Matthew Llewellyn-Jones

Devon Partnership INHS

NHS Trust

Response to a Regulation 28 Report to Prevent Future Deaths
Matthew Liewellyn-Jones (deceased)
Date of Death 16/03/16 — Inquest held 10 to 13 October 2016

Matter of Concern (1)

The Devon Partnership NHS Trust acknowledged in inquest that the ‘locked door' is
still being breached on occasion. An electronic pad or sign has been considered to
offer clearer indications of when the door should be secured, but not yet trialled or
actioned. The door therefore remains an on-going security risk for the ward.

Actions planned or taken:

e The locked door and permanently locking has been discussed at our Senior
Management Board and it has been agreed that the Entry and Exit Policy is reviewed
with a recommendation for locked doors on all of our in-patient units.

e The Entry and Exit Policy is under review, it will be revised to support a ‘locked door’
policy with a clear expectation of how to ensure that the restriction in movement does not
impact on individual's right to exit. It is anticipated that policy ratification will be
sought at Senior Management Board on 10/2/17.

e The doors at the Cedars have been ‘locked’ since the inquest. Review continues as
outlined in the Entry and Exit policy. Entrances to our in-patient units have notification
that the door is locked. Patients are informed of the locked door position on admission
and the process of supportive engagement prior to leave.

¢ LED signs for doors have been ordered and we are waiting for them to be delivered and
installed. These are due to be installed within the next month.

e There are signs placed on both doors to the ward stating it is closed/locked and to ring
for assistance, these will remain in place in addition to the

Matter of Concern (2)

Observations when carried out in the context of a secure mental health environment
should not be predictable or entirely regular. This is not currently part of the ward
policy, although it appeared to be accepted by senior staff at inquest. The Trust
should consider further measures to ensure that training and instruction given to all
staff in relation to observations is clear, constantly reinforced, and in line with best
practise.

The ‘Engagement Policy’ has been reviewed by the Deputy Director of Nursing and is
currently being finalised, it has been changed to include the following -

6.7 For anyone who requires intermittent engagement and observation, the minimal interval
of these must be documented in the care plan, and the actual times of engagement
and observation recorded on the relevant form. Minimum interval time may start at 5
minutes. Staff should be mindful to ensuring that observations are neither predictable
nor entirely regular (i.e. Person 1, 15 minutes engagement should not be at exact
intervals of 15, 30, 45 etc. minutes past the hour.)

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The revised policy will be published in January 2017 across the Trust and will be shared
directly with colleagues in the Adult Directorate in its Directorate Bulletin in January 2017.

The form used for recording observations had been changed at the time of the inquest and
now requires the specific time of observation to be recorded on the form for each patient.

A copy of the recording form is attached for information (ref-1.0). New or temporary staff are
briefed on team practices as part of their local induction. Compliance with the engagement
policy is monitored via the Quality Monitoring Tool; adjustments to the relevant quality areas
will be actioned upon ratification of policies.

Matter of Concern (3)

A new system of note recording has been introduced since this death, but it still does
not make obtaining information from carers and / or family mandatory on admission.
The importance of this information was really acknowledged by the Trust in their
inquiry (RCA) and at inquest. The electronic recording system should be able to
facilitate capturing such information with the use of mandatory fields to avoid this
oversight and could assist the Trust in achieving their stated aims in this respect.

The introduction of a mandatory field has been considered by the Care Notes team and
senior clinical colleagues. The decision has been made not to add as a mandatory field, it
will continue to be recorded as a ‘free text’ field. The rational for this decision is that a
mandatory field could be completed with a generic comment for example ‘have been unable
to contact family at this time’, when audited as detailed below, this would be identified as
completed. [f the field is left ‘blank’ the audit will highlight this and allow individual review
and follow up with the staff member concerned.

A copy of the Care Notes forms are attached, the specific changes that have been made
are-

e Care Planning (Information sought from carer/family) — this is now active on the
Care Notes system (ref 2.1)

e Risk Assessment (Specific area looking at carer/family views) — this is due to
become active by the end of January 2017 (ref 2.2)

e Anew single Assessment & Review format for all services is being developed -
work to date is attached. Implementation date is by end of February
2017. (ref 2.3)

The compliance with this change in practice will be monitored and reported using the new
‘Quality Monitoring Review Tool’, this focuses on assessing the quality of record keeping as
part of delivering overall high quality, safe and effective care. A copy of the Quality
Monitoring Review Tool and an example of the Inpatient Team Quality Monitoring RAG
feedback report are attached for information (ref 3.1 and 3.2)

The ‘Quality Monitoring Review Tool is:

e Team/service specific

e¢ Capable of providing quick clear feedback to teams on their recording quality in Care
Notes

e Provides assurance to LDU / Directorate / Trust on the quality of recording / how noted
improvements were progressed

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e Supports the engagement from the Multi-Disciplinary team (including medical staff) in
reviewing and embedding practice change across the team / service

Methodology

A pro-forma has been produced for quality checking, with a range of key quality areas
pertinent to their service areas. These quality areas are selected and reviewed on a rolling
basis. Teams use the Quality Review feedback forms to inform practice via team meetings /
handovers and supervision

e Teams are provided assurance on impact of feedback via Local Delivery Unit
Governance / Learning from Experience meetings

e This information will inform Directorates on themes and trends in clinical record quality
and where practice issues might be wider and require corporate involvement.

Changes to the care record, such as the indicated plans with risk assessment and
assessment / review form can be reflected in the proforma ensuring the quality of recording
during a period of changed practice. The Quality tool is owned by the services that develop
its own proforma’s enabling dynamic and responsive changes based on practice change,
new innovation or learning from ‘experiences’ (RCA, Complaint, RMS etc).

All of these actions will be monitored and progress reported through the Adult

Directorates Directorate Governance meetings, this progress will be reported to the
Trusts Quality and Safety Committee.

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