Noleen McPharlane

Camden and Islington NHS

NHS Foundation Trust

Executive office

4" Floor, East Wing
St Pancras Hospital
4 St Pancras Way
LONDON NW1 OPE
Tel: 020 3317 3224
Fax: 020 3317 3230
www.candi.nhs.uk

2" October, 2014

Coroner ME Hassell

Senior Coroner

Inner North London

St Pancras Coroner’s Court
Camley Street

London N1C 4PP

Dear Coroner Hassell,
Re: Ms Noleen Mary McPharlane (died 22 April 2014)

| write further to your report on the above dated 7th August 2014 in which you highlighted
concerns about the care delivered by the Trust to Ms McPharlane. | wish to thank you for
bringing your concerns to our attention and | am writing to address the issues you have
raised and give assurance that we have and continue to address these.

In your report you state that, “during the course of the inquest, the evidence revealed
matters giving rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances it is my statutory duty to report to you.” You
outlined your concerns in three areas:

Clinical specialist not once directly asked Ms McPharlane about thoughts of her taking her
own life

Clinical specialist never once asked her about the known risk of her buying medication from
the internet and taking this to excess

Lack of exploration of the possible therapeutic benefit of direct input from an alternative
healthcare professional

| will address the first two points together and then the third.

Clinical specialist not asking about thoughts of her taking her own life, and not
asking about her buying medication from the internet and taking this to excess

The Trust has a clinical risk assessment and management policy in place. It has been
reviewed and updated in September 2014 and is currently being consulted upon. The Trust
believes that effective clinical risk assessment and management is crucial to the delivery of
high quality services across all parts of the Trust and is a core component of mental

Chair: Leisha Fullick Your partner in CRI
Chief Executive: Wendy Wallace care & improvement

2 Cal is an NHS Foundation Trust providing treatment and social care for mental ill-health
= Camden ® ISLINGTON and substance misuse in adults in partnership with Camden and Islington councils.

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healthcare and the Care Programme Approach. Effective care includes an awareness of a
person’s overall needs as well as an awareness of the degree of risk that they may present
to themselves, to others and from others. Many practitioners make decisions every day
about how to help a service user live independently and manage their potential for self-
harm, suicide, self-neglect, violence and risk from others. The policy is intended to guide
mental health practitioners making these decisions.

Individual members of staff working with people with mental health and substance misuse
problems are expected to follow the clinical risk policy by:

e Incorporating clinical risk management into their ongoing work with service users

e Carrying out formal risk assessments and completing the appropriate documentation

e Discussing risk and risk management with the service users (and others involved in their
care) with whom they are working. Wherever possible the service user should be offered to
take a lead role in identifying the risks from their point of view and in the drawing up of plans
to deal with the risk. The plans should include individual advanced decisions on early
warning of a relapse, as well as preferred early interventions at times of crisis.

e Seeking advice and support from colleagues on risk management issues, not only when
there are difficult decisions to make, but also as part of reviewing their practice on an
ongoing basis. This will usually be through their multidisciplinary team, using the structure of
the Care Programme Approach (CPA) process with the Consultant agreeing to individual
management plans. All staff must be in regular supervision which includes discussion on
risk assessment, safeguarding and a review of risk documentation on the Trust’s patient
record system undertaken within supervision. In addition there are a series of meetings held
in the Trust where high risk cases are discussed

e Attending Risk Assessment training every two years

The Head of Quality Assurance and Regulation is responsible for

e Ensuring there is organisational learning and continuous improvement in clinical risk
management.

e Ensuring that all Trust serious untoward incidents are investigated

e Advising Associate Divisional Directors about the findings and recommendations presented
within national reports, inquiries and investigations

e Setting out an annual audit plan to review and learn from the way in which clinical risk is
managed within the organisation.

A risk assessment must be undertaken with all new service users and at intervals thereafter as
appropriate. The risk assessment and management plan should be refreshed at least once a
year and more frequently if new circumstances arise, e.g. a change in care setting. It is not
possible to provide an exact formula for staff to use to assess risk. Rather, staff must assess risk
based upon reasoned judgment and their in-depth knowledge of a service user. Although a risk
assessment is based on information given by the service user themselves and a synopsis of the
risk history evident in the case file, information may also be gleaned by engaging with personal
networks (such as carers and friends if consent is given) and professional networks (such as
other Trust teams, social services, police etc). A robust risk assessment utilises information from
a variety of sources to obtain a clear and accurate picture of the risks present. Corroboration of
information by multiple sources means that clinicians may be more confident in the factual
accuracy of that information.

Care Plans (regardless of whether they are ward based care plans or community CPA care
plans) should contain agreed interventions that aim to manage and/or reduce the risk behaviours
identified in the assessment and aim to build on a service user’s strengths and recovery.

Positive risk management means being aware that risk can never be completely eliminated, and
aware that management plans inevitably have to include decisions that carry some risk. This

2

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should be explicit in the decision-making process and should be discussed openly with the
service user. Positive risk management as part of a carefully constructed plan is a required
competence for all mental health practitioners.

The clinical risk assessment and management policy is monitored by the Clinical Governance
and Performance team through interrogating the electronic patient record. The department for
Learning and Development monitor that staff attend clinical risk management training.

In this case the Trust policy on risk assessment and management was not adhered to.

2. Lack of exploration of the possible therapeutic benefit of direct input from an
alternative healthcare professional

The Trust has a practice supervision policy which states that the aim of clinical supervision is to
look at a staff member's professional practice and conduct in the workplace, measuring it against
relevant codes of conduct and expectations of a competent and high quality practitioner in their
area of practice. A supervision conversation might usefully touch upon the following types of
issues:

e A reflection on a significant incident in practice, such as an exchange with a patient or
client that either went extremely well or that the staff member feels could have gone
better

e Consideration of key elements of professional practice, such as issues around
safeguarding of children and adults or working in an anti-discriminatory fashion

e Critical examination of electronic patient case records

e Ways and means of extending key aspects of professional competence, possibly with the
aim of making a personal plan for career progression

e Supporting a move from reflection to reflexivity around practice, meaning that the staff
member is encouraged to look beyond the detail of their experience to assess the context
in which their practice takes place — that is, the social, cultural and economic framework —
and to develop an awareness of the way in which their contribution as a practitioner
impacts on the circumstances in which they work

e Proposals for innovation or continuous improvement in terms of both individual
professional practice and that of the team or service in which they work.

Clinical practice supervision is provided to those who work in key professions — specifically,
medicine, nursing, social work, psychology and occupational therapy — along with any staff
members who work directly to provide care to service users. Supervision is expected to take
place at least 10 times a year (or at a frequency that is stipulated in specific professional
guidance on this matter.) These sessions take place with a more senior member of their team or
own profession and take place on a 1:1 basis or provided to a group of staff and are distributed
at regular intervals throughout the year.

The Clinical Director in each division of the Trust is responsible for ensuring that clinical practice
supervision takes place for all of the relevant staff in accordance with the Trust policy. They are
responsible for maintaining a list of all trained supervisors within their division alongside a
summary of the individuals and groups for which each respective supervisor is responsible. They
are responsible for auditing on a quarterly basis to ensure that the record of these arrangements
is accurate.

In this case the lack of a therapeutic relationship between the clinical worker and the Ms
McPharlane should have been discussed in either the team meeting or individual supervision
and consideration given whether it might have been better to offer her an alternative clinical
worker or clinical intervention.

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Trust action in the light of coroner’s PFD report

The following have and will be undertaken by the Trust to specifically address the issues you
raised in this case.

As with all serious untoward incidents in the Trust, our policy requires an internal investigation.
This investigation has now been completed and recommendations made. This will be shared
with Ms McPharlane’s mother, the staff involved in the case and the organisation more widely.
The implementation of the recommendations is the responsibility of named managers.

The Head of the Personality Disorders Service had recognised that the clinical worker had
performance issues and the manager has organised and put in place additional supervision and
support for him from a senior staff member. This is ongoing.

The Head of the Personality Disorders Service will ensure that there are procedures in place to
monitor the quality of documentation, including updating risk assessments and care plans and
ensuring the formal review of service users in line with Trust policy. The deadline for this is
November 2014.

The Trust has a clinical dashboard that is populated from the electronic patient record system
which alerts team managers when risk assessments are out of date. The head of the Personality
Disorders Service has strengthened processes in the team that clinical dashboards are accessed
during supervision and at other times to check that risk assessments are up to date.

The Head of the Personality Disorders Service will raise with supervisors in the service that the
content of risk assessments are checked during supervision.

The Director of Nursing & People and the Interim Medical Director will ensure that all clinical staff
are instructed to ensure that the risk assessments of all services users include asking about risks
to self and others and, if risks are identified, that these are addressed in care plans. The deadline
for this is November 2014.

The Interim Medical Director will ensure that all clinical staff are instructed that where it is known
the methods of self-harm service users employ, including the purchase of non-prescribed
medication through the internet, they must have these practices discussed with them regularly.
A plan should be set in place to include monitoring the frequency of these practices, e.g. the
medication purchased and consideration given to the impact of this on their prescribed
medication and the likelihood of overdosing. The care plan should set out clear actions to be
taken to prevent self-harming practices where possible. The deadline for this is November 2014.

The Head of the Personality Disorders Service will ensure that teams discuss the therapeutic
impact and benefits of the care provided to service users specifically ensuring that it is meeting
the needs of the service user and is having a positive impact on their mental health. This will be
monitored through individual supervision. The deadline for this is November 2014.

The Trust services did not identify the enhanced risks associated with Ms McPharlane buying
non-prescribed medication over the internet and taking this to excess. The Trust did not monitor
her risk of suicide in an ongoing way. The quality of her therapeutic relationship with her clinical
worker was not evaluated and the possibility of an alternative clinical worker was not considered.
All these issues were shortfalls in the care provided to Ms McPharlane and are not in keeping
with Trust policies and procedures. Our internal investigation also highlighted similar concerns,
which | can assure you we take very seriously. As highlighted in our response, the Trust is
taking a number of significant actions to address these concerns and are committed to improve

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the care and safety of people at risk of suicide. | trust that this addresses the concerns you have
raised.

Yours sincerel

Director of Finance

(signed in the on behalf of the Chief Executive in her absence)

Enc.....