DEVON PARTNERSHIP NHS TRUST

QUALITY AND SAFETY COMMITTEE

Meeting on 27 April 2017

COMBINED REPORT - EXPERIENCE, SAFETY AND CLINICAL RISK WITH QUALITY

AND SAFETY OPERATIONAL INPUT FROM SENIOR MANAGEMENT BOARD

1. Purpose of report

 To inform the Trust, Directorates and Commissioners of the learning arising from a cross
referencing of qualitative and quantitative data as a result of complaints, incidents,
experience and root cause analysis investigations.

 The report will be submitted to the Senior Management Board (SMB), Quality and Safety
Committee (Q&S) and Directorates.

2. Background

2.1 A review of this report and the Quality and Safety Operational Report has been completed to
reduce repetition and streamline reports. The two reports have now been combined. A
summary of what was reported from Directorate Governance Boards (DGB’s) to the SMB
Directorate Performance Meeting is now provided in section 4.16.

2.2 This replaces the directorate level analysis of incidents, complaints and patent experience
from previous reports. That data is still produced at Directorate level and sent to DGBs for
discussion. Any issues of concern or of note should now be reported through DGBS to the
performance meeting and hence then be summarised in the new section 4.16

2.3 This single report will continue to consider the following areas where these have an ongoing
impact on governance and assurance.
 The reporting and investigation of all incidents including Serious Incidents Requiring
Investigation and near misses, the dissemination of learning and the implementation of
service improvements.
 Responding to safety alerts (Central Alerting System) in a timely manner.
 The receipt and management of litigation against the Trust.
 Provision of information to inform coroner’s inquests and the support of staff involved and
the management of the recommendations and learning arising from inquests.
 The maintenance of the Trusts policy framework.
 Reporting of the patient safety incidents that have reached the threshold for the Duty of
Candour process.
 The investigation and response to complaints, dissemination of learning and implementation
of service improvements.
 The work being undertaken to encourage and respond to feedback from people who use
services about the quality, safety and effectiveness of the services they receive.
 The development of quality improvement projects and ongoing work that links the
Improvement Academy and the Experience, Safety and Risk Team with services to improve
areas identified by the production and consideration of this report.

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3 Key points for the Committee to note

3.1 Between the months of December to March there has been an increase in the number of
incidents reported across the Trust to 3,117 from 2,826 in the previous four month period.

3.2 By the end of March there were a total of 7 overdue Serious Incidents Requiring Investigation
reports; of these 4 went overdue in March. There is a requirement by the Clinical
Commissioning Group for exception reporting for any volume greater than five. The reasons
for these delays are communicated to the Clinical Commissioning Groups and NHSI along
with an agreed completion date on a monthly basis. Following concerns being raised by both
the commissioners in relation to the delays a number of improvement actions have been
proposed and are detailed below.

3.3 There continues to be a number of incidents awaiting manager’s review for greater than the
policy timeframe of 48 hours. There are currently 490 incidents that are either awaiting
manager’s review or are under review. This is the largest number of incidents ever reported to
the Trust. Of the 490 incidents either awaiting managers review or under review 222 are within
three inpatient wards.

3.4 There is a continued focus on the timely ratification of new and ongoing policies.

3.5 Duty of Candour information sessions are continuing across the Trust and are delivered to
teams on request by the Experience, Safety and Risk Manager.

3.6 There have been five claims against the Trust submitted during the reporting period, all of
which are claims of clinical negligence cases and have all been submitted to NHS Resolution
(formally NHSLA).

3.7 There have not been any breaches of CAS Alert deadlines.

3.8 There has been a levelling in the number of complaints open which is now 77 (84 end Feb, 81
end September, 74 end July, 87 end May 2016, 93 end March 2016, 96 end February 2016,
113 end January 2016, 135 end December 2015), of which approximately a quarter are in the
quality assurance review and sign off stages. Between January 2017 and the end of March
2017 there have been 72 new complaints received and 62 complaints closed.

3.9 There are currently six complaints being investigated by the Parliamentary and Health Service
Ombudsman. Between January 2017 and end March 2017, the Trust has been advised of
three new cases to be investigated by the Parliamentary and Health Service Ombudsman.

3.10 The number of responses for the Friends and Family Test during February 2017 and March
2017 was 354 (630 last report) and the percentage of people answering the Friends and
Family Test question positively is 94% (last report 90%).

3.11 The Central Investigation resource has been reduced from three full time equivalents to two,
and has been extended until the end of September 2017.

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4 Trust Level Analysis

The two tables below show the number of incidents for inpatient and non-inpatient (other)
incidents.

Inpatient Incidents
Older Peoples Secure Specialist
Month Adult MH MH Services Services Total
01/04/2016 160 63 136 24 383
01/05/2016 213 103 165 110 591
01/06/2016 203 129 164 54 550
01/07/2016 217 108 123 36 484
01/08/2016 212 93 135 40 480
01/09/2016 210 64 157 56 487
01/10/2016 210 77 151 66 504
01/11/2016 158 73 162 67 460
01/12/2016 202 90 124 107 523
01/01/2017 245 76 179 156 656
01/02/2017 182 91 144 49 466
01/03/2017 257 91 124 57 529
Total 2469 1058 1764 822 6113

The above table illustrates the improvement in incident reporting within the Trust by inpatient
units. This is evident across all directorates, with the exception of Secure Services. It is noted
that there has been a significant increase in the number of incidents reported within Specialist
Services.

Other Incidents
Older
Adult Peoples Secure Specialist
Month MH HQ IPP MH Services Services Total
01/04/2016 61 6 4 38 5 37 151
01/05/2016 78 13 9 32 4 62 198
01/06/2016 69 7 4 27 1 81 189
01/07/2016 64 10 5 32 8 63 182
01/08/2016 60 8 6 45 4 59 182
01/09/2016 80 12 10 48 11 85 246
01/10/2016 59 9 8 43 5 94 218
01/11/2016 49 28 6 43 12 111 249
01/12/2016 39 20 7 47 9 99 221
01/01/2017 54 10 4 50 16 127 261
01/02/2017 48 7 4 43 5 94 201
01/03/2017 74 8 9 54 6 109 260
Total 735 138 76 502 86 1021 2558

The above table continues to show an improvement in the number of incidents reported
across the Trust by community teams, with the exception of the Adult Directorate, which
shows a reduction in the number of incidents reported. As noted in the table above, there has

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 been a significant improvement in the number of incidents reported within the Specialist
Directorate.

4.1 Manager Reviews of Incidents

Trust - Outstanding Manager Reviews

550
Trust - Outstanding Manager Reviews

500

450

400
UCL 379

350
CL 325

300
LCL 271
250

200
Aug-15

Dec-15

Dec-16
Apr-15
May-15

Apr-16
May-16

Oct-16

Apr-17
Jan-15

Mar-15

Jun-15

Oct-15
Nov-15

Jan-16

Mar-16

Jun-16

Aug-16

Nov-16

Jan-17

Mar-17
Feb-15

Jul-15

Sep-15

Feb-16

Jul-16

Sep-16

Feb-17
Month

There continues to be a delay in the completion of manager’s reviews of incidents which has
significantly worsened since December 2016 and we currently have the most overdue
manager’s reviews that have ever been reported.

Data from April 2017 shows that of the 490 incidents either awaiting managers review or
under review, 222 are within three Adult inpatient wards.

The April reports have been sent to each Directorate and the Directorate Senior Teams as this
will with a request that they need to be added to the local governance meetings for
consideration and escalation as needed. All of these incidents must be reviewed and
completed by the 30 April 2017 as the deadline for next national NRLS report is due and if
they are not completed they will not be included in the national reporting figures.

The delay in the reviewing and closure of incidents by managers’ impacts on the safety of
trust units and also data submitted to external agencies such as the CCGs and National
Patient Safety Agency. We remain in the bottom 25% of all mental health trusts in the country
for incident reporting and delays in completing these forms is a significant factor in this
position as they cannot be uploaded until they are completed by the relevant manager, this
attracts additional scrutiny from external bodies including the CQC and NHS England.

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4.2 National Reporting and Learning System

The National Reporting and Learning System (NRLS) take the view that “there is an emerging
evidence base that organisations with a higher rate of reporting have a stronger safety culture.
High reporters aim to learn from incident reporting to make patient care safer.”

The comparative reporting rate summary shown below provides an overview of incidents
reported by NHS organisations to the National Reporting and Learning System (NRLS)
occurring between April 2016 to September 2016. Our Trust reported 1,551 incidents (rate of
31.39) during this period; this compares to the previous period October 2015 to March 2016.
Your organisation reported 1,107 incidents (rate of 23.82).

Our Trust remains is in the bottom 25% of Mental Health Trusts in the country for the number
of patient safety incidents reported. The number of incidents reported has improved in the
NRLS report covering the period April to September 2016; the two graphs below illustrate the
changes in our level of reporting over the last two reporting periods.

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The risk team is continuing to consider how the level of reporting can be improved, actions
being taken include:

 Developing team level benchmarking to allow teams to compare like with like and identify
and share areas of good reporting, particularly in community teams
 Provide team based training sessions to explain about how and what to report
 Develop new ‘short forms’ to reduce the amount of unnecessary information required for
particular types of incident, we have recently developed and introduced a shorter form for
self-harm incidents.
 Raise the issue of low levels of reporting with the Directorate Governance meetings
 Review our reporting levels against other trusts who have higher levels and check whether
there services are similar or include others for example non mental health community
services; this could account for some variation when compared
 Develop information for teams to tell them how many incidents that they need to report to
meet the expected levels based on caseload and benchmarking

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4.3 Serious Incidents Requiring Investigation (SIRI)

The table below shows the number and categories of Serious Incidents Requiring
Investigation entered on to the Strategic Executive Information System (StEIS) from the
beginning of January 2017 to end of March 2017

Adult OPMH
Category / Directorate Adult Inpatient OPMH Inpatient Specialist Total
Abuse/alleged abuse of adult
0 1 0 0 0 1
patient by staff
Apparent/actual/suspected self-
7 1 1 0 3 12
inflicted harm
Confidential information
leak/information governance 0 0 0 0 1 1
breach
Disruptive/ aggressive/ violent
0 1 0 0 0 1
behaviour
Medication incident 0 0 0 0 1 1
Pressure ulcer meeting 0 0 0 1 0 1
Slips/trips/falls meeting 0 0 0 1 0 1
Unauthorised absence 0 1 0 0 0 1
Total 7 4 1 2 5 19
Of these incidents reported, the CCG has been contacted to request deletion of one and this
request has been agreed

By the end of March there were a total of 7 overdue Serious Incidents Requiring Investigation
reports; of these 4 went overdue in March. There is a requirement by the Clinical
Commissioning Group for exception reporting for any volume greater than five. The reasons
for these delays are communicated to the Clinical Commissioning Groups and NHSI along
with an agreed completion date on a monthly basis. Following concerns being raised by both
the commissioners in relation to the delays a number of improvement actions have been
proposed and are detailed below.

During the reporting period, there were 23 RCA reports submitted to the CCG and 19 were
closed from StEIS. These incidents were seven ‘unexpected death’, two ‘self-harm’, two
‘disruptive, aggressive/violent behaviour’. The learning from these reports are shared with the
teams and feed into the Learning from Experience groups.

Apparent/actual/s
uspected self- Unauthorised
Department/Team inflicted harm absence Total
Coombehaven Ward 3 3
Delderfield Ward 1 2 3
Devon Liaison & Diversion - Exeter 1 1
Drug Service Torbay 1 1
East & Mid Crisis Resolution Home
Treatment Team 1 1
Exeter Crisis Resolution Home
Treatment Team 4 4
Exeter Liaison Service 1 1
Exeter Mental Health & Recovery 1 1
Moorland View Ward 1 1

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 Apparent/actual/s
uspected self- Unauthorised
Department/Team inflicted harm absence Total
North Devon Crisis Resolution
Home Treatment Team 2 2
North Devon Mental Health &
Recovery 1 1
Ocean View Ward 1 1
South & West Devon Crisis
Resolution Home Treatment Team 1 1
Teignbridge Crisis Resolution
Home Treatment Team 1 1
Teignbridge Crisis Resolution
Home Treatment Team 1 1
Total 21 2 23

Upon completion of the Root Cause Analysis report, an action plan is formulated and this
action plan is monitored through to the completion. Actions can only be closed when evidence
has been submitted. There is ongoing difficulty with the timeliness of the completed actions.

At the end of March 2017 there were 153 actions open of which 106 are past their target date.

4.4 Improvement to the Management and Investigation of Serious Incidents Requiring

Investigation (SIRI)

Both the NEWD and TSD Commissioners have recently written to the Trust raising concerns
about delays in the completion of RCA investigations and related process; we have responded
to the CCGs; the key areas of concern are -

4.3.1The submission of initial reports within 3 working days of the incident being identified
We routinely review each incident that is reported and determine whether it meets the
requirements for serious incident reporting. This is undertaken daily and where we identify an
incident that appears to meet the requirement we will request the detailed managers review
normally on the day it is reported, this will include any specific questions or further information
we require to confirm that the incident needs to be reported as a SIRI.

The managers’ review is generally requested from the senior manager, team leader or
equivalent in the service that reported the incident. We have historically and continue to have
delays in obtaining these reviews in the required timescale, as a result our risk team will now
often review the clinical records and STEIS report based on the original report and information
they are able to obtain pending the manager’s review. This avoids delays in the reporting on
STEIS while we continue to expedite the manager’s review. It is also noted that we have
historically provided the managers review on request from the CCG rather than for all SIRIs
reported, we have reviewed this and considered the national reporting framework and will be
amending our processes as summarised below:

 For incidents that are believed to require SI reporting the risk team will be piloting using a
teleconference call with the relevant service managers and others who can contribute as
soon as the incident is reported and within the first 48 hours, this will avoid waiting for the
manager to access the risk management system and complete the review.
 Any manager’s reviews for SIs that are not completed within 48 hours will be escalated to
the Clinical Director and Managing Partner for the relevant services, they will be expected
to follow these up and ensure they are completed within the three working days.

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  All overdue managers’ reviews are currently reported to the Directorate Governance
Boards monthly identifying the responsible managers, time taken to respond and the
number that remain overdue. These reports will continue but will be adapted to highlight
SIs.
 The manager’s review for all SIs will be sent to the CCG within the required timescale,
where this is delayed, the reason for the delay and the information available at that time
will be sent pending the completed manager’s review.
4.3.2 RCA reports submitted to the CCG within 60 working days (brought forward date)
We have had some difficulty in maintaining a level of overdue RCA reports to below the
required five. This has been a difficulty over the last 3-4 years and whilst there has been
significant improvements; there have been periods when there were between 20 and 30
overdue at any time, we continue to work on how to reduce the level of overdue reports.

We have limited influence over the number of incidents that require RCA investigation and the
resource we have to investigate them is fixed. We are reviewing the process of investigation
to see how we can improve the timeliness without compromising the quality of the
investigations or the level of engagement we encourage with families and carers in the
process. We are proposing and have started to implement the following:

 Benchmark reviewing our reports with examples from other mental health providers. To
date we have noted that our reports are often significantly longer and appear to contain a
greater level of detail than other providers. We will be working with the RCA leads to
ensure we provide appropriately detailed reports but avoid unnecessary levels of detail if
not required.
 We currently use a the more traditional RCA process that can result in extended
timescales as we contact and interview staff involved and family separately, the RCA lead
reviews records and documentation independently of staff involved etc. We are planning
to pilot the use of the ‘SWARM’ methodology which encourages early facilitated review
meetings with all those involved in the case and the review of the related materials,
information and records together; the review is then a shared process with the report being
an outcome of the meeting and or follow up meetings. This will enable us to complete the
review and draft the report in a much more joined up and timely way.
 We will now be monitoring the completion of each RCA against the ‘brought forward’ date
within each month rather than monitoring to the month end position, the RCA process has
been amended to reflect the need to complete and submit the report within the 60 day time
scale without the additional time that we have used to complete the final quality assurance
review and sign off.
 The national framework for reporting makes provision for the use of aggregated and multi-
incident RCA investigations; we will be reviewing how we can apply this approach to make
best use of the available investigation resource.

4.3.3 Timely responses to additional questions raised following the CCG review of the RCA
reports
 The risk team have reviewed their process for receiving and tracking the requests for
additional information and responses; they will be more closely monitoring these
responses and will ‘chase up’ with the relevant RCA leads as needed.
 The risk team have suggested that it would be helpful if the CCG could endeavour to
complete their initial reviews and submit any requests for further information within the 20
working days required by the national reporting framework, this will ensure the RCA lead
can deal with these questions sooner and allow earlier agreement of the report; this allows

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 the RCA lead to share the final approved report with the family, carers and clinical team at
the earliest opportunity.
 The risk team have suggested that it would be helpful to undertake a reconciliation with
the CCG teams of all open cases and those that are awaiting further information; this
would provide a clear baseline for the continuing work to close the remaining cases.
 The RCA leads will be provided with a clear deadline for each request, the CCGs have
been asked if we could either agree a standard timescale for these requests or specify a
reasonable timescale for each request.
Each CCG has proposed further discussions with their teams regarding these proposals and
this will be progressed during the next quarter.

4.5 Royal College of Psychiatrists (RCPsych) pilot service to analyse and utilise the
information collected by mental health providers during Serious Untoward Incidents
Reviews

The Trust has agreed to participate in a pilot service being developed by the Royal College of
Psychiatrists. The service will lead a peer group of organisations to develop a more
sophisticated understanding of what ‘good’ Serious Incident investigations look like and
introduce external expert advice to help develop better local plans to improve patient safety
through thematic analysis, prioritisation and monitoring of implementation.

The initial proposal is to pilot the scheme in four NHS Trusts in England. Anonymised SI
reports from individual organisations will be analysed in order to develop and prioritise specific
safety improvement plans. In the first instance the pilot scheme:

1. Will have simple aims and limited scope

2. Will provide relevant expertise
3. Will emphasise implementation, monitoring and overcoming obstacles

Long term goals

 To promote a high standard of SI investigations in the NHS and to promote learning.

 To help Trusts develop appropriate local plans to improve patient safety through
prioritisation and monitoring of implementation.
 To meet the demands of the developing patient safety and deaths review agenda.

4.6 Interventions

During September 2016 there was a change to the Risk Management System to allow more
than one intervention to be recorded along with detailed information regarding holds and
restraints. There has been some confusion of how to report Seclusion / Segregation which
leads to uncertainty about the accuracy of the data.

Please find below the interventions reported since November 2016.

Type of Intervention Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total

De-Escalation 6 4 2 5 0 17
De-Escalation Whilst
Restrained 0 10 8 11 13 42
Medication 10 5 1 7 5 28

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 Type of Intervention Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total
Physical Force 1 1 0 1 1 4
Physical Restraint 41 57 40 40 36 214
Seclusion 33 17 10 16 17 93
Sedation 0 0 0 0 1 1
Segregation 3 0 2 2 3 10
Total 94 94 63 82 76 409

The table below shows the breakdown of Prone Restraint by Department.

Department Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total

Ashcombe Ward 3 1 0 0 0 4
Avon House 0 1 0 0 0 1
Belvedere 0 0 0 0 1 1
Coombehaven 3 0 0 0 0 3
Delderfield 1 1 2 2 3 9
Haytor 0 1 0 1 2 4
Holcombe Ward 1 1 0 0 0 2
Moorland View 0 0 0 2 2 4
Ocean View 0 1 0 0 2 3
Rougemont 0 0 0 1 0 1
Total 8 6 2 6 10 32

4.7 Mixed Sex Accommodation Breaches

The NHS is committed to providing every patient with same-sex accommodation, helping to
safeguard their privacy and dignity when they are often at their most vulnerable. This means
providing a same-sex sleeping area, bathroom and toilet facilities. (DoH Operating Framework
2009/10)

All single sex breaches are reported to our commissioners, along with a rational for the breach
and a description identifying whether the breach is considered to be ‘justified’ and therefore
not to be considered as a breach. This information needs to be sent to the CCG Chief Nursing
Officer within 24 hours of the breach occurring. Once a breach has been established and
reported, there is a financial penalty, this penalty is £250 per day, per service user affected.

Breaches of mixed sex accommodation guidelines have been reported five times during the
period December 2016 and March 2017. Each was reviewed against the further guidance
that we had sought from the Department of Health and it was agreed that the breaches we
have reported would not meet the threshold for national reporting. Three of the breaches
were on Rougemont OPMH ward, the forth was in the ASU.

4.8 Duty of Candour

During the reporting period there have been 204 patient safety incidents reported on RMS
with the actual impact of moderate or above identified by the reporter and/or the reviewing
manager as meeting the threshold for implementing the Duty of Candour process.

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 Of these 17 incidents there is evidence on RMS of 17 people being contacted with an
explanation and an apology and of these nine letters were sent.

There is an increasing understanding of the Duty of Candour amongst Trust staff, anecdotally
these open and transparent conversations are happening with the people involved in or
affected by incidents, but there is a disconnect between this and the Risk Teams ability to
capture and evidence this information on the reporting system.

4.9 Trust Policies

One policy was ratified in December 2016, five in January 2017, four in February 2017 and
three in March 2017

4.10 Litigation

There have been five claims against the Trust submitted during the reporting period, all of
which are claims of clinical negligence cases and have all been submitted to NHS Resolution
(formally NHSLA).

4.11 Central Alerting System (CAS)

There were no breaches of the alerts due for completion during December 2016 to end of
March 2017

4.12 Coroners

The Risk team manage the process for coroners inquests, this includes the day to day liaison
with the coroners offices, trust legal representatives, preparation and submission of
statements, evidence and reports, support for staff, management of any Regulation 28 reports
and internal reporting and briefing in liaison with the communications team.

A regular summary of deaths that will be subject to coroner’s inquest in following month is now
prepared and shared with the core operational group and senior management team, a report
showing the next two weeks of coroners inquests is also shared weekly to allow the clinical
Directorates to review and identify any further management support that may be required if
staff have been called to attend the inquest. .

In preparation for these inquests where witnesses have been called to attend to give evidence
which is normally based on their previously submitted written statements each staff member
will be given the opportunity to attend a coroner’s inquest training session. These sessions
are provided by the Trust Solicitor and are available to all staff. Where staff request individual
support this is provided by the Experience, Safety and Risk team and/or the Trust Solicitor.

For those cases where legal representation has been sought the solicitor (or counsel) will not
only support the Trust witnesses, but also ensure that the Trust's interests are protected when
other witness evidence is being given and any submissions invited from the Interested Parties.
The legal representative will prepare a note of evidence given and advise on any evidence
which might impact on the reputation of the Trust or any subsequent litigation.

There were 18 inquests listed for the period December 2016 to March 2017, of which 8 had
witnesses called to attend, these are summarised below:

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RMS Team Cause of death Inquest verdict
ID / STEIS
17267 Devon Liaison and Amisulpride and Trazodone Drug/Alcohol Abuse
2016/2596 Diversion Toxicity
17646 Exeter Liaison 1a) Asphyxia b) Aspiration Accidental death
Service pneumonia and bolus obstruction
2) Bipolar affective disorder and
Parkinsonism
18276 Exeter Mental Hanging Suicide
2016/7843 Health and
Recovery - Exe
18263 Exeter Liaison 1a) Liver Failure Narrative -
2016/19764 Service 1b) Overdose of Paracetamol Regulation 28 report
ll) Asthma issues by the coroner
18669 Meadow View 1a) Hypoxic Encephalopathy. 1b) Accidental death
2016/14258 Choking on a Bolus of Food in a
Woman with Known
Cerebrovascular Disease
188 Not recorded 1a Inhalation of Butane Volatile substance
abuse
19086 Torbay Central 1a) Hanging
2016/12014 AMHP Team
20261 LD District General 1a Multi Organ Failure that Misadventure
Hospital Teams developed following complications
of Procectomy (Previous total
Colectomy for Ulcerative Colitus) II
Previous Cardiac Surgery, Cerebral
Aneurysm (Treated), Seizure
Disorder.
19259 Exeter Liaison a) Acute respiratory distress Suicide
2016/29383 Service syndrome and small bowel
infarction
1b) Drug overdose
19518 Teignbridge Mental Unascertained pending toxicology Suicide
2016/13420 Health
216 Depression and 1a) Morphine toxicity Took own life whilst
Anxiety Service - suffering from a
North depressive illness.
19716 North Devon CRHT 1a) Pulmonary embolus Misadventure
2016/14495 1b) Left calf deep vein thrombosis
1c) Immobility following mixed
overdose
20401/20437 North Devon CRHT 1a Hanging Narrative
2016/168
215 East Devon OPMH 1a Epileptic seizure Misadventure
Community 2b Serotonin Syndrome 2
Schizoaffective Disorder
21519 Devon Liaison and Multiple injuries Narrative
Diversion
21653 North Devon CRHT 1a Hanging Suicide
2016/21681
22331 Exeter CRHT 1a Multi organ failure Suicide
2016/24605 1b Colchine toxicity
22696 East and Mid CRHT 1a Ligature Strangulation Suicide
2016/27145

Of these one related to the death of a service user who had been an inpatient at the RD&E
immediately prior to her discharge and subsequent overdose that resulted in her death. The
coroner issued a regulation 28 report which identified two matters of concern –

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  Availability of in-patient beds and Crisis Resolution and Home Treatment teams
 Training of physical healthcare staff

A joint RCA investigation has been undertaken with the RD&E prior to the inquest and a full
response to the coroner’s report was made within the required timescale. A claim has since
been submitted to both our Trust and the RD&E.

4.13 Complaints, Concerns and Compliments

Volume and theme of complaints

The total number of complaints received between January 2017 and end March 2017 is 72.

Specialist Services
Older Peoples MH

Secure Services
Headquarters
Adult MH

Total
IPP
Category of Complaint

Access To Treatment Or Drugs 4 0 0 0 0 0 4

Admissions & Discharges (Exc Delayed
Discharge) 2 0 0 2 0 3 7
Appointments 2 0 0 0 0 1 3
Clinical Treatment 5 0 0 1 0 0 6
Communications 10 0 0 0 0 2 12
Consent 1 0 0 0 0 0 1
Other 0 0 0 0 1 0 1
Patient Care 4 1 1 1 0 1 8
Trust Admin/Policies/Procedures Inc Patient
Record 2 0 0 1 0 2 5
Values And Behaviours (Staff) 10 1 0 2 2 7 22
Waiting Times 1 0 0 0 0 2 3
Total 41 2 1 7 3 18 72

The control chart below shows common cause variation within very wide boundaries of 11-42
(11-42), however 14 of the last 17 data points have been below the centre control line which
indicates that the system has become more stable.

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 Number of Complaints (Monthly)
45
UCL 42
40
Number of Complaints

35
30
CL 26
25
20
15
LCL 11
10
5

Month

The graph below shows the number of complaints by month and year. This graph will help
identify if there is a monthly trend each year. The graph indicates that there is an upward trend
in both April and October which could indicate that there will be a similar peak in April 2017.

Complaints by Year
40

35
Number of Complaints

30

25 2014

20 2015

15 2016
2017
10

0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

The following control chart shows common cause variation within very wide boundaries of 0-
14 (0-14 last report) which makes it very difficult to plan ahead.

Page 15 of 24
 Number of Complaints - Weekly
16
14 UCL 14
Number of Complaints

12
10
8
CL 6
6
4
2
0

2015_16 - 8
2014_15 - 1
2014_15 - 7

2015_16 - 2

2016_17 - 4
2014_15 - 13
2014_15 - 19
2014_15 - 25
2014_15 - 31
2014_15 - 37
2014_15 - 43
2014_15 - 49

2015_16 - 14
2015_16 - 20
2015_16 - 26
2015_16 - 32
2015_16 - 38
2015_16 - 44
2015_16 - 50

2016_17 - 10
2016_17 - 16
2016_17 - 22
2016_17 - 28
2016_17 - 34
2016_17 - 40
2016_17 - 46
2016_17 - 52
Week Number

Open Complaints

There has been a levelling in the number of complaints open which is now 77 (84 end Feb, 81
end September, 74 end July, 87 end May 2016, 93 end March 2016, 96 end February 2016,
113 end January 2016, 135 end December 2015), of which approximately a quarter are in the
quality assurance review and sign off stages. Between January 2017 and the end of March
2017 there have been 72 new complaints received and 62 complaints closed.

The graph below details the volume of complaints received in relation to the number of final
responses sent.

50 New Complaints Closed Complaints

Linear (New Complaints) Linear (Closed Complaints)
45

40

35

30

25

20

15

10

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 Parliamentary and Health Service Ombudsman

There are currently six complaints being investigated by the Parliamentary and Health Service
Ombudsman. Between January 2017 and end March 2017, the Trust has been advised of
three new cases to be investigated by the Parliamentary and Health Service Ombudsman.
During the same period there were three completed investigations by the Parliamentary and
Health Service Ombudsman, One was partly upheld with an ongoing action plan, one was
withdrawn and one was not upheld.

Compliments

The control chart below shows common cause variation within very wide boundaries 26-66
(24-64 last report) with nine of the last ten data points above the control line.

Number of Compliments
80

70 UCL 66
Number of Compliments

60

50
CL 46

40

30
LCL 26

20

10

Month

4.14 Friends and Family Test – Patient / Carers

From April 2016 the Friends and Family Test response rate has been included in the National
NHS England contract and the Trust is now required to report a monthly response rate against
a target of 15% across all services and achieve a 'likely to recommend' score of 85%.

The graph below shows that the Trust is still significantly below the expected target of 15%
across all services.

Page 17 of 24
 Trust - FFT Response Rate (Target 15%)
16.00
UCL 14%
14.00
Trust - FFT Response Rate %

12.00

10.00

8.00
CL 6.5%
6.00

4.00

2.00

0.00
Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17
Month

The data from Friends and Family Test surveys (below) shows common cause variation within
much narrower boundaries than previous reports 58%-100% (57%-100% last report) although
the % recommended has been fairly static in the last few months and consistently above the
median line. 15 or more data points near the mid line indicates that we have a stable and
predictable system although more work needs to be undertaken to positively impact on this
position.

Trust - % Recommend
UCL 100
100
95
90
CL 85
Trust - % Recommend

85
80
75
70
65
60 LCL 58
55
50
Mar-15

Aug-15

Mar-16

Aug-16

Mar-17
Dec-14

Apr-15

Dec-15
May-15

Apr-16

Dec-16
May-16
Jun-15

Oct-15

Jun-16

Oct-16
Nov-14

Jan-15

Nov-15

Jan-16

Nov-16

Jan-17
Feb-15

Jul-15

Sep-15

Feb-16

Jul-16

Sep-16

Feb-17

Month

The data from Friends and Family Test surveys (below) shows common cause variation within
much narrower boundaries 140-220 (131-209 last report) although the number of responses
has been above the upper control limit for eight of the past nine months. The boundaries are

Page 18 of 24
 much narrower due to the ‘special cause’ in August 2016 which was due to one team entering
all the surveys for year in to the system as they had previously been entering them into a
spread sheet. The increase in the number of responses overall is mainly attributed to the
Specialist Services Directorate.

Trust - Number of Responses

825

725
Trust - Number of Responses

625

525

425

325

225 UCL 220

CL 180
LCL 140
125

25
Dec-14

Mar-15
Apr-15

Dec-15
May-15

Aug-15

Mar-16
Apr-16

Dec-16
May-16

Aug-16

Mar-17
Jun-15

Oct-15

Jun-16

Oct-16
Nov-14

Jan-15

Nov-15

Jan-16

Nov-16

Jan-17
Feb-15

Jul-15

Sep-15

Feb-16

Jul-16

Sep-16

Feb-17
Month

4.15 Friends and Family Test – Staff

The Trust produces Friends and Family Test (Staff) results on a quarterly basis. It uses the
NHS National Staff Survey results for the Q3 results, and has its own survey for the other
three quarters.

There is no commentary for this report as it is drawn from the results of the NHS National Staff
Survey which will be provided in the next report.

4.16 Community Mental Health Survey 2017

The Community Mental Health Survey for 2017 is currently in its early stages. The contracts
have been agreed and the Performance Team have produced the patient sample for Quality
Health. The Trust currently has a response rate of 17% against a nationwide average of 14%.

4.17 Patient Opinion Website

There have been three recent postings regarding the Trust.

Posted by anonymous “PALS to not even help after complaining”

“I contacted PALS last summer about not receiving the support I need from Wonford House.
Although it was investigated and I received a detail report which showed the failings. ( I was
promised and promised)
I was on a waiting list to receive help with my mental health issues

Page 19 of 24
 I still desperate for help. I have contacted PALS 3 times since their report, asking them to
contact my Care coordinator plus his Manager which they have replied saying " they will set
up a meeting " but have had not one call. What do I need to do for help?
I really thought after emailing PALS ( which took me 2 months to be confident to complain)
they wouls ensure I would be cared for”
Trusts response
We are so sorry to hear of the issues you have been experiencing and would like to apologise
for the time we are taking to resolve them. Please do have confidence that you can ask for
help at any time should you feel that your care and treatment is not satisfactory and we will do
our utmost to help. PALS - our Patient Advice and Liaison Service - is the main channel for
doing this so please keep in contact with them. As you probably already know, they have a
Freephone number 0800 073 0741 or can be contacted by email dpn-tr.pals@nhs.net Thanks
for sharing your feedback.

Posted by anonymous "Vexatious complainant because the trust can't..."

This was a very long complaint from a well known complainant regarding therapy.
Trusts response
Thanks for leaving your feedback about our services. We are extremely sorry to learn of your
experiences and that we have not been able to identify suitable treatment for you as yet. We
are following up the concerns you have shared with us through the complaints process, and
the clinical team responsible for your care is fully aware of the issues you have raised. With
best wishes.

Posted by anonymous “Beech trust Beech“

“I was apprehensive of leaving my wife in any mental health unit but after 18 months, have
nothing but praise for this unit staff always seem to create a good atmosphere, under
sometimes very difficult circumstances. would have no problem with having to leave her there
again.”
Trusts response
Thank you for sharing your experience of Beech Unit. We are very pleased to hear that you
are happy about the care we provided for your wife and will pass on your feedback to the staff
on Beech. With best wishes.

4.18 Directorate Governance Boards

The following refers to the Directorate SBAR reports submitted and discussed at the
Performance Senior Management Board on the 27th of March. It also summarises the issues
of relevance to the safe, effective delivery and experience of those receiving care and
treatment and the staff that provide those services. The report provides assurance of the
quality and safety of services across the clinical Directorates. It reviews the impact of CIP on
quality and delivery of safe and effective services

Main areas of concern have been highlighted in the following report alongside some examples
of positive outcomes from the past reporting month. It is an increasingly challenging
environment with significant financial challenges requiring discussion and agreement for the
next financial year. The quality and safety of service provision will require on-going scrutiny
and review to ensure we can continue with our organisational aim to become a centre of
excellence.

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Older Adult Directorate – Exceptions Report

 Medical staffing -There remain on-going challenges with recruiting Consultant

Psychiatrists. Helen Smith, Medical Director, continues to review options with all
Directorates.

General staffing concerns:

Meadowview:
 Recruitment of Band 5 RMN’s remaining challenging
 Ward Consultant has given notice (finishes May)
 Difficulty staffing the ward recently due to high acuity across ward & unit, leaving team
below minimum safe staffing numbers. This has impacted on team morale
 A paper has been written concerning the future of Meadowview which will be taken to
the May 2017 Senior Management Board

 Second Opinion Approved Doctors – Recent audit identified that there are delays up to 28
weeks for getting a Second Opinion Approved Doctor (SOAD) from the CQC. This means
that patients are being treated on a Section 62 for an extended period. This is not good
practice. It will affect all patients treated for a prolonged period in in-patient units and
patients on Community Treatment Orders. There is a particular impact on patients
requiring ECT. This could curtail the duration of an ECT treatment and undermine
recovery for people with severe depressive episodes.

Mitigation: Carole Camps from the Mental Health Act Office is working with the
Directorate to draft a letter to send to the CQC from Paul Keedwell, as the Director of
Nursing and Professions

The above issue will be raised at the Senior Management Board meeting with a view to
adding it to Corporate Risk Register.

 Timely Assessment – meeting the 10 day assessment standard. There has been a slight
improvement in meeting this standard but not consistently. The Directorate senior
management team is clear that only Exeter CMHT has significant challenges due to a lack
of staff and other teams should be able to meet the requirements. Work on-going to
improve.

 The number of outstanding Section 117 reviews is a risk to the organisation and has been
on the Corporate Risk register for over 12 months. A task and finish group has revised the
processes to ensure the review processes are made as easy as possible. Staff bulletins
have been developed and widely disseminated however there is little or no improvement
from a Directorate perspective. The teams have until October 2017 to ensure there are no,
or a significant reduction, in outstanding Section 117 reviews

 IR35 tax return changes will affect everybody employed via an agency and may
encourage staff to work substantively rather on through an agency. This could impact on
the availability of bank or agency staff.

 The CIP programme remains challenging but is currently on track. The Directorate plans
have not indicated a significant negative impact on quality of service delivery and they are
confident the pathway work is well underway to deliver better dementia and care home
interventions. Further CIP requirements would concern the Directorate in terms of being
able to deliver safe and effective services.

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Adult Directorate – Exception Report

 There has remained a high use of out of area acute beds by the Directorate, however bed
management controls are working well and whilst the number of beds fluctuates there is
greater senior management understanding and oversight.

 Further work to try to reduce out of area placements includes further development of the
urgent care pathways. This works includes review and redesign of Russell Clinic, step
down, home treatment and Single Point of Access.

 Waiting list management in Torbay has improved however there has been an increase in
referrals. On-going review and oversight by senior management is in place

 Staffing remains challenging with staff retiring and losing senior staff with a sound
knowledge base. There are currently 92 vacant or unfilled posts across all staff groups in
both In-Patients and community teams. The Directorate are working in conjunction with the
newly formed Workforce Group to address alternative approaches to recruitment.

 A particular focus on the Personality Disorder pathway has taken place in February and
March 2017. Up to 40% of admissions to the Acute In-Patient units are people with a
diagnosis of Borderline Personality Disorder. Clinical experts agree that hospital should
only be accessed for this group of people for short time frames and that clear care plans
are needed to ensure admissions are well managed. At this point in time this group of
people can remain in hospital for long periods of time and David Somerfield, Chief
Operating Officer, set up a meeting to review and agree actions needed to re-focus the
Personality Disorder pathway work stream.

 The ten day target on assessments has dipped across the Trust. This is thought to be due
to variations on referrals, vacancies, sickness and annual leave.

 Complaints – the Directorate remain supported by the central complaints team. This team
is earmarked to go, they are on fixed term contracts, and the Directorate need to review
how it will ensure lessons learnt from past challenges with the handling of complaints is
taken forward

 Band 5 agency and Bank staff are still used but there is better control since the
introduction of the safer staffing team and centralised rotas.

 The number of Section 117 reviews is concerning for the Adult Directorate with over 1,000
reviews outstanding (many of these are people who are no longer receiving services but
have not been taken off the Section 117 register correctly). The Directorate are
scrutinising at the Directorate Governance Board and have seen a small improvement in
the number of outstanding reviews. The Directorate are aware this must be a priority for
the next 6 months.

 The CIP programme remains challenging but is currently on track. The Directorate plans
have not indicated significant negative quality impact on those plans they are confident in
delivering. Pathway work is well underway to deliver the Change (Personality Disorder)
programme and the Initial Interventions programme. Both of these pathway workstreams
are linked to the delivery of SMART and initial feedback is very positive. Further CIP
requirements would concern the Directorate in terms of being able to deliver safe and
effective services.

Page 22 of 24
Specialist Services – Exceptions Report

 Currently there is no Head of Profession for the Specialist Directorate. The Directorate has
interviewed twice externally but have not managed to recruit to the post. It has now been
put out internally for a 6 month secondment

 Depression and Anxiety services continue to be concerned about gaps in finding suitable
clinical space from which to operate. Work conducted by the Estates Department
illustrates the real costs of clinic space is significantly more than the available budget.
Work is on-going to find solutions and the Estates Strategy group is very aware of the
issues and seeking to support solutions. Discussions with the Sustainability and
Transformation Planning (STP) estates group are underway.

 Perinatal and Liaison North Devon District Hospital (NDDH) office space is deemed unfit
by clinical staff. NDDH may start charging due to their internal cost pressures. Mother and
Baby unit new estate proposal also causes financial risk.

 The Extra Care Area and seclusion room at the ASU is currently out of use as is being
refurbished.

 There are growing concerns at Directorate level regarding the management and
organisation of the Gender Services. The concerns are being addressed through the
correct formal processes. The service is deemed to be safe, in terms of the people using
the service, however there are concerns with waits of over a year and a lot of complaints
regarding those waits. If the service is to expand the current concerns require resolution.

Individual Patient Placement – Exceptions Report

The IPP team is supporting the development of a clear commissioning arm for DPT. As such,
it has limited clinical services it is responsible for. Those it does the Directorate have a robust
review programme at a person centred level and in terms of the review of the placements
required to ensure they are safe and of a high standard

 The CIP was fully achieved safely

 Contract negotiations with all the providers are on-going. All conversations include value
for money and expectations on quality of service
 The IPP Directorate continues to work collaboratively with the Adult Directorate to
proactively manage the PICU beds.
 The lack of a Community Forensic Service is likely to impact on the timely step-downs
from secure services into wrap around community care packages. The impact on IPP is
likely to be increased length of stays with increased costs. IPP is concerned about the
possible impact the “pace” of change in developing the new care models may have on
IPP in moving secure patients in a timely manner.

Secure Services – Exception Report

 Patients have requested Wi-Fi facilities in low risk and open wards. The Directorate
Governance Board agreed this would not be an option for MSU and LSU due to secure
quality network standards, however, the option of this will be reviewed for the open
cluster. Nick Hopkinson has been advising.
 There are a range of training gaps especially when training needs to be face to face.

Page 23 of 24
  Fire Training – The target for Fire Training have not been met for this quarter –
current figures are 84%. Work is underway to provide more in situ training

 Life Support training – gaps in ability to co-ordinate the face to face training has led
to a number of staff being overdue on refresher courses. Dates are being sought and
prioritised

 Staffing remains challenging and the Directorate reported that it will exceed its agency
expenditure cap of £1.3m by £51k (3.9%). This will continue to be reviewed. There are
gaps across both nursing and medical staffing

 The Directorate met its CIP safely

5 Recommendations

Members of the Quality and Safety Committee are asked to receive the report and confirm
whether it provides adequate assurance or, where assurance is inadequate, that appropriate
and sufficient action is being taken.

Compiled by:
Shaun Alexander
Head of Experience, Safety and Risk

Paul Tucker
Experience, Safety and Risk Manager

Trudy Emmett
Experience, Safety and Risk Manager

Presented by:
Shaun Alexander
Head of Experience, Safety and Risk

Page 24 of 24