A mental health trust has apologised to families, after a critical review of 10 killings found that it underestimated the risks posed by some of its patients.
Sussex Partnership NHS Foundation Trust provides mental health, specialist learning disability and substance misuse services across and outside Sussex. The review looked at nine killings by patients and the case of one patient who was killed while in the trust’s care.
“The review sends us a very strong message”
The review, commissioned by the trust and NHS England in March, examined homicides linked to patients of the trust between 2007 and 2015. It was carried out by Caring Solutions UK and published on 18 October.
In two of the nine cases, the homicides were judged to be predictable or preventable. The main common factor in the incidents was the need for improvement in risk management and risk assessment.
Trust chief executive Colm Donaghy said: “On behalf of the trust, I want to extend my sincere apology and condolences. We commissioned this review with NHS England because we want to make sure we have done everything we should have in response to these tragic incidents.
“The review sends us a very strong message about the need to identify and embed the learning from when things go wrong in a way that changes clinical practice and improves patient care. This goes beyond action plans; it’s about organisational culture, values and leadership,” he said.
Jan Fowler, director of nursing and quality at NHS England South, said the point of the review was not to reinvestigate cases, but to assess the trust’s response to homicides involving people in its care so lessons could be learned.
She said: “The review provided some recommendations for NHS England around how we can improve future investigations. We have already started work on these to ensure we have the right processes in place to help to improve care for patients.”
Recommendations for the trust
- Monitor the implementation of the care delivery service structure and the use of the safeguard serious incident recording system to ensure the investigation management and implementation of action plans are consistent with trust policies, processes and systems.
- Provide assurance and evidence that learning from all recommendations is fully embedded across the organisation in a timely manner.
- Ensure clinical staff have dedicated time for making notes and record keeping; that staff record the rationale for the clinical decisions they make; and use risk assessment and formulation to inform relapse planning.
- Investigate the feasibility of technological solutions to make it easier to complete records and improve productivity, such as the use of voice recognition technology.
- Develop a checklist of key requirements based on the themes identified in the report, to be used at all care plan approach reviews.
- Evaluate the impact of training and education.
- Implement the “triangle of care” approach to involving carers in the care and treatment of service users and achieve membership of the national programme within 12 months.
Recommendations for local commissioners
- Specifying that providers carry out audits of quality rather only using electronic systems to count the number of times things are done.
- Specifying that providers carry out patient safety auditing of basic practice – eg: recording, assessments and risk management planning.
Recommendations for NHS England
- Requiring independent investigation teams to produce no more than three high impact key recommendations. If the team considers that more are necessary, these should be listed in order of priority for improving the service/reducing the likelihood of recurrence.
- Investigation teams should be told to focus recommendations on outcomes rather than processes when the serious incident framework is next revised.
- NHS England should hold discussions regarding access to specialist services such as neurobehavioral services.
Caring Solutions UK report
18 October 2016