Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0163, written 1 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jun 2022 |
|---|---|
| Reference | 2022-0163 |
| Deceased | Samuel Gomm |
| Coroner | Graeme Hughes |
| Coroner area | South Wales Central |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Powys Teaching Health Board Powys County Council 1 CORONER I am Graeme Hughes, Senior Coroner, for the coroner area of South Wales Central. 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 10th June 2019, I commenced an investigation into the death of Samuel Joseph GOMM. The investigation concluded at the end of the inquest on 18th May 2022. The conclusion of the inquest was Suicide. The medical cause of death was: - 1a. Laceration to neck 4 CIRCUMSTANCES OF THE DEATH These were recorded as: - Samuel Joseph Gomm suffered from chronic mental ill health exacerbated by periods of alcohol abuse. On 3.6.19 whilst at home at , he has deliberately self-inflicted a number of lacerations to his neck. These have led to acute blood loss and his death. It is more likely than not, that he intended the consequences of his actions to be his own death. The Inquest focused upon: - a. The direct circumstances leading to his death. b. The role that Mental Health & Local Authority Services took in the management of his risk of self-harm in the months preceding his death & whether such management may have contributed to his death. I recorded no findings in relation to such management, which were directly causative of his death. 5 CORONER'S CONCERNS At the conclusion of the Inquest, I directed written submissions from the three Interested Person's as to whether my duty under Regulation 28 was engaged & if so, in respect of which matters. I have received & considered the same. 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. The MATTERS OF CONCERN are as follows. - (1) The assessment of Sam's risk of self-harm was recorded by his care-co- ordinator in a Wales Applied Risk Research Network (WARRN) assessment tool in March 2019. This form of assessment was adopted by the Integrated Mental Health Services (Powys County Council & Powys Teaching Health Board) in Powys. I also received evidence that it is used throughout Wales by similar services. (2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that, nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk. (3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam's risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user. This, for example, might be a new care co-ordinator (as in Sam's case), Crisis Team/Community Nurse, or clinician not previously involved with Sam. (4) Given the variety of services involved in Sam's care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (my emphasis). The ability of those charged with Sam's care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an under- estimation of the current risk & sub-optimal mitigating measures being put in place. (5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker's, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded. Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm It may well be helpful (given the Integrated Services approach to Mental Health Services in Powys) if I were to receive one jointly prepared response from both organisations to whom this Report has been sent. 2 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th July 2022. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to family who may find it useful or of interest. , Minister for Health & Social Services I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 1st June 2022 SIGNED: 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
IN THE WELSHPOOL CORONER’S COURT
BEFORE SENIOR CORONER MR GRAEME HUGHES
IN THE MATTER OF THE INQUEST TOUCHING THE DEATH OF:
MR SAMUEL GOMM
_____________________________________________________________
RESPONSE TO REGULATION 28
PREVENTION OF FUTURE DEATHS REPORT
_____________________________________________________________
This response is sent in accordance with the direction of HM Senior Coroner Graeme
Hughes dated 1 June 2022 that a response from Powys Teaching Health Board and
Powys County Council is provided to the Regulation 28 Prevention of Future Deaths
Report in the inquest touching the death of Samuel Gomm. This is a joint response on
behalf of the local authority Powys County Council (PCC) and Powys Teaching Health
Board (PTHB). This response seeks to explain the actions to be taken to address the
matters of concern and recommendations as identified by the learned Coroner.
Improvement Risk assessments (self-Harming patients) record keeping systems
throughout Powys County Council and Powys Teaching Health Board and Wales
1.
Powys Teaching Health Board and Powys County Council provide co-located
Mental Health Support to the residents of Powys. Both organisations have
agreed to use the Welsh Applied Risk Research Network technique (Welsh
Applied Risk Research Network) and the Welsh Community Care Information
System for case recordings (WCCIS). This is fully implemented in all
Community Mental Health Teams (CMHTs) with plans to expand to other parts
of the service, e.g., inpatient, learning disability and primary care. This is being
managed by the integrated organisational Gateway Group.
2.
As Powys Teaching Health Board inpatient staff are currently only able to read
information stored on the Welsh Community Care Information System for case
recordings, they have relied on a Welsh Applied Risk Research Network Word
Document. This is then uploaded and attached to Welsh Community Care
Information System by admin staff. It is accepted that this has led to a
duplication of work and the risk of important information being lost. Having
identified this, Powys Teaching Health Board are updating training and access
arrangements for inpatient staff required to complete the Welsh Applied Risk
Research Network document. This will ensure that all Welsh Applied Risk
Research Network document will be recorded on the Welsh Community Care
Information System and there will no longer be a need to use the Word
Document template. It is anticipated that this will be achieved by the 2nd August
2022.
3.
There have been concerns that the Welsh Applied Risk Research Network
document accessible on WCCIS is distorted and is not compliant with the
copyright held by Welsh Applied Risk Research Network authors. To address
this, both organisations have worked closely together to change the current
document and to ensure that the copyrighted form is used on the WCCIS system.
This enables staff to use the research and formulation-based techniques for the
assessment and management of serious risk. (Appendix 1)
4.
This work will be completed by the end of July 2022 when staff will be advised
of the changes and any old Welsh Applied Risk Research Network document
templates will be removed.
5.
Powys Teaching Health Board currently commission inpatient services from
external providers. This can cause difficulties in information sharing. Powys
Teaching Health Board will work collaboratively with commissioned services to
ensure robust risk assessment utilising their formats with intensive handover of
service users on discharge to include risk information. Their risk assessment will
be used to populate Powys Welsh Applied Risk Research Network assessments
following this handover.
6.
Powys County Council are in the process of updating WCCIS documentation to
support practitioners in identifying a list of services/people who should have
sight of the completed documentation. This will include the cared for person,
their GP, and external commissioned services (for example, Kaleidoscope or
Domiciliary Care).
On completion, WCCIS/Practitioners will alert
administration staff that key documents are ready to send to those identified.
These documents will include, the Welsh Applied Risk Research Network risk
assessment, initial assessment and Care and Treatment Plan. Practitioners will
have to justify on clinical grounds, why this isn’t appropriate for specific
individuals. This will be re-enforced during Social Care Team Meetings. Team
administrators will take responsibility for the sending of documents and will
keep a record of those sent. Appendix 2, 3, 4
7.
“The Welsh Community Care Information System (WCCIS) is intended to enable
health and social care staff to deliver more efficient and effective services using
a single system and a shared electronic record.” (Welsh Community Care
Information System, Report of the Auditor General for Wales, October 2020.) It
has been Welsh Governments intention to implement WCCIS in all Welsh Health
Boards and Local Authorities. This does not currently include external
organisations who do not have direct access to records held by statutory
organisations due to IT limitations and Information Governance.
8.
The National roll out of WCCIS is taking much longer and proving more costly
than expected, with concerns about functionality and performance being
reported in the media. National System performance issues were particularly
difficult during Autumn 2021, where some organisations found WCCIS
unavailable. These issues were resolved following a Systems upgrade in
February 2022 with the system performance now being reported as good both
nationally and locally.
9.
In February 2022, Welsh Government reported its findings in an Independent
Review of the WCCIS programme. A series of actions to “reset” and “course
correct” were identified. This included an increase in Welsh Government
funding and the recommendation for a new WCCIS business case to support
health boards and local authorities. The report also identified the need to
simplify processes and reduce its scope with regards to data collection and some
of the programmes within Digital Health and Care Wales. It is anticipated that
this will allow for greater system stability and improvement of user experience.
A further National review will take place in November 2022. (Audit Wales, 1
July 2022).
10.
Alongside National consideration, WCCIS remains under review by Powys
Teaching Health Board and Powys County Council’s internal Change
Management groups allowing for prompt responses to local challenges. Joint
initiatives are also improving access to WCCIS training by using a series of open
access videos. This is supporting user confidence for both new users and more
experienced staffing groups.
Welsh Applied Risk Research Network assessments (content reviews/
integrating systems/ updating of current information)
11.
A Risk Assessment is an essential part of Mental Health Work and should be
evidence based and carried out in conjunction with cared for persons and their
support networks.
12. Welsh Applied Risk Research Network is the current risk assessment tool used
by both organisations and is stored on the WCCIS system. Whilst the document
should be fluid and regularly updated it cannot remain as a live document on
WCCIS. Following completion on WCCIS the form should be closed and re-
opened at the point of review. WCCIS automatically copies the information from
the previous form to aid completion. This ensures that practitioners are able to
clearly see how often and when the Welsh Applied Risk Research Network is
updated.
13.
The Welsh Applied Risk Research Network document should be considered
alongside other Care and Treatment documentation which assists the writer in
considering whether a formal Mental Capacity Assessment is required.
14.
Along with meeting the requirement of data collection, this ensures that the
fluidity of risk is reflected, drawing workers attention to any changes.
Supporting staff to easily identify when a change of risk management is required.
This has been identified as the preferred method by Welsh Applied Risk
Research Network authors. To ensure that all risk activities are easily captured,
WCCIS has introduced an embedded Chronology. This allows for all events to
be recorded, supporting practitioners to recognise when there is a change to risk
behaviours. Non-Welsh Applied Risk Research Network assessors can add to
the Chronology and events reported by partner agencies can be included,
supporting the sharing of information and highlighting any need for re-
assessment of risk management.
15. Monitoring and reviewing changes are an essential part of effective care and
treatment and risk management. Completion of the Welsh Applied Risk
Research Network document should be part of the initial care planning process
for everyone under Secondary Mental Health Services. Along with the Care and
Treatment Plan, the Welsh Applied Risk Research Network should be reviewed
a minimum of once in a 12-month period and at any change of circumstances that
might impact on risk and wellbeing. (Mental Health Measure Wales, 2010).
16.
This would include but is not limited to events such as, relationship breakdown,
loss of carer, increase in substance use, increase in contact with services,
particularly out of hours. All significant self-harming events should be recorded
on the document, this includes disclosure of thoughts of self harm. To support
this WCCIS will be updated to include a Chronology of events to enable workers
to keep a succinct and easily accessible record. This will allow staff to easily
identify if there has been a recordable event, creating a clear timeline of
presenting risks. This will alert practitioners to any changes or patterns of
behaviour and enable better dynamic risk assessing.
17. Whilst this function will be only accessible to registered WCCIS users, it will
enable staff to update incidences/concerns easily, without necessarily being
involved in the full Welsh Applied Risk Research Network assessment. For
example, support workers recording concerns following a visit in addition to
reporting this to Care Coordinator/or Senior Member of staff. This will be
implemented by the end of July 2022.
18.
External agencies without access to WCCIS will be provided with an up to date
Care Plan which will include the contact details for involved Powys Teaching
Health Board and Powys County Council staff. They will be advised of both
organisations Information Sharing Protocol at the start of their input and on
regular occasions in line with Care and Treatment Reviews. Whilst external
agencies are currently unable to use WCCIS, they will be supported to contribute
to the development of Welsh Applied Risk Research Network by statutory staff
who will then provide a copy of the updated assessment as detailed above.
19.
Alongside any notable changes of circumstances, the Welsh Applied Risk
Research Network will be updated at the following points:
(a) Admission and discharge from Psychiatric Inpatient Care/CRHTT
(b) Referral to internal risk panels (REP, IRIS)
(c) Referral and review at MAPPA
(d) Inclusion in Crisis Care Forum Multiagency discussion
20.
Any concerns noted by the receiving team regarding the timeliness of Welsh
Applied Risk Research Network assessment update or divergent staff views
should be reported via Powys Teaching Health Board Datix system and through
Powys County Council line management structure. This will ensure that both
systemic and independent practitioner concerns are captured.
21.
Staff will be updated on the new processes when complete by Welsh Applied
Risk Research Network Lead and Quality and Safety Team for each organisation.
22.
In October 2021 and April 2022 Powys Teaching Health Board undertook an
internal audit of Welsh Applied Risk Research Network documentation.
Compliance with reviews and the quality of content was rated as good. Powys
Teaching Health Board will continue to audit Service User records on a 6 monthly
basis.
23.
Prior to entering business continuity through Covid, Powys County Council
undertook regular monthly in-depth random audits, which included feedback
from service users and carers as appropriate.
24.
Part of this process included analysis of the Welsh Applied Risk Research
Network and CTP (care and Treatment Plan) documentation, alongside case
recordings. Audit feedback was provided to Powys County Council Senior
Managers and staff both at supervision and in team meetings. Powys County
Council Team meetings are used to support staff in understanding when
improvements need to be made but also to celebrate good practice.
25.
Unfortunately, Audits were stopped due to Covid Business Continuity and
increased pressures on the local authority. A small number of audits have taken
place during this time but there will be a full rollout of mental health audits by
the end of August 2023.
26.
Recommendations by the Welsh Applied Risk Research Network author from
this case will be used to inform training for both Powys Teaching Health Board
and Powys County Council staff.
Welsh Applied Risk Research Network assessments (format/ ease of
accessibility / infrequent users/ new users)
27. Work is currently in progress to ensure that the correct Welsh Applied Risk
Research Network is available on the WCCIS system by the end of July 2022.
This will enable all Community Staff to have access to the copyrighted version,
stored in an easily accessible part of the database. This can be accessed by both
Powys Teaching Health Board and Powys County Council. To enable the Welsh
Applied Risk Research Network to maintain its evidence base it needs to remain
in its original state and cannot be altered to provide additional prompts or data
collection. The accompanying CTP documentation focuses on areas not directly
included in Welsh Applied Risk Research Network. For example, capacity is
considered within the CTP assessments, asking the practitioner to consider
whether an additional WCCIS embedded Capacity Assessment also needs to be
completed. The practitioner is directed to offer the support of an advocate
through this non-Welsh Applied Risk Research Network document.
28.
As the lead agency for Welsh Applied Risk Research Network, Powys Teaching
Health Board facilitate initial and refresher training. ESR (Powys Teaching
Health Board Electronic Staff Record) system will provide information on Powys
Teaching Health Board staff requiring updates to ensure appropriate targeting.
29.
Powys County Council will use their Business Insight process to identify workers
requiring Welsh Applied Risk Research Network updates and infrequent users.
This will ensure that refresher training is undertaken within the specified
guidance of 3 years. Both organisations will use their Welsh Applied Risk
Research Network trainers as “Champions” who can act as a point of contact for
infrequent users supporting them to develop skills and confidence and ensuring
that completed Welsh Applied Risk Research Networks are of an acceptable
standard.
30.
Powys County Council induction policy will be extended to include Welsh
Applied Risk Research Network training as mandatory as is the case in Powys
Teaching Health Board. This will be overseen by Powys County Council Service
Improvement Manager and Powys Teaching Health Board Quality and Safety
Team.
31.
Staff changes, particularly agency staffing, will create extra pressures for
training. Whilst Welsh Applied Risk Research Network training is currently
provided by Powys Teaching Health Board, the local authority Powys County
Council will nominate 2 workers to train as trainers, to support this programme.
We anticipate an integrated approach to WCCIS training across both
organisations, with Powys Teaching Health Board and Powys County Council
staff delivering joint Welsh Applied Risk Research Network training.
Welsh Applied Risk Research Network and associated assessments –
reviews/ quality assurance monitoring/updating of current needs/
access by relevant bodies)
32.
The Welsh Applied Risk Research Network document sits alongside additional
Care and Treatment paperwork (Assessment, Care and Treatment Plan). It is an
integral part of the assessment and treatment process. Powys Teaching Health
Board and Powys County Council will continue to follow their own internal
audit as detailed above.
33.
Along with considering the Welsh Applied Risk Research Network document,
Powys County Council’s audit process extends to include additional electronic
records and feedback from service users/carers. This process is overseen by
Powys County Council Service Improvement Manager and outcomes are fed
back to Senior Management and to individual workers through supervision and
during team meetings if appropriate.
34.
Outcomes of these audits are embedded in Service User records and available to
Powys Teaching Health Board. Powys Teaching Health Board have identified
greater service user/carer involvement as a piece of work following their most
recent audit in June 2022.
35.
Powys Teaching Health Board audit outcomes are discussed in monthly
Learning and Development Group and disseminated to front line staff, with
service improvements and action plans delivered directly by Service Managers
and overseen by Operational Leads.
36.
The offer of advocacy is a legal requirement of both the Mental Health Measure
(2010) and the Social Services Well Being Act, 2014. This is reflected in Care and
Treatment Programme documentation, where staff are directed to offer advocacy
and to confirm whether it is required. This is reported on through Powys County
Council Business Insight programme and in Powys County Council audits.
Advocacy clinics have been reinstated in CMHT’s and inpatient units following
Covid19. These are advertised in patient access areas and can be booked directly
with the advocate if preferred.
37.
The Information Sharing protocol is explained to a cared for person during any
initial assessment, where the person is advised that any information provided
may be shared with supporting agencies. The need to break confidentiality in
relation to concerns about risk is included within this explanation. Workers shall
remind cared for persons of this duty at all reviews and further will do so should
a requirement to inform partner agency arise. (Appendix 6).
38.
To support understanding of this protocol, Powys County Council are in the
process of updating their “privacy notice” which includes a guide written for
those using services. This is currently in the process of being ratified, with no
changes expected. This is attached as Appendix 7.
Welsh Applied Risk Research Network assessment tools – accessibility to
Patient / integration referral process to secondary services, working together
optimisation approaches
39.
The Welsh Applied Risk Research Network as per all other CTP documentation
should be written in conjunction with the cared for person where possible and
unless this leads to increased risk to self or others. The Welsh Applied Risk
Research Network is one part of an assessment process and should be considered
alongside the Initial Assessment which provides an overall view of a person’s
life and helps develop an understanding of the impact of any mental health
problem and what matters to them as individuals. Both documents should sit
together to form a Care and Treatment and Risk Management Plan. Powys
Teaching Health Board currently use the All Wales Assessment Document held
on the Welsh Applied Risk Research Network. Powys County Council have not
implemented this document as they felt it did not align with the Social Services
Wellbeing Act. This view was shared by a visiting Inspector from the Care
Inspectorate Wales at the time the decision was made. Regardless of which
documentation is used the plans should be done in partnership with identified
individuals and organisations.
40.
To improve communication, staff will be directed to identify those that are
involved in the person’s care. Administration officers will be notified by WCCIS
and will ensure that the correct documentation is sent directly to them. This will
include, the cared for person, the GP and any other organisation providing care
and support.
41.
On completion the document should be shared with the cared for person’s GP
and other appropriate agencies as documented in the care plan. Any changes
that affect risk are to be communicated with appropriate partner agencies.
External agencies who do not have direct access to the Welsh Applied Risk
Research Network document should ensure that their information is passed to
the Care Coordinator or representative. This can then allow for review of the
Welsh Applied Risk Research Network documentation held on WCCIS system.
It is not possible for external agencies to have access to the WCCIS system due to
the level of information governance compliance required.
42.
Identification and management of risk is a shared responsibility and partner
agencies should work closely together to protect the safety of service user, staff
and members of the public. External agencies without access to WCCIS will be
provided with an up-to-date Care Plan covering both a relapse plan and 24-hour
contact details for statutory services. Whilst this is routinely available on the
WCCIS system, staff will be advised of the need to share risk information with
involved agencies under the appropriate framework.
43.
External agencies who are not included in the WCCIS programme will be
encouraged to report any changes in risk to statutory staff, normally the Care Co-
ordinator or their deputy. The details will be added to the chronology and used
to inform robust risk assessment. This will be communicated to involved partner
agencies.
44. Whilst staff may have concerns about the sharing of relevant information, they
should be supported to understand the legal framework that facilitates
partnership working. Once approved a copy of the Powys County Council’s
Privacy Notice will be forwarded to staff to ensure that staff are comfortable in
this process.
45.
Any referral to external agencies should be accompanied by an up to date Welsh
Applied Risk Research Network and Care and Treatment Plan, which will
include relevant contact details and a relapse plan. These documents will be
embedded in WCCIS and forwarded to agencies in their preferred means, digital
or paper.
Appendix
1 The new Welsh Applied Risk Research Network now available on WCCIS
system
2 Assessment – All Wales (used by Powys Teaching Health Board)
3 Assessment – used by Powys County Council
4 Care Plan - All Wales (used by Powys Teaching Health Board)
5 Care Plan – Powys (used by Powys County Council
6 Powys County Council Privacy Notice
7 Joint Action Plan
APPENDIX 1
Powys - MHM – Welsh Applied Risk Research Network Risk Formulation
(CTP4)
Service User Details
CCIS ID
First Name
Date of
Birth:
Gender
Religion
Primary
Address
Post Code
Home
Phone
Preferred
Language
NHS No
Middle
Name
Age
Email
Address
Mobile
Phone
Preferred
Contact
Method
Last Name
Age if
Estimated
Nationality
Ethnicity
Work Phone
Interpreter
Required
Risk Formulation and Management Plan
This document provides a template to allow the accurate recording of your
risk assessment.
Please give as much detail as possible
Assessment Start Date
Assessor Details
Name of Assessor
Team
Designation
RISK FORMULATION 5Ws
What
What is the nature of the risk (describe) remember there can be more than
one risk area, remember children/vulnerable adults. Please put as many
details as possible
Who
Who are the likely victims, either specifically or the type or nature of the likely
victims if this can be specified. Remember risks to other children/ vulnerable
adults. Do not forget risk to self.
Why
What are the likely trigger situations for risk related behaviour: e.g., response
to feeling threatened, arguments with others, command hallucinations etc.
Where
Where is the risk posed (in the context it is most likely to occur - e.g., home,
hospital, community setting etc.) Are there any protective environments (e.g.,
a grandparent's house, school/college, foster care, etc)?
When
How imminent is the risk likely to be? When is the risk most likely to occur?
Are there any dates that indicate a particular vulnerability (e.g., Christmas,
anniversary of a death or of trauma, etc)? Is there any time of day when risk is
increased (e.g., night-time)?
Key Risk Indicators
Those factors most associated with the risk increasing e.g., drug/alcohol use,
being in confined space (ward), command hallucinations, lack of insight into
illness.
Risk Reducing Factors
Those factors that can decrease the risk (e.g., being at home/in school, being
with a family member, good relationship with a teacher, involvement of Social
Services, compliance with medication).
Please give as much detail as possible. Select the appropriate category.
Probability: What is the likelihood that the risk behaviour will
occur
Risk Category
Severity: Describe the impact of the risk behaviour on self or
others
Risk Category
Imminence: When do you consider the risk behaviour is likely
to occur?
Consider presence of active risk indicators
Risk Category
Summary of Risk Formulation:
- Include RISK REDUCING FACTORS: those factors that can decrease the risk
e.g., being at home/in hospital, being with a family member/compliance with
medication.
CLINICAL FORMULATION - 4 Ps
Predisposing Factors
Things that make a person vulnerable to developing psychological problems
(e.g., childhood trauma, physical health problems, or family history of mental
illness).
Precipitating Factors
Things that happened in a person's life that seems to trigger an episode of
illness/change in functioning (e.g., significant life changes, bereavement or loss
of job).
Perpetuating Factors
Things that seem to keep a person in their current state of distress (e.g.,
pervasive negative thinking, lack of close relationships, or lack of adherence to
medication).
Protective Factors
Things which seem to keep a person well and if maintained or strengthened
decreases the likelihood of the problem reoccurring e.g., strong relationships, a
skill/strength in a specific area, or good sense of humour (personality traits).
Risk Management Plan:
Clearly highlight the measures that you feel are necessary to manage
Consider what you need to do now, as well as longer term options.
Include contingencies (e.g., what if mental state changes?)
Who do you need to inform of your formulation/plan? Consider your
•
the identified risks.
•
•
•
responsibilities to inform external agencies (e.g., If children have been
identified as at risk inform Child and Family Social Services and/or the police).
•
Remember "What I Can Do (WICD)"
REVIEW
What signs/symptoms/circumstances/events would prompt an urgent review
before the planned review date?
Future Reviews Due?
Yes
No
Date of Next Planned Review
DD
MM
YYYY
Comments/Action
Form Data Entry
Owne
r
Actua
l Start
Date
Statu
s
Modifie
d On
Modifie
d By
Completio
n Date
Complete
d By User
Appendix 2
Person Information
Is the person information in the banner up to date?
Yes
No
Is the person a veteran
Yes
No
Consent to Share Information
Consent to share information within health /social care professionals is covered by GDPR.
Record consent or refusal to share information with individuals ( rather than care
professionals).
Consent
ed To
Mod
e
Wh
o
Free
Text
Nam
e
Conse
nt
Given
to
Perso
n
Conse
nt
Given
to
Provid
er
Refus
al
Reas
on
Remov
al
Reaso
n
Consents
Conse
nt
Given
Sta
rt
Dat
e
En
d
Dat
e
Social Context
Emergency Contact
Last
Name
First
Name
Property
No
Property
Name
Postcode
Phone
Address
Phone 1
Carer
Is the person a carer?
Does this person have a carer?
Yes
No
Language
Languages
Language
Fluency
Preference
Are there any language accessibility needs
Yes
No
Interpreter Required
Yes
No
If yes please specify:
About this Assessment
Please be aware of any ceiling of care documents or agreements. These may include but not
limited to: Do Not Attempt Resuscitation (DNAR)/Do Not Attempt CPR (DNACPR); Advance
directives/ decisions/ refusal of treatment; Living will; Lasting power of Attorney.
Confirmation that an Active Offer to have this Assessment undertaken in the Welsh Language
has been made
Yes
No
Assessment Start Date
Location of Assessment
Assessing Service
Type of Assessment
MHM Care Coordinator
Professional (User)
Start Date
End Date
Who Has Been Involved/Contributed to this Assessment
Date
Name
Designation
Location
Involvement/C
ontribution
First/Follow/Reassess/Repeat
Name of Assessor
Designation
Person Engagement
Do you have any concerns about the person's capacity to engage in this assessment
Yes
No
Is there a record/concerns of Deprivation of Liberty Safeguards (DoLS)
Please specify any restrictions and expiry date (maximum 12 Months)
What other agencies, care & support that have been / are involved?
Detail any Services/Agencies that have supported you in the past, and what care & support
you are currently receiving.
Person Perspective and 'What Matters'
Include the individuals own words. If the person isn't able to communicate this, an advocate
can provide the answers.
Person's Current Circumstances
Tell me a bit about what's happening/ What concerns you most? / Presenting Needs
Presenting need
Background/Personal History
MHA Section 117 Applicable
Accommodation need
Accommodation Status
Property Access Arrangements
Children the person has contact with
Name
DOB
Person's Education
Relationship to
child
if known
In household
Yes
No
Establishme
nt Type
Statu
s
Person
Educatio
n Year
Year
Grou
p
Education
Establishme
nt
For
m /
Clas
s
Year
Grou
p
Curre
nt
Year
Yea
r
End
Dat
e
Person's Employments
Employment Status
Employment Type
Start Date
What Matters
Supporting person's perspective
Supporting persons’ view
Physical Health
Is the person currently pregnant
Physical Health
Has the person received information / had a conversation about how to manage their lifestyle
choices?
Yes
No
Height and Weight
Weight
Kilograms
Height Metres Date/Time
Taken
Date/Time of
Next Screening
BMI Score
Waist Circumference
Measured in centimetres
Client Disability/Impairment
Diagnose
d Date
Disability
or
Impairmen
t
Disabilit
y
Impairmen
t
Severit
y
Registere
d
Disability
No
End
Dat
e
Star
t
Dat
e
Allergies
Allergy Type
Allergen -
What
Substance
Caused the
Reaction
Reaction
Start Date and
Time
Level
Surgery/Practice
GP Name
Surgery/Practice Address
Surgery/Practice Phone Number
Is the person in regular contact with their GP
Does the person smoke or use a vape
Current Alcohol Intake – weekly
Other substances misused including prescribed and over the counter
Current Medication/Treatments at The Time of This Assessment
Is the person currently taking any medication
Yes
No
The Person's Experiences of Treatment & Responses To Medication
Mental State Examination
Person's view of their current mental health conditions
Objective Mental State Examination
Safety and risk screening
Past Risk History
Forensic History
What
What is the nature of the risk (describe) remember there can be more than one risk area,
remember children/vulnerable adults. Please put as many details as possible
Have risks that require management been identified?
Yes
No
Person risks
Role
Type
Details
Created
On
Review
Date
End Date
End
Reason
Clinical Measures Undertaken and Scores
What, if any, other assessment tool(s)/ outcome measure(s) have been completed
Assessment
Date of
previous
Assessment
Previous score Date of
Assessment
Score
following
current
assessment
Other tool/s completed
Measure
Date of
previous
Assessment
Previous score Date of
Assessment
Score
following
current
assessment
Outcome of Assessment
Agreed Needs
Agreed Need
Eligibility
Personal Outcomes
Personal
Outcome
National
well-
being
outcome
Care and
Treatment
Plan
Outcomes
Baseline
self-
assessment
measure
(1-10)
What
does this
look
like?
Baseline
self-
assessment
goal
What
does this
look
like?
Recommended next actions
Recommended actions and immediate
next steps and by who
Target Date
Formulation
This is a summary of how the person's life events, and circumstances have led to the current
difficulties, and the impact and meaning this has had. This should be shared and agreed with
the person if appropriate
Is a safeguarding referral required?
Yes
No
Outcome of Assessment
If Signposted Enter Name of Service(s)
Eligibility decision
Assessment Information
Confirm the current assessment is complete
Has the individual been offered a copy of the assessment
Date Offered
DD
MM
YYYY
Name of Assessor
Designation
Assessment last Modified On
Assessment last Modified by Whom
Appendix 3
Service User Details
CTP Assessment
CCIS ID
First Name
Date of
Birth:
Gender
Religion
Primary
Address
Post Code
Home
Phone
Preferred
Language
NHS No
Middle
Name
Age
Email
Address
Mobile
Phone
Preferred
Contact
Method
Last Name
Age if
Estimated
Nationality
Ethnicity
Work Phone
Interpreter
Required
No
CTP Assessment
Assessment Date
DD
MM
YYYY
Location of Assessment
Assessor
Designation
Referrer
Name
Address
Telephone
Initial/Full/Re-assessment
Source Of Information/Contributors
Service User
Referrer
Past Notes
Family/Carer
Other
Carer
Name
Address
Telephone
Carer's Assessment Offered?
Carer's Assessment Accepted / Declined?
Is this person a young carer
Issues of confidentiality & consent have been explained
Consent to approach your Carer / Next of Kin / Advocate
Details of advocacy requirements
Service user and Carer Perspective
Service users expectations/outcomes
Carer's Perspective
Presenting Problem
History of presenting problem, previous contact with mental health services
and interventions.
Mental Health
Speech, presentation, mood, symptoms, insight, cognitive ability.
Medical history, family history of mental illness, childhood, and schooling
Are there any particular risks to children due to the service
user's mental illness?
i.e. delusional beliefs / suicide plans involving children. If yes, a referral to
Children's Social Services should be made.
Does the service user care for children?
How many children, of what ages?
Does the service user's mental health affect their role as a parent?
Are there any other significant carers?
Does the service user need support in their role as a parent?
Is the child on the Child Protection Register?
Yes
No
Is a referral to Children's Social Services required?
Date of Referral
DD
MM
YYYY
Substance Misuse
Alcohol use - If use is problematic, should assessment of this be made?
Tobacco and caffeine use
Use of other substances
Day To Day Living & Environmental Resources
Personal care, sleeping pattern, mobility/falls.
Budgeting, financial circumstances, benefits, keeping warm, transport, exercise
and leisure, shopping, cooking, eating and drinking, household tasks, work or
education.
What are the factors supporting the service user? What are their personal
strengths?
Social Circumstances
Current social circumstances, housing needs, family circumstances, cultural
needs, spirituality, needs for support. What support is available from others?
Are there any immediate issues / decisions requiring an assessment of mental
capacity?
Does a Mental Capacity Assessment and Best Interest Decision Form need
completing?
Is there a need to consider whether a Deprivation of Liberty Assessment
should be made?
Physical Health
Physical illnesses, chronic pain, mobility/falls, sensory deprivation
Medication At Time of Assessment
N.B. Medication changes frequently. This information should not be relied
upon as an accurate reflection of current prescribed medication
This page to be sent to GP following completion of initial assessment
Current
Medication
Frequency
Dose
Date
Commenced
Does a review of medication need to be made?
Assessment Date
DD
MM
YYYY
RISK ASSESSMENT
Ensure all appropriate risk assessment tools are completed, in addition to this
assessment form.
Evaluation of Risks (including Forensic History)
Date of Welsh Applied Risk Research Network Risk Assessment
DD
MM
YYYY
Is a referral to POVA required?
Date of Referral
DD
MM
YYYY
Formulation / Summary of Needs
Fair Access to Care (FaC) Eligibility
Health & Safety
Autonomy
Managing Daily Routines
Involvement
Plan
Does the individual have complex health needs that require further
assessment?
Does the individual have needs that could trigger eligibility for Continuing NHS
Health Care?
Concerns
Consider: concerns / issues re: discharge, home circumstances,
accommodation, ability to manage, carer issues, large packages of care, the
need for specialist equipment, the nature, intensity, complexity and
unpredictability of the individual's needs.
Are any Specialist Assessments Required?
Specialist Assessments required
Referral
Passed
To
Role
Organisation Date
Referred
Date
Returned
Reason
If Outcome
is
Assessment
Completed
for S4
please state
reason
Data Protection Act 1998
All 'data subjects' can apply for access to records held about them, this could
include this assessment document. Please indicate whether or not access
should be given, in the event of an application, in your opinion:
Reasons for access not being given
If the Service User is unable to sign, please state the reason below
Assessed Person
Name
Initial Assessor
Name
Joint Assessor
Name
Manager
Name
Date
Date
Date
Date
Appendix 4
CARE AND TREATMENT PLAN
Gall y cynllun hwn cael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg ac yn
rhannol yn Saesneg
This plan may be completed in either the Welsh or the English language, or partly in Welsh and partly in
English
Mental Health (Wales) Measure 2010 Section 18 – Care and Treatment Plan
This care and treatment plan has been prepared under section 18 of the Mental Health (Wales) Measure
2010, and in accordance with the requirements of the Mental Health (Care Coordination and Care and
Treatment Planning) (Wales) Regulations 2011.
This is the care and treatment plan of
Name of
relevant patient
Full usual
address of
relevant patient
who lives at
The care coordinator who has prepared this care and treatment plan is
who can be contacted at
The care coordinator has been appointed by, and is acting on behalf of,
Name of care
coordinator
Telephone
number, postal
address, and
where
appropriate,
email address
of care
coordinator
Name of Local
Health Board or
Local Authority
that appointed the
care coordinator
This plan was made on
and is to be reviewed no later than
Date plan was made and
date by which the plan
must be reviewed
However,
Name of relevant patient
his or her carer(s), or adult placement carer(s), may request a review of
this care plan at any time.
This part of the care and treatment plan records the outcomes which the provision of mental health services are designed to
achieve, details of those services that are to be provided, and the actions that are to be taken with a view to achieving those
outcomes.
Area of life
Outcome to be
achieved
What services are to
be provided, or
actions taken
When
Who by
The following thoughts, feelings or behaviours may indicate that the person is becoming more unwell and may require extra help
from the care team (these are sometimes called relapse signatures):
If the person feels that his or her mental health is deteriorating to the point where he or she requires extra help or support, the
following actions ought to be taken (this is sometimes known as a crisis plan and must include the details of services to be
contacted):
49
Any language or communication requirements or wishes which the person has (including in relation to the use of the Welsh
Language) ought to be recorded here:
The views of the person on this care and treatment plan, the Mental Health services that are to be provided, and any future
arrangements that ought to be considered, are:
This care and treatment plan has:
Date Care and Treatment Plan Agreed/Not Agreed with Person
50
DD
MM
YYYY
So far as it is reasonably practicable to do so, the following mental health service provider(s) must ensure that the mental health
services set out in this care and treatment plan are provided:
Enter the name of the Local Health Board and/or the Local Authority who are responsible for providing secondary mental health
services to the relevant patient
Has the individual been offered a copy of the Care and Treatment Plan
Date copy of Care and Treatment Plan was offered
DD
MM
YYYY
The relevant patient may sign the care and treatment plan, if they wish- Did they?
Yes
No
51
Individuals Electronic Signature
Date Care and Treatment Plan Made
Date Care and Treatment Plan last Modified
52
53
Appendix 5
54
Care and Treatment Plan
Gall y cynllun hwn cael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg ac yn
rhannol yn Saesneg
This plan may be completed in either the Welsh or the English language, or partly in Welsh and partly in English
Mental Health (Wales) Measure 2010 Section 18 – Care and Treatment Plan
This care and treatment plan has been prepared under section 18 of the Mental Health (Wales) Measure
CCIS ID
First Name
Date of
Birth:
Gender
Religion
Primary
Address
NHS No
Middle
Name
Age
Last Name
Age if
Estimated
Nationality
Ethnicity
55
This is
and
Post Code
Home
Phone
Preferred
Language
Treatment Plan of:
Care Coordinators
the Care
Email
Address
Mobile
Phone
Preferred
Contact
Method
Work Phone
Interpreter
Required
No
The care coordinator who has prepared this care and treatment plan is
Who can be contacted at
The care coordinator has been appointed by, and is acting on behalf of
Date of Care & Treatment Plan
DD
MM
YYYY
56
And is to be reviewed no later than
However, the patient, his or her carer(s) or adult placement carer(s) may request a review of this care plan at any time
DD
MM
YYYY
Care Plan
This part of the care and treatment plan records the outcomes which the provision of mental health services are designed to
achieve, details of those services that are to be provided, and the actions that are to be taken with a view to achieving those
outcomes.
The planned outcome(s) included in the following part of the plan must relate to one or more of the areas listed, and include an
explanation of how each outcome relates to each area.
Outcomes also may be achieved in other areas, and are to take into account any risks identified in relation to the relevant patient.
This part of the plan should also set out details of the services that are to be provided, or actions taken, to achieve the planned
outcomes, including when, and by whom those services are to be provided or actions taken. Outcomes to be achieved must be
agreed in relation to at one of the following areas:
Accommodation
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
Completed
57
What services are to be provided, or actions taken
Intervention
When
Who by
Completed
Related
Outcome
Number
Yes
No
Education and training
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
What services are to be provided, or actions taken
58
Yes
No
Completed
Yes
No
Intervention
When
Who by
Completed
Related
Outcome
Number
Yes
No
Finance and money
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
Completed
Yes
No
What services are to be provided, or actions taken
Intervention
When
Who by
Completed
Related
Outcome
Number
59
Medical and other forms of treatment, including psychological interventions
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
What services are to be provided, or actions taken
Yes
No
Completed
Yes
No
Intervention
When
Who by
Completed
Related
Outcome
Number
Yes
No
Parenting or caring responsibilities
60
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
What services are to be provided, or actions taken
Intervention
When
Who by
Completed
Related
Outcome
Number
Yes
No
Personal care and physical well-being
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
61
Completed
Yes
No
Completed
What services are to be provided, or actions taken
Intervention
When
Who by
Completed
Related
Outcome
Number
Yes
No
Social, cultural and spiritual
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
What services are to be provided, or actions taken
62
Yes
No
Completed
Yes
No
Intervention
When
Who by
Completed
Related
Outcome
Number
Yes
No
Work and occupation
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
Completed
Yes
No
What services are to be provided, or actions taken
Intervention
When
Who by
Completed
Related
Outcome
Number
63
Outcomes to be achieved may also be agreed in relation to other areas
Outcomes to be achieved may also be agreed in relation to other areas
Outcomes to be achieved
Outcome
Number
Outcome to be achieved
Yes
No
Completed
Yes
No
What services are to be provided, or actions taken
Intervention
When
Who by
Completed
Related
Outcome
Number
Yes
No
64
Relapse signatures
The following thoughts, feelings or behaviours may indicate that the person is becoming more unwell and may require extra help
from the care team (these are sometimes called relapse signatures):
Crisis plan
If the person feels that his or her mental health is deteriorating to the point where he or she requires extra help or support, the
following actions ought to be taken (this is sometimes known as a crisis plan and must include the details of services to be
contacted):
Language or communication requirements
Any language or communication requirements or wishes which the person has (including in relation to the use of the Welsh
Language) ought to be recorded here:
65
Person views
Record any views that the relevant patient wishes to be included (including past and present wishes and feelings about the matters
covered by the plan) and include any statements about any future arrangements which may apply.
If the patient does not have any views or statements on these matters, or the patient's views cannot be ascertained, this ought to be
recorded also. The views of the person on this care and treatment plan, the mental health services that are to be provided, and any
future arrangement that ought to be considered, are:
This care and treatment plan has:
Date Care and Treatment Plan Agreed/Not Agreed with Person
DD
MM
YYYY
Provider and sharing of information
So far as it is reasonably practicable to do so, the following mental health service provider(s) must ensure that the mental health
services set out in this care and treatment plan are provided
Enter the name of the Local Health Board and/or the Local Authority who are responsible for providing secondary mental health
services to the relevant patient
66
Has the individual been offered a copy of the Care and Treatment Plan
Date copy of Care and Treatment Plan was offered
DD
MM
YYYY
The relevant patient may sign the care and treatment plan, if they wish- Did they?
Yes
No
Actual Start Date
67
Appendix 6
68
Privacy Notice
Purpose
Powys County Council Adult Social Care
This privacy notice has been developed by Powys County Council’s (the Council) Adult Social Care (ASC) service, to ensure its
transparency with collecting and processing personal information.
Anyone receiving a service from ASC will have a record kept about them. We collect personal information to enable us to provide
you with social care services, in partnership with other agencies and voluntary organisations. This privacy notice also includes the
processing of personal information that takes place by the Social Services Customer Feedback Team in order to improve our
services.
This notice explains what information we collect, why we collect it and how we keep it secure. It also explains your rights and our
legal obligations.
The Legal Basis
ASC have considered appropriate lawful grounds for collecting and processing your data. Your personal information is needed so
that we are able to carry out our legal responsibilities.
In some cases, this may result in a legal requirement for information to be provided and collected. If you refuse to provide the data
we require, this could result in us not being able to provide you with services. Some of the key pieces of legislation that ASC work
under includes:
• Social Services and Wellbeing (Wales) Act 2014
• Wales Safeguarding Procedures 2019
• Mental Health Act 1983
- Mental Health Act Code of Practice for Wales
- Mental Health (Wales) Measure 2010
69
• Mental Capacity Act 2005
- Deprivation of Liberty Safeguards (soon to be replaced by the Liberty Protection Safeguards)
• Regulation and Inspection of Social Care (Wales) Act 2016
The Data Protection Act 2018
The Council is a Data Controller under the Data Protection Act 2018 which is the UK’s implementation of the General Data
Protection Regulation.
The Council’s Data Protection Officer (DPO) can be contacted at the Information Compliance Team at
information.compliance@powys.gov.uk or at 01597 826 400.
What information we hold about you
ASC will store any details relating to your situation in a way that will assist us in supporting you to meet your, and / or your family’s,
care and support needs as well as our responsibilities regarding the protection of adults at risk from abuse and neglect.
Categories of personal data obtained
ASC may obtain the following categories of your personal data:
• Name
• Address
• Date of Birth
• Gender
• Contact Details
• National Insurance Number
We may also obtain and hold more specific information, including:
• Details about your care and support needs
•
• Details of family relationships in and outside of your household
Information about other members of your household
70
• The names and contact details of your close relatives and/or carers
•
• Things that other organisations (such as health, schools, or care homes) tell us to help us understand your situation and
Information used to assess your situation, such as assessments and reports
needs and co-ordinate your care services more effectively
• Recordings of any visits or contact you have made, or we have made with you
• Any additional needs or disability
• Financial information
• Details of your mental health and capacity
• Details of your physical health
• Details of your wellbeing
• Details of your personal outcomes
• Details about your lifestyle
• Details about your engagement with ASC
• Culture, religion/ belief
• Criminal record
• Restorative justice
• Allegations of abuse or neglect towards you
• Allegations or concerns raised regarding your conduct or safeguarding concerns from you about others.
Source of the personal data
• You
• Your representative/ advocate/ legal representative
• Your family
• Police
• Health authorities
• Education authorities
• Other local authorities
• Housing associations/ registered social landlords
71
• Regulatory bodies, such as Care Inspectorate Wales/ Health Inspectorate Wales
• Partner Agencies
• Medical professionals/ General practitioners
• Disclosure and Barring Service
• Members of the public
• Domiciliary Care Agencies
• Residential and Nursing Care Homes
• National Prosecution Service
• Secure Estates (prisons)
• Others (including professionals/ volunteers/ carers) who may be involved in your care
• Your employer
Is Personal Information shared with anyone else?
The sharing of your information will be undertaken in line with our tasks and the applicable legislation.
We will only share information with an organisation if they need it to do their job, or where the law requires or allows us to do so, for
example:
If a Court orders that we provide the information
• Partner organisations that provide care and support services
•
• Regulatory bodies (such as CIW) that inspect and monitor our work
• Organisations such as the police, health, education services and third sector partners who work jointly with us to provide
services and protect individuals.
Retention of Personal Information
ASC will retain your information for some time after we have stopped delivering services to you. The Retention Periods are
specified within the Council’s Corporate Retention Schedule. After this time records are safely destroyed.
Further information
72
For more information as to how the Council uses personal data, and on your data protection rights, please visit the Council’s
privacy notice here: Data Protection and Privacy - Powys County Council
73
Appendix 7
74
POWYS TEACHING HEALTH BOARD and POWYS COUNTY COUNCIL
PATIENT SAFETY INCIDENT
ACTION PLAN from Regulation 28.
FOR WEB39318.
June 2022.
REF
ISSUE
ACTION
MHLD LEAD
OUTCOME
1. Welsh Applied Risk
Research Network
assessments content
reviews/ integrating
systems/ updating of
current information.
a) Copyrighted Welsh
Applied Risk Research
Network to be added to
WCCIS database.
a) Service
Improvement
Manager/Powys
County Council
Powys Teaching
Health Board IT
Service Manager
a) Correct
evidenced
based Welsh
Applied Risk
Research
Network
available on
75
COMPLETION DATE AND
ACTIONS TAKEN
a) Early August
2022
PROGRESS
AND/OR
ACTION AT
REVIEW DATE
a) July 2022-
correct form
has been built
and currently
in testing
stage.
shared IT
system
b) Inpatient
staff able to
use WCCIS
Welsh Applied
Risk Research
Network,
avoiding
duplication and
possibility of
lost
information.
b) Acute General
adults to be in
place by
September
2022, Older
adults to follow.
b) July 2022
Increased
authorisations
in progress.
Digital
training
available to
support
increased
permissions.
d) WCCIS
stability has
improved –
July 2022
d) Further National
monitoring November
2022, monthly
monitoring via internal
Gateway Group
b) Powys Teaching
Health Board Inpatient
Staff to be given
improved WCCIS access
to enable them to
complete documentation.
b) Powys
Teaching Health
Board Clinical
Lead Quality &
Safety.
Consultant
Nurse Welsh
Applied Risk
Research
Network Lead.
c) Powys Teaching
Health Board to work
with external partner
agencies to improve risk
sharing information with
commissioned inpatient
care.
d) National and Local
Review of WCCIS
c)Clinical Lead
Quality & Safety.
Consultant Nurse
Welsh Applied
Risk Research
Network Lead
76
2. Welsh Applied Risk
Research Network
assessments format/ ease
of accessibility /
infrequent users/ new
users.
A) Approved Welsh
Applied Risk Research
Network form will be
placed on the person
level in WCCIS so this is
accessible to both
services in Powys County
Council and PtHB.
d) Welsh
Government/
Powys Teaching
Health
Board/Powys
County Council
gateway group
a) Clinical Lead
Quality & Safety.
Consultant Nurse
Welsh Applied
Risk Research
Network Lead.
Head of MH
services Powys
County Council.
b) Chronology form
added to WCCIS,
replicating that
recommended by Welsh
Applied Risk Research
Network.
b) Clinical Lead
Quality & Safety.
Consultant Nurse
Welsh Applied
Risk Research
Network Lead.
77
d) Ongoing
monitoring of
WCCIS system
performance
a) Updates to
include new
format and
form will
enable a
consistent
approach to
risk
assessments
and evaluation
for Powys
County Council
and PtHB staff.
b) This will
allow for all
risk activities
to be added in
an easily
accessible way
by internal
practitioners.
a) This will be
completed by 01 August
2022
a) July 31st
2022.
The approved
form is going
live and has
been agreed/
approved by
the author.
b) July 2022
Developed
and in testing
stage.
b) To be completed by
01 August 2022
c)Identification of staff
ongoing.
c)Powys
County
Council staff
records
updated to
reflect Welsh
Applied Risk
Research
Network
training as
mandatory
c)Organisational Staff
record to be used to
identify staff requiring
Welsh Applied Risk
Research Network
training.
Head of MH
services Powys
County Council.
c)Clinical Lead
Quality & Safety.
Consultant Nurse
Welsh Applied
Risk Research
Network Lead.
Quality
Improvement
Manager, and
CMHT Team
Manager for
Powys County
Council.
c)Staff
requiring initial
and refresher
training will be
identified and
monitored.
Names of
Powys County
Council staff
requiring
training will be
given to Powys
Teaching
Health Board
who lead on
training,
enabling them
to target
staffing
groups. This
will be
reviewed on a
3 monthly
basis.
78
d)Training is dependent
on courses being run by
Welsh Applied Risk
Research Network
authors. No dates have
been set but it is hoped
that they will occur in
Spring 2023.
e) August 2022
d)Identification of Powys
County Council
practitioners to train as
trainers.
e) Business Insight
programmes used to
identify infrequent Welsh
Applied Risk Research
Network users. This will
allow targeted support
for those less confident
via contact with
Champions.
Powys County
Council CMHT
Team Manager
d)Clinical Lead
Quality & Safety.
Consultant Nurse
Welsh Applied
Risk Research
Network Lead.
Quality
Improvement
Manager, and
CMHT Team
Manager for
Powys County
Council
79
d)2 Powys
County Council
Welsh Applied
Risk Research
Network
Practitioners
will be trained
as trainers to
support
ongoing
programme.
d)Powys
County
Council Staff
have been
identified and
their names
will be
submitted to
Welsh Applied
Risk Research
Network
authors by 01
August 2022.
e) Practitioners
will feel more
confident in
undertaking
Welsh Applied
Risk Research
Network
assessments.
e) The need
to link in with
Champions to
be reiterated
through
Powys
Teaching
Health Board
Learning and
Development
Group and
through
Powys County
Council Team
Meetings.
Alongside
supervision.
a)Audit processes to
continue through Powys
Teaching Health Board.
3. Welsh Applied Risk
Research Network and
associated assessments –
reviews/ quality
assurance
monitoring/updating of
current needs/ access by
relevant bodies.
a)Clinical Lead
Quality & Safety.
Consultant Nurse
. Welsh Applied
Risk Research
Network Lead.
Head of MH
services in Powys
County Council.
Head of MH
services in Powys
County Council.
a)6 monthly
audits to target
learning and to
identify any
development
to be
completed
jointly by
Powys County
Council and
PtHB.
a)next audit scheduled
for October 2022.
b)Powys County Council
to restart Quality
Assurance Audit
b)Clinical Lead
Quality & Safety.
80
b)Powys
County Council
to reinstate
b)Service
Improvement
Manager is
currently
restarting
b)To be restarted in
September 2022, with
results fed back via
Senior Management,
supervision and
Learning and
Development Group on
completion.
random
audits, with
each
identified
auditor
allocated 2
per month.
Consultant Nurse
Welsh Applied
Risk Research
Network Lead.
Quality
Improvement
Manager, and
CMHT Team
Manager for
Powys County
Council
randomised
monthly audits
focussing on all
electronically
held
documentation.
This process
requires the
auditor to
speak directly
with the person
cared for and if
appropriate,
their Carers.
Audit findings
to be shared
with Senior
Managers and
at Team
Meetings. Also
discussed with
involved
practitioners
during their
monthly
supervision.
4. Welsh Applied Risk
Research Network
assessment tools –
accessibility to Patient /
integration referral
process to secondary
a)Greater users/carer
involvement in the
assessment process and
the sharing of that
information as identified
as a piece of work
a)Clinical Lead
Quality & Safety.
Consultant Nurse
Welsh Applied
Risk Research
Network Lead.
a)Feedback
provided by
the author of
Welsh Applied
Risk Research
Network Dr
a)October
2022.
81
services, working
together optimisation
approaches
following the last audits
completed by PtHB.
Confirmed this will be
part of the training
moving forward with the
Welsh Applied Risk
Research Network
trainers to be delivered
to Welsh Applied Risk
Research Network
assessors in both PtHB
and Powys County
Council.
b) Powys Teaching
Health Board and Powys
County Council to
support practitioners in
understanding how and
when to share
information.
Head of MH
services in Powys
County Council.
b) Clinical Lead
Quality & Safety.
Consultant Nurse
Welsh Applied
Risk Research
Network Lead.
Quality
Improvement
Manager, and
CMHT Team
Manager for
Powys County
Council
supported by
Head of Data
Protection.
82
Gray has
provided good
learning and
development
to take forward
to improve and
imbed future
collaborative
working, audit
and review of
the Welsh
Applied Risk
Research
Network.
b) Powys
Teaching
Health Board
to share
information
sharing
processes via
Learning and
Development
Group.
Powys County
Council are in
the process of
updating its
Privacy
Statement,
b) Ongoing
and on a
monthly
basis.
This was sent
for ratification
at the end of
June 2022
and is
expected to
be approved.
This will then
be shared
with
practitioners.
August 2022
which can
support
Practitioners
and those we
care for to
understand the
need to share
information.
(Attached as
Appendix 6)
c)The People we Care for
should remain integral in
assessment process.
Assessments should be
shared routinely with
them unless there is a
risk to self or others.
c)Practitioners
to be reminded
of the need to
coproduce
documents
with those we
care for.
Practitioners to
update admin
83
October 2022
Completed and ongoing
Powys County
Council
Professional
Lead for Data
Protection
invited to
Teams
Meeting, to
support
practitioners
understanding
of information
sharing
process.
c)Practitioners
reminded of
need during
Team
Meetings and
throughout
supervision.
To be
considered
through audit
process.
staff when
documents are
completed and
ready to share
with those
identified in
care plan,
including
external
agencies,
subject to
appropriate
authorisation.
84
85
See every Prevention of Future Deaths report matching Mental Health related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.