Susan George

HEALTHIER PEOPLE,
BE I I ER F UTU RE
Heywood Middleton and
Clinical Commissioning Group
Your Ret: 54658-2014 Postal address: NHS HMR CCG
PD Box 100
Rochdale
26 April 2016
OL169NP
Mrs L J Hashmi Location address: NumberOne Riverside
Smith Street
Area Coroner
Rochdale
The Phoenix Centre Lancashire
LICpI Stephen Shaw Way OL161XU
Heywood OL1O 1LR
DirectTel: 0161 655 1324.
Email Address: ianmello@nhs.net
www.hmr.nhs.uk
Dear Mrs Hashmi,
Re: Regulation 28 Letter Inquest into the Death of Susan George held on 15 February
—
2016
On 2 March 2016, as HM Coroner for Greater Manchester North, you issued a Regulation 28
Form to the Director of Commissioning at Heywood Middleton and Rochdale CCG (‘HMR
CCG”). The Regulation 28 Form was worded as follows:
‘There is no inpatient Clinical Psychologist service available within PCFT. This is a second
(possibly third) PFD form on the same issue. The Trust maintains this is a result of
commissioning issues. Without inpatient clinical psychology there is a marked service gap that
puts patients such as Susan at risk.’
In developing this joint response to the above, the CCG and Pennine Care NHS Foundation
Trust (‘PCFT”) have liaised closely regarding this matter. The position advised by PCFT is as
follows:
‘To support the required response from the commissioners, the Trust would like to inform them
that whilst we acknowledge there is no dedicated Clinical Psychologist available to the In
patient unit on a full time basis, and that this is due, in part, to the level of funding available to
the service, a session is available on both wards on a weekly basis for the staff to utiise.
These sessions are designed to discuss formulation, difficult cases, to use as reflection and
support and to supervise practice. This is greatly welcomed by all staff and well engaged with
atallbann
In addition, since the case in question, the wards at Birch Hill are now a recognised learning
placement forpsychology stLldeflts and benefit from regular input from this perspective.
The Trust would welcome furtherinvestment in psychological input into its in-patient unit and is
working with the CCG on a programme of Transformation for the whole acute care pathway
that will include re-design of the service and a review of skills required with a corresponding
action plan to realise the aspiration.’
The COG recognises the requirement to support a Transformation programme for the acute
care pathway, including community services, and has committed investment in 2016/17 to
progress this workstream. This Transformation programme will be co-produced between the
CCG and PCFT. The COG welcomes the clarification from POET that psychology input is
available as part of the inpatient service, as described above. The COG will continue to work
closely with POET in order to implement the local Transformation programme, in line with the
COG’s vision for Mental Health Services, as described in both the Rochdale Borough Mental
Health and Wellbeing Commissioning Strategy (2014-17) and the Rochdale Borough Locality
Plan.
I hope that this response addresses the issue raised by the Regulation 28 Form, but should
HM Coroner wish to discuss this response or require further information she should not
hesitate to contact Ian Mello, Director of Commissioning and Provider Management at HMR
COG on 0161 655 1324.
Yours faithfully,
Ian Mello
Director of Commissioning and Provider Management
Pennme Care
NHS Foundation Trust
Trust Headquarters
225 Old Street
Ashton-Under-Lyne
Lancashire
0L6 7SR
April 2016
Ms L Hashmi
Area Coroner, Manchester North Our Ref: KB/ELD
Phoenix Centre Department: Trust Headquarters
L/Cpl Stephen Shaw Way
Heywood
OLIO ILR
Dear Ms Hashmi,
Re: SUSAN GEORGE (Deceased)
Thank you for your Regulation 28 Report, dated 29’ February 2016, and for bringing
to my attention the concerns that you had after hearing all the evidence. Your
concerns have been reviewed in line with the stipulated timescales. I list below the
Trust response to the nine points you raised.
1. No review of the decision.to discharge was sought or conducted when it
became apparent that there had been a material change in Susan’s
presentation on the lO November 2014. Had a review taken place then it is
likely that the discharge would have been deferred or cancelled.
Response:
The issues raised in points 1, 2 and 3 can be considered together.
It is acknowledged that should staff have sought a review at the point of SG ringing
the police, expressing her concerns to Access and Crisis, then a different outcome
may have been agreed as regards her discharge that night.
The ward has appointed a substantive Ward Manager since this case and the
development of a more robust discharge process has now been implemented.
The discharge assessment document is prepared prior to planned discharges and is
then completed on the day of discharge by the discharge nurse. The final page of
this document is the ‘Discharge Plan’ which contains the emergency contact
numbers and a crisis contingency plan. A copy of this is handed to the patient upon
discharge.
The discharge nurse obtains the date and time of the 7 day follow up prior to the
patient leaving and informs the patient of this appointment.
All relevant parties are informed of the planned discharge with the patients’ consent.
This is also in line with the revised Mental Health Act Code of Practice 2015.
We are also undertaking a pilot of shift pattern for nurses which means the
‘meetings’ nurse will work 08:30 —to 16:00 in order to ensure full completion of
discharge documentation by the same staff member and thus avoids this task being
handed over to a nurse who may not have been involved in the discharge meeting.
This is supported with the development ofthe Triangle of Care initiatives, in which
the involvement offamily members providing information regarding the patient, even
if the service user does not give consent to share information, is still included in the
information that informs the discharge process.
The current discharge protocol will be reviewed to ensure it is still reflective of all
required processes and add a note of guidance to staff should they be faced with a
similar situation.
The guidance will be updated through the Trust Acute Care Forum and ratified
through Governance process for implementation in all areas.
2. The discharge process was disjointed, lacked co-ordination and did not involve
SGs primary/associate nurse.
Response:
As above.
3. The discharge policy was perfunctory and stafffailed to follow it in any event.
Response:
As above.
4. Poor record keeping, predominantly on the part of the nursing staff
Response:
The Trust acknowledges that the record keeping evident in this case at times fell
below the expected Trust and professional bodies’ standard.
Since this case the ward has now appointed a substantive ward manager and has
fully implemented the Standard of Record Keeping audit on the ward. This process
includes each set of notes being audited on a monthly basis with individual results
being feedback to each named nurse/qualified nurse during their supervision with
any performance issues being addressed and monitored through this process. This
has led to a significant improvement in the quality of record keeping within the ward.
To continue to undertake this monthly process to take into account changes in
documentation as the services develop and evolve. The results to be fed through
the ward benchmarking processes and the monthly ward manager’s forum managed
and chaired by the In Patient Services Manager for the North Division.
This process is further assured by an annual Trust wide record keeping audit and the
ward has shown continued high compliance rates within this audit in the last 12
months. There is an annual Integrated Quality Matrix (IQM) conducted on each ward
and as part ofthis matrix, documentation is scrutinised. The audit conducted in
September 2015 on Moorside has shown an improvement in identifying and liaising
with patients’ carers’ and also in care planning and risk management. The ward staff
have also implemented a written weekend handover, which is read out in Mondays’
board round, detailing how each patient has been, any incidents and their mental
state over the weekend.
5. There is no protocol/guidance on what steps to be taken when an inpatient
contacts the emergency services (e.g. police via 999). This is important as it
goes to risk assessment and management.
Response:
To develop an agreed protocol/guidance for staffto utilise if a service user contacts
the emergency services via 999, including review of risks and appropriate action to
take to safeguard the service user and support the staff response.
6. Unprofessional staff attitudes towards patientlcare provision- two qualified
nurses involved in Susan’s care used inappropriate language and
demonstrated negative ways of thinking during both conversations with
colleagues and the police communications operator. Prevailing affitudes such
as this, particularly towards vulnerable adults, puts care standards at risk.
Response:
There have been some specific actions taken as regards the two nurses identified
via the coroner. Although of course we cannot divulge the full details ofthis action it
is appropriate to the allegations highlighted and being managed through the Trusts
Conduct and Disciplinary processes and the NMC Fitness to Practice processes.
In relation to the overall culture and attitudes on the ward, as previously mentioned
the ward now has a substantive ward managerwho has instilled a more proactive
and positive culture but it is recognised that ward environments have many
challenges, with difficult cases to manage safely, staffing levels and acuity
challenges and the need to have a stabilised ward team to foster a positive culture
led by senior clinical leaders who are excellent role models and instil expectations
into every level of the team. This is being addressed through a targeted
organisational development review of the team as a supportive measure to help
foster further embedding of a positive culture and build on the work already
undertaken.
The safer staffing work and transformation plans for the next 12 months led jointly by
PCFT and the CCG will further enable the development ofthis on the ward through
investment and transformation plans.
All adult wards, including Moorside are implementing safe wards initiative. When
giving handover staff should say something positive about what each patient has
been doing during the shift, or draw attention to some positive quality they have, or if
this is not possible something positive about the way in which staff supported the
patient (positive appreciation). In addition, if any difficult or disruptive behaviour is
reported, a possible psychological understanding ofthe patient’s behaviour must be
offered.
In addition to this and in order to promote a positive milieu on the ward Moorside are
implementing a ‘positive quote ofthe day’ This would be displayed for both staff and
patients.
7. Poor advocacy on the part of the nursing staffwhose decisions appear to have
been clouded by the rigidity of the medical decision to discharge.
Response:
Point 7 and 8 can be taken together.
To re-iterate to staffthe fact they are responsible and accountable fortheir own
decision making. If they are unhappy or not clear in what they have been directed to
undertake then to utilise the escalation process in place through the ward manager,
In patient service manager on on-call system if required.
To develop a briefing on guidelines for staffto follow on how service users can
access support if they are unhappy with the decision made about their care.
These guidelines will include the use of advocacy, the principles in the Triangle of
Care and the engagement of the full MDT and how the nursing staff can supportthis
process in the best interests of the service user.
8. Staffwere unaware of how to support and advise patients on the issue of
obtaining a second medical opinion where the patient disagrees with the first
doctor’s decision (in this case, to proceed to discharge).
Response:
As above.
PCFT and HMR CCG:
9. There is no inpatient Clinical Psychologist service available within PCFT. This
is a second (possibly third) PFD form on the same issue. The Trust maintains
this is a result of commissioning issues. Without inpatient clinical psychology
there is a marked service gap that puts patients such as SG at risk.
Response:
PCFT acknowledges there is no dedicated Clinical Psychologist available to the
inpatient unit on a full time basis. This is due in part to the level of funding available
to the service.
There is a session available on both wards on a weekly basis for the staffto utilise to
discuss formulation, difficult cases, use as reflection and support and supervise
practice. This is greatly welcomed by all staff and well engaged with.
In addition, since the case in question, the wards at Birch Hill are now a recognised
learning placement for psychology students and benefit not from regular input from
this perspective.
The Trust would welcome further investment in psychological input into its in-patient
unit and is working with the CCG on a programme of Transformation for the whole
acute care pathway that will include re-design of the service and a review of skills
required with a corresponding action plan to realise the aspiration.
I hope this response assures you that the Trust takes seriously any concerns that
you raised.
Yours sincerely
Dr Henry Ticehurst
Medical Director
E-mail: henryticehurstnhs.net