the Adult Forensic Mental Health Service is generally much improved since 2002 and that this satisfies the spirit of the recommendation. The identified "action required" only partially matched the recommendation which was (in the context of narrative in the main body of the Internal Inquiry report) that guidelines were needed for each individual patient within their nursing care plan. My fieldwork discussions confirmed that this issue is in practice discussed in clinical supervision. The view was expressed that experience, training and awareness were more important for front line staff around this issue than guidelines.
This recommendation in the Internal Inquiry report was ambiguous. It suggests guidelines but on closer examination appears to be intended to be more to do with clarity in respect of individual patients about the appropriate responses to continuing and unremitting illicit drug use. Because of this it is difficult to be sure whether the implementation of the recommendation is complete.
Recommendation 11
The Adult Forensic Mental Health Service Directorate should consider, as part of its clinical and social care governance agenda, commissioning an audit of a sample of current care plans for patients with continuing and unremitting illicit drug use. The findings of the audit should be used to identify any training, supervision and practice guidance issues to assist in service improvement. The outcomes should be shared across the Trust as a whole.
Comment
This review has confirmed that 22 of the 24 recommendations have been implemented. Two recommendations appear not to have been fully implemented. They are discussed above. Where further work is indicated recommendations are included above.
One recommendation in the Internal Inquiry report and its subsequent identified action appear to have been somewhat ambiguous. A recommendation above identifies the need for further work on this within the Adult Forensic Service which could be shared across the Trust as a whole.
Overall, as should be expected given the time span between this review and the Internal Inquiry, good progress has been made in the implementation of changes arising from the recommendations of the Internal Inquiry.
6.3 A Learning Organisation
During my review of documentation and in the helpful and open discussions in fieldwork meetings, a number of issues arose concerned with the framework within the Trust for learning lessons from such tragic incidents and sharing the learning across the organisation to help with the processes of service improvement. These were mostly reflections on positive progress made over the past three or four years in a number of key areas. It seemed appropriate that a summary of those reflections should be included in this report as a validation of work in the Trust to secure improvements and as an encouragement to build on the momentum created.
The Trust's Learning Forum now appears to be an important vehicle for encouraging and enabling shared learning. The Forensic Services Directorate's Nurse Consultant for clinical risk and the Forensic Services Site Manager are both members of the forum. The key messages for learning across the Trust and Directorates are promoted regularly via the "Factfile" newsletter. Roles of nurse consultants in driving and facilitation of good practice and change were discussed as reported above. The Trust's investment in these posts provides evidence to confirm that shared learning and good practice remains a high priority.
It could be helpful to focus further RCA training on a smaller number of managers who could form a panel of RCA expertise within and across the Trust and which could operate as a "virtual team" sharing and developing expertise and practice.
Post incident support for staff and others involved in this incident appears to have been good. As well as access to counselling and / or one to one support, a support group was quickly set up and met regularly guided by the Forensic Service's Associate Clinical Director. The gap in support offered to staff who may have left the employment of the Trust was discussed in Paragraph 5.7 above.
Recommendation 12
The Greater Manchester Strategic Health Authority should look at ways of speeding up the commissioning of external independent reviews in cases involving homicide.
Recommendation 13
The Trust should consider identifying an appropriate number (around 6-10) of suitably qualified and experienced managers to undertake further training in root cause analysis (RCA) as a group. These RCA trained managers could then form a RCA panel for the Trust. Once the RCA panel is in place, all internal reviews of critical incidents should be led by a RCA panel member who does not have direct line responsibility for the service or locality in which the incident happened.
7 Summary of Recommendations
Appendix A
Bibliography and list of documents examined
Serious Incident Review Internal Inquiry and Action Plans
Internal Inquiry Report MS Serious Incident Bolton Salford and
12 Feb 2002 – undated Trafford Mental Health
NHS Trust (BSTMHT)
Specialist Services Directorate Mental Health Services
Report- Local Multi-Disciplinary Review of Salford NHS Trust
Into a Serious Incident -19 Feb 2002 (MHSMHT)
Adult Forensic Services BSTMHT
Serious Incident Review - Incident Details form and
(Completed) Action Plan form -undated
Adult Forensic Services BSTMHT
Action Plan in Response to the Internal Review of MS
undated
Policies and Procedures
Policy for Reporting and Management BSTMHT
of Untoward Incidents - Sep 2003 - Revised Sep 2005
Untoward Incident -Policy and Procedure - Jul 2000 MHSMHT
reviewed Feb 2002
Protocol for the Post Incident Debriefing and Support MHSMHT
(of patients and staff following serious incidents)
Feb 2002
Care Programme Approach Policy - Edenfield Centre MHSMHT
Oct 2000
Key Policy Renewal Dates - Jan 2005 BSTMHT
Adult Forensic Mental Health Service Directorate BSMHT
Index to the Procedures and Guidance Manual
Transporting Patients Under Escort - Feb 2002 MHSMHT
Forensic and High Dependency Service Directorate MHSMHT
Guidelines for Escorting Patients Outside the Unit
Jul 1998 - reviewed Jan 2000
Adult Forensic Mental Health Service Directorate BSTMHT
Guidelines for Escorting Patients Outside the Unit
(Nursing) and (Occupational Therapy)
Reviewed Apr 2004
Forensic and High Dependency Directorate MHSMHT
Police Liaison Protocol - Oct 1997
Forensic and High Dependency Service Directorate MHSMHT
Protocol for Out of Hours/On Call Service
Provided by the Forensic Community Mental Health
Nurses - Jun 2001
Information Sharing Protocol -2005 BSTMHT
Equality Strategy and Action Plan - 2005-2008 BSTMHT
Service Standards
Adult Forensic Mental Health Service Directorate BSTMHT
Multi disciplinary Standards - Draft 4 -Sep 2005
Adult Forensic Mental Health Service Directorate BSTMHT
Service Plan 2006 and Health Commission Core
Standards
Minutes and Notes of Meetings
Trust Board Meeting Minutes - 9 Dec 2002 BSTMHT
Policy and Procedures Group Minutes - 8 Jun 2005 BSTMHT
Policy and Procedures Group Minutes - 14 Oct 2005 BSTMHT
Clinical and Social Care Governance Committee BSTMHT
Minutes - 1 Sep 2005, 3 Nov 2005 & 12 Jan 2006
Working Group (Multi disciplinary Standards) BSTMHT
Adult Forensic Mental Health Services Directorate
10 Nov 2005
Other Documents and Reports
National Service Framework for Mental Health: Department of Health
Sep 1999
Guidance on the Discharge of Mentally Disordered NHS Executive
People and their Continuing Care in the Community
(HSG(94)27
Notes for the Guidance of Social Supervisors – Mental Home Office/DOH/
Health Act 1983 – 1997 Welsh Office
Clinical Governance Review -Bolton Salford and Healthcare Commission
Trafford Mental Health NHS Trust - Apr 2004
Appendix B
Individuals and groups who met the reviewer
John Rimmer- Forensic CPN and John Kinsella Adult Forensic Mental Health
Team Leader Social Work Service Directorate -BSTMHT
Diane Turnbull- Clinical and Social Care BSTMHT
Governance Manager and Gary McNamee -
Associate Director of Risk and Patient Safety
Dr Josanne Holloway- Clinical Director and Adult Forensic Mental Health
Nicola Lees - Associate Clinical Director Service Directorate -BSTMHT
Appendix C